NEWER CONCEPT ON CONTRACEPTION. A JOINT PROJECT OF IMA AND UNFPA

1. Family planning :Current Contraceptive Scenario in India IMA DISTRICT LEVEL WORKSHOP ON CONTRACEPTIVE UPDATES & SAFE ABORTION TECHNIQUES

2. Contraceptive Updates Seminar, October 2005 Source: NFHS-3 (2005-06) Percentage use of contraception by married Women (15-49) – Total urban rural N

3. Knowledge among eligible population (%) Contraceptive method Ever use (%) Current use (%) Contraceptive Scenario in India Any method 99 55.1 48.2 For all modern methods 98.9 49.3 42.8 Combined Oral pills 79.5 8.4 2.1 IUDs 70.6 5.6 1.6 Condoms 71 7.9 3.1 Female sterilization 98.2 34.2 34.2 Male Sterilization 89.3 2 1.9 Natural methods 48.9 11.8 5

5. Trends in Contraceptive Use by Method Percent of currently married women age 15-49

7. Not using contraception Pregnant or amenorrhoeic Not pregnant or amenorrhoeic Pregnancy intended Pregnancy mistimed Need for spacing Need for limiting Fecund In fecund Want later Want no more Want soon Need for spacing Need for limiting Total Unmet Need Pregnancy unwanted

27. Female Condom in Place Inner ring Outer ring Plastic sheath with ring at both ends How to grasp female condom for insertion

45. Standard Day Method Fertility Awareness Based Method

48. CycleBeads

49. CycleBeads

50. CycleBeads

51. CycleBeads

52. CycleBeads

53. CycleBeads

54. CycleBeads

57. Oral Contraceptives and Emergency Contraceptive Pills Contraceptive Updates Seminar, October 2005

59. Combined Oral Contraceptive pills Contraceptive Updates Seminar, October 2005 Alteration of endometrium to make it unsuitable for implantation even if the ovum is fertilized. Mechanism of action: Changes in cervical mucous which make it hostile for sperms Inhibition of ovulation by suppressing FHS and LH

60. Effectiveness Contraceptive Updates Seminar, October 2005 Failure rate is 0.3% as commonly used and only 0.1% on correct and consistent use. 99.97% to 99.99%.

63. Side effects Contraceptive Updates Seminar, October 2005 Breakthrough bleeding-common with low dose progesterone pills due to low or absent estrogen. Nausea, vomiting, decreased appetite; usually pass off after 2-3 months of use Oligo and ammenorrhoea due to lack of proliferation of endometrium of cycle. Common among women who had menstrual problems before starting oral contraceptive pills.

64. Side effects Contraceptive Updates Seminar, October 2005 Vaginal discharge due to congestion and hypertrophy of cervical epithelium. Breast changes- oedema, heaviness and tenderness. Chloasma Weight gain in some cases due to estrogen and progesterone . Acne and oily skin.

65. ELIGIBILITY CRITERIA: (For low dose combined contraceptive pills) Contraceptive Updates Seminar, October 2005 Most women can use Combined Oral Contraceptives. Are of any age, including adolescents and over 40 (except women 35 years or older and who smoke) Smoke cigarettes but are under age 35 Have just had abortion or miscarriage

66. ELIGIBILITY CRITERIA: (For low dose combined contraceptive pills) Contraceptive Updates Seminar, October 2005 Heavy, painful menstrual periods or iron deficiency anemia (condition may improve) Benign breast disease Diabetes without vascular, kidney, eye or nerve disease Irregular menstrual periods Mild headaches Malaria Varicose veins

67. ELIGIBILITY CRITERIA: (For low dose combined contraceptive pills) Contraceptive Updates Seminar, October 2005 Thyroid disease Endometriosis Pelvic inflammatory disease Begin ovarian tumour Past ectopic pregnancy Uterine fibroids Tuberculosis (unless taking Rifampicin)

68. Who cannot use COCs? Contraceptive Updates Seminar, October 2005 Fully Breastfeeding within 6 month postpartum; If partially BF she can start after six weeks Are age 35+ and smoke more than 15 cigarettes per day Have multiple risk factors for arterial cardiovascular disease Have hypertension with systolic BP 140-159 and diastolic 90-99 and those having vascular disease. Have clear history of deep vein thrombosis (DVT), pulmonary thrombosis or current DVT or pulmonary thrombosis. Have known thrombogenic mutations. Have current history of ischemic heart disease or known hyperlipidaemias

69. Who cannot use COCs? Contraceptive Updates Seminar, October 2005 Women who have Migraine with aura Current breast cancer Diabetes with neuropathy, retinopathy, nephropathy and other vascular disease Acute hepatitis or severe cirrhosis of liver or benign or malignant liver tumours Complicated pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis

70. Important Contraceptive Updates Seminar, October 2005 Women having the above health conditions should be encouraged to use other more appropriate contraceptives than COCs.

