Chapter-4

FAMILY PLANNING

By Edosa (BSc, MPH/RH)

 Introduction
 Family Planning(FP) – is defined as the use of
various methods of fertility control that will help
individuals or couples to have the number of children
they want & when they want them to assure the well-b
eing of children & the parents.

 FP is one of the most basic & essential healthcare

services that can promote & ensure
reproductive health
The Rationales for FP
• FP has:
a. Demographic Rationale
b. Health benefits Rationale
c. Human Rights Rationale
a.
A. Demographic Rationale
• This is based on concerns over the potentially
negative effects of rapid population growth &
high fertility on:
–Living standards & human welfare,
–Economic productivity,
–Natural resources, and
–The environment in the developing world,

• FP can protect the environment by stabilizing popul

ation growth.
World Population Growth, in Billions
Number of years to add each billion (year)
All of Human History
First Billion (1800)
Second 130 (1930)

Third 30 (1960)

Fourth 15 (1975)

Fifth 12 (1987)

Sixth 12 (1999)
Seventh 14 (2013)

Eighth 14 (2027)

Ninth 21 (2048)

Sources: First and second billion: Population Reference Bureau. Third through ninth billion: United Nations,
World Population Prospects: The 2004 Revision (medium scenario), 2005.
 Growth in More, Less Developed Countries

Billions
10
9
8
7
6
5
4
3 Less Developed Regions
2
1
More Developed Regions
0
1950 1970 1990 2010 2030 2050

Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.
The Classic Stages of Demographic Transition

Stage 1 Stage 2 Stage 3 Stage 4

Bi rth rate

Natural
i ncre ase

De ath rate

Ti me

Note: Natural increase is produced from the excess of births over deaths.
 Ethiopian Population Growth
[

• The total population of Ethiopia was increased about

eightfold between1900 and 2015.
Year Total population Doubling time GR

In1900 11.8 million 0.3%

In 1960 23.6 million took 60 yrs to double

In 1988 47.3 million took only 28 yrs to double 3.1 %

In 2015 90 million 2.7%

• If the current fertility rate is unchanged, the population of Ethi

opia is projected to reach 173.8 million by 2050 (PRB 2010).
 Trends in TFR, Eth 1990-2011

Source: NFFS(1990), EDHS(2000 ,2005 & 2011)

11/17/2024 10
 Adverse effects of rapid population growth

• Rapid population growth results in :

1. Higher dependency ratios / lower savings
2. Increasing demand for public investment in social ser
vices (health, education) at the expense of investment
in productive goods & services (infrastructure)
3. Changing ratios of land/labor & capital/labor
affecting productivity
1. Population pressure on key natural resources
2. Slower economic growth
 b. Health benefits rationale of FP
1. Reduction in Maternal Mortality & Morbidity
– Multiple & closely spaced pregnancies lead to & worsen
such conditions as anemia, maternal malnutrition, & lo
w birth-weight babies.
• Using an effective FP method reduces maternal deaths
by preventing high-risk pregnancies among women w
ho are too young, too old, or too ill to bear children safely.
• Maternal deaths can be prevented if unwanted pregnan
cies are avoided and pregnancies are spaced by at leas
t two years.
– About 35% of maternal deaths could be eliminated if all
women & men had access to contraception to prevent un
wanted pregnancies.
 Health benefits….. cont’d
2. Reduction in Infant & Child Mortality & Morbidity
– FP protects the health of children by allowing suf
ficient time b/n pregnancies
– Multiple studies show that spacing of births by a
t least two years could prevent at least 20% of
these infant deaths.

