HEALTH TALK WITH BABARIMISA OLUWATOYIN: FAMILY PLANNING
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 birth which is achieved through the use of contraceptive methods and the treatment of involuntary infertility (WHO, 2008).
Family planning is a way of thinking and living adopted voluntarily upon the basis of knowledge, attitudes and responsible decision by individuals and couples in order to promote the health of the family, group, and thus contribute effectively to the social development of a country.
Family planning is defined as the information, means and methods that allow individuals to decide if and when to have children.
It is one of the 10 great public health achievement of the twentieth century.
Abstinences from sexual activities is the only 100% effective way to avoid unintended pregnancy.
OBJECTIVES OF FAMILY PLANNING
It serves three critical needs, which are the first 3 of these objectives:
1) It helps couples avoid unintended pregnancies.
2) It reduces the spread of sexually transmitted diseases (STDs).
3) It helps reduce rates of infertility by addressing the problem of STDs.
4) Help couples conceive when they are ready.
5) Help a mother to have a healthy pregnancy e.g nutrition, education, birth preparedness, complication readiness, good nurturing to the new born.
6) Help child in successful growth and development.
7) Help couple terminate child bearing when satisfied with family size.
8) Help family prevent illness through child spacing.
EPIDEMIOLOGY
Family planning prevents about one-third of pregnancy-related deaths as well as 44% of neonatal deaths. Nigeria is the most populous country in Africa and the 6th in the world with an estimated population of 167million as at 31st October 2011. The rate of unintended pregnancy are highest among the following groups:
Women age 18-24
Women who were cohabiting
Women whose income is below the poverty line
Women with less than a high school diploma.
Black or Hispanic women
• High risk groups for family planning services are women:
Under the age of 15 and over 35
Who have delivered four or more children?
With previous complicated pregnancies or childbirth
With chronic illness which increases the health risk of pregnancy.
Note: Abortion is not to be promoted as a method of family planning, although prevention of unsafe abortion is a priority for public health
, lawyers, journalists, health professionals and religious leaders.
ETHICAL ASPECT OF FAMILY PLANNING
• Privacy should be provided.
• Information should never withheld.
• Clients always have a right to ask for as much information as they need.
• A provider should always maintain professional standards e.g sterilized instruments, expired drugs, negligence.
• A client’s choice of any method should always be voluntary.
• Confidentiality should be maintained.
• Varieties of family planning should be provided for clients to make a choice.
LEGAL ASPECT
a) LAW:
Presently there are no written laws governing family planning practice in Nigeria. All persons in Nigeria, regardless of age, are free to seek family planning services.
b) REGULATIONS:
In any religion or institution, there may be regulations concerning family planning practices. These may include:
- Husband’s consent
- Age of client
- Types of services offered methods may be restricted because of religion and other socio-cultural norms.
C) POLICY:
Policies are guidelines for influencing decision and course of action. Nigeria issued a National policy on population in 1988. The goals of the policy are to:
- Improve the standards of living
- Promote health and welfare
- Achieve lower population growth rates
- Achieve more even distribution of population.
A key aspect of the National Policy on population is the aspect for the right of each couple to determine voluntarily the number and spacing of children in order to achieve the goal as stated above.
• Family planning services includes:
• Contraceptive services
• Pregnancy testing and counselling
• Pregnancy- achieving services including preconception services, health services.
• Basic infertility services
• Sexually transmitted services
• Breast and pelvic examinations.
• Breast and cervical cancer screening
STIs and HIV prevention education, counselling, testing and referral
• Traditional method
• Natural family planning
• Hormonal
• Barrier
• Intrauterine Device (IUD) OR Intrauterine Contraceptive (IUC)
• Permanent sterilization
TYPES OF BIRTH CONTROL
• This includes:
| Male | female |
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Permanent | vasectomy | Tubal ligation (Tubes tied) |
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Short term | condoms | Condoms Birth control pills Cervical caps Diaphragm Contraceptive injection Natural family planning The patch, IUCD Morning after pill |
|
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Traditional methods of FP
• Native rings, wooden crafts (omolangidi), scarifications, herbs, potash powder, feathers, blue powder (solution) omi oku (fluid from dead body/ corpse), 7up and salt.
