FAMILY PLANNING

Definition Basic human right Scope Health aspects Terms small family norm target couple eligible couple

National Population Policy of Nepal

Definition

A way of thinking and living based upon the knowledge, attitude and responsible decisions made by an individual or a couple to promote health of family groups and thus to contribute to social development of a country

Basic human right - UN conference on Human rights 1968 - Bucharest conference on world population 1974 - World Conference of the International womens year 1975

Objectives 1. To avoid unwanted pregnancies 2. To limit births 3. To space out pregnancies 4. To time the pregnancies 5. To bring about wanted births Scopes 1. 2. 3. 4. 5. 6. 7. To limit & space pregnancies To advice about sterility Premarital consultation & examination Marriage counselling Pregnancy test Counsel couple for birth of first baby Genetic counselling

8. Screen for related pathological conditions 9. Nutrition education 10. Provide services to unwed mothers 11. Advice on parenthood 12. Sex education 13. Adoption services

Health aspects of family planning

Health aspects

Womens

Foetal

Child

Unwanted preg

Death

Development

Mortality

Limit and space

Growth & develop

Timing

Infectious disease

Intelligence

Small family norm

Eligible couple - currently married - wife in reproductive age group - 150-180 per 1000 - 20% b/w 15-24 years - in need of FP services - eligible couple registers
Target couple - priority group within the eligible couples - with 2-3 living children - concept change

Couple protection rate - contraceptive prevalence rate - percentage of eligible couples effectively protected from childbirth by one or the other approved methods of family planning - NRR=1 only if CPR=60 - most protection in Nepal is via sterilization

National Population Policy of Nepal

A public policy which deals with laws, administrative regulations,
and action programmes having an indirect or direct effect on population growth and distribution.

1959 Family Planning Association of Nepal (FPAN) 1968 FP/MCH 1975 National Planning Commission (NPC) task force PPCC later became 1980 National Commission on Population (NCP) 1983 National Population Strategy 1995 Ministry of Pop & Environ (MOPE)

Now under Department of Health Services (DoHS)

Earlier plans - population mobility - provision of family planning methods - reducing growth rate

10th Plan - poverty alleviation - give quality family planning services

Long term concept - reduce fertility to replacement level in 20 yr

Objectives - to promote small and quality family - to systematize the migration process

Targets for the 10th Plan

Strategies of the 10th Plan

1. For first objective

easy access public awareness review of laws and policies enhance womens status involve educational inst. and NGOs. special programmes

2. For 2nd objective - systemetize both internal and external migration

Special emphasis - population perspective plan (PPP) - review the legal system - population pressure index - vital registration system - girl child

Contraceptive methods

Preventive methods to help women avoid unwanted pregnancies

Ideal contraceptive - effective - safe - long lasting - reversible - low cost - convenient - consumer control - cultural acceptability - independent of coitus

Contraceptive methods
Preventive methods to help women avoid unwanted pregnancies Ideal contraceptive - effective - safe - long lasting - reversible - low cost - convenient - consumer control - cultural acceptability - independent of coitus

Classification
Contraceptive methods
Spacing Barrier IUDs
Hormonal

Terminal
Female sterilization

Male sterilization

Post-conceptional
Miscellaneous

Barrier methods
A. Physical B. Chemical C. Combined A. Physical 1. Condoms male - thin sheaths of latex rubber - mechanism of action- prevent sperm from gaining access to female reproductive tract Failure rate: 3 to 14 per 100 woman years

Method of use - use a new condom every time - condom should be unrolled onto erect penis - squeeze at the tip for the ejaculate - while holding on to the base (ring) of the condom, withdraw penis before losing erection.

