Kli ik R d S l h Klinik Raden Saleh DepartmentofObstetrics&Gynecology F lt f M di i U i it f I d i / FacultyofMedicine,UniversityofIndonesia/ Cipto Mangunkusumo GeneralHospital k Jakarta Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010 Objectives: Objectives: 1 T d t t t 1.Toupdatepostpartum contraception contraception 2 To review IUD 2.ToreviewIUD POSTPLACENTA POSTPLACENTA 3.To discuss medical barriers 3.Todiscussmedicalbarriers Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010 MillenniumDevelopmentGoals 1 E di d h 1.Eradicateextremepovertyandhunger 2.Achieveuniversalprimaryeducation 3.Promotegenderequality&empowerwomen 4.Reducechildmortality 5.Improvematernalhealth 6.CombatHIV/AIDS,malaria&otherdiseases 7.Ensureenvironmentalsustainability 8.Develop a global partnership for development 8.Developaglobalpartnershipfordevelopment MDGs challenges are not new MDGs challenges are not new; what is new is that they involve ; what is new is that they involve MDGs challenges are not new MDGs challenges are not new; what is new is that they involve ; what is new is that they involve concrete, time concrete, time--bound & quantitative bound & quantitative targets targets for action by 2015. for action by 2015. Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010 GOAL5ImproveMaternalHealth TARGET6 Reducebythreequarters,between1990and 2015,thematernalmortalityratio Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010 Maternalmortalityisan indicatorofgrossinequality, human rights abuse and humanrightsabuseand developmentfailure. Allmaternalhealthproblems bl l h arepreventableaslongasthe government pays attention and governmentpaysattentionand prioritizesmaternalhealth. Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010 AffandiB.KesehatanReproduksidanUpayaKesehatanMaternaldiIndonesia,QuoVadis?OrasipadaPITXVIIIPOGI,Jakarta,7Juli2010 Ofthe11countriesthatcontributeto65 l b l l d h fi i percenttoglobalmaternaldeath,fivearein AsiancountriesincludingIndonesia, Bangladesh,Pakistan,IndiaandAfghanistan. Ahighmaternalmortalityrateisan g y indicatorofthestatusofpoorfunctioningof a countrys health system including lack of acountry shealthsystemincludinglackof supportiveandprotectivelegalandpolicy environment environment. Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010 Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010 GOAL5ImproveMaternalHealth p Target6:Reducebythreequarters,between 1990and2015,thematernalmortalityratio Indicators: Maternalmortalityratio Percentageofbirthsattendedbyskilled g y healthpersonnel Contraceptiveprevalencerate AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010 Threeprongedstrategy toreducingmaternalmortality Family planning to ensure that every birth is Familyplanningtoensurethateverybirthis wanted Skilled care by a health professional with Skilledcarebyahealthprofessionalwith midwiferyskillsforeverypregnantwoman d i d hildbi th duringpregnancyandchildbirth EmergencyObstetricCare(EmOC)toensure timelyaccesstocareforwomenexperiencing complications. UNFPA,2009 p AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010 PERENCANAANKELUARGA 1. Seorangwanitatelahdapatmelahirkan,segera setelahiamendapathaidyangpertama ( h ) (menarche) 2. Kesuburanseorangwanitaakanterusberlangsung, sampai mati haid (menopause) sampaimatihaid(menopause) 3. Kehamilandankelahiranyangterbaik,artinya risikopalingrendahuntukibudananak,adalah p g , antara2035tahun 4. Persalinanpertamadankeduapalingrendah i ik risikonya 5. Jarakantaraduakelahiransebaiknya24tahun Affandi, 1984 Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010 POLA PERENCANAAN KELUARGA POLAPERENCANAANKELUARGA Fase Fase Fase Fase Fase Fase M d M d M j k M j k Menunda Menunda Kehamilan Kehamilan Menjarangkan Menjarangkan Kehamilan Kehamilan Tidak Tidak Hamil Hamil lagi lagi 2 2 44 20 20 35 35 Affandi, 1984 Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010 PEMILIHANKONTRASEPSIRASIONAL Fase Fase Fase Fase Fas Fasee menunda menunda Kehamilan Kehamilan Menjarangkan Menjarangkan Kehamilan Kehamilan Tidak Tidak hamil hamil lagi lagi 2 2 44 Pil Pil IUD IUD IUD IUD Suntikan Suntikan IUD IUD Suntikan Suntikan Steril Steril IUD IUD 20 20 35 35 Sederhana Sederhana Suntikan Suntikan Implant Implant Suntikan Suntikan MiniPil MiniPil Pil Pil Implant Implant Sederhana Sederhana Suntikan Suntikan MiniPil MiniPil Pil Pil Implant Implant Sederhana Sederhana Implant Implant Suntikan Suntikan Sederhana Sederhana Pil Pil Sederhana Sederhana Sederhana Sederhana Steril Steril Affandi, 1984 Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010 CONTRACEPTIVEPREVALENCE INDONESIA 19702007 INDONESIA,1970 2007 70 80 61 4 % 60 70 48 % 57 % 60 % 61.4 % 40 50 20 30 26 % 10 20 5 % (?) 