71. When can a woman start COCs? Contraceptive Updates Seminar, October 2005 During a menstrual cycle Amenorrhoea Between 2 menstrual cycles Breastfeeding Switching to another hormonal method Switching from non-hormonal method After miscarriage or abortion Switching from IUD (including hormonal)

72. Key steps for providing COCs Contraceptive Updates Seminar, October 2005 Give pills, 3 months supply if possible. Running out of pills is one of the major reasons for unintended pregnancy. Explain how to use If possible give condoms or spermicide to use: Until she can start taking the pills If she starts packet of pills late, misses pills in row or stops taking pills for any other reason If there is possibility of transmission of STIs/HIV Show her how to use condoms and spermicide. Invite the client to come back any time if she has any questions, problems or wants another method Plan for return visit

73. Pills missed? Contraceptive Updates Seminar, October 2005 WHAT TO DO IF YOU MISS ONE OR MORE PILLS Every time you miss one or more active pills (days 1-21): In these special cases, ALSO follow these special rules If you miss nay of the 7 inactive pills (in a 28–pill pack only) 1. Take a pill as soon as you remember 1. Take the next pill at the usual time 3. Keep taking active pills as usual, one each day Source: Johns Hopkins University Bloomberg School of Health, Population information program Started pack 2 or more days late? Missed 2–4 pills of first 7 pills days 1–7 Missed 5 or more active pills in a row days 1–7 Missed 2–4 pills of last 7 active pills days 15–21 Avoid sex or another method for 7 days Finish all active pills in the pack. Do not take last 7 (inactive) pills in 28–pill pack. Do not wait 7 days to start next 21– pill pack. Start a new pack. 1. Throw away missed pills 2. Keep taking one pill each day 3. Start new pack as usual

74. What to do at follow up visit Contraceptive Updates Seminar, October 2005 Ask if client has any questions or anything to discuss. Ask client about her experience with the method. Give her any information she needs and invite her to return any time for help. If she has problems that cannot be resolved, help her choose another method. Plan for next visit before she will need more pills.

75. Emergency Contraceptive Pills (ECPs) Contraceptive Updates Seminar, October 2005 Emergency contraception: Is method of contraception used before missing a period to prevent pregnancy. It is also called “morning after” or post-coital contraception.

76. Indications for using emergency contraception Contraceptive Updates Seminar, October 2005 A woman who had unprotected sex, and wants to prevent pregnancy. For example: She did not expect to have sex and was not using any contraception Sex was forced Condom broke or slipped She ran out of contraceptives, or was irregular in taking pills and did not use condoms or spermicide. She is late for a contraceptive injection.

77. What pills can be used as ECPs? Contraceptive Updates Seminar, October 2005 Progestin-only dedicated products: Levonorgesterol pills are generally used GOI emergency contraceptive pills also available through public systems Several commercial preparations available in market

78. Contraceptive Updates Seminar, October 2005 Levonorgesterol alone EC pills- A dedicated product 0.75 mg of tablets Levonorgestel available in India. The current recommendation: 1 pill of LNG 0.75 mg to be taken as soon as possible after unprotected coitus (within 72 hours) followed by another pill 12 hours later. Depending on the composition 1 pill of 1.5mg in a single dose can be taken.

79. GOI Guidelines Contraceptive Updates Seminar, October 2005 The Government of India guidelines for Emergency Contraception recommend use of Levonorgestrel (progestogen only) LNG as a “dedicated product” for effective emergency contraception. The Drug Controller of India has approved only Levonorgestrel for use as ECP.