3. FP helps in fighting HIV/AIDS through providing inf

ormation, counseling, & access to condoms;
 c. Human Rights Rationale
• This is based on the agreed basic human rights r
elated to RH & fertility regulation that include:
– All couples & individuals have the basic rights:
to decide freely & responsibly the number, s
pacing & timing of their children & to have the i
nformation & means to do so; and
to attain the highest standard of SRH includ
ing FP information & access to safe, effective,
affordable & acceptable methods of their cho
ice for fertility regulation
 NEED AND DEMAND FOR FAMILY PLANNING

• Unmet need for FP

– Women who say they are not using contraception and who say eithe
r that they do not want any more children or that they want to wait tw
o or more years before having another child are considered to have
an unmet need for FP.
• Met need for FP
– Conversely, women using a FP method are said to have
a met need for FP.
• Demand for FP
– The combination of women with unmet need & women with met nee
d for FP constitutes the total demand for FP.
 COUNSELLING FOR EFFECTIVE FP USE

Definition:
A type of client-provider interaction (CPI) invol
ving two-way communication between a health
care staff member and a client for the purpose
of confirming or facilitating a decision by the cl
ient or helping the client address problems or con
cerns.
 IMPORTANCE OF COUNSELING
• It ensures clients’ right to informed & voluntary de
cision making

• It is an essential element of quality FP services

• It is a key determinant of the adoption & continuat

ion of FP
 THE DIFFERENCE THAT COUNSELING MAKES

•CLIENT PROVIDER INTERACTION (CPI)

Critical for effective FP counselling

Is interpersonal communications (verbal/nonverbal

) between health care staff and the client.

Health care staff includes anyone associated wit

h a service site e.g., medical and paramedical st
aff, outreach staff, receptionists, cleaners, and dr
ivers
 PRINCIPLES OF GOOD CPI
1. Treat each client with respect

2. Tailor the interaction to the individual client’s needs, circu

mstances, & concerns

3. Interact; elicit/promote the client’s active participation

4. Avoid information overload

5. Provide the client’s preferred method (for FP) or address t

he client’s primary concern (for other SRH issues)

6. Use & provide memory aids

 THE DIFFERENCE B/N CPI & COUNSELLING
The key principles for good CPI also apply to counseling,
• In addition, providers should follow these guidelines during counseling:
1. Create an atmosphere of privacy, respect, & trust.
2. Engage in two-way communication with the client.
3. Ensure confidentiality.
4. Remain nonjudgmental about values, behaviors, & decisions that differ fro
m your own

5. Show empathy for the client’s needs.

6. Demonstrate comfort in addressing sexual & gender issues.

7. Remain patient with the client during the interaction & express interest.

8. Provide reliable & factual information tailored to the needs of the client.

9. Support the client’s rights to sexual & reproductive health.

 EFFECTIVE COUNSELING

• Enables clients to chose a method that suits their needs

• Enables clients to use their chosen method correctly

• Enables the client to continue using a FP method with satisf

action

• Informs and prepares clients for side effects

BUILDING COMMUNICATION SKILLS

• Good counseling requires good communication skills.

• Counselors need the ability to:
–Establish rapport/understanding, and
–Provide information effectively in order to s
upport clients’ informed & voluntary decision
making
 BUILDING COMMUNICATION SKILLS IS
• To effectively assess clients’ needs,
 Providers must couple open-ended questions that encourage clients
to talk about themselves and listen actively

• To give appropriate information,

 Providers must be able to effectively communicate their knowledge
about RH/FP issues.

 They must have the ability to explain things in language & terms t
hat the client understands and

 They must be comfortable talking about issues related to sexuality.