Female condoms - polyurethane sheath with rings - flexible rings at both ends - 17 cm long - pre-lubricated

Method - place the index finger on the inside of the condom - push the inner ring up as far as it will go - be sure the sheath is not twisted - the outer ring should remain on the outside - failure rate: 5-21 PHW Special: - expensive - does not require special storage - conducts heat

Advantages: - effective immediately - do not affect breastfeeding - no method-related health risks - no systemic side effects - widely available - no prescription or medical assessment necessary - inexpensive (short-term) - easy to use - protects against STIs - may protect against cervical cancer

Disadvantages - tears or splits - interferes with sensation (male) - continued motivation needed - must be available at the time of coitus - regular supply needed Contraindications for female condom: - vaginal stenosis - genital anomalies - physical disability - severe cystocoele or rectocoele - uterine proplapse

2. Diaphragms - dutch cap - synthetic rubber or plastic material - 5-10 cm diameter - flexible plastic or metal ring - held by ring and vaginal muscle tone - placed and kept for 6 hrs or more afterwards - used with spermicidal jelly - failure rate: 6-12 PHWY advantages: no side effect/ contraindications disadvantage: demonstration/ involuted uterus /privacy/ practice/ TSS

3. Vaginal sponge - polyurethane foam sponge - 5 cm x 2.5 cm - saturated with nonoxynol-9 - failure rate: 9-20 in nulliparous 20-40 in multiparous

B. Chemical methods - Foams: foam tablets, aerosols - Creams, jellies and pastes - Suppositories - Soluble films

- mostly nonoxynol-9 - surface active agents that attach to spermatozoa & inhibit oxygen uptake breaks cell membrane and decreases motility Aerosol is immediately active Suppositories and foam tablets need 10-15 min Jellies used only with diaphragm or condoms

Advantages: - effective immediately (foams and creams) - do not affect breastfeeding - no method-related health risks - no systemic side effects - easy-to-use - increases wetness(lubrication) during intercourse - no prescription or medical assessment necessary Disadvantages: - high failure rate: 6-26 PHWY - used before intercourse and each time - introduced to areas where sperm likely to deposit - irritation & messiness

INTRAUTERINE DEVICES What? It is a small plastic frame with or without medication, placed inside the uterine cavity that prevents pregnancy from occuring Plastic T frame Barium sulphate coat

Copper wire on limbs

Tail attached nylon threads

Types Non-medicated (first generation) Medicated - Copper (second generation) - Hormonal (third generation)

Non-medicated (First Generation)

Lippes loop -polyethylene -spiral, coil, ring -different sizes A-D -kept till needed

T Cu

Earlier

-T Cu-7 -T Cu-200B

Newer variant of T -T Cu-220C -T Cu-380A Nova T (silver core) Multiload device -ML-Cu-250 -ML-Cu-375

Advantages: - low expulsion rate - low incidence of side effects - easier to fit - better tolerated by nullipara - increased effectiveness - effective as post-coital contraceptive (3-5 days)

Hormonal Progestasert - ethylene vinyl actetate copolymer - vertical stem has reservior of 38 mg progesterone - slow release @ 65ug per day - life span one year LNG-20 (Mirena/Levonova) - polyethylene frame - levonorgestrel containing cylinder - covered with rate controlling membrane - releases 20 ug levonorgestrel per day - effective for 5 years

Mechanism of action
Inert - foreign body reaction - biochemical & cellular changes - impair viability of sperm & ova - reduce chances of fertilization

Copper

- enhance cellular response - affects enzymes - biochemical change - affects sperm motility, survival

Hormonal - render endometrium unfavourable - thicken cervical mucus - decrease tubal mobility

Effectiveness
T Cu-380A: 3 to 8 per 1,000 (0.3% to 0.8%) LNG-IUD: 1 to 3 per 1,000 (0.1% to 0.3%) Paling Palette:

Change
Lippes loop not required TCu TCu-200 4 years Nova T 5 years TCu-380A 10 - 12 years Hormonal Progestasert LNG-20 1 year 5 -10 years

Advantages
1. 2. 3. 4. 5. 6. 7. 8. 9. Simple Insertion takes little time Once in place stays long Reversible effect Inexpensive Free from systemic side effects High continuation rate No need for continual motivation Independent of time of intercourse

Disadvantages i) Requires a skilled provider to insert ii) Does not protect against STDs including HIV/AIDS iii) Cannot be used by women who suffer from RTIs/ STDs or by women with spouse/partner with STD.