• Disadvantages
• Method of mechanism are not clearly understood.
• Effectiveness cannot be measured.
• Some of the method are irreversible, especially when user makes mistakes.
• Operated only by traditional medicine men.
• Injurious to the body
Natural family planning
Is the use of fertility of awareness and periodic abstinence to avoid pregnancy, does not require any kind of medication or device.
1) Fertility awareness-based methods:
This is based on the ability to notice certain physiological changes associated with ovulation to recognize fertile and infertile phases of menstrual cycle. Examples includes:
a) Basal Body Temperature
b) Calendar /Rhythm method
c) Cervical mucus method (CMM) or Billings ovulation method
d) Sympto-Thermal method (STM)
CALENDER /RHYTHM METHOD
• Also called as the rhythm method, this natural method of family planning involves refraining from coitus during the days that the woman is fertile.
• According to the menstrual cycle, 3 or 4 days before and 3 or 4 days after ovulation, the woman is not likely to conceive.
• The process in calculating for the woman’s safe days is achieved when the woman records her menstrual cycle for six months.
• She subtracts 18 from the shortest cycle and the difference is the first fertile day.
• She also subtracts 11 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.
• It has an ideal fail rate of 5%, but when used it has a typical fail rate of 25%.
BASAL BODY TEMPERATURE
• The basal body temperature is the woman’s temperature at rest.
• BBT falls at 0.5⁰F before the day of ovulation and during ovulation, it rises to a full degree because of progesterone and maintains its level throughout the menstrual cycle, and this is the basis for the method.
• The woman must take her temperature early every morning before any activity, and if she notices that there is a slight decrease and then an increase in her temperature, this is a sign that she has ovulated.
• The woman must abstain from coitus for the next 3 days.
• The BBT method has an ideal fail rate of 9% and has a typical use fail rate of 25%
CERVICAL MUCOUS METHOD (CMM) OR BILLINGS OVULATION METHOD
• The basis of this method is the changes in the cervical mucus during ovulation.
• To check if the woman is ovulating, the cervical mucus must be copious, thin, and watery.
• The cervical mucus must exhibit the property of spinnbarkeit, wherein it can be stretched up until at least 1 inch and feels slippery.
• The fertile days of a woman according to this method is as long as the cervical mucus is copious and watery and a day after it. Therefore, she must avoid coitus during these days.
• When used typically, it has a fail rate of 25%.
Symptothermal and Ovulation detection method
• The symptothermal method is simply a combination of the BBT method and the cervical mucus method.
• The woman takes her temperature every morning before getting up and also takes note of any changes in her cervical mucus every day.
• She abstains from coitus 3 days after a rise in her temperature or on the fourth day after the peak of a mucus change.
• Symptothermal method has an ideal failure rate of 2%.
OVULATION DETECTION
• The ovulation detection method is an over-the-counter kit that can predict ovulation through the surge of luteinizing hormone that happens 12 to 24 hours before ovulation.
• The kit requires the urine specimen of the woman to detect the LH.
• The kit is 98% to 99% accurate and is fast becoming the method of choice by women.
• 2) Lactational Amenorrhea Method (LAM): it involves practice of exclusive breastfeeding by a nursing method. Instruct as follows:
• Breast feed exclusively for the first 6 months and as often as the child wants.
• Refrain from giving a pacifier.
• Allow a long time on the breast each time (at least 15minutes).
• Breast feed both during the day (8 times) and at night (twice).
• Give no other food, drink, herbs or water before 6months of age.
• Use another method of contraception, if for any reason the breast milk begins to fall, or breast feeding is interrupted or irregular.
• Return to the clinic if breast feeding pattern changes or menses resumes.
• NOTE: likelihood of pregnancy is lower during the first month after delivery whether or not she breast feeds her child since she’s usually amenorrheic during this time. After menstruation resumes the risk for pregnancy is similar whether or not she breastfeeds. This suggests that the pregnancy preventing properties of breast feeding are primarily limited to the amenorrheic period.