 …cont’d
BUILDING COMMUNICATION SKILLS…cont’d

•PRAISE AND ENCOURAGEMENT

–Praise is the expression of recognition, approval,& admirat
ion.
–Encouragement is the provision of support, courage, confi
dence, & hope
The purposes of praise & encouragement are to:
– Show that you are listening to the client & valuing wh
at he or she says
– Show your support
– Motivate the client to continue the discussion (telling
& asking)
 BUILDING COMMUNICATION SKILLS…cont’d
•USING THREE ASPECTS OF COMMUNICATION
– The following three key components of communi
cation have been shown to have varying degrees
of impact on the person(s) with whom you are int
eracting:
 BodyLanguage 55%
Tone of Voice 38%
Actual Words 7%
 BUILDING COMMUNICATION SKILLS…cont’d
•LISTENING, PARAPHRASING & REFLECTING
–ACTIVE LISTENING
–Active Listening is listening to another person in a
way that communicates understanding, empathy, & in
terest.
–It is different from hearing.
–It requires energy, attentiveness, skills, & comm
itment.
–It makes the speaker feel important, acknowledged,
& empowered.
 … cont’d
LISTENING, PARAPHRASING & REFLEC
TING…cont’d
• PARAPHRASING
–Paraphrasing means restating the client’s messag
e simply & in your own words.
–The purposes of paraphrasing are to:
–Make sure you correctly understand the client
–Let the client know that you are trying to under
stand what he or she is saying
–Clarify what client is saying
 LISTENING, PARAPHRASING, REFLECTING…

• Reflecting
Reflecting is recognizing and interpreting the client’s feel
ings and integrating what has been said into further disc
ussion.

• Clarification
Clarification is asking questions to better understand wh
at the client has said.
COMMUNICATION TECHNIQUES
Positive Nonverbal Cues
• Leaning towards the client
• Smiling (in a way that is culturally appropriate);
not showing tension
• Avoiding nervous or inappropriate mannerisms
• Presenting facial expressions that inspire trust
• Maintaining eye contact with the client
• Making encouraging gestures, such as nodding
one’s head
 COMMUNICATION TECHNIQUES…cont’d

Negative Nonverbal Cues

• Reading from a chart
• Glancing at one’s watch
• Yawning or looking at papers or out of the window
• Not maintaining eye contact
 The new COUNSELING STEPS IN FP
THE REDI FRAMEWORK
R = Rapport Building
E = Exploration
D = Decision Making
I = Implementing the decision
 THE REDI FRAMEWORK
[

• The REDI framework moves away from traditional F

P counseling that relies on routinely giving detailed i
nformation about every FP method.
• It avoids overloading clients with unnecessary info
rmation and
• Instead it emphasizes on the client’s preferences,
individual circumstances, and sexual relationships a
nd knowledge.
• It helps address the differing needs of clients
 COMPARING REDI & GATHER
REDI GATHER
Rapport Building (R) = Greet, Ask/Assess
Exploration (E) = Ask/Assess,Tell
Decision Making (D) = Ask/assess, tell, help
Implement the decision(I) = Help,explain,return
 STEP 1: RAPPORT BUILDING
1. Greet client with respect
2. Make introductions
Identify category of the client—i.e., ne
w, satisfied return, or dissatisfied return
3. Assure confidentiality & privacy
4. Explain the need to discuss sensitive & pe
rsonal issues
 STEP 2: EXPLORATION
Explore in depth the client’s reason for the visit
This information will help determine the client’s counseling needs & the foc
us of the counseling session
FOR NEW CLIENTS:
1. Explore client’s past experience, current situation, & future RH-related plans
a. Explore client’s reproductive history and goals,
b. Explore client’s social context, circumstances, & relationships
c. Explore issues related to sexuality
d. Explore client’s history of STIs, including HIV
e. Explain STI risk and dual protection, and help the client perceive his or her ri
sk for contracting and transmitting STIs
2. Focus your discussion on the method(s) of interest to client
– Discuss the client’s preferred method, if any, or
– Relevant FP options if no method is preferred,
– Give information as needed, and correct misconceptions
3. Rule out pregnancy and explore factors related to monthly bleeding, any r
ecent pregnancy and medical conditions
 STEP 2: EXPLORATION ……cont’ed
FOR RETURNING CLIENTS:
1. Explore the client’s knowledge & satisfaction with the current method used
2. Confirm correct method use
3. Ask the client about changes in his or her life
Such as -Plans about having children, -STI risk and status, and so on

