Recent advance in family planning

Overview of family planning, its program and recent advance

1. Recent advance in Family planning Presented by: SHIKHA BASNET MPH-2021 SPH & CM Total Slides: 51

2. Outline of Presentation Family planning Introduction History of Family planning Global scenario South East Asia Nepal Scenario Family Planning methods Recent Advance Conclusion References 12/30/2021 2

3. Family Planning 12/30/2021 3

4. Introduction 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. 12/30/2021 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 . International studies have repeatedly confirmed that family planning ranks among the most cost-effective of all health services, along with other basic and preventive health measures such as vaccinating children and preventing HIV/AIDS. 12/30/2021 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. Contraceptive information and services are fundamental to the health and human rights of all individuals. 12/30/2021 6

7. Introduction (4) 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 . 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). 12/30/2021 7

8. History of Family planning Family planning has been of practice since the 16th century by the people of West Africa. In 1968, Human Rights Conference was held in Tehran which considered voluntarism in family planning R eproductive health and right was defined by the United Nations (UN) in 1994 at the Cairo International Conference on Population and Development.  The Government of Nepal began to offer family planning services from 1965 12/30/2021 8

9. Milestone of Family planning program in Nepal Year History 1965 Government adopted family planning policy as a means of maintaining a balance between population growth and economic growth. 1968 a national service delivery system was started with the establishment of the Family Planning and Maternal-Child Health board 1995 Ministry of population and environment was established following the FP and reproductive health principles of ICPD 1998 National reproductive health strategy was formed 1998 Safe motherhood policy: need of FP services as a key components of maternal care. 2000 National adolescent health and development strategy was endorsed 2003 National safe abortion policy 2005 MoPE dissolved and its population division was merged in the MOH and the MOH renamed as MOHP. 12/30/2021 9

10. 12/30/2021 10 Source: https://ourworldindata.org/world-population-growth-past-future

11. Trend in Growth of population in Nepal 12/30/2021 11 Source: https://worldpopulationreview.com/countries/nepal-population

12. Trends of Fertility and Contraceptive use in Nepal 12/30/2021 12

13. 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 . 12/30/2021 13

14. 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. 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. 12/30/2021 14

15. 12/30/2021 15 Source: United Nations, Department of Economic and Social Affairs, Population Division. (2020). Estimates and Projections of Family Planning Indicators 2020 .

16. South East Asia Central and Southern Asia has seen the largest decline in the number of women with unmet need since 2000. Globally, the number of women aged 15-19 years who had unmet need for family planning decreased from 17 million in 2000 to 14 million in 2020. The large decline in unmet need among adolescent girls and young women in Central and Southern Asia from over 6 million women in 2000 to 2.6 million in 2020 was the primary reason for the decrease at the global level. 12/30/2021 16

17. 12/30/2021 17 Source: United Nations, Department of Economic and Social Affairs, Population Division. (2020). Estimates and Projections of Family Planning indicators 2020.

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19. 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. 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. 12/30/2021 19

20. Nepal Scenario (2) 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. The total fertility rate (TFR) of women aged 15-49 declined from 4.1 children per women in 2000 to 2.3 in 2016 and has declined to 2.0 in 2019. 12/30/2021 20

21. SDG Target 12/30/2021 21 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

22. 12/30/2021 22 Source: DoHS , Annual Report 2076/77 (2019/20 )

23. 12/30/2021 23 Source: DoHS , Annual Report 2076/77 (2019/20)

24. 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 12/30/2021 24

25. 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 12/30/2021 25

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27. Temporary Methods 12/30/2021 27 Natural Methods Abstinence Coitus interruptus or withdrawal method  Lactational amenorrhea Biological Methods •    Calendar (rhythm) method •     Basal body temperature method •     Cervical mucus method (billings method) Hormonal Contraceptive Method Contraceptive skin patch Vaginal ring  Pills (Combined and Minipill)  Injection  Implant  Emergency Pill   Intrauterine device Chemical Method •    Foams •    Creams, jellies and pastes •     Soluble films I. Mechanical Family Planning Method Male condoms  Female condoms   Diaphragms   Cervical cap   Intrauterine devices (IUD) Sponge

28. Permanent methods Male Sterilization Vasectomy Female Sterilization Minilap 12/30/2021 28

29. Recent Advance 12/30/2021 29

30. Reversible Inhibition of Sperm Under Guidance (RISUG) (1) In 1979, Prof. Sujoy K. Guha, School of Medical Science and Technology, Indian Institute of Technology, proposed a radically new technique of male contraception 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. 12/30/2021 30 https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1

31. Reversible Inhibition of Sperm Under Guidance ( 2) 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.   12/30/2021 31 https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1

32. Reversible Inhibition of Sperm Under Guidance ( 3) RISUG was formulated as an occlusive polymer which was claimed to sterilize subjects by single injection and reversed at any time following vas occlusion. Within 72 h of injection, RISUG forms electrically charged precipitates in the lumen and further layers the lumen wall and inner walls of vas deferens. Precipitates are dominated with positive charge creating an acidic environment. Passing through the RISUG injected vas deferens, sperms suffer ionic and pH stress, causing acrosomal damage, rendering them unable to fertilize oocytes. 12/30/2021 32 https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1

