Family planning and contraceptive choices

Family Health

1. Family Planning and Contraceptive Choices Presented By: Shikha Basnet MPh , 2021 BPKIHS

2. Outline of presentation Family Planning Introduction Contraception Classification of Contraceptive methods Benefits of Family planning Global Scenario Nepal Scenario Challenges Priority actions Conclusion References 1/24/2022 2

3. Family Planning 1/24/2022 3

4. Introduction (1) Family planning is defined as “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” - WHO Family planning refers to supplies and services which enable individuals and couples to attain and plan for their desired number of children, and the spacing and timing of births. 1/24/2022 4

5. Introduction (2) Supplies include modern contraceptive methods and services include health care, counselling and information and education related to sexual and reproductive health. The ability of individuals to determine their family size and the timing and spacing of their children has resulted in significant improvements in health and in social and economic well-being . 1/24/2022 5

6. Introduction (3) Family planning could prevent up to one-third of all maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies, and unsafely performed abortions, and stop childbearing when they have reached their desired family size. Pregnancy and childbirth in adolescence can have long-lasting impact on the social and economic well-being and are among the leading causes of death among women aged 15-19 years (World Health Organization, 2018). 1/24/2022 6

7. Introduction (4) Contraceptive information and services are fundamental to the health and human rights of all individuals. Family planning is often characterized as a key investment because it provides a lifetime of benefits to users and their families and communities. At the individual level, there are benefits in infant, child and maternal health outcomes (SDG 3), improved educational outcomes (SDG 4), gender equality and women’s empowerment (SDG 5) and equal access to the labor market, social protection and the political process (SDGs 5, 8, and 16). 1/24/2022 7

8. Introduction (5) The Family Planning Sustainable Development Goals model demonstrated that improvements in socioeconomic status along with investments in family planning maximize long-term progress towards reducing poverty and food insecurity and increasing income . These analyses have helped to build the economic case for investment in family planning and have shown the relevance of family planning for achieving the Sustainable Development Goals. 1/24/2022 8

9. Introduction (6) Eligible couples : An  "eligible couple" refers to a  currently married couple where in the  wife is  in the reproductive age, between the ages  of 15 to 49. Target couples :   Eligible couples who have 2 – 3 living children. These formed a priority group among the eligible couples. Now even couples with just one or newly married couples are also considered a priority for family planning services. 1/24/2022 9

10. Introduction (7) Contraceptive Prevalence Rate Contraceptive prevalence is the percentage of women who are currently using, or whose sexual partner is currently using, at least one method of contraception, regardless of the method used. Total Fertility Rate The average number of children a woman will bear by the end of her reproductive life under prevailing fertility conditions Net Reproduction Rate It is defined as the number of daughters a newborn girl will bear during her lifetime assuming fixed age specific fertility and mortality rates. If the NRR is less than 1 then the reproductive performance of the population is said to be below replacement level. 1/24/2022 10

11. What is Contraception? (1) Contraception is t he deliberate prevention of conception by any of various drugs, techniques, or devices of birth control. Contraceptive methods are preventive methods to help women avoid unwanted pregnancies. It includes all temporary and permanent measures. 1/24/2022 11

12. What is Contraception? (2) Safety, effectiveness, availability (including accessibility and affordability), and acceptability need to be considered whil e choosing contraceptive methods. Voluntary informed choice of contraceptive methods or present approach is to provide a ‘cafeteria choice’. While choosing a method of contraception, dual protection from the simultaneous risk for HIV and other STDs also should be considered. 1/24/2022 12

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16. Natural Methods 1/24/2022 16

17. Abstinence Only method of birth control which is completely effective is sexual abstinence Abstinence is simply not having sexual intercourse. It prevents pregnancy by not giving the opportunity for semen to enter the vagina. A sperm can’t fertilize an egg if there is no intercourse. 1/24/2022 17

18. Coitus Interruptus It is also known as withdrawal, is a traditional family planning method Coitus interruptus prevents sperm from entering the woman’s vagina, thereby preventing contact between spermatozoa and the ovum. Failure rate is as high as 25% 1/24/2022 18