For Dissatisfied clients

Explore the reasons for the client’s dissatisfaction or the problem
Including: Causes of dissatisfaction and
Possible solutions such as : Reassurance
Treatment of side effects,
Switching methods to other options
 STEP 3: DECISION MAKING

1. Identify the decisions client needs to confirm or make

2. Explore relevant options for each decision
3. Help the client weigh the benefits, disadvantages, &
consequences of each option. Provide information to fill
any remaining knowledge gaps
4. Encourage the client to make his or her own decision
 HELPING THE CLIENT REACH TO DECISION
• Does the client want any more children?
Permanent vs temporary methods
• How long does the client want to be protected from pregnancy?
Long-acting vs short-acting methods
• Can the client use & does the client want to use hormonal metho
ds?
Hormonal vs non-hormonal methods
• Does the client want a method for herself or himself or for his or
her partner?
Male vs. female methods
• Does the client want a method that will be used each time he or
she has sexual relations, or does he or she want
continuous protection?
 STEP 4: IMPLEMENTING THE DECISION

1. Assist the client in making a concrete and specific plan for

carrying out the decision(s) (obtaining & using the FP method
chosen, risk reduction for STIs, dual protection, and so on)
2. Have the client develop skills to use his or her chosen
method and condoms
3. Identify barriers that the client might face in implementing
his or her decision
4. Develop strategies to overcome the barriers
5. Make a plan for follow-up &/or provide referrals as needed
 Successful Counseling
• Good counseling helps clients choose and use fam
ily planning methods that suit them.
• Clients differ, their situations differ, and they need
different kinds of help.
• The best counseling is tailored to the individual clie
nt
• Give time to clients who need it. Many clients are r
eturning with no problems & need little counseling.
Returning clients with problems and new clients wit
h no method in mind need the most time, but usuall
y they are few.
 Tips for Successful Counseling

• Show every client respect, and help each client feel at ease.
• Encourage the client to explain needs, express concerns, ask question
s.
• Let the client's wishes and needs guide the discussion.
• Be alert to related needs such as protection from sexually transmitted i
nfections including HIV, and support for condom use.
• Listen carefully. Listening is as important as giving correct information.
• Give just key information and instructions. Use words the client knows.
• Respect and support the client’s informed decisions.
• Bring up side effects, if any, and take the client's concerns seriously.
• Check the client understands.
• Invite the client to come back any time for any reason.
• Counseling has succeeded when:
– Clients feel they got the help they wanted
– Clients know what to do and feel confident that they can
do it
– Clients feel respected and appreciated
– Clients come back when they need to
– And, most important, clients use their methods effectively
and with satisfaction.
 FP Delivery Strategies
 Service delivery strategies need to be tailore
d to reach populations in different locations:-
urban areas, rural towns, villages, and remot
e areas.
 The most common service delivery sites i
nclude :
1. Clinic-based services
2. Community-Based Distribution (CBD)
3. Commercial Retail Sales
4. Workplace programs
 Quiz (40%)
1. What is family planning (3%)
2. How FP reduce maternal mortality & morbidity(5%)
3. Explain the demographic rationale
4. Define unmet need for FP (5%)
5. List 5 principles of good CPI (5%)
6. Write 3 importance of building communication skills
during counselling for FP (5%)
7. Clearly describe the REDI framework(8%)
8. Mention 3 most common service delivery sites (5%)
 Chapter Five
Contraceptive Methods
• Offering a wide range of FP methods is crucial to
any FP program trying to offer quality services to
its clients.
• Each method has its own mechanism of action, ef
fectiveness, advantages, & disadvantages.
• By gaining familiarity with these methods, service
providers can offer a wide range of services & ref
errals to their clients.
Classification of FP Methods:
A. Classification based on methods types :
B. Classifications based on their EFFECTIVENESS
• In practice, contraceptive methods can be divided into three categ
ories based upon their effectiveness :
a. Most effective methods:
– Long-acting reversible contraception (IUCD, implants) & ste
rilization are associated with a low pregnancy rate.
• Women should be encouraged to first consider a metho
d from this tier of options.
b. Effective methods:
– Injectable contraceptives are the most effective in this tier of
choices.
– OCPs, the transdermal contraceptive, & the vaginal ring are
also associated with a very low pregnancy rate if they are taken
consistently & correctly, but actual pregnancy rates are substant
ially higher because of inconsistent / incorrect use.
c. Least effective methods:
• Other methods of contraception, including diaphragm /cervi
cal caps, condoms, spermicides, withdrawal, and periodi
c abstinence are associated with actual pregnancy rates tha
t are much higher than perfect use rates
 50

