Methods of Family Planning as per National Family Welfare Programme

Family Planning Methods

1. Enumerate & Describe METHODS OF FAMILY PLANNING ( Advantages & Shortcomings) CM 10.6

2. Introduction Contraceptive methods are, by definition, preventive methods to help women avoid unwanted pregnancies. They include all temporary and permanent measures to prevent pregnancy resulting from coitus. The contraceptive methods may be broadly grouped into two classes spacing methods and terminal methods,

3. I. Spacing methods 1. Barrier methods (a) Physical methods (b) Chemical methods (c) Combined methods 2. Intra-uterine devices 3. Hormonal methods 4. Post-conceptional methods 5. Miscellaneous. II. Terminal methods Male sterilization Female sterilization.

4. Module 4 Contraception and family planning B ASIC information and choices There are a lot of beliefs and misconceptions associated with contraceptives methods. For example: Contraceptive methods can cause infertility Women lose libido with hormonal contraception Contraceptive methods can cause birth defects Health professional and harm reduction providers may also share these beliefs. The lack of accurate information will impact and limit people’s choices around pregnancy prevention. Every person will have different needs and preferences for contraception. Give them a choice!

5. Module 4 Contraception and family planning METHODS OF CONTRACEPTION The main effective methods of contraception are: Hormonal methods: implants, pills (progestogen and combined),IUD, injectables Other methods: copper IUD, vasectomy and female sterilisation Barrier methods : internal (female) and external (male) condoms, diaphragm Other methods exist but are less effective and are not under the control of women (for instance the natural method of withdrawal).

6. Module 4 Contraception and family planning HORMONAL METHODS Implant Small, flexible rods or capsules placed under the skin of the upper arm; contains progestogen hormone only. A healthcare provider must insert and remove it. It can be used for 3–5 years, depending on implant. Irregular vaginal bleeding common but not harmful. Efavirenz-based ART may reduce the effectiveness of the implant. Women living with HIV should receive appropriate counselling to choose the contraceptive method most suited to their situation. Progestogen-only pills It thickens cervical mucous to block sperm and egg from meeting and prevents ovulation. It is highly effective when taken correctly and consistently. Can be used while breastfeeding. Must be taken at the same time each day Combined contraceptive pills Contains two hormones (estrogen and progestogen). Prevents the release of eggs from the ovaries (ovulation). Reduces risk of endometrial and ovarian cancer but not other cancers. It is highly effective when taken correctly and consistently. For women who use drugs i t may increase the risk of vein problems , such as venous thrombosis or varicose veins. Check with a health professional.

7. Module 4 Contraception and family planning Other methods The copper IUD (Intrauterine device) Small flexible plastic device containing copper sleeves or wire that is inserted into the uterus. Copper component damages sperm and prevents it from meeting the egg. Longer and heavier periods during first months of use are common but not harmful. Vasectomy Permanent contraception to block or cut the vas deferens tubes that carry sperm from the testicles. It keeps sperm out of ejaculated semen. It is highly effective after three months. Does not affect male sexual performance. Voluntary and informed choice is essential. Female Sterilisation Permanent contraception to block or cut the fallopian tubes. Eggs are blocked from meeting sperm. It is highly effective and informed choice is essential.

8. Module 4 Contraception and family planning barrier methods Diaphragm, cervical c ap, sponge The diaphragm and cervical cap are dome-shaped and made of silicone. The cap covers only the cervix. The diaphragm is larger. It lodges behind your pubic bone. You need to use spermicide with the diaphragm or cap to help prevent pregnancy. The diaphragm, cervical cap and sponge are among the least effective forms of birth control. External c ondom (male condom) Made of very thin latex or polyurethane, it fits over an erect penis. Forms a barrier to prevent sperm and egg from meeting. It is effective when used correctly and consistently, with lubricant. Can prevent unintended pregnancy and also protects against sexually transmitted infections, including HIV. Internal c ondom (female condom) Made of very thin, transparent, soft polyurethane – m ost are latex-free. It f its loosely inside the vagina. Unlike external condoms, internal condoms can be used even when the penis isn’t erect. Can be used for vaginal and anal sex. It is best to insert the internal condom ahead of time, and always before and until vaginal or anal sex is finished. It is effective when used correctly and consistently (with lubricant). It can prevent unintended pregnancy and HIV, and it offers increased protection against SITs by partially covering external genitalia.