19. Lactational amenorrhea method Lactation prolongs postpartum amenorrhea and provides some degree of protection against pregnancy Through exclusive breastfeeding  of the infant, the woman is able to suppress ovulation through this method. By 6 months of exclusive breast feeding about 20-50 %of women are menstruating and are in need of contraception. It is also best to advise the woman that after 3 months of exclusive breastfeeding, she must make plans of choosing another method of contraception. 1/24/2022 19

20. Biological Methods 1/24/2022 20

21. Safe period (rhythm method) this natural method of family planning involves refraining from coitus during the days that the woman is fertile. Also called Calendar method The process in calculating for the woman’s safe days is achieved when the woman records her menstrual cycle for six months. Using the rhythm method for birth control requires careful record keeping and persistence. 1/24/2022 21

22. Safe period (rhythm method) Contd.. She subtracts 18 from the shortest cycle and the difference is the first fertile day. She also subtracts 10 from the longest cycle, and this becomes the last fertile day. Starting from the first fertile day until the last day, the woman should avoid coitus to avoid conception. For example: If a woman’s menstrual cycle varies from 26-31 days, the fertile days during which she should not have intercourse would be from the 8 th day to the 21 st days of the menstrual cycle, counting day one as the first day of the menstrual period. It has an ideal fail rate of 5%, but when used it has a typical fail rate of 25%. 1/24/2022 22

23. Basal Body Temperature It is the temperature of body of woman when she is in complete at rest. After a woman ovulates, her body temperature rises slightly as a result of an increase in the production of progesterone . While tracking the basal body temperature during multiple menstrual cycles can help to establish a pattern. She will then be able to understand when she is likely to ovulate. The best time to take this temperature is immediately after waking up. This method may not accurately predict ovulation in all women, including those with irregular menstrual cycles. 1/24/2022 23

24. Cervical mucus method Also called the Billings Ovulation Method It is based on careful observation of mucus patterns during menstrual cycle. Before ovulation, cervical secretions change creating an environment that helps sperm travel through the cervix, uterus and fallopian tubes to the egg. At the time of ovulation cervical mucus becomes watery, clear resembling raw egg white, smooth, slippery and profuse. After ovulation, mucus thickens and lessens in quantity. This method requires a high degree of motivation than most other methods. 1/24/2022 24

25. Chemical Methods 1/24/2022 25 Spermicides are sperm-killing chemicals inserted deep into the vagina, near the cervix, before sex. They are available in foaming tablets, melting or foaming suppositories, melting film, jelly and cream. the least effective family planning methods, with a 29% chance of pregnancy, Spermicides should not be used alone as the primary method of birth control.

26. Mechanical Methods 1/24/2022 26

27. Condom 1/24/2022 27 A  condom  is a sheath-shaped barrier device  prevents the semen from being deposited in the vagina. There are both male and female condoms. It provides protection against STD. It can be highly effective method of contraception if used correctly at every coitus. Failure rates varying from 2-3 per 100 women to more than 14 in typical users.

28. Diaphragm 1/24/2022 28 Diaphragm It is a vaginal barrier Also known as ‘Dutch cap’ It is a shallow cup made of synthetic rubber or plastic material It is inserted before sexual intercourse and must remain in place for not less than 6 hours after intercourse. Failure rate with spermicide vary between 6 to 12 per 100 women-years.

29. Vaginal Sponge 1/24/2022 29 Vaginal Sponge It is a type of birth control (contraceptive) that prevents sperm from entering the uterus. It is soft and disk-shaped and made of polyurethane foam. The contraceptive sponge contains spermicide, which kills sperm. An estimated 12 out of 100 women who have never given birth will get pregnant during the first year of typical use of the contraceptive sponge. Source: https://www.mayoclinic.org/tests-procedures/contraceptive-sponge/about/pac-20384547

30. Intra- Uterine Device (IUD) 1/24/2022 30

31. Intra- Uterine Device An IUD is a small object T shaped that are inserted inside the uterus. There are two types: hormonal IUD and copper IUD (TCu-380 A ) Works for three, five or 10 years depending on the type of IUD More than 99% effective The device can be inserted or taken out only by trained health person. 1/24/2022 31 Source: https://www.familyplanning.org.nz/advice/contraception/intra-uterine-device-iud