Failure rate/ pregnancies per 100 women in the first 12 months

Method Typical us Perfect use

e
No Method 85 85
Fertility awareness-based method 25 5
Spermicides 29 18
Coitus Interruptus / Withdrawal 27 4
Diaphragm 16 6
Male Condom 15 2
Female Condom 21 5

50
 51

Failure rate/ pregnancies per 100 women in the first 12 months

Method Typical use Perfect use

Lactational Amenorrhea/ LAM 2 0.5
COC, Progesterone Only Pill /P 8 0.3
OP , Evra patch, Nuva ring

Injectable (DMPA) 3 0.3

Implanon 0.05 0.05
IUD (Copper T) 0.8 0.6
Female Sterilization 0.5 0.5
Male Sterilization 0.15 0.1
51
 52

Effectiveness
Spermicides
Female condom
Diaphragm w/spermicides
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A) Rate during perfect use
Female sterilization
Rate during typical use
Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use

Source: CCP and WHO, 2007.

Factors Affecting Contraceptive Use

a. Patient & Provider Beliefs

– The providers’ opinions about contraception, such a
s the belief that contraceptive can cause female i
nfertility, negatively affected their willingness to
distribute contraceptives, particularly to young u
nmarried women
b. Male Attitudes towards Contraception
– Male attitudes towards contraception stron
gly influence the willingness and ability of w
omen to use contraception.
Factors Affecting….
c. Lack of access to contraceptives:
• Women in many communities face significant
barriers to contraceptive access, with at lea
st 9 to 15 % of married women in developing c
ountries reporting that they
– “do not have access to contraceptives,
– cannot afford them, or
– do not know about them.
Factors......
d. Governmental policies regulating contraceptive access
– Although governmental policies regulating contra
ceptive use vary, 91% of all countries supporte
d FP programs & contraceptives by 2001, eithe
r
• directly (through government facilities) or
• indirectly (by supporting NGO activities).

– The majority of African countries directly suppor

t the distribution of contraceptives
– while Somalia, Cameroon, Central African Republic,
Chad,& Sierra Leone offer indirect support.
 56

1. Natural methods
a. Fertility awareness based (FAB) methods

– "Fertility awareness" means that a woman k

nows how to tell when the fertile time of her mens
trual cycle starts and ends. (The fertile time is when
she can become pregnant.)
– The couple prevents pregnancy by avoiding unpr
otected vaginal sex during these fertile days—us
ually by abstaining or by using condoms or a diap
hragm.
• Types:
– Calendar-based methods involve keeping track of days of the menstrual cy
cle to identify the start & end of the fertile time.
Examples: Standard Days Method & Rhythm method.

– Symptoms-based methods depend on observing signs of fertility.

