Family Planning.pptxxxxxxxxxxxxxxxxxxxxxx

bbbbb

1. Policy, Methods and Counseling Family planning

2. D efinition of Family Planning

3. What is Family Planning? A program that allows individuals and couples to determine the number of children to have, when to have them, and at what intervals . This is achieved through the voluntary use of various devices, sexual practices, chemicals, drugs, or surgical procedures that interfere with the normal process of ovulation, fertilization, and implantation.

4. Goal of FP programs in Rwanda: To provide voluntary comprehensive family planning services at all levels of care to all men, women, and young people of reproductive age, thereby promoting good health and socioeconomic development .

5. FP is a Basic Human Right! A number of international rights declarations and other documents recognize the importance of access to reproductive health, including family planning, as basic human rights .

6. Programme of Action from the International Conference on Population and Development (ICPD) held in Cairo, Egypt in 1994 179 countries agreed that empowering women and meeting people's needs for education and health, including reproductive health, are necessary for both individual advancement and balanced development. This programm of Action included advancing gender equality, eliminating violence against women , and ensuring women's ability to control their own fertility as cornerstones of population and development policies.

7. The following year, 1995, the United Nations Fourth World Conference on Women took place in Beijing , China. The Platform of Action from this meeting included the following: Reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.

8. , Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this condition are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice.

9. Statistics : M ore than one-third of pregnancies in developing countries about 76 million each year—are unintended. About half of these end in induced abortions, most of which are either illegal or unsafe . The remaining half (16% of all pregnancies) result in unwanted or mistimed births . Two-thirds of these unintended pregnancies occur among women who were not using any method of contraception.

10. If these pregnancies could be avoided, the following could be averted: • 90% of abortion-related mortality and morbidity • 20% of obstetric-related mortality and morbidity • 150,000 maternal deaths annually.

11. *Preventing unintended pregnancies could significantly improve these figures, saving lives and preserving the well-being of families. *

12. The Importance of Family Planning to Women, Families, and Societies Help avert maternal morbidity and mortality that result when pregnancies are too early, too many , and too frequent. Complications related to pregnancy and childbirth are among the leading causes of mortality and morbidity of women of reproductive age in many parts of the developing world. Most of these deaths, health problems, and injuries are preventable through improved access to adequate health care services, including safe and effective family planning methods .

13. The lifetime probability of maternal death in developing country is 1 in 54. This compares to : 1 in 74 in Namibia 1 in 150 in South Africa 1 in 2,600 in the United States. Source: World Bank, 2010

14. Maternal Mortality — FP Saves Lives “ Promotion of family planning in countries with high birth rates has the potential to . . . avert 32% of maternal mortality. ” 90% of abortion-related mortality and morbidity 20% of obstetric-related mortality and morbidity Source : Cleland et al. 2006.

15. Family planning also helps prevent infant and child morbidity and mortality , significant problems in Rwanda.

16. Child Mortality — FP Saves Lives Conservatively, “ 1 million of the 11 million deaths in children <5 could be averted by elimination of inter-birth intervals of less than 2 years. Effective use of postpartum family planning is the most obvious way in which progress should be achieved. ” Source : Cleland et al. 2006.

17. In addition to saving women’s and children’s lives, family planning helps: • Preserve women’s health by preventing untimely and unintended pregnancies and reducing their exposure to the health risks of childbirth and abortion • Prevent HIV/AIDS , including preventing mother-to-child-transmission, by preventing unintended pregnancies • Provide social, educational, and economic benefits for women, increasing their rights and self -determination and giving them more time to care for their children and themselves

18. And… • Improve the socioeconomic status of families , for instance, by leading to healthier individuals with higher literacy rates and improved nutrition • Stabilize societies and accelerate the socioeconomic status of nations • Reduce population pressures on the natural environment .