80. How effective are ECPs? Contraceptive Updates Seminar, October 2005 Pregnancy rate 8%, if women have sex once in the second or third week of the menstrual cycle without using contraception. Pregnancy rate 2% if women use combined oral contraceptives for emergency contraception Pregnancy rate 1% if women use progestin-only ECPs

81. How do ECPs work? Contraceptive Updates Seminar, October 2005 Probable mechanisms are: Inhibition or delay of ovulation Thickening of cervical mucous Direct inhibition of fertilization Histological and biochemical alteration in endometrium leading to impaired endometrial receptivity to implantation of the fertilized egg Alteration in transport of egg, sperm and embryo Interference with corpus luteum function and luteolysis

82. Medical eligibility criteria for Emergency Oral Contraception Contraceptive Updates Seminar, October 2005 Any woman can use emergency oral contraception if she is not already pregnant within the stipulated time period.

84. Advice on common problems Contraceptive Updates Seminar, October 2005 Nausea: Eat something soon after taking the pills to reduce nausea.Take anti-emetic half an hour before taking emergency contraceptive pills and every 4-6 hours thereafter. Vomiting: If the woman vomits within 2 hours of taking the pills, she may take another dose. Otherwise she should not take any extra pills. Extra pills will not make the method more effective, and they may increase nausea. Her next monthly period may start a few days earlier or later than expected. Reassure her that this is not a bad sign.

85. Specific reasons to return to the healthcare provider Contraceptive Updates Seminar, October 2005 Advise her to return or see another health care provider if her next period is quite different from usual for her, especially if: There is unusually light bleeding (possibly pregnancy) Bleeding does not start within 4 weeks (Possible pregnancy) Unusually painful (possibly ectopic pregnancy). But emergency oral contraception does not cause ectopic pregnancy. If there are symptoms of sexually transmitted diseases.

86. Some facts about ECPs Contraceptive Updates Seminar, October 2005 Will not disrupt an established pregnancy Offer no protection against STIs. Do not provide continuing protection from pregnancy. No medical conditions rule out ECPs.

87. Providing ECPs: Key steps Contraceptive Updates Seminar, October 2005 Help the client feel at ease. Ask when unprotected sex took place. Give the woman pills. Explain how to take them. She can take first dose at once.

88. Providing ECPs: Key steps Contraceptive Updates Seminar, October 2005 Explain and discuss important points about ECPs. Discuss her ongoing need for contraception Tell her that if she vomits within 2 hours of taking pills, she may take another dose.

132. In India DMPA currently approved and available in 106 countries and NET-EN in over 60 countries. Some social marketing organizations also provide ICs Approved by Drug Controller of India and commercially available.

145. WHO Eligibility Criteria Source : WHO 2004. Category Description When clinical judgment is available When clinical judgment is limited 1 No restriction for use Use the method under any circumstances Use the method 2 Benefits generally outweigh risks Generally use the method 3 Risks generally outweigh benefits Use of method not usually recommended, unless other methods are not available/acceptable Do not use the method 4 Unacceptable health risk Method not to be used

149. REMEMBER! Counseling does not terminate when the client accepts a method or undergoes the procedure, its process completes when the acceptor returns to the service centre/provider for follow up and goes back home with satisfaction.

162. Preparing the IUD for insertion

169. Swab the cervix with antiseptic. Gently introduce the loaded inserter assembly through the cervical canal until the flange comes in contact with the cervix.

170. Hold the plunger stationary and withdraw the insertion tube so as to release the arms of the T.

171. Gently push the insertion tube upwards, towards the top of the uterus until a slight resistance is felt. This ensures that the T is closer to the fundus.

172. Withdraw the plunger while holding the insertion tube stationary.

173. Gently withdraw the insertion tube. Cut the threads so that they protrude only 2-3 centimeters into vagina. Use sharp scissors.

175. Family Planning Permanent Methods: Male & Female Sterilisation Dr. Kiran Ambwani, Deputy Commissioner, Family Planning Divison, MoHFW GOI

176. Source: Family Planning: A Global Handbook for Providers, WHO, 2007

182. REFER to a centre with experienced staff and equipment in case of Endometriosis Fixed uterus due to previous surgery or infection Hernia (umbilical or abdominal wall) Postpartum uterine rupture or perforation Post-abortion uterine perforation

184. Requirements of a safe procedure Client assessment Counseling Laboratory tests Informed consent Anesthesia Infection prevention Instructions to accompanying persons

185. Counseling: Ensure Informed Choice A FRIENDLY COUNSELLOR: LISTENS to the concerns of the women GIVES clear & practical information HELPS her to make informed choice to avoid later regret Source: Family Planning: A Global Handbook for Providers, WHO, 2007

189. Five common causes of female sterilization failure Surgical “occlusion” of a structure other than the fallopian tube (most often, the round ligament) An undetected luteal-phase pregnancy that was present at the time of sterilization Incomplete or inadequate occlusion of the fallopian tube Misplacement of the mechanical device Development of tuboperitonoal fistula.