• Cervical secretions: When a woman sees or feels cervical secretions, she
may be fertile. She may feel just a little vaginal wetness.
• Basal body temperature (BBT): A woman's resting body temperature goes up
slightly after the release of an egg (ovulation), when she could become preg
nant.
Her temperature stays higher until the beginning of her next monthly bleeding.
Examples:, Ovulation method (Billings method),
 Key Points for Providers and Clients

• Fertility awareness methods require partners' cooper

ation. Couples must be committed to abstaining or using
another method on fertile days.
• Must stay aware of body changes or keep track of day
s, according to the rules of the specific method.
• No side effects or health risks.
 60

i. Standard Day Method(SDM)

•Used for women with menstrual cycle
s between 26 & 32 days long

•White beads days are days when she

can get pregnant

•Brown bead days are days when preg

nancy is unlikely

60
 62

SDM …
 63

SDM …

1 2 3 4 5 6 7 8 9 10 1112 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

•Days 8-19 of the cycle as fertile

63
 64

ii. Ovulation Method/ Billing method

– By observing & evaluating their cervical secretio
ns, avoiding unprotected sex until 3 days after the
‘peak day’
b. Withdrawal methods
• What Is Withdrawal?
– The man withdraws his penis from his partner's
vagina and ejaculates outside the vagina, keepi
ng his semen away from her external genitalia.
– Also known as coitus interruptus & "pulling
out."
 c. Lactational Amenorrhea Methods(LAM)
What is the LAM?
– A temporary FP method based on the natural eff
ect of breastfeeding on fertility.
("Lactational" means related to breastfeeding.
"Amenorrhea" means not having monthly bleeding.)
– The LAM requires 3 conditions. All 3 must be me
t:
1. The mother's monthly bleeding has not returned
2. The baby is fully or nearly fully breastfed & is fed often
, day and night
3. The baby is less than 6 months old
When Can a Woman Use LAM?
2. Barrier methods

69
69
 70

Types of Barrier Methods

1. Condoms (Male and Female Condom)

2. Diaphragms
3. Cervical caps
4. Spermicides

70
a. Condoms
• The theoretical & actual effectiveness of co
ndoms is higher than for the other barrier c
ontraceptives, although the actual effective
ness of all barrier methods of contraception
is highly user-dependent.
 72

Male condom
• Latex rubber
 73

Female condom
• Poly urathane
• 15 cm in length and 7 cm in width
• Female condom —
– The female condom is indicated for preventing pregnanc
y, HIV/AIDS, & other STIs.

– The female condom covers the cervix, lines the vagina an

d shields the introitus, thus providing a physical barrier bet
ween male and female genitalia & secretions during sexua
l intercourse.

– No contraindications exist to its use, but it may not be appr

opriate for women who are not comfortable touching their

genitals or who may have other problems with insertion .

 75

Female Condom: Insertion

75
 b. Diaphragm and cervical cap

• Diaphragms & cervical caps require fitting by a train

ed clinician & are only effective when used with a s
permicide.
– the diaphragm must be left in the vagina for 6 to
8 hours after intercourse;
– the cervical cap can be left in place for up to 48 h
ours.

• These considerations have caused them to be less

desirable methods of contraception for many wome
n.
 77

Diaphragm
Should be kept in place for at least 6 hours
but not longer than 24 hours
 c. Spermicides
• Spermicides containing nonoxynol-9 are availabl
e without a prescription and in a variety of forms inc
luding gel, foam, cream, film, suppository, and table
t.
• They are not a highly effective method of contracep
tion when used alone (without a barrier method).
• Effectiveness is reduced
• if the patient does not wait long enough for the
spermicide to disperse before having intercour
se,
• if intercourse is delayed for more than one hou
r after administration, or
• if a repeat dose is not applied before each add
itional act of intercourse.
 81

3. Hormonal methods

81
I. Oral contraceptive pills (COP)
[Link] oral contraceptive pills (COC)

– Contains both estrogen & progesterone in

a single tab.
• Estrogens are either ethinyl estradiol or m
estranol.
• Progestens are, levonorgestrel, nrethisteron
e and lynosterol.
 84

b. Progesterone only pills/ POPs

oContains only progesterone in small dose
o Levonorgestrel 0.75mg, norethisterone 3.5mg, no
rgesterone 0.3mg are commonly used ones
oIndicated for: those women in whom estrogen are contraindicated
• Schedule: 28 pill pack all active, 1 pill to be taken daily
oAdvantages is
o it eliminates S/E of estrogen (thrombosis, lipid profile changes etc)
– Can be used for lactating mothers, women with HTN, DM and smoker
s.
• Disadvantages are
– increased incidence of menses changes like breakthrough bleeding,
and amenorrhea
 85

