KENYA MEDICAL TRAINING COLLEGE

FACULTY OF PUBLIC HEALTH SCIENCES

DEPARTMENT OF HEALTH PROMOTION AND COMMUNITY HEALTH

Module-Reproductive Health
Module Competence

This module is designed to enable the learner apply basic principles of reproductive Health
in the community

Module outcomes.

By the end of this module, the learner should

1. Explain the concepts of Reproductive health, family planning and pillars of safe
motherhood
2. Identify danger signs in pregnancy and during post-natal period
3. Provide family planning commodities
4. Provide health education of reproductive health

Module units:

1. CONCEPTS OF REPRODUCTIVE HEALTH

Module content:

1.1: Definition of terms:

Health: Refers to a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity. The enjoyment of the highest attainable

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standard of health is one of the fundamental rights of every human being without
distinction of race, religion, political belief, economic or social condition

Reproductive health: Reproductive health is a state of complete physical, mental and

social well-being and not merely the absence of disease or infirmity, in all matters relating
to the reproductive system and to its functions and processes. Reproductive health implies
that people are able to have a satisfying and safe sex life and that they have the capability
to reproduce and the freedom to decide if, when and how often to do so.

Family planning: is the ability of individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their births. It is achieved through
use of contraceptive methods and the treatment of involuntary infertility.

Pregnancy: is the term used to describe the period in which a fetus develops inside a
woman's womb or uterus. Pregnancy usually lasts about 40 weeks, or just over 9 months,
as measured from the last menstrual period to delivery. It is usually divide into three
trimesters; 1st trimester, 2nd trimester and 3rd trimester.

Abortion: is the termination of a pregnancy by removal or expulsion of an embryo or fetus.

An abortion that occurs without intervention is known as a miscarriage or "spontaneous
abortion" and occurs in approximately 30% to 40% of pregnancies. When deliberate steps
are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced
miscarriage". The unmodified word abortion generally refers to an induced abortion.
Although it prevents the birth of a child, abortion is not generally considered birth control
(another term for contraception).

Ante-natal: Is the care given to expectant mothers and their unborn children. Through this
form of preventive health care, women can learn from skilled health personnel about
healthy behaviors during pregnancy, better understand warning signs during pregnancy
and childbirth, and receive social, emotional and psychological support at this critical time
in their lives.

Through antenatal care, pregnant women can also access micro nutrient supplementation,
treatment for hypertension to prevent eclampsia, as well as immunization against tetanus.
Antenatal care can also provide HIV testing and medications to prevent mother-to-child
transmission of HIV.

In areas where malaria is endemic, health personnel can provide pregnant women with
medications and insecticide-treated mosquito nets to help prevent this debilitating and
sometimes deadly disease.

Post-natal: World health organization stated that postnatal care is defined as a care given
to the mother and her newborn baby immediately after the birth of the placenta and for the
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first six weeks of life. Majority of maternal and neonatal deaths occur during childbirth and
the postpartum period. Scaling up of maternal and newborn health through proper
postnatal care services is the best way of reducing maternal and neonatal mortality.

Menopause: is the time that marks the end of your menstrual cycles. It's diagnosed after
a woman has gone 12 months without a menstrual period. Menopause can happen in 40s
or 50s, but the average age is 50 in the united States . Menopause is a natural biological
process.

Menstrual cycle: Each month during the years between puberty and menopause, a
woman’s body goes through a number of changes to get it ready for a possible pregnancy.
This series of hormone-driven events is called the menstrual cycle.

During each menstrual cycle, an egg develops and is released from the ovaries. The lining of
the uterus builds up. If a pregnancy doesn’t happen, the uterine lining sheds during a
menstrual period. Then the cycle starts again.

A woman’s menstrual cycle is divided into four phases:

 menstrual phase
 follicular phase

 ovulation phase

 luteal phase

The length of each phase can differ from woman to woman, and it can change over time.

Infant: An infant is a formal or specialised synonym for the common term baby, meaning
the very young offspring of human beings. The term may also be used to refer to juveniles
of other organisms. A newborn is, in colloquial use, an infant who is only hours, days, or up
to one month old.

Adolescent; This period of development corresponds roughly to the period between the
ages of 10 and 19 years, which is consistent with the World Health Organization's
definition of adolescence.

Adolescent-Friendly Services: These are Sexual and Reproductive Health services

delivered in ways that are responsive to specific needs, vulnerabilities and desires of
adolescents. These services should be offered in a nonjudgmental and confidential way that
fully respects human dignity.

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Fertility: is the capability to produce offspring through reproduction following the onset of
sexual maturity. The fertility rate is the average number of children born by a female during her
lifetime and is quantified demographically.

Infertility: is difficulty or an inability to reproduce naturally. Infertility is widespread, with

fertility specialists available all over the world to assist mothers and couples who
experience difficulties having a baby.

Human fertility depends on factors of nutrition, sexual behaviour, consanguinity, culture, instinct,
endocrinology, timing, economics, personality, way of life, and emotions.

Sexual Health: A state of physical, emotional, mental and social well-being in relation to
sexuality; it is not merely the absence of disease, dysfunction or infirmity.

Sexual health requires a positive and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual experiences,
free of coercion, discrimination and violence. For sexual health to be attained and
maintained, the sexual rights of all persons must be respected, protected and fulfilled.

Sexuality: It is a central aspect of being human throughout life and encompasses sex,
gender identities and roles, sexual orientation, pleasure, intimacy and reproduction.

Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes,

values, behaviors, practices, roles and relationships

1.2: Reproductive health encompasses;-

1) The ability to reproduce
2) Freedom to control reproduction

3) The ability to go through pregnancy and childbirth safely, with successful maternal
and infant survival and outcomes

4) The ability to obtain information about and access to safe, effective and affordable
methods of family planning

5) The ability to have a satisfying, safe sex life, free from fear of pregnancy and disease

The ability to minimize gynecologic disease and risk throughout all stages of life

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1.3 ANATOMY AND PHYSIOLOGY OF MALE AND FEMALE REPRODUCTIVE SYSTEM
1.3.1 Structures of female reproductive system:
Definition:

The female reproductive system consists of the uterus, a bag-like structure, and the
ovaries, which produce a woman’s egg cells. They are internal genitalia. It also contains
external genital organs. Together they form a reproductive system in females.

Overview of structures of female reproductive system

The female reproductive system in humans has two parts, external and internal
reproductive organs. The main functions of the female genital organs include the
production of eggs, fertilization, implantation of the embryo, development of the fetus
inside it. A pair of ovaries are the major structure that produces the ovum. The fallopian
tube is a tube-like structure. The uterus carries the ovum that is released from the ovary.
The endometrium undergoes cycle changes and prepares the uterus for implantation of the
fetus. The vagina is a tube-like structure extending from the cervix and opens outside.
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The external structures of the female reproductive system are the mons pubis, labia
majora, labia minora, clitoris, and Bartholin’s glands. They protect the internal genital
organs. It also enables the sperm to enter the female reproductive tract.

Anatomy of female Reproductive organs:

The reproductive organs in female are those which are concerned with copulation,
fertilization, growth and development of the fetus and its subsequent exit to the outer
[Link] organs are divided into:

 External genitalia
 Internal genitalia

External genitalia:

The external organs of the female reproductive system are the mons pubis, labia minora,
labia majora, clitoris, and Bartholin’s glands. The external genital organs protect the
internal genital organs and enable the sperm to enter the female reproductive tract for
fertilization.

Mons pubis is a fatty tissue arranged in a triangular shape. It is covered by hair. It secretes
pheromones and contains the sebaceous gland. The labia majora are fleshy folds. It
protects the external genital parts of the females. The labia majora also contain sweat
glands. The labia minora has small folds of tissues that line the opening of the vagina. The
mucus membrane lining the minora keeps it moist. The clitoris is a small protrusion. It is
present in the upper ends of the labia minora. On either side of the vagina, the Bartholin

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glands are present. They are important glands in females. They secrete thick translucent
fluid that acts as a lubricant.

Internal Genitalia:

Internal genitalia are the female reproductive organs that are located inside the pelvic
cavity. They include ; Vagina, Uterus, Uterine tubes(fallopian tubes) and ovaries.

Vagina: The vagina is the outermost internal female sex organ. It extends from the uterus to
the vulva (external genitalia). Functionally, it facilitates menstruation, sexual intercourse and
childbirth. The vagina is located posterior to the urinary bladder and urethra, and anterior to
the rectum.

The upper end of the vagina is attached to the cervix of the uterus. These structures form a
pouch (vaginal fornix) which has anterior, posterior, and lateral parts. The lower end of the
vagina (vaginal orifice) opens into the vaginal vestibule just behind the urethral orifice.
The vaginal orifice may be partially covered with a membrane called hymen.

The vagina is supplied by branches of the internal iliac artery; uterine, vaginal and internal
pudendal arteries.

Uterus:

The uterus (womb) is a hollow muscular organ located deep within the pelvic cavity. Anterior to
the rectum and posterosuperiorly to the urinary bladder, the uterus normally sits in a
position of anteversion and anteflexion. The endometrial lining of the uterus proliferates
each month in preparation for embryo implantation. If fertilization occurs, the uterus acts to

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 house the growing fetus and its placenta. If pregnancy does not occur, the endometrial
lining is shed during menstruation

The uterus is divided into three parts:

 Body (corpus) - the main part of the uterus, connected to the uterine (fallopian) tubes via
the uterine horns. The body has a base (fundus) and an internal chamber (uterine cavity).
 Isthmus - the constricted part of the uterus, located between the body and the cervix.

 Cervix - the inferior portion of the uterus. It consists of two parts (supravaginal, vaginal),
two openings (internal os, external os) and a cervical canal.

The uterus is partially covered by peritoneum. As it reflects from the uterus to the rectum and
urinary bladder, two folds are formed: the rectouterine pouch (of Douglas) and the
vesicouterine pouch, respectively. Several peritoneal ligaments support the uterus and hold it in
place: broad ligament, round ligament, cardinal ligament, uterosacral ligament and
pubocervical ligament.

The uterus is supplied mainly by the uterine artery which arises from the internal iliac artery.
The superior branch of the uterine artery supplies the body and fundus, while the inferior
branch supplies the cervix. The venous blood of the uterus is drained via the uterine
venous plexus into the internal iliac vein.

The uterus receives innervation from the inferior hypogastric plexus via the uterovaginal
nervous plexus, similar to the vagina. Lymphatic drainage of the uterus is into the lumbar,
superficial inguinal, iliac (internal, external) and sacral lymph nodes.

Ovaries:

The ovaries are bilateral female gonads and the equivalent of the male testes. They release the
ovum (egg) for the purpose of fertilization. In addition, they act as endocrine glands,
secreting various hormones necessary for fertility, menstruation and sexual maturation of
the female.

Each ovary is located in the ovarian fossa of the true pelvis, adjacent to the uterus and
below the fallopian tubes. The ovary contains four surfaces (anterior, posterior, medial,
lateral) and two poles (superior, inferior). It is held in its normal position by several
paired ligaments: suspensory ligament of the ovary, proper ovarian ligaments (ligament of
ovary) and mesovarium.

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 Ovaries receive arterial supply from the ovarian arteries, which arise from the abdominal
aorta. These blood vessels reach the gonads by traveling within the suspensory ligaments.

Venous blood of the ovaries is drained by the pampiniform plexus. These veins later
coalesce and form the ovarian veins. The right ovarian vein drains into the inferior vena
cava, whereas the left ovarian vein flows into the left renal vein. The ovaries are innervated
by the ovarian nervous plexus which receives fibers from the aortic, renal and hypogastric
(superior, inferior) plexuses. Sympathetic fibers are derived from the lesser splanchnic
nerves (T10-T11). Parasympathetic innervation arises from the pelvic splanchnic
nerves (S2-S4). Lumbar lymph nodes are responsible for lymphatic drainage of the
ovaries.

Uterine tubes:

The uterine (fallopian) tubes are bilateral muscular organs that extend from the uterine horns to
the superior poles of the ovaries. The fallopian tubes represent the usual site for ovum
fertilization. They also transport the resulting zygote into the uterus for implantation.

The uterine tubes are intraperitoneal organs, covered completely by a part of the broad
ligament of the uterus called the mesosalpinx. They consist of four main parts:

 Infundibulum - the distal part of the uterine tube that opens into the peritoneal cavity via
the abdominal ostium. The infundibulum contains finger-like projections
called fimbriae which extend over the medial surface of the ovaries.
 Ampulla - is the longest and widest part of the uterine tube. It is the most common site of
fertilization.

 Isthmus - is the narrowest part of the uterine tube

 Intramural (uterine) part - it communicates directly with the uterine cavity via the uterine
ostium.

The uterine tube receives arterial supply from the uterine and ovarian arteries. The former is
a branch of the internal iliac artery, and the latter arises from the abdominal aorta. Venous
drainage of the uterine tubes is mediated by the tubal veins. These drain into
the uterine and pampiniform venous plexuses.

The uterine tube receives sympathetic innervation from the superior hypogastric
plexus (T10-L2) via the hypogastric nerve. Parasympathetic innervation stems from the pelvic
splanchnic nerves and the vagus nerve. Lymph is drained from the uterine tubes to the para-
aortic, internal iliac and inguinal nodes.
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The Breast:

The breasts are the mammary glands, varying in size according to age, heredity, and the
amount of fatty tissue present. Each breast has 15-20 glandular lobes separated by
connective tissue. After childbirth, the pituitary gland stimulates these lobules with the
hormone prolactin… and they produce milk

The dark-colored circle at the tip of the breast is called the areola . It contains sebaceous
glands to keep the skin conditioned. In the center is the nipple, where ducts from the lobules
open. The first secretion from the breast is not a true milk, but a thin yellowish substance
called colostrum. Colostrum contains nutrients and the mother’s immunities that can protect
baby.

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1.3.2: Male reproductive system

The male reproductive system includes a group of organs that make up a man’s
reproductive and urinary system. These organs do the following jobs within your body:

 They produce, maintain and transport sperm (the male reproductive cells) and semen
(the protective fluid around sperm).
 They discharge sperm into the female reproductive tract.

 They produce and secrete male sex hormones.

The male reproductive system is made up of internal (inside your body) and external (outside your
body) parts. Together, these organs help you urinate (rid your body of liquid waste materials), have
sexual intercourse and make children.

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Function of the male reproductive system

The entire male reproductive system is dependent on hormones. These are chemicals that
stimulate or regulate the activity of your cells or organs. The primary hormones involved in
the functioning of the male reproductive system are follicle-stimulating hormone (FSH),
luteinizing hormone (LH) and testosterone.

FSH and LH are produced by the pituitary gland. It’s located at the base of your brain and
it’s responsible for many functions in your body. FSH is necessary for sperm production
(spermatogenesis). LH stimulates the production of testosterone, which is necessary to
continue the process of spermatogenesis. Testosterone is also important in the
development of male characteristics, including muscle mass and strength, fat distribution,
bone mass and sex drive.

Anatomy
External male reproductive structures

Most of the male reproductive system is located outside of your abdominal cavity or pelvis.
The external parts of the male reproductive system include the penis, the scrotum and the
testicles.

Penis

The penis is the male organ for sexual intercourse. It has three parts:
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  The root: This is the part of the penis that attaches to the wall of your abdomen.
 The body or shaft: Shaped like a tube or cylinder, the body of the penis is made up
of three internal chambers. Inside these chambers there’s a special, sponge-like
erectile tissue that contains thousands of large spaces that fill with blood when you’re
sexually aroused. As the penis fills with blood, it becomes rigid and erect, which
allows for penetration during sex. The skin of the penis is loose and elastic, allowing
for changes in penis size during an erection.

 The glans: This is the cone-shaped end of the penis. The glans, which is also called
the head of the penis, is covered with a loose layer of skin called foreskin. This skin is
sometimes removed in a procedure called circumcision.

The opening of the urethra — the tube that transports both semen and urine out of the
body — is located at the tip of the glans penis. The penis also contains many sensitive
nerve endings.

Semen, which contains sperm, is expelled (ejaculated) through the end of the penis when a
man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked
from the urethra, allowing only semen to be ejaculated at orgasm.

Scrotum

The scrotum is the loose pouch-like sac of skin that hangs behind the penis. It holds the
testicles (also called testes), as well as many nerves and blood vessels. The scrotum
protects your testes, as well as providing a sort of climate control system. For normal
sperm development, the testes must be at a temperature slightly cooler than the body
temperature. Special muscles in the wall of the scrotum allow it to contract (tighten) and
relax, moving the testicles closer to the body for warmth and protection or farther away
from the body to cool the temperature.

Testicles (testes)

The testes are oval organs about the size of very large olives that lie in the scrotum,
secured at either end by a structure called the spermatic cord. Most men have two testes.
The testes are responsible for making testosterone, the primary male sex hormone, and for
producing sperm. Within the testes are coiled masses of tubes called seminiferous tubules.
These tubules are responsible for producing the sperm cells through a process called
spermatogenesis.

Epididymis

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The epididymis is a long, coiled tube that rests on the backside of each testicle. It carries
and stores sperm cells that are created in the testes. It’s also the job of the epididymis to
bring the sperm to maturity — the sperm that emerge from the testes are immature and
incapable of fertilization. During sexual arousal, contractions force the sperm into the vas
deferens.

Internal male reproductive organs

You have several internal organs — also called accessory organs — that play a big part in
the male reproductive system. These organs include:

 Vas deferens: The vas deferens is a long, muscular tube that travels from the
epididymis into the pelvic cavity, to just behind the bladder. The vas deferens
transports mature sperm to the urethra in preparation for ejaculation.
 Ejaculatory ducts: These ducts are formed by the fusion of the vas deferens and
the seminal vesicles. The ejaculatory ducts empty into the urethra.

 Urethra: The urethra is the tube that carries urine from the bladder to outside of
your body. In males, it has the additional function of expelling (ejaculating) semen
when you reach orgasm. When the penis is erect during sex, the flow of urine is
blocked from the urethra, allowing only semen to be ejaculated at orgasm.

 Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas
deferens near the base of the bladder. The seminal vesicles make a sugar-rich fluid
(fructose) that provides sperm with a source of energy and helps with the sperms’
ability to move (motility). The fluid of the seminal vesicles makes up most of the
volume of your ejaculatory fluid, or ejaculate.

 Prostate gland: The prostate gland is a walnut-sized structure that’s located below
the urinary bladder in front of the rectum. The prostate gland contributes additional
fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra,
which carries the ejaculate to be expelled during orgasm, runs through the center of
the prostate gland.

 Bulbourethral glands: The bulbourethral glands, or Cowper’s glands, are pea-sized

structures located on the sides of the urethra, just below the prostate gland. These
glands produce a clear, slippery fluid that empties directly into the urethra. This fluid
serves to lubricate the urethra and to neutralize any acidity that may be present due
to residual drops of urine in the urethra.

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1.4: The menstrual cycle:
During each menstrual cycle, an egg develops and is released from the ovaries. The lining
of the uterus builds up. If a pregnancy doesn’t happen, the uterine lining sheds during a
menstrual period. Then the cycle starts again.

Phases of Menstrual cycle

The day count for menstrual cycle begins on the first day of menstruation when blood starts
to come out of the vagina. In this section, the length of menstrual cycle has been assumed
to be 28 days (which is the average among women). The entire duration of a Menstrual
cycle can be divided into four main phases:
1. Menstrual phase (From day 1 to 5)
2. Follicular phase (From day 1 to 13)

3. Ovulation phase (Day 14)

4. Luteal phase (From day 15 to 28)

Menstrual phase (day 1-5)

Menstrual phase begins on the first day of menstruation and lasts till the 5th day of the
menstrual cycle. The following events occur during this phase:
 The uterus sheds its inner lining of soft tissue and blood vessels which exits the body
from the vagina in the form of menstrual fluid.
 Blood loss of 10 ml to 80 ml is considered normal.

 You may experience abdominal cramps. These cramps are caused by the contraction of
the uterine and the abdominal muscles to expel the menstrual fluid.

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Follicular phase (day 1-13)
This phase also begins on the first day of menstruation, but it lasts till the 13th day of the
menstrual cycle. The following events occur during this phase:
 The pituitary gland secretes a hormone that stimulates the egg cells in the ovaries to
grow.
 One of these egg cells begins to mature in a sac-like-structure called follicle. It takes 13
days for the egg cell to reach maturity.

 While the egg cell matures, its follicle secretes a hormone that stimulates the uterus to
develop a lining of blood vessels and soft tissue called endometrium.

Ovulation phase (day 14)

On the 14th day of the cycle, the pituitary gland secretes a hormone that causes the ovary
to release the matured egg cell. The released egg cell is swept into the fallopian tube by
the cilia of the fimbriae. Fimbriae are finger like projections located at the end of the
fallopian tube close to the ovaries and cilia are slender hair like projections on each
Fimbria.

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Luteal phase (day 15-28)
This phase begins on the 15th day and lasts till the end of the cycle. The following events
occur during this phase:
 The egg cell released during the ovulation phase stays in the fallopian tube for 24 hours.
 If a sperm cell does not impregnate the egg cell within that time, the egg cell
disintegrates.

 The hormone that causes the uterus to retain its endometrium gets used up by the end
of the menstrual cycle. This causes the menstrual phase of the next cycle to begin.

1.5 Menopause

Menopause is the end of a woman’s menstrual cycles. The term can describe any of the changes
you go through just before or after you stop having your period, marking the end of your
reproductive years.
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Menopause Causes

Women are born with all of their eggs, which are stored in their ovaries. Their ovaries also make
the hormones estrogen and progesterone, which control their period (menstruation) and the release
of eggs (ovulation). Menopause happens when the ovaries no longer release an egg every
month and menstruation stops.

Menopause is a regular part of aging when it happens after the age of 40. But some women
can go through menopause early. It can be the result of surgery, like if their ovaries are
removed in a hysterectomy, or damage to their ovaries, such as from chemotherapy. If it happens
before age 40, for any reason, it’s called premature menopause.

Menopause Symptoms
First signs of menopause

Most women nearing menopause will have hot flashes, sudden feelings of warmth that spread
over the upper body, often with blushing and sweating. These flashes can range from mild in
most women to severe in others.