19. FP in Rwanda Over the past decade, Rwanda’s FP program has achieved tremendous results, mainly through the government’s commitment to addressing the country’s very high population density – current population is over 12 million ! Modern contraceptive use has more than quadrupled from 2005 to 2010, rising from 10% to 45 % , but the government’s Economic Development and Poverty Reduction Strategy calls for an increase the modern contraceptive prevalence to more than 70 % in coming 5 years. 19% of currently married women have an unmet need for FP

20. In spite of all of the reasons for using family planning, married women cite a number of reasons why they do not always use a method. These include: 1. Misconceptions about pregnancy risk (don’t think they will get pregnant) * 2. Health concerns about side effects * 3. Lack of knowledge 4. Lack of access and high cost 5. Lack of empowerment for women to participate in decision-making related to family planning use 6. Opposition to family planning (religious or other).

21. The most significant barrier has been access to health facilities in Rwanda’s hilly terrain where population is dispersed. Have you found this to be true? What are your thoughts on biggest barriers to family planning?

22. s Recommendation for spacing after a live birth: The recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, perinatal and infant outcomes.* Recommendation for spacing after miscarriage or induced abortion: The recommended minimum interval to next pregnancy should be at least six months in order to reduce risks of adverse maternal and perinatal outcomes. Source : WHO 2006. Birth Spacing

23. Birth Spacing For adolescents : The recommended age for a first pregnancy is at least 18 years.

24. Risk of Pregnancy May Return Soon after Birth Between 5% and 10% of women conceive within the first year postpartum. For the non-breastfeeding mother: The mean average for first ovulation is 45 days after delivery Return to fertility occurs prior to the return of menses in two out of three women. Once menses return, a woman is at as high risk for pregnancy as before conception.

25. 26 Counseling: Pregnancy Risk When a woman can become pregnant after delivery depends on: Breastfeeding practices Return of menses Return to sexual activity

26. Counseling: Return to Fertility for Breastfeeding Women Period of infertility longer with only/exclusive breastfeeding – Lactation amenorrhea method (LAM): Likelihood of menses and ovulation is low during first six months After six months, even if her period has not returned, she is at risk of pregnancy Women can ovulate before menses if she is no longer only breastfeeding or the baby is more than six months old

27. Counseling: Women Who Want to Limit Pregnancies Some couples do not want to become pregnant now or in the future. For them, there are long-term contraceptive options (male or female sterilization, IUDs) While they are deciding or in process of reaching long-term contraception services, she should use a short-term method to prevent pregnancy until she can get the long-term method.

28. Initiation of Post-LAM Contraception You do NOT need to wait for the woman to have her menses in order to initiate another modern method of contraception You can initiate a modern contraceptive method at ANY TIME you are reasonably sure that a woman is not pregnant If a woman has been using LAM, you can be reasonably sure she is NOT pregnant

29. 30

30. Factors Affecting Method Choice Reproductive goals of woman or couple (spacing or limiting births) Personal factors including client preference, time, travel costs, discomfort associated with FP method Accessibility and availability of products that are necessary to use method Medical factors

31. The contraceptive methods available in Rwanda can be divided into several categories:

32. Nonhormonal methods : • Barrier methods such as male and female condoms • Lactational Amenorrhea Method (LAM) for breastfeeding women • Fertility Awareness Methods ( FAM) • Withdrawal – coitus interruptus

33. Hormonal methods : • Oral contraceptives (pills) : can be either combined estrogen/progestin oral contraceptives (COCs) or progestin-only pills (POPs) • Injectable contraceptives (such as DMPA/ Depo Provera) containing the hormone progestin • Emergency contraceptive pills ( ECs ): can be either combined estrogen/progestin oral contraceptives (COCs) or progestin-only pills (POPs)

34. Long-term methods * • Contraceptive implants (such as Jadelle ) containing the hormone progestin • Intrauterine contraceptive devices ( IUDs ) Permanent methods • Female sterilisation (tubal ligation) • Male sterilisation (vasectomy)