9. PHYSICAL METHODS

10. PHYSICAL METHODS Condom Condom is the most widely known and used barrier device by the males around the world. In India, it is better known by its trade name NIRODH. Condom is receiving new attention today as an effective, simple "spacing" method of contraception, without side effects. In addition to preventing pregnancy, condom protects both men and women from sexually transmitted diseases. Female condom The female condom is a pouch made of polyurethane, which lines the vagina. An internal ring in the close end of the pouch covers the cervix and an external ring remains outside the vagina. It is prelubricated with silicon, and a spermicide need not be used. It is an effective barrier to STD infection. However, high cost and acceptability are major problems.

11. Diaphragm The diaphragm is a vaginal barrier. Also known as "Dutch cap'\ the diaphragm is a shallow cup made of synthetic rubber or plastic material. It ranges in diameter from 5-10 cm (2-4 inches). It has a flexible rim made of spring or metal. It is important that a woman be fitted with a diaphragm of the proper size. The diaphragm holds the spermicide over the cervix. Vaginal sponge Another barrier device employed for hundreds of years is the sponge soaked in vinegar or olive oil, but it is only recently one has been commercially marketed in USA under the trade name TODAY for the sole purpose of preventing conception. It is a small polyurethane foam sponge measuring 5 cm x 2.5 cm, saturated with the spermicide, nonoxynol-9. The sponge is far less effective than the diaphragm, but it is better than nothing. The failure rate in parous women is between 20 to 40 per 100 women-years and in nulliparous women about 9 to 20 per 100 women years.

12. b. CHEMICAL METHODS a) Foams: foam tablets, foam aerosols b) Creams, jellies and pastes squeezed from a tube c) Suppositories inserted manually, and d) Soluble films - C-film inserted manually . C. COMBINED DEVICES Using chemical contraceptives with condoms is known as combined devices or method. It provides deep and double protection against pregnancy

13. 2. Intra-uterine devices Intrauterine Contraceptive Devices are the ones, which are placed in the uterus and provide protection from pregnancy: of these devices is an ancient method. Intra-uterine devices available today can be divided into two groups. 1. Non-Medicated - e.g. Lippe's loop 2. Medicated - e.g. Copper T.

14. Types of IUCDs Some important devices (IUCDs) are discussed here: Lippe's Loop Copper – T: Copper - T-200, Tcu - 380 A, Tcu - 220 C, Nova T, M2 Cu – 250, ML - Cu 375 & 250 Progestasert T Shaped Device Insertion of IUCD Loop can be fitted at any time except the pregnancy, during reproductive age . Also Copper T should be inserted, 6-8 weeks after the pregnancy. Before that the body might expel it. It should not be inserted during menstrual period.

15. Advantages of IUCD Inexpensive, easy to use and can be inserted in minimum time. Effective contraceptive. Fertility can be restored after the removal of Copper-T / loop. Free from any harmful effects like those of hormonal devices. Can be used up to 10 years (maximum). Doesn't require continuous supervision. Disadvantages of IUDS Spontaneous expulsion of Copper-T / Loop. Pain and bleeding. Ectopic pregnancy. Infection and ailments of pelvis Perforation of uterus.

16. 3. HORMONAL CONTRACEPTIVES Hormonal contraceptives when properly used are the most effective spacing methods of contraception. Oral contraceptives of the combined type are almost 100 per cent effective in preventing pregnancy. Classification Hormonal contraceptives currently in use and/or under study may be classified as follows : A. Oral pills 1. Combined pill 2. Minipill 3. Post-coital pill 4. Weekly pill 5. Long term / Monthly pill 6. ECPs B. Depot (slow release} formulations 1. Injectable 2. Subcutaneous implants 3. Vaginal rings

17. Oral Pills Popularity of pills can be gauged from the fact that 65 million people in the world and more than 10 million women in India use pills. These are available in various combinations. Mixed Pills It includes both oestrogen and progestogen. This pill is to be taken orally from 5th day of menstrual cycle to 21st day, continuously. After this, there is a break or rest period of 7 days, during which the cycle begins again. The day bleeding starts, is considered to be the first day of next menstrual cycle. Mala-N : Norethisterone acetate + Ethynyl oestradiol . Mala-D :D Norgestrol + Ethynyl Oestradiol .

