Providing Comprehensive Family Planning Service

NURSING LEVEL III
Unit of Competence: Providing Comprehensive

Family Planning Service
Module Title: Providing Comprehensive Family
Planning Service
TTLM Code: HLT NUR3 09 0122
LO1: Describing and Plan family planning
services
Instruction sheet learning guide
This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics:
Introduction to family planning

Resource mapping
Identification of WHO medical eligibility criteria
Developing plan of action
This guide will also assist you to attain the learning outcome stated in the cover page.
Specifically, upon completion of this Learning Guide, you will be able to:
 Conduct resource mapping using the standard format of FMOH

 Identify family planning eligible and number of expected target group for family
planning
 Develop plan of action to reach eligible
Learning Instructions:
Read the specific objectives of this Learning Guide.
1. Follow the instructions described in number 2 to 9.
2. Read the information written in the “Information Sheets 1”. Try to understand what
are being discussed. Ask you teacher for assistance if you have hard time
understanding them.
3. Accomplish the “Self-check” in page 8.
4. Ask from your teacher the key to correction (key answers) or you can request your
teacher to correct your work. (You are to get the key answer only after you finished
answering the Self-check 1).
5. If you earned a satisfactory evaluation proceed to “Information Sheet 2”. However, if
your rating is unsatisfactory, see your teacher for further instructions.
6. Submit your accomplished Self-check. This will form part of your training portfolio.
7. Your teacher will give you feedback and the evaluation will be either satisfactory or
unsatisfactory. If unsatisfactory, your teacher shall advice you on additional work.
But if satisfactory you can proceed to Learning Guide
Information Sheet-1 Introduction to family planning
1. Introduction to family planning
1.1.1. Concept of FP
Family planning is defined as the ability of individuals and couples to anticipate

and attain their desired number of children and the spacing and timing of their births. It
is achieved through use of contraceptive methods and the treatment of
involuntary infertility.
It promotes the health of women and families and part of a strategy to reduce high
maternal, infant and child mortality. People should be offered the opportunity to
determine the number and spacing of their own children. Information about FP should
be made available, and should actively promote access to FP services for all individuals
desiring them. Also its use various methods of fertility control that will help individuals
(men and women) or couples to have the number of children they want and when they
want them in order to assure the well being of children and the parents. Family planning
simply means preventing unwanted pregnancies by safe methods of prevention. This is
considered to be part of the basic human rights of all individuals or couples as it was
endorsed by the International Conference on Population and Development in Cairo in
1994. Family planning saves the lives of women and children and improves the quality
of life for all. It is one of the best investments that can be made to help ensure the
health and well-being of women, children, and communities.
The rationale for family planning includes:
 Allowing women and men the freedom to control the number, spacing and the
time at which they have children, family planning helps women and their families
preserve their health and fertility and also contributes to improving the overall
quality of their lives.
 Family planning also contributes to improving children’s health and ensuring that
they have access to adequate food, clothing, housing, and educational
opportunities.
 It allows families, especially women, the time to adequately participate in
development activities.
Health benefits:
Family planning reduces mortality and morbidity from pregnancy and childbirth. Spacing
childbirth with intervals of three to five years significantly reduces maternal,
prenatal and infant mortality rates. Pregnancy and childbirth poses special risk for some
groups of women –adolescents, women more than 35 years of age, women with more
than four previous births and women with underlying diseases. It is estimated that if all
these high risk pregnancies were avoided through the use of family planning 25%
of maternal deaths could be prevented (Royston and Armstrong, 1989). Moreover,
unwanted pregnancy that leads to unsafe abortion with its resultant complications
can be prevented by the use of family planning.
1.1.2. History of family planning

High fertility and rapid population growth have an impact on the overall socio-economic
development of the country in general and maternal and child health in particular. The
rationale was based on concerns over the potentially negative effects of rapid
population growth and high fertility on living standards and human welfare, economic
productivity, natural resources, and the environment in the developing world, but still
surveys showed substantial unmet need for family planning. During the 1980s, the
public health consequences of high fertility for mothers and children are set of concerns
for international community especially for developing countries. High rates of infant,
child, and maternal mortality as well as abortion and its health consequences, were
pressing health problems in many developing nations and had also become of greater
concern for international development agencies.
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 and hence contributes to the nation‘s
social and economic development. Ethiopia, like most countries in sub-Saharan
Africa, is experiencing rapid population growth. Ethiopia's current population is
estimated at 100 million, second most populous country in Africa and will reach 174
million by 2050 to become the 9th largest country in the world preventing any gain in the
national development effort. Widespread access to family planning services is essential
to population stabilization. The health of mothers, children and general quality of life is
also improved through the implementation of family planning programs.
Information Sheet-2 Resource mapping
1.2. Resource mapping