Who can and cannot use the IUD

Most women can safely use the IUD

But usually cannot use IUD if :

Previous ectopic preg

May be pregnant

Gave birth recently

At high risk for STIs

Unusual vaginal bleeding recently

Infection or problem in female organs

Relative contraindications

- anaemia - menorrhagia - H/O PID since last pregnancy - purulent cervical d/s - anomaly of uterus - fibroids - unmotivated

Ideal IUD candidate

- borne at least one child - no h/o pelvic disease - has normal menstrual periods - has access to treatment & follow up - has a monogamous relationship

WHO Guidance to Use IUDs

PID Purulent cervicitis, chlamydia , or gonorrhea
Do not insert (Category 4)

Other STIs

HIV
Clinically well on ART

AIDS
Not well on or not taking ART Usually do not insert (Category 3)

Condition Exists Before Insertion Condition Develops After Insertion At High Individual Risk for Condition

Do not insert (Category 4)

Generally can insert (Category 2)

Generally can insert (Category 2)

Generally can insert (Category 2)

Generally can keep her IUD while being treated (Category 2) NA

Generally can keep her IUD while being treated (Category 2) Usually do not insert (Category 3)

Generally can keep her IUD while being treated (Category 2) NA

Generally can keep her IUD (Category 2)

Generally can keep her IUD (Category 2)

Generally can insert (Category 2)

NA

NA

Timing of insertion

- during menstruation - within 10 days of menstrual period - first week after delivery - 6-8 weeks after delivery - after first trimester MTP
Follow up - motivate and support - confirm presence - manage complications

- after her first menstrual period - 3 months - 6 months - 1 year

Advice to client
- check thread regularly - report immediately if thread absent - report for complications

Side Effects and Complications i) Common Side Effects: In the first week: mild cramps, bleeding or spotting In the first three months: longer and heavier periods, increased cramps, spotting & expulsion ii) Less Common Side Effects and Complications continuation beyond 3 months anaemia, perforation of uterus, lost Copper-T strings, pelvic Inflammatory Disease (PID) ectopic pregnancy

Bleeding commonest accounts for 10-20% removals volume or duration usually not>3 months IDA give iron tabs lowest with hormonal IUD remove or change

Pain
2nd major side effect accounts for 15-40% removals during insertion, after or during periods low back aches or cramps check for incorrect placement/infection

Pelvic infection 2-8 times more likely to develop PID risk highest in first 20 days after insertion incidence of PID NOT decreased with prophylactic antibiotics can be decreased by proper screening can be decreased by proper procedure Uterine perforation rare with <2/1000 insertions highest risk during insertion suspect if - give way sound >9 cm rapid pulse severe cramps

suspect after insertion if thread shorter severe pain more commom in post abortion, post partum and uterine size <6 cms asymptomatic & revealed on X-ray remove all displaced TCus Pregnancy TCu-380A: 3 to 8 per 1,000 (0.3% to 0.8%) LNG-IUD: 1 to 3 per 1,000 (0.1% to 0.3%) if occurs remove 15-60% pregnancies result in miscarriage if desired and indicated abortion

Ectopic pregnancy chance more in users i.e. 3-4% suspect if severe pain, scanty bleed, amenorrhoea increased risk if h/o PID higher in hormone containing device Expulsion rate vary b/w 4-30% partial or complete most common in the 1st year and 1st 3 months more common in postpartum &post abortion clients early in the mentrual cycle young in age nulliparous 20% go unnoticed at the time

Fertility after removal 72% to 96% of women conceive in 1st yr only PID increases risk

Mortality deaths associated with IUD is extremely rare <1 per 100,000 women due to septic abortion or ectopic pregnancy