35. 36 Postpartum Contraceptive Options Adapted from : The MAQ Exchange: Contraceptive Technology Update

36. What are progestin-only pills (POPs)?

37. Progestin-Only Pills (POPs): What Are They? Pills that contain a very low dose of a progestin like the natural hormone progesterone in a woman ’ s body Does not contain estrogen Also called “ mini-pills ” Work primarily by: Thickening the cervical mucus (this blocks sperm from meeting egg) Disrupting the menstrual cycle, including preventing ovulation

38. Progestin-Only Pills : Key Benefits Safe for breastfeeding women—No effect on breastfeeding, milk production or infant growth and development after infant is six weeks old Adds to the contraceptive effect of breastfeeding—Together, if taken correctly, failure rate less than 1% during first year of use Does not interfere with sex

39. Progestin-Only Pills: Limitations Less effective for non-breastfeeding mother—If taken correctly, 3 – 10 women/100 will become pregnant first year Pill must be taken every day, at the same time. Bleeding changes (more frequent, irregular) are common but not harmful A few women may have headaches, dizziness or breast tenderness

40. Progestin-Only Pills : Key Counseling Considerations Discuss limitations (bleeding irregularities) Can be given to a woman at any time to start later Discuss tips to help woman remember to take pill every day—link to a daily activity, such as brushing teeth; take same time every day; etc. Provide back-up method (e.g., condoms) to use if/when pill is missed

41. Progestin-Only Injectables The injectable contraceptive DMPA (depot medroxyprogesterone acetate) contains a progestin similar to the progesterone naturally in a woman ’ s body Does not contain estrogen Also known as “ the shot ” or the injection Given by injection into the muscle Works primarily by preventing the release of eggs from the ovary

42. What are some key benefits of injectables ? (most commonly used method in Rwanda*)

43. Progestin-Only Injectables : Key Benefits No effect on breastfeeding, milk production or infant growth and development; safe for use immediately postpartum. When women have injections on time, failure rate less than 1% during first year of use Does not require daily action Are private Do not interfere with sex

44. Progestin-Only Injectables : Key Benefits ( cont .) Helps protect against: Cancer of lining of uterus (endometrial cancer) Uterine fibroids Iron-deficiency anemia

45. Progestin-Only Injectables : Limitations Bleeding irregularities for first two to three months (usually no bleeding at one year) Some women may have weight gain, headaches, dizziness, mood changes Should wait until six weeks to give first injection to the breastfeeding woman (who is not using LAM), but can also be given immediately postpartum if no other option is available. Benefit may outweigh the risk.

46. Progestin-Only Injectables : Counseling Considerations Agree on date for next injection in three months (can give injection even if woman is four weeks early or late, but d o not regularly extend DMPA injection interval by four weeks ) If there is a chance she will be late for next injection, tell her she may come early (up to four weeks). Better early than late! She should come back no matter how late she is for her next injection; if reasonably sure she is not pregnant, can give injection any time Assure her that she is welcome to return any time she has questions, concerns or problems

47. What are combined oral contraceptives?

48. COCs : What Are they? Pills that contain low doses of two hormones — a progestin and an estrogen Also called “ the pill ” Work primarily by: Preventing the release of eggs from the ovary Thickening cervical mucus so that sperm cannot penetrate

49. COCs : Mechanisms of Action Suppress ovulation Thicken cervical mucus (preventing sperm penetration) Reduce sperm transport in upper genital tract (fallopian tubes)

50. You are counseling a woman who is transitioning from LAM to COCs. What will you tell her are the benefits of COCs?

51. COCs : Key Benefits Highly effective when taken daily (failure rate 0.1–0.5 % during first year of use) Controlled, and can be stopped, by the woman Does not interfere with sex Pelvic examination or routine labs for hormonal levels not required to initiate use Helps protect against cancer of the uterine lining, cancer of the ovary, symptomatic pelvic inflammatory disease (PID) and anemia