Community resource mapping is a method of showing information regarding the
occurrence, distribution, access to and use of resources; topography; human
settlements; and activities of a community from the perspective of community members.
Step 1: Select Local Analysts. Identify the groups of people to talk to about their
perceptions of their local resources.
Step 2: Provide Introductions and Explanations.When working with each group, the
facilitator and observer/note-taker should begin by introducing themselves.
Step 3: Produce a Community Resource Map.First decide what type of area the map
will show or any limitations, such as a village, an indigenous ancestral domain, a
watershed, and so on.
Possible Approach:
Step 4: Analyze a Community Resource Map.Once the map has been completed, use
it as a basis for conducting semi-structured interviews on topics of interestfor collecting
more statistical data and for enabling local analysts to conduct their own discussions
and analysis.
Step 5: Conclude the Activity.Check again that the analysts know how the information
will be used.
Information Sheet-3 Identification of WHO medical eligibility

criteria
1.3. Identification of WHO medical eligibility criteria
The medical eligibility criteria improve both the quality of and the access to
family planning services for clients. This medical eligibility criterion was developed
within the context of clients’ informed choices and medical safety. Medical eligibility
criteria is one of the four tools that WHO produced to provide quality and
accessible FP services based on objective evidence.
The curriculum address medical criteria for the initiation and continuation of use of all
methods included. The issue of continuation criteria is clinically relevant if a
woman develops the condition while she is using the method. When categories for
initiation and continuation are different, these differences are noted in the columns
‘I=Initiation’ and ‘C=Continuation’. Where I and C are not shown, the category is the
same for initiation and continuation of use.
On the basis of this classification system, the eligibility criteria for initiating and
continuing use of a specific contraceptive method are presented in a set of tables. The
first column indicates the condition. Several conditions were subdivided to differentiate
between varying degrees of the condition. Each condition is defined as representing
either an individual’s characteristics (e.g., age, history of pregnancy) or a known
medical/pathological condition (e.g., diabetes, hypertension). Conditions that are of
public health significance for Ethiopia are included in the MEC table. Client history is
often the most appropriate approach to decide if condition is present.
Category Description
A condition for which there is no restriction for the use of the
1 contraceptive method.
A condition where the advantages of using the method generally outweigh
2 the theoretical or proven risks.
A condition where the theoretical or proven risks usually outweigh the
3 advantages of using the method.
4 A condition which represents an unacceptable health risk if the
contraceptive method is used.
Categories 1 and 4 are self-explanatory. Classification of a method/condition as

category 2 indicates the method can generally be used, but careful follow-up may be
required. However, provision of a method to a woman with a condition classified
as category 3 requires careful clinical judgment and access to clinical services; for such
a woman, the severity of the condition and the availability, practicality, and acceptability
of alternative methods should be taken into account.
For a method/condition classified as category 3, use of that method is not

usually recommended unless other more appropriate methods are not available or
acceptable.
Information Sheet-4 Developing plan of action
1.4. Developing plan of action
Action plan is a document developed by the manager and staff, which lists all planned
activities, the date on which they will occur or by which they will be accomplished, the
resources they will require, and the person who is responsible for carrying them out.
Such a document is a valuable tool for efficient and effective programmed
implementation, and should be used regularly and consistently as a monitoring tool at
all levels. It increase prevalence of modern contraceptive methods and needs, offers
family planning service in Primary Health Care and encourage trained Primary Health
Care personnel on counseling and provision of contraceptive methods.
Its aim:to Increase the knowledge of individuals and couples on their

reproductive right to obtain information on the number and time to have children
and encourage ensuring that every child is desired by them.
Improve access to contraception services to every individual in need of them and
reduce the use of abortion as a tool to prevent unwanted pregnancies.
Expand the network of contraceptive methods offered for each individual in
need in order to raise awareness on and demand for Family Planning
services
Promotion, education, counseling, informing about family planning and reduction
of the incidence of unwanted and dangerous pregnancies, aiming at increasing
men and boys’ active participation and their responsibilities in making
reproductive health decisions
Self-Check -1 Written Test
I- Multiple Choices: Choose the best answer.
1. Family planning:
A. Can prevent pregnancies in women past the desirable child-bearing age
B. Facilitates love and affection by parents to the children
C. Reduces maternal and child mortality
D. Contributes to the quality of family life and economic development
ANSWER SHEET
Name: ________________ Date: _______
I - Multiple choices
1._________________________
LO2. Promote family planning services
Instruction sheet learning guide

Consultation of community representatives and voluntaries

Inter-sectoral collaboration
Family planning promotion and education
Supporting family planning Practices
 Identify consultative influential community representatives and voluntaries

 Promoting family planning practice and organized education in partnership with
the community and relevant organizations on the basis of inter-sectoral approach
 Promoting family planning Practice and sustain education activities involving the
resources of the community on the basis of stakeholders’ genuine participation
 Supporting family planning Practices to take self-care approach in line with
individual needs for changing unhealthy behavior on the basis of healthy
promotion and strategic behavioral change approach of FMOH
understanding them.
But if satisfactory you can proceed to Learning Guide # 52.
Information Sheet-1 Consultation of community
representatives and voluntaries
2.1. Consultation of community representatives and voluntaries
Community-based family planning brings family planning information and methods to

women and men in the communities where they live. One of the main objectives of
CBFP programs is to increase access to and choice of contraceptive methods in
underserved areas. A voluntary, well-considered decision that an individual makes on
the basis of options, information, and understanding represents his or her informed
choice. The decision-making process begins in the community, where people get
information even before coming to a facility for services. It is the provider’s responsibility
either to confirm a client’s informed choice or to help him or her reach one.
Informed choice is defined as a voluntary choice or decision, based on the knowledge of

all available information relevant to the choice or decision. In order to allow people to
make an informed choice about family planning, you must make them aware of all the
available methods, and the advantages and disadvantages of each. They should know
how to use the chosen method safely and effectively, as well as understanding possible
side-effects.In areas that do not have any type of health facility nearby, family
planning services may be made available through community-based distribution or
CBD programmes. In this approach, CBD workers, usually village women are trained
to educate their neighbors about family planning and to distribute certain
contraceptives. In their training, the CBD workers learn the basic concepts of family
planning, how each method must be used, what the precautions and side effects
are for each method, and how to keep simple records and report the information
to their supervisors.
Information Sheet-62 Inter-sectoral collaboration
2.2. Inter-sectoral collaboration
Collaboration should be considered at all levels of health care delivery system.