3) Modern/ Artificial method: Coitus interruptus
Coitus interruptus (withdrawal method) is when the penis is withdrawn from the vaginal just before ejaculation.
Instruct client as follows:
- withdraw penis from vaginal before ejaculation.
- Wipe any fluids at the tip of the penis before intercourse (pre-sexual emission may contain sperm).
- Do not use this method if there is going to be repeated acts of intercourse.
- Do not use this method if your partner is not full control of ejaculation.
- Failure to withdraw completely before ejaculation has taken place use a quick acting spermicide such as foaming tablet or jelly immediately & emergency contraceptive within 72hrs.
4) Abstinence:
• This is a method of avoiding or refusing sexual intercourse.
• The only method the adolescents/ youths are encouraged to adopt.
• It is morally and culturally acceptable.
• It is 100% effective in the prevention of pregnancy, STIs, HIV and AIDS
• It bestows on young people a sense of self-worth
BARRIER METHOD OF CONTRACEPTION
CHEMICAL BARRIER
• Chemical barriers such as spermicides, vaginal gels and creams, and glycerin films are also used to cause the death of sperms before they can enter the cervix and also lower the pH level of the vagina so it will not become conducive for the sperm. Placed in the vaginal before intercourse.
• These chemical barriers cannot prevent sexually transmitted infections; however, they can be bought without any prescription.
• The ideal fail rate of chemical barriers is 80%.
Tablets must be inserted before intercourse. Read and follow instructions for specific type regarding time for placement, duration and effectiveness.
• Advantages
• Serves as lubricants, easy to apply, no effect on breast milk, readily available, easy to carry about, does not affect menstrual cycle.
• Disadvantages
• Can cause minor vaginal or skin irritations or produce burning sensation if a woman is allergic to ingredients of the spermicides.
• Disadvantageous and risky to ingredients of the spermicides.
• Can be difficult to hide from partners
DIAPHRAGM
• A diaphragm works by inhibiting the entrance of the sperm into the vagina.
• It is a circular, rubber disk that fits the cervix and should be placed before coitus.
• If a spermicide is combined with the use of a diaphragm, there is a failure rate of 6% ideally and 16% typically.
• The diaphragm should be fitted only by the physician, and should remain in place for 6 hours after coitus.
• It can be left in place for not more than 24 hours to avoid inflammation or irritation.
• It’s safe for most women except for women with chronic bladder infections or frequent urinary tract infections.
• Post-partum mothers must wait 6-12weeks after delivery or abortion.
• Types includes: arcing spring, flat spring, coil spring and wide seal rim.
• Disadvantages
• Sensitivity to rubber or spermicide
• Not readily available in Nigeria and expensive for some clients.
• Only good for women with infrequent intercourse.
• Cervical Cap
• The cervical cap is another barrier method that is made of soft rubber and fitted on the rim of the cervix.
• It is shaped like a thimble with a thin rim, and could stay in place for not more than 48 hours. same as diaphragm disadvantages
• Male Condoms
• The male condom is a latex or synthetic rubber sheath that is placed on the erect penis before vaginal penetration to trap the sperm during ejaculation.
• It can prevent STIs and can be bought over-the-counter without any fitting needed.
• Male condoms have an ideal fail rate of 2% and a typical fail rate of 15% due to a break in the sheath’s integrity or spilling.
• After sexual intercourse, the condom is removed to be disposed.
• Female Condoms
• These are also latex rubber sheaths that are specially designed for females and prelubricated with spermicide.
• It has an inner ring that covers the cervix and an outer, open ring that is placed against the vaginal opening.
• These are disposable and require no prescription.
• The fail rate of female condoms is 12% to 22%.
• Disadvantages of female condoms
• Difficult to place in the vagina.
• Makes embarrassing noise during intercourse.
• May cause rash if allergic to poly urethane
.