52. COCs : Limitations User-dependent (require continued motivation and daily use); forgetfulness increases method failure Some nausea, dizziness, breast tenderness, headaches, spotting or depression may occur (but usually stop after three to four months of use) Effectiveness may be lowered when certain drugs are taken Re-supply must be readily and easily available Do not protect against STIs (e.g., HBV, HIV/AIDS)

53. WHO Eligibility Criteria Category With Clinical Judgment With Limited Clinical Judgment 1 Use method in any circumstance Yes (Use the method) 2 Generally use method Yes (Use the method) 3 Use of method not recommended unless other more appropriate method not available/acceptable No (Do not use method) 4 Method not to be used No (Do not use method)

54. COCs : Who Should Not Use (WHO Category 4) COCs should not be used if a woman: Has migraine headaches with aura Has BP 160/100 (140–159/90–99 is Category 3) Is breastfeeding (less than six weeks postpartum) Is jaundiced (symptomatic viral hepatitis or cirrhosis) Has ischemic heart disease or stroke Has blood clotting disorders (deep vein thrombophlebitis or pulmonary embolus) Source : WHO 2004

55. COCs : Who Should Not Use (WHO Category 4) ( cont .) COCs should not be used if a woman: Has breast cancer Is 35 years old or older and smokes 15 cigarettes/day Has breast cancer Has liver tumors Has to undergo major surgery with prolonged bed rest Source : WHO 2004 .

56. COCs: Counseling Considerations Discuss limitations (side effects) Can start three weeks after delivery if not breastfeeding; six months after delivery if breastfeeding Can start even if menses has not started, as long as you are reasonably sure she is not pregnant, but will need to use condoms or abstain for the first week of use

57. COCs : Counseling on What to Do for Missed Pills Take a missed hormonal/active pill as soon as possible Keep taking pills as usual, even if this means she will take 2 pills on same day If missed 1 or 2 pills: Take pill as soon as possible If missed 3 or more pills in Week 1 or 2: Take pill as soon as possible and use back-up method for seven days

58. COCs : Counseling on What to Do for Missed Pills ( cont .) If missed 3 or more pills in Week 3: Take a hormonal pill as soon as possible Finish all hormonal pills in pack and throw away all non-hormonal pills Start a new pack the next day Use a back-up method for seven days If missed non-hormonal pills discard the missed non-hormonal pills and continue COCs, one a day

59. COCs : Counseling on Danger Signs Return immediately to healthcare provider or clinic if you develop any of the following problems: Severe chest pain or shortness of breath Severe headaches or blurred vision Severe leg pain Absence of any bleeding or spotting during pill-free week (21-day pack) or while taking seven inactive pills (28-day pack)—may be a sign of pregnancy

60. Danger Signs – Cont’d A – Abdominal pain C – Chest pain H – Headache E – Eye problems S – Severe leg pain

61. Emergency Contraception (EC) Questions for Group Activity: What is “ emergency contraception ” ? What EC ’ s key benefits? What are EC ’ s limitations?

62. Emergency Contraception (EC) : What Is It? Methods that prevent pregnancy after unprotected sexual intercourse has occurred Regular contraceptive pills (COCs or POPs) used in a special way. Used in higher dosages Used as soon as possible after unprotected sex (within 120 hours or five days) NOTE: Emergency contraception does not stop a pregnancy that has started!

63. Types of EC Pills (ECPs) POPs: levonorgestrel (LNG) or norgestrel Two tablets LNG-only (750 µg each tablet) in single dose [local brand name] Three mg norgestrel in single dose [local brand name] 40 tablets (30 or 37.5 µg of LNG or 75 µg of norgestrel ) [local brand name] COCs: LNG and ethinylestradiol (EE) Two tablets of high-dose pills containing 0.05 mg EE and 0.25 mg (250 µg) LNG [local brand name]; repeat after 12 hours Four tablets of low-dose pills containing 30–35 µg EE and 150 µg LNG [local brand name]; repeat after 12 hours

64. EC: Key Benefits Again, EC is the only method that prevents pregnancy after unprotected sex.* EC could prevent: Millions of unintended pregnancies and abortions At least 20 million unsafe abortions and the deaths of 80,000 women Woman should have EC on hand in case of emergency.