Integration of FP with other RH service delivery is cost effective and enables maximum
utilization of health care services in one visit. The following services shall be integrated
with FP services.
o Voluntary counseling and testing:
VCT services can be good entry points to FP services and vice versa. Both HIV and
unwanted pregnancy are consequences of unprotected sex. Hence, clients attending
VCT clinics and clients seeking FP services are sexually active people. Integrating VCT
and FP service delivery is cost effective and enables maximum utilization of health care
in one visit. Health care providers catering to the needs of VCT and FP clients
are obligated to explore the sexual habits of their clients. Knowledge and skill of
counseling prevails in health care workers that provide services for PLWHA and FP
clients. With minimum input, both types of providers can provide service to clients
seeking VCT and FP services at one stop.
o Education, screening and treatment of STIs:
Health care providers catering to the needs of patients with STIs and FP clients have
the opportunity to discuss the sexual behavior of their clients. Health care
providers that use the syndromic approach in the management of STIs should
educate and counsel their clients about high risk behavior and promote condom
use and dual use of FP. Partner notification and treatment in syndromic
management of STIs creates an opportunity for male involvement in FP.
Family planning providers can talk to clients about how they can protect themselves
both from STIs, including HIV, and pregnancy (dual protection). Program managers and
providers can choose approaches that fit their clients’ needs, their training, and
resources, and the availability of services for referral. Many people seeking family
planning services are in stable, mutually faithful, long-term relationships and so face
little risk of getting an STI. People with sexually transmitted infections (STIs), including
HIV, can use most family planning methods safely and effectively. Male and female
condoms can prevent STIs when used consistently and correctly. Every family planning
client needs to think about preventing STIs, including HIV—even people who assume
they face no risk.
o Delivery and postnatal care:
A woman seeks abortion or post-abortion care largely because of unwanted pregnancy.

One of the elements of comprehensive abortion and post-abortion care is provision of
FP counseling and services based on free and informed choice. Abortion and post
abortion care can be the first encounter of a woman with the health system. So,
this opportunity should be utilized to counsel and provide FP services. he Technical
and Procedural Guidelines for Safe Abortion Services in Ethiopia recommends
that a woman should be provided with the choice of contraception immediately after
abortion considering the medical eligibility criteria of WHO. If a woman comes for a
repeat abortion, then, the health system has failed in preventing unwanted pregnancy.
Over a quarter of pregnant women in Ethiopia attend ANC. FP counseling should be

part of focused ANC services. Though institutional delivery and postpartum care is
currently less than 10% of all deliveries, it is imperative that all women who give birth at
health facilities should be counseled on FP and informed about the availability of
FP services.
o Child health, immunization and other RH services
Child health and immunization services create a good opportunity for provision of FP
information and counseling. More than half of children under one year are immunized
for BCG and DPT 1. Though no reliable figure is available, it can reasonably be
assumed that most child immunization services are reached by women. Hence, these
services should be utilized to address issues related to FP.
Furthermore, family planning programs and services should also be integrated

with programs that address HTPs, GBV, prevention and management of infertility,
screening for gynecological malignancies, family life education (FLE), and oth er RH
services.
Information Sheet-3 Family planning promotion and

education
2.3. Family planning promotion and education
The community should be made aware of the overall benefits and availability of services
for FP. FP programs and services including IEC/BCC activities should respect the
customs and traditions of the community. Community involvement is key to dispelling
rumors and misconceptions and to developing ownership of FP programs by the
community for successful and sustainable outcomes. The following strategies should
be used for the promotion of FP and reproductive health in the community:
Advocacy
Community engagement /conversation
Promoting family life education
Strengthening the use of RH data base
o Screening for reproductive organ cancers:
Family Planning offers a unique opportunity to screen and teach the client to do self
examination for some of the ROC cancers. Health workers should teach all clients to
regularly do self-breast examination. Where facilities exist, women should be
encouraged to have an annual Pap smear or have visual inspection of the cervix using
acetoacetic acid or Lugol’s solution (VIA/VILI) at the health center level.
Community health workers should educate women and their families about ROCs and
the benefits of screening.
Family planning services are educational and comprehensive medical or social activities
which enable individuals and couples to determine freely the number and spacing of
their children, and to select the means by which this may be achieved. The service
includes education, information, Counseling, provision of contraceptive methods and
referrals. Like other health services, a variety of methods, both formal and informal are
used in health education to offer family planning programs. Some are personal, that is,
involving a health worker in direct contact with an individual or a group.
Others are impersonal, in which the communication does not involve such contact, for
example the use of posters, leaflets, and the mass media (newspapers, radio,
television, and internet). Each method has its advantages and limitations.
Family planning services are educational and comprehensive medical or social activities
which enable individuals and couples to determine freely the number and spacing of
their children, and to select the means by which this may be achieved. The service
includes education, information, Counseling, provision of contraceptive methods and
referrals. Family life education helps prepare young people for the transition to
adulthood. In school programs can result in positive behavior changes.
Family planning enables people to make informed choices about their sexual and
reproductive health. Family planning represents an opportunity for women for
enhanced education and participation in public life, including paid employment in non-
family organizations. Additionally, having smaller families allows parents to invest more
in each child. Children with fewer siblings tend to stay in school longer than those with
many siblings.
The basic concepts of family planning, how each method must be used, what the
precautions and side effects are for each method, and how to keep simple
records and report the information to their supervisors and a usually distribute
condoms; some also provide pills and spermicidal.
2.4. Supporting family planning practice

