2. Kenya’s average total fertility in 2010 is between 4-5
children per woman (TFR- 4.6)
Social and cultural beliefs and practices, gender
dynamics, lack of male involvement, and weak health
management systems continue to impede the demand
for and utilization of reproductive health care.
Contraceptive prevalence rate (CPR) has modestly
improved to 46% from 39% in 2003 however it falls far
below the national target for CPR of 56% by 2015.
Meanwhile, Kenya’s maternal mortality rate (MMR) of
414 per 100,000 live births has not improved.
Unmet need for FP is 24%.
3. Family planning allows 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.
A woman’s ability to space and limit her pregnancies has
a direct impact on her health and well-being as well as
on the outcome of each pregnancy.
4. Birth spacing
Unintended pregnancies are often associated with short
between-birth intervals, which can have deadly
consequences for infants and children.
Short birth intervals (<27 months) are associated with
an elevated risk of infant, neonatal and perinatal
mortality; low birth weight; small size for gestational
age; and preterm delivery.
Women should wait at least two years after giving birth
before getting pregnant again.
Family planning education, counselling, and
contraceptive services can help in spacing births at
intervals recommended for the health of the mother
and the baby.
5. Rights of FP client
All clients have certain rights, including:
• The right to decide whether to practice FP
• The freedom to choose which method to use
• The right to privacy and confidentiality
• The right to refuse any type of examination
• The freedom to choose where to seek services
6. Factors affecting access of
FP
These factors include logistical, social, and behavioural
barriers to meeting the contraceptive needs and wishes
of individuals and couples, as well as obstacles that
stem from the organization of the services.
The major restrictive barriers include distance, cost,
religion, culture, provider bias, and legal and medical
regulations.
7. UNMET NEED OF FP
Women with unmet need are those who are fecund and
sexually active but are not using any method of
contraception, and report not wanting any more
children or wanting to delay the birth of their next
child.
Unmet need for contraception can lead to unintended
pregnancies, which pose risks for women, their families,
and societies.
In less developed countries, about one-fourth of
pregnancies are unintended—that is, either unwanted or
mistimed
8. Unmet need is especially high among groups such as:
Adolescents
Migrants
Urban slum dwellers
Refugees
Women in the postpartum period
9. WHO categories
The WHO groups medical conditions into these four categories:
1. Conditions for which there is no restriction on the use of the contraceptive
method.
2. Conditions for which the advantages of using the method generally outweigh
the theoretical or proven risks. In most situations, the method can be used
freely, but careful follow-up might be required.
10. WHO categories
3. Conditions for which the theoretical or proven risks
usually outweigh the advantages of using the method. In
this case, use of the method is not usually
recommended unless other more appropriate
alternative methods are not available or acceptable.
4. Conditions that present an unacceptable health risk if
the contraceptive method is used, (i.e., the method
should not be used).
11. Fertility awareness based
(FAM)/Natural Methods of FP and
contraceptive
It is called natural because it does not involve use of drug
or device and it require abstention from intercourse
during the fertile time of a woman’s menstrual cycle,
thereby avoiding conception.
The following are the available methods:
· Withdrawal method (coitus interruptus)
· Safe period (rhythm method)
· Lactational amenorrhea method (LAM)
· Cervical mucus membrane
· Basal body temperature (BBT) method
· Sympto thermal method
12. Fertility awareness based
(Natural) Methods of FP and
contraceptive
Newer FAM options, such as the Standard Days Method®
(SDM) and TwoDay Method® (TDM), require less reliance
on the provider, as they are offered and learned in one
client-provider contact.
Effectiveness of FAMs is enhanced by use of multiple
techniques to identify the fertile time.
13. Mechanical methods of family
planning and contraceptive
This type of family planning method involves use
of devices which may sometime have some form of
drug(hormone ) attached to it ,there mode of function
is by placing a barrier so that sperm does not get into
the fallopian tube to fertilize the woman’s egg. The
following are the available mechanical methods of
family planning
· Intrauterine contraceptive
Devices(IUCD,LOOP,COIL)
· Condoms
· Diaphragm
14. Hormonal methods of family
planning and contraceptive
This is the most common used method of family planning
and contraceptive .
Hormonal contraceptives are highly effective (if used
correctly), safe, and convenient. They can be taken in the
form of oral pills, injectables, implants, skin patches, or
hormone-releasing intrauterine systems.
- Combined oral contraceptives
· Emergency pills
· Ordinary pills
-Progesterone only contraceptives
· Injectables
· Implants i.e. Jadelle®, Implanon® ,
Norplant®
15. Hormonal Contraceptives
The following are the methods commonly available in Kenya:
■ Combined oral contraceptive pill (COC)
■ Progestin-only contraceptive pill (POP)
■ Progestin-only injectable contraceptives (DMPA, NET-EN)
■ Progestin-only contraceptive implants (Norplant, Jadelle)
Less commonly available methods in Kenya:
■ Combined injectable contraceptives (Cyclofen, Cycloprovera, Mesigyna,
Norigynon)
■ Combined vaginal contraceptive ring
■ Combined contraceptive (skin) patch
17. Hormonal Contraceptives
COCs are highly effective , they primarily prevent
pregnancy by:
■ Suppressing ovulation
■ Thickening the cervical mucus, thereby preventing
penetration of the sperm
■ Possibly changing the endometrial lining, making
implantation less likely
18. COMBINED ORAL
CONTRACEPTIVE PILL
Contains a combination of PROGESTOGEN and
OESTROGEN the quantities of which may vary with the
particular preparation.
The pill acts by: inhibiting ovulation and thickening
cervical mucus, thus providing a physical barrier to
spermatozoa and making the endometrium too thin for
implantation.