II. Transdermal patch/ Ortho-evra

•Contains estrogen and progesterone
– 1 patch per week for 3 weeks followed by a week off

85
 86

III. Vaginal ring/ Nuva ring

•Contains estrogen & progesterone
•Ring( 5 cm in diameter) in to the vagina f
or 3 weeks & out the 4th week

86
 87

IV. Injectables
 Injectable contraception
• Contains only progesterone
– Depo-provera (medroxy progesterone acetate) &
– Norethisterone enanthate(NET-EN).
• Route: given IM
• Doses & schedule:
– Depo is given in a dose of 150mg 3 monthly, &
– NET-EN in 200mg 2 monthly
• Mechanism of action is
– mainly by inhibition of ovulation
– Additionally by cx mucus thickening,.

• Advantages:
– Avoids daily dosing
– Causes amenorrhea(absence) there by relieves disorders like
menorrhagia and dysmenorrhea(pain).

• Disadvantages:-
– Difficult to reverse S/E promptly
– Delay of menses return or fertility for up to 6-9 months
S/E of Depo
• Are:-
– Wt gain
– Headache
– Back pain
– Mood changes

• Failure rate of Depo is <1%

 91

V. Implants
 Types of implants
6-Rod 2-Rod 1-Rod
Norplant Jadelle Implanon
for 7 years for 5 years for 3 years

Sino-Implant (II) is labeled for 4 years of use.

92
 Mechanism of Action
Work primarily by:
Thickening cervical mucus (this blocks sperm from meet
ing an egg)

Disrupting the menstrual cycle, including preventing the

release of eggs from the ovaries (ovulation)

Alters endometrium (Suppression of endometrial growth,

hyperplasia)
 Advantages
• High contraceptive effectiveness
• No need for user compliance
• Minimal requirement for medical follow-up
• Low, stable serum hormone levels minimizing metabolic effects
• Rapid reversibility

Power J. Cochrane Database Syst Rev. 2007

 Disadvantages

• If removed before 3 yrs of use not economical

• No protection of STI & HIV
• Decrease in effectiveness with the use of some drugs
• Some users may experience side effects
 96

4. IUCD
 Key Notes:
 The IUCD is a safe, easy to use, reversible, effective method of child spacing f
or couples who are at low risk for STIs/HIV

 Careful screening and counseling are essential for successful use of an IUCD

 IUCD can be used safely by breast-feeding women

 Different IUCD can remain in from 5 -10 yrs

 IUCD can be a good choice for women with COC precautions

 98

Types of IUD

 Copper T 380A
 Polyethylene with barium sulfate
 For 12 years

 Progestin-releasing( Mirena)
 Medicated (Levonorgestrel Intrauterine System) /IUS
 For 5 years
 Parts of IUCDs (Tcu 380A)

Arms (Rt./Lt.)

Copper sleeve (33mm×2

=66mm2 )
Stem

Copper wire (3
14mm2 )
String/Thread

Main frame:- T shaped, flexible & containing barium sulfate

 Copper IUCD: Mechanisms of Action

Inflammatory rxn :-
Creates hostile environment
for sperm motility/transport,
is spermicidal & inhibits imp
lantation of blastocyst
 Advantages of IUCD
• Highly effective and very safe
• Does not interfere with intercourse
• Easy to use
• Long-acting
• Easily reversible
• Quick return to fertility
• No systemic effects
• Complications are rare
 Disadvantages of IUCD
• Side effects, including cramping and increase
d or prolonged bleeding