You may also notice:

 Uneven or missed periods

 Vaginal dryness

 Sore breasts

 Needing to pee more often

 Trouble sleeping

 Emotional changes

 Dry skin, eyes, or mouth

Symptoms of menopause

Later symptoms often include:

 Fatigue
 Depression

 Crankiness

 Racing heart

 Headaches

 Joint and muscle aches and pains

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  Weight gain

 Hair loss

 Changes in libido (sex drive)

What Happens During Menopause?

Natural menopause isn’t caused by any type of medical or surgical treatment. It’s slow and
has three stages:

 Perimenopause. This phase usually begins several years before menopause, when
your ovaries slowly make less estrogen. Perimenopause lasts until menopause, the point at
which your ovaries stop releasing eggs. In the last 1 to 2 years of this stage, estrogen
levels fall faster. Many women have menopause symptoms.

 Menopause. This is when it's been a year since you had a period. Your ovaries have
stopped releasing eggs and making most of their estrogen.

 Postmenopause. These are the years after menopause. Menopausal symptoms such
as hot flashes usually ease. But health risks related to the loss of estrogen increase as you
get older.

What Conditions Cause Premature Menopause?

Your genes, some immune system disorders, or medical procedures can cause premature
menopause. Other causes include:

 Premature ovarian failure. When your ovaries prematurely stop releasing eggs, for
unknown reasons, your levels of estrogen and progesterone change. When this happens
before you’re 40, it's called premature ovarian failure. Unlike premature menopause,
premature ovarian failure isn’t always permanent.

 Induced menopause. This happens when your doctor takes out your ovaries for
medical reasons, such as uterine cancer or endometriosis. It can also happen
when radiation or chemotherapy damages your ovaries.

How Long Do Symptoms of Menopause Last?

Menopause is different in each woman. In general, the symptoms of perimenopause last about
4 years.

Menopause Diagnosis

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You might suspect that you’re going into menopause. Or your doctor will say something, based
on symptoms you've told them about.

You can keep track of your periods and chart them as they become uneven. The pattern will
be another clue to your doctor that you’re menopausal.

Your doctor might also test your blood for levels of:

 Follicle-stimulating hormone (FSH). This usually goes up as you near menopause.

 Estradiol. This tells your doctor how much estrogen your ovaries are making.

 Thyroid hormones. This shows problems with your thyroid gland, which can affect
your period and cause symptoms that look like menopause.

 Anti-Mullerian hormone (AMH). Your body makes this in its reproductive tissues. It
can help your doctor learn about the reserve of eggs in your ovaries.

Menopause Treatment

Menopause is a natural process. Many symptoms will go away over time. But if they’re causing
problems, treatments can help you feel better. Common ones include:

 Hormone replacement therapy (HRT). This is also called menopausal hormone

therapy. You take medications to replace the hormones that your body isn’t making
anymore. Certain drugs or combinations can help with hot flashes and vaginal
symptoms, as well as making your bones stronger. But they can also put you at higher
risk of health problems like heart disease or breast cancer, so you should take the lowest
dose that works for the shortest time possible.
 Topical hormone therapy. This is an estrogen cream, insert, or gel that you put in
your vagina to help with dryness.

 Non hormone medications. The depression drug paroxetine (Brisdelle, Paxil) is FDA-
approved to treat hot flashes. The nerve drug gabapentin (Gralise, Neuraptine,
Neurontin) and the blood pressure drug clonidine (Catapres, Kapvay) might also ease
them. Medicines called selective estrogen receptor modulators (SERMs) help your body
use its estrogen to treat hot flashes and vaginal dryness.

 Medications for osteoporosis. You might take medicines or vitamin D supplements

to help keep your bones strong.

Lifestyle changes

Lifestyle changes help many women deal with menopause symptoms. Try these steps:

 If you’re having hot flashes, drink cold water, sit or sleep near a fan, and dress in layers.

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  Use an over-the-counter vaginal moisturizer or lubricant for dryness.

 Exercise regularly to sleep better and prevent conditions like heart disease, diabetes,
and osteoporosis.

 Strengthen your pelvic floor muscles with Kegel exercises to prevent bladder leaks.

 Stay socially and mentally active to prevent memory problems.

 Don’t smoke. Tobacco might cause early menopause and increase hot flashes.

 Limit how much alcohol you drink, to lower your chance of getting breast cancer and
help you sleep better.

 Eat a variety of foods and keep a healthy weight to help with hot flashes.

 Practice things like yoga, deep breathing, or massage to help you relax.

Alternative and Complementary Menopause Treatments

Some studies have found that soy products relieve hot flashes, but researchers are still looking
into it. There aren’t many large studies on whether other supplements such as black cohosh or
“bioidentical” hormones work for menopause symptoms. Talk to your doctor before starting
any herbal or dietary supplements.

Yoga, tai chi, and acupuncture are safer ways to manage menopause symptoms.

Menopause Complications

The loss of estrogen linked with menopause is tied to a number of health problems that
become more common as women age.

After menopause, women are more likely to have:

 Bone loss (osteoporosis)

 Heart disease

 Bladder and bowels that don’t work like they should

 Higher risk of Alzheimer's disease

 More wrinkles

 Poor muscle power and tone

 Weaker vision, such as from cataracts (clouding of the lens of the eye) and macular
degeneration (breakdown of the tiny spot in the center of the retina that is the center
of vision)

20
It can be tough to manage the sexual changes that come along with menopause, like vaginal
dryness and a loss of sex drive. You might also find that you don’t enjoy sex as much and have
trouble reaching orgasm. As long as it isn’t painful, regular sexual activity may help keep your
vagina healthy by promoting blood flow.

COMPONENTS OF REPRODUCTIVE HEALTH

Your ovaries have stopped sending out eggs once you’re in menopause, so you can’t get
pregnant. But you can still get a sexually transmitted disease. Use safer sex practices if you’re
not in a relationship with one person.

UNIT TWO:

2.1: Maternal Health

Maternal health refers to a woman's health and well-being before, during, and after
pregnancy and encompasses aspects of physical, mental, emotional, and social
health. The World Health Organization defines maternal health as: “the health of women
during pregnancy, childbirth, and the postnatal period

Maternal and child health (MCH) care is the health service provided to mothers (women in
their child bearing age) and children. The targets for MCH are all women in their
reproductive age groups, i.e., 15 - 49 years of age, children, school age population and
adolescents.

Objectives and Targets of WHO

a. To reduce maternal morbidity and mortality due to pregnancy and child birth
b. To reduce morbidity and mortality due to unsafe abortion
c. To reduce perinatal and neonatal morbidity and mortality
d. To promote reproductive health awareness for young children
e. To increase knowledge of reproductive biology and promote responsible
behaviour of adolescents regarding contraception, safe sex and prevention of
sexually transmitted infections.
f. To reduce the levels of unwanted pregnancies in all women of reproductive
age.
g. To reduce the incidence and prevalence of sexually transmitted infections, in
order to reduce the transmission of HIV infection.
h. To reduce the incidence and prevalence of cervical cancer
i. To reduce female genital mutilation and provide appropriate care for females
who have already undergone genital mutilation
21
 j. To reduce domestic and sexual violence and ensure proper management of the
victims.
Objectives for MCH:

General Objective: To improve maternal and child health services in order to decrease
maternal and childhood morbidity and mortality

Specific Objectives
• To provide primary health care services
• To extend integrated MCH services into the rural areas.
• To prevent malnutrition and infection among mothers and children through education in
health and nutrition
• To promote the use of safe water, sanitation and immunization
• To promote supply and promote effective FP programmes.
• To provide services at a cost commensurate with the financial, material and manpower
resources of the country.
• To initiate, develop and co-ordinate operational and other relevant research in MCH.

Strategies of the MCH Programme

• The health services at all levels, including the CHS shall carry out integrated services.
Health education programmes are to be included.
• The health services shall be continually expanded
• The skills and knowledge of the health personnel shall be constantly improved.
a. Adequate emphasis on MCH shall be ensured in the curricula of health workers.
b. An adequate number of health workers for the various levels shall be trained.
c. Textbooks, manuals and other reference materials will be distributed to all health
institutions.
d. Knowledge shall be continuously upheld through appropriate training and supervisory
activities.
 Revision and improvement of the referral system
• Co-ordinate with other organisations and institutions involved in activities related to MCH.
• To engage the participation of the agricultural extension workers and the Kenyan
nutrition Institute in the promotion of the production and utilisation of supplementary
feeding mixes.
• Promote community participation and involvement as an essential component of the MCH
Programme.
• Seek resources for the expansion of services from the government and Non-
Governmental Organisations.

22
• Manpower training and research should be carried out whenever necessary and feasible.
Regions should develop their respective in service training capability and implement a
training programme to develop and upgrade the skill and knowledge of the health workers.

Assignment:
 Describe major health problems of mothers and children
 Identify the factors that affect the health of mothers and children
 Major causes of maternal mortality and prevention
 Recognize the available maternal and child health services

Maternal Health Problems:

More than 150 million women become pregnant in developing countries each year and an
estimated 500,000 of them die from pregnancy-related causes. Maternal health problems
are also the causes for more than seven million pregnancies to result in stillbirths or infant
deaths within the first week of life.

In Kenya, complications of Pregnancy, Childbirth and the puerperium are the leading causes
of inpatient morbidity and mortality in females over 5 years of age (Facts and figures
2009). Maternal mortality levels in Kenya have remained unacceptably high at 488 per
100,000 live births, with some regions reporting MMRs of over 1000 /100 000 live births.
The neonatal mortality rate is 31 per 1,000 live births (KDHS 2008 /09). Currently in Kenya,
neonatal mortality contributes to 60% of all infant mortality cases in Kenya.

Maternal death, of a woman in reproductive age, has a further impact by causing grave
economic and social hardship for her family and community.

Causes of Maternal Mortality in Kenya

Reporting of the cause of maternal death is incomplete in the HMIS. Overall, the lead
causes appear to be antenatal and postnatal haemorrhage. Also common were ecclampsia,
sepsis, ruptured uterus and obstructed labour. (Kenya Health situation and trends 1994-
2010)

Maternal Morbidity
For every woman who dies another 30 suffer long term injuries and illness due to
pregnancy and childbirth related complications. Maternal morbidity is any symptom or
condition resulting from or made worse by pregnancy. Severe maternal morbidity (Near
Miss) is defined as: “any pregnant or recently delivered woman (within six weeks after
termination of pregnancy or delivery), in whom immediate survival is threatened and who
survives by chance or because of the hospital care she receives.”
23
Maternal conditions reported by WHO 2005.
[Link]'s %

Hypertensive 885 14.9

disorders of
pregnancy
Stillbirth 828 13.9
Preterm 489 8.2
delivery
Induced 400 6.7
abortion
Hemorrhage 365 6.2
(antepartum,
intrapartum,
postpartum,
unspecified)
Anemia 267 4.5
Placenta 245 4.1
anomalies
(praevia,
abruptio, etc.)
Spontaneous 235 4.0
abortion
Gestational 224 3.8
diabetes
Ectopic 146 2.5
pregnancy
Premature 140 2.4
rupture of
membranes
Perineal 139 2.3
laceration
Uterine rupture 116 2.0
Obstructed 102 1.7
labor
Depression (postpartum, during pregnancy)
96 1.6

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Factors Affecting Health Status of Mothers

1) Socio economic development of the country has serious Impact on morbidity and
mortality.
2) Poor agricultural development results in inadequate household food and has direct
influence on nutritional status of mothers.
3) Poor sanitary environment, poor housing, unsafe and inadequate water, adverse
social and physical environment.
4) Access to health services.: Lack of access to modern health care services has great
impact on increasing maternal death. Most pregnant women do not receive antenatal
care; deliver without the assistance of trained health workers etc. Less than 10% of
women in Ethiopia and many countries
5) Access to education: In many countries women have poor education and 2/3 of
illiterate adults are women. Poor education of women has to be given serious
consideration. Because denial of education indicates that women are denied the role
they can play in decision-making and decreases the extent of contribution to their
lives, family and community.
6) Education: is proved to have significant effect on women's health and reproductive
behaviour through its influence on age at marriage,contraception and health care
use, and awareness of risks and danger signs.
7) Women’s reproductive and health behaviour.: Reproductive and health behaviour
involves, for example, the age at which a woman becomes pregnant, whether the
pregnancy is wanted, and what kind of health care the woman seeks.
8) Access to and control of income and resources: Women's income, access to
household resources, and power to make decisions influence their ability to seek and
utilize health services.
9) Political commitment: Political commitment is crucial to allocate the available
resources and to provide services which are accessible to those most in need.
10) Low social status of women: The health and well being of women is related and
highly influenced with their social status. Low social status leads to severe burden &
over work (Conjugal,maternal, domestic, and professional) exposing to physically
demanding activities.

Haemorrhage
It can occur during pregnancy, delivery and post partum period.
During pregnancy it can occur at the
• 1st trimester due to abortion
• 2nd trimester due to placental location and pre term labour
• 3rd trimester due to abnormal placental location, premature separation of placenta, and
premature labour
25
During delivery due to
• Uterine or placental bleeding
• Traumatic damage to Vagina or cervix
During post partum period due to:
Non-involution of the uterus
Haemorrhage is more common among multiparous women, following
• Unsafe abortion
• In cases of antepartum haemorrhage
• Prolonged labour
• Retained placenta and it is also common among women with a
history of problems in delivering the placenta.

Predisposing cause for Ante partum haemorrhage

• Placenta praevia
• Common in multi-parity
• Increases with age
• Scarred uterus
• Multiple pregnancy

Predisposing cause for abruptio placenta

• Common in patients with hypertension
• Trauma
• Injuries to abdomen
• Excessively hard work
• Emotional trauma

Predisposing cause for Post partum haemorrhage

• Atonic uterus
• History of post partum haemorrhage,increased chance for recurrence
• High parity
• Multiple pregnancy
• Anaemia – causing poor contraction
• Prolonged labour
• Trauma – this can show quality of care

Most primary postpartum haemorrhage results either from failure of the uterus to contract
and remain contracted or from retained placenta (partial or complete). WHO has
recommended that midwives be trained to perform manual removal of the placenta,
because the results in terms of blood loss, infection and mortality are best when this is
done within an hour of delivery.
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Infection
Infection is prevalent among the disadvantaged and risk increases by factors like anaemia,
malaria, goitre, and malnutrition. Maternal infection is a serious problem as a result of the
vicious cycle caused by low caloric intake, heavy workload and infection.
It is also compounded by pregnancies at young age and too many pregnancies too close
together.
Poverty also perpetuates the problem through illiteracy, poor sanitation, inadequate
housing (crowding), and Inadequate and unsafe water.

a. Puerperal Sepsis
Puerperal sepsis occurs following long and complicated deliveries and it is rare in
uncomplicated spontaneous delivery. Sepsis is also very common after unsafe abortion.
Usually sepsis is fatal when the mother’s condition is compromised due to difficult labour
and severe bleeding.

Important factors that are related with and increase the risk are:
• Majority deliver at home and expose to poor sterile procedure
• Assistance by Untrained person during delivery
• Vaginal examination with unclean hands during delivery and
number of vaginal examination• Prolonged labour (the larger it lasts the greater the risk)
• Duration of ruptured membrane before delivery (increase chance of
the liquor to become infected)
• Use of Instruments to assist delivery
• Trauma
• Caesarean section specially in ruptured uterus
• Pre-existing genital and reproductive tract infections
• Those who survive infection face increased risk of
• Pelvic inflammatory disease
• Infertility, and Ectopic pregnancy

Effective strategies to prevent sepsis include:

• Improvement in standards of hygiene in routine care.
• Keeping interventions and vaginal examinations to a minimum
• Provision of “clean delivery” for all women. Basic aseptic technique is simple in facilities
with adequate supplies of water, soap and disinfectant.
One of the primary aims of trained birth attendant training programs throughout the
developing world is to promote clean delivery in the home through deduction and provision
of basic supplies such as:
sterile razor blades and washable plastic sheets.
27
It is, however, difficult to ensure cleanliness in all deliveries, particularly where access to
clean water is limited.
• Referring women with pre-term prolonged rupture of membranes (longer than 12 hours)
to a referral-level facility for assessment.
• Use of prophylactic antibiotics following pre-labour rupture of membranes (longer than 12
hours).
• Transferring women with prolonged labour (longer than 12 hours) to a referral- level
facility.
• Evacuating retained placental fragments promptly.
Early detection and timely use of antibiotics for postpartum sepsis reduces the risk of
mortality or long-term sequelae.
. Malaria
Malaria is cause of severe under weight during birth and 3 million infants are affected in
Africa. It is common at first pregnancy.
During pregnancy the risk of getting malaria increases two times and the risk for cerebral
malaria is high. During pregnancy malaria is also the cause of :
• Severe anaemia
• Spontaneous abortion
• Pre mature labour
• Still birth, and
• Low birth weight
Wherever malaria is common pregnant women should take anti malarial tablets throughout
pregnancy.

Anaemic women due to malaria face

• Risk during child bearing
• Less tolerance to blood loss (bleeding)
• Risk for anaesthesia and operative delivery
• Poor pregnancy outcome
• Bleeding, illness, and death during delivery
• Still birth
• Poor foetal growth
• Pre term labour
• Low birth weight (serious effect on infancy)
When anaemia is severe pregnant mothers face (directly) congestive heart failure and
haemorrhage (indirectly). This can happen in 3-9% of pregnant mothers. In moderate cases
of anaemia there will be poor ability to recover form haemorrhage and infection

Hepatitis

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Hepatitis A is related with socio economic status and usually women of low socio
economic status (SES) are susceptible as a result of poor hygienic conditions. Faecal
contamination of food & water are responsible as the mode of transmission.
Incidence during pregnancy increases two times and pregnant are more seriously ill and
likely to die than non-pregnant women. In Ethiopia it is reported as one of the major causes
of maternal death due to infectious diseases. Premature labour, liver failure, and sever
haemorrhage are common complications of severe hepatitis.

Sexually Transsimited Diseases and Pelvic Infections:

Sexually transmitted diseases and pelvic infections have grave consequence on mother and
child. They can result from
• Sexual activity
• Poor obstetric and gynecological practices specially associated with Induced abortion,
spontaneous abortion and childbirth
Fatality depends on the type of organism and the organs affected.
Its effects and complications include:
• Tubal scarring leading to infertility
• Ectopic pregnancy
Spontaneous abortion
• Pre mature rupture of membrane
• Congenital anomalies such as blindness, and mental retardation
etc.
e. Acquired Immuno Deficiency Syndrome (AIDS)
The spread of AIDS is increasing and rapid specially in sub-Saharan Africa and other
developing countries putting stress on the already strained health care system.
Magnitude:
According to the WHO estimate16,000 people are infected every day and there are 3
million infected women and it is becoming a serious threat and alarmingly increasing in
pregnancy. In countries like Rwanda 18.30% of women who came for Ante Natal Care were
found to be HIV positive in a routine screening. This condition is further aggravated as a
woman with AIDS has a 25-40% chance of passing on HIV in the womb or at birth (the
number of children born with HIV is reported to be 3.8 million).
AIDS is expected to be the major cause of maternal mortality.

Poverty is also related with AIDS and as a cause of death. Some of the reasons
are:
• Poor health care
• Poor availability of drugs for protection of immunity and increasing survival Immunity
• Crowding (increases transmission)
• Malnutrition further lowers immunity for common diseases like water borne infections etc.
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2.2 Antenatal Care
Ante Natal Care (ANC) is the care given to pregnant mothers that they have safe pregnancy
and healthy baby. It also helps in minimizing complications of pregnancy, labour the post
partum and neonatal periods.
The purpose of ANC is to care for pregnant mothers and to have all births attended by
trained health workers, and to identify pregnancies where risk is high and provide special
care for the mother and the infant.

Activities During the First Ante Natal Care Visit

• Diagnose pregnancy
• History taking
• Physical Examination

• Laboratory Examination. Haemoglobin measurement. VDRL test for syphilis is one of the
important tests to be done irrespective of any condition provided that the facilities are
available. Because syphilis has a grave impact on the foetus then on the new born.
• Immunization: give Tetanus Toxoid injection. If first time repeat after one month.

Protection: 2 doses of tetanus Toxoid protect for 3 years, 3 doses for 5 years, 4 doses for
10 years and 5 doses for life .
• Treat anaemia
• Treat syphilis and other problems accordingly

Second and Following ANC Visits

• Measure blood pressure
• Measure the symphasis fundal height
• Tetanus Toxoid and other examinations as indicated

Health and Nutrition Education During ANC

Health and nutrition education during ANC must focus on:
• Pregnancy: foetal movement (specially for primigravida), labour and common problems
• Diet and Nutrition: extra food, weight gains, fasting and rest
• Avoiding alcohol, tobacco, and drugs (specially in the first trimester)
• Personal hygiene
• Delivery preparation
• Labour signs
• Breast-feeding
• Newborn care
• Family planning

30
• Traditional beliefs and practices

Weight Gain During Pregnancy

Pre-pregnancy weight and weight gain in pregnancy are both critical and additive in their
effect on pregnancy outcome. Equal emphasis should be given to assuring that both are
normal.
A pregnant mother has to have weight measurement a month apart, anytime during the
second or third trimester. A gain of less than one kg per month is the danger signal, with no
weight gain or weight loss being even more severe and calling for immediate action, such
as food supplementation directly for the woman.

Risk Factors Identifiable In ANC

Risk factors identifiable in ANC include:
• Age under 18 or above 35
• Primigravida
• Previous caesarean section, vacuum, or forceps delivery
• Previous perinatal death, stillbirth
• Previous Post partum haemorrhage
• Previous ante partum haemorrhage
• More than 6 pregnancies
• Twins
• Hydrominos
• Pre eclampsia
• Diabetes, cardiac problem, renal disease etc.

