note

1. FP and its focus on IUCD, Postpartum FP and counselling
skills an overview
Mr.Rudrappa Angadi(MPH)
Program officer EAISI project
Jhpiego-Chhattisgarh

2. Course Goals
• To influence in a positive way the attitudes of
the students toward the concepts of Family
Planning (FP).
• To provide updated knowledge on IUCD, Post
partum FP and counselling skills.

3. Learning Objectives
• To know the meaning of FP
• Unmet need
• Overview of IUCD
• Medical Eligibility Criteria
• Post-partum FP
• Counselling

4. FP in RMNCH+A Strategy
• Family planning means that the couples decide and plan when and how
many children they want to have
• Family planning is central to improve maternal and newborn survival and
health, not just for population stabilization
• Family planning can avert
> 30% of maternal deaths
>10% of child mortality
• FP save women’s lives and health by preventing unwanted, closely spaced
and mistimed pregnancies and thus avoiding pregnancies with higher risks
and chances of abortions, many of which may be unsafe.

5. Unmet need for Family Planning
WHO Definition:
• 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 next child.
• Women in reproductive age group, who want to
avoid or delay pregnancy but are not using any form
of family planning.

6. Unmet Need for Family Planning in India
As per DLHS 3 (2007-08)
 Unmet need for family planning is 20.5%
- 7.2% unmet need for spacing (delaying next pregnancy)
- 13.3% unmet need for limiting (avoiding any further
pregnancy)
Unmet need and Non Users ????????????

7. Overview of Copper IUCD
 A small, flexible polyethylene impregnated with barium
sulfate frame containing copper
 2 types of Cu IUCDs available under the national program
1. Cu IUCD 380A
2. Cu IUCD 375

8. Basic Information on IUCD
 T shaped device
 3.6 cm long and 3.2 cm wide
 Vertical stem and horizontal arms
are wound with copper wire
 380 sq. mm of Cu
 White thin polyethylene strings
 10 years from the day of insertion
 Inverted U shaped flexible arm
 3.5 cm long and 1.8 cm wide and 5
stubs on each side on the “U”
 Only vertical stem is wound with
copper wire
 375 sq. mm of Cu
 Florescent Green mmonofilament
nylon threads
 5 years from the day of insertion
IUCD Cu 380 A
IUCD Cu 375

9. Global use of IUCD
Recent estimates suggest that almost one in five married contraceptive users is
currently using an IUCD

10. IUCD Usage in India
Source: DLHS -3 (2007-2008), IIPS, Mumbai
IUCD is one of the most effective reversible and safe contraceptive methods, but still
remains largely underutilized.

11. Mechanism of Action
 Preventing fertilization by
Copper ions decreasing sperm
motility and function, by
altering the uterine and tubal
fluid environment, thus
preventing sperms from
reaching the fallopian tubes
 Preventing implantation as it
stimulates foreign body
reaction in the endometrium
that releases macrophages
Decreases
sperm motility
and function
Interferes
with ability
of sperm to
pass
through
uterine
cavity
Alters the uterine
and tubal
environment
Does not allow fertilization to occur as
sperms are not able to reach the ovum

12. Contraceptive Effectiveness
 Effective as soon as it is inserted.
 IUCD is comparable to female
sterilization and male sterilization in
contraceptive effectiveness.
 The failure (pregnancy) rate is:
- < 1% in the first year of use. This
means less than 1 pregnancy per
100 women in the first year of
use (6 to 8 pregnancies per 1000
women).

13. Advantages of Cu IUCD
 Offers long-term, highly effective reversible protection against pregnancy.
 Effective and Reversible.
 Suitable for use by most women.
 Can be used as an emergency contraceptive .
 It can be replaced, without any gap, and be used as an alternative to terminal method.
 Does need special attention.
 Insertion is one time and simple procedure and is cost effective.
 Can be used by lactating women.
 Does not interact with any medicines the client may be taking.
 Easily accessible and affordable

14. Limitations of Cu IUCD
 Requires skilled provider .
 Pelvic examination is necessary before insertion.
 Does not protect against STIs/ HIV.
 Cannot be inserted in women with active RTI/STI.
 Cannot be inserted in women who currently have PID.