Hormonal contraceptives
Contents
1. Synthetic oestrogens - ethinyl estradiol - mestranol 2. Synthetic progestogens - pregnanes: megestrol, chlormadinone, medroxy progesterone acetate - oestranes: norethisterone, norethisterone acetate, lynesterol, etc. - gonanes: levonorgesterel

Mechanisms of Action

Suppress ovulation
Reduce sperm transport in upper genital tract (fallopian tubes)
Change endometrium making implantation less likely

Thicken cervical mucus (preventing sperm penetration)

52

Months

Ovulation

Days of cycle
Changes in the endometrium during normal menstrual cycle

Months

Ovulation

Days of cycle

Endometrium in resting state

Classification
A. Oral pills 1. combined oral contraceptive 2. progesterone only pill 3. post-coital pill 4. once a month pill 5. male pill B. Depot 1. Injectable progesterone only combined 2. Subcutaneous implants 3. Vaginal rings

A. Oral pills
Combined pills

Monophasic: All 21 active pills contain same amount of Estrogen/Progestin

Biphasic: 21 active pills contain 2 different E/P combinations Triphasic: 21 active pills contain 3 different E/P combinations Monophasic0.3 mg norgestrol 0.03 mg ethinyl estradiol

Progestogen only pill (POP) - minipill or micropill - small doses throughout the cycle - poor cycle control - in older women and young with neoplasia risk Post-coital contraception - unprotected intercourse, rape, contraceptive fail. - high dose of estrogen - 4 standard OC pills immediately and 12 hrs later Yuzpes regimen - IUDs

Once a month pill - quinestrol with short acting progestogen - high pregnancy rate - irregular bleeding

Male pill - prevent spermatogenesis, interfere with sperm storage & maturation, prevent transport, affect seminal fluid - gossypol from cotton seed oil azoospermia & oligospermia 10% permanent after 6 months use

Effectiveness - almost 100% effective - actual rate lower - failure rate: 0.1-5 pregnancies PHWY

Disadvantages - nausea, dizziness, mild breast tenderness, headaches or spotting may occur - effectiveness may be lowered when certain drugs are taken - forgetfulness increases method failure - can delay return to fertility - rare serious side effects possible - resupply must be readily and easily available - do not protect against STDs (e.g., HBV, HIV/AIDS

Benefits - pelvic examination not required to initiate use - do not interfere with intercourse - few side effects - convenient and easy to use - client can stop use - can be provided by trained nonmedical staff - decrease menstrual flow - decrease menstrual cramps - may improve anemia - protect against ovarian and endometrial cancer - decrease benign breast disease & ovarian cysts - prevent ectopic pregnancy - protect against some causes of PID

Adverse effects 1. Cardiovascular effects - 40% excess mortality due to MI, cerebral & venous thrombosis - risk increase with age & smoking - reduce dose of oestrogen 2. Carcinogenesis - increased risk of cervical cancer 3. Metabolic effects - primarily attributed to progestogen - high BP, decrease HDL, increased bl. sugar, blood clotting, etc. - increased MI and stroke

4. Other adverse effects - Liver disorders - Lactation - Subsequent fertility - Ectopic pregnancies - Foetal development 5. Common unwanted effects - breast tenderness - weight gain - headache and migraine - bleeding disturbances

Absolute Contraindications: - is pregnant (known or suspected) - is breastfeeding (< 6 weeks postpartum) - viral hepatitis or cirrhosis - ischemic heart disease or stroke - has DVT /pulmonary embolus - is a smoker and age 35 years or older - has diabetes (> 20 years duration) - has headaches (migraine) - has high blood pressure (> 180/110) - has breast cancer - has liver tumors - has to undergo major surgery with prolonged bed rest

Relative contraindications: - has unexplained vaginal bleeding - has high blood pressure (< 180/110) - has a history of breast cancer - has symptomatic gall bladder disease - is taking drugs for epilepsy or tuberculosis