Infections During Pregnancy

Pregnant women are sexually active and at risk of sexually transmitted disease, including
HIV/AIDS. In prenatal care screening and treatment for syphilis is routine and is a cost-
effective intervention .
Many studies in developing countries have demonstrated high prevalence levels of both
syphilis and gonorrhoea in pregnant women,leading to considerable long-term morbidity in
women, and to congenital disease and prenatal mortality.
Researchers estimate that of those women, who are currently pregnant, 10 to 15 percent
have syphilis and two-thirds of all these pregnancies have an adverse outcome.
Reliable screening tests exist for both syphilis and gonorrhoea, as do safe, effective
treatments. Screening can be conducted in the clinic while women are attending and
treatment started immediately.
Women are at higher risk of AIDS because the two predominant modes of transmission of
HIV infection are sexual and prenatal.

31
In the case of HIV, curative treatment is not available, and even treatment to delay the
onset of symptomatic disease with antiviral drugs is not readily available or affordable in
developing countries. However,some of the most effective strategies for sexually
transmitted diseases are equally important for AIDS prevention.

These include :
• Promoting education strategies that modify or eliminate risk behaviours
• Providing adequate diagnostic and treatment facilities for patients
• Limiting complications by early detection and adequate treatment;
• Reducing the risk of infection during genital tract procedures through safe delivery
procedures
• Reducing exposure to infection by offering health education;
• Limiting further transmission through counselling and partner referral and
• Promoting condom use and targeting family planning programs more aggressively toward
men.

Treatment of symptomatic urinary tract infections is important, and it has been shown that
screening for asymptomatic bacteriuria, followed by appropriate antibiotic treatment,
reduces the incidence of pyelonephritis in the mother, as well as the incidence of low
weight and premature delivery.
The increased risk of low birth weight babies and the risk of neonatal and infant mortality
associated with low birth weight are of major concern in areas of endemic malaria.
Chorio-amnionitis and fetal infection and loss can be prevented through prompt referral of
women with pre-term or pre-labour rupture of the membranes and prophylactic use of
antibiotics.

Role of Trained Traditional Birth Attendants

(TTBA’s)
In general Trained traditional birth attendants are important and helpful in advising and
referring during pregnancy & delivery. Because TTBA’s can easily identify problems such as
• Young primigravida
• Previous pregnancy problems
• Short stature (depending on local norms of risk)
• Bleeding before or during labour
• Pre mature rupture of membrane

TBAS - assist 60% -80% deliveries throughout the world are called by different names such
as ‘’comadrone’’ co mother of clients in Latin America. The name explains their importance.

32
One of the primary aims of trained birth attendant training programs throughout the
developing world is to promote clean delivery in the home through deduction and provision
of basic supplies such as:
sterile razor blades and washable plastic sheets. It is, however, difficult to ensure
cleanliness in all deliveries, particularly where access to clean water is limited.

1. Family Planning:

 FP is an important component of safe motherhood

 It is necessary to ensure that individuals and couples have adequate information and services regarding FP
 FP is also necessary to plan the timing, number of children, spacing between pregnancies, delay pregnancy,
etc.

2. Antenatal Care (ANC)

 ANC checkup is necessary to detect complications early and treat them as soon as possible
 It is also essential to provide pregnant women with vitamin supplements, iron tablets and vaccinations so that
they can have a healthy and strong pregnancy.

3. Obstetric and Newborn Care

 Obstetric and newborn care refers to all the care and health care level initiatives provided to the mother and
newborn to reduce maternal and newborn mortality and morbidity.
 Birth attendants should have the knowledge, skills, and equipment to perform a clean and safe delivery.
 Moreover, emergency care for high-risk pregnancies and complications are made available to all women and
newborn who need it.
 vaccinations so that they can have a healthy and strong pregnancy.

3.1 Essential Obstetric and Newborn Care (EONC):

 Essential obstetric and newborn care encompasses all care that is provided during pregnancy, labor,
childbirth and postpartum period to prevent and manage complications.
 It is a term used to describe the elements of obstetric and newborn care needed for the management of
normal and complicated pregnancy, delivery, postpartum period.

Essential Obstetric and Newborn Care is differentiated into two levels:

33
3.1.1 Basic Emergency Obstetric and Newborn Care (BEmONC)

It includes following signal functions (i.e., key interventions to treat/manage key causes of maternal and newborn
mortality):

 Management of pregnancy complications by assisted vaginal delivery

(using vacuum extractor or forceps)
 Availability/administration of antibiotics
 Availability/administration of sedatives and anticonvulsants for eclampsia
 Availability/Administration of parenteral Uterotonics (a drug that causes contraction of uterus) like oxytocin,
ergometrine, misoprostol, or prostaglandin etc. *(Note: Ergometrine should NEVER be given to a woman
with elevated blood pressure because it can precipitate an eclamptic seizure/convulsion.)
 Availability/Administration of parental drugs (for PPH, infection and pre-eclampsia and eclampsia
 Manual removal of placenta
 Manual removal of retained products of conception. (facilitated with a manual vacuum aspirator or dilatation
& curettage (D&C))
 Resuscitation of newborns (using a self-inflating bag and mask (Ambu bag) and room air).
 Availability/Administration of parenteral antibiotics to the newborn.

BEmONC services are usually provided at the primary health care levels by skilled birth attendants of any cadre.

3.1.2 Comprehensive Emergency Obstetric and Newborn Care (CEmONC):

It includes all the services of basic essential obstetric services along with following additional services:

34
  Cesarean section/surgery
 Blood transfusion
 Anesthesia
 Umbical vein insertion and
 Intubation of the newborn

CEmONC services are basically provided at the referral hospitals by physicians, clinicians or specially trained
midwives.

4. Postnatal Care (PNC)

 It is necessary to ensure that postpartum care is provided to the mother and baby.
 It includes counselling mothers about child handling, exclusive breast feeding, etc.
 Moreover, PNC also comprises of providing awareness regarding the FP, and managing the danger signs and
symptoms seen in both mother and child.

5. Post abortion Care

 It is necessary to prevent complications of abortion.

 Post abortion care helps to identify/detect if there are any complications of abortion.
 Useful to refer other reproductive health problems when necessary.
 An essential element of post abortion care services is providing the woman with a family planning
method before she leaves the facility.
 It also provides counselling and awareness about different family planning methods.

Essential Elements of Post Abortion Care (PAC) services are:

 Emergency treatment of incomplete abortion and potentially life-threatening complications .

 Post abortion family planning counseling and services.
 Links between emergency PAC services and other reproductive health care.

6. STD/HIV/AIDS Control
 HIV screening is done to prevent, and manage HIV and AIDS transmission to the baby
 To assess risk for future infection
 To provide voluntary counseling and testing
 To expand services to address mother to child transmission.

35
Direct cause for the majority of maternal deaths are:

1. Severe bleeding

 Mostly bleeding after childbirth

 Includes antepartum, postpartum, abortion, and ectopic pregnancy.

2. Infections

 Usually after childbirth

 Includes infection of the uterus, tubes, urinary system and fetal infection.
 Also caused due to unhygienic delivery site and practice

3. High blood pressure during pregnancy

 Includes pre-eclampsia and eclampsia

4. Complications from delivery

 Several complications can arise during the pregnancy

 Teenage pregnancy, advanced maternal age, parity, etc and many other factors can
cause complications

5. Unsafe abortion

 Common cause of maternal death

 Unsafe abortions are high in countries where abortion is not legalized

These factors contribute to nearly 75% of all maternal deaths.

Indirect causes:

a) 3 delays

Three delays usually refer to:

 Delay in the decision to seek care (seeking care)

 Delay arrival at a health facility (reaching care) and
 Delay in obtaining the adequate treatment (receiving care)

36
These delays contribute to increase the complication in pregnancy. However, these delays
are determined by the educational status, financial status, accessibility of health care and
services, etc.

b) Accessibility

 Health services and facilities are still not available in every knock and corner of many
countries
 Reaching health facility is often riskier in some places
 Lack of accessibility promotes the delay

c) Poverty

 Poverty is the other important factor contributing to maternal deaths

 People of rural areas do not fancy health services
 Seeking health services often is not the priority to those people who have to worry
about hands to mouth

d) Cultural practices

 Traditional practices often prevent individual from seeking health care

 Cultural practices also determine the care given to pregnant women, food practices,
etc.,
 Unsafe abortion is also an example of cultural practices.

2.5 POSTNATAL CARE:

It the care given to the mother and newborn from one hour after delivery upto 6 weeks
post-delivery. During postnatal care always give equal attention and care for both the
mother and the new born.

Objectives of Postnatal Care:

 To access the health status of the mother and institute effective therapy to rectify the
defect if any Medical disorders like Diabetes mellitus should be reassessed.
 To ascertain outcome of each pregnancy and follow up of the survival of the newborn.
 To detect and treat the earliest any gynecological condition arising out obstetric
legacy.
 To note the progress of the baby including Immunization schedule for the infant.
 To promote physical well-being of the mother and the baby.
 Promote and support on breast-feeding.
37
  Guidance on Family Planning.
 Provide emotional support.
 Health education on weaning and food preparation.
 Discuss about menstruation (when it will restart) and when to start sexual relation
(this point is usually overlooked in post natal clinics) .

Components of postnatal care:

1- History
 a) Any complications during pregnancy or labour.
 b) Any abnormal symptoms or signs of complications,(hemorrhage, infections and
eclampsia)

 Vaginal bleeding, normally it is blood in the few days after delivery, later it becomes
brownish
then pink, and it becomes colorless only by 24 th day.

 Bad smelling vaginal discharge.

 Pain or tenderness in the abdomen or breast.

 Fever.

 c) Diet What she is eating.

2- physical examination
 The Mother
 Measuring temperature, blood pressure

 Abdomen for swelling, distended bladder, for cesarean incision and for determining
the size and firmness (involution) of the uterus.

 Perineum for swelling, discharge, tears episiotomies.

 NB No vaginal examination should be performed early in puerperium except when it

is absolutely indicated.

 breast for cracked nipples, engorgement or abscess.

 Leg for thrombosis.

 Checking for signs of anemia.

 The newborn for vital signs, umbilical stump,suckling power, respiratory

 distress (cyanosis), tremors, convulsion and jaundice. Ask about

38
  vomiting, constipation or anuria

3- Give the proper treatment if needed, give 200 000 IU of vitamin A orally iron

4- Refer the post-partum cases requiring special treatment.

5- Record the finding on the maternal card.

6. Health education.
 The key messages that should be covered are the followings

1- Avoid puerperal infection

o Personal hygiene particularly that after urination and defecation

o No person with any upper respiratory tract infection or hand infection should be
attending during exposure of the genitalia.

2- Care for the episiotomy or first degree Perineal tear

o The woman has to be trained to clean the wound daily in the morning and each
time after she
passes any urine or stools using warm water and soap.

3- Sleep and rest

o The mother should have periods of rest

o Gradual return to household duties is advisable starting by the end of the first
week. She should avoid any strenuous activity for about 4 weeks.

4- Diet

 She should be aware that all her nutritional needs are increased during the first
six months of lactation together with fluid intake iron supplementation.

5- Advice and counseling on breastfeeding

 The woman should be instructed about:

o Advantages of breast feeding

o Importance of early initiation of breast feeding (within ½ -1 hr)

o Encourage breast feeding on demands.

39
 o Personal hygiene after feeding. Only water is recommended for washing

o nipples and allowed to dry in air after feeding and then covered with

o clean pads. Drying agents as boric acid alcohol must be avoided.

2.6: ABORTION:

 Abortion is the termination of pregnancy by any means, resulting in expulsion of an

immature nonviable foetus of less than 28 weeks.
 Abortion can be early or late depending on gestation, early up to 12 weeks gestation
and late between 13-28 weeks gestation.
 It could be induced or spontaneous.
 Three consecutive abortions would be termed; habitual abortion.
 The frequency of spontaneous abortions is 12 to 15%.
 The frequency of habitual abortion is about 0.4 to 0.8%.
 Habitual abortion affects 2 to 5% of childless couples.
 75% of spontaneous abortions occur before the 16th week of gestation and 62%
before 12 weeks.
 The incidence of sub clinical abortions is estimated at 8%.
 A few risk factors have been elucidated:
 The risk increases with age (OR=2.3 after the age of 30).
 Past history: risk after one abortion is 8%, 40% after 3 abortions and 60% after 4
abortions.
 Ethnic origin and psychological factors.
 Parity, history of voluntary induced abortion, medically assisted conception,
contraceptive method, tobacco consumption do not seem to play any significant role
in spontaneous abortions (J Lansac).

CLASSIFICATION OF ABORTION:

1) Threatening abortion
2) Inevitable abortion
3) Incomplete abortion
4) Complete abortion
5) Missed abortion
6) Septic abortion
7) Criminal abortion

40
CAUSES OF ABORTION:

Chromosomal causes (genetic) are most frequent, about 70% within the first 6 weeks, 50%
before 10 weeks, 5% after 12 weeks.

• Could be: -errors during gametogenesis, non disjunction in paternal or maternal meiosis,
resulting in monosomy (15%), trisomy (54%) or a double trisomy (3%).

• Infections are the second cause of abortions, representing about 15% of the cases.

• Common viruses like the mumps virus, influenzae, varicella and herpes zoster have no
proven risk.

• Cervical incompetence, acquired (D/C, deliveries, conization, synechiae operations etc.)

or congenital, causes 30% of 2nd trimester [Link] and hypotrophy,
leiomyomas, synechiae or congenital malformations.

Metabolic and vascular causes

• Diabetes: risk doubles if poorly controlled.

• HTN increases the risk.

• Tobacco consumption.

• Chronic renal diseases.

• Disseminated lupus erythematosis.

COMPLICATIONS OF ABORTION:
 Haemorrhage
 Septicaemia
 Bacteraemia shock with rigors, nausea, vomiting, diarrhoea, hypotension,
confusion, delirium and coma
 Renal failure
 Secondary infertility
 Death
MANAGEMENT OF A WOMAN WITH ABORTION:
General management of abortion
 The woman with abortion must be admitted to gynaecological ward for close
observation and treatment

41
  History taking to obtain possible aetiological factors together with details of
bleeding, pain and products of conception expelled
 Perform a full physical examination
 Check and record vital signs i.e. temperature, pulse, respiration and blood
pressure
 Observe aseptic technique when performing vaginal examinations
 Provide pads to observe severity of blood loss
 Put up intravenous fluids if the woman is bleeding severely i.e. normal saline,
ringers lactate
 If necessary Check Hb, grouping and cross matching and arrange for blood donor
 Give antibiotics to treat infection in case of septic abortion
 MVA is the method of choice for the management of incomplete or inevitable
Abortion for gestation of 14 weeks or less, because it has fewer complications compared to
curettage.

UNIT 3: FAMILY PLANNING

Objectives

By the end of this unit, the learner should be able to;

o Explain the meaning of family planning methods and their benefits

o Demonstrate basic counselling skills
o Explain the basic information about all family planning methods,
including their effectiveness, advantages, non-contraceptive benefits,
expected side effects and provision in special cases

Introduction

Family planning involves planning the number, frequency and timing of

pregnancy. In other words, it is engaging in activities aimed at regulating the
number and spacing of children in the family through the practice of
contraception or other methods of birth control.

Purpose of family planning

 Raising a child requires significant amounts of resources: time, social,

financial and environmental. Planning can ensure that resources are
42
 available.
 To improve the health of the mother and the child
 Help
preventHIV/AIDS

Family Planning Methods

Methods of contraception include oral contraceptive pills, implants, injectables,
patches, vaginal rings, Intra uterine devices, condoms, male and female
sterilization, lactational amenorrhea methods, withdrawal and fertility
awareness-based methods. These methods have different mechanisms of action
and effectiveness in preventing unintended pregnancy. Effectiveness of methods
is measured by the number of pregnancies per 100 women using the method
per year.

Methods are classified by their effectiveness as commonly used into: Very

effective (0–0.9 pregnancies per 100 women); Effective (1-9 pregnancies per 100
women); Moderately effective (10-19 pregnancies per 100 women); Less
effective (20 or more pregnancies per 100 women)

Criteria for ideal contraceptive

 It should be safe for use, means free from any kind of side effects
 It should be reliable
 It should be easy to administer and convenient
 It should be cost effective
 It should be culturally feasible and acceptable

A. ORAL PILLS

COMBINED ORAL CONTRACEPTIVES (COCs) pills

E.g., Microgynon or Femiplan

43
What it is?

 Pills that contain low doses of two hormones (oestrogen and progestin)
in it like the natural hormones in the woman’s body (progesterone and
oestrogen).

How it works

 The two hormones (oestrogen and progestin) works by preventing

release of egg (ovum) from ovaries (ovulation) each month. It also
thickens cervical mucus and blocks sperm from meeting egg in the
uterine tube.

How effective?

 Effectiveness depends on the user: risk of pregnancy is greatest when

a woman starts a new pill pack 3 or more days late; or misses 3 or
more pills near the beginning or end of a pill pack.
 As commonly used, about 8 pregnancies per 100 women using COCs
over the first year. This means that 92 of every 100 women using COCs
will not become pregnant.
 hen no pill-taking mistakes are made, less than one pregnancy per
100 women using COCs over the past year (3 per 1000 women).
 No delay in return of fertility when COC used is stopped.

44
Who can use it?

 Women of child bearing age

 Have or have not had children
 Are of any age including adolescents and women over 40 years old
 Have just had an abortion or miscarriage
 Smoke cigarette if under 35 years of age
 Have anemia now or had in the past
 Have varicose veins
 Are infected with HIV whether or not on retroviral therapy, unless that
therapy includes ritonavir

Who cannot use?

 Women who are pregnant

 Breastfeeding mothers with babies less than six months old

How to use

 Take one pill every day at the same time

 When you finish a pack of 21 pills, rest for seven days and start a new
pack on the eighth day. If using 28-pill pack start a new pack the next
day

If you miss a pill

o If you miss 1 or 2 pills; take missed pill as soon as you remember

and continue taking one pill every day. It is alright to take 2 pills at
the same time
o If you miss more than 3 days of pills in a row or start a pack 3 days
late, use condoms or abstain for 7 days and keep taking pills
o If you miss 3 pills or more in week 3, SKIP the remaining pills and
start a new pack; use condom or abstain for the next 7 days if
missed any of the last 7 pills (iron pills in a 28- pill pack), discard
the missed pills and continue taking

45
What to expect

o Change in bleeding patterns (irregular, light, or absence of periods)

o Some women have stomach upset or mild headaches that go away
after the first three Months
o Breast tenderness and weight gain
o Some women may experience nausea (ask them to take pill with food)
o Mood changes
o Does not disrupt existing pregnancy
o Use condoms for protection against STI’s including HIV.

Advantages of the pill

o Safe
o Effective when a pill is taken every day
o Less monthly bleeding and cramps
o Can be stopped any time if the woman desires pregnancy
o Can sometimes be used to treat period pain, heavy periods,
premenstrual syndrome, acne and endometriosis.
o Does not interfere with sex.
o Can be provided by trained non-technical staff e.g.,
Community Health Workers/Community Based Distributors
(CHV/CBDs)

Disadvantages

o Failure rate increases if the intake is irregular

o Minor side effects like dizziness, nausea, vomiting, headache, weight gain etc.
o Increases the risk of heart problems if the woman is already at risk
o May increase the risk of cervical cancer and gall bladder disease
Known health benefits

 Help protect against:

 Risks of pregnancy
46
  Cancer of the lining of the uterus (endometrial cancer)
 Cancer of the ovary
 Symptomatic pelvic inflammatory disease
 May help protect against:
 Ovarian cysts
 Iron-deficiency anemia
 Reduce:
 Menstrual cramps
 Menstrual bleeding problems
 Ovulation pain
 Excess hair on face or body
 Symptoms of polycystic ovarian syndrome (irregular bleeding,
acne, excess hair on face or body)
 Symptoms of endometriosis (pelvic pain, irregular bleeding)

Known health risk

o Very rare
 Blood clot in deep veins of legs or lungs (deep vein
thrombosis or pulmonary embolism)
o Extremely rare:
 Stroke
 Heart attack
Correcting Misunderstanding

 Combined oral contraceptives:

o Do not build up in a woman’s body.
o Women do not need a “rest” from taking COCs.
o Must be taken every day, whether or not a woman has sex that day.
o Do not make women infertile.
o Do not cause birth defects or multiple births.

47
 o Do not change women’s sexual behavior.
o Do not collect in the stomach. Instead, the pill dissolves each day.
o Do not disrupt an existing pregnancy.

PROGESTIN-ONLY PILLS (POPs)

Also called “mini pills”

What it is
Pills that contain very low doses of a progestin like the natural progesterone
hormone in a woman’s body.

Safe and most effective when used while breastfeeding less than 6 months after
delivery since they do not contain oestrogen

How POP work?

Work primarily by;

 Thickening the cervical mucus thus, blocks sperms from reaching the egg (ovum)
 Disrupting the menstrual cycle, including preventing the release of
eggs from ovary (suppresses ovulation)
 Making the lining of the uterus thin

48
  Slowing down the egg (ovum) in the fallopian tube

How effective?

Effectiveness depends on the user: for women who have monthly bleeding
(monthly period), risk of getting pregnant is greatest if pills are taken late or
missed completely. Less effective for women who are not breastfeeding.

Breastfeeding:

As commonly used, about 1 pregnancy per 100 women using POPs over the first
year. This means that 99 of 100 women will not become pregnant

When pills are taken every day, less than 1 pregnancy per 100 women using
POPs over the first year (3 per 1000 women)

Less effective for women not breastfeeding:

As commonly used, about 3 to 10 pregnancies per 100 women using POPs over
the first year. This means that 90 to 97 of every 100 women will not become
pregnant.

When pills are taken every day at the same time, less than one pregnancy per
100 women using POPs over the first year (9 per 1000 women).
There is no delay in return of fertility after POPs are stopped.
Who can use?

o Women of child bearing age

o Women who are breastfeeding and baby is less than six months
o Women who can follow a daily routine of pill taking
o Have or have not had children
o Are of any age including adolescents and women over 40 years of age
o Have just have an abortion, miscarriage or ectopic pregnancy
o Smoke cigarettes irrespective of the woman’s age or number of cigarettes
smoked
o Have anemia now or had anemia
o Have varicose veins

49
 o Are infected with HIV, whether or not on a n t i retroviral
therapy, unless that therapy includes ritonavir.