18. Mini pill This contains only progestogen. These are to be taken throughout the menstrual cycle. These are not used much due to poor control on menstrual cycle and the higher rate of failure. These are also known as POP (Progestogen only pills). Post-Coital Contraception (Pill / IUCD) This pill should be taken within 48 hours of the unsafe coitus. Earlier estrogen tablets were advised for five days (diethyl- stilboestrol 50 mg.). At present, two mixed pills are advised to be taken immediately after the unsafe coitus. These pills have less harmful effects than the estrogen pills.

19. Male Pill Despite many experiments a safe male contraceptive pill is yet to be invented. Though some work has been done on Gossypol (derived from the cotton seed oil) but it has toxic effects, as well. No Steroidal Weekly Oral Pill Central drug research institute, Lucknow has developed a pill named " Centchroman ". This is a weekly pill that is to be taken orally. This pill is free from the side effects like vomiting, nausea, weight gain, dizziness and continuous or excessive bleeding, which generally arise by the use of other contraceptives. This pill is famous by the brand name " Saheli ”.

20. Long Acting / Once a Month Pill Long acting oestrogen and short acting progestogen are mixed in this tablet. Though this pill is taken only once a month, its harmful effects and rate of failure is very high. Therefore its use is almost negligible. Emergency Contraceptive Pills (ECPs or E-Pills) In India 21% pregnancies are unplanned and 6.5 million induced abortions are carried out (NRHM News letter - Jan.2007). Situations such as unprotected sex, improper use of contraceptive, failure of occlusive methods, sexual violence etc. often leads to an unwanted pregnancy. Emergency Contraceptive Pills (ECPs/E-Pills) are used to prevent pregnancy following an unprotected sexual intercourse, if taken within 72 hours.

21. Depot Formulation Injectable Contraceptives The base of these injections is progestogen and they are very effective. Important of these injections are: DMPA (Depot Medroxy Progesterone Acetate) Women are given one intramuscular injection of DMPA (150 mg.) every 3 months, which protects her against pregnancy for 3 months. NET-EN (Nor Ethisterone Enantate ) This is also an intra-muscular injection (200 mg) but it should be given at an interval of 2 months. This is a less effective contraceptive injection as compared to DMPA.

22. Sub-dermal-Implants Norplant or Norplant R-2 is used in these devices. Cilastic capsules or rods are implanted below the skin of upper arm. It can prevent pregnancy for the 5 years. After that, it is removed. Major disadvantages of this technique are the need of surgery and irregularity of bleeding in menstrual cycle. Vaginal Rings Vaginal rings containing levonorgestrel have been found to be effective. The hormone is slowly absorbed through the vaginal mucosa, permitting most of it to bypass the digestive system and liver, and allowing a potentially lower dose. The ring is worn in the vagina for 3 weeks of the cycle and removed for the fourth.

23. 4. POST-CONCEPTIONAL METHODS These are the methods, which lead to termination of pregnancy. For this, regulation of menstrual cycle and the methods of abortion are used. A short description of these methods is given below. 1. Menstrual Regulation and Induction In menstrual cycle regulation method, within 6 to 14 days of stopping the cycle, aspiration of uterine contents is done. This is very similar to primary abortion. Similarly, for menstrual induction, solution of prostelendin F2 is inserted in the uterus due to which uterus starts contracting and the menstrual bleeding begins, which continues for 7-8 days.

24. 2. Abortion/MTP Termination of pregnancy before the foetus reaches the state of independent survival, is termed as abortion. This duration is of almost 24-28 weeks. There are a number of reasons for abortion. Government of India has formed the Medical Termination of Pregnancy Act (1971) with the objective of reducing maternal mortality and morbidity rate. Simultaneously, it has also provided the abortion a medical look and recognition. This is popularly known as Medical Termination of Pregnancy (MTP). It is an important part of the family planning programme. MMA (Medical Methods of Abortion) is also an important tool for termination of early pregnancies

25. 5. MISCELLANEOUS METHODS Abstinence Coitus Interruptus Breast-feeding Birth Control Vaccine Safe Period Cervical Mucus Method Mix Calculation Methods Genetic Engineering

26. Module 4 Contraception and family planning EMERGENCY CONTRACEPTIVE PILLS Also called the ‘morning after’ pill. Emergency contraception is not an abortive method as the pill helps avoid conception. Pills are high dose hormonal pills that can be taken up to 72 hours AFTER intercourse but the sooner someone uses emergency contraception the more effective it is. If it contains two pills, take both at the same time. There are no major side effects , but some people may experience vomiting, headache or breast tenderness. If the period does not start in three weeks after taking the pill, check for pregnancy .