The client should know the characteristics of the method, how to use the method, the
side effects and complications of the method, and when to return to the facility. To avoid
inconvenience to clients, a family planning practicing health worker can prescribe
13 cycles of pills at a visit. Similarly, 48 units of condoms to be used for 3 months can
be prescribed for a client at one visit, and the client should be informed that he/she can
come for more if these run out before the day of appointment.
Date of expiry and physical characteristics of the method to be provided should

be checked.

I- Say True if statement is correct and False if statement incorrect
1. Informed choice is defined as a voluntary choice or decision, based on the
knowledge of all available information.
2. Community-based family planning brings family planning information to men in
the communities
ANSWER SHEET
Name: ________________ Date: _______
I - True or False
1.________________
2. ________________
LO3. Provide family planning services
Instruction sheet # 1 learning guide # 1

National family planning guideline

Describing “REDI” frame work
Family planning methods
Natural family planning methods
Artificial family planning methods
Permanent methods
Emergency family planning methods
Postpartum and post-abortal family planning
Managing side effects
Misconceptions, and compliance
Counseling and follow ups
 Providing counsel on method mix for advantages, side effects, misconceptions,

and compliance on continual usage to clients based on national family planning
guideline of FMOH
 Supplying method mix (OCP, injectables, implants, IUCD, barrier methods) for
clients according to family planning protocol of FMOH and client’s preference.
 Managing side-effects and problems occurred from the method mix.
 Managing side-effects and problems occurred from the method mix.
 Referring Clients preference of permanent methods to the next higher health
facility according to the standard procedure
 Providing continuous follow up to family planning clients based on the standard
guidelines
understanding them.
But if satisfactory you can proceed to Learning Guide # 53.
Information Sheet-1 National family planning guideline
3.1. National family planning guideline
The Health Policy of Ethiopia boldly states that the health needs of women and children
deserve particular attention. The policy recommends decentralizing services and
“enriching the concept and intensifying the practice of family planning for optimal family
health and planned population dynamics.”Access to voluntary family planning and
reproductive health services for everyone, inclusive of women, men, couples, and
adolescents, supports the health and well-being of individuals and can have positive
economic, environmental, and social benefits for families and communities.Thus, high-
quality family planning services and the people who deliver them respect, protect, and
fulfill the human rights of all their clients.Non-discrimination: Respect every client’s
needs and wishes. Set aside personal judgments and any negative opinions. Promise
yourself to give every client the best care you can. Availability of contraceptive
information and services: The family planning methods available and how to provide
them. Help make sure that supplies stay in stock. Do not rule out any method for a
client, and do not hold back information.
Accessible information and services: Help make sure that everyone can use your
facility, even if they have a physical disability. Participate in outreach, when possible. Do
not ask clients, even young clients, to get someone else’s permission to use family
planning or a certain family planning method. Acceptable information and services:
Be friendly and welcoming, and help make your facility that way. Put yourself in the
client’s shoes. Think what is important to the clientPrivacy and confidentiality: Do not
discuss your clients with others except with permission and as needed for their care.
When talking with clients, find a place where others cannot hear. Participation: Ask
clients what they think about family planning services. Act on what they say to improve
care
Information Sheet-1 Describing “REDI” frame work
3.2. Describing “REDI” frame work

Definition: REDI stands for Rapport building, Exploration, and Decision making,
and Implementing the decision.
The REDI framework:

Emphasizes the client’s right and responsibility for making decisions and carrying
them out
Provides guidelines to help the counselor and client consider the client’s
circumstances and social context
Identifies the challenges a client may face in carrying out their decision
Helps clients build skills to address those challenges
The REDI framework moves away from traditional FP counseling that relies on routinely
giving detailed information about every FP method. It avoids over loading clients with
unnecessary information and instead emphasizes the client’s preferences, individual
circumstances, and sexual relationships and knowledge. In this way, the provider can
help clients narrow down their FP method choices more quickly and better tailor the
information to clients’ needs. This not only saves time, it also meets clients’ needs more
effectively. The REDI framework helps address the differing needs of clients: those who
are new and have already chosen a method and those who have not, and those who
are returning clients, whether they are experiencing problems or changes in personal
circumstances or are merely visiting the facility for a re-supply of contraceptives.
Phases and steps of REDI
Step 1: Rapport Building
Greet client with respect