19. Types
Pills come in packets of 21 or 28 tablets. In the 28-pill
packet only the first 21 are active pills (they contain
hormones); the remaining 7 are not active and usually
contain iron.
The low-dose pill comes in three types:
■ Monophasic– each active pill contains the same amount of
oestrogen and progestin. Examples are Microgynon, Lo-
Femenal, Nordette, Marvelon.
■ Biphasic– the active pills in the packet contain two
different dose-combinations of oestrogen and progestin.
For example in a cycle of 21 active pills, 10 may contain
one combination while 11 contain another. Examples are
Biphasil, Ovanon, Normovlar.
20. Types
■ Triphasic– the active pills contain three different dose
combinations of oestrogen and progestin. Out of a cycle
of 21 active pills, 6 may contain one combination, 5
another combination, while 10 pills contain other
combinations of the same two hormones. Examples are
Logynon and Trinordial.
21. Advantages of COCs
Contraceptive Benefits
As a method of contraception, COCs have many benefits:
• COCs are highly effective and are effective immediately
when started within the first five days of the menstrual
cycle.
• COCs are safe for the majority of women.
• COCs are easy to use.
• COCs can be provided by trained non-clinical service
providers.
• A pelvic exam is not required to initiate use if COCs.
22. Non-contraceptive Benefits
• Reduce menstrual flow (lighter, shorter periods)
• Decrease dysmenorrhoea.
• Protect against ovarian and endometrial cancer
• Decrease benign breast disease
• Prevent ectopic pregnancy.
Improvement and prevention of anaemia
Protection against ovarian and endometrial cancer
Possible protection from symptomatic pelvic
inflammatory disease
Treatment for acne and hirsutism
23. Eligibility for Using COCs
Women Who Can Use COCs without Restrictions (Category 1)
• Women of any parity, including women who have never given birth
(the nulliparous)
• Women who want highly effective protection against pregnancy
and who feel they can follow a daily routine of pill taking
• Post-abortion women (should begin within fi ve days of abortion
for immediate effectiveness)
• Women with severe dysmenorrhoea
• Women with a history of ectopic pregnancy
• Women who suffer from headaches (can initiate pill use
[category 1]; but if headaches continue, eligibility changes to category
2)
24. Eligibility for Using COCs
• Women on antibiotics that do not affect effectiveness of
COCs
• Women with AIDS but not on antiretroviral (ARV) therapy,
or those receiving ARVs that do not interfere with
effectiveness of COCs
• Women at increased risk of STIs, or with a very high
individual risk of exposure to STIs
• Women at high risk of HIV, or those already infected with
HIV
25. Eligibility for Using COCs
• Women with any of the following conditions:
– Malaria
– Non-pelvic TB
– Thyroid disease
– Iron-deficiency anaemia
– Benign breast disease
– Endometrial or ovarian cancer
– Cervical ectropion, uterine fibroids without cavity distortion or endometriosis
– Abnormal vaginal bleeding patterns: irregular, heavy, or prolonged bleeding
– Chronic hepatitis, carrier state or mild cirrhosis
– Vaginitis, current purulent cervicitis, chlamydia or gonorrhoea or current PID
– Other STIs excluding HIV and hepatitis B
26. Side effects
Some women experience irregular menstrual bleeding, nausea, weight
gain, headaches, skin colour changes, and other side effects that may go
away after several months or continue as long as oral contraceptives are
taken.
27. Limitations
■ Use may be associated with minor and major side effects
Minor Side Effects
- Nausea (common in first 3 months)
- Spotting or bleeding in between menstrual periods, especially
if a
woman forgets to take her pills or takes them late (common in
first 3 months)
- Mild headaches
- Breast tenderness
- Slight weight gain
- Amenorrhoea (some women see amenorrhoea as an
advantage
28. Limitations
Major Side Effects
- Serious major side effects and complications, though rare, are possible.
They include myocardial infarction, stroke, and venous
thrombosis/embolism.
■ Their effectiveness may be lowered when certain drugs are taken
concurrently (e.g., certain anti- tuberculosis, anti-epileptic, and anti-
retroviral drugs).
■ Effectiveness may also be lowered in the presence of
gastroenteritis, vomiting and diarrhoea.
■ The combined pills offer no protection against STls
29. Client Education
• Requires strict compliance in taking the daily regime
• Highly protective against pregnancy
• Pregnancy rate increases if pill not taken regularly
• May cause MINOR complaints; nausea, headache, weight
gain, gastrointestinal upsets
• Unsuitable to breastfeeding mothers due to a relative
reduction of milk output.
• If you forget to take one pill, take it as soon as you
remember. Take the next pill at the regular time, even
if this means you take 2 pills on the same day.
30. Client Education
Return to the clinic if you experience:
- suspected pregnancy
- swelling or pain in legs
- yellowing of skin or eyes
- pain in abdomen, chest, or arms; shortness of breath
- severe headaches, depression, vision difficulties.
31. Complications
Increased risk of cardiovascular disease in women over
35 years of age who smoke and increased risk of
hypertension;
users exposed to STIs may be at risk of serious diseases,
including PID and possibly cervical cancer.
32. PROGESTOGEN-ONLY PILL
(Minipill)
This is a pill that is taken daily and contains a
progestogen only. They act by altering cervical mucus
making it thicker/denser, thus preventing sperm
transport. Also suppresses ovulation and inhibits
implantation of fertilised ovum.
contain only one hormone—progestin; they do not
contain any oestrogen.
33. Progestin-Only Pills (POPs)
Therefore they do not cause many of the side effects
associated with COC use. Progestins do not suppress
production of breast milk, which makes POPs an ideal
contraceptive method for breastfeeding women.
POPs prevent pregnancy by thickening the cervical
mucus, which prevents the passage of sperm, and
suppressing ovulation in about 50 percent of cycles.