32. Hormonal Methods 1) Oral Pills -Combined oral pills -Progestogen only pill (POP) -Post-coital pill -Once- a- month (long acting) pill -Male pill 2) Depot (slow release) formulations Injectables Implants Vaginal rings 1/24/2022 32

33. Combined Oral Pills The oral contraceptive pill is a pill taken daily. The pill needs to be taken at the same time every day to effectively prevent pregnancy. It’s ability to prevent pregnancy depends on a person using it correctly. It’s one cycle contains 21 hormonal tablets and 7 Iron tablets. The composition of each white colored tablet contains Levonorgestrel 0.15 mg, Eithinyl Estradiol 0.03 mg and each brown tablet contains Ferrous Fumarate 75 mg.   Effectiveness = 99% 1/24/2022 33

34. Progestogen only pill (POP) Commonly referred to as ‘minipill’ or ‘micro pill’ It is a form of oral contraception that is taken every day at the same time to prevent pregnancy. Mostly used progesterone are norethisterone and levonorgestrel. It is useful for women who can't use the combined pill which contains estrogen. It is about 93% effective. 1/24/2022 34

35. Once a month (long acting) pill It is a slowly releasing hormones to prevent a pregnancy. Quinestrol , a long acting estrogen is given in combination with a short acting progesterone. The prototype is a star-shaped drug delivery system packaged into an easy-to-swallow dissolvable capsule no bigger than a regular fish oil tablet. Once it reaches the stomach, the star unfolds like a flower and starts doing its work of steadily releasing contraceptive hormones housed on its six arms. The star is too big to immediately exit the stomach and will remain there for weeks until it has finished its job and can be broken down and excreted from the body. Effectiveness= 91% 1/24/2022 35

36. Male pill The search for male contraceptive began from 1950 A male pill made of gossypol (a derivative of cotton seed oil) is effective in producing azoospermia or severe oligospermia. More than 10% of men may be permanently azoospermic after taking it for 6 months. 1/24/2022 36

37. Injectables Contraceptives DMPA or Depo-Provera Depot-medroxyprogesterone acetate has been in use since 1960s. The standard dose is an intramuscular injection of 150mg every 3 months. It gives protection from pregnancy in 99% of women for at least 3 months. The side effects of DMPA are weight increase, irregular menstrual bleeding, and prolonged infertility after its long term use. 1/24/2022 37

38. Implant ( jadelle ) The implant is made up of two small rods the size of a matchstick. The rods are put under the skin in the inside of arm. Each implant contains 75 mg of the  progestin levonorgestrel. It is indicated for the prevention of  pregnancy  and are a long-term (up to 5 years) reversible method of contraception. The implant is more than 99% effective. 1/24/2022 38

39. Vaginal rings The vaginal ring (NuvaRing) is a small soft, plastic ring that is placed inside vagina. It releases a continuous dose of the hormones estrogen and progestogen into the bloodstream to prevent pregnancy. If used correctly, the vaginal ring is  more than 99%  effective. One ring provides contraception for a month , so women don't have to think about it every day. 1/24/2022 39

40. Post-coital contraceptive It is advocated as an emergency method; for example, after unprotected intercourse, rape or contraceptive failure. Two methods are available: IUD and hormonal. IUD (copper device) can be inserted within 5 days. Hormonal can taken as emergency contraceptive pill which consists of Levonorgestrel (1 tablet of 1.5 mg or 2 tablets of 0.75 mg). To obtain optimal efficacy, it should be taken as soon as possible within 120 hours of intercourse. 1/24/2022 40

41. Permanent Methods 1/24/2022 41

42. Vasectomy A vasectomy (male sterilization ) is a surgical procedure to cut or seal the tubes that carry a man's sperm to permanently prevent pregnancy. It's usually carried out under local anesthesia. more than 99% effective. Contraception should be used for at least 8 to 12 weeks after the operation, because sperm will still be in the tubes leading to the penis. 1/24/2022 42