33. Reversible Inhibition of Sperm Under Guidance ( 4 ) 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. In 2018, a total of 315 subjects enrolled at 5 different centers in the country were reported to show no adverse side-effects of the drug with overall contraceptive efficacy of 99.02%. If approved for widespread application, it could provide an alternative to the current two major methods of male contraception:  Condoms and vasectomies 12/30/2021 33 https://bacandrology.biomedcentral.com/articles/10.1186/s12610-020-0099-1

34. 12/30/2021 34 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

35. Advantages of RISUG over other methods of male contraception RISUG creates a physical and chemical barrier preventing sperm from reaching the oocyte. The polymer is injected into the vas deferens through the non scalpel technique, thus avoiding surgery in the initial sterilization procedure. Early azoospermia: Clinical trials with RISUG demonstrate promising results showing azoospermia in subjects as early as 4 weeks after the injection that is sustained over years. A few sperms that are observed in ejaculates after RISUG were found to be functionally inactive. 12/30/2021 35

36. Advantages of RISUG over other methods of male contraception Reversibility : In any contraceptive method a great concern is the reestablishment of fertility when required. Removal of SMA co-polymer can be induced by injecting DMSO or NaHCO 3   that acts as partial solvent. After preclinical trials in various animal models based on blockage of vas deferens without any toxicity, the studies have been moved toward its reversibility aspect without affecting cellular integrity. Despite the promising results of reversibility in animal models, the reversibility studies have not yet been carried out in humans. 12/30/2021 36

37. Kyleena Smallest and the lowest dose of 5 years 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. 12/30/2021 37 Kyleena Source: https://www.kyleenahcp.com/

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39. Sayana Press (1) 12/30/2021 39 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.  

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41. It is suitable for community-based distribution and for women to administer themselves through self-injection with minimal training. The first Sayana Press introduction launched in Burkina Faso in July 2014. 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. 12/30/2021 41 Sayana Press (2)

42. The drug has already been tried and approved, and is available for use in 40 European countries including UK. Introductions of Sayana Press also aim to support the Family Planning 2020 coordinated effort to ensure that voluntary family planning services reach an additional 120 million women and girls in the world’s poorest countries by 2020. 12/30/2021 42 Sayana Press (3)

43. In 2015, the UK Medicines & Healthcare products Regulatory Agency (MHRA) authorized Sayana Press for self-injection in the United Kingdom. The World Health Organization (WHO) also recommends self-administration of Sayana Press “in contexts where mechanisms to provide the woman with appropriate information and training exist, referral linkages to a healthcare provider are strong, and where monitoring and follow-up can be ensured.” 12/30/2021 43 Does Sayana Press have regulatory approval for self injection?

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45. 12/30/2021 45 This study recruited women seeking injectable contraception at 14 public health facilities in Nepal selected for geographic diversity. They enrolled women who self-selected either Sayana Press or DMPA-IM and used structured interviews to obtain baseline demographics and assess satisfaction and continuation rates at 1, 3, and 6 months. What they concluded is Sayana Press is acceptable to women in Nepal with the preference for Sayana Press over DMPA-IM (higher proportion chose the method when counseled and given the option, better continuation). Implications: The potential for self-injection with Sayana Press may have implications for continuation and opportunity for future research and strategies to roll out this innovative technology must be explored.

46. 12/30/2021 46 In this prospective cohort study, 380 18–45-year-old participants completed self-injection training by licensed study nurses, guided by a client instruction booklet, and practiced injection on prosthetics until achieving competence. Nurses supervised participants' self injection and evaluated injection technique using an observation checklist. Those judged competent were given a Sayana Press unit, instruction booklet and reinjection calendar for self-injection at home 3 months later. Participants completed an interview before and after self-injection. The study concluded that Self-injection is feasible and highly acceptable among most study participants in Uganda. Results can inform self injection programs which aim to increase women's autonomy and access to injectable contraception. Source:Ref:eader.elsevier.com /reader/ sd / pii /S0010782416304590? &originRegion=eu-west-1&originCreation=20211210063631

47. CONC L U S I ON 12/30/2021 47

48. References 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 12/30/2021 48

49. References   PRB. 2021.  ENGAGE Snapshot: Family Planning Leads to Poverty Reduction . [online] Available at: <https://www.prb.org/resources/engage-snapshot-family-planning-leads-to-poverty-reduction/> 2021. [online] Available at: <https://www.un.org/development/desa/dpad/wpcontent/uploads/sites/45/WESP2021_CH3_SA.pdf> Dhsprogram.com. 2021. [online] Available at: <https://dhsprogram.com/pubs/pdf/FA119/FA119.pdf> 2021. [online] Available at: <https://asiapacific.unfpa.org/sites/default/files/pubpdf/210112_unfpa_impact_of_covid19_on_human_fertility_sp.pdf> 12/30/2021 49

50. References Un.org. 2021. [online] Available at: <https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Sep/unpd_2020_worldfamilyplanning_highlights.pdf> 2021. [online] Available at: <https://nepal.unfpa.org/sites/default/files/pubpdf/FP%20Costed%20Implementation%20Plan.pdf> Usaid.gov. 2021.  Family Planning and Reproductive Health . [online] Available at: <https://www.usaid.gov/global-health/health-areas/family-planning#dataSources> PRB. 2021.  Family Planning Saves Lives . [online] Available at: <https://www.prb.org/resources/family-planning-saves-lives/> https://www.injectsayanapress.org/ 12/30/2021 50

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