190. Male Sterilisation OR Vasectomy A safe & Effective Method of Contraception

191. Source: Family Planning: A Global Handbook for Providers, WHO, 2007

194. Medical Eligibility Most men who want vasectomy can have safe and effective procedures in routine settings. Most men can have vasectomy This includes men of any age who are HIV positive or at high risk of HIV or other STIs have sickle cell disease or hereditary anaemia; have no children

195. Medical Eligibility Active sexually transmitted infection If he has the following, DELAY vasectomy and refer for treatment Scrotal skin infection or mass in the scrotum Acute systemic infection or significant gastroenteritis Inflamed (swollen and tender) tip of penis, ducts or testicles

196. If he has any of the following, REFER him to a center with experienced staff and equipment that can handle potential problems: Hernia in the groin (can perform vasectomy at the same time as repairing hernia. If this is not possible, the hernia should be repaired first) Filariasis or elephantitis Undescended testicles - both sides Current-AIDS related illness Coagulation disorders

197. If he has any of the following, use CAUTION Large varicocoel or hydrocoele (swollen veins or membranes in the spermatic cord or testes, causing swollen scrotum) Previous scrotal surgery or injury Undescended testicles – one side only (vasectomy is performed on the normal side only. Then if any sperm remains in the semen after 3 months, the other side must be done, too) Diabetes

198. Having a vasectomy Counseling Requirement of safe procedure: Informed consent Infection prevention Client assessment Anaesthesia Instructions to client

200. GoI: Program, Guidelines and Standards in Sterilisation Services

225. COMPENSATION For Public (Govt.) facilities High Focus States Breakage of the Compensation package Acceptor Motivator Drugs and dressing Surgeon charges Anesthetist Staff nurse OT technician/helper Refreshment Camp management Total VAS. (ALL) TUB. (ALL) 1100 600 200 150 50 100 100 75 - 25 15 15 15 15 10 10 10 10 1500 1000

226. COMPENSATION B. For Private Facilities: High Focus States Type of operation Facility Motivator Total Vasectomy (ALL) Tubectomy (ALL) 1300 1350 200 150 1500 1500

227. Need of the HOUR Involvement Partnership Commitment IMPROVING AVAILABILITY & QUALITY of CONTRACEPTIVE SERVICES PUBLIC & PRIVATE

228. Orientation on safe abortion for private providers Dr. Dinesh Agarwal NPO(RH), UNFPA

230. Legal Aspects of Abortion Care

234. Facilities required for site appro val MTP rules segregate sites which offer only 1 st trimester MTPs & sites that offer MTPs up to 20 weeks. For MTP up to 12 weeks For MTP up to 20 weeks Gynecological examination/ labor table Operation table Resuscitation & sterilization equipment Instrument for performing abdominal or gynecological surgery Drugs & parenteral fluid Anesthetic equipment Back up facilities for treatment of shock & facilities for transportation Resuscitation & sterilization equipment Drugs & parenteral fluids for emergency use notified by the government of India from time to time

237. Counselling

241. Clinical Assessment

245. Infection Prevention

250. Vacuum Aspiration Techniques for 1 st trimester MTP

255. Manual Vacuum Aspiration

261. Medical Methods of Abortion (MMA)

266. MMA drug protocol Protocols for mifepristone & misoprostol administration Gestational Age Mifepristone on Day 1 Misoprostol on Day 3 Dose Route Recommended options Up to 49 days 200 mg orally (one 200 mg tablet) 400 μ g (two 200 μ g tablets) Oral/ vaginal Up to 63 days 200 mg orally (one 200 mg tablet) 800 μ g (four 200 μ g tablets) Sublingual/ vaginal

269. Methods of 2 nd Trimester Abortion

272. Methods S econd trimester pregnancy termination Induction method: Emcredyl Instillation Surgical Method: Dilatation & Evacuation (D&E) Medical method: Combination of mifepristone & misoprostol *This is currently not an approved method for 2 nd trimester MTP in India