• Rare complications include perforation & PID

• Insertion and removal require trained provider

• No STI/HIV protection
 Indications/eligible for IUCD
 Healthy reproductive tract –no infection, ca, or congenital anomaly
 Mutually faithful sexual relationship
 Women who have completed child bearing & do not want VSC
 Who wants a long term reversible method
 Who has precautions for other methods
 Breast feeding women
 Immediately postpartum (from delivery of placenta to 48hrs)
 Who has successfully used IUD in the past
N.B. An IUD may be provided to young, nulliparous women
after thorough consideration
 Contraindications/not eligible
 Pregnancy or suspicions of pregnancy

 Uterine abnormalities/anomalies –myoma

 Acute PID or Hx of PID in the past 3 months

 Postpartum endometritis /septic abortion

 Pelvic malignancies; cervical ca, endometrial ca, GTD

 Undiagnosed AUB

 Untreated acute cervicitis or vaginitis, including BV, gonococcus, chlamydia

 Client or her partner has multiple sexual partners

 Uterus that measures <6cm or >10cm in depth

 Facilities & Equipments for IUCD service
• Skilled provider • Toilet facility
• Waiting area; Room with privacy • Sterile packed IUCD
• IEC material; Chair/Table • Sterile/HLD gloves
• Log book/Client card • Antiseptics solutions (water based
• Gyn exam coach preparations)
• Storage cabinet • Stool; light source
• Instrument tray • Heavy duty gloves + Cleaning brush
• Pick up jar & forceps • Water source + Sink
• Puncture proof container • Steam auto clave, Boiler or Dry ove
• Bleach & Decontamination bucke n
t • Sterilized insertion/removal sets
IUCD 107
 Facilities & Equipments for
Insertion/Removal set:- Insertion/Removal set :-
• Instrument tray 02 • Utility forceps 02
• Bivalve speculum 02 • IUD retriever forceps 01
• Sponge forceps 02 • Pick up/Sponge forceps:- 01
• Tenaculum 02 • Galli pot + Kidney dish:- each 01
• Uterine sound 02 • Wrapping towel:- 01; Sterile gauze
• Long curved scissor 02
IUCD Insertion Steps
 110

5. Emergency Contraceptives
 Types of EC
1. Progesterone only pills
– Levonorgestrel(0.75mg) 1 pill as soon as possible followed by 1 pill
12 hours later or 1.5 mg can be taken as a single dose stat within 3days
2. Combined OCP
– High dose pills. Eg. neogynon, eugynon
– 2 pills as soon as possible then 2 pills 12 hours later
– Low dose pills. Eg. microgynon
– 4 pills for the 1st & 2nd dose

3. IUD :
• is much more effective at preventing pregnancy than t
he pill methods and usually used by women who want
to keep the IUD as an ongoing method of birth control.

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 How Effective?
• If 100 women each had sex once during the seco
nd or third week of the menstrual cycle without us
ing contraception, 8 would likely become pregnant.
• If all 100 women used progestin-only ECPs, one
would likely become pregnant.
• If all 100 women used estrogen and progestin E
CPs, 2 would likely become pregnant.
113
• Assignment
• 1. Permanent Methods of family planning
• -Tuba legation
• -Vasectomy
• 2. STIs including HIV

 Definition of STI and its Magnitude

 Types and common symptoms

 Mode of transmission

 Prevention

 Importance of early diagnosis, treatment and partner notification

 Assignment
3. Management of STIs and prevention strategies

Complications of untreated STIs

Stigma and discrimination

4. Gender and GBV

 Gender Issues in Ethiopia

 Gender related problems in Ethiopia

 Status of Ethiopian Women

 Intervention of GBV
• Correcting Misunderstandings
– Emergency contraceptive pills:
• Do not cause abortion.
• Do not cause birth defects if pregnancy occurs.
• Are not dangerous to a woman's health.
• Do not promote sexual risk-taking.
• Do not make women infertile.
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