Family Planning Kumar sachin La1 163

Family Planning
Definition
According to WHO in 1971 it is defined as “a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of a country’’

Objectives of family planning
Family planning refers to certain objectives;
To avoid unwanted births
To bring about wanted births
To regulate intervals b/t pregnancies
To control the time of birth in relation to the age of parent
To determine the number of children in the family

Scope of family planning services
Family planning is not mere birth control and by WHO expert committee it includes ;
the spacing and limitation of birth
advice on sterility
education for parenthood,
marriage counseling
genetic counseling
providing adoption services
.

Eligible couples
An “eligible couple” is a newly married couple wherein the wife is in the reproductive age between 15 and 45 years.
Target couples
The term target couples was applied to couples who have had 2-3 living children, or even newly married couples to make them accept the idea of family planning from the earliest possible stage.

CONTRACEPTIVE METHODS
Definition :
By definition, these are preventive methods to
help women avoid unwanted pregnancies. They
include all temporary and permanent measures to prevent pregnancy resulting from coitus.

Ideal contraceptive
The term “ideal contraceptive” that is safe, effective, long lasting, inexpensive, acceptable, these may be suitable for one group and may be unsuitable for another. Now this approach is replaced and family planning programs provide a “cafeteria choice”.

Classification
Contraceptive methods are classified as follows:
Spacing methods
Barrier Methods
Physical methods 1)condoms/male and female 2)Diaphragm(female)
3) vaginal sponge
Chemical method
Foams: tablets, aerosols Creams, jellies, and pastes.
Suppositories_ inserted manually Soluble films_ C_film .

Combined methods
Combination of physical and chemical methods.
ii. Intra- utrine devices
Types of IUCDs:
Non-medicated includes :
Lippes loop Medicated IUCDs includes:
copperT and multiload Harmone releasing IUCDs are:
progestasert and levonorgestrel

iii. Hormonal Contraceptives
May be classified as follows:
Oral pills
Combined pills
Progestogen only pill ( POP)
Post- coital pill
Once – a- month (long – acting) pill
Male pill
Depot(slow release) formulations
Injectables
Subcutaneous implants
Vaginal rings

iv. Post-conceptional methods
These include:
Menstrual regulation
consists of aspiration of the uterine contents 6 to 14 days of a missed cycle.
Menstrual induction
based on disturbing the normal physiology of uterus by adding 1-5 mg of prostaglandin F2 .
Abortion
It is the termination of pregnancy before the foetus become viable till 28 weeks of gestation.

v. Miscellaneous methods
Includes:
Abstinence
Coitus interruptus
Safe period (rhythm method)
Natural familly planning method
Breast feeding
Birth control vaccine

2. TERMINAL METHODS (Sterilization)
Male sterilization or vasectomy
Female tubal ligation

Choose best contraceptive for these women…
A) 21 yrs old recently married woman presents to your clinic after having unprotected coitus last night. What method/s that you can use in this woman as post-coital contraceptive method/s.
B) A 35 yrs old healthy woman with two children aged 3 & 5 yrs requests an emergency contraceptive after unplanned coitus 4 days ago. Name a method that you would offer this woman.

key
post-coital pill containing levonorgesterol 0.75mg 12 hrs apart within 72 hours of unprotected coitus.
Insert an IUCD. Best within 5 days
of unprotected coitus.

How would you confirm that she is an ideal candidate for IUCD?

An ideal candidate for IUCD should have
At least one child
No history of pelvic disease
Normal menstrual period
Willingness to check IUCD tail
Access to follow-up
A monogamous relationship

Scenarios …
A 30-year-old married woman having positive history of Deep Vein Thrombosis during last pregnancy came for family planning advise. Her menstrual cycle is regular and have three children 2, 5 and 7 years of age. Choose best contraceptive for her.

A 30-year-old married woman, suffering from hypertension, came for family planning advise. Her menstrual cycle is regular and have three children 2, 5 and 7 years of age. Choose best contraceptive for her

A 30-year-old married woman having positive history of Ischemic Heart disease came for family planning advise. Her menstrual cycle is regular and have three children 2, 5 and 7 years of age. Choose best contraceptive for her

A 30-year-old married woman having positive history of hyperlipidemia came for family planning advise. Her menstrual cycle is regular and have three children 2, 5 and 7 years of age. Choose best contraceptive for her.

A 36-year-old married woman, who is healthy and have a regular menstrual cycle, came for family planning advise. She has three children 2, 5 and 7 years of age. Choose best contraceptive for her.

key
For all these woman OCP is contraindicated.
They are all best candidates for IUCD insertion.

So! remember to rule out the contraindications for OCP

Contraindications for OCP
Absolute:
CA Breast, CA genitalia
Liver disease
Hx of thromboembolism
Cardiac problems
Hyperlipidemia
Undiagnosed abnormal uterine bleeding
Special conditions:
Age over 35
Smoking
Epilepsy
Diabetes
Chronic renal disease
Migraine
Nursing mothers first six months

Question
30 yrs old female who is on OCP has forgotten to take her last two pills. what advise would you give her?