Who cannot use?

o Women who are breastfeeding infants more than six months of age
o Women with breast lumps or breast cancer
o Women with yellow discoloration of eyes
o Women with blood clots in their legs or lungs
o Women taking drugs for TB, epilepsy, or HIV

How to use

o If breastfeeding, can start 4 weeks after childbirth

o Take one pill at the same time every day
o When you finish a pack of pills, start a new pack the next day
 Late taking pill, for women who are breastfeeding:
o Take a pill as soon as you remember, and continue taking pills
 Late taking pill, for women who are not breastfeeding:
o If you take a pill more than three hours late, use condoms for the
next 2 days and keep taking pills

What to expect, if not breastfeeding

 Changes in monthly bleeding including irregular bleeding, spotting,
heavier bleeding or no monthly bleeding, are common, safe and not
life threatening
 Nausea and dizziness

Advantages of POPs

 Easy to use. It is simple and convenient

 Does not interfere with sexual intercourse
 Does not affect breastfeeding
 Can be used by people of any age

50
  There are few side effects

Disadvantages of POPs

 The pill must be taken every day whether you have sexual intercourse
on that day or not. some POPs need to be taken at the same time
every day.
 May change the woman’s period. may have some irregular bleeding for
a few months after starting pills.
 Does not protect against STIs and HIV/AIDS

Side effects

 Headache
 Dizziness
 Mood changes
 Breast tenderness
 Abdominal pain
 Nausea

Known health benefit

 Risks of pregnancy

Known health risks

 None

Correcting misunderstanding
 Progestin-only pills:
 Do not cause a breastfeeding woman’s milk to dry up.
 Must be taken every day, whether or not a woman has sex that day.
 Do not make women infertile.
 Do not cause diarrhea in breastfeeding babies.
 Reduce the risk of ectopic pregnancy.
51
Note:

 These effects are temporary and will disappear with time. If it bothers
you or persists refer to the nearest health facility
 Does not affect breast milk production
 Use condoms for protection against STIs including HIV/AIDS
 Emergency contraceptive pills

EMERGENCY CONTRACEPTIVE PILLS (ECPs)

Also called “morning after pills” or postcoital contraceptives

What it is

 Pills that contain a progestin alone, or a progestin and an oestrogen

together, hormones like the natural hormones in a woman’s body.
 Pills used to prevent pregnancy within 120 hours (5 days) after
unprotected sex. The earlier they are taken the better

When to take them

o As soon as possible after unprotected sex. The sooner ECPs are taken
after unprotected sex, the better they prevent pregnancy.
o Can help to prevent pregnancy when taken any time up to 5 days after
unprotected sex

How Effective?
 If 100 women each had sex once during the second or third week of
the menstrual cycle without using contraception, 8 would likely
become pregnant.
 If all 100 women used ulipristal acetate ECPs, fewer than one woman
would likely become pregnant.
 If all 100 women used progestin-only ECPs, one woman would likely become
pregnant.
 If all 100 women used combined estrogen and progestin ECPs, 2
women would likely become pregnant
 Return of fertility after taking ECPs: No delay. A woman can become
pregnant immediately after taking ECPs. Taking ECPs prevents
52
 pregnancy only from acts of sex that took place in the 5 days before.
They will not protect a woman from pregnancy from acts of sex more
than 24 hours after she takes ECPs. To stay protected from pregnancy,
women must begin to use another contraceptive method.

Protection against sexually transmitted infections (STIs): None

How it works

 Work primarily by preventing or delaying the release of eggs from the

ovaries (ovulation). Thus, no egg can be fertilized. They do not work if
the woman is already pregnant
 They may also work by changing the lining of the womb that may
prevent implantation of a fertilized egg.

What pills can be used as emergency contraceptive pills?

 A special ECPs product with levonorgestrel only, or oestrogen and

levonorgestrel combined or ulipristal acetate
 Progestin-only pills with levonorgestrel or nogestrel
 Combined oral contraceptives with oestrogen and a progestin-
levonorgestrel, norgestrel, or norethindrone

It can be taken in the following situations:

 If the condom breaks

 If one misses to get her pillsIf one has unprotected sex and does not want
pregnancy
 ECPs can also be used any time a woman is worried that she might
become pregnant. For example, after:
o Sexual assault
o Any unprotected sex
o Mistakes using contraception, such as:
 Condom was used incorrectly, slipped, or broke
 Couple incorrectly used a fertility awareness method (for
example, failed to abstain or to use another method during
the fertile days)
53
  Man failed to withdraw, as intended, before he ejaculated
 Woman has had unprotected sex after she has missed 3 or
more combined oral contraceptive pills or has started a
new pack 3 or more days late
 IUD has come out of place
 Woman has had unprotected sex when she is more than 4
weeks late for her repeat injection of DMPA, more than 2
weeks late for her repeat injection of NET-EN, or more than
7 days late for her repeat monthly injection.

Side effects

Some users report the following:

 Changes in bleeding patterns including:

 Slight irregular bleeding for 1–2 days after taking ECPs
 Monthly bleeding that starts earlier or later
than expected In the week after taking ECPs:
 Nausea
 Abdominal pain
 Fatigue
 Headaches
 Breast tenderness
 Dizziness
 Vomiting

Advantages:

 Safe
 Effective and easy to use
 No medical exam
 No Pregnancy tests necessary

Known health benefit

54
  Help protects against pregnancy

Known health risk

 None

Note:

Does not disrupt existing pregnancy and should not be used as a regular method

Why some women say they like emergency contraceptive pills

o Can be used as needed

o Offer a second chance at preventing unwanted pregnancy
o Enable a woman to avoid pregnancy if sex was forced or she was
prevented from using contraception
o Are controlled by the woman
o Reduce the need for abortion in the case of contraceptive errors or if
contraception is not used
o Can have on hand in case the need arises

Correcting misunderstanding

Emergency contraceptive pills:

 Can be used by women of any age, including adolescents
 Do not cause abortion
 Do not prevent or affect implantation
 Do not cause birth defects if pregnancy occurs
 Are not dangerous to a woman's health
 Do not increase risky sexual behavior
 Do not make women infertile
 Can be used more than once in a woman’s cycle.

Avoid Unnecessary Procedures

55
  A woman can take ECPs when needed without first seeing a health care provider.

 No procedures or tests are needed before taking ECPs. The exception

is that a woman who missed her last menses should have a pregnancy
test before taking Ulipristal acetate (UPA)- ECPs.

B. INJECTABLE
CONTRACEPTIVES What it is
Injections given every 1 month (CIC), 2 months (NETEN) or 3 months (DMPA)

Depo Provera
What it is
 The injectables contraceptives depot medroxyprogesterone acetate
(DMPA) and norethisterone enanthate (NET-EN) each contain a
progestin like the natural hormone progesterone in a woman’s body.
(In contrast, monthly injectables contain both estrogen and progestin.
 Do not contain estrogen, and so can be used throughout breastfeeding
and by women who cannot use methods with estrogen.
 DMPA, the most widely used progestin-only injectable, is also known as
“the shot,” “the jab,” the injection, Depo, Depo-Provera, Megestron,
and Petogen.
 Injectable contraceptive given every 3 months. Given by injection into
the muscle (intramuscular injection) either in the deltoid muscle of the
arm or buttocks. The hormone is then released slowly into the
bloodstream.

56
How it works

 Works primarily by preventing eggs from leaving the ovaries (ovulation)

 Works by thickening the cervical mucus, thus prevents sperm from
successfully reaching the egg

How effective?

 Effectiveness depends on getting injections regularly: risk of pregnancy

is greatest when a woman misses an injection. It is 97% effective.
 As commonly used, about three pregnancies per 100 women using
progestin-only injectables over the first year. This means that 97 of
every 100 women using injectables will not become pregnant
 When women have injections on time, less than 1 pregnancy per 100
women using progestin-only injectables over the first year (3 per 1000
women)
o Return of fertility after injections are stopped. An average of about 4
months for DMPA and 1 month longer for NET-EN than with most other
methods.
o Protection against sexually transmitted infections (STIs): None

Who can use?

 Women of reproductive age who desire highly effective and long-term

protection against pregnancy
57
  Breastfeeding mothers 4 weeks after delivery
 Women who cannot use contraceptives that contain oestrogen
 HIV positive women
 Women who have miscarried or had still birth

Who cannot use?

 Women who are pregnant or suspected to be pregnant

 Women with breastfeeding babies less than 4 weeks after delivery
 Women with abnormal vaginal bleeding

How to use

 Get one injection every thirteen weeks (three months)

 Start anytime you are sure that the client is not pregnant. For women
who are breastfeeding wait until four weeks postpartum
 If starting after the first seven days of a menstrual cycle, don’t have
sex for seven days or use a condom

If late for an injection

 DMPA: Can still get an injection up to 4 weeks late

 NET-EN: Can still get an injection up to 2 weeks late
 If later, use condoms and return for an injection as soon as possible.

What to expect

 Irregular bleeding at first, then spotting or no monthly bleeding is common and

safe
 Possible slight weight change
 After stopping injections, it can take several months to become pregnant

Side effects, health benefits and

health risks Side effects
o Some users report the following

58
  Changes in bleeding patterns including, with DMPA:
 First three months:
 Irregular bleeding
 Prolonged bleeding
 At one year
 No monthly bleeding
 Infrequent bleeding
 Irregular bleeding
 Weight gain
 Headache
 Dizziness
 Abdominal bloating and discomfort
 Mood changes
 Less sex drives
 May also experience loss of bone density

Known health benefits

DMPA

 Help protect against

 Risk of pregnancy
 Cancer of the lining of the uterus (endometrial cancer)
 Uterine
fibroids May help
protect against
 Symptomatic pelvic inflammatory disease
 Iron-deficiency
anemia Reduces
 Sickle cell crises among women with sickle cell anemia
 Symptoms of endometriosis (pelvic pain, irregular bleeding)

59
Correcting
misunderstanding
Progestin-only
injectables;
 Can stop monthly bleeding, but this is not harmful. It is similar to not
having monthly bleeding during pregnancy. Blood is not building up
inside the woman
 Do not disrupt an existing pregnancy
 Do not make women infertile

Note:

 These effects are common and safe. However, visit your nearest
health facility if they persist and bother you
 Does not cause infertility
 Use condoms if you need protection from STIs or HIV
 Very effective when injections are given on time and are safe
 Use can be kept private

BARRIER METHODS

These are those methods which prevent meeting of sperm with the ovum. There
are many major types of barrier methods.

i. Physical barrier
methods FEMALE CONDOM
What it is
Plastic pouch inserted into the vagina before sex

60
  Sheaths, or linings, that fit loosely inside a woman's vagina, made of
thin, transparent, soft plastic film.
 Have flexible rings at both ends
 One ring at the closed end helps to insert the condom
 The ring at the open end holds part of the condom outside the vagina
 Female condoms are made of various materials, such as latex, polyurethane, and
nitrile.
 Work by forming a barrier that keeps sperm out of the vagina,
preventing pregnancy. Also helps to keep infections in semen, on the
penis, or in the vagina from infecting the other partner.

How effective?
Effectiveness depends on the user: Risk of pregnancy or sexually transmitted
infection (STI) is greatest when female condoms are not used with every act of

61
sex. Few pregnancies or infections occur due to incorrect use, slips, or breaks.

Protection against pregnancy:

 As commonly used, about 21 pregnancies per 100 women using

female condoms over the first year. This means that 79 of every 100
women using female condoms will not become pregnant.
 When used correctly with every act of sex, about 5 pregnancies per
100 women using female condoms over the first year.

Return of fertility after use of female condom is stopped: No delay

Protection against HIV and other STIs:

 Female condoms reduce the risk of infection with STIs, including

HIV, when used correctly with every act of sex

Why some women say they like female condom

o Women can initiate their use

o Have a soft, moist texture that feels more natural than male latex condoms
during sex
o Help protect against both pregnancy and STIs, including HIV
o Outer ring provides added sexual stimulation for some women
o Can be used without seeing a health care provider

Why some say they like female condom

o Can be inserted ahead of time so do not interrupt sex

o Are not tight or constricting like male condoms
o Do not dull the sensation of sex like male condoms
o Do not have to be removed immediately after ejaculation

Who can use and who cannot use?

 Women who wish to participate actively in Family Planning
 Couples needing a backup method (e.g., for missed pills)
62
  Couples who do not have sex frequently and do not need continual protection
 Couples who want protection from STIs including HIV

Who should not use condoms?

 Couples who cannot use condoms consistently and correctly

 Those allergic to rubber (does not apply to female condoms which are made of
plastic)

How to use

 Insert new female condom into vagina before every sex act
 Dispose of properly in pit latrine or burn
 Make sure penis enters inside the condom ring and stays in during sex

Explaining how to use

IMPORTANT: Whenever possible, show the client how to insert the

female condom. Use a model or picture, if available, or your hands to
demonstrate. You can create an opening similar
to a vagina with one hand and show how to insert the female condom with
the other hand

Explain the 5 Steps of Using a Female Condom

Basic steps Important details

 Check the condom
1. Use a new female condom for each act of package. Do not use if
sex torn or damaged. Avoid
using a condom past
the expiration date. Do
so only if newer
condoms are not
available.
 If possible, wash your
hands

63
 with mild soap and clean
water before inserting the
condom.
2. Before any physical contact, insert the  For the most
condom into the vagina protection, insert the
condom before the
penis comes in contact
with the vagina. Can be
inserted up to 8 hours
before sex.
 Choose a position that
is comfortable for
insertion— squat, raise
one leg, sit, or lie
down.
 Rub the sides of the
female condom
together to spread the
lubricant evenly.
 Grasp the ring at the
closed end, and
squeeze it so it
becomes long and
narrow.
 With the other hand,
separate the outer lips
(labia) and locate the
opening of the vagina.
 Gently push the inner
ring into the vagina as
far up as it will go.
Insert a finger into the
condom to push it into
place. About 2 to 3
centimeters of the
condom and the outer
ring
remain outside the vagina
64
  The man or woman
3. Ensure that the penis enters the should carefully guide
condom and stays inside the condom the tip of his penis
inside the condom—
not
between the condom and the

65
 wall of the vagina. If his penis
goes outside the condom,
withdraw and try again.
 If the condom is
accidentally pulled out
of the vagina or the
outer ring is pushed into
it during sex, put the
condom back in place.

 The female condom

4. After the man withdraws his penis, hold does not need to be
the outer ring of the condom, twist to seal removed immediately
in fluids, and gently pull it out of the vagina after sex.
 Remove the condom
before standing up, to
avoid spilling semen.
 If the couple has sex
again, they should use a
new condom.
 Reuse of female
condoms is not
recommended

 Wrap the condom in its

5. Dispose of the used condom safely package and put it in
the rubbish bin or
latrine. Do not put the
condom into a flush
toilet, as it can cause
problems with
plumbing.

66
Advantages

 Effective
 Provides protection against STDs and HIV

Disadvantages

 Must be used for every sex act

 Requires partners cooperation

Side effects

 None

Known health benefits

 Help protect against:

 Risks of pregnancy
 STIs, including HIV

Known health risks

 None

Note:

Can be used with other Family Planning methods to prevent

 Sexually-transmitted infections
including HIV Important to use correctly
every time you have sex
Partners must agree to use
Emergency contraceptive pills can be used if
 Condom slips or is not used correctly

Correcting Misunderstandings

67
  Female condoms:
Cannot get lost in the woman's body.
Are not difficult to use, but correct use needs to be
learned. Do not have holes that HIV can pass through.
Are used by married couples. They are not only for use outside marriage.
Do not cause illness in a woman because they prevent semen or sperm
from entering her body.

MALE CONDOM

What it is

A thin rubber covering that fits over the erect penis

 Also called rubbers, “raincoats,” “umbrellas,” skins, prophylactics

and preservatives; known by many different brand names.
 Most are made of thin latex rubber. Male condoms also are made
from other materials, including polyurethane, poly isoprene, lambskin,
and nitrile.
 Work by forming a barrier that keeps sperm out of the vagina,
preventing pregnancy. Also keep infections in semen, on the penis, or
in the vagina from infecting the other partner

How effective

Effectiveness depends on the user: Risk of pregnancy or sexually

transmitted infection (STI) is greatest when condoms are not used with every act
68
of sex. Very few pregnancies or infections occur due to incorrect use, slips, or
breaks.

69
Protection against pregnancy:

 As commonly used, about 13 pregnancies per 100 women whose

partners use male condoms over the first year. This means that 87 of
every 100 women whose partners use male condoms will not become
pregnant.
 When used correctly with every act of sex, about 2 pregnancies per
100 women whose partners use male condoms over the first year.

Return of fertility after use of condoms is stopped: No delay

Protection against HIV and other STIs:

 Male condoms significantly reduce the risk of becoming infected with

HIV when used correctly with every act of vaginal or anal sex
 When used consistently and correctly, condom use prevents 80% to
95% of HIV transmission that would have occurred without condoms.
 Condoms reduce the risk of becoming infected with many STIs when
used consistently and correctly during vaginal or anal sex.
o Protect best against STIs spread by discharge, such as HIV, gonorrhea, and
chlamydia.
o Also protect against STIs spread by skin-to-skin contact, such as
herpes and human papillomavirus.

Who can use condoms?

 Men who wish to participate actively in Family Planning

 Couples needing a backup method (e.g., for missed pills)
 Couples who do not have sex frequently and do not need continual protection
 Couples who want protection from STIs including HIV

Who should not use condoms?

 Couples who cannot use condoms consistently and correctly

 Those allergic to rubber (does not apply to female condoms which are made of
plastic)

70
How to use

 Put a new condom onto erect penis before each sex act
 Dispose in pit latrine or burn

IMPORTANT: Whenever possible, show clients how to put on a condom.

Use a model of a penis, if available, or another item, like a banana, to
demonstrate

Explain The 5 Basic Steps of Using a Male Condom

Basic Steps Important Details

1. Use a new condom for

each act of sex
 Check the condom

package. Do not use if torn or damaged. Avoid

using a condom past the expiration date. Do
so only if a
newer condom is not available.

 Tear open the package carefully. Do

not use
fingernails, teeth, or anything that can
damage the condom.

2. Before any physical

contact, place the condom
on the tip of the erect penis
with the rolled side out

 For the most protection, put the

condom on before the penis makes any
genital,
71
oral, or anal contact.

72
  The condom should unroll easily. Forcing
3. Unroll the condom all the it on could cause it to break during use.
way to the base of the erect  If the condom does not unroll easily, it
penis may be on backwards, damaged, or too
old. Throw it away and use a new
condom.
 If the condom is on backwards and
another one is not available, turn it over
and unroll it onto the penis.

 Withdraw the penis.

4. Immediately after
ejaculation, hold the rim of  Slide the condom off, avoiding spilling
the condom in place and semen.
withdraw the penis while it is
still erect  If having sex again or switching from one
sex act to another, use a new condom

 Wrap the condom in its package and put

5. Dispose of the used in the rubbish bin or latrine. Do not put
condom safely the condom into a flush toilet, as it can
cause problems with plumbing.

73
Some practices can increase the risk that will make condom break and should be
avoided.

 Do not unroll the condom first and then try to put it on the penis.
 Do not use lubricants with an oil base. These lubricants can damage latex.
 Do not use a condom if the color is uneven or changed.
 Do not use a condom that feels brittle, dried out, or very sticky.
 Do not reuse condoms.
 Do not have dry sex.
 Do not use more than one condom at the same time.
 Do not use a male and female condom at the same time
 Also, do not use the same condom when switching between different
penetrative sex acts, such as from anal to vaginal sex. This can
transfer bacteria that can cause infection.

Advantages

 Can be effective if used correctly

 Provide protection against STI and HIV
 Easy to use
 Disposable
 No medical supervision is required

Disadvantages

 Must use for every sex act

 Requires partners cooperation
 If not used correctly, it may slip or get tear of and the semen get spilled into the
vagina
 In some cases, an individual maybe allergic to the rubber
 Some people may not enjoy sex because of interference with the sensation.

Side effects
74
  None

Known health benefits Note:

 Help protect against:
o Risks of pregnancy
o STIs, including HIV
 May help protect against:
o Conditions caused by STIs:
 Recurring pelvic inflammatory disease and chronic pelvic pain
 Cervical cancer
 Infertility (male and female)

Known health risks

 Extreme rare:
 Severe allergic reaction among people with latex allergy

Why some men and women say they like condom

 Have no hormonal side effects

 Can be used as a temporary or backup method
 Can be used without seeing a health care provider
 Are sold in many places and generally easy to obtain
 Help protect against both pregnancy and STIs, including HIV
 Can make sex last
longer Note:
 Can be used with other Family Planning methods to prevent sexually-
transmitted infections including HIV
 Important to use correctly every time you have sex
 Be careful not to tear condom when opening package or putting on
 Partners must agree to use
 Emergency contraceptive pills can be used if condom breaks or is not used
75
  Does not have any side effects

Correcting misunderstandings
 Male condoms:
Do not make men sterile, impotent, or weak.
Do not decrease men's sex drive.
Cannot get lost in the woman's body.
Do not have holes that HIV can pass through.
Are not laced with HIV.
Do not cause illness in a woman. Exposure to semen or sperm is not needed
for a woman’s good health.
Do not cause illness in men by making sperm “back up”.
Not only for use outside marriage. They are also used by married
couples. Do not cause cancer and do not contain cancer-causing
chemicals.

DIAPHRAGMS

What is the diaphragm?

76
 A soft latex cup that covers the cervix. Plastic and silicone
diaphragms may also be available.

77
  The rim contains a firm, flexible spring that keeps the diaphragm in place.
 Used with spermicidal cream, jelly, or foam to improve effectiveness.
 Most diaphragms come in different sizes and require fitting by a
specifically trained provider. A one-size-fits-all diaphragm is becoming
available. It does not require seeing a provider for fitting
 Works by blocking sperm from entering the cervix; spermicide kills or
disables sperm. Both keep sperm from meeting an egg.

How effective?

Effectiveness depends on the user: Risk of pregnancy is greatest when the

diaphragm with spermicide is not used with every act of sex.

 As commonly used, about 17 pregnancies per 100 women using the

diaphragm with spermicide over the first year. This means that 83 of
every 100 women using the diaphragm will not become pregnant.
 When used correctly with every act of sex, about 16 pregnancies per
100 women using the diaphragm with spermicide over the first year.