Make introductions (identify category of the client—i.e., new, satisfied return, or
dissatisfied return)
Assure confidentiality and privacy
Explain the need to discuss sensitive and personal issues
Step 2: Exploration
1. Explore in depth the client’s reason for the visit (This information will help
determine the client’s counseling needs and the focus of the counseling session.)
For new clients:
2. Explore client’s future RH-related plans, current situation, and past experience
Explore client’s reproductive history and goals, while explaining healthy timing
and spacing of pregnancy (HTSP)
Explore client’s social context, circumstances, and relationships
Explore issues related to sexuality
Explore client’s history of STIs, including HIV
Explain STI risk and dual protection, and help the client perceive his or her risk
for contracting and transmitting STIs
3. Focus your discussion on the method(s) of interest to client: discuss the client’s
preferred method, if any, or relevant FP options if no method is preferred, give
information as needed, and correct misconceptions
4. Rule out pregnancy and explore factors related to monthly bleeding, any recent
pregnancy and medical conditions
For returning clients: Explore the client’s satisfaction with the current method used.
Confirm if clients were given all the options while they made the decision. If not, tell all
the available options.
Confirm correct method use
Ask the client about changes in his or her life (i.e., plans about having children, STI risk
and status, and so on)
For dissatisfied clients only: explore the reasons for the client’s dissatisfaction or the
problems, including the issue, causes, and possible solutions such as switching
methods as well as other options (if the client decides to switch methods, continue with
Phase 3, Steps 2–5)
Step 3: Decision Making
Identify the decisions the client needs to confirm or make (for satisfied clients,
check if client needs other services; if not, go to Phase 4, Step 5)
Explore relevant options for each decision
Help the client weigh the benefits, disadvantages, and consequences of each
option (Provide information to fill any remaining knowledge gaps)
Encourage the client to make his or her own decision
Step 4: Implementing the Decision

Assist the client in making a concrete and specific plan for carrying out the
decision(s) (obtaining and using the FP method chosen, risk reduction for STIs,
dual protection, and so on)
Have the client develop skills to use his or her chosen method and condoms
Identify barriers that the client might face in implementing his or her decision
Develop strategies to overcome the barriers
Make a plan for follow-up and/or provide referrals as needed
Information Sheet-1 Family planning methods
3.3. Family planning methods

Family planning methods are broadly categorized into two: Natural Family Planning
Methods and Modern Family Planning Methods.
3.4. Natural family planning methods
Natural family planning refers to methods used to prevent or postpone pregnancy by
giving attention to natural reproductive events related to fertility
 All natural methods except for LAM require partners’ cooperation. Couple must
be committed to abstaining or using another method on fertile days.
 Couple/client must stay aware of body changes or keep track of days, according
to rules of the specific method.
 Methods do not have side effects or health risks.
These methods include:
Withdrawal method
Fertility awareness method
Rhythm /calendar method
Standard days method
Symptom based methods
Lactational amenorrhea method
3.4.1. Withdrawal Method
The man withdraws his penis from his partner’s vagina before ejaculation and
ejaculates outside the vagina, keeping his semen away from her external genitalia.
The method is also known as coitus interruptus and “pulling out.”
Mechanism of action:
Withdrawal method works by keeping the sperm out of the woman’s body.
Effectiveness:
 Effectiveness of withdrawal method largely depends on the user: Risk of
pregnancy
is greatest when the man does not withdraw his penis from the vagina
before he ejaculates with every act of sex.
 Withdrawal is one of the least effective methods, as commonly used.
 As commonly used, about 27 pregnancies per 100 women whose partner
uses withdrawal over the first year. This means that 73 of every 100 women
whose partners use withdrawal will not become pregnant.
 When used correctly with every act of sex, about 4 pregnancies per 100
women whose partners use withdrawal over the first year will occur.
 Key points:
If the man has ejaculated recently, he should urinate and wipe the tip of his penis
before sex. This is to remove any sperm remaining
Always available in every situation. Can be used as a primary method or as
a backup method.
Requires no supplies and no clinic or pharmacy visit.
One of the least effective contraceptive methods. Some men use this method
effectively, however. Offers better pregnancy protection than no method at all.
Promotes male involvement and couple communication.
No protection against sexually transmitted infections.
3.4.2. Fertility Awareness Methods
 Fertility awareness means that a woman knows how to tell when the fertile time
of her menstrual cycle starts and ends. (The fertile time is when she can become
pregnant.)
 It is sometimes called periodic abstinence or natural family planning.
 A woman can use several ways, alone or in combination, to tell when her fertile
time begins and ends.
 Fertility awareness methods are divided into two broad categories: Calendar
based and symptom based methods
 A woman can use several ways, alone or in combination, to tell when her fertile
time begins and ends.
 Fertility awareness methods are divided into two broad categories: Calendar
based and symptom based methods
 Calendar-based methods involve keeping track of days of the menstrual
cycle to identify the start and end of the fertile time.
o Examples: Standard Days Method and calendar rhythm method.
 Symptoms-based methods depend on observing signs of fertility.
 Cervical secretions: When a woman sees or feels cervical secretions, she
may be fertile. She may feel just a little vaginal wetness.
 Basal body temperature (BBT): A woman’s resting body temperature goes up
slightly after the release of an egg (ovulation), when she could become
pregnant. Her temperature stays higher until the beginning of her next
monthly bleeding.
o Examples: BBT method, ovulation method (cervical mucus method or
 Billings method), and the sympto-thermal method.
 Generally, fertility awareness methods work primarily by helping a woman
know when she could become pregnant.The couple prevents pregnancy by
avoiding unprotected vaginal sex during these fertile days-usually by abstaining
or by using condoms or a diaphragm.
 Return of fertility after use of fertility awareness methods is immediate.
 There is no protection against sexually transmitted infections.
Some women say they like fertility awareness methods for the following reasons:
Have no side effects