65. EC : Key Benefits ( cont. ) COCs and POPs are most effective if used as soon as possible after unprotected sex and up to 72 hours (three days) , but can still be effective up to 120 hours (five days) Progestin-only regimen safe for breastfeeding woman , but breastfeeding should be delayed (8 –24 hours) after EC ( Source : Gainer et al. 2007)

66. EC : Limitations A woman using EC may experience the following side effects, none of which indicate illness: Nausea and vomiting Less common with POPs May take anti-nausea medicine Changes in bleeding pattern Abdominal pain, fatigue, headaches, dizziness or nausea in the week after taking the EC pills

67. EC : Counseling Considerations Be sure that client does not want to be pregnant Take as soon as possible after unprotected intercourse Explain: Correct use — more effective when taken sooner EC is not suitable for regular use because not as effective as other routine methods Nausea and vomiting are common with COCs; significantly less common with POPs EC pills will not cause menses to come immediately EC pills do not provide protection against STIs (e.g., HIV/AIDS, HPV)

68. EC in Rwanda POLICIES Essential Drug List: The 2010 EDL includes levonogestrel in the proper dose for EC Rwanda’s National Family Planning Policy does not include specific directives regarding EC; however, Rwanda’s National Training Module for Family Planning (March 2008) includes a chapter on EC Prescription status: It appears that EC can be purchased without a prescription Post-rape care: A 2012 report states that EC information is currently included in the police protocol for survivors of sexual violence/rape

69. WHERE WOMEN CAN ACCESS EC EC in the commercial sector: EC can be purchased at pharmacies and through private providers EC in the public sector: Rwanda’s Essential Medicines List stipulates that EC should be available in the public sector, but the Service Provision Assessment Survey of 2007 found that only 16% of facilities surveyed had ever offered EC, and on the day of assessment, only 5% had EC available. Community -based distribution of EC: EC is not distributed at the community level in Rwanda

70. What is an intrauterine contraceptive device (IUD)?

71. The IUD: What Is It? The IUD is a small T-shaped plastic device with fine copper wire wrapped around it; it is inserted into the uterus through the vagina. Most IUDs have one or two strings tied to them that hang through the cervix. IUDs work primarily by causing a chemical change that damages the sperm and egg before they can meet.

72. Postpartum Insertion of IUDs (PP-IUD) IUDs can be inserted: Immediately after delivery of the placenta During cesarean section Within 48 hours of childbirth If not inserted within 48 hours of delivery, insertions should be delayed for at least four weeks NOTE: An IUD can be inserted immediately after first-trimester abortion. *

73. Risk of Expulsion and Timing of Insertion Postpartum IUD Expulsion Rates by Timing of Insertion Time Of IUD Insertion Definition Expulsion Rate Observations Postplacental Within 10 minutes after delivery of placenta 9.5–12.5% Ideal; low expulsion rates Immediate Postpartum After 10 minutes to 48 hours post delivery 25–37% Still safe Late Postpartum After 48 hours to 4 weeks post delivery NOT RECOMMENDED Increased risk of perforation and expulsion Interval-Extended Postpartum After 4 weeks post delivery 3–13% Safe

74. Time for a debate… Participants will be divided into two groups to hold a debate. One side will argue for benefits of using an IUD Other side will argue for limitations and reasons not to use an IUD

75. IUDs : Key Benefits Highly effective (failure rate <1% in first year of use) Very safe (WHO Category 1) from 4th week postpartum Effective immediately Long-term method (up to 12 years with Copper T 380A) Immediate return to fertility upon removal

76. IUDs : Key Benefits ( cont .) Do not affect quantity or quality of breast milk; can be used by postpartum women whether or not they are breastfeeding Few side effects Do not interfere with intercourse