27. Module 4 Contraception and family planning Dual protection People who use drugs and their sexual partners must be counselled on dual protection strategies to prevent the transmission of HIV and STIs, as well as to avoid unintended pregnancy. These include:  Condoms, plus another contraceptive method  Condoms, plus emergency contraception if condom fails  Selectively using condoms and another method (for example, using the pill with the main partner, but the pill plus condoms with others).

28. Module 4 Contraception and family planning Methadone and contraception Offering contraception services in conjunction with substance use treatment like methdaone could help the women and gender non-conforming people who use drugs meet their needs for contraception. It can reduce unintended pregnancy. There is no evidence that methadone is incompatible with contraceptive methods. HIV treatment and hormonal contraception There is no evidence of incompatibility between ARVs and hormonal contraceptives.

29. Module 4 Contraception and family planning FERTILITY/INFERTILITY Infertility is a problem for both men and women , but women are often the ones who are blamed. Infections, some reproductive cancers, abnormalities of the reproductive tract (including blocked fallopian tubes), fibroids or long-term hormone use among trans-women can cause infertility. Environmental and lifestyle factors play also a role. Contraceptives do not cause infertility problems.

30. Module 4 Contraception and family planning KEY FAMILY PLANNING AND CONTRACEPTIVE SERVICES INCLUDE: Accurate information on a wide range of methods Counselling about the desire to have children Availability of condoms and lubricants and other contraceptives methods Emergency contraception Encouraging shared responsibility between partners Addressing infertility issues and their social consequences

31. Module 4 Contraception and family planning BARRIERS: Lack of access to services and limited choice of methods in the country/area Legal restriction and lack of access to services for ‘under age’ (under 18 or 16 years old) and unmarried women, etc. Low quality of services (like lack of confidentiality) and negative attitudes of the professionals (judgement), internalised-stigma Gender-based violence Lack of autonomy in making health decisions Lack of meaningful involvement of women and gender non-conforming people who use drugs in service provision Stigmatisation, and fear of stigma and hostility Fear of violence or coercion to adopt long-acting or irreversible methods of contraception Discrepancies between representations of women's sexuality and contraceptive needs Lack of financial means Lack of knowledge, misbeliefs and fear of side effects, perceived health risks Non-recognition of sexuality among certain groups (teenagers, people with disabilities) APPROACHES TO OVERCOME BARRIERS Political level Advocacy to improve political priorities and funding to SRHR and to improve supply chains Programmatic level Availability of appropriate services, including stocking a wide range of contraceptive methods Emergency pills available with peers on outreach Involvement and training of health professionals and harm reduction providers Support the meaningful involvement of women and gender non-conforming people; support the development of skills and structure in communities and networks Creation of new services, such as individual or couple counselling on contraception Counselling couples on infertility Community level Empowerment of women and gender non-conforming communities; participation of communities Participation and buy-in of men and the wider community Developing education materials on contraception and the importance of individual choice selecting contraceptive methods

32. Module 4 Contraception and family planning Role play: B ased on the stories , provide counselling on contraceptive methods. One person plays the role of a women who uses drugs, the other the health professional/harm reduction provider. Debriefing and discussion: Do you think the counsellor provided accurate information? As a client, do you feel you were given a choice (informed choice)? Why? As a counsellor, did you feel you could respect the choice of the woman? In your opinion, what are the most important skills needed to provide counselling on contraception? 20 mins 10 mins

33. Module 4 Contraception and family planning Counselling skills Importance of providing accurate information Non-judgmental attitudes Active listening Clear communication without technical words – use simple language Respect people’s right to confidentiality, privacy and informed choice Non-discrimination (regardless of their age, family or social status, sexual behaviour, kind and frequency of drug use, etc.)

34. Module 4 Contraception and family planning BRAINSTORMING What are the main barriers to accessing contraception? 15 mins

35. Module 4 Contraception and family planning GROUP EXERCISE: What do you need to do to address the barriers? In groups of 5 or 6: Consider the different barriers and propose approaches to overcome them Think of 2 or 3 solutions/actions to improve access to contraception in your organisation/community Discussion: 15 mins 10 mins