Return of fertility after use of the diaphragm is stopped: No delay

Protection against STIs: May provide some protection against certain STIs but
should not be relied on for STI prevention

Who can use and cannot use diaphragm?

o Nearly all women can use diaphragm safely and effectively

Advantages

 Effective if used effectively with spermicides

 Has no hormonal side effects
 Failure rate is low

Disadvantages
 Must use for every sex act

78
  Requires visit to healthcare provider. That is, requires the assistance
of the doctor or any other health personnel.
 It requires privacy and time to place it in the vagina.
 Requires periodic checkup
 Does not protect against STIs and HIV
 It requires facilities for its proper care and storage

Side effects

 Some users report the following

 Irritation in or around the vagina or penis
 Other possible physical changes:
 Vaginal lesions

Known health benefits

 Help protect against:

o Risks of pregnancy
 May help protect against:
o Certain STIs (chlamydia, gonorrhea, pelvic inflammatory disease,
trichomoniasis)
o Cervical precancer and cancer

Known health risks

 Common to uncommon:
o Urinary tract infection
 Uncommon:
o Bacterial vaginosis
o Candidiasis
 Rare:
o Frequent use of nonoxynol-9 may increase risk of HIV infection
 Extremely rare:
79
 o Toxic shock syndrome
Why some women say they like the diaphragm

 Is controlled by the woman

 Has no hormonal side effects
 Can be inserted ahead of time and so does not interrupt sex

Correcting Misunderstandings

 Diaphragms:
o Do not affect the feeling of sex. A few men report feeling the
diaphragm during sex, but most do not.
o Cannot pass through the cervix. They cannot go into the uterus
or otherwise get lost in the woman's body.
o Do not cause cervical cancer.
ii. Chemical barrier methods

These methods usually kill sperm and through this actions, chemical
contraceptives help in preventing the pregnancy. They include;

SPERMICIDES

What are spermicides

 Sperm-killing substances inserted deep in the vagina, near the cervix, before sex.
 Nonoxynol-9 is most widely used.
 Others include benzalkonium chloride, chlorhexidine, menfegol,
octoxynol-9, and sodium docusate.
 Available in foaming tablets, melting or foaming suppositories, cans of
pressurized foam, melting film, jelly, and cream.
 Jellies, creams, and foam from cans can be used alone, with a
diaphragm, or with condoms.
 Films, suppositories, foaming tablets, or foaming suppositories
can be used alone or with condoms.

80
How it works

 Work by causing the membrane of sperm cells to break, killing them

or slowing their movement. This keeps sperm from meeting an egg.
 Chemicals in the spermicide, such as nonoxynol -9 prevent sperm from entering
the uterus.

How effective is spermicides

Effectiveness depends on the user: Risk of pregnancy is greatest when

spermicides are not used with every act of sex.

 One of the least effective family planning methods.

 As commonly used, about 21 pregnancies per 100 women using
spermicides over the first year. This means that 79 of every 100
women using spermicides will not become pregnant.
 When used correctly with every act of sex, about 16 pregnancies
per 100 women using spermicides over the first year.

Return of fertility after spermicides are stopped: No delay

Protection against sexually transmitted infections (STIs): None (Does not

protect against STIs). Frequent use of nonoxynol-9 may increase risk of HIV
infection

Who can use and cannot use spermicide?

 Who can use?

 All women can safely use spermicide
 Who cannot use spermicide?
 Are at high risk for HIV infection
 Have HIV infection
 Women who are at high risk for HIV infection or who have HIV
should use another method

How to use spermicides

 Explaining how to use spermicides
81
  Give as much spermicide as possible
Give spermicides —even as much as a year's supply, if
available.

Explain how to insert 1. Check the expiration date and avoid

spermicide into the vagina using spermicides past their expiration
date.

 Wash hands with mild soap and

clean water, if possible.

2. Foam or cream: Shake cans of foam

hard. Squeeze spermicide from the can
or tube into a plastic applicator. Insert
the applicator deep into the vagina, near
the cervix, and push the plunger.

Tablets, suppositories, jellies: Insert the

spermicide deep into the vagina, near the
cervix, with an applicator or with fingers.
Film: Fold film in half and insert with fingers
that are dry (or else the film will stick to the
fingers and not the cervix).

Explain when to insert  Foam or cream: Any time less than one
spermicide into the vagina hour before sex.

 Tablets, suppositories, jellies, film:

Between 10
minutes and one hour before sex, depending
on type.
 Insert additional spermicide before
Explain about multiple acts of each act of vaginal sex.
sex

82
 Do not wash  Douching is not recommended because
the vagina (douche) it will wash away the spermicide and
after sex also increase the risk of sexually
transmitted infections.
 If you must douche, wait for at least 6
hours after sex before doing so.

Side effects

 Some users report the following:

 Irritation in or around the vagina or penis
 Other possible physical changes:
 Vaginal lesions

Known health benefits

 Help protect against:

 Risks of pregnancy

Known health risks

 Uncommon:
 Urinary tract infection, especially when using spermicides 2 or more times a
day
 Rare:
 Frequent use of nonoxynol-9 may increase risk of HIV infection

Why some women say they like spermicides

 Are controlled by the woman

 Have no hormonal side effects
 Increase vaginal lubrication
 Can be used without seeing a health care provider
83
  Can be inserted ahead of time and so do not interrupt sex

Correcting Misunderstandings

 Spermicides:
Do not reduce vaginal secretions or make women bleed during sex.
Do not cause cervical cancer or birth defects.
Do not protect against STIs.
Do not change men's or women's sex drive or reduce sexual pleasure for most
men.
Do not stop women's monthly bleeding.
C. IMPLANT
S What are
implants
 Small plastic rods or capsules, each about the size of a matchstick,
that release a progestin like the natural hormone progesterone in a
woman’s body.
 A specifically trained provider performs a minor surgical procedure to
place the implant under the skin on the side on the inside of a
woman’s upper arm.
 Do not contain estrogen, and so can be used throughout breastfeeding
and by women who cannot use methods with estrogen.

Many types of implants:

 Jadelle: 2 rods, effective for 5 year

 Implanon: 1 rod, effective for 3 years

84
  Sino-Implant: also known as Femplant, Trust implant, and Zarin: 2
rods, effective for 4 years

 Norplant: 6 capsules, labeled for 5 years of use

How it work

The implant slowly releases a progestin hormone called etonogestrel into the
body which then work primarily by:

85
  Thickening cervical mucus (this blocks sperm from meeting an egg)
 Disrupting the menstrual cycle, including preventing release of eggs
form ovaries (ovulation).

How Effective

One of the most effective and long-lasting method?

Less than 1 pregnancy per 100 woman using implants over the first year (5 per
10,000 women). This means that 9,995 of every 10,000 women using implants
will not become pregnant.

A small risk of pregnancy remains beyond the first year of use and continues as
long as the woman in using implants:

Over 5 years of jadelle use: about 1 pregnancy per 100 women

Over 3 years of implanon use: Less than 1 pregnancy per 100 women (1 per
1,000 women). Over 7 years of Norplant use: about 2 pregnancies per 100
women.

Jadelle, Sino-implant (II), and Norplant implants start to lose effectiveness

sooner for heavier women.

 For women weighing 80 kg or more, jadelle, sino-implant (II) and

Norplant become less effective after 4 years of use.
 For women weighing 70-79 kg, Norplant becomes less effective
after 5 years of use These users may want to replace their implants
sooner
o Return of fertility after implant are removed: No delay
o Protection against sexually transmitted infection (STI): None

Who can and cannot use implants?

 Safe and suitable for nearly all women

 Nearly all women can use implants safely and effectively, including women
who;
 Have or have not had children

86
 Are not married

87
  Are of any age, including adolescents and women 40 years old
 Have just had an abortion, miscarriage or ectopic pregnancy
 Smoke cigarettes, regardless of woman’s age or number of cigarettes
smoked
 Are breastfeeding (starting as soon as 6 weeks after childbirth)
 Have anemia now or in the past
 Have varicose veins
 Are infected with HIV, whether or not on
antiretroviral therapy Women can began using implants
o Without pelvic examination
o Without any blood tests or other routine laboratory tests
o Without cervical cancer screening
o Without a breast examination
o Even when a woman is not having monthly bleeding at the time, if it is
reasonably certain she is not pregnant

Side effects

 Some users report the following

 Changes in bleeding patterns
including: First several months
 Lighter bleeding and fewer days of bleeding
 Irregular bleeding
 Infrequent bleeding
 No monthly bleeding
 After about one year
 Lighter bleeding and fewer days of bleeding
 Irregular bleeding
 Infrequent bleeding

Implanon users are more likely to have infrequent or no monthly bleeding than irregular
bleeding
88
 Headache

89
  Abdominal pain
 Acne (can improve or worsen)
 Weight change
 Breast tenderness
 Dizziness
 Mood changes
 Nausea

Other possible physical changes

 Enlarged ovarian follicles

Known health benefits

 Help protect against:

 Risk of pregnancy
 Symptomatic pelvic inflammatory disease
 May help protect against
 Iron-deficiency anemia

Known health risk

 None

Complications

 Uncommon:
 Infection at insertion site (most infection occur within the first 2 months after
insertion)
 Difficult removal (rare if properly inserted and provider is skilled at removal)
 Rare
 Expulsion of implants (expulsions most often occur within the first 4
months after insertion).

90
Correcting
misunderstanding
Implants:
 Stop working once they are removed. their hormone do not remain in a woman’s
body
 Can stop monthly bleeding, but this is not harmful. it is similar to
not having monthly bleeding during pregnancy. blood is not building
up inside the woman
 Do not make woman infertile
 Do not move to other parts of the body
 Substantially reduce the risk of ectopic pregnancy

INTRAUTERINE DEVICES (IUDs)

a) COPPER-BEARING INTRAUTERINE
DEVICE What is the intrauterine device?
 The copper-bearing intrauterine device (IUD) is a small, flexible plastic
frame with copper sleeves or wire around it. A specifically trained
health care provider inserts it into a woman’s uterus through her
vagina and cervix.
 Almost all types of IUDs have one or two strings, or threads, tied to them.
 The strings hang through the cervix into the vagina.

How it works

 Copper wire coiled around the device produces an inflammatory

reaction that is toxic to sperm and eggs, thus works primarily by
causing a chemical change that damages sperm and egg before they
can meet.
 May also make it difficult for the fertilized egg (ovum) to implant in the uterus.

How Effective?

One of the most effective and long-lasting methods:

 Less than 1 pregnancy per 100 women using an IUD over the first year
91
 (6 to 8 per 1,000 women). This means that 992 to 994 of every 1,000
women using IUDs will not become pregnant.
 A small risk of pregnancy remains beyond the first year of use and
continues as long as the woman is using the IUD.
o Over 10 years of IUD use: About 2 pregnancies per 100 women

92
  It has been found that the TCu-380A is effective for 12 years. The TCu-
380A is labeled for up to 10 years of use, however. (Providers should
follow program guidelines as to when the IUD should be removed.)
 Return of fertility after IUD is removed: No delay
 Protection against sexually transmitted infections (STIs): None

Who can and cannot use the copper-

bearing IUCD? Safe and Suitable for
Nearly All Women
Most women can use IUDs safely and effectively, including women who:

 Have or have not had

children
 re not married
 Are of any age, including adolescents and women over 40
years old Have just had an abortion or miscarriage (if no
evidence of infection) Are breastfeeding
 Do hard physical work
 Have had ectopic pregnancy
 Have had pelvic inflammatory disease
(PID) Have vaginal infections
 Have anemia
 Are infected with HIV or on antiretroviral therapy and doing well
 Women can begin using IUDs:
 Without STI testing
 Without an HIV test
 Without any blood tests or other routine laboratory tests
 Without cervical cancer screening
 Without a breast examination

Side Effects

 Some users report the following:

o Changes in bleeding patterns (especially in the first 3 to 6 months)
including:

93
  Prolonged and heavy monthly bleeding
 Irregular bleeding
 More cramps and pain during monthly bleeding

Known Health Benefits Known Health Risks

 Helps protect against:

 Risks of pregnancy
 May help protect against:
 Cancer of the lining of the uterus (endometrial cancer)

Known Health Risks

 Uncommon:
 May contribute to anemia if a woman already has low iron
blood stores before insertion and the IUD causes heavier
monthly bleeding
 Rare:
 Pelvic inflammatory disease (PID) may occur if the woman has
chlamydia or gonorrhea at the time of IUD insertion

Complications

 Rare:
 Puncturing (perforation) of the wall of the uterus by the IUD or an
instrument used for insertion. Usually heals without treatment.
 Miscarriage, preterm birth, or infection in the rare case that the
woman becomes pregnant with the IUD in place.

Why some women say they like the IUCD

 Prevents pregnancy very effectively

 Is long-lasting
 That there are no further costs after the IUD is inserted
 Does not require the user to do anything once the IUD is inserted
94
Correcting Misunderstandings

 Intrauterine devices:
o Rarely lead to PID.
o Do not increase the risk of contracting STIs, including HIV.
o Do not increase the risk of miscarriage when a woman becomes
pregnant after the IUD is removed.
o Do not make women infertile.
o Do not cause birth defects.
o Do not cause cancer.
o Do not move to the heart or brain.
o Do not cause discomfort or pain for the woman during sex.
o Substantially reduce the risk of ectopic pregnancy.
b) Levonorgestrel
Intrauterine Device What Is the
Levonorgestrel Intrauterine Device?
 The levonorgestrel intrauterine device (LNG-IUD) is a T-shaped plastic
device that steadily releases small amounts of levonorgestrel each
day. (Levonorgestrel is a progestin widely used in implants and oral
contraceptive pills.)

 A specifically trained health care provider inserts it into a woman’s

uterus through her vagina and cervix. Also called the levonorgestrel-

95
releasing intrauterine system, LNG-IUS, or Hormonal IUD.

96
  Marketed under the brand name Mirena.

How it works

An IUCD coated with progestin works in a similar way as the copper coated one,
but also works by;

 Works primarily by suppressing the growth of the lining of uterus

(endometrium), thins the uterine lining.
 Thickens the uterine mucus thus preventing sperm from meeting the egg.
 Can also stops the release of egg form the ovary (ovulation) during
the monthly period. This prevents the sperm from fertilizing the egg
and implanting.

How Effective?

 One of the most effective and long-lasting methods:

 Less than 1 pregnancy per 100 women using an LNG-IUD over the first
year (2 per 1,000 women). This means that 998 of every 1,000 women
using LNG-IUDs will not become pregnant.
 A small risk of pregnancy remains beyond the first year of use and
continues as long as the woman is using the LNG-IUD.
 Over 5 years of LNG-IUD use: Less than 1 pregnancy per
 100 women (5 to 8 per 1,000 women).
 Approved for up to 5 years of use.
 Return of fertility after LNG-IUD is removed: No delay
 Protection against sexually transmitted infections (STIs): None

Side Effects

 Some users report the following:

Changes in bleeding patterns, including:
 Lighter bleeding and fewer days of bleeding
 Infrequent bleeding
 Irregular bleeding

97
  No monthly bleeding
 Prolonged
bleeding Acne
Headaches
Breast tenderness or pain
Nausea
Weight gain
Dizziness
Mood changes
Other possible physical changes:
 Ovarian cysts

Known health benefits

 Helps protect against:

 Risks of pregnancy
 Iron-deficiency anemia
 May help protect against:
 Pelvic inflammatory disease
 Reduces:
 Menstrual cramps
 Symptoms of endometriosis (pelvic pain, irregular bleeding)

Complications

 Rare:
 Puncturing (perforation) of the wall of the uterus by the LNG-IUD
or an instrument used for insertion. Usually heals without
treatment.
 Very rare:
 Miscarriage, preterm birth, or infection in the very rare case
that the woman becomes pregnant with the LNG-IUD in place.

98
PERMANENT METHODS OF FAMILY PLANNING
These are methods that are intended to provide lifelong, permanent and very
effective protection against pregnancy. Reversal is usually impossible.

a) FEMALE STERILIZATION
What Is Female
Sterilization?
 Permanent contraception for women who will not want more children.
 The 2 surgical approaches most often used:
o Minilaparotomy: This involves making a small incision in the
abdomen. The fallopian tubes are brought to the incision to be
cut or blocked.
o Laparoscopy involves inserting a long thin tube with a lens in it
into the abdomen through a small incision. This laparoscope
enables the doctor to see and block or cut the fallopian tubes in
the abdomen.
 Also called tubal sterilization, tubal ligation, voluntary surgical
contraception, tubectomy, bi-tubal ligation, tying the tubes, minilap,
and “the operation.”
 Works because the fallopian tubes are blocked or cut. Eggs released
from the ovaries cannot move down the tubes, and so they do not
meet sperm.

How Effective?

 One of the most effective methods but carries a small risk of failure:
 Less than 1 pregnancy per 100 women over the first year after
having the sterilization procedure (5 per 1,000). This means that
995 of every 1,000 women relying on female sterilization will not
become pregnant.
 A small risk of pregnancy remains beyond the first year of use and until
the woman reaches menopause.
 Over 10 years of use:
 About 2 pregnancies per 100 women (18 to 19 per 1,000 women).
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  Effectiveness varies slightly depending on how the tubes are blocked,
but pregnancy rates are low with all techniques. One of the most
effective techniques is cutting and tying the cut ends of the fallopian
tubes after childbirth (postpartum tubal ligation).
o Fertility does not return because sterilization generally cannot be
stopped or reversed. The procedure is intended to be permanent.
Reversal surgery is difficult, expensive, and not available in most
areas. When performed, reversal surgery often does not lead to
pregnancy
o Protection against sexually transmitted infections (STIs): None

Side effects

 None

Known health benefits

 Helps protect against:

 Risks of pregnancy
 Pelvic inflammatory disease (PID)
 May help protect against:
 Ovarian cancer

Known health risk

 Uncommon to extremely rare:

 Complications of surgery and anesthesia

Complications of Surgery

 Uncommon to extremely rare:

 Female sterilization is a safe method of contraception. It requires
surgery and anesthesia, however, which carry some risks such as
infection or abscess of the wound. Serious complications are
uncommon. Death, due to the procedure or anesthesia, is
extremely rare.
 The risk of complications with local anesthesia is significantly lower
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 than with general anesthesia. Complications can be kept to a minimum
if appropriate techniques are used and if the procedure is performed in
an appropriate setting.

Correcting Misunderstandings
 Female sterilization:
Does not make women weak.
Does not cause lasting pain in back, uterus, or abdomen.
Does not remove a woman’s uterus or lead to a need to have it
removed. Does not cause hormonal imbalances.
Does not cause heavier bleeding or irregular bleeding or otherwise change
women’s menstrual cycles.
Does not cause any changes in weight, appetite, or
appearance. Does not change women’s sexual behavior or
sex drive.
Substantially reduces the risk of ectopic pregnancy.

Who Can Have Female

Sterilization? Safe for All
Women
 With proper counseling and informed consent, any woman can have
female sterilization safely, including women who:
 Have no children or few children
 Are not married
 Do not have husband’s permission
 Are young
 Just gave birth (within the last 7 days)
 Are breastfeeding
 Are infected with HIV, whether or not on antiretroviral therapy
 In some of these situations, especially, careful counseling is important
to make sure the woman will not regret her decision

Women can have female sterilization:

 Without any blood tests or routine laboratory tests

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  Without cervical cancer screening
 Even when a woman is not having monthly bleeding at the time, if it is
reasonably certain she is not pregnant
Why some women say they like female sterilization

 Has no side effects

 No need to worry about contraception again
 Is easy to use, nothing to do or remember.
b) VASECTOMY
What Is
Vasectomy?
 Permanent contraception for men who will not want more children.
 Through a puncture or small incision in the scrotum, the provider
locates each of the 2 tubes that carries sperm to the penis (vas
deferens) and cuts or blocks it by cutting and tying it closed or by
applying heat or electricity (cautery).
 Also called male sterilization and male surgical contraception.
 Works by closing off each vas deferens, keeping sperm out of semen.
 Semen is ejaculated, but it cannot cause pregnancy.

How Effective?

One of the most effective methods but carries a small risk of failure:

 Where men cannot have their semen examined 3 months after the
procedure to see if it still contains sperm, pregnancy rates are about 2
to 3 per 100 women over the first year after their partners have had a
vasectomy. This means that 97 to 98 of every 100 women whose
partners have had vasectomies will not become pregnant.
 Where men can have their semen examined after vasectomy, less than
1 pregnancy per 100 women over the first year after their partners
have had vasectomies (2 per 1,000). This means that 998 of every
1,000 women whose partners have had vasectomies will not become
pregnant.
 Vasectomy is not fully effective for 3 months after the procedure.
 Some pregnancies occur within the first year because the couple

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 does not use condoms or another effective method consistently
and correctly in the first 3 months, before the vasectomy is fully
effective.
 A small risk of pregnancy remains beyond the first year after the
vasectomy and until the man’s partner reaches menopause.
 Over 3 years of use: About 4 pregnancies per 100 women
 If the partner of a man who has had a vasectomy becomes pregnant, it may be
because:
 The couple did not always use another method during the first 3
months after the procedure
 The provider made a mistake
 The cut ends of the vas deferens grew back together
 Fertility does not return because vasectomy generally cannot be
stopped or reversed. The procedure is intended to be permanent.
Reversal surgery is difficult, expensive, and not available in most
areas. When performed, reversal surgery often does not lead to
pregnancy.
 Protection against sexually transmitted infections (STIs): None

Side effects, known health risk and health risk

 None

Complications

 Uncommon to rare:
 Severe scrotal or testicular pain that lasts for months or years.
 Uncommon to very rare:
 Infection at the incision site or inside the incision (uncommon
with conventional incision technique; very rare with no-scalpel
technique)
 Rare:
 Bleeding under the skin that may cause swelling or bruising (hematoma).

Correcting Misunderstandings

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  Vasectomy:
Does not remove the testicles. In vasectomy the tubes carrying sperm
from the testicles are blocked. The testicles remain in place.
Does not decrease sex drive.
Does not affect sexual function. A man’s erection is as hard, it lasts as long,
and he ejaculates the same as before.
Does not cause a man to grow fat or become weak, less masculine, or
less productive.
Does not cause any diseases later in life.
Does not prevent transmission of sexually transmitted infections, including HIV.