ORAL CONTRACEPTIVE
• Also known as the pill, oral contraceptives contain synthetic estrogen and progesterone.
• Estrogen suppresses the FSH and LH to suppress ovulation, while progesterone decreases the permeability of the cervical mucus to limit the sperm’s access to the ova.
• To use the pill, it is recommended that the woman takes the first pill on the first Sunday after the beginning of a menstrual flow, or the woman may choose to start the pill as soon as it is prescribed.
• Advise the woman that the first 7 days of taking the pill would still not have an effect, so the couple must use another contraceptive method on the initial 7 days.
• If the woman has skipped one day of taking the pill, she must take it the moment she remembers it, than still follow the regular use of the contraceptive.
• If the woman has missed taking the pill for more than one day, she and her partner must consider an alternative contraception to avoid ovulation.
• Side effects for OCs are nausea, weight gain, headache, breast tenderness, breakthrough bleeding, vaginal infections, mild hypertension, and depression.
• Contraindications to OCs are breastfeeding, age of 35 years and above, cardiovascular diseases, hypertension, smoking, diabetes, and cirrhosis.
TRANSDERMAL PATCH
• The transdermal patch has a combination of both estrogen and progesterone in a form of a patch.
• For three weeks, the woman should apply one patch every week on the following areas: upper outer arm, upper torso, abdomen, or buttocks.
• At the fourth week, no patch is applied because the menstrual flow would then occur.
• The area where the patch is applied should be clean, dry free from any applications. And without any redness or irritation.
• Patches can be worn while bathing or swimming, but when the woman notices that the patch is loose, she should immediately replace the patch.
• If the patch has been loose for less than 24 hours, the woman need not use an alternative form of contraceptive, but if she is not sure of how long the patch has been loose, she should replace it and start with a new week cycle and also use an additional contraceptive method.
SUBDERMAL
• The subdermal implants are two rod-like implants embedded under the skin of the woman during her menses or on the 7th day of her menstruation to make sure that she is not pregnant.
• It contains etonogestrel, desogestrel, and progestin.
• It is effective for 3 to 5 years.
• Subdermal implants have a fail rate of 1%.
HORMONAL INJECTION
• A hormonal injection consists of medroxyprogesterone a progesterone, and given once every 12 weeks intramuscularly.
• The injection inhibits ovulation and causes changes in the endometrium and the cervical mucus. They are long actin.
• They are given intramuscularly. After administration the site should not be massaged so it could absorb slowly.
• It has an effectiveness of almost 100%, making it one of the most popular choices for birth control.
• Advise the woman to ingest an adequate amount of calcium in her diet as there is a risk for decreased of bone mineral density and to engage in weight-bearing exercises.
• TYPES: PROGESTIN ONLY, NORETHESTIRONE ENANTHATE (NORISTERAT, NET-EN), CYCLOFEM
DISADVANTAGES OF INJECTABLES
• Requires frequent visits to the clinic.
• May cause irregular bleeding.
• Menses may cease for several month.
• Return of fertility may be delayed.
• May cause weight gain.
• Does not protect against sexually transmitted disease.
• May cause headaches, breast tenderness, moodiness, nausea, hair loss and reduced libido.
CONTRAINDICATION
Existing malignancy of the breast or genital organ.
Abnormal uterine bleeding
Pregnancy.
Depression
History of stroke, heart attack, or blood clot problem.
Contraceptive implants
• Implant are progestin only contraceptives inserted under the skin of a woman upper arm through a minor surgical procedure.’
• Fertility returns to normal level on removal of implant
TYPES
• Norplant: (6soft plastic rods each contsining 36mg of levonorgesterol). 5years
• Jadelle: (2 silicon rods contains 75mg levonorgesterol). This is an improved version of norplant. 5years
• Uniplant: (1 rod, contains normegesterol acetate). 1 year
• Implanon (1rod contains progestin 3-ketodesogesterol. 3years.
INTRAUTERINE DEVICE
• An IUD is a small, T-shaped object that is inserted into the uterus via the vagina.
• It prevents fertilization by creating a local sterile inflammatory condition to prevent implantation.