34. Types of POPs
The brands commonly available include Microlut,
Micronor, Microval, Ovrette, Norgeston, and Noriday.
35. Advantages of POPs
• They are effective.
• They are safe (POPs have no known health risks).
• Women return to fertility immediately upon
discontinuation.
• A pelvic exam is not required to initiate use.
• They can be given to a woman at any time to start later.
• Taking POPs does not affect milk production or
breastfeeding.
• POPs add to the contraceptive effect of breastfeeding.
• Taking POPs does not increase blood clotting.
36. Non-contraceptive Benefits
• Does not affect lactation
• Lighter shorter periods
• Decreased breast tenderness
• Do not increase blood clotting
• Decrease dysmenorrhoea
• Protect against endometrial cancer.
37. Limitations of POPs
• They provide a slightly lower level of contraceptive
protection than COCs.
• They require strict daily pill-taking, preferably at the
same time each day.
• They do not protect against STIs, including hepatitis B
and HIV/AIDS.
• They may lower effectiveness when certain drugs are
taken concurrently (e.g., certain anti-tuberculosis, anti-
retroviral and anti-epileptic drugs).
38. Side Effects of POPs
• Irregular spotting or bleeding, frequent or infrequent
bleeding, prolonged bleeding, amenorrhea (less
common). Bleeding changes are common, but not
harmful.
• Headaches, dizziness, nausea.
• Mood changes.
• Breast tenderness (although less common than with
COCs).
39. Eligibility for Using POPs
Women Who Can Use This Method without Restrictions (Includes MEC
Category 1)
• Women of any parity, including women who have never given
birth (nulliparous women)
• Women immediately postpartum, if they are not breastfeeding
• Breastfeeding mothers from four weeks postpartum
• Women of any age who are cigarette smokers
• Women who cannot use COCs as a result of oestrogen-related
contraindications
• Post-abortion clients
40. Eligibility for Using POPs
• Women with any of the following conditions:
– Hypertension
– Sickle cell disease
– Benign breast disease
– Viral hepatitis, acute or chronic, or mild (compensated)
cirrhosis
– Gestational trophoblastic disease (GTD)
– Migraine without aura
• Obese women and girls (individuals whose BMI is greater
than 30 kg/m2)
• Women with a family history (fi rst-degree relatives) of
DVT or PE, and those who have had minor or major surgery
without prolonged immobilization
41. Women Who Should Not Use POPs
(Includes MEC Categories 3 and 4)
Conditions that require extra care when taking POPS
Women with diabetes (including those with vascular
complications) and hypertension (BP higher than
160/100).
Undiagnosed breast lumps
42. Women Who Should Not Use POPs
(Includes MEC Categories 3 and
4)
Initiate method and evaluate the lump or refer as
appropriate as soon as possible.
After evaluation, women with benign breast disease fall
into category 1; women with breast cancer fall into
category 4 and POPs should be discontinued.
Allow it if these three criteria are met: no other
method is available or acceptable, clinical judgement is
possible, and careful follow-up can be assured (category
3)
43. Women Who Should Not Use POPs
(Includes MEC Categories 3 and
4)
These circumstances include the following:
• Breastfeeding women less than four weeks postpartum
• Women who have breast cancer or a history of breast cancer
• Women with severe (decompensated) cirrhosis, and liver tumours
(benign hepatocellular adenoma and malignancy hepatoma)
• Women with acute DVT or PE
• Women on any of the following:
– ARV regimen with ritonavir or ritonavir-boosted protease inhibitors
– Anticonvulsants, such as phenytoin, carbamazepine,barbiturates,
primidone, and oxcarbazepine
– Rifampicin or rifabutin therapy for TB
• Women with SLE with positive or unknown antiphospholipid
antibodies
44. Method Prescription and Use
POPs can be given to a woman at any time to start later.
Clients should take one pill every day.
POPs must be taken at the same time every day (+/-
two hours) to avoid pregnancy and minimize side
effects.
When one pack is finished, client should begin the next
pack with no break in between packs.
An estimated 48 hours of POP use is usually required to
achieve the contraceptive effects on cervical mucus.
45. Client Education
• Used in breastfeeding mothers because it does not
interfere with lactation
• Has a high level of pregnancy protection
• There is need for compliance on a daily regimen
• Unrelated to sexual intercourse
• May cause menstrual irregularities
• If you forget to take one pill, take it as soon as you
remember (see combined pills)
• Return to the clinic immediately for a pregnancy
check if 45 days have passed since your last menstrual
period.
46. EMERGENCY CONTRACEPTIVES
Emergency contraception (EC) refers to the use of
certain contraceptive methods by women to prevent
pregnancy after unprotected sexual intercourse.
Hormonal ECPs must be taken within 120 hours of
intercourse, however, the sooner they are taken, the
more effective they are.
Emergency contraceptives reduce the occurrence of
pregnancy in unprotected intercourse from 8% to 2%
(75% protection).
47. EMERGENCY CONTRACEPTIVES
Indications
ECPs provide a second chance or preventing pregnancy
after:
unprotected sex, either accidental or coerced sex, or
rape.
• Condom leakage
• Condom breakage/slippage.
An IUCD has come out of place.
A woman has run out of oral contraceptives, has missed
two or more POPs, or is more than four weeks late for
her DMPA injection, and has had unprotected
intercourse.
48. EMERGENCY CONTRACEPTIVES
Types
Combined Oral Contraceptives
• Two tablets of a 50 mcg pill e.g. eugynon to be taken within 72 hours of
unprotected intercourse. Repeat same after in 12 hours. Requires total of 4
tablets of 50 mcg pill.
OR
• Four tablets of a 30 mcg pill (e.g. microgynon or nordette) to be taken within 72
hours of unprotected intercourse. Repeat same dose 12 hours later.