77. IUDs : Limitations Requires a trained healthcare provider to insert Some users report: Changes in bleeding patterns, especially during first three months of use More cramping and pain during monthly menses NOTE: None of these side effects indicate illness. Counseling clients and obtaining informed consent should be done during ANC

78. PP-IUDs : Who Should Not Use (WHO Category 4) Woman with the following should not use the IUD: Current puerperal sepsis/ endometritis /pelvic inflammatory disease (PID) Membranes ruptured >18 hours before delivery (for immediate PP insertion) Unexplained vaginal bleeding, which may indicate serious condition Cervical or endometrial cancer

79. PP-IUDs : Conditions Requiring Precautions (WHO Category 3) Insertion from 48 hrs to less than four weeks postpartum Woman with AIDS who are not clinically well

80. PP-IUDs : Method May Not Be Best Choice if Other Methods Available (WHO Category 2) HIV infected but clinically well High risk of HIV or STIs Vaginitis ( trichomoniasis or bacterial vaginosis ) Anatomic abnormalities of uterus Endometriosis Complicated valvular heart disease (use prophylactic antibiotic if insertion) Less than 20 years of age

81. IUDs : Counseling Considerations Discuss limitations (note that cramping occurs during involution even without IUD insertion) Explain procedure prior to insertion Talk with client during the procedure to tell her what is happening and reassure her Advise return after three to six weeks or any time she has questions or concerns

82. What are some benefits of male condoms?

83. Male Condoms : Benefits When used consistently and correctly, male condoms are highly effective against pregnancy (97%) and STIs/HIV Can be used soon after childbirth (as soon as intercourse is resumed) Can be used by the breastfeeding mother

84. Male Condoms : Limitations Moderately effective (three to 14 pregnancies per 100 women during the first year) with typical use; with perfect use, 97% effective Effectiveness as contraceptives depends on willingness to follow instructions User-dependent (require continued motivation and consistent use with each act of intercourse) May reduce sensitivity of penis, making maintenance of erection more difficult

85. Male Condoms : Counseling Considerations Explain limitations and discuss need to use for every act of intercourse Ensure that client knows how to correctly use condoms, demonstrating on model, banana or cucumber as needed Ask client how many condoms are needed—provide plenty of condoms, as well as information on where more can be purchased Discuss skills and techniques for negotiating condom use with partner

86. What is postpartum female sterilization and when can it be done?

87. Postpartum (PP) Female Sterilization Permanent contraception for women who want no more children Performed by mini laparotomy, which involves small incision in abdomen Works because fallopian tubes are blocked or cut so egg cannot move down tube and reach sperm

88. PP Female Sterilization ( cont .) Ideally done within 48 hours after delivery May be performed immediately following delivery or during cesarean section If not performed within one week of delivery, delay for six weeks Follow local protocols for counseling clients and obtaining informed consent in advance Must be done during antenatal care for immediate PP sterilization

89. PP Female Sterilization : Key Benefits Highly effective (99.5%); comparable to vasectomy, implants, IUDs No long-term side effects No need to worry about contraception again Is easy to use; nothing to remember or do

90. PP Female Sterilization : Limitations Involves a physical examination and surgery Cannot be reversed or stopped if couple changes their mind about wanting another pregnancy Rare complications of surgery, such as wound infection or anesthesia complication

91. Female Sterilization : Who Should Not Use (WHO Category 4) While contraindications are rare, surgery should be delayed for: Women with symptomatic systemic infection (AIDS*, malaria, etc.) Women who are more than one week and less than six weeks postpartum * Minilap may be performed on women with AIDS if in a specialized facility

92. What is a “ vasectomy ” ?

93. Vasectomy (Male Sterilization): What Is It? Permanent contraception for men who want no more children A safe, convenient, highly effective and simple contraceptive procedure for men that is provided under local anesthesia in an out-patient setting Surgery through a small incision in the scrotum that closes off the vas deferens, keeping sperm out of semen www.maqweb.org Technical briefs