43. Minilap Female sterilization is an operation to permanently prevent pregnancy. The fallopian tubes are cut and tied to prevent the eggs reaching the sperm and becoming fertilized. Female sterilization is more than 99% effective at preventing pregnancy. It does not affect hormone levels and monthly periods. 1/24/2022 43

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45. Recent advance in family planning 1/24/2022 45

46. Kyleena Smallest and the lowest dose of 5 years hormonal IUD The Kyleena IUD consists of a soft, flexible polyethylene (plastic) frame in the shape of a T. The Kyleena IUD contains 19.5 milligrams (mg) of levonorgestrel. It releases 17.5 micrograms (mcg) of this hormone per day. After one year, this rate slowly declines to 9.8 micrograms daily, and then to 7.4 micrograms per day. Effectiveness: 98.6% 1/24/2022 46

47. Sayana Press It is a lower-dose formulation and presentation of the contraceptive Depo-Provera, manufactured by Pfizer Inc.  a subcutaneous self administered contraceptive injection for women. pre-filled with the drug, so the injection is ready-to-use. single-dose container with 104 mg medroxyprogesterone acetate (MPA) in 0.65 ml suspension for injection. prevent pregnancies for 3 months. It is being launched in Nepal in two districts: Nawalpur and Sindhuli , by the reproductive health agency Ipas Nepal in coordination with the UK’s Department for International Development (DFID) and the MoH. 1/24/2022 47

48. Reversible Inhibition of sperm under guidance (RSIUG) RISUG is a co-polymer of Styrene Maleic Anhydride (SMA) dissolved in Dimethyl Sulfoxide (DMSO) to form a gel It is a non-surgical method of male sterilization that is inexpensive, highly effective, and reversible. It involves an injection of the solution into each of the patient's Vas deferens, which forms a layer around the vas walls partially (but not completely) blocking the flow of sperm cells. It causes the disruption of the membrane of spermatozoa and release of enzymes that are essential for the fertilization of ova. Thus the ejaculation after RISUG contains infertile spermatozoa. RISUG has also been tested successfully in number of human volunteers during Phase-I, Phase-II and Phase-III clinical trials. Presently the drug is under extended Phase-III clinical trials at various centers in India. 1/24/2022 48

49. 1/24/2022 49 RISUG: mode of action. (A) Vas is exposed from inguinal region and RISUG is injected in both vas deferens towards distal region by a micro-syringe. (B) RISUG coats the wall of the vas deferens blocking sperm movement. (C) Complete reversal obtained after DMSO/NAHCO3 is injected bilaterally, flushing component of RISUG

50. Evaluation of Contraceptive methods Pearl Index It is defined as the number of ‘failures per 100 woman-years of exposure’ Pearl Index = (Number of pregnancies x 12) x 100 / (Number of women in the study x Duration of study in months) 1/24/2022 50

51. 1/24/2022 51 Source: https://www.usaid.gov/global-health/health-areas/family-planning#dataSources

52. Global Scenario (1) Expanding access to contraception is an essential component of achieving universal access to sexual and reproductive health-care services, as called for in the 2030 Agenda for Sustainable Development. In 2020, among 1.9 billion women of reproductive age (15-49 years), 1.1 billion women are considered to have a need for family planning , meaning that they desire to limit or delay childbearing. Of these women, 851 million are using a modern method of contraception and 85 million are using a traditional method . 1/24/2022 52

53. Global Scenario (2) An additional 172 million women are using no method at all, despite their desire to avoid pregnancy, and thus are considered to have an unmet need for family planning. Most women who use contraception rely on modern methods, but the specific contraceptive methods used vary by region. Still, nearly 1 in 10 women of reproductive age worldwide have an unmet need for family planning: they want to avoid or postpone pregnancy but are not using any form of contraception. 1/24/2022 53

54. Global Scenario (3) Between 2000 and 2020, the contraceptive prevalence rate (percentage of women aged 15-49 who use any contraceptive method) increased from 47.7 to 49.0 percent. Whereas contraceptive use is currently lowest in sub-Saharan Africa, at 27.8 percent, this level is projected to increase over the next decade to 32.9 per cent. The proportion of women who have their need for family planning satisfied with modern methods (SDG indicator 3.7.1) has increased from 74 to 76 per cent from 2000 to 2019. 1/24/2022 54