OR
Progestin-only Oral Contraceptives
• one tablet of 75 mcg levonorgestrel e.g postinor 2, Pregnon, Smart lady, ECee2,
and Truston2 and repeat same dose 12 hours later all within 72 hours of
exposure.
They are more effective than the combined pills, preventing up to 95 percent of
expected pregnancies.
49. EMERGENCY CONTRACEPTIVES
ECPs prevent pregnancy by:
• Preventing or delaying ovulation
• Inhibiting or slowing down transportation of the egg and
sperm through the fallopian tubes, which prevents
fertilization and implantation
50. Benefits of ECP
• It is safe, effective, and easy to use.
• No medical examination or pregnancy tests are
necessary or required.
• It can be used at any time during the menstrual cycle.
ECPs are available in government, private, and NGO
health facilities; and over the counter at pharmacies.
51. Limitations and Side Effects of
ECPs
• ECPs are only effective if used within 120 hours of
unprotected intercourse.
• They are not to be used as a regular method.
• ECPs do not protect against STls, HIV/AIDS.
• They can cause nausea (more common for the COC
regimen).
52. Women Who Can Use ECPs
Any woman can use ECPs, however emergency oral
contraception should not be used in place of regular FP
methods.
It should be emphasised that ECPs contain a much
higher dose of hormones compared to the regular
hormonal contraceptive methods.
53. Women Who Should Not Use
ECPs
Includes MEC Categories 3 and 4
EC is not to be used as a regular method.
Recurrent demand for ECPs is an indication that the
woman requires further counselling to use other
contraceptive options.
54. INJECTABLE CONTRACEPTIVES
These are either progesterone only or combined
progesterone + oestrogen.
They comprise of long acting progestogen usually
administered as deep intramuscular injections. They act
by: suppressing ovulation, inducing a thin atrophic
endometrium, producing a thick cervical mucus difficult
for sperm penetration.
55. INJECTABLE
CONTRACEPTIVES
It is available in three forms:
Depot-medroxyprogesterone acetate (DMPA): Depo-
ProveraR, Megestron 150mg is given every three months
(13 weeks), but it can be given as much as two weeks
(14 days) earlier or four weeks (28 days) later.
56. The dosages for the different
injectables
• Norethisterone enanthate (NET-EN): NoristeratR
200mg is given every two months, but it can be given as
much as two weeks (14 days) earlier or two weeks (14
days) later.
• Depo-subQ provera 104 (also called DMPA-SC) is a new,
lower-dose formulation of DMPA that is injected sub-
cutaneously instead of intramuscularly. It contains 104
mg of DMPA instead of the 150 mg in the IM formulation.
DMPA-SC is given at three-month intervals.
57. INJECTABLE
CONTRACEPTIVES
Client Education
• May be associated with heavy menses, amenorrhoea or spotting
• Regular administration as required
• Return to the clinic as scheduled to continue using this method
• Return to the clinic if you suspect pregnancy, dizziness, heavy
bleeding.
Side effects: Users may experience menstrual irregularity
(amenorrhoea, spotting, and rarely, heavy bleeding).
Complications
Studies to date have shown no long term complications.
58. COMBINED INJECTABLE
CONTRACEPTIVES
• Cyclofem (DMPA 25 mg + oestradiol cypionate 5 mg)
• Mesiyna/Norigynon (NET EN 50 mg + oestradiol valerate 5
mg)
They give effective protection for 30 days hence the name
monthly injectable.
Advantages:
They contain natural oestrogens and hence have a
protective effect on CVS and CNS and give a better
cycle control.
59. Advantages of Injectable
Contraceptives
Contraceptive Benefits
• They are highly effective and safe.
• A pelvic exam is not required to initiate use.
• They contain no oestrogen, so they do not have the
cardiac and blood-clotting effects, which are associated
with oestrogen-containing pills and injectables.
• These are long-acting methods: each injection provides
protection for two or three months, depending on the
type.
• Confidentiality
60. Non-contraceptive Health
Benefits
• Amenorrhea, which might be beneficial for women with
(or at risk of) iron-deficiency anaemia
• Decrease in sickle cell crises
• Reduction of symptoms of endometriosis
• Protection against endometrial cancer
• Protection against uterine fibroids
• Possible protection from symptomatic pelvic
inflammatory disease
• Possible prevention of ectopic pregnancy
61. Limitations of Injectable
Contraceptives
• Return of fertility may be delayed for about four
months or longer after discontinuation.
• They offer no protection against STIs, including
hepatitis B and HIV; individuals at risk for these should
use condoms in addition to injectable contraceptives.
• This method is provider-based, so a woman must go to
a health care facility regularly.
62. Side effects:
– Menstrual changes, such as:
- irregular bleeding
- heavy and prolonged bleeding
- light spotting or bleeding
- amenorrhea, especially after one year of use
– Weight gain
– Headache
– Dizziness
– Mood swings
– Abdominal bloating
– Decrease in sex drive
63. Women Who Can Use Injectables
without Restrictions (Includes
MEC Category 1)
• Women who had children or have never given birth
• Women who want highly effective, long-term protection against pregnancy
• Mothers who are breastfeeding (after four weeks postpartum)
• Mothers who are not breastfeeding (immediate postpartum)
• Women with fibroids, endometrial cancer, or benign breast disease
• Women who cannot remember to take the pill everyday
• Post-abortion clients
• Women with anaemia, sickle cell disease, and thyroid disease
• Women with STIs and PID
• Women with family history (first-degree relatives) of DVT or PE and those
that have had minor or major surgery without prolonged immobilization
• Women with gestational trophoblastic disease
64. Category 2 conditions:
• Women who are younger than 18 or older than 45.