94. Vasectomy : Key Benefits No serious side effects Vasectomy is safer, simpler, less expensive and equally effective as female sterilization (tubal ligation) Can be timed to coincide with the breastfeeding woman ’ s postpartum period when fertility is reduced Does not affect male sexual performance www.maqweb.org Technical briefs

95. Vasectomy : Key Benefits ( cont .) After first 3 months, highly effective in preventing pregnancy (99.6 to 99.8% effective) Is safe, permanent and convenient Allows man to take responsibility for contraception Increases enjoyment and frequency of sex

96. Vasectomy : Limitations Is not effective for three months after procedure Need backup method—LAM may be appropriate Cannot be reversed if man changes his mind Rarely man may have Severe scrotal or testicular pain Infection at the incision site Bleeding under the skin Vans deferens grow back together after some time

97. Which methods of contraception can an HIV-positive woman use?

98. PPFP Considerations for the HIV-Positive Woman The HIV-positive woman can use any method of contraception that is not contraindicated by WHO MEC If symptomatic AIDS, should not use IUD or female sterilization until woman is on ARVs and HIV infection is not symptomatic As noted in LAM workshop/update, in areas where formula feeding does not meet AFASS criteria (acceptable, feasible, affordable, sustainable and safe), an HIV-positive woman may use LAM

99. Successful Counseling Good counseling helps clients choose and use family planning methods that suit them. Clients differ, their situations differ, and they need different kinds of help. The best counseling is tailored to the individual client. Give time to clients who need it. Many clients are returning with no problems and need little counseling . Returning clients with problems and new clients with no method in mind need the most time, but usually they are few.

100. T ips for successful counseling Show every client respect , and help each client feel at ease . Listen carefully. Listening is as important as giving correct information. Encourage the client to explain needs, express concerns, ask questions. Let the client’s wishes and needs guide the discussion.

101. Give just key information and instructions. Use words the client knows . Respect and support the client’s informed decisions. Bring up side effects, if any, and take the client’s concerns seriously Check the client’s understanding . Invite the client to come back any time for any reason.

102. Counseling has succeeded when: Clients feel they got the help they wanted Clients know what to do and feel confident that they can do it Clients feel respected and appreciated Clients come back when they need to And, most important, clients use their methods effectively and with satisfaction .

103. Family Planning Quiz

104. References Cleland et al. 2006. Lancet Series, Sexual and Reproductive Health; Vol 368, Number 9549.] http ://www.moh.gov.rw/fileadmin/templates/Docs/Rwanda-Family-Planning-Strategic-2012-2013. pdf http://www.cecinfo.org/custom-content/uploads/2013/09/Rwanda_2013. pdf http://www.moh.gov.rw/fileadmin/templates/Docs/Rwanda-Family-Planning-Strategic-2012-2013. pdf

105. The United Nations, Division for the Advancement of Women, Department of Economic and Social Affairs. September 1995. The United Nations Fourth World Conference on Women Platform for Action. Beijing, China. http://www.un.org/womenwatch/daw/beijing/platform/health.htm (accessed March 22, 2010). United Nations Population Fund. 1995. Summary of the ICPD program of action. http://www.unfpa.org/icpd/summary.cfm (accessed March 22, 2010). United States Agency for International Development. 2006. Long-acting and permanent methods of contraception: Meeting clients’ needs. Issue Brief. Washington, D.C.: USAID. http://www.usaid.gov/our_work/global_health/pop/techareas/repositioning/briefs/lap_metho ds.pdf (accessed April 8, 2010). Westoff, Charles F. 2006. New estimates of unmet need and the demand for family planning. Demographic and Health Surveys Comparative Reports No. 14. Calverton, Maryland: Macro International Inc. http://www.measuredhs.com/pubs/pdf/CR14/CR14.pdf (accessed April 8, 2010)