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Planning and
Demographic Transition

Family Planning and Contraception

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Distribution of contraceptive methods:

Family Planning and Contraception

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Distribution of contraceptive methods:
Sri Lanka

Family Planning and Contraception

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Analyzing the population growth

 Momentum of the population 58%

– Large size of population in the reproductive age-group
 Unmet need for contraception 20%
– Only 44 % of 168 million eligible couples are currently
– Role of Health sector
 High wanted fertility 20%
– insurance against multiple infant and child deaths in a
 Early age of marriage

Family Planning and Contraception

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Unmet Need

Unmet need for family planning is defined as the

percentage of women of reproductive age, either
married or in a union who are want to stop or delay
childbearing but are not using any method of

Family Planning and Contraception

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Family Planning and Contraception
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Reasons for Unmet Need

 Perceived low risk of pregnancy

– Infrequent sexual activity
– Post-partum amenorrhoea
– Sub-fecundity

 Opposition to use a contraceptive method

 Reasons related to knowledge, access or side effects

– Lack of awareness
– Cost and access to good quality Services
– Side effects, health concerns

Family Planning and Contraception

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Characteristics of ideal contraceptive

 Safe

 100% effective

 Free of side effects

 Easily obtainable

 Affordable

 Acceptable to the user and sexual partner

 Free of effects on future pregnancies

Family Planning and Contraception
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Quality in Family Planning

Family Planning and Contraception

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Quality is often defined as ‘meeting the needs of clients’.

 Programs that are customer focused consistently involve

clients in defining their needs and in designing the services.

 Providing quality services is fundamental to sustainable


 Providing and subsequently maintaining quality services can

only be accomplished through continuous problem solving
and quality improvement.

Family Planning and Contraception

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Elements of ‘Quality of Care’ in
family planning

 Choice of method

 Interpersonal communication (verbal & non verbal)

 Technical Competence

 Information

 Follow-up

 Appropriate constellation of services

Family Planning and Contraception

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Choice of method
Cafeteria approach/ Contraceptive method mix
 Offering the right to the client to choose the
method means giving confidence to the individual.
 He/she feels more comfortable in
using the method for which he/she has been
provided with clear, accurate and specific
information and which is the best for his/her

Family Planning and Contraception

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Competence of the provider
Technical competence

Good interpersonal communication

(verbal & non verbal)

Family Planning and Contraception

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Other tenets of quality of carre
 Right information

 Follow-up

 Appropriate organization of services

Family Planning and Contraception

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 Number of contraceptive methods available at a specific outlet
(basket of choice)
 Percentage of counseling sessions with new acceptors in
which provider discusses all methods
 Percentage of client visits during which provider demonstrates
skill at clinical procedures, including asepsis
 Percentage of clients reporting “sufficient time” with provider
 Percentage of clients informed of timing and sources for re-
 Percentage of clients who perceive that hours/days are
convenient and the range of services provided is adequate.
Family Planning and Contraception
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Family Planning and Contraception

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Approach to Counseling

 Greet the client in a friendly and respectful manner

 Ask the client about FP/RH needs
 Tell the client about different methods/services
 Help the client to make her own decision about which
method/service to use
 Explain to the client how to use the method/service she has
 Return visit and follow-ups of client scheduled
Family Planning and Contraception
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Rights of Clients

 Information
 Knowledge of not only the benefits but also the risks / side
 Outlets providing FP/ RH services should carry a sign on
a prominent place.
 Access to get the FP/RH services regardless of his/her
sex, race, religion, color and socio-economic status. FP
services should be available to people in their closest
 Privacy
 Continuity
Family Planning and Contraception
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Rights of Clients (cont.)

 Choice to practice FP or RH service should be absolutely

voluntary and free. A competent provider will help the client
to make a decision and will not pressurize the client to make
certain choice for a certain method/service.

 Privacy for FP/ RH counseling where the client would feel

open and frank with the provider.

 Continuity to obtain the FP/RH services without any break or

discontinuation to avoid the after effects and the give-ups of
the service.

 Opinion about the subject, method used and the service

provided. This feedback is always helpful for the provider to
improve one’s service delivery.
Family Planning and Contraception
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Using backup methods to increase
contraceptive effectiveness
 Backup methods: contraceptive methods used simultaneously
w/another method to support it

 Condoms, foam, diaphragm, can all be combined w/other

methods for extra protection

 When a backup method might be a good idea:

– If on the pill:
• During first cycle of the pill
• After forgetting 2 or more pills, or after several days of diarrhea or vomiting when on the pill
• First month after switching pill type
• When taking medications that can reduce effectiveness of the pill
– During first 1-3 months after IUD insertion
– When first learning how to use a new method
– To increase overall effectiveness of contraception
Family Planning and Contraception
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Methods of Contraception

 Natural methods

 Barrier methods

 Hormonal methods


 Sterilization

Family Planning and Contraception

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Effectiveness of birth control methods

w/o spermicide

Family Planning and Contraception

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Natural Family planning methods
 They include:
– Calendar (Rhythm) method
– Standard Day Method
– Basal body temperature
– Cervical mucous method
– Symptothermal method
– Ovulation awareness method
– Lactational amenorrhea method
– Withdrawal ( Coitus interruption )

Family Planning and Contraception

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Fertility Awareness Methods

 Standard days method

– For women w/cycles b/w 26 & 32 days
– Couples avoid unprotected intercourse b/w days 8-19 of each menstrual cycle
– Highest rate of effectiveness of natural family planning methods

 Calendar method: self- knowledge of fertility

– After charting cycles for some time (preferably 1 year), a woman estimates the
time she is ovulating based on the calendar

 Mucus method: based on cyclical changes

– Vaginal secretions change throughout cycle; woman learns to “read” these
changes and keeps a daily chart

 Basal body-temperature
– Based on changes in body temperature around ovulation

 Combination of these methods

Family Planning and Contraception

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Standard Days Method (w/Cyclebeads)
If you have not started 1 On the day you start your
your period by the day your period, move the
after you put the ring on ring to the RED bead.
the last brown bread,
contact your provider. Also, mark this date
on your calendar

2 Every morning
If you start
your period move the ring
before you put to the next
the ring on the bead.
darker brown Always move
bead, contact the ring from
your provider. On WHITE bead days the narrow to
(may not be a good you can get pregnant. the wide end.
method for you)
Avoid unprotected
intercourse to prevent
On BROWN bead a pregnancy.
days you can
have intercourse
with very low When you start your
probability of next period, move the
pregnancy. ring directly to red
bead and begin again.
Family Planning and Contraception
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Arevalo M et al., Contraception, 2002;65:333-338.
Cervical Mucus Method

Early Transitional Highly Fertile

Mucus Mucus Mucus

• Slight amount • Increasing • Profuse

• Thick amounts • Thin
• White • Thinner • Transparent
• Sticky • Cloudy • Stretchy
• Holds its shape • Slightly stretchy
Family Planning and Contraception
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Calendar or Rhythm Method

Low-risk Days

These days may be

unsafe if 28-day cycle
varies as much as 8-9
days between shortest
and longest cycles.

Intercourse on these days

may leave live sperm to
fertilize egg.
Egg may still
be present Ovulation

Family Planning and Contraception

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Basal Body Temperature Method
 BBT=body temp in resting state on waking

 Slight drop immediately before ovulation

 After ovulation, release of progesterone causes

slight increase in temperature

Family Planning and Contraception

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Fertility Awareness Methods
pros & cons
 Pros:
– Essentially free
– No medical side effects
– Does not interrupt sexual activity
– Woman gains awareness about her body and natural cycles, which
can increase comfort w/sexuality
– Acceptable to Catholic Church

 Cons:
– No STI protection
– Requires some degree of discipline in order to keep track of
calendar/charts, etc.
– Need to abstain from intercourse or use a backup method during
fertile days

Family Planning and Contraception

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Barrier & spermicide methods

 Include:
– Condoms (male & female)
– Spermicides (foam, sponge)
– Cervical barriers (diaphragm & cervical cap)

 Work by preventing sperm from reaching an egg

 Condoms provide protection against STIs

Family Planning and Contraception

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Condoms (male)

 Sheath that fits over the erect penis

 The only temporary method of birth control for men

 Only form of contraception that effectively

reduces STI transmission

 Made of thin latex, polyurethane, or natural membrane

 Many varieties
– Different features, shapes, textures, colors, flavors
– Lubricated or nonlubricated

 Note: average shelf life of condoms is 5 years; don’t store latex condoms in
hot places (glove compartment, back pocket) b/c heat can deteriorate the latex

Family Planning and Contraception

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How to use the (male) condom

 Pinch reservoir tip or twist tip of nonreservoir tip condom before unrolling
condom over the penis to leave room for ejaculate--reduces chance of
condom breaking
 Unroll condom over erect penis before any contact between the penis and
vulva occurs

 Use a water-based lubricant to reduce risk of condom breaking (oil-based

lubricants deteriorate condom)

 Hold condom at the base of the penis before withdrawing from the vagina to
avoid spilling semen inside vagina

Family Planning and Contraception

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Female condom

 Consists of two flexible polyurethane rings and a soft,

loose-fitting polyurethane sheath
– One ring at closed end fits loosely against cervix; other ring
at open end encircles the labial area

 Can be inserted before sexual activity; don’t need to

remove it immediately following ejaculation

Family Planning and Contraception

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Costs, pros, & cons of condoms
 Costs
– Male condoms, about $0.75-$1 each
– Female condoms, about $3 each

 Advantages
– STI protection!
– Available w/o prescription or medical intervention

 Disadvantages
– Can reduce sensation
• Polyurethane transmits heat well, so some say that the female condom has less reduction in
– Interruption of sexual experience (though some couples find sensual
ways of incorporating condoms into foreplay)
– Note: female condom can be inserted several hours before intercourse

Family Planning and Contraception

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Vaginal spermicides

 Include: foam, sponge, suppositories, creams, film

 Spermicide: chemical that kills sperm (nonoxynol-9)

 Cost: $0.85 per application

 Advantage: no prescription necessary

 Disadvantages:
– Interruption of sexual experience (except for the
– Skin irritation (which can increase susceptibility to
STI infection)
– No protection from STIs
– Not effective enough to be used w/o a condom or
other method
Family Planning and Contraception
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Cervical barrier devices
diaphragm Cerv cap
 Cervical cap: covers cervix only

 Diaphragm: covers upper FemCap

Lea’s shield
vaginal wall behind cervix
underneath pubic bone

 FemCap & Lea’s shield have

removal straps

 Lea’s Shield allows a one-way flow

of fluid from cervix to vagina

 Method is usually combined


Family Planning and Contraception

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How to use cervical barrier devices

 Diaphragm & cervical cap: need to be fitted (may need to be refitted w/weight
gain or loss >10 lbs.)

 FemCap & Lea’s Shield do not have to be fitted, but still require a prescription
in the U.S.

 Use diaphragm & cervical cap only with water-based lubricants b/c they are
latex (FemCap & L.S. are silicone)

 Can insert up to 6-8 hr. before intercourse; should leave in at least 8 hr after

Family Planning and Contraception

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Placement of cervical barrier devices

(& FemCap)

Family Planning and Contraception

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Intrauterine Devices (IUDs)

 Small plastic objects inserted into


 3 generations
– Inert progesterone
– Copper-releasing
– Hormone-releasing (progesterone)

 Have fine plastic threads attached that hang slightly out of

cervix into vagina for removal

 Very high continuation rate (how many women are still using
it one year after starting) compared w/other methods
Family Planning and Contraception
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IUD Mechanisms of Action

Levonorgestrel-Releasing IUD Copper-Releasing IUD

(LNG-IUS, Mirena®) (ParaGard® T380A)
– Inhibits fertilization – Inhibits fertilization
– Thickens cervical mucous – Releases copper ions (Cu2+)
– Inhibits sperm function that reduce sperm motility
– Thins and suppresses the – May disrupt the normal
endometrium division of oocytes and the
formation of fertilizable ova
Family Planning and Contraception
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Costs, pros, & cons of IUDs

 Advantages
– Very effective (essentially no “user error”)
– Long-term protection
– No interruption of sexual activity
– Don’t have to remember to use
– Can be used during breast-feeding

 Disadvantages
– No STI protection
– Risk of PID (usually within first 1-2 months following insertion)
– Rare incidence of perforating uterine wall

Family Planning and Contraception

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Hormone-based contraceptives

1) Oral contraceptives (pills)

2) Vaginal ring
3) Transdermal patch
4) Injected hormones
5) Hormonal IUDs

Family Planning and Contraception

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Gonadotropin releasing How hormonal
hormone (GnRH) triggers
release of gonadotropins
contraceptives work

FSH & LH trigger


Estrogen & progesterone in
hormonal contraceptives
inhibit LH, FSH, and GnRH
secretion, preventing ovulation

 Progesterone also:
•thickens cervical mucus to prevent
Passage of sperm into the uterus
•changes uterine lining to inhibit implantation
Family Planning and Contraception
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Types of oral contraceptives

 Constant-dose combination pill

– Contains both estrogen and progestin
– Dose of each is constant throughout cycle
– Amount of estrogen in pills has decreased from approx. 175 micrograms in 1960
to avg. of 25 micrograms today

 Triphasic pill
– Levels of hormones (estrogen & progestin) fluctuate during cycle

 Seasonale
– Reduces the # of menstrual periods to 4 instead of 13 per year
– Has lower dose of estrogen and progestin

 Progestin-only pill
– Low dose of progestin and no estrogen
– For women who should not take estrogen (breastfeeding, high b.p., at risk for
blood clots, smoke)
Family Planning and Contraception
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How to use oral contraceptives

 Different types of OCs will differ in how to begin, and other

instructions--read instructions carefully & talk w/health care

 Don’t skip pills, regardless of whether or not you are having


 Take pill at the same time each day

– If you miss 1 pill: take missed pill as soon as you remember, and then
take next pill at the regular time
– If you miss >1 pill: consult health care practitioner for advice; use a
backup method for remainder of your cycle

Family Planning and Contraception

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Oral contraceptives
possible side effects & health issues
 Women who should not take OCs:
– history of blood clots, strokes, heart/circulation problems,
jaundice, breast or uterine cancer, liver disease

 Women considered risky for taking OCs:

– Women who smoke, have migraines, depression, high b.p.,
epilepsy, diabetes/prediabetes, asthma, varicose veins

 Side effects of OCs can include:

– Weight gain, decreased sexual interest, headaches, mood
changes, nausea, bleeding between periods
– May clear up after 2-3 cycles on the pill

Family Planning and Contraception

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Oral contraceptives
possible side effects & health issues
 Rare but serious side effects of OCs--must be
reported to a health care practioner ASAP


Family Planning and Contraception

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Other hormonal methods
(contain both estrogen and progestin)

 Vaginal ring (Nuvaring)

– 2” ring inserted into the vagina during period
– Worn for 3 weeks, removed for 1 week, then
replaced with new ring
– Pros: no daily pill; spontaneity
– Cons: no STD protection, not effective for obese

 Transdermal patch (Ortho Evra)

– Patch is placed on buttock, abdomen, outer
upper arm, or upper torso
– Replaced weekly for 3 weeks, then a patch-free
– Pros: no daily pill; spontaneity
– Cons: no STD protection, skin irritation
Family Planning and Contraception
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Other hormonal methods (cont.)

 Injected Contraceptives
– Depo-Provera (prog.); Lunelle (prog.+est.)
– Injections: D-P every 12 weeks; Lunelle monthly
– Pros: no daily pill; spontaneity
– Cons: no STD protection, weight gain, bleeding, mood
change, frequent clinic visits
– D-P: takes up to 10 months for a woman to get
pregnant after stopping injections

 Contraceptive Implants
– 1.5” rod is inserted under skin of upper arm
– Progestin-only
– Effective for up to 3 years
– Cost not yet known
– Pros: no daily pill; spontaneity
– Cons: no STD protection, weight gain, bleeding, mood
change, surgical procedure
Family Planning and Contraception
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 Essentially permanent, although vasectomies are sometimes


 Does not affect hormones, desire, sexual functioning

 Female sterilization
– Tubal sterilization: fallopian tubes are severed to block passage of
sperm & eggs
– Transcervical sterilization: tiny coil inserted through cervix into fallopian
• Coil promotes tissue growth that, after 3 months, blocks fallopian tubes

 Male sterilization (vasectomy)

– Safer, less expensive, fewer complications than female sterilization
– Cutting and closing vas deferens (ducts that carry sperm)
Family Planning and Contraception
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Ex. of female sterilization procedure

 Laparoscope: narrow, lighted viewing instrument that is

inserted into abdomen to locate the fallopian tubes
Family Planning and Contraception
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Ex. of male sterilization procedure

 Vas deferens on each

side is cut; small
section is removed,
and the ends are tied
off or cauterized

Family Planning and Contraception

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