• Decreased bone density
• Heavy or irregular vaginal bleeding patterns. Consider evaluating for
an underlying condition, such as cervical cancer, after method
initiation.
• CIN or cervical cancer awaiting treatment. The treatment might
render the woman sterile.
• Migraine without aura.
• History of DVT or PE, current DVT or PE and established on
anticoagulant therapy, known thrombogenic mutations and
hyperlipidaemias, or major surgery with prolonged immobilization.
• SLE with negative antiphospholipid antibodies, on immunosuppressive
treatment and those without severe thrombocytopenia. If a woman
has positive or unknown antiphospholipid antibodies, she would fall
into category 3.
65. Category 2 conditions:
• History of hypertension, adequately controlled BP
, or BP
between 140/90 and 159/99.
• Diagnosis of AIDS and under treatment with ARVs, including
ritonavir. This applies to NET-EN only; DMPA is category 1.
• Rifampicin or rifabutin for TB. This applies to NET-EN only;
DMPA is category 1.
• Anticonvulsants such as phenytoin, carbamazepine,
barbiturates, primidone, topiramate, and oxcarbazepine.
This applies to NET-EN only; DMPA is category 1.
• Gall bladder disease, symptomatic or asymptomatic.
• Uncomplicated diabetes.
• Focal nodular hyperplasia (benign liver tumour).
66. Contraceptive implants
Are small rods that are inserted under the skin of a
woman’s upper arm to release the hormone progestin
slowly and prevent pregnancy. Contraceptive implants,
which are also called sub-dermal implants, do not
contain oestrogen; therefore, they are free from the
side effects associated with that hormone.
The latest implant to be registered in Kenya is the two-
rod Sino-implant-II (Zarin).
Contraceptive implants prevent pregnancy primarily by
making cervical mucus too thick for sperm to pass
through it, and they also suppress ovulation in many
cycles.
67. Types
Device Design Hormone Duration of
effectiveness
Jadelle 2 rods Levonorgestrel 75
mg/rod
5 years
Implanon 1 rod Etonogestrel
68 mg/rod
3 years
Sino-implant
[ZARIN]
2 Rods Levonorgestrel 75
mg/rod
4 years
(possibly 5)
68. Advantages and Benefits of Using
Contraceptive Implants
Contraceptive Benefits
As a method of contraception, contraceptive implants
are highly effective and safe, and they have significant
benefits:
• Contraception is immediate if inserted within the first
seven days of menstrual cycle, or within the first five
days for Implanon.
• There is no delay in return to fertility.
• They offer continuous, long-term protection
69. Non-contraceptive Health Benefits
• Implants do not affect breastfeeding.
• They reduce menstrual flow.
• They help prevent ectopic pregnancy (but do not
eliminate the risk altogether).
• They protect against iron-deficiency anaemia.
• They help protect from symptomatic PID.
70. Benefits
• Highly effective
• Immediate return to fertility
• Offer continuous, long-term protection
• Reduce menstrual flow
• Protect against endometrial cancer and ectopic
pregnancy
• Do not affect lactation.
71. Limitations of Contraceptive
Implants
• Contraceptive implants must be inserted and removed
by trained providers.
This requires a minor surgical procedure with
appropriate infection prevention practices.
72. Side Effects of Contraceptive
Implants
Common side effects of using implants include
menstrual changes, such as irregular light spotting or
bleeding, prolonged bleeding, infrequent bleeding, and
amenorrhea.
• Non-menstrual side effects include headache,
dizziness, nausea, breast tenderness, mood changes,
weight change, and mild abdominal pain.
73. SUB-DERMAL IMPLANTS
(Norplant)
A silastic system comprises of 6 small capsules which
contain a progestogen and are inserted under the skin
of the arm slowly releasing progestogen for up to 5
years. They act by: Thickening cervical mucus.
Suppression of ovulation. Causing atrophic endometrium
which is unsuitable for zygote implantation.
74. Client Education
• May be associated with prolonged menses, sporting or
amenorrhoea
• Requires a minor surgical procedure for insertion and
removal
• If possible return to the same clinic if you desire
implant or removal
• Return for removal any time you desire, but it can be
kept in place for 5 years
75. Client Education
Return to the clinic if:
- suspect pregnancy
- experience pain, swelling or pus at the implant site
- experience dizziness, headache.
- experience heavy bleeding
76. Side effects: Users may experience infection at insertion
site, irregular menstrual bleeding (longer bleeding
episodes, amenorrhoea, or spotting).
Complications
Studies to date have shown no serious long-term
complications.
77. Mechanical Methods of
Family Planning
Intrauterine contraceptive device is a small device
(sometimes medicated) coil which is placed inside the
uterus through the vagina, after the device has been
inserted there are two strings which hang down high up
in the vagina, woman check to feeling this string be
sure her coil is still in place.
78. Mechanical Methods of
Family Planning
The best time of insertion of IUCD is between 4-6
weeks after delivery when woman is still passionate
about family planning and the cervix is still soft.
Another good time is just after menstruation by this
time the cervix is slightly more expanded. After
insertion the IUCD shall be checked at clinic at third
month of insertion followed by checking at sixth month
after insertion then one yearly Kenyan style.
79. Intrauterine Contraceptive
Devices (IUCDS)
A widely used family planning method. A plastic device
usually bound with copper wire and placed in the uterus
through the cervix. Lippes's loop has no copper.
The IUCDs act by preventing implantation of fertilised
ovum, inhibiting sperm mobility, and inhibiting
fertilization.
81. IUCD shall NOT be used by a woman with any of the
following condition
· Irregular vaginal bleeding of unknown cause
· Heavy or painful menstruation
· Cancer of uterus
· Infection of the vaginal or uterus until it has completely
been cured
82. Advantages
It is acceptable because it does not interfere with
intercourse in any way
Available at all government hospitals
• Highly and immediately effective
• Long-term protection with immediate return to fertility
upon removal
• Do not interfere with intercourse
• Can be used in women who are breastfeeding
84. Side effects
Users may experience pain on insertion and increased
menstrual bleeding and abdominal cramps.
Slight bleeding at any time of the circle otherwise
known as sporting may occur.
Very rarely perforations occur during insertion, this is
not serous provided it is recognized and treated.
· There is risk of infection.
· Expulsion
Special comment
IUCD does not interfere with sexual intercourse.
85. Client Education
• Check regularly to ensure IUD is in place
• Return for removal any time, but can be worn for 3-10
years and the Lippes Loop R for an indefinite period of
time
• May cause dysmenorrhoea and menorrhagia
• Return to the clinic if client experiences:
- signs of pregnancy, heavy bleeding or spotting
- abnormal sexual pain or vaginal discharge
- chills or fever.
86. DISPLACED IUCDs
• When threads not visible at cervix and pregnancy
ruled out then:
- attempt removal with a simple artery forceps. If it
fails then localization by ultrasound, plain X-ray with
tracer IUCD and removal
• If one conceives with IUCD remove it if possible,
otherwise leave alone (ultrasound if possible) and
counsel client accordingly.
87. THE MALE CONDOM
Offer physical barrier to sperm deposition into the
vagina.
Condoms also offer some protection against STIs
including HIV/AIDS, HBV and carcinoma of the cervix.
Effectively prevent pregnancy if used every time of
intercourse
88. Condoms
· Some people argue that it reduces sexual
intercourse pleasure
· Available over the counter in shops and free
distribution in some places
· On side effect rarely allergic reaction to rubber
89. THE MALE CONDOM
Client Education
• Before every intercourse, place condom on erect penis,
leaving tip empty to collect semen
• Withdraw the penis from the vagina after each ejaculation
while the penis is still erect
• Remove condom after use
• Do not re-use condoms
• Discard used condom immediately in toilet or pit latrine
• Using spermicides with condoms increases the effectiveness
• Complications may include local irritation if allergic to
latex/lubricants
• May interfere with sexual pleasure for some people.
90. THE MALE CONDOM
Benefits
• Fairly effective if used properly
• Immediately effective
• Highly effective protection against STIs/HIV/AIDS
• May prevent premature ejaculation
Side effects: Some users experience sensitivity to
rubber or lubricants.
91. THE FEMALE CONDOM
The female condom is a thin (0.05 mm) polyurethane
sheath, 7.8 cm in diameter and 17 cm long. It is soft,
loose fitting and has two flexible rings. One ring is
inserted into the vagina and acts as an internal anchor.
The other ring forms the open edge of the device and
remains outside the vagina after insertion.
The female condom provides protection for one act of
intercourse. It can be inserted (up to 8 hours) before
intercourse but must be removed immediately after.
92. SPERMICIDES
Spermicidal creams, jellies and/or foaming tablets are inserted into
vagina before sexual intercourse and act by inactivating the spermatozoa
and physically preventing entry into uterus.
Best used with condoms.
Client Education
• Interferes with natural spontaneity of sexual act
• May cause local irritation
• May be difficult to insert by client
• Low effectiveness as a contraceptive.
Side effects: Some users experience sensitivity to spermicide.
Complications
None.
93. Diaphram
A diaphram is a shallow silicon or rubber cup made of
about three inches in diameter, inserted before
intercourse and act by creating a barrier of sperm at
entrance of at the cervix, after intercourse diaphragm
is left 6-8 hours sometime up to 16 hours before
removal should intercourse be desired again. Additional
spermicidal cream may be added with the diaphragm.
94. Diaphram
Diaphragm is moderately effective (moderately reliable
“effective” for a woman, who is motivated,) this means
that it is not particularly reliable for average women.
Diaphragm is not widely acceptable because of
difficulty to use without adequate privacy and standard
hygiene has to be maintained.
95. Diaphram
Diaphragm because of its reduced effectiveness ,
infection and dislodging it is not widely available in
Kenya and can in most cases be found at larger clinics
On side effect rarely allergy to rubber
Diaphragm does not protect from sexually transmitted
diseases
Once the woman has stopped using the diaphragm she
has equal chance of conceiving like any ordinary normal
woman
There is risk of infection
96. Diaphram
Client Education
- by a provider and refitted after marked weight change
(5kg gained or lost, or after child birth)
- must be kept clean and stored properly
- must be used with spermicide
- can be inserted up to 6 hours before intercourse
- can remain in place for 6 hours (not longer than 24 hours)
97. Diaphram
• Contraceptive sponge must be moistened with water to
activate its spermicide; contraceptive sponge must
never be re-used and must not be used during
menstruation.
Side effects: Some users experience sensitivity to
rubber or lubricants/spermicides; some diaphragm users
experience increased frequency of urinary tract
infection.
Complications
None.
98. Surgical Contraception
Many factors have contributed to improved safety of
Voluntary Surgical Contraceptive in the last 20 years:
These include improved anaesthetic methods, better
surgical techniques, asepsis, improved training of
personnel and better selection and monitoring of
clients.
TUBAL LIGATION
A voluntary irreversible procedure for fallopian tubal
occlusion which can be done under general or local
anaesthesia by minilaparotomy and laparoscopy. It is
one of the most widely used methods in Kenya.
99. Surgical Contraception
Client Education
• IRREVERSIBLE (permanent)
• Failure very rare when done by trained professional
• Counselling absolutely necessary
• No loss of libido or vigour or health
Return to the clinic if:
- post-operative fever, pus or pain at the surgical site
- weakness or rapid pulse
- vomiting or persistent abdominal pain.
100. Surgical Contraception
Benefits
• Permanent, highly and immediately effective
• No change in sexual function
• Good for client if pregnancy would be a serious health risk
• Does not affect lactation
Side effects: Some users experience minor pain and bleeding
and wound infection following procedure.
Complications
Injury to other organs (e.g. gut, bladder) and rarely death; risk
of complications increased if general anaesthesia is used.
Haemorrhage.
101. Surgical Contraception
VASECTOMY
A voluntary surgical procedure done to cut and ligate
the vas deferens so that spermatozoa cannot be
ejaculated. Done under local anaesthesia. Now
gradually becoming accepted in Kenya.
102. Client Education
• Counselling necessary, permanent and irreversible
• Use condom for at least 15 ejaculations
• Return to the clinic if you experience:
- post-operative fever
- excessive swelling, pus or pain at the surgical site.
Side effects: Some users experience minor swelling, pain,
infection, and bruising following procedure.
Complications
Risk of serious complications or death extremely low.
103. Periodic Abstinence (Natural
Family Planning)
Avoidance of sexual intercourse during ovulation and for
a safety margin before and after ovulation. Various
methods may be used to determine the fertile period:
cervical mucus, basal body temperature, rhythm.
Benefits
• No physical side effects it is cheap
• No need for prescriptions by medical person
• Improved knowledge of reproductive system and possible
closer relationship between couples.
104. Periodic Abstinence (Natural
Family Planning)
Client Education
• Requires high motivation
• Has a high failure rate
• Assumes a regular, perfect menstrual cycle
• Requires proper record-keeping
• Has no health risks, except for pregnancy.
Side effects: None.
Complications
None.
105. Calendar-Based Methods
In the calendar-based methods, the couple keeps track
of the days in the menstrual cycle to identify the start
and end of the fertile time.
106. Standard Days Method® (SDM)
The SDM is based on the fact that there is a fertile
window during the woman’s menstrual cycle when she
can become pregnant.
Typically, this window occurs several days before
ovulation and a few hours after. To prevent pregnancy,
couples avoid unprotected sex or abstain between days
8-19 of the menstrual cycle.
107. Standard Days Method® (SDM)
The SDM makes use of CycleBeads, a color-coded string
of beads used with the SDM that represent the days of a
woman’s fertility cycle.
CycleBeads help the woman track her cycle days, know
on which days she is fertile, and monitor her cycle
length.
The woman and her partner must avoid unprotected
intercourse or abstain on the 12 fertile days identified
by the white colour beads.
108. Symptoms-Based Methods
Symptoms-based methods depend on observation of
signs of fertility, such as the presence or absence of
cervical mucus, changes in the amounts and
characteristics of the cervical mucus, changes in body
temperature, a combination of the latter two, or use of
specific ovulation detection kits.
109. TwoDay Method® (TDM)
The TwoDay method® (TDM) is a simple, symptom-based
method by which women check for the presence or
absence of cervical secretions as the sign of fertility.
The TDM does not require interpretation of the quality
or quantity of secretions.
A woman who uses the TDM asks herself two questions:
(1) “Did I note secretions today?” and (2) “Did I note
secretions yesterday?” She should consider herself
fertile today if she notices cervical secretions of any
type today, or if she noticed them yesterday. Women
who use the TDM are instructed to avoid unprotected
intercourse on these days to prevent pregnancy.
110. Cervical Mucus, or Billings
Ovulation Method
In this method, the days of infertility, possible fertility,
and maximum fertility of the menstrual cycle are
defined by observation of changes in the cervical
mucus. The woman identifies the fertile time by
observing the characteristics of the cervical mucus.
111. Cervical Mucus, or Billings
Ovulation Method
To use this method correctly, the woman should:
• Avoid sex on days of monthly bleeding. In cases when
ovulation occurs early in the cycle, bleeding could make it
hard to observe cervical mucus
• Avoid sex as soon as she notices any secretions. The
fertile phase of the menstrual cycle begins with the
appearance of a mucus secretion, which changes as the
days go by, becoming more stretchy and slippery.
• Recognise evidence of ovulation (peak day), when the
mucus is
very clear, stretchy (Spinnberkeit’s sign), and slippery.
• Continue to avoid sex for three more days after peak day,
even if secretions completely disappear before three days
have expired.
112. Basal Body Temperature (BBT)
With this method, the woman is instructed to take her
body temperature either orally, rectally, or vaginally at
the same time each morning before getting out of bed
and before eating anything.
The routine for taking the temperature must be the
same for the entire cycle.
113. Basal Body Temperature
(BBT)
The temperature readings are recorded on a special
graph paper, which makes it easy to identify small
changes in temperature readings.
The woman’s temperature rises by 0.20C - 0.50 C,
around the time of ovulation (about midway through the
menstrual cycle for many women). The couple avoids
sex from the first day of monthly bleeding until three
days after the woman’s temperature has risen above her
regular temperature.
114. Sympto-thermal Method
(Cervical Mucus + BBT)
In this method, the pre-ovulatory and post-ovulatory
infertile phases of the menstrual cycle are identified by
a combination of the above two techniques (the cervical
mucus and BBT shift), as well as other signs and
symptoms around ovulation.
115. Sympto-thermal Method
(Cervical Mucus + BBT)
The signs and symptoms used in the sympto-thermal
method include:
• Thermal shift (BBT)
• Cervical mucus changes (BILLINGS)
• Cervical changes (consistency, position, openness, or
closure)
• Other appropriate signs and symptoms, such as sharp
lower abdominal pain (mittelschmerz), breast
tenderness, increased libido, or intermenstrual bleeding
116. Summary
METHOD RECOMMENDED
FOR:
NOT RECOMMENDED FOR
WOMEN/COUPLES:
Combined Pill
• Women under 40 years, of
any parity
• Women who want highly
effective contraception
• Breast-feeding mothers
after 6 months post-partum
• Younger
women/adolescents who are
sexually active and have been
adequately counselled
• with suspected pregnancy
• who are over 35 years and a
smoker
• with history of blood
clotting disorders or heart
disease
• with lump in either breast,
liver disease
• with unexplained abnormal
vaginal bleeding
• win BP over 140/90 mm/Hg
confirmed on revisit
Progestin Only Pill
117. Summary
Injectable Methods
• Women of proven fertility
• Breast-feeding mothers
after 6 weeks post partum
• Women who want long-term
contraception
• Women who want at least 2
years between pregnancies
(SAME AS PROGESTIN ONLY
PILL)
Implants
• Women with 2+ children
needing long-term protection
• Breast-feeding mothers
after 6 weeks post partum
• (Long term highly effective
contraception)
• Women who have their
(SAME AS PROGESTIN ONLY
PILL)
118. Summary
Intrauterine Devices
• Women who have delivered
1 or more times
• Breast-feeding mothers
• Women who want long-term
contraception
• Women in a stable
monogamous sexual
relationship
• Women after 6 weeks post-
partum; before 6 weeks if
provider has specialised IUD
insertion training.
• with suspected pregnancy,
history of PID or ectopic
pregnancy
• with anaemia or heavy
menstrual bleeding
• having no menses after 6
weeks post-partum
• with history of heart
disease
• with abnormalities or
cancer of pelvic organs
• having unexplained vaginal
bleeding or severe menstrual
pains
• at risk of exposure to STDs
119. Summary
Diaphragm, Cervical Cap,
Spermicides, Sponge
NOT RECOMMENDED FOR
WOMEN/COUPLES:
• Women needing an
immediately effective
method
• Breast-feeding mothers
• Women who do not want
hormonal methods or IUCDs
• Women waiting to rule out
a suspected pregnancy
• Women needing a back-up
method (forgotten pill)
• Women desiring some
protection against AIDS, STDs
• who are unable or unwilling
to feel their own cervix
• who desire more effective
contraception
• who do not want the
inconvenience of the method
• who themselves or their
partners are either allergic to
the spermicide or device
• with frequent urinary tract
infections, vaginal
abnormalities
• with poor vaginal muscle
tone (for diaphragm only)
120. Summary
Condom
• Men who desire to
take contraceptive
initiative
• Couples needing an
immediately effective
method
• Couples waiting to
rule out a suspected
pregnancy
• Couples at risk of
exposure to AIDS,
• who desire or
require highly
effective protection
against pregnancy
121. Summary
Natural Family Planning
• Couples willing to learn
about the woman's cycle and
to practise abstinence from
1-2 weeks each cycle
• Couples who, for religious
or any other reasons, desire
to practise periodic
abstinence
• who need/want more
effective contraception
• with irregular menstrual
cycle is irregular
• who are breast-feeding
• who must not become
pregnant for health or any
other reasons
• who are unwilling to
abstain during fertile period
122. Summary
Tubal Ligation or Vasectomy
• Couples or individuals who
have been fully counselled,
understand and have
voluntarily signed consent
form.
• Couples with desired
family size?
• Women for whom age or
health problems might cause
an unsafe pregnancy?
• Couples certain they want
no more children regardless
of accidental death of a
• who do not fully
understand VSC or are
unwilling to agree to items
on the consent form
NOTE: Men or women whose
spouses oppose VSC should
be considered on a case by
case basis for the procedure.
123. Guide to Family Planning Methods Pregnancy Rate =
percentage accidental pregnancies in first year,
typical rate and (rate when used perfectly).
METHOD PREGNA
NCY
RATE?
USED AT
INTERCO
URSE?
EFFECT
ON STD
RISK?
COMPATI
BLE
WITH
BREASTF
EEDING?
RETURN
TO
FERTILIT
Y AFTER
STOPPIN
G?
Male
sterilizati
on
0.15
(0.1)
No None Yes Permane
nt
method
Female
sterilizati
on
0.4
(0.2)
No None Yes Permane
nt
method
Implants 0.2
(0.04)
No Probably
none
Yes, but
not
preferred
method.
Immediat
e on
removal
124. Guide to Family Planning Methods Pregnancy Rate =
percentage accidental pregnancies in first year,
typical rate and (rate when used perfectly).
Progesti
n-only
minipill
3-10
(0.5-3)
No None Yes, but
not
preferre
d
method.
Wait 6
weeks
post-
partum
Immedia
te to
short
delay
Injectabl
es
0.3-0.4 No Unknown Yes, but
not
preferred
method.
Wait 6
weeks
post-
Delayed
4 to 12
months
125. Guide to Family Planning Methods Pregnancy Rate =
percentage accidental pregnancies in first year,
typical rate and (rate when used perfectly).
Combine
d oral
contrace
ptives
1-8
(0.1-3)
No May
protect
against
some
forms of
PID, but
increase
risk of
infection
with
some
STDs
After 6
months
post-
partum,
but not
preferre
d
method
if
breastfe
eding
Immedia
te to
short
delay
(average
2-3
months)
Condoms 12
(2)
Yes Protectiv
e (70%
against
AIDS)
Yes Immediat
e
126. Guide to Family Planning Methods Pregnancy Rate =
percentage accidental pregnancies in first year,
typical rate and (rate when used perfectly).
Vaginal
spermici
des
21
(3)
Yes May
have
some
protectiv
e effect
Yes Immedia
te
Diaphrag
m,
cervical
cap,
other
vaginal
barrier
methods
18-28
(6-9)
Yes May have
some
protectiv
e effect
Yes Immediat
e
Natural
family
planning
20
(1-9)
No None No,
method
not
Immediat
e