15. Side Effects of IUCDs
 Unpleasant but are not harmful and usually subside or resolve
within a few months after insertion.
 Menstrual changes:
- Increase in the duration/amount of menstrual bleeding
- Spotting or light bleeding during the first few days or months
after insertion.
 Discomfort or cramps during insertion and for the next few days
which subsides in due course.

16. Possible Complications
Potential health risks which are uncommon or rare, are:
 Spontaneous expulsion occurs in about 2-8 % clients.
(most likely to occur during the first three months after insertion, and during
menstrual periods).
 If pregnancy occurs with the IUCD in situ, there is a risk of spontaneous abortion,
sepsis and ectopic pregnancy; no adverse effects on the fetus.
 Infection following insertion is less than 1% -risk is highest during the first 20 days
after insertion. Due to non compliance to IP practices, rather than the device itself.
 Uterine perforation during insertion is a rare complication which occurs in 0.5 - 1.5
per 1000 insertions and is associated with the level of provider's skill and
experience.

17. POSTPARTUM FAMILY
PLANNING

18. Miss conceptions towards IUCD……..??????

19. Objectives
By the end of this session the Students will be able to:
• Discuss methods of Postpartum Family Planning
• Describe the specific situations of postpartum women
• Discuss breastfeeding and LAM
• List opportunities and mechanisms for post partum FP
integration
19

20. Outcome of Pregnancy at Young Age
Postpartum Hemorrhage Maternal Death Premature Delivery
Maternal age All young girls Women
Source: A. Conde Agudelo et al., 2003
*Adjusted OR (95% CI) for the association between maternal age and adverse
maternal and perinatal outcomes
Pregnancy at young age - Adverse outcomes of mother and newborn

21. The Postpartum Period
Post-placental period
The first 10 minutes after placenta delivery .
Immediate postpartum
Up to 48 hours after giving birth.
Early postpartum
48 hours to 6 weeks after giving birth.
Extended postpartum
6 weeks to 1 year after giving birth.

22. Definitions
Birth to pregnancy interval:
Time period between a live birth and the start of the next
pregnancy
Birth to birth interval:
Time period between a live birth and the next live birth

23. WHO Technical Recommendations on Pregnancy
Spacing
 Recommendation for spacing after a live birth:
o The recommended interval before attempting the next pregnancy is
at least 24 months
o The recommended interval between two live births is at least 36
months
 Recommendation for spacing after abortion:
o The recommended interval for the next pregnancy should be at least
6 months

24. Outcomes of Mother and New born of
short birth interval
Short birth to pregnancy (BTP) intervals <24 months are
associated with increased risk of:
For Mother
 Maternal death
 Induced abortion
 Miscarriage
 Premature Labor
 Antepartum/Postpartum
Hemorrhage
 Anemia
For New born
 Low birth weight baby
 Premature baby
 Neonatal death

25. Post Abortion Outcomes
Interval between post abortion and next pregnancy, if less than 6
months, the following risks increases:
 Premature rupture of membrane
 Maternal anemia
 Premature delivery
 Low for birth weight baby
 IUGR

26. Return to Fertility after Delivery or Abortion
• 5-10% of breastfeeding women get pregnant in first year postpartum
• Fertility returns before menses
• Contraceptive methods…..??????? and effectiveness…??????????????
Condition of woman Return to fertility
 Breastfeeding
- Using LAM accurately (All 3
criteria fulfilled for 6 months)
− Sometime after 6 months -
variable
- Breastfeeding without using LAM − Possibly even before 6 months,
but again, variable
− Average is 45 days
 Non-Breastfeeding − 3 weeks or 21 days postpartum
 After abortion − 2 weeks or 10-14 days post-
abortion

27. 27

28. FP Methods for Breastfeeding Mothers

29. FP Methods for Non-Breastfeeding Mothers

30. Criteria for LAM
1. Baby is being only breastfed
– The baby is not receiving any other solid food or liquids;
only breast milk
– Breastfeeding on demand - Gap between two consecutive
feeds is not more than 4 hours during day and 6 hours
during night
2. Menstruation has not returned since the birth of the child
3. Baby is less than 6 months old