55. Nepal Scenario (1) Family planning (FP) is one of the important components of Nepal’s national health system. The aim of National FP program is to ensure individuals and couples fulfil their reproductive needs and rights by using quality FP methods voluntarily based on informed choices. Government of Nepal ( GoN ) is committed to equitable and right based access to voluntary, quality FP services based for all individuals with special focus on hard to reach communities such as adolescents, migrants, slum dwellers, sexual minorities and other vulnerable groups ensuring no one is left behind . 1/24/2022 55

56. Nepal Scenario (2) To achieve this, GoN is committed and striving: to strengthen policies and strategies related FP within the new federal context, mobilize resources, improve enabling environment to engage effectively with supporting partners, promote public-private partnerships, and involve non-health sectors. FP has been enshrined as a fundamental right in the constitution, and included in the basic health service package under the Public Health Act 2018, thus paving a way towards universal health coverage. 1/24/2022 56

57. Nepal Scenario (3 ) FP is an essential health care services of Nepal Health Sector Program II (2010‐2015), National Family Planning Costed Implementation Plan 2015‐ 2021, Nepal Health Sector Strategy 2015‐2020 (NHSS) and the Government of Nepal’s commitments to FP2020. FP information, education and services are provided through the government, social marketing, NGOs and the private sector (including commercial sectors). In public health system, short acting reversible contraceptive methods are provided through PHCCs, health posts, Urban Health Units (UHC), Community Health Units (CHU), PHC-ORCs. 1/24/2022 57

58. Nepal Scenario (4) FCHVs provide information and education to women and couple at community and distribute male condoms and resupply OCPs. Access to LARC services in remote area is provided through satellite clinics, extended visiting service providers and mobile camps. A sterilization service is provided at static sites or through scheduled seasonal and mobile outreach services. 1/24/2022 58

59. Objective of Family planning program Overall objective of the FP program is to improve health status of all people through accountable and equitable health service delivery system through informed choice to access and use voluntary FP (through increased and equitable access to quality FP information and services) 1/24/2022 59

60. Policies and Strategies 1 . Enabling Environment: Strengthen enabling environment for family planning Establish family planning as reproductive rights of females and males. 2. Demand Generation: Increase health care seeking behavior among population with high unmet need for modern contraception. 1/24/2022 60

61. Policies and Strategies 3. Service Delivery: Enhance FP service delivery including commodities to respond to the needs of marginalized, rural residents, migrants, adolescents and other special groups. Increase availability of broader range of modern contraceptives and improved method mix. Effective integration of family planning services with other health services Strengthen effective procurement and logistics management system to ensure regular availability of family planning commodities. Promote family planning services delivery through government, private, non-­‐ governmental organization and social marketing approaches. 1/24/2022 61

62. Policies and Strategies 4. Capacity Building: Strengthen capacity of service providers to expand FP service delivery network. 5. Research and Innovation: Strengthen evidence base for effective program implementation through research and innovations. 1/24/2022 62

63. SDG Target 1/24/2022 63 Target and Indicators 2020 status Source 2030 3.7.1 Proportion of women of reproductive age (aged 15-49 years) who have their need for family planning satisfied with modern methods 61.9 NMICS 80 a. Contraceptive prevalence rate (modern methods) (%) 44.2 NMICS 60 b. Total Fertility Rate (TFR) (births per women aged 15-49 years) 2.0 NMICS 2.1 c. Adolescent birth rate (aged 10-14 years, aged 15-19 years) per 1,000 women in that age group 63 NMICS 30

64. 1/24/2022 64 Source: DoHS , Annual Report 2076/77 (2019/20)

65. 1/24/2022 65 Source: DoHS, Annual Report 2076/77 (2019/20)

66. Major activities (1) Provision of regular comprehensive FP service including post-partum and post abortion FP services Provision of long acting reversible services, Permanent FP Methods or Voluntary Surgical Contraception (VSC) FP strengthening program through the use of decision-making tool (DMT)and WHO medical eligibility for contraceptive (MEC) wheel Micro planning for addressing unmet need of FP in hard to reach and underserved communities Provision of RANM and VSP service to increase FP service use 1/24/2022 66