If you skip one or more pills, take the following precautions:
Missing the first pill in a new cycle. Take a tablet as soon as you remember and the next one at the usual time. Two tablets can be taken in one day. Use barrier contraception for 7 days after the missed dose.
Missing a pill 2 days in a row. Take 2 pills as soon as you remember and then 2 more the following day. Also use back-up barrier contraception until the next pill cycle.
Missing more than 2 days. Discard the pack, use a back-up birth control method, and begin a new cycle on the following Sunday, even if you have started bleeding.

A 20-year-old married woman comes for FP advise. She had a history of irregular and heavy menstrual cycle and an abortion 1 month ago. GPE show marked pallor. Lab investigations confirm Iron deficiency anaemia. What is the best choice of contraceptive for her?

A 20-year-old married woman comes for FP advise. She had a history of irregular and heavy vaginal bleeding due to Endometriosis. GPE show marked pallor. What is the best choice of contraceptive for her?

A 25-year-old married woman comes for FP advise. She had a history of benign ovarian tumor and severe dysmenorrhea. GPE show marked pallor. What is the best choice of contraceptive for her

A 25-year-old married woman comes for FP advise. She had a history of benign breast lump which was excised 2 months ago. Her GP and systemic examination was normal. What is the best choice of contraceptive for her

A 28-year-old married woman having two children comes for FP advise. She had a history of gestational Diabetes during last pregnancy. Her GP and systemic examination was normal. What is the best choice of contraceptive for her?

Key: the best contraceptive for all these women is OCP provided that no contraindication is present!!

Other women in whom OCP can be given are those
Tuberculous
Goitre +, hyper or hypothyroid
Thalassemic
HIV +,
Suffering from STIs, PID, Ovarian Cancer, Endometrial cancer
Depressed

What if contraindication for OCP is present?

A 35-year-old married woman having two children comes for FP advise. She is a smoker and had a history of gestational Diabetes during last pregnancy. Her GP and systemic examination was normal. What is the best choice of contraceptive for her?

Key:
POP
Progestin only implants OR
Cu- T

Scenario
A 23-year-old illiterate woman who has just given birth to her first baby wants an advice on FP. She is medically fit and wants to breastfeed her child. What is the best choice of contraceptive for her?

1st Choice Methods
These methods do not interfere with breastfeeding and are safe to use any time after birth:
LAM (for up to six months)
Condoms (also the best protection against AIDS and sexually transmitted diseases)
Diaphragm
Spermicides
IUD (non-hormonal)
Natural Family Planning (breastfeeding disrupts the signs and symptoms of fertility, which may make charting difficult)

Upon inquiry she told the doctor that she is not willing to place anything in her uterus.

2nd Choice Methods
Methods under this category contain the hormone progestin. In most cases, these methods do not affect a woman's milk supply. However, to avoid any risk, it is recommended to wait six weeks after delivery before using a progestin-only method, which include the following:
Mini-pill
Injectables (such as Depo-Provera®)
Implants (such as Norplant®)

3rd Choice Methods
These methods contain the hormone estrogen which can reduce a woman's milk supply. Women should be informed of this risk and advised
to delay the use of such methods until at least six months postpartum.
However, if the breastfeeding woman chooses this method, she can continue breastfeeding and should be encouraged to do so for its numerous health benefits.
Combined oral contraceptives Combined Injectables

Scenario
A 27-year-old married woman having two children comes for FP advise. She is suffering from PID. Her GP and systemic examination was normal. Her lab investigations show lipid disorder. What is the best choice of contraceptive for her?

Key
Barrier method by the partner or
Safe period (Rhythm or natural method)

Natural methods:
Calendar method
Cervical mucus method
Basal body temperature method

Drawbacks of calendar method
Menstrual cycles are not always regular.
Only possible to be used by educated couples.
Compulsory abstinence for nearly half of every month.
Method is not applicable during post-natal period.
High failure rate i.e. up to 9 per HWY.

Other names of natural methods
Billings method = ovulation method = cervical mucus method
Symptothermic method =
basal body temperature + cervical mucus method + calendar method

Pearl’s index
Denominator i.e. total months of exposure =
no of woman x years of exposure

Suppose 200 females on OCPs were followed over a period of 2years to observe the effectiveness of the contraceptive method. During the study period six females conceived and left the study. Determine the failure rate of OCPs in this study.

Calculation of Contraceptive Failure
Rate
We need to calculate the Pearl’s Index.
Total accidental pregnancies = 6
Total months of exposure = 2x 12=24
– 6 x1200 / 200 x 24 = 1.5 per HWY

Unmet need for family planning
Many women who are sexually active would prefer to avoid becoming pregnant, and had not being using any method of contraception(including use by their partner).
These women are considered to have an “unmet need “ for family planning.

Reason for unmet need
Unsatisfactory services
Lack of information
Fear of side effects
Opposition from the husband or relatives.

How to overcome
Maximize access to good quality services
Expand mass media communication
Address facts and myths about family planning
Address men directly with information about benefits and safety