Do not require procedures and usually do not require supplies
Help women learn about their bodies and fertility
Allow some couples to adhere to their religious or cultural norms
about contraception
Can be used to identify fertile days by both women who want to
become pregnant and women who want to avoid pregnancy.
3.4.3. Rhythm Method
 The Rhythm method is a method by which a woman calculates the fertile days of
her menstrual period and the couple avoids vaginal sex, or uses
temporary methods during the fertile time.
 This method does not protect from STIs including HIV.
 Return of fertility after stopping the method is immediate.
 Rhythm method works primarily by helping a woman know on which days
of the menstrual cycle she is fertile or can become pregnant. The couple
prevents pregnancy by avoiding unprotected vaginal sex during these fertile
days-usually by abstaining or by using condoms or a diaphragm.
Effectiveness:
 With consistent and correct use, about 9 pregnancies per 100 women in the first
year of use will occur. This means more than 90 women will avoid potential
unplanned pregnancy in the first year of use.
How to Use Rhythm Method:
 Before relying on Rhythm method, a woman records the number of days in each
menstrual cycle for at least 6 months. The first day of monthly bleeding is always
counted as day 1.
 The woman subtracts 18 from the length of her shortest recorded cycle. This tells
her the estimated first day of her fertile time. Then, she subtracts 11 days from
the length of her longest recorded cycle. This tells her the estimated last day of
her fertile time.
 The couples avoid vaginal sex, or use condoms or a diaphragm, during fertile
time. They can also use withdrawal or spermicides, but these are less effective.
 She updates these calculations each month, always using the 6 most recent
cycles.
Example:
o If the shortest of her last 6 cycles was 27 days, 27 –18 = 9. She starts
avoiding unprotected sex on day 9.
o If the longest of her last 6 cycles was 31 days, 31 – 11= 20
She can have unprotected sex again on day 21.
o Thus, she must avoid unprotected sex from day 9 through day 20 of
her cycle.
 Key points:
The client records/recalls her menstrual cycles for at least six months. The
woman subtracts 18 days from the shortest recorded cycle and 11 days from the
longest recorded cycle. This tells her the estimated fertile days.
The couple avoids unprotected vaginal sex in the fertile days or uses
other temporary methods.
No medical conditions prevent the use of this method.
The method does not need resources or supplies (unless the couple uses
condoms or other barrier methods during fertile days of the cycle).
3.4.4. Standard Days Method (SDM):
 Standard Days Method is a calendar-based method which can be used by
women who have regular cycles that are 26 – 32 days long. The woman
calculates the fertile periods and avoids unprotected vaginal sex or use temporary
method.
How to Use Standard days Method:
Remember: A woman can use the Standard Days Method if most of her menstrual
cycles are 26 to 32 days long. If she has more than 2 longer or shorter cycles within a
year, the Standard Days Method will be less effective and she may want to
choose another method.
 A woman keeps track of the days of her menstrual cycle, counting the first day of
monthly bleeding as day 1.
 Avoid unprotected sex on days 8–19
o Days 8 through 19 of every cycle are considered fertile days for all users of the
Standard Days Method.
o The couple avoids vaginal sex or uses condoms or a diaphragm during
days 8 through 19. They can also use withdrawal or spermicides, but these
are less effective.
o The couple can have unprotected sex on all the other days of the cycle-days 1
through 7 at the beginning of the cycle and from day 20 until her next monthly
bleeding begins.
 Use memory aids if needed
o The couple can use Cycle Beads, a color-coded string of beads
that
indicates fertile and non-fertile days of a cycle, or they can mark a
calendar or use some other memory aid.
 Key points:
A woman can use the Standard Days Method if most of her menstrual cycles are
26 to 32 days long.
Avoid unprotected sex on days 8–19 from LMP or use other temporary methods
like condoms in this fertile time period.
No medical conditions prevent the use of this method.
3.4.5. Symptoms-Based Methods
The following three methods are collectively termed as symptoms-based methods:
 Cervical mucus method
 Basal body temperature method
 Symptom-thermal method
 All women can use symptoms-based methods. No medical conditions prevent
the use of these methods, but some conditions can make them harder to use
effectively.
 Caution means that additional or special counseling may be needed to
ensure correct use of the method.
 Delay means that use of a particular fertility awareness method should be
delayed until the condition is evaluated or corrected. Give the client another
method to use until she can start the symptoms-based method.
Cervical Mucus Method- CMM (Billings Ovulation Method)
 Cervical Mucus Method is a symptoms-based fertility awareness method. The
method relies on the woman’s ability to predict her fertile days by following the
characteristics of cervical mucus.
Effectiveness
With consistent and correct use, 3 pregnancies per 100 women using cervical mucus
method will get pregnant in the first year. This means that 97 of every 100 women
relying on cervical mucus method will not become pregnant.
Important: If a woman has a vaginal infection or another condition that changes
cervical mucus, this method may be difficult to use.
Check cervical secretions daily: The woman checks every day for any cervical
secretions on fingers, underwear, or tissue paper or by sensation in/ around the vagina.
Avoid unprotected sex on days of heavy monthly bleeding: Ovulation might occur
early in the cycle, during the last days of monthly bleeding, and heavy bleeding could
make mucus difficult to observe.
Resume unprotected sex until secretions begin: Between the end of monthly
bleeding and the start of secretions, the couple can have unprotected sex, but not on 2
days in a row. (Avoiding sex on the second day allows time for semen to disappear and
for cervical mucus to be observed.)
It is recommended that they have sex in the evenings, after the woman has been in an