31. Mechanism of Action of LAM
1. Stimulation of nipple causes release of
prolactin
2. Prolactin and oxytocin result in
increased milk production (which
encourages suckling)
3. Prolactin reduces estrogen secretion
and suppresses ovulation

32. Effectiveness of LAM
• LAM is 99.5% effective with consistent and correct use;
and more than 98% effective as typically used
• Effectiveness is same as other effective modern
methods

33. Timings of integration of PPFP Services With Other
Services
 ANC
 Immediately after delivery
 Postpartum check up for mother or baby
 At the time of discharge from hospital
 Contacts for mother/baby check up during 1-6 weeks postpartum
 Immunization visits
After delivery, make postpartum family planning services
available to women/ couples as per their need

34. Counselling
• Motivation
• Health Education
• Counselling

35. Counselling is a type of client – provider interaction that
involves two – way communication between a health care staff
member and a client for the purpose of confirming or facilitating
an informed decision by the client or helping the client address
problems or concerns.

36. Counselling
The purpose of family planning counseling is to help women
and couples to choose family planning method according to
their choice to prevent unwanted pregnancy.
Counseling will help client to:
 Choose the best option for them from available contraceptive
methods
 Correctly use the chosen method
 Continue use of chosen method

37. Clients who start method of their choice after complete
information are satisfied clients and then the possibility of
continuation of the method is high.

38. The concept of ……………….
Informed choice
Informed consent

39. GATHER approach Counselling
Greet
Ask
Tell
Help
Explain
Return

40. Types in FP counselling
General counselling
Method specific counselling
Follow-up counselling

41. Family Planning Counseling…
General Counseling
If the couple has already decided to have the next baby after few
years and not early, then
 Tell them - to prevent unwanted pregnancy and for good
health of mother and baby, they should use any contraceptive
method for at least 2 years after childbirth
 Ask - If have they have thought of using any contraceptive
method after delivery? If yes, then what do they know about
the method.
41

42. Family Planning Counseling…
General Counseling…
 Help client to choose method of choice after basic
information on all methods
 Give information on PPFP methods and PPIUCD
 Clarify, if they have any mistaken beliefs or misconceptions
about specific family planning methods
 On the basis of key information, help woman or couple to
choose method of their choice
42

43. Family Planning Counseling…
Method specific counseling
Give detailed information of the chosen method like:
 How does the method act
 How effective the method is
 What are its benefits
 Does it affect breastfeeding or not
 Does it protect from sexually transmitted infections
 Common side effects of the method and their treatment
 When to come for follow-up
43

44. How to do Follow-up of
Family Planning Clients
Follow-up counseling
 Greet client and ask the purpose of visit
 Encourage to continue the method if client has no concerns or problems
 Repeat if client has forgotten any important information
 Reassure client about side effects that these will be resolved on their own
within a few months
 If client wants to change the method, help her/couple to choose another
method
44

45. New client with a method in mind
 Ensure that client knows about other options
o This can be done through group discussion
 Check that the client has correct information about
her chosen method
 Support client if she is medically eligible for the
method
 Discuss with client about method’s use and
management of side effects

46. References
• http://www.fhi.org/training/en/modules/AFTER/default.htm (accessed April 14, 2010).
• Ross, J.A. and W.L. Winfrey. 2001. “Contraceptive use, intention to use and unmet needs during
• the extended postpartum period.” International Family Planning Perspectives 27, no. 1: 20-7.
• Speroff, L. and D.R. Mishell Jr. 2008. “The postpartum visit: It’s time for a change in order to
• optimally initiate contraception.” Contraception 78, no. 2: 90-98.
• United Nations Population Fund. 2004. State of the world population 2004.
• http://www.unfpa.org/swp/2004/english/ch9/page5.htm (accessed February 15, 2010).
• World Health Organization/Department of Reproductive Health and Research (WHO/RHR) and
• Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP),
• Knowledge for Health Project. Family Planning: A global handbook for providers (2008 update).
• Baltimore and Geneva: CCP and WHO/RHR.

47. Talk to yourself at least once in a Day.. Otherwise you
may miss a meeting with an EXCELLENT person in this
World………..
-Swami Vivekananda
Thank You for your Kind attention