Who Can Have a

Vasectomy? Safe for All
Men
 With proper counseling and informed consent, any man can have a
vasectomy safely, including men who:
o Have no children or few children
o Are not married
o Do not have wife’s permission
o Are young
o Have sickle cell disease
o Are at high risk of infection with HIV or another STI
o Are infected with HIV, whether or not on antiretroviral therapy.
 In some of these situations, especially careful counseling is important
to make sure the man will not regret his decision.
o Men can have a vasectomy:
o Without any blood tests or routine laboratory tests
o Without a blood pressure check
o Without a hemoglobin test
o Without a cholesterol or liver function check
o Even if the semen cannot be examined by microscope later to
see if still contains sperm.

Why some men say they like vasectomy?

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  Is safe, permanent, and convenient
 Has fewer side effects and complications than many methods for women
 The man takes responsibility for contraception. That is, takes burden off the
woman
 Increases enjoyment and frequency of sex

NATURAL FAMILY PLANNING METHODS

a) Fertility
awareness methods What
Are Fertility Awareness
Methods?
 “Fertility awareness” means that a woman knows how to tell when the
fertile time of her menstrual cycle starts and ends. (The fertile time is
when she can become pregnant.)
 Sometimes called periodic abstinence or natural family planning.
 A woman can use several ways, alone or in combination, to tell when
her fertile time begins and ends.
 Calendar-based methods involve keeping track of days of the
menstrual cycle to identify the start and end of the fertile time. For
example, Standard Days Method, which avoids unprotected vaginal sex
on days 8 through 19 of the menstrual cycle, and calendar rhythm
method.
 Symptoms-based methods depend on observing signs of fertility.
o Cervical secretions: When a woman sees or feels cervical
secretions, she may be fertile. She may feel just a little vaginal
wetness.
o Basal body temperature (BBT): A woman’s resting body
temperature goes up slightly after the release of an egg
(ovulation). She is not likely to become pregnant from 3 days
after this temperature rise through the start of her next monthly
bleeding. Her temperature stays higher until the beginning of her
next monthly bleeding.
o Examples: Two Day Method, BBT method, ovulation method (also
known as Billing’s method or cervical mucus method), and
symptothermal method.
 Work primarily by helping a woman know when she could become
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 pregnant. The couple prevents pregnancy by avoiding unprotected
vaginal sex during these fertile days, usually by abstaining or by using
condoms or a diaphragm. Some couples use spermicides or
withdrawal, but these are among the least effective methods.
How Effective?

 Effectiveness depends on the user: Risk of pregnancy is greatest when

couples have sex on the fertile days without using another method.
 As commonly used, in the first year about 15 pregnancies per 100
women using periodic abstinence. This means that 85 of every 100
women relying on periodic abstinence will not become pregnant.
 Pregnancy rates with consistent and correct use vary for different
types of fertility awareness methods.
 In general, abstaining during fertile times is more effective than using
another method during fertile times.
 Return of fertility after fertility awareness methods are stopped: No delay
 Protection against sexually transmitted infections (STIs): None

Why some women say they like fertility awareness methods

 Have no side effects

 Do not require procedures and usually do not require supplies
 Help women learn about their bodies and fertility
 Allow some couples to adhere to their religious or cultural
norms about contraception
 Can be used to identify fertile days by both women who want to
become pregnant and women who want to avoid pregnancy

Explaining how to use Calendar-based Methods

Standard Days Method

Important point: A woman can use standard days method if most of her
menstrual cycles are 26 to 32 days long. If she has more than 2 longer or
shorter cycles within a year, the standard days method will be less effective
and she may want to choose another method.
A woman keeps track of the days of

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Keep track of the days of the menstrualher menstrual cycle, counting the first
cycle day of
monthly bleeding as day 1.
Avoid unprotected sex on days 8–19 Days 8 through 19 of every cycle are
considered fertile days for all users of
the Standard Days Method.
The couple avoids vaginal sex or uses
condoms or a diaphragm during days 8
through
19. They can also use withdrawal or
spermicides, but these are less
effective.
The couple can have unprotected sex
on all the other days of the cycle—
days 1 through 7 at the beginning of
the cycle and from day 20
until her next monthly bleeding begins.

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 Use memory aids if needed The couple can use Cycle Beads, a
color-coded string of beads that
indicates fertile and nonfertile
days of a cycle (see diagram
below), or they can mark a
calendar or use some other
memory aid.

Cycle beads

A colour coded string of beads that indicates fertile and nonfertile days of a cycle.

 Each bead represents a day of the menstrual cycle

 On day 1: the first day of the monthly period. move the rubber ring to the red
bead
 The next day, move the ring to the next bead. Do this every day, even bleeding
days.
 White bead days are days when the woman can become pregnant.
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She should avoid unprotected sex.

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  Brown bead days are days when pregnancy is unlikely and she can have
unprotected sex.
 If monthly bleeding begins again before reaching the dark brown bead,
her menstrual cycle is shorter than 26 days.
 If monthly bleeding does not begin before reaching the last brown
bead, her menstrual cycle is longer than 32 days.

Calendar Rhythm Method

Keep track of the days of

theBefore relying on this method, a
menstrual cycle woman records the number of days
in each menstrual cycle for at least
6 months. The first day of
monthly bleeding is always counted as
day 1.
Estimate the fertile time The woman subtracts 18 from the
length of her shortest recorded cycle.
This tells her the estimated first day
of her fertile time. Then she subtracts
11 days from the length of her
longest recorded cycle. This tells her
the estimated last
day of her fertile time.
Avoid unprotected sex during fertileThe couple avoids vaginal sex, or
time uses condoms or a diaphragm, during
the fertile time. They can also use
withdrawal or
spermicides, but these are less
effective.

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Update calculations monthly She updates these calculations each
month, always using the 6 most
recent cycles.
Example:
If the shortest of her last 6 cycles was
27 days, 27–18 = 9. She starts
avoiding unprotected sex on day 9.
If the longest of her last 6 cycles was
31 days,
31–11=20. She can have unprotected
sex again on day 21.

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 Thus, she must avoid unprotected sex
from day
9 through day 20 of her cycle.

Who can use symptom-based methods?

 All women can use symptoms-based methods. That is, no medical

conditions prevent the use of these methods. However, some
conditions can make them harder to use effectively.
o Caution means that additional or special counseling may be needed
to ensure correct use of the method.
o Delay means that use of a particular fertility awareness method
should be delayed until the condition is evaluated or corrected. Give
the client another method to use until she can start the symptoms-
based method.
 In the following situations, use caution with symptoms-based methods:
 Recently had an abortion or miscarriage
 Menstrual cycles have just started or have become less frequent
or stopped due to older age. (Menstrual cycle irregularities are

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common in young women in the first

113
several years after their first monthly bleeding and in older women who are
approaching menopause. Identifying the fertile time may be difficult)
 A chronic condition that raises her body temperature (for basal
body temperature and symptothermal methods)
 In the following situations, delay starting symptoms-based methods:
 Recently gave birth or is breastfeeding. (Delay until normal
secretions have returned—usually at least 6 months after
childbirth for breastfeeding women and at least 4 weeks after
childbirth for women who are not breastfeeding. For several
months after regular cycles have returned, use with caution.)
 An acute condition that raises her body temperature (for basal
body temperature and symptothermal methods)
 Irregular vaginal bleeding
 Abnormal vaginal discharge
 In the following situation, delay or use caution with symptoms-based methods:
 Taking any drugs that change cervical secretions, for example,
antihistamines, or drugs that raise body temperature, for
example, antibiotics.

Explaining how to use Symptom-based methods

Two-day methods

IMPORTANT: If a woman has a vaginal infection or another condition that

changes cervical
mucus, the Two-day Method will be difficult to use.

Check for secretion The woman checks for cervical

secretions every afternoon and/or
evening, on fingers, underwear, or
tissue paper or by sensation in or
around the vagina.

As soon as she notices any secretions

of any type, color, or consistency,
she considers
herself fertile that day and the

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following day.

115
 Avoid sex or use another method The couple avoids vaginal sex or uses
on fertile days condoms or a diaphragm on each day
with secretions and on each day
following a day with secretions. They
can also use withdrawal
or spermicides, but these are less
effective.
Resume unprotected sex after 2 dryThe couple can have unprotected
days sex again after the woman has had
2 dry days (days
without secretions of any type) in a
row.

Basal Body Temperature (BBT) Method

IMPORTANT: If a woman has a fever or other changes in body

temperature, the BBT method
will be difficult to use.
Take body temperature daily
The woman takes her body
temperature at the same time each
morning before she gets out of bed
and before she eats anything. She
records her temperature on a
special graph.

She watches for her temperature to

116
rise slightly, that is, 0.2° to 0.5°C
(0.4° to 1.0°F), just after ovulation
(usually about midway
through the menstrual cycle).

117
Avoid sex or use another method The couple avoids vaginal sex, or
until 3 days after the temperature uses condoms or a diaphragm from
rise the first day of monthly bleeding
until 3 days after the woman’s
temperature has risen above her
regular temperature.
They can also use withdrawal or
spermicides, but these are less
effective.

Resume unprotected sex until next When the woman’s temperature has
monthly bleeding begins risen above her regular temperature
and stayed higher for 3 full days,
ovulation has occurred and the
fertile period has passed.

The couple can have unprotected sex

on the 4th
day and until her next monthly
bleeding begins.

Ovulation Method

IMPORTANT: If a woman has a vaginal infection or another condition that

changes cervical mucus, this method may be difficult to use.

The woman checks every day for

Check cervical secretions daily any cervical secretions on fingers,
underwear, or tissue paper or by
sensation in or around the vagina

Avoid unprotected sex on days of Ovulation might occur early in the

heavy monthly bleeding cycle, during the last days of monthly
bleeding.
Heavy bleeding could make mucus
difficult to observe.
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Resume unprotected sex until Between the end of monthly
secretions begin bleeding and the start of secretions,
the couple can have unprotected
sex, but not on 2 days in a row.
(Avoiding sex on the second day
allows time for semen to disappear
and for cervical mucus to be
observed.)

It is recommended that they have

sex in the evenings, after the
woman has been in an upright
position for at least a few hours and
has
been able to check for cervical
mucus.

Avoid unprotected sex when As soon as she notices any

secretions begin and until 4 days secretions, she considers herself
after “peak day” fertile and avoids unprotected sex.

She continues to check her cervical

secretions each day. The secretions
have a “peak day”— the last day
that they are clear, slippery,
stretchy, and wet. She will know this
has passed when, on the next day,
her secretions are sticky or dry, or
she has no secretions at all.
She continues to consider herself
fertile for 3 days after that peak day
and avoids unprotected sex.

The couple can have unprotected

Resume unprotected sex sex on the 4th day after her peak
day and until her next monthly
bleeding begins.

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Symptothermal Method (Basal Body Temperature + Cervical Secretion
+ Other Fertility Methods)

120
Avoid unprotected sex on fertile days Users identify fertile and non fertile
days by combining BBT and
ovulation method instructions.

Women may also identify the fertile

time by other signs such as breast
tenderness and ovulatory pain
(lower abdominal pain or cramping
around the time of ovulation).

The couple avoids unprotected sex

between the first day of monthly
bleeding and either the fourth day
after peak cervical secretions or the
third full day after the rise in
temperature (BBT), whichever
happens later.

Some women who use this method

have unprotected sex between the
end of monthly bleeding and the
beginning of secretions, but
not on 2 days in a row.

How can a partner help?

 The client’s partner is welcome to participate in counseling and learn

about the method and what support he can give to his partner. A male
partner can:
 Support a woman’s choice of a fertility awareness method
 Discuss and agree to use a fertility awareness method with a full
understanding of how to use it
 Share responsibility for keeping track of cycles and knowing
when is the fertile period
 Not insist on sex without contraception during the fertile period
 Agree in advance how to avoid pregnancy if they are going to
have sex in the fertile period (for example, use of another
method)
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  Help to make sure she has ECPs on hand in case they have
unprotected sex during the fertile period
 Use condoms consistently in addition to a fertility awareness
method if he has an STI/HIV or thinks he may be at risk of an
STI/HIV
b) WITHDRA
WLL Withdrawal
 Just before ejaculation, the man withdraws his penis from his partner’s
vagina and ejaculates outside the vagina, keeping his semen away
from her external genitalia.

 Also known as coitus interruptus and “pulling out.”

 Works by keeping sperm out of the woman’s body.

How Effective?

 Effectiveness depends on the user: Risk of pregnancy is greatest when

the man does not withdraw his penis from the vagina before he
ejaculates with every act of sex.
 One of the least effective methods, as commonly used.
 As commonly used, about 20 pregnancies per 100 women whose
partners use withdrawal over the first year. This means that 80 of
every 100 women whose partners use withdrawal will not become
pregnant.

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  When used correctly with every act of sex, about 4 pregnancies per
100 women whose partners use withdrawal over the first year.
 Return of fertility after use of withdrawal is stopped: No delay
 Protection against sexually transmitted infections: None

Side Effects, Health Benefits, and Health Risks

 None

Who Can and Cannot Use Withdrawal?

 All men can use withdrawal. No medical conditions prevent its use.
 Withdrawal may be especially appropriate for couples who:
 have no other method available at the time
 are waiting to start another method
 have sex infrequently
 have objections to using other method

Using Withdrawal

 Can be used at any time.

 Effectiveness depends on the willingness and ability of the couple to
use withdrawal with every act of intercourse.

Explaining How to Use

When the man feels close to He should withdraw his penis from
ejaculating the woman’s vagina and ejaculate
outside the vagina, keeping his
semen away from her
external genitalia.
Before sex he should urinate and
If the man has ejaculated recently wipe the tip of his penis to remove
any semen remaining.

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 c) LACTATION AMENORRHEA METHOD
What Is the Lactational Amenorrhea Method?

 A temporary family planning method based on the natural effect of

breastfeeding on fertility. (“Lactational” means related to
breastfeeding. “Amenorrhea” means not having monthly bleeding.)
 The lactational amenorrhea method (LAM) requires 3 conditions and All
the 3 must be met:
 The mother’s monthly bleeding has not returned.
 The baby is fully or nearly fully breastfed and is fed often, day and night.
 The baby is less than 6 months old.
 “Fully breastfeeding” includes both exclusive breastfeeding (the infant
receives no other liquid or food, not even water, in addition to breast
milk) and almost-exclusive breastfeeding (the infant receives vitamins,
water, juice, or other nutrients once in a while in addition to breast
milk).
 “Nearly fully breastfeeding” means that the infant receives some liquid
or food in addition to breast milk, but the majority of feedings (more
than three-fourths of all feeds) are breast milk.
 Works primarily by preventing the release of eggs from the ovaries
(ovulation). Frequent breastfeeding temporarily prevents the release of
the natural hormones that cause ovulation.

How Effective?

 Effectiveness depends on the user: Risk of pregnancy is greatest when

a woman cannot fully or nearly fully breastfeed her infant.
 As commonly used, about 2 pregnancies per 100 women using LAM in
the first 6 months after childbirth. This means that 98 of every 100
women relying on LAM will not become pregnant.
 When used correctly, less than 1 pregnancy per 100 women using LAM
in the first 6 months after childbirth.
 Return of fertility after LAM is stopped: Depends on how much the
woman continues to breastfeed
 Protection against sexually transmitted infections: None

Side Effects

 None. Any problems are the same as for other breastfeeding women.
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Known Health Benefits

 Helps protect against:

 Risks of pregnancy
 Encourages:
 The best breastfeeding patterns, with health benefits for both mother and
baby

Who Can Use the Lactational Amenorrhea Method?

 Medical Eligibility Criteria for the Lactation Amenorrhea Methods

 All breastfeeding women can safely use LAM, but a woman in the
following circumstances may want to consider other contraceptive
methods:
 Has HIV infection
 Is using certain medications during breastfeeding (including
mood-altering drugs, reserpine, ergotamine, anti-metabolites,
cyclosporine, high doses of corticosteroids, bromocriptine,
radioactive drugs, lithium, and certain anticoagulants)
 The newborn has a condition that makes it difficult to breastfeed
(including being small-for-date or premature and needing
intensive neonatal care, unable to digest food normally, or
having deformities of the mouth, jaw, or palate)

Lactation Amenorrhea Method for Women with HIV

 Women who are living with HIV can use LAM. Breastfeeding will not
make their condition worse. However, there is a chance that mothers
living with HIV, if they are not taking antiretroviral therapy (ART), will
transmit HIV to their infants through breastfeeding.
 Women taking ART can use LAM. Giving ART to an HIV-infected mother
or an HIV- exposed infant very significantly reduces the risk of HIV
transmission through breastfeeding. Among women who are not taking
ART, 14% of their babies will be infected after 2 years of breastfeeding.
Among women taking ART, less than 1% of their babies will be
infected.
 Exclusive breastfeeding reduces the risk of death from common
childhood illness and improves the health and development of the

125
 child and also the health of the mother.
 If national policy supports breastfeeding by women with HIV, they
should receive the appropriate ART interventions and should
exclusively breastfeed their infants for the first 6 months of life,
introduce appropriate complementary foods at 6 months, and continue
breastfeeding for the first 12 months. Breastfeeding should then stop
only once a nutritionally adequate and safe diet without breast milk
can be provided.
 Urge women with HIV to use condoms along with LAM. Used
consistently and correctly, condoms help prevent transmission of HIV
and other STIs.

126
  At 6 months or earlier if her monthly bleeding has returned or she
stops exclusive breastfeeding, a woman should begin to use another
contraceptive method in place of LAM.

Why some say they like LAM

o It is a natural family planning method

o It supports optimal breastfeeding, providing health benefits for the baby and the
mother
o It has no direct cost for family planning or for feeding the baby

Explaining how to use LAM

Breastfeed often An ideal pattern is feeding on

demand (that is, whenever the
baby wants to be fed) and at least

10 to 12 times a day in the first few

weeks after childbirth and
thereafter 8 to 10 times a day,
including at least once at night
in the first months.

Daytime feedings should be no

more than 4 hours apart, and night-
time feedings no more than 6 hours
apart.
Some babies may not want to
breastfeed 8 to 10 times a day and
may want to sleep through the
night. These babies may need
gentle encouragement to
breastfeed more often.
Start other foods at 6 months
She should start giving other foods
in addition to breast milk when the
127
baby is 6 months old.
At this age, breast milk can no
longer fully nourish a growing
baby.

128
 Plan follow-up visit Plan for the next visit while the LAM
criteria still apply, so that she can
choose another method and
continue to be protected from
pregnancy.

If possible, give her condoms or

progestin- only pills now. She can
start to use them if the baby is no
longer fully or nearly fully
breastfeeding, if her monthly
bleeding returns, or if the baby
reaches 6 months of age before she
can come back for another method.
Plan for a follow-on method. Give
her any supplies now.

d) ABSTINE
NE What is
abstinence?
 Abstinence is simply not having sexual intercourse. If you’re
abstinent, it means you’ve decided not to have sex - this includes
vaginal, oral and anal sex.
 Abstinence prevents pregnancy by not giving the opportunity for
semen to enter the vagina. A sperm can’t fertilize an egg if you don’t
have intercourse

How Effective?

 Effectiveness depends on the user: Abstinence is the only form of birth

control that is 100% effective in preventing pregnancy
 Practicing abstinence ensures that a woman Will not become pregnant
because there is no opportunity for a sperm to fertilize an egg
 Return of fertility after abstinence is stopped: Immediately.
 Protection against sexually transmitted infections: Yes

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Advantages

 It is free.
 It is endorsed by many religious groups.
 It is 100% effective in preventing pregnancy.
 No medical or hormonal side effects.
 It encourages you to build your relationship and express intimacy in other ways.
 It does protect you from sexually transmitted infections, including
HIV/AIDS, if there is no oral, anal or vaginal contact of any kind

Disadvantage

 Both you and your partner must be committed to not having intercourse.
 You might change your mind in the "heat of the moment," and not
have alternative birth control on hand.
 Pregnancy is still possible even without penetration if semen is on or near the
vagina.
 Other sexual activity such as oral sex can expose you to STIs

Side effects

 None

Known health benefits

 Helps protects against:

 STIs or HIV
 Risk of pregnancy

Health risk

 None

Cautions and Things to Consider when Practicing Abstinence

 Abstinence is the safest way to avoid getting an STI or HIV.

 To practice abstinence effectively and consistently you need to:
 Set your own limits and feel good about your decision.

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  Believe that having sex is not something to do because everyone is doing
it.
 Want to uphold your personal, religious or moral beliefs.
 Accept that you can enjoy intimacy in a variety of other ways.
 Handling Pressure
 Simply not having sex might sound easy, but pressure from your
partner, peers and the media can make this decision very
difficult. Do not let teasing or pressure from family, friends, or
your partner make you do something you do not want to do.
 Doing what is right for you is what is important. There are other ways to
be intimate and you should never feel bad about saying no to
intercourse.
 Talking to Your Partner About Your Decision
 Abstinence may be difficult for some couples to maintain. It’s
important that your partner realizes what abstinence means to
you, especially if you’re entering a new relationship. He or she
needs to know about your decision - and support it - before
sexual situations arise.
 Any couple can still have a positive and loving relationship
without having sexual intercourse. Give your partner examples of
ways of expressing sexual desire that you are comfortable with
such as kissing or fondling.
 Remember: abstinence is a valid choice. So, respect the
decisions you and your partner have made. Learn ways to
communicate with your partner about this and other issues in your
relationship and discuss ways to enjoy your abstinence.
 Have Back Up Protection on Hand
 Plan ahead so that you and your partner know your sexual limits
before you get into a sexual situation.

FAMILY PLANNING COUNSELING

The main goal of family planning counseling is to improve the quality of life
and reproductive health by empowering individuals and couples to excise
their right to safe sexuality, and to decide whether and when to have
children and how many to have. This goal is to provide opportunities for
people, their circumstances, needs and options to help clients make
informed decisions about contraception, fertility and sexual health.