0 1970 1980 1987 1997 2002 2007 Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand,2023January2010 CurrentContraceptiveUsers Indonesia March 2006 Indonesia,March2006 METHODS USERS % METHODS USERS % INJECTABLES 9 743 550 35 2 INJECTABLES 9,743,550 35.2 PILLs 7,796,474 28.1 IUDs 5 218 196 18 8 IUDs 5,218,196 18.8 IMPLANTABLES 3,156,705 11.4 STERILIZATION 1 515 406 5 5 STERILIZATION 1,515,406 5.5 OTHERS 278,473 1.0 TOTAL 27 708 804 100 0 TOTAL 27,708,804 100.0 BKKBN, 2007 Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010 BIRTHRATE BIRTHRATE STILL HIGH ! ! ! STILL HIGH ! ! ! 4 5 5 Million/year 4.5 5 Million/year Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010 FAKTA FAKTA 1.PascasalinOVULASIdapat p terjadidalamwaktu21hari 2.PascakeguguranOVULASI dapatTERJADIdalamwaktu 11hari Affandi B.Kontrasepsi Terkini dan IUDPascaplasenta .Pertemuan Koordinasi Peningkatan KBPascapersalinan di Rumah Sakit ,Makassar31Agustus 2010 Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30(3):181189 SimplifiedClassificationofEligibility ( ) Criteria(WHO) AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010 12.Theuseofprogestogenonlymethodsinthefirst6 weekspostpartumdoesnotappeartohaveanadverse p p pp effectonbreastmilkvolume(GradeB). 13.Theuseofprogestogenonlymethodswhen b f di id 99% ffi (G d ) breastfeedingprovidesover99%efficacy(GradeB). 14.Theproblematicbleedingassociatedwithprogestogen only methods appears to be more acceptable than that onlymethodsappearstobemoreacceptablethanthat experiencedbywomenwhoarenotbreastfeeding (GradeB). Aftercounselling,breastfeedingwomenmaychooseto useaprogestogenonlymethodofcontraceptionbefore 6 weeks postpartum if other contraceptive methods are 6weekspostpartumifothercontraceptivemethodsare unacceptable. Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189 Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 17.DMPAusebefore6weekspostpartumis not usually recommended (Grade C) notusuallyrecommended(GradeC). 18.TroublesomebleedingcanoccurwithDMPA useintheearlypostpartumperiod(GradeC). DMPAwillnotrequiretheinjectionuntilDay 21postpartum,butiftheriskofimmediate subsequentpregnancyishighitmaybegiven beforethistime. Contraceptive choices for breastfeeding women. Journal of Family Planning and Reproductive Health Care 2004; 30: 181189 Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181 189 Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Breastfeedingwomenmaychooseto useaprogestogenonlyimplantbefore Day 28 without the need for Day28withouttheneedfor additionalcontraceptiveprotection. IMPLANTwillnotberequireduntil Day 28 postpartum, but if the risk of Day28postpartum,butiftheriskof immediatesubsequentpregnancyis high it ma be gi en before this time highitmaybegivenbeforethistime. C i h i f b f di J l f il l i d d i H l h C 2004 30 181 189 Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189 Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Statement,WHOGeneva,22Oct.2008: Progestinonlycontraceptiveuseduringlactation 1. Useofprogestinonlymethods,withtheexceptionofthe l l b ll d d f levonorgestrel bearingIUD,isnotusuallyrecommendedfor womenwhoarelessthan6weekspostpartumandbreastfeeding, unlessothermoreappropriatemethodsareunavailableor unacceptable. 2. Beyond6weekspostpartum,thereisnorestrictionfortheuseof progestin only contraceptive methods among breastfeeding progestinonlycontraceptivemethodsamongbreastfeeding women. 3. ThelevonorgestrelbearingIUDisnotusuallyrecommendedfor th fi t 4 t t k l th i t thefirst4postpartumweeks,unlessothermoreappropriate methodsareunavailableorunacceptable.Beyond4weeks postpartum,thereisnorestrictiononitsuse. Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 IUDCu AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010 ThepostpartuminsertionofIUDshas b f d l d anumberofadvantages,including ease of insertion, availability of skilled easeofinsertion,availabilityofskilled personnelandappropriate f ili i d i f h facilities,andconvenienceforthe woman. Practitionershavebeenconcerned aboutthepossibilityofhigher expulsion, infection and perforation www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm expulsion,infectionandperforation rates. Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Postplacental (preferably within Postplacental (preferablywithin 10minutesafterexpulsionofthe placenta)andimmediate postpartum insertion during the postpartuminsertionduringthe firstweekafterdelivery(but preferablywithin48hours)are convenient effective and safe convenienteffectiveandsafe timestoinsertcopperIUDs. Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010 {ManagingContraception20052007,page92} Teknik Pemasangan AKDR Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Fundal placement ThewaytheIUDisinsertedismoreimportantthan thedesignofthedevice. Diff i IUD l i b DifferencesinIUDexpulsionratesbetweencenters participatinginthetrialsweregenerallygreaterthan expulsion rates for different IUDs; expulsionratesfordifferentIUDs; FHIdatashowthatemphasisneedstobegiventothe fundal placement of the device. fundal placementofthedevice. Theprovidershouldbeabletofeelthedevicethrough theabdominalanduterinewallsatthetimeof insertion. Retrainingisnecessaryforthoseindividualswho reporthighexpulsionrates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Teknik Pemasangan AKDR Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 Allowthewomantorest. Besureshegetscomplete t t postpartumcare. P id i i Providepostinsertion instructions instructions. Expulsion Expulsion Afterbirth,astheuterusreturnstonormal size(involution),uterinecontractionsexpel retainedplacentalandbloodclotsandmay p y haveasimilareffectonanyforeignbody introduced into the uterus. introducedintotheuterus. IUDsinsertedwithin10minutesofplacenta l i h h l l i i k expulsionhaveamuchlowerexpulsionrisk thanthoseinsertedlaterinthepostpartum period. www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010 BarrierThatPreventContraceptive SSuccess Barriertoeffectivefamily planning services Outcomewhenbarrier planningservices areovercome Accesstoservice Contraceptive f preference Quality services Qualityservices MAQExchangecurriculum(Online)MaximizingAccessandQualityinitiative,WashingtonDC,2001 Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010 Medical barriers Medicalbarriers weredefinedas "practices,derivedat p , leastpartlyfromamedical rationale,thatresultina scientifically unjustifiable scientificallyunjustifiable impedimentto,ordenialof, p , , contraception" SheltonJD,etal.Lancet,1992;340:13341335 Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010 MedicalBarriersthatrestrict f accesstofamilyplanningservices 1 Provider bias When the provider is 1. Providerbias Whentheprovideris fororagainstaspecificmethod 2 O l t i ti li ibilit it i 2. Overlyrestrictiveeligibilitycriteria Whocangetwhatcontraceptive 3. Unnecessaryprocesshurdles Requirementsthat,fromtheuser's pointofview,makeitdifficultto obtainacontraceptive SheltonJD,etal.Lancet,1992;340:13341335 Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010 4.Inappropriatecontraindications Medical conditions that restrict the Medicalconditionsthatrestrictthe useofsomecontraceptives 5 Overly restrictive regulations 5.Overlyrestrictiveregulations Nationallawsandclinicorhospital regulations regulations 6.Providerlimitation Whocan provide what method providewhatmethod 7.Inappropriatemanagementofside effects Actions taken by the effects Actionstakenbythe providertohelptheusertoleratea contraceptive method Shelton JD et al Lancet 1992;340:13341335 contraceptivemethod Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010 SheltonJD,etal.Lancet,1992;340:1334 1335 Checklists ReduceMedicalBarriers Medicalbarriersoftenpreventclientsfromusingtheir desiredmethodoffamilyplanning. Thepregnancy,COC,DMPA,andIUDchecklistscan effectivelyincreaseaccesstofamilyplanningwhile helping ensure client safety helpingensureclientsafety. Introductionofchecklistsintoservicedeliverysettings shouldincludecarefultrainingonhowtousethe g checklistsaswellasthemedicaleligibilitycriteriaon whichtheyarebased. Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010 Knowingisnot enough,wemustapply Willingisnotenough,we t d mustdo G h Goethe Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010