When to start - anytime reasonably sure the client is not pregnant - days 1-7 of the menstrual cycle - postpartum: after 6 months if using LAM after 3 weeks if not breastfeeding - post-abortion (immediately or within 7 days) Usage - fixed time every day - if forgets one day, 2 the next day - if forgets 2 days use other method

Initial and follow up - examination before starting .for contraindications & special precautions .checklist - annual medical examination

B. Depot preparations
Injectables

- progestogen only - combined

Depot preparations - Injectables - subcuntaneous implants - vaginal rings

Progestin only contraceptive DMPA (depo medroxy progesterone acetate) - Depo provera NET-EN (nor ethisterone enanthate) - Noresterat Combined 25mg DMPA + 5 mg estradiol cypionate - Cyclofem 50mg NET-EN + 5 mg estradiol valerate - Mesigyna

36 mg levo -norgestrel

Mechanism of action

- suppress the pituitary surge of Luteinizing Hormone (LH) and Follicular Stimulating Hormone (FSH) thus preventing ovulation
- thicken the cervical mucus making sperm entry into the uterus difficult

- decreases tubal mobility

Months

Ovulation

Days of cycle
Changes in the endometrium during normal menstrual cycle

Months

Ovulation

Days of cycle

Endometrium in resting state

Time of starting - any time if sure woman is not pregnant - 1-7 days of menstrual cycle .if within 7 days & not bleeding .if after 7 days

Back up

- post-partum (progesterone only) -immediately or when sure not pregnant if not breastfeeding -6 weeks after delivery if breastfeeding -if practicing LAM then (whichever first) .when menses return .6 months .no longer fully breastfeeding

- if combined then only after 6 mths or after weaning - post abortion within 7 days

Eligibility criteria
Most women can safely use progestin only inj.

But usually cannot use this injectable if:

Very high blood pressure

Breastfeeding 6 weeks or less

May be pregnant

Some other serious health conditions

Who can and cannot use a monthly injectable

Most women can safely use combined

But usually cannot use this injectable if:

Smokes heavily AND age 35 or older

High blood pressure

Gave birth Breastfeeding May be in the last 3 pregnant 6 months weeks or less

Some other serious health conditions

Method
Intramuscular at deltoid or gluteus

Preparation
Depo-provera (Sanghini) NET-EN Mesigyna or Cyclofem

Dosage/route
150 mg im 200 mg im As given Earlier im

Schedule
3 monthly 2 monthly monthly

Subsequent injections (grace period) Preparation Late Early

DMPA
NET-EN Combined

2-4 weeks
1-2 weeks 3 days

4 weeks
2 weeks 3 days

After grace period: if sure not pregnant - give injection if not sure - use barrier method till sure

Possible side-effects
many women dont have any Often go away after a few months Most common:

Nausea (upset stomach)

Spotting or Mild bleeding headaches between periods

Tender breasts

Dizziness

Slight weight gain

Norplant

- pain & itching at the insertion site - infection at the insertion site - keloid - expulsion of the capsule

Effectiveness

DMPA:
NET-EN:

0.3% after first year of use

0.4% after first year of use

Cyclofem: <0.1% after first year of use Mesigyna: 0.2% after first year of use But effectiveness depends on: - the time of first injection - injection schedule - injection technique

Return to fertility

DMPA:
NET-EN: Norplant:

9 months
11 months 12 months

Advantages

1. Gives long term protection 2. Is independent of the time of intercourse 3. Some women have amenorrhoea that protects from Iron deficiency anaemia
Disadvantages 1. Is an invasive technique 2. Bleeding irregularities 3. Late return of fertility 4. Ectopic pregnancy 5. Norplant needs surgical procedure 6. Training needs

Vaginal rings - rings contain levoneorgestrel - slow release of hormone - bypass liver & lower dose - worn for 3 weeks and taken out on 4th

Post-conceptional method (termination of pregnancy)

Menstrual regulation - 6-14 days after missed period - uterine aspiration - no confirmation of pregnancy - no legal problems - safer Menstrual induction - 1-5mg solution pellet of prostaglandin F2 - sustained contraction for 7 minutes and cyclic for 3-4 hours

Abortion

Miscellaneous

1. Abstinence best but difficult 2. Coitus interruptus good but high failure rate 3. Calendar 4. Natural 5. Lactational 6. Vaccine

Calendar - depending upon the length of the cycle - safe period calculated - ovulation occurs between 12-16 days

shortest cycle 18=1st day of unsafe period longest cycle 10=last day of unsafe period Eg 24-30 days cycle 24-18 = 6 30-10=20 Fertile period (unsafe) = 6th to 20th day of the cycle Abstinence or use contraception

The Standard Days Method

Based upon 26-32 days cycle

Identifies days 8-19 of the cycle as fertile. A client can use a color-coded string of beads to help her keep track of where she is in her cycle and know when she is fertile.

Standard Days Method

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Efficacy of the SDM

Correct use (with abstinence)

4.7

Correct use (with other method) Correct + non-compliance

5.6 11.9

Natural FP methods
- self recognition of ovulation - abstains 1. Basal body temperature (BBT) 2. Cervical mucus method (Billings method) 3. Symptothermic BBT - rise of BBT at ovulation - 0.3-0.5 degree C - morning - restrict intercourse to post-ovulatory period - begin 3 days after rise

NFP: Basal Body Temperature Chart

Temp. (Celsius)

37.1 37.0 36.9 36.8 36.7 36.6 36.5 36.4 36.3 36.2 36.1 36.0

Infertile

Cover Line

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Day

Cervical mucus method - watery clear mucus during ovulation - egg white appearance - smooth, slippery and profuse - afterwards, thickens - tissue paper - high degree of motivation Symptothermic - combination of Billings, Calendar and cervical mucus method

LAM: Mechanisms of Action

Frequent intense suckling disrupts secretion of gonadotrophin releasing hormone (GnRH)
Irregular secretion of GnRH interferes with release of follicle stimulating hormone (FSH) and leutinizing hormone (LH)

Decreased FSH and LH disrupts follicular development in the ovary to suppress ovulation
96

LAM: Contraceptive Benefits

Effective (1-2 pregnancies per 100 women during first 6 months of use) Effective immediately Does not interfere with sexual intercourse No systemic side effects No medical supervision necessary No supplies required No cost involved
97

LAM: Noncontraceptive Benefits

For child:
Passive immunization and protection from other infectious diseases Best source of nutrition Decreased exposure to contaminants in water, other milk or formulas, or on utensils

For mother:
Decreased postpartum bleeding
98

LAM: Limitations
User-dependent (requires following instructions regarding breastfeeding practices) May be difficult to practice due to social circumstances Highly effective only until menses return or up to 6 months Does not protect against STDs (e.g., HBV, HIV/AIDS)
99

Who Can Use LAM

Women who: Are fully or nearly fully breastfeeding Have not had return of menses Are less than 6 months postpartum1

1WHO

recommends supplementation at 6 months. If begun earlier, LAM is not as effective. 100

LAM: Client Instructions

Breastfeed from both breasts on demand (about 6 to10 times per day)

Breastfeed at least once during night (no more than 6 hours should pass between any two feedings) Do not substitute other food or liquids for breastmilk meal
Once you substitute other food or drink for breastfeeding meals, the baby will suckle less, and LAM will no longer be effective contraceptive method
101

FEMALE AND MALE STERILIZATION

Female Male tubectomy vasectomy

Permanent methods of contraception Eligibility

Preparation
Procedure After care

Female sterilization
(VSC, minilap, tubectomy) - Surgical method for women - Very effective - Convenient

- Permanent
- Safe, simple procedure - No known long-term side effects

Eligibility Categories A Accept - no medical reason to deny C Caution - procedure is normally conducted in a routine setting - with extra preparation & precautions D Delay - delayed until the condition is evaluated and/or corrected. - alternative temporary methods S Special - undertaken in a setting with an experienced surgeon & staff, needed to provide general anaesthesia, and other back-up medical support - the capacity to decide on the most appropriate procedure - alternative temporary methods

- have 2 children any age - uterine fibroids DM, mild HT Hb 7-10 gm% obesity - abdominal skin infection current PID Hb <7 gm%

- vascular disease or DM of >20 yrs duration - hyperthyroid, severe Ht

When?

- immediately postpartum
- till 7 days pp or after 6 weeks pp - post abortion within 48 hrs - any time sure she is not pregnant

Counselling
Discuss:

Temporary methods are also available

Sterilization is a surgical procedure

Has risks and benefits

Prevents having any more children Permanentdecision should be carefully considered You can decide against procedure any time before surgery
Are you ready to choose tis method? Want to know more about the procedure?

Ask about

- gynae or obstetric problems - cardiovascular problems - chronic disease or conditions

Examination General physical and systemic exam pallor, BP, lung, heart, pelvic exam

Procedure

1. Minilap 2. Laproscopic
Steps: 1. Light sedative 2. Local anaesthesia just above the pubic hairline 3. Incision of 2-5 cm

4. Raise uterus with elevator for fallopian tubes 5. Each tube tied and cut(15 mm) or rings/clips 6. Suture the incision wound & cover 7. Advice to the woman

AFTER THE PROCEDURE THE WOMAN SHOULD: Rest for 2 or 3 days and avoid heavy lifting for a week; Keep the incision clean and dry for 2 or 3 days; Be careful not to rub or irritate the incision for 1 week Take pain-relief medicine as needed but not aspirin or ibuprofen Not have sex for at least 1 week Come after 7 days to remove suture & follow up

Medical reasons to return

In first week, come at once if:

High fever

Pus or Pain, heat, bleeding swelling, from redness of wound wound

At any time in the future, come at if:

You think you may be pregnant

Steady or worsening pain, cramps, tenderness once in belly

Faintin g or very dizzy

Pain or tenderness in belly, or fainting

ADVANTAGES

Very effective. Permanent. A single procedure leads to lifelong, safe, & very effective family planning. Nothing to remember, no supplies needed, and no repeated clinic visits required. No interference with sex. Increased sexual enjoyment no worry about pregnancy. No effect on breast milk. No known long-term side effects or health risks. Minilaparotomy can be performed just after a woman gives birth.

DISADVANTAGES usually painful at first uncommon complications of surgery: - infection & bleeding - injury to internal organs - related to anaesthesia ectopic if pregnancy occurs specially trained person compared to male riskier and expensive reversal difficult does not protect against HIV/STD

Other methods of sterilization:

Microcoil-essure

Failure rate: 0.2 per 100 women years in the first yr post partum its <0.02 per 100 WY

Male sterilization
Surgical method for men - Very effective - Convenient - Permanent

- Safe, simple procedure

- No known long-term side effects

Eligibility criteria

A
C D S

HIV risk
young age, depressive, diabetics scrotal skin infection, active STI AIDS, coagulation disorder

When ?
Most men can have vasectomy at any time

But may need to wait if: Any problems with genitals such as infection, swelling, injuries, lumps in penis or scrotum Some other serious conditions or infections

Counselling - permanent/irreversible - complications - time to become sterile - no change in libido - other methods available - not protect against STI/HIV - pre-operative care - post operative care Prepare - bathe & shave - anxiolytic

Procedure: conventional Inject local anaesthetic over incision site

Vas isolation using the three-finger technique.

Simulation of vas isolation using the "pincer-grasp" technique.

1- to 2-cm incision over scrotal skin overlying the vas

A clamp is used to isolate the vas

Fibrous tissue surrounding the vas is incised longitudinally

Vas is fully isolated and ready for division.