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 During counseling, the following should form the context of counseling;

 Bridge knowledge gap:

o Provide brief information on the anatomy and physiology of
reproductive health to clients
o Explain about the contraceptive technology; that is, the benefits,
risks, effectiveness and mode of actions (how the FP method
works) for all available family planning methods
o Myths and beliefs should be told.
 Help client make informed choice
o Consider that women may be unprepared to make their own
[Link] clients to take responsibility for decision-making
o Give complete information about the method chosen by the client.
 Provide services
o Record should be kept for a client
o Give family planning services
o Should schedule follow-up

The GATHER steps

 G -Greet clients in an open, respectful manner. Assure the client of

confidentiality. Give as much time in listening than talking.
 A -Ask clients about themselves. Help client talk about their family
planning practices, intentions, concerns and wishes.
 T -Tell client about choices. depending on the clients need, tell the
client what reproductive health choices she/he might take. Focus on
methods that interest the client. Also explain other services that the
client may want
 H -Help client makes an informed choice. Help the client think about
options. Encourage the client to express opinions and ask questions.
Consider medical eligibility for the family planning method that interest
the client. In the end, make sure that the client has made clear
decision.
 E -Explain fully how to use the chosen method; after a client chooses a
family planning method, give her or him the supplies if appropriate.
Encourage questions, and answer them openly and fully. Give condoms
to any one at risk for sexually transmitted diseases (STDs) and
encourage using condoms along with any other family planning
method. Check that the clients understand how to use their methods.
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  R- Return visits should be welcomed: Discuss and agree when the
client will return for follow-up or for more supplies if needed. Always
invite the client to return any time for any reason.

Why Counseling is Crucial in Family Planning

o Counseling help clients make and carry out their own choices about
reproductive health and family planning
o Counseling helps to make clients more satisfied with family planning methods
o Counseling also helps to make clients to use family planning methods
longer and more successfully.

NB: Counseling should be tailored according to the need of each client. At

the same time, most counseling about method choice should cover the
following six topics;

 Effectiveness
 Advantage and disadvantage
 Side effects and complications
 How to use
 STI prevention
 When to return

Tips for Successful Counseling

 Show every client respect, and help each client feel at ease.
 Encourage the client to explain needs, express concerns, ask questions.
 Let the client’s wishes and needs guide the discussion.
 Be alert to related needs such as protection from sexually transmitted
infections including HIV, and support for condom use.
 Talk with the client in a private place, where no one else can hear.
 Assure the client of confidentiality, that you will not tell others about
your conversation or the client’s decisions.
 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.
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  Bring up side effects, if any, and take the client’s concerns seriously.
 Check the client’s understanding.
 Invite the client to come back any time for any reason.

Reasons for not using contraceptives

 Concerns with contraceptive side effects

 Religious and other opposition to family planning
 Fertility-related reasons, mainly desire for more children
 Opposition to use
 Lack of knowledge
 Method-related reason

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UNIT 4: SEXUALLY TRANSMITTED INFECTIONS

Objectives

By the end of this section, the learner should be able to;

o List the principal causes of sexually

transmitted infections
o Classifications of STIs
o State the risk factors for STIs acquisition
and transmission
o Underscore the syndromic approach in STIs
management
o Outline the public health significance of STIs
o Understand STIs control strategies and obstacles.
o Explain the effects of sexually transmitted infections

Introduction

Reproductive tract infections (RTIs) are infections of the genital tract of

women and men. There are three types of RTIs:
a) Sexually transmitted infections (STIs)

Infections caused by viral, bacterial and parasitic microorganisms that are

passed through sexual activity with an infected partner. however, other
modes of transmission may include mother-to- child during pregnancy and
childbirth, blood transfusion or other contact with blood and blood products.
More than 40 have been identified, including Chlamydia, gonorrhea, hepatitis
B and C, herpes, HPV, syphilis, trichomoniasis, and HIV.

b) Endogenous infections

Infections that result from an overgrowth of organisms normally present in

the vagina. These infections are not usually sexually transmitted, and include
bacterial vaginosis and candidiasis.
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 c) Iatrogenic infections

Infections introduced into the reproductive tract by a medical procedure such

as menstrual regulation, induced abortion, IUD insertion, or childbirth. This
can happen if surgical instruments used in the procedure are not properly
sterilized, or if an infection already present in the lower reproductive tract is
pushed through the cervix into the upper reproductive tract.

These three types of RTIs overlap and should be considered together. For
example, some STIs, like gonorrhea or Chlamydia, can be spread in the
reproductive tract if not treated prior to a procedure. In addition, some non-
sexual infections, such as candidiasis, can be passed on through sexual
activity. Not all STIs are RTIs; and not all RTIs are sexually transmitted; STI
refers to the way of transmission whereas RTI refers to the site where the
infections develop.

PRINCIPLE CAUSES OF SEXUALLY TRANSMITTED INFECTIONS

Chlamydia

The organism Chlamydia trachomatis causes inflammation of the female

cervix. Infection may ascend through the reproductive tract and cause pelvic
inflammatory disease.

In the male, it may cause urethritis, which may also ascend and lead to
epididymitis. Chlamydia infection is often present in conjunction with other
sexually transmitted diseases. The same organism causes trachoma, an eye
infection that is the primary cause of blindness worldwide.

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Gonorrhea

This is caused by Neisseria gonorrhoeae, which infects the mucosa of the

reproductive and urinary tracts. In the male, suppurative urethritis occurs
and the infection may spread to the prostate gland, epididymis and testes. In
the female the infection may spread from vulvar glands, vagina and cervix to
the body of the uterus, uterine tubes, ovaries and peritoneum. Healing by
fibrosis in the female may cause obstruction of the uterine tubes, leading to
infertility. In the male it may cause urethral stricture.

Syphilis

This disease is caused by Treponema pallidum. There are three clearly

marked stages. After an incubation period of several weeks, the primary sore
(chancre) appears at the site of infection, e.g., the vulva, vagina, perineum,
penis or round the mouth. In the female the primary sore may be undetected
if it is internal. After several weeks, the chancre subsides
spontaneously. The secondary stage, 3 to 4 months after infection, involves
systemic symptoms including lymphadenopathy, skin rashes and mucosal
ulceration of the mouth and genital tract. There may then be a latent period
of between 3 and 10 years. Tertiary lesions (gummas) then develop in many
organs, including skin, bone and mucous membranes, and may involve the
nervous system, leading to general paralysis and dementia.

Sexual transmission occurs during the primary and secondary stages when
discharge from lesions is highly infectious. Congenital transmission from
mother to fetus carries a high risk of stillbirth.

Trichomonas vaginalis

These protozoa cause acute vulvovaginitis with irritating, offensive

discharge. It is usually sexually transmitted and is commonly present in
women with gonorrhoea. Males are often asymptomatic.

Candidiasis

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 The yeast Candida albicans is frequently a commensal in the normal vagina
and causes no problems. It is normally prevented from flourishing by vaginal
acidity, but in certain circumstances it proliferates, causing candidiasis
(thrush).

Common precipitating factors include:

o Antibiotic therapy, which kills the bacteria that keep vaginal pH low
(Lactobacteria)
o Pregnancy
o Reduced immune function
o Diabetes mellitus.

In women, persistent itch is the main symptom, with discharge, swelling and
erythema of the vulvar area.

Acquired immune deficiency syndrome (AIDS) and hepatitis B infection

These viral conditions may be sexually transmitted, but there are no local
signs of infection. For a description of AIDS and HIV and hepatitis B.

A. Non-specific genital infection

This is increasingly common, especially in males. General symptoms include

painful urination and urethral discharge, and there is a wide range of
possible causative organisms. Some cases are not sexually transmitted and
arise from, for example, urinary tract infection or the presence of a foreign
body in the urethra.
Genital herpes

One form of the herpes virus, Herpes simplex 2 (HSV2) is associated with
genital infections. Initial infection tends to present as clusters of small,
painful ulcers on the external genitalia. There is often fever and headache.
Recurrences of the disease occur because the virus establishes itself within
the dorsal root ganglion, from where it can be reactivated from time to time.

DISEASES OF THE FEMALE REPRODUCTIVE SYSTEM

Objectives:

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 By the end of this section, the learner should be able to;

I. Describe the causes and consequences of pelvic

inflammatory diseases (PID).
II. Discuss the disorders of the vulva
III. Define the term imperforate hymen
IV. Outline the causes and effects of cervical cancer
V. Discuss the main pathologies of the uterus
and uterine tube
VI. Describe the causes and effects of ovarian
disease
VII. Describe the causes of female infertility
VIII. Discuss the principal disorders of the female breast
Pelvic inflammatory disease (PID)

This condition is usually a consequence of sexually transmitted infections

(STIs). It usually begins as vulvovaginitis and may spread upwards to the
cervix, uterus, uterine tubes and ovaries.

Upward spread can also occur when infection is present in the vagina before
a surgical procedure, childbirth or miscarriage, especially if some of the
products of conception are retained.

Complications of PID include:

o Infertility due to obstruction of uterine tubes

o Peritonitis
o Intestinal obstruction due to adhesions between the bowel and the
uterus and/or uterine tubes
o Bacteremia, which may lead to meningitis, endocarditis or suppurative arthritis.
Vulvar dystrophies
a) Atrophic dystrophy

This is thinning of vulvar epithelium and the formation of fibrous tissue,

occurring after the menopause due to oestrogen withdrawal. It predisposes
to infection, especially in debilitated women, and to malignant epithelial
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 neoplasia.
Vulvar intraepithelial neoplasia (VIN)

This refers to early neoplastic (cancerous) changes in epithelial cells of the

vulva. It is commonest in younger women, often those infected with human
papilloma virus, and may proceed to malignancy.

A. Imperforate hymen

This congenital abnormality may not be noticed until the onset of

menstruation. When complete (imperforate), the hymen forms a barrier in
the vagina. Blood accumulates in the vagina, uterus and uterine tubes with
each menstrual cycle, and it may enter the peritoneal cavity and cause
peritonitis. The uterine tubes may become obstructed by coagulated blood,
leading to infertility.
Disorders of the cervix
a) Cervical carcinoma

Dysplastic changes, referred to as cervical intraepithelial neoplasia (CIN)

begin in the deepest layer of cervical epithelium, usually at the junction of
the stratified squamous epithelium of the lower third of the cervical canal
with the secretory epithelium of the upper two-thirds.

Dysplasia may progress to involve the full thickness of epithelium. Not all
dysplasias develop into malignant disease, but it is not possible to predict
how far development will go, and whether it will remain static or regress.

Early detection with a screening programme can allow abnormal tissue to be

removed before it becomes malignant. Established malignancy is staged
according to how extensive the tumour is.

Stage I refers to disease confined to the cervix. Stages II through IV reflect

increasing spread, including involvement of the rectum, bladder and
structures out with the pelvis. Early spread is via lymph nodes and local
spread is commonly to the uterus, vagina, bladder and rectum. In the late
stages, spread via the blood to the liver, lungs and bones may occur.

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 The disease takes 15 to 20 years to develop and it occurs mostly between 35
and 50 years of age. It is likely that a significant proportion of cases are due
to the transmission of some sexually transmitted carcinogen.

Risk factors include having frequent sexual intercourse with multiple

partners from an early age, all of which increase the likelihood of being
exposed to a carcinogenic agent. Barrier contraceptives protect against the
disease. The human papillomavirus (HPV), which causes genital warts, is
strongly associated with this cancer.

Disorders of the uterine body

a. Endometriosis

This is usually caused by non-specific infection, following childbirth or

miscarriage, especially if fragments of membranes or placenta have been
retained in the uterus. It may also be caused by an intrauterine
contraceptive device (IUD). The inflammation may subside after removal of
retained products or the IUD. The infection may spread to surrounding pelvic
structures, e.g., uterine tubes, or deeper layers of the uterus.

b. Endometriosis

This is the growth of endometrial tissue outside the uterus, usually in the
ovaries, uterine tubes and other pelvic structures. The ectopic tissue, like the
uterine endometrium, responds to fluctuations in sex hormone levels during
the menstrual cycle, causing menstrual-type bleeding into the lower
abdomen and, in the ovaries, the formation of coloured cysts, ‘chocolate
cysts.

There is intermittent pain due to swelling, and recurrent haemorrhage

causes fibrous tissue formation. Ovarian endometriosis may lead to pelvic
inflammation, infertility and extensive pelvic adhesions, involving the
ovaries, uterus, uterine ligaments and the bowel.

c. Adenomyosis

This is the growth of endometrium within the myometrium. The ectopic

tissue may cause general or localized uterine enlargement. The lesions may
cause dysmenorrhea and irregular excessive bleeding (menorrhagia), usually

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beginning between 40 and 50 years of age.

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 d. Endometrial hyperplasia

Hyperplasia of the endometrium is associated with high blood oestrogen

levels, e.g., in obesity, oestrogen therapy or an ovarian tumour. Sometimes
it is associated with increased risk of malignant change.

e. Leiomyoma (fibroid, myoma)

These are very common, often multiple, benign tumours of myometrium.

They are firm masses of smooth muscle encapsulated in compressed muscle
fibres and they vary greatly in size. Large tumours may undergo
degenerative changes if they outgrow their blood supply, leading to necrosis,
fibrosis and calcification. They develop during the reproductive period and
may be hormone dependent, enlarging during pregnancy and when oral
contraceptives are used. They tend to regress after the menopause. Large
tumours may cause pelvic discomfort, frequency of micturition, menorrhagia,
irregular bleeding, dysmenorrhoea and reduced fertility. Malignant change is
rare.

f. Endometrial carcinoma

This occurs mainly in women who have never been pregnant and is most
common between 50 and 60 years of age. The incidence is increased when
an oestrogen-secreting tumour is present and in women who are obese,
hypertensive or diabetic, because they tend to have a high level of blood
oestrogen. As the tumour grows, there is often ulceration and vaginal
bleeding.

Endometrium has no lymphatics, so lymph spread is delayed until there is

extensive local spread that involves other pelvic structures. Distant
metastases, spread in blood or lymph, develop later, most commonly in the
liver, lungs and bones. Invasion of the ureters leads to hydronephrosis and
uraemia, commonly the cause of death.
Disorders of the uterine tubes and ovaries
g. Acute salpingitis

Salpingitis is inflammation of the uterine tubes. It is usually due to infection

spreading from the uterus, and only occasionally from the peritoneal cavity.

143
The uterine tubes may be left permanently

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 damaged by fibrous scar tissue, which can cause obstruction and infertility.
Infection may spread into the peritoneum and involve the ovaries.

h. Ectopic pregnancy

This is the implantation of a fertilized ovum outside the uterus, most

commonly in a uterine tube. As the fetus grows the tube may rupture and its
contents enter the peritoneal cavity, causing acute inflammation (peritonitis)
and possibly severe intraperitoneal haemorrhage (bleeding).

i. Ovarian tumours

The majority of ovarian tumours are benign, usually occurring between 20

and 45 years of age. The rest occur mostly between 45 and 65 years and are
divided between borderline malignancy (low-grade cancer) and frank
malignancy.

Ovarian cancer is associated with developed societies, higher socioeconomic

groups, and, in some families, a genetic susceptibility. Pregnancy and the
use of the contraceptive pill have a protective effect. Most malignancies of
the ovary arise from epithelium, but some arise from the germ cells of the
ovary, or from stromal cells.

j. Metastatic ovarian tumours

The ovaries are a common site of metastatic spread from primary tumours in
other pelvic organs, the breast, stomach, pancreas and biliary tract.

B. Disorders of the breast

Mastitis (inflammation of the breast)
 Acute non-suppurative mastitis

This occurs during lactation and is associated with painful congestion and
oedema of the breast. It is of hormonal origin.

 Acute suppurative (pyogenic) mastitis

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 The microbes enter through a nipple abrasion caused by the infant sucking.
The most common causative microbes are Staphylococcus aureus and
Streptococcus pyogenes usually acquired by the infant while in hospital. The
infection spreads along the mammary ducts of a lobe causing localized
swelling and redness. If it does not resolve it can become chronic and an
abscess may form.

Tumours of the breast

 Benign tumours

Most breast tumours (90%) are benign. Fibroadenomas are the commonest
type and occur any time after puberty; incidence peaks in the third decade.
Some are cystic and some solid, and they usually occur in women nearing
the menopause. They may originate from secretory cells, fibrous tissue or
from ducts.

 Malignant tumours

The most common types of tumour are usually painless lumps found in the
upper outer quadrant of the breast. There is considerable fibrosis around the
tumour that may cause retraction of the nipple and necrosis and ulceration
of the overlying skin. It is increasingly common between 35 and 70 years.

Early spread beyond the breast is via lymph to the axillary and internal
mammary nodes. Local invasion involves the pectoral muscles and the
pleura. Blood-spread metastases may occur later in many organs and bones,
especially lumbar and thoracic vertebrae. The causes of breast cancer are
not known, but an important predisposing factor appears to be high
oestrogen exposure.

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DISEASES OF THE MALE REPRODUCTIVE SYSTEM

Objective

By the end of this section, the learner will be able to;

Outline the causes and effects of penile and

urethral infections Describe the main
pathologies of the testis
Discuss the principal disorders of the
prostate gland List the main causes of
male infertility
A. Penile and Urethral infections
Infections of the penis

Inflammation of the glans and prepuce may be caused by a specific or non-

specific infection. In non-specific infections, or balanitis, lack of personal
hygiene is an important predisposing factor, especially if phimosis is present,
i.e., the orifice in the foreskin (prepuce) is too small to allow for its normal
retraction. If the infection becomes chronic there may be fibrosis of the
foreskin, which increases the phimosis.

Infections of the urethra

Gonococcal urethritis is the most common specific infection. Non-specific

infection may be spread from the bladder (cystitis) or be introduced during
catheterisation, cystoscopy or surgery. Both types may spread throughout
the system to the prostate, seminal vesicles, epididymis and testes. If
infection becomes chronic, fibrosis may cause urethral stricture or
obstruction, leading to retention of urine.

Epididymis and testes

a. Infections

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 Non-specific epididymitis and orchitis are usually due to spread of infection
from the urethra, commonly following prostatectomy. The microbes may
spread either through the deferent duct (vas deferens) or via lymph.

b. Specific epididymitis

This is usually caused by gonorrhoea spread from the urethra.

Orchitis (inflammation of the testis)

This is commonly caused by mumps virus, blood-borne from the parotid

glands. Acute inflammation with oedema occurs about 1 week after the
appearance of parotid swelling. The infection is usually unilateral but, if
bilateral, severe damage to germinal epithelium of the seminiferous tubules
may result in sterility.

Undescended testis (cryptorchidism)

During embryonic life the testes develop within the abdominal cavity, but
descend into the scrotum prior to birth. If they fail to do this and the
condition is not corrected, infertility is likely to follow and the risk of
testicular cancer is increased.

Hydrocele

This is the most common form of scrotal swelling and is accumulation of

serous fluid in the tunica vaginalis. The onset may be acute and painful or
chronic. It may be congenital or be secondary to another disorder of the
testis or epididymis.

Testicular tumors

Most testicular tumors are malignant, the commonest malignancies in young

men. They occur in childhood and early adulthood when the affected testis
has not descended or has been late in descending into the scrotum. The
tumor tends to remain localized for a considerable time but eventually
spreads in lymph to pelvic and abdominal lymph nodes, and more widely in
the blood. Occasionally, hormone-secreting tumors develop and may cause
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 precocious development in boys.
B. Prostate gland
a. Infections

Acute prostatitis is usually caused by non-specific infection, spread from the

urethra or bladder, often following catheterization, cystoscopy, urethral
dilation or prostate surgery. Chronic infection may follow an acute attack.
Fibrosis of the gland may occur during healing, causing urethral stricture or
obstruction.

Benign prostatic enlargement

Hyperplastic nodules form around the urethra and may obstruct the flow of
urine, causing urinary retention. Urethral stricture may prevent the bladder
emptying completely during micturition, predisposing to infection, which may
spread upwards, causing pyelonephritis and other complications. Prostatic
enlargement is common in men over 50, affecting up to 70% of men aged
over 70. The cause is not clear, but it may be an acceleration of the ageing
process associated with the decline in androgen secretion, which changes
the androgen/oestrogen balance.

Malignant prostatic tumours

These are a relatively common cause of death in men over 50. The
carcinogen is not known but changes in the androgen/oestrogen balance
may be significant or viruses may be involved. Invasion of local tissues is
widespread before lymph-spread metastases develop in pelvic and
abdominal lymph nodes. Blood-spread metastases in bone are common and
bone formation rather than bone destruction is a common feature. Lumbar
vertebrae are common sites, possibly due to retrograde spread along the
walls of veins. Bone metastases are often the first indication of malignant
prostatic tumours.

C. Breast

Breast tissue in men consists of ducts and stroma only.

a. Gynaecomastia

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 This is proliferation of breast tissue in men. It usually affects only one breast
and is benign. It is common in adolescents and older men, and is often
associated with:

 Endocrine disorders, especially those associated with high oestrogen levels

 Cirrhosis of the liver
 Malnutrition
 Some drugs, e.g., chlorpromazine, spironolactone, digoxin.
 Klinefelter’s syndrome, a genetic disorder with testicular atrophy and
absence of spermatogenesis.

b. Malignant tumours

These develop in a small number of men, usually in the older age groups.