• The IUD is fitted only by the physician and inserted after the woman’s menstrual flow to be sure that she is not pregnant.
• The device contains progesterone and is effective for 5 to 7 years.
• A woman with IUD is advised to check the flow of her menstruation every month and the IUD string, and also to have a pelvic examination yearly.
VASECTOMY
• Males undergo vasectomy, which is executed through a small incision made on each side of the scrotum.
• The vas deferens is then tied, cauterized, cut, or plugged to block the passage of the sperm.
• This procedure is done with local anesthesia, so advise the patient that mild local pain can be felt after the procedure.
• Advise the patient to use a back-up contraceptive method until two negative sperm count results are performed because the sperm could remain viable in the vas deferens for 6 months.
• There is a 99.5% accuracy rate for vasectomy and has a few complications.
TUBAL LITIGATION
• In women, tubal ligation is performed by occluding the fallopian tubes through cutting, cauterizing, or blocking to inhibit the passage of the both the sperm and the ova. After menstruation and before ovulation, the procedure is done through a small incision under the woman’s umbilicus.
• A laparoscope is used to visualize the surgery, and the patient is under local anesthesia.
• The woman may return to her sexual activities after 2 to 3 days of the operation.
• Educate that menstrual cycle would still occur, and make sure that coitus before ligation is protected to avoid ectopic pregnancy.
• The effectiveness of this method is at 99.5%.
• The reproductive system is our tool as humans to multiply or procreate. However, the earth would become unlivable if the growth of the population continues to boom. You have a choice among all these birth control methods, and these are only a call to be a responsible parent and citizen.
IMPORTANCE OF FAMILY PLANNING
• It saves lives: Contraceptives prevented unintended pregnancies, reduce number of abortions, lowers death & disability (maternal or child) incidence related to complications of pregnancy and delivery. It also provides protection again STIs including HIV.
• Empowers women: When women and couples are able to plan whether and when to have children, and how many women are better able to complete their education; women’s autonomy within their household is increased; and they can earn more. This strengthen economic security and wellbeing and that of their families.
Economic benefits:
• It contribute to poverty reduction and global development.
• Reduction of high parity will decrease complications like uterine rupture.
• Improve quality of life of people in the community.
• Improve women economic and social status.
• Increased financial potential for families.
• Increase education potential therefore intellectual potential.
• Encourages child spacing therefore reducing sibling rivalry.
• Emotional stability due to attention and love received from parents therefore prevent juvenile delinquency.
Negative outcomes associated with unintended pregnancy
• Delay in initiating prenatal care.
• Reduce likelihood of breast feeding.
• Increase risk of maternal depression.
• Increase risk of physical violence.
BARRIERS TO FAMILY PLANNING
• Cost of services.
• Religion and culture
• Taboos, myths and misconceptions
• occupation
• Poverty, ignorance and lack of awareness.
• Lack of youth-friendly services.
• Clinic locations and long waiting hours that are not convenient for clients.
• Logistic problem such as difficulty travelling to health facilities or stuck outs at health clinics.
• Oppositions by partners or families (spousal consent).
• Lack of knowledge about the various contraceptive methods available.
STRATEGIES FOR ACCEPTANCE OF FAMILY PLANNING
• Correct any misconception on family planning methods.
• Dispel rumours, myths and taboos on family planning.
• Promote community distribution and social marketing of FP services.
• Provide full and accurate family planning information and counselling in an atmosphere that ensures privacy and confidentiality.
• Investment in adolescents and youth by educating them on various contraceptives available to them, creating a youth friendly clinic for them.
• Strengthening supply chains so that contraceptives reach those who need them and the often un-reached populations.
• Ensuring that family planning services and supplies have sustained funding support.
• Improving the quality care in family planning service.
• Promote dual protection (pregnancy and STI’s) e.g. Condoms.
• Discuss post-partum contraceptive options during pregnancy.
• Counsel clients about all available methods, do not limit choices.
Babarimisa Oluwatoyin writes from Lagos Nigeria
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