Metal surgical Remove 1.5 cm clips are placed Thermal cautery is before division inserted into the free ends of the vas

Fascia is closed over the proximal end in a purse -string fashion

wound is closed with absorbable suture

Non-scalpel vasectomy

- one puncture - ringed clamp - procedure of vas division same - no suture required

Advantages over conventional - shorter operating time - less pain & swelling - faster recovery - combine with fascial interposition

Afterwards: - ice application & scrotal support - should rest for 2 days - avoid heavy work for a few days - Important! Use condoms for next 3 months semen analysis Complications 1. Pain 2. Swelling 3. Haematoma 4. Infection 5. Sperm granuloma 6. Prostatitis 7. Failure due to re-canalization

Medical reasons to return

Come at once if: Swelling in first few hours after surgery Fever in first 3 days

Pus or bleeding from wound

Pain, heat, redness of wound

Conclusion
VSC is a very effective method of permanent contraception Ideal for ones who have completed family Safe and inexpensive

Abortion
termination of pregnancy before the viability of the foetus - 28 weeks/1000 gms Types Spontaneous - in every 15 pregnancies - known and unknown reasons Induced - used as family planning method - health of mother and baby

Abortion data

Worldwide
- 20 million unsafe abortion-95% develp. count. - 80,000 maternal deaths - 40-70/1000 women of reproductive age group - 260-450 abortions per 1000 live births Nepal - 5.4% maternal deaths due to abortion - 117/1000 women aged 15-49 years(1994)

Abortion hazards Early - haemorrhage, shock - sepsis - uterine perforation - cervical injury - thromboembolism - anaesthesia - psychaitric Late

- infertility - ectopic - increased risk for spontaneous abortion - reduced birth weight

Abortion in Nepal Till 2002 illegal, imprisonment Since September 2002 - legalized

Comprehensive abortion care (CAC)

Conditions under which abortion can be done: With the consent of the lady and 1. Pregnancy is < 12 weeks 2. Upto 18 weeks if pregnancy is result of rape or incest 3. Life threatening to the mother/disabled child

Abortion will be termed illegal and punishable if: 1. Done without consent 2. Woman forced or coerced 3. After sex discrimination 4. Beyond 12 weeks/18 weeks Safe abortion 1. Done by a trained personnel 2. Done within 12 weeks 3. Done at a place where adequate facilities are available

Method used in Nepal: Manual Vacuum Aspiration (MVA)

Trained personnel - trained by Family Health division of MoH Registered centres - centres who have trained their personnel and registered under MoH as an abortion centre e.g FPAN, Marie Stopes International, etc. Centres - maintain abortion registers and forms - patient details, consent - details of P/S and P/V examination - duration of procedure - amount of bleeding

- product obtained - reasons for CAC - contraception adopted

Family Planning Programme of Nepal

Started in 1959 FPAN
Now part of Reproductive Health/Family Planning Prog. under FH division under MoH Objectives - Space or limit children - Prevent unwanted pregnancies - Manage infertility - Improve overall reproductive health

Targets - TFR 3.5 by 2007 and 2.5 by 2007 - CPR 47% by 2007 and 65% by 2017

Strategies - ensure maximum coverage and quality services - increase awareness about benefits of delayed marriage, birth spacing & small family norm - availability & accessibility via static & outreach - expand mobile VSC services, IUDs - manage & treat infections, counsel - increase free access & supply of condoms, pills, depo provera, etc. - train, monitor, evaluate Percentage of contraceptive used in Nepal - female sterilization 16.5% - male sterilization 7%

- depo provera - condoms - pills - norplant - IUCD

9.3% 3.2% 1.8% 0.7% 0.4%

Unmet need: women who on survey say that they want to postpone or avoid childbearing but are not using contraception neither are their partners - demand 67.1% met need-39.3% unmet need-27.8% - Unmet spacing-11.4% limiting-16.4%

Counselling for family planning

- GATHER approach G- greet A- Ask T- Tell H- Help (choice) cafeteria approach E- Explain R- Return