Classification of STIs

B. Diseases characterized by genital ulcer

 Chancroid
 Genital herpes simplex virus,
 Granuloma inguinale (Donovanosis),
 Lymphogranuloma Venarum,
 Syphilis
II. Diseases characterized by urethritis and cervicitis
 Chlamydial infection,
 Gonorrhea
III. Diseases characterized by vaginal discharge
 Bacterial vaginosis,
 Trichomoniasis,
 Vulvovaginal candidiasis
IV. Pelvic Inflammatory Disease (PID)
V. Epididymitis
VI. Human papillomavirus infection (Genital wart)
VII. Vaccine preventable STDs
 Hepatitis A,
 Hepatitis B
VIII. Proctitis, Proctocolitis and enteritis
IX. Ectoparasitic Infections
 Pediculosis Pubis,
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  Scabies

Prognostic classification of STDs

 Curable (mostly bacterial)

 Gonorrhea
 Syphilis
 Chlamydia
 Trichomoniasis
 Incurable (virus)
 HIV/AIDS
 Hepatitis
 Herpes
 Human papilloma virus

Risk factors for STIs Acquisitions and Transmission

o Participation in unprotected vaginal, oral or anal sex (no condom or dental dam
used)
o Genital to genital sexual contact
o Previous history of STIs.
o Having multiple sexual partners
o Use of non-barrier contraceptives, such as spermicides especially those
containing n-9 due to disruption of the genital epithelium
o Use of injection drugs, alcohol or other substances that can impair decision
making ability
o Use of PrEP (Pre-exposure prophylaxis) which may lead to decreased
use of condoms hence increased risk
o Inconsistent and irregular use of condoms during sex
o Vaginal practices e.g., Douching
o IUD placement for women especially within the first 20 days of placement
o Use of spermicides

Treatment of STIs

Syndromic Approach to STI Management

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  The syndromic approach to STI management uses flowcharts to guide
diagnosis and treatment of Sexually transmitted infections.
o A syndrome is a combination of symptoms and signs that appear
together and characterize a disease or medical condition (e.g., a
combination of pain on passing urine and urethral discharge).
o Many common STIs present with similar signs and symptoms and
can therefore be grouped into a small number of syndromes. The
aim of the syndromic approach to STI management is to identify
each syndrome and treat it with a combination of antimicrobial
agents effective against the main causal pathogens.
 Flow charts used for syndromic management of STIs are graphic
representations of logical sequences for decision-making towards the
management of clients who present symptoms of STIs.
 It presents a series of consecutive decisions and actions that need to
be taken, starting with specific symptoms and signs, through
identification of syndromes and finally the choice of treatment.

Advantages of Syndromic Approach to STI Management

 The advantages of the syndromic approach to STI management are:

o The flow charts used in this approach represent a combination of
simple, practical scientific information for decision making in
primary health settings and in most cases does not require
highly trained health care providers.
o STI managed is based on characteristic symptoms and signs
without using expensive lab equipment.
o It allows for prompt initiation of STI treatment at first contact
with clients reducing delays in diagnosis.
o The treatment covers the entire range of known causative
agents for the syndrome, reducing chances of treatment failure
and expediting effective treatment which reduces the risk of
transmission and development of serious complications.
o The use of flow charts in this approach standardizes STI
treatment across diverse settings and allows for comparative
results across sites, builds client confidence, and allows for
efficient centralized procurement of drugs.
o It allows for rapid, effective management of STIs in busy primary
health care clinics.

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Disadvantages of Syndromic approach to STI management

 Syndromic approach to STI management however has one major disadvantage.

o Many patients may receive more drugs than they need hence
resulting in their being over treated

NB: Despite its disadvantages, the syndromic approach to STI management

can lead to substantial improvements in quality and effectiveness of STI case
management and control. It is recommended that this approach be utilized
as the main approach for management of STIs in Kenya. In extreme cases of
treatment failure, patients should be referred to the designated referral
health facilities equipped to manage STIs etiologically.

Public Health Significance of STIs

The links between STIs and HIV is one of the reasons that force the world to
give attention to almost neglected sexually transmitted infections, because:
 The presence of an untreated STI enhances both acquisition and
transmission of HIV. HSV-2 plays an important role in the transmission
of HIV infection.
 STI treatment is an important HIV prevention strategy in a general population
 Integration of HIV/AIDS programs with STIs prevention and care
programs is economically advantageous (similar interventions and
target audiences). NASCOP in Kenya.
 Clinical services offering STI care are important for providing
information and education about STIs including HIV in order to promote
lower risk behavior.

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 Another reason to consider STIs as public health problems is because STIs
can lead to the development of serious complications like:
 In women: STIs can lead to cervical cancer, pelvic inflammatory
disease, chronic pelvic pain, ectopic pregnancy and infertility. That is,
untreated gonococcal and chlamydial infections in women will result in
pelvic inflammatory disease in up to 40% of cases. One in four of these
will result in infertility.
 In men: STIs can lead to sub-fertility.
 In newborn: Mother-to-child transmission of STI can result in stillbirth,
neonatal death, low-birth weight babies, prematurity, sepsis,
pneumonia, neonatal conjunctivitis and congenital deformities.
 Syphilis can result in congenital syphilis for the baby and fatal cardiac,
neurological and other complications in adults
 Genital warts can lead to ano-genital cancers
 In pregnancy, untreated early syphilis will result in a stillbirth, thus
contributing to neonatal deaths, premature births or low birth weights
babies.
 The socioeconomic costs of STIs and their complications are substantial:
 Ranks among the top 10 reasons for health-care visits in most
developing countries, and substantially drain both national
health budgets and household income.
 Care for the sequel of STIs accounts for a large proportion of
tertiary health-care costs
 Social costs of STIs include conflict between sexual partners and
domestic violence.

These are the main reasons to consider STIs as public health problems and to
design and implement appropriate intervention both preventive and
curative.

Why Invest in STI Prevention and Control Now?

To reduce STI-related morbidity and mortality

 To prevent HIV infection because:

 Genital ulcer diseases increase the risk of transmission of HIV
during unprotected sexual intercourse

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  Improved syndromic management of STIs helps to reduce HIV incidence.
 To prevent serious complication in women
 STIs are main preventable cause of infertility
 PID, ectopic pregnancy and cervical cancer
 To prevent adverse pregnancy outcome
 Perinatal deaths
 Spontaneous abortions
 Preterm deliveries
 Ophthalmia neonatorum

STI Control Strategies

 Abstinence
 Prevention by promoting safer sexual behaviors;
What is safer sex? It is any sexual activity that reduces the risk of
passing STI and HIV from one person to another.
Some safer sex practices:
 Consistent use of condom every time individual is having sex
 Reducing the number of sex partners. Sex with uninfected monogamous is
safe
 Massaging, rubbing touching, dry kissing, hugging or
masturbation instead of intercourse
 To be away from unsafe sexual practices, like “dry sex”
 Not to have intercourse with partner having genital sore or discharge
 General access to quality condoms at affordable prices; to help
increase their use, and reduce barriers to utilization.
 Promotion of early recourse to health services by people suffering from
STIs and by their partners;
 Inclusion of STI treatment in basic health services;
 Specific services for populations with frequent or unplanned high-risk sexual
behaviors
 Proper treatment of STIs, i.e., use of correct and effective medicines;
treatment of sexual partners; education and advice; reliable supply of
condoms;
 Screening of clinically asymptomatic patients;
 Provision for counseling and voluntary testing for HIV infection;

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  Prevention and care of congenital syphilis and neonatal conjunctivitis;
 Behavioral change interventions with explicit messages about the risks of STIs.
 Human Papilloma Vaccine (HPV) for females aged 11-12 years.
 Vaccination against Hepatitis A and B for all men sexing men (MSM) is
recommended.
 Involvement of all relevant stakeholders, including the private sector
and the community, in prevention of STIs and prompt contact with
health services for those requiring care. Thus, any effective control
strategy requires identification of vulnerable populations and working
towards mitigation strategies with them. An individual is vulnerable to
STIs when his /her ability to avoid infection is diminished by
inadequate personal knowledge or skills, cultural norms or
circumstances. These vulnerabilities include:

 Having primary education or less for an individual and/or their spouse

 Lack of formal employment
 Poverty
 Low income
 Intra uterine device (IUD) placement for women especially within
the first 20 days of placement
 Alcohol and substance abuse
 Use of spermicides especially those containing n-9 due to
disruption of the genital epithelium
 Individuals and/or partners with multiple sex partners
 Gender based violence
 Mental and physical disability
 Childhood sexual abuse
 Child marriage
 Key populations
 Out of school adolescents
 Early sexual debut
 Disempowerment of women
 People living with HIV
 Conflict situations
 Refugees/internally displaced persons and immigrants
NOTE:

Many people with an STI/RTI do not seek treatment since they are
asymptomatic or have mild symptoms and do not realize that anything is
wrong. Others who have symptoms may prefer to treat themselves or seek
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 treatment at pharmacies or from traditional healers. Even those who come to
a clinic may not be properly diagnosed and treated. In the end, only a small
proportion of people with an STI/RTI may be cured and avoid re-infection.

In order to address these challenges, health providers should:

o Raise awareness in the community about STIs/RTIs and how they can be
prevented
o Promote early use of clinic services.
o Promote safer sexual practices when counseling clients.
o Detect infections that are not obvious.
o Prevent iatrogenic infection
o Manage symptomatic STI/RTI effectively
o Counsel patients on staying uninfected after treatment.

Obstacles to Provision of Services for STI Control

 Decline in interest and resources for STIs prevention and control

globally in favor of ART and VCT
 Lack of integration of prevention and care activities for STIs (including
HIV) into sexual and reproductive health services
 Problem with Syndromic management of women with vaginal
discharge, especially in low prevalence areas
 Intervention efforts to prevent STIs have failed to take into
consideration the full range of the underlying determinants.
 Inability to ensure consistent supplies of STI medicines and condoms
 Counseling on risk reduction is also usually lacking
 Inadequate participation of partners, especially communities
 Diagnostic problem: either asymptomatic or do not seek care

 or sex toy, not before it goes on.

SEXUAL HEALTH
Sexual health is a state of physical, emotional, mental and social well-being
related to sexuality; it is not merely the absence of disease, dysfunction or
infirmity.

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Sexual health requires a positive and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and violence. For sexual health to
be attained and maintained, the sexual rights of all persons must be respected,
protected and fulfilled

Sexual health is the ability to embrace and enjoy our sexuality throughout our
lives. It is an important part of our physical and emotional health. Being sexually
healthy means:

o Understanding that sexuality is a natural part of life and involves more

than sexual behavior.
o Recognizing and respecting the sexual rights we all share.
o Having access to sexual health information, education, and care.
o Making an effort to prevent unintended pregnancies and STDs and
seek care and treatment when needed.
o Being able to experience sexual pleasure, satisfaction, and intimacy when
desired.
o Being able to communicate about sexualhealth with
others including sexual partners and healthcare providers

Sexual health practices

 Using barrier methods can lower the risk of contracting STIs. These methods can
include:
 Using external or internal condoms for penetrative intercourse,
including with sex toys
 Using condoms or dental dams for oral sex
 Using gloves for manual stimulation or penetration
 Maintaining good hygiene before and after sexual contact can also
help prevent STI transmission. This can include:
 Washing your hands before any sexual contact
 Rinsing off after sexual contact

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  Urinating after sex to help prevent urinary tract infections (UTIs)
 Using condoms correctly
 When using condoms and other barrier methods, it’s important
to follow instructions. Using condoms correctly makes them more
effective. Follow these safety precautions when using internal
and external condoms:
 Check the expiration date.
 Put the condom on correctly.
 For external condoms, always leave room at the tip and
unroll the condom onto the penis or sex toy, not before it
goes on.
 Use condom-safe lubricant, avoiding oil-based lubes with latex
condoms.
 Hold onto the condom after sex, so it does not slip.
 Dispose of the condom properly.
 Never remove a condom and try to put it on again.
 Never reuse a condom.

 lubricant, avoiding oil-based lubes with latex condoms.

 Hold onto the condom after sex, so it does not slip.
 Dispose of the condom properly.
 Never remove a condom and try to put it on again.
 Never reuse a condom

SEXUAL DYSFUNCTION AND INFERTILITY

Sexual dysfunction
It refers to a problem that can happen during any phase of sexual response
cycle that prevent individual or couple from experiencing satisfaction from
sexual activity.

SEXUAL DYSFUNCTION AND INFERTILITY

Sexual dysfunction
It refers to a problem that can happen during any phase of sexual response
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 cycle that prevent individual or couple from experiencing satisfaction from
sexual activity.
The sexual response cycle traditionally includes excitement, plateau,
organism and resolution. Desire and arousal are both part of excitement
phase of the sexual response. It is important to know that women do not
always go through these phases in order.

Causes of sexual dysfunctions

 Physical causes: many physical and or medical conditions can cause

problems with sexual functions:
o Diabetes
o Heart and cardiovascular conditions
o Chronic kidney and liver disease
o Alcoholism
o Drug abuse
 Psychological causes
o Work related stress and anxiety
o concern about sexual performance
o Marital or relationship problems
o Feeling guilt
o concerns about body image
o Effect of past sexual trauma
o Depression

Categories of Sexual Dysfunction

 Primary sexual dysfunction:

This includes individual whom has never experienced satisfying sexual response

 Secondary sexual dysfunction

This includes individuals who have experienced satisfying sexual response

earlier but is currently suffering from sexual dysfunction.
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 Types of Sexual
Dysfunction
Dysfunction in male:

o Erectile dysfunction: inability to achieve or maintain an erection (hard

penis) suitable for intercourse.
o Premature ejaculation: inability to control timing of an erection.
o Retarded ejaculation: absent or delayed ejaculation despite enough sexual
stimulation
o Inhibited sexual desire

Dysfunction of female

o Primary orgasmic dysfunction: inability to achieve organisms.

o Secondary orgasmic dysfunction: inability to reach organism both one has had
one before.
o Vaginismus: inability to relax the vaginal muscle enough to allow intercourse.
o Diminished lubrication: inadequate vaginal lubrication before and during
intercourse.
o Dyspareunia: painful sexual intercourse.

In both men and women

 Desire disorder: lack of sexual desire or interest in sex.

 Arousal disorder: inability to become physically aroused or excited during sexual
activity Organism disorder: delay or absence of organism (climax)
 Pain disorder: pain during intercourse.

INFERTILITY
Definition

 Failure to conceive within one year of regular unprotected intercourse.

Types of infertility include;

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  Primary infertility: This is whereby, a woman has never been pregnant
and cannot conceive after one year of not using any family planning
method
 Secondary infertility: occurs when a woman cannot get pregnant again
after having had at least one successful pregnancy.

Causes of infertility

Male factors:
o Defective spermatogenesis. Suppression of spermatogenesis by, e.g.,
ionizing radiation, chemotherapy and other drugs.
o Failure to deposit sperm high in the vagina
o Errors in seminal fluid
o Endocrine disorders
o Obstruction of the deferent duct
o Failure of erection or ejaculation during intercourse
o Vasectomy
Female factors:
o Ovulation problems
o Blockage of uterine tubes, often the consequence of pelvic inflammatory disease
o Anatomical abnormalities, e.g., retroversion (tilting backwards) of the uterus
o Endocrine factors; any abnormalities of the glands and hormones
governing the menstrual cycle can interfere with, for example,
ovulation or the uterine cycle
o Low body weight, e.g., in anorexia nervosa, or severe malnourishment
o Endometriosis.

The sexual cycle traditionally includes excitement, plateau, organism and

resolution. Desire and arousal are both part of excitement phase of the
sexual response. It is important to know that women do not always go
through these phases in order.

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Causes of sexual dysfunctions

 Physical causes: many physical and or medical conditions can cause

problems with sexual functions:
o Diabetes
o Heart and cardiovascular conditions
o Chronic kidney and liver disease
o Alcoholism
o Drug abuse
 Psychological causes
o Work related stress and anxiety
o concern about sexual performance
o Marital or relationship problems
o Feeling guilt
o concerns about body image
o Effect of past sexual trauma
o Depression

Categories of Sexual Dysfunction

 Primary sexual dysfunction:

This includes individual whom has never experienced satisfying sexual response

By the end of this section, the learner should be able to;

 Understand harmful traditional practices

 Understand the concept, magnitude and effect of violence on women’s
reproductive health

HARMFUL TRADITIONAL PRACTICES

Objectives
By the end of this section, the learner should be able to;

 Understand harmful traditional practices

 Understand the concept, magnitude and effect of violence on women’s
reproductive health
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Introduction
Traditional
Practices
Tradition represents the sum total of all behaviours that are learned, shared
by a group of people and transmitted from generation to generation. Thus,
traditional cultural practices reflect values and beliefs held by members of
community for periods often spanning generations. Every social grouping in
the entire world has specific traditional cultural practices and beliefs, some
of which are beneficial to all members, while others are harmful to a specific
group, such as women.
Harmful practices
Some of these harmful practices include;

 Female genital mutilation (FGM):

Female genital mutilation (FGM), or female circumcision as it is
sometimes erroneously referred to, involves surgical removal of parts
or all of the most sensitive female genital organs. It is an age-old
practice which is perpetuated in many communities around the world
simply because it is customary. FGM forms an important part of the
rites of passage ceremony for some communities, marking the
coming of age of the female child. It is
believed that, by mutilating the female's genital organs, her sexuality
will be controlled; but above all it is to ensure a woman's virginity
before marriage and chastity thereafter. In fact, FGM imposes on
women and the girl child a catalogue of health complications and
untold psychological problems. The practice of FGM violates, among
other international human rights laws, the right of the child to the
"enjoyment of the highest attainable standard of reproductive health.
 Severely restricted weight gain during pregnancy. That is, nutritional
taboos
Food taboos are common practices of certain food items for pregnant
and/or lactating women or girls in general. Cultural practices, including
nutritional taboos, ensure that pregnant women are deprived of
essential nutriments, and as a result they tend to suffer from iron and
protein deficiencies. this is because foods that are good sources of
energy and protein are not allowed to be consumed by pregnant
women for reasons such as difficult and prolonged labor due to fears of

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 a large baby
 Forced feeding of women
This involves forcing the young girls and women to feed with those
failing is inflicted with pain especially by older women in the
community.
 Withholding colostrum from newborn
This involves depriving the newborn colostrum which is important for
newborns in boosting their immunity. This is because, colostrum in
some communities is considered dirty and bad omen.
 Low levels of breast feeding
Some cultural and social beliefs and practices have an influence in
breastfeeding. Despite the benefits of breastfeeding, in some
communities, breastfeeding level is low due to sociocultural reasons.
 Postpartum nutritional restriction
In many cultures, the belief in the avoidance of certain food intake
(food taboos) protects the health of the mother leads to increased risk
of deficiency of proteins, fats, vitamins A and calcium during lactation.
 Vaginal douching
Vaginal douching (VD) is the process of washing the vagina with water
or other liquid solutions. VD can be widely seen in cultures that define
the female body, menstruation and
sexual intercourse as dirty. Douching upsets the natural balance of
bacteria in the vagina (called vaginal flora). These changes make the
environment more favorable for the growth of bacteria that causes
infections of the vagina.
 Female infanticide and son preference:
Sex bias or son preference places the female child in a
disadvantageous position from birth. In some communities, especially
among the Asians, the practice of infanticide ensures that some female
children have no life at all, violating the basic right to life. Selective
abortion, foeticide and infanticide all occur because the female child is
not valued by her culture, or because certain economic and legislative
acts have ruled her life worthless
 Early marriage, pregnancy and dowry price
Early marriage is another serious problem which some girls, as
opposed to boys, must face. The practice of giving away girls for
marriage at the age of 11, 12 or 13, after which they must start
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 producing children, is prevalent among certain ethnic groups in Asia
and Africa. The principal reasons for this practice are the girls' virginity
and the bride-price. Young girls are less likely to have had sexual
contact and thus are believed to be virgins upon marriage; this
condition raises the family status as well as the dowry to be paid by
the husband. In some cases, virginity is verified by female relatives
before the marriage
 “Dry sex” practices (removal of vaginal fluid with absorbent materials)
Dry sex and virginity testing are useful and valuable traditional
practices that seek to uphold cultural values in an increasingly
westernized society. It could even be said that these two practices
constitute appropriate responses to the HIV/AIDS pandemic in Africa.
However, dry sex and virginity testing could also be seen as decidedly
harmful, in that they seek to maintain (and indeed entrench) the
cultural and sexually based subordination of women in Africa.

Others include

 Breast and penis implants

 Wife inheritance
 Wife adoption

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 NB: Despite of their harmful nature and their violation of international
human rights laws, such practices has continued to persist because they are
not questioned and are considered to be morally correct among those
practicing them.

Violence against Women

o Violence against women is any act of gender-based violence that

results in, or is likely to result in, physical, sexual, psychological harm
or suffering to women, including threats of such acts, coercion or
arbitrary deprivations of liberty, whether occurring in public or private.
o Abuse of women and girls is best understood within gender framework
because it stems in part from women’s and girl’s subordinate status in
the society.

Violence against women (VAM) encompasses, but is not limited;

 Spousal battering
 Sexual abuse of female children
 Dowry-related violence
 Rape including marital rape
 Traditional practices harmful to women such as FGM.
 Non-spousal violence
 Sexual harassment and intimidation at work and in school
 Trafficking in women
 Forced prostitution
 Violence perpetuated or condoned by the state, such as rape in war

Dealing with Harmful Practices

o Develop and support implementation of appropriate laws and policies.

o Support community-level transformation of social norms and practices.
o Empower women and girls to express and exercise their rights.

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o Increase access to quality prevention, protection and care services

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 o Increase global knowledge of the problem and political commitment to
end child marriage and FGM
o Increase government ownership over relevant programmes and efforts

LIST OF REFERENCES

Benti T., T. (2015). Factors Determining Health Institutional Delivery Among

Pregnant Women Living in Agarfa Town of Bale Zone, Oromia, South East
Ethiopia. American Journal of Health Research, 3(3), 130.

Campbell, G., Roberts, K. A. & Sarkaria, N. (2010). Other Harmful Traditional Practices
(pp.
119–127). Ethiopia Public Health Training Inintiative.

Ministry of Health Kenya. (2018). National Guidelines for Prevention,

Management and Control of Sexually Transmitted Infections (Issue
September, pp. 2–98). NASCOP.

Otsea, K. (1987). Progress and Prospects: The Safe Motherhood Initiative 1987-1992.

Van der Poll, L. (2011). The iImpact of Traditional Sex Practices on the
Construction of Female Sexuality: An African Human Rights Perspective.
In Law, Democracy & Development (Vol. 13, Issue 2, pp. 1–21).
University of Cape Town.

WHO. (2011). Family Planning: A Global Handbook For Providers. In

Department of Reproductive Health and Research. WHO Press.

Worku, F. & Gebresilassie, S. (2008). Reproductive Health for Health Science Students.
In
University of Gondar (Issue Md, pp. 1–416). University of Gandor.

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World Health Organization. (2018). 2018 Edition Family
Planning: A Global Handbook for Providers (3rd Editio).
WHO Press`

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