upright position for at least a few hours and has been able to check for cervical mucus.
Avoid unprotected sex when secretions begin and until 4 days after “peak day”:
As soon as she notices any secretions, she considers herself fertile and avoids
unprotected sex. She continues to check her cervical secretions each day.The
secretions have a “peak day”—the last day that they are clear, slippery, stretchy, and
wet. She will know this has passed when, on the next day, her secretions are sticky or
dry, or she has no secretions at all. She continues to consider herself fertile for 3 days
after that peak day and avoids unprotected sex.
 Key points:
Avoid unprotected sex when cervical secretions begin to appear and until 4 days
after the ‘peak day’.
Almost all women can use the method provided they don’t have conditions that
change the characteristics of cervical secretions.
Method does not need resources or supplies (unless condoms or other barrier
methods are used during the fertile days).
Basal Body Temperature-BBT Method
 The BBT method is a symptom-based method that relies on the woman’s ability
to notice a slight increase in her body temperature. The elevation in the
temperature is as a result of hormonal changes that result in ovulation.
Mechanism of action
 The method works primarily by helping a woman to identify days when she could
become pregnant. And, the couple avoids unprotected vaginal sex from the first
day of menstruation until 3 days after the woman’s temperature has risen above
her regular temperature.
 Important: If a woman has a fever or other changes in body temperature, the
BBT method will be difficult to use.
 Take body temperature daily: The woman takes her body temperature at the
same time each morning before she gets out of bed and before she eats
anything. She records her temperature on a special graph. She watches for her
temperature to rise slightly—0.2° to 0.5° C—just after ovulation (usually about
midway through the menstrual cycle).
 Avoid sex or use another method until 3 days after the temperature rise:
The couple avoids vaginal sex, or uses condoms or a diaphragm from the first
day of monthly bleeding until 3 days after the woman’s temperature has risen
above her regular temperature. They can also use withdrawal or spermicides, but
these are less effective.
 Resume unprotected sex until next monthly bleeding begins: When the
woman’s temperature has risen above her regular temperature and stayed higher
for 3 full days, ovulation has occurred and the fertile period has passed. The
couple can have unprotected sex on the 4th day and until her next monthly
bleeding begins.
 Key points :
Watch for a slight rise in temperature at about midway between the menstrual
cycles.
Avoid unprotected vaginal sex from the first day of monthly bleeding until 3 days
after the woman’s temperature has risen above her regular temperature.
All women can use the BBT method except those with fever.
Sympto-thermal Method
 The symptom-thermal method is a method that uses a combination of cervical
mucus (ovulation) method and BBT method to prevent unwanted pregnancy.
 Method does not protect from STIs including HIV.
 Return of fertility after stopping the method is immediate
 Key points :
 Method uses a combination of ovulation method and BBT method.
 The woman looks for the presence of mucus and identifies the ‘peak day’. She
also records her body temperature every day.
 The couple avoids unprotected vaginal sex from the first day of menses until
either the fourth day after ‘peak’ cervical secretions or the third full day after the
rise in temperature (BBT), whichever happens later.
3.4.6. Lactational Amenorrhea Method-LAM
4. A temporary family planning method based on the natural effect of breastfeeding on
fertility. (“Lactation” means related to breastfeeding. “Amenorrhea” means not having
monthly bleeding.)
The lactation amenorrhea method (LAM) requires 3 conditions. All 3 conditions must
be met:
The mother’s monthly bleeding has not returned
The baby is fully or nearly fully breastfed and is fed often, day and night
The baby is less than 6 months old
5. “Fully breastfeeding” includes both exclusive breastfeeding (the infant receives
no other liquid or food, not even water, in addition to breast milk) and almost exclusive
breastfeeding (the infant receives vitamins, water, juice, or other nutrients once in a
while in addition to breast milk).
NB:The infant should suckle not less than 8 times in 24 hours and at least 1 of the
feeds should be during the night.
6. “Nearly fully breastfeeding” means that the infant receives some liquid or food in
addition to breast milk, but supplementation never replaces or delays a breastfeed.
Mechanism of action
LAM works primarily by preventing the release of eggs from the ovaries (ovulation).
Frequent breastfeeding temporarily prevents the release of the natural hormones that
cause ovulation. Suckling causes increased prolactin, which inhibits estrogen
production and ovulation.
Characteristics:
 LAM does not provide protection against sexually transmitted infections.
 It is a natural family planning method.
 It supports optimal breastfeeding, providing health benefits for the baby and the
mother
 It has no direct cost for family planning or for feeding the baby.
 Key points:
Lactation Amenorrhea Method –LAM:
 A family planning method based on breast feeding. LAM provides contraception
for the mother and is best feeding for the baby.
 Can be effective for up to 6 months after childbirth, as long as menstrual bleeding
has not returned and the woman is fully or nearly fully breastfeeding.
 Requires breastfeeding often, day and night. All of the baby’s feedings should be
breast milk (even if sometimes some small amounts of other liquids or food are
added to breast milk feeding).
 Provides an opportunity to offer a woman an ongoing method that she can
continue to use after 6 months.
 I- Multiple Choices: Choose the best answer.
1. W/c one of the following is not natural family planning method
A. Cervical mucus method
B. Withdrawal method
C. Fertility awareness method
D. Intra uterine contraceptive device
2. W/c one of the following is the least effective contraceptive methods
A. coitus interruptus
B. Rhythm method
C. Abstinence
D. Billings ovulation method
ANSWER SHEET
Name: ________________ Date: _______

1._________________________
2. _________________________
6.3. Artificial family planning methods
6.3.1. Barrier Methods

Condoms
Condoms were first used to prevent STIs in the British royalty in the 18 th
century. Condoms were first made from gut intestine of sheep/goat. There are two
types of condoms: the male condom which is made of latex and the female
condom which is made of plastic.
‘Dual protection’ (also known as ‘dual use’) implies consistent and correct use of
condoms (male or female condoms) in addition to other contraceptive methods
(also called “dual method use”), or the consistent and correct use of condoms
alone, to effectively prevent pregnancy as well as STIs including HIV. Dual protection is
critical in reducing transmission of STIs and HIV.
Male Condoms:
 Sheaths, or coverings, that fit over a man’s erect penis.
 Most are made of thin latex rubber.
Proper use of condom
 Use a new condom for each act of sex
Check the condom package. Do not use if torn or damaged. Avoid using a
condom past the expiration date-do so only if a newer condom is not available.
Tear open the package carefully. Do not use fingernails, teeth, or anything that
can damage the condom.
 Before any physical contact, place the condom on the tip of the erect penis with
the rolled side out
For the most protection, put the condom on before the penis makes any
genital, oral, or anal contact.
 Unroll the condom all the way to the base of the erect penis
The condom should unroll easily. Forcing it on could cause it to break during use.
If the condom does not unroll easily, it may be on backwards, damaged, or too
old. Throw it away and use a new condom.
If the condom is on backwards and another one is not available, turn it over and
unroll it onto the penis.
 Immediately after ejaculation, hold the rim of the condom in place and
withdraw the penis while it is still erect
Withdraw the penis.
Slide the condom off, avoiding spilling semen.
If having sex again or switching from one sex act to another, use a new condom.
 Dispose of the used condom safely
Wrap the condom in its package and put in the rubbish or latrine or pit. Do not
put the condom into a flush toilet, as it can cause problems with plumbing.
 Key points:
Male condoms help protect against sexually transmitted infections, including HIV.
Condoms are the only contraceptive method that can protect against both
pregnancy and sexually transmitted infections.
Require correct use with every act of sex for greatest effectiveness.
Require both male and female partner’s cooperation. Talking about condom use
before sex can improve the chances condom will be used.
Female condoms: A female condom enables a woman to control its use to prevent
pregnancy and STIs including HIV.
Have flexible rings at both ends
One ring at the closed end helps to insert the condom
The ring at the open end holds part of the condom outside the vagina
Lubricated with a silicone-based lubricant on the inside and outside.
Latex female condom is available in Ethiopia
 Key points:
Female condoms:
Help protect against sexually transmitted infections, including HIV.
Condoms are the only contraceptive method that can protect against both
pregnancy and sexually transmitted infections.
A woman can initiate female condom use, but the method requires her partner’s
cooperation.
May require some practice. Inserting and removing the female condom from the
vagina becomes easier with experience.
Spermicidal:
Sperm-killing substances inserted deep in the vagina, near the cervix, before
sex.
Nonoxynol-9 is the most widely used spermicide
Others include chlorhexidine, octoxynol-9
Available in foaming tablets, melting or foaming suppositories, jelly and cream
Jellies, creams, and foam from cans can be used alone, with a diaphragm, or
with condoms.
Films, suppositories, foaming tablets, or foaming suppositories can be used
alone or with condoms.
Mechanism of action
Spermicides work by causing the membranes of sperm cells to break, killing them or
slowing their movement. This keeps sperm from meeting an egg.
All women can safely use spermicides except those who:
Are at high risk for HIV infection
Have HIV infection
Have AIDS
How to insert spermicide into the vagina:
Check the expiration date and avoid using spermicides past their expiration date.
Wash hands with mild soap and clean water, if possible.
Foam or cream: Shake cans of foam hard. Squeeze spermicide from the can or
tube into a plastic applicator. Insert the applicator deep into the vagina, near the
cervix, and push the plunger.
Tablets, suppositories, jellies: Insert the spermicide deep into the vagina, near
the cervix, with an applicator or with fingers.
 Do not wash the vagina (douche) after sex
Douching is not recommended because it will wash away the spermicide and
also increase the risk of sexually transmitted infections.
If you must douche, wait for at least 6 hours after sex before doing
 Key points:
Spermicides are placed deep in the vagina shortly before sex
Requires correct use with every act of sex for greatest
effectiveness
One of the least effective contraceptive methods
Can be used as a primary method or a as back up method.
Not a good method for women at risk of HIV or with HIV/AIDS
Diaphragms:
A soft latex cup that covers the cervix. Plastic diaphragms may also be available.
The rim contains a firm, flexible spring that keeps the diaphragm in place.
Used with spermicidal cream, jelly, or foam to improve effectiveness.
Comes in different sizes and requires fitting by a specifically trained provider.
Mechanism of action
Diaphragm works by blocking sperm from entering the cervix; spermicide
kills or disables sperm. Both keep sperm from meeting an egg.
 Key points :
The diaphragm is placed deep in the vagina before sex. It covