FAMILY PLANNING

1. SESSION 6: FAMILY PLANNING METHODS
TO CLIENTS LIVING WITH HIV/AIDS

2. Learning Tasks
At the end of this session student is expected to be
able:
• Identify FP methods relevant for PLWHIV
• Explain importance of integrating FP with HIV and
AIDS services
• Explain interaction of hormonal contraceptives and
ARVs
• Counsel FP clients for HIV and AIDS
• Test FP clients for HIV and AIDS

3. Family Planning Methods Relevant for
PLWHIV
• Condoms – prevent pregnancy, STI’s as well as HIV
• IUCD
• Depoprovera
• Implants
• COC’s and POP’s except for ARV’s with Ritonavir
• Female and Male sterilization
• Fertility awareness based methods
• Emergency contraceptives

4. Importance of Integrating FP With HIV and
AIDS Services
• Increase Access to Life-Saving Services to Improve
Health Outcomes.
• The provision of FP/RH information and services
helps individuals and couples make informed
health decisions that protect them against
HIV/AIDS and other sexually transmitted diseases,
as well as unintended pregnancies
• Promote Dual Protection.

5. Importance of Integrating FP With HIV
and AIDS Services cont’
• Unintended pregnancy and the sexual transmission
of HIV both result from unprotected sex.
• The provision of integrated FP/RH-HIV services
enables clients to receive thorough information
about healthy behaviors and the full range of tools
available to them.
• Save Money.
• Integrating services generates significant savings
when compared to the costs of stand-alone services

6. Importance of Integrating FP With HIV
and AIDS Services cont’
• Increasing access to family planning and reducing
unintended pregnancies among HIV clients i lower
costs for PMTCT, lower costs for pediatric treatment
and reduced costs for mitigating the consequences
(such as lower birth weights) of unintended births
• Increased family savings and productivity, and
better prospects for education
• Decrease Stigma and Discrimination.

7. Importance of Integrating FP With HIV and
AIDS Services cont’
• Offering FP/RH and HIV/AIDS services at a single site
can help overcome the stigma and discrimination that
impedes access to HIV/AIDS prevention, treatment and
care
• Improved Health Impact
• Integration helped to formalize client referrals between
family planning and HIV clinics, which, in turn,
increased male and female attendance at the family
planning clinic and boosted the use of family planning
methods
• Family planning services provide an opportunity to
increase access to HIV counseling and testing and other
HIV services

8. Interaction Of Hormonal Contraceptives
and ARVS
• Some antiretroviral (ARV) therapies might alter the
pharmacokinetics of combined oral contraceptives
(COCs). Contraceptive steroid levels in the blood
decrease substantially with ritonavir-boosted
protease inhibitors.
• Such decreases have the potential to compromise
contraceptive effectiveness.
• Some of the interactions between contraceptives
and ARVs also led to increased ARV side effects

9. Counseling FP Clients For HIV And AIDS
HIV counseling seeks to reduce HIV acquisition and
transmission through the following:
• Information. Clients should receive information
regarding HIV transmission and prevention and the
meaning of HIV test results. Provision of information is
different from informed consent.
• HIV prevention counselling. Clients should receive help
to identify the specific behaviours putting them at risk
for acquiring or transmitting HIV and commit to steps
to reduce this risk. Prevention counselling can involve
>1 sessions.

10. Information
All clients who are recommended or who request HIV
testing should receive the following information, even if
the test is declined:
• Information regarding the HIV test and its benefits and
consequences.
• Risks for transmission and how HIV can be prevented.
• The importance of obtaining test results and explicit
procedures for doing so.
• The meaning of the test results in explicit,
understandable language
• Where to obtain further information or, if applicable,
HIV prevention counselling.
• Where to obtain other services (see Typical Referral
Needs).

11. HIV Prevention Counselling
• HIV prevention counseling should focus on the
client's own unique circumstances and risk
and should help the client set and reach an
explicit behavior-change goal to reduce the
chance of acquiring or transmitting HIV

12. The following elements should be part of all HIV
prevention counselling sessions:
• Keep the session focused on HIV risk reduction
• Include an in-depth, personalized risk assessment
• Acknowledge and provide support for positive steps
already made
• Clarify critical rather than general misconceptions
• Negotiate a concrete, achievable behaviour-change
step that will reduce HIV risk
• Seek flexibility in the prevention approach and
counselling process
• Provide skill-building opportunities
• Use explicit language when providing test results

13. Testing FP clients for HIV and AIDS
• Activity: Small Group Discussion (20 minutes)
• DIVIDE Students in small manageable groups
• ASK Students to discusssteps for HIV testing
• ALLOW a few students to respond
• CLARIFY and SUMMARIZE by using the following
logarithm

14. The National HIV Testing Algorithm

15. Key Points
• HIV and AIDS clients can use any contraceptive
method provided has no indicated contraindication
to the method, however dual protection is advised
• One of the important information needs to be
included while counseling HIV client is behaviour
modification to avoid risks
• Before testing for HIV a client need to be counseled
and educated on the importance of testing
• Before giving test results whether reactive or non-
reactive the client must be given post test
counseling

16. Session Evaluation
• What are the recommended FP methods for people
living with HIV?
• What information will you give to a Client with HIV
when counseling for FP services?
• What action will you take if you will encounter non-
reactive results after HIV testing?

17. References
• Diane, M.F. &Magret, A. C. (2003).Myles Textbook for Midwives (14th Ed).
Churchill Livingstone ElsevierEdinburg London New York Oxford Philadelphia
St Louis Sydney Toronto
• Diane M.F, Magret, A. C. & Anna, G.W. N. (2009).Myles Textbook for
Midwives (African edition). Churchill Livingstone Elsevier Edinburg London
New York Oxford Philadelphia St. Louis Sydney Toronto
• Diane, M. F. &Magret, A. C. (2009).Myles Textbook for Midwives (15th Ed).
Churchill Livingstone Elsevier Edinburg London New York Oxford
Philadelphia St. Lois Sydney Toronto.
• MoHSW(2008).Emergency obstetric care job aid.
• MoHSW(2010).National Family Planning Procedure Manual.
• MoHSW(2010). Learning Resource Package for Basic Emergency Obstetric
and Newborn Care (BEmONC) Facilitator guide.
• WHO Family planning (2011).A Global Handbook for Providers. United
States Agency for International Development USAIDS
• Speroff L, Glass R H and Kase N G. Clinical gynaecological endocrinology and
infertility

18. SESSION 7: INTEGRATION OF FAMILY
PLANNING SERVICES WITH POST- PARTUM
AND POST-ABORTION CARE

19. Learning Tasks
At the end of this session a student is expected to be
able:
• Define postpartum family planning and post
abortion family planning
• Explain importance of integrating FP with
postpartum and post-abortion care
• Explain stages of postpartum FP
• Provide FP methods suitable for immediate and
extended postpartum
• Provide FP method to post abortion client
• Counsel on post-abortion fertility return

20. Definition of Postpartum Family Planning
and Post Abortal Family Planning
• Postpartum family planning is the initiation and use
of family planning methods in the first six weeks
following delivery
– Aim at preventing unintended pregnancy, particularly
soon after childbirth, when another pregnancy could be
harmful to the health of the mother or breastfeeding
baby.

21. • Post-abortion family planning is the initiation and
use of family planning methods immediately after,
and within 48 hours of an abortion, before fertility
returns.
– In most women fertility returns on average about two
weeks after an abortion; however, ovulation can occur
as early as 11 days post-abortion.

22. Importance of Integrating FP with
Postpartum and Post-Abortion Care
• Women who have experienced abortion or who
have just been treated for post abortion
• Complications need immediate and easy access to
family planning services.
• Family planning could prevent 90% of maternal
mortality associated with unsafe abortion

23. Stages Of Postpartum Family Planning
• Postpartum family planning refers to the use of family
planning during the first year after delivery to ensure
the healthy spacing of pregnancies. Return to fertility
after delivery or abortion is not predictable, often
occurs prior to the return of menses. It can be as early
as 4-6 weeks postpartum
• For breastfeeding women, return to fertility delays if a
mother is breastfeeding exclusively, in the first six
months. For these women, ovulation may resume 6
months after delivery
• Non-breastfeeding woman may resume menstruation
within 12 weeks after delivery with first ovulation
occurring at 45 days or earlier.

24. The three stages of postpartum period in
the context of family planning:
• Immediate postpartum:
-FP given within 48 hours after delivery, before
woman leaves facility. Methods that can be used
include IUCD, tubal ligation and Implants
• Early postpartum family planning
-Is given after 48 hours up to 6 weeks. Methods that
can be used POP and Implants
• Extended postpartum
-Provided 6 six weeks to 1 year after birth.
At this time all methods can be used

25. FP Methods Suitable For Immediate And
Extended Postpartum
Methods Suitable for Immediate postpartum: (Up to
48 hours after giving birth)
– For breastfeeding women:
• Intrauterine device (IUCD)
• Implants
• Progestogen-only pills
• Progestinonly injectable
• Lactation amenorrhea method (LAM)
• Male and female condoms

26. FP Methods Suitable For Immediate And
Extended Postpartum cont’
• For non-breastfeeding women:
• IUCD
• Implants
• Injectables
• Combined oral contraceptives
• Male and female condoms
• Emergency contraception

27. Methods suitable for extended postpartum family
planning(6 weeks to 1 year after giving birth.)
• Fertility awareness
• Progestin only pills (POP)
• Progestin only injectable (DMPA)
• Combined oral contraceptives(COC)

28. Family Planning Methods To Post Abortion
Client
• Post-abortion family planning should be started
immediately, ovulation can occur as early as eleven
days post-abortion.75% of women will have ovulated
within four to six weeks post-abortion.
• All modern family planning methods are appropriate
for post-abortion women:
• Condoms (which also prevent STIs and HIV)
• Oral contraceptives
• IUCDs
• Injectables
• Implants
• Spermicides

29. Family Planning Methods To Post
Abortion Client cont’
Recommended time for initiation post abortion
contraceptive
• Immediately
• Combined oral contraceptives
• Progestin-only pills
• Progestin-only injectables
• Contraceptive implants
• Male and female condoms

30. Family Planning Methods To Post
Abortion Client cont’
Once infection is ruled out or resolved
• IUCDs
• Female sterilization
• Fertility awareness methods
Once any injury to the genital tract has healed
• IUCDs
• Female sterilization
• Fertility awareness methods

31. Special considerations
• IUCD insertion immediately after a second-
trimester abortion requires a specifically trained
provider.
• Female fertilization must be decided upon in
advance, and not while a woman is sedated, under
stress or in pain. Counsel carefully and be sure to
mention available reversible methods as another
option
• Fertility awareness methods a woman can start
symptoms-based methods like the two-day Method
once she has no infection -related secretions or
bleeding due to injury to the genital tract.

32. Counseling on Post-Abortion Fertility
Return
• A woman who has had an abortion needs support.
• A woman who has faced the double risk of pregnancy
and unsafe induced abortion especially needs help and
support.
• Good counseling gives a post abortion client much
needed support.
• In particular, the counselor should try to understand
what the clienthas been through
• Treat her with respect and avoid judgment and criticism
• Ensure privacy and confidentiality

33. • Ask if she wants someone she trusts to be present
during counseling.
• Post abortion counseling messages
• A woman has important choices to make after
receiving post abortion care.
• To make decisions about her health and fertility,
she needs to know:
• Fertility returns quickly within 11 days after a first-
trimester abortion or miscarriage and within 4
weeks after a second-trimester abortion or
miscarriage. Therefore, she needs protection from
pregnancy almost immediately.

34. • Encourage the use of an effective FP method of their
choice for at least six months before trying to become
pregnant again.
• She can choose from among many different family
planning methods that can be started at once
• Methods that women should not use immediately after
giving birth pose no special risks after abortion.
• If a woman decides not to use contraceptives at this
time, providers can offer information on available
methods and where to obtain them. Also, providers can
offer condoms, oral contraceptives, or emergency
contraceptive pills for women to take home and use
later

35. • She can wait before choosing a contraceptive method
for ongoing use, but she should consider using a
backup method in the meantime if she has sex.
• To avoid infection, she should not have sex until
bleeding stops—about 5 to 7 days. If being treated for
infection or vaginal or cervical injury, she should wait to
have sex again until she has fully healed.
• She should wait at least 6 months before trying to
become pregnant.
• Waiting at least 6 months reduces the chances of low
birth weight, premature birth, and maternal anemia.

36. • Consider using a family planning method of your
choice during that time.
• A woman receiving post abortion care may need
other reproductive health services. In particular, a
provider can help her consider if she might have
been exposed to a sexually transmitted infection.

37. Counselling for Post-partum mothers
• Provide counseling about the benefits of
delaying the next pregnancy for two years
• Tell the woman that when pregnancies are too
close together (less than 24 months from the
last live birth to the next pregnancy):

38. Counselling for Post-partum mothers
cont’
• Newborns can be born too soon and/or with a
low birth weight.
• Infants and children may not grow well and are
more likely to die before the age of five.
• Less than six months from the last live birth to
the next pregnancy:
• Mothers may die in childbirth.
• Newborns can be born too soon, too small, or
with a low birth weight.
• Infants and children may not grow well and are
more likely to die before the age of five.

39. Key Points
• Postpartum family planning is the initiation and use
of family planning methods in the first six weeks
following delivery.
• The aim is to prevent unintended pregnancy, too
soon after childbirth, when another pregnancy
could be harmful to the health of the mother or
breastfeeding baby.
• Fertility returns on average about two weeks post-
abortion.
• All modern family planning methods are
appropriate for post-abortion women.

40. Session Evaluation
• What are the four Stages of postpartum family
planning?
• What are the suitable family planning methods for
Immediate postpartum?
• What are the suitable family planning methods for
extended postpartum?

41. References
• MoHSW (2010).National Family Planning Procedure Manual.
• Trainees Manual, comprehensive Post Abortion Care
(2016)Ministry of Health, Community Development, and
Gender [available on line]http/www.moh.go.tz | E-mail:
ps@moh.go.tz
• WHO (2003) Programming strategy for postpartum family
planning, Maternal and child health integrated programs
• WHO Medical Eligibility Criteria for Contraceptive Use (2015).
Fifth edition.[available on line]
https://www.google.com/search?client=firefox-
b&q=WHO+Medical+Eligibility+Criteria:accessed on
17/12/2018