67. Major activities (2) Integration of FP and immunization service Satellite clinic services for long acting reversible contraceptives Contraceptive update for Obstetrician/Gynecologist, nurses & concerned key players Interaction program on FP and RH including ASRH with pharmacist and marginalized communities Community interaction with satisfied clients for promoting permanent method and IUCD 1/24/2022 67

68. Unmet need Unmet need for family planning is defined as the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning. Women with unmet need are those who are want to stop or delay childbearing but are not using any method of contraception. 1/24/2022 68

69. Why are people still reluctant in using FP? limited choice and access to contraception a fear or experience of side-effects cultural or religious opposition poor quality of available services Lack of youth-friendly services Lack of awareness of family planning services among hard-to-reach populations migration Source: https://dhsprogram.com/pubs/pdf/FR336/FR336.pdf 1/24/2022 69

70. Challenges Inefficient public procurement system, which creates delays for contraceptive procurement leading to frequent stock outs. Issues with quality of data: accuracy, adequacy, and time. Quality of FP counseling services remains an issue Lack of skilled health workers to provide quality FP High rate of spousal separation due to migration. 1/24/2022 70

71. Priority actions (1) Advocate for family planning at all levels of government and with donor agencies to ensure that family planning is included in budgeting and planning. Reform service delivery to ensure that the health systems supporting family planning function well and provide quality care. Create demand for family planning services through information, education, and behavior change communication programs. 1/24/2022 71

72. Priority actions (2) Involve communities and community leaders, particularly in rural areas where the majority of the population lives. Reach out to underserved groups, especially adolescents, men, and the poorest segments of society. Partner with the private sector to increase the reach of family planning services and foster long-term sustainability . 1/24/2022 72

73. Priority actions (3) Improve health system mechanisms for procurement and supply-chain to ensure regular availability of commodities at service delivery points. Expand LARC service sites and also training sites on quality FP (including in counseling) Integration of family planning with maternal and child health services. 1/24/2022 73

74. Conclusion (1) Family planning is the information, means and methods that allow individuals to decide if and when to have children. Access to safe, voluntary family planning is a human right. The main strategy of family planning program is to offer to client easy access to a wide range of affordable contraceptive method through multiple service delivery channel in a good quality and reliable fashion. 1/24/2022 74

75. Conclusion (2) Family planning is not only a means to control population. It is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty. For every additional dollar that is invested in contraception, the cost of pregnancy-related care will be reduced by about three dollars, according to by UNFPA's partner Guttmacher. Hence program should be committed to "leaving no one behind" and "reaching the unreached" to accelerate the progress of increasing the number of additional users of family planning. 1/24/2022 75

76. References (1) Program, I., Butler, A. and Clayton, E., 2021. Overview of Family Planning in the United States. [online] Ncbi.nlm.nih.gov. Available at: <https://www.ncbi.nlm.nih.gov/books/NBK215219/> Who.int. 2021. Contraception. [online] Available at: <https://www.who.int/health-topics/contraception  Countdown2030europe.org. 2021. [online] Available at: <https://www.countdown2030europe.org/storage/app/media/IPPF_FactSheet-5_poverty.pdf Who.int. 2021. Family planning/contraception methods. [online] Available at: <https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception Un.org. 2021. [online] Available at: <https://www.un.org/en/development/desa/population/publications/pdf/family/fam 1/24/2022 76

77. References (2) https://www.cdc.gov/reproductivehealth/contraception/index.htm https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception https://www.mcsprogram.org/resource/how-contraception-works-mechanisms-of-action/ https://www.nhs.uk/conditions/contraception/male-pill/ https://www.mariestopes.org.np/services/contraception-and-family-planning/oral-contraceptive-pill/ https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/ https://www.bbc.com/news/health-50644485 1/24/2022 77

78. References (3) https://www.nhs.uk/conditions/contraception/contraceptive-implant/ https://www.nhs.uk/conditions/contraception/vasectomy-male-sterilisation/ https://www.nhs.uk/conditions/contraception/female-sterilisation/ https://publichealthupdate.com/national-family-planning-program-nepal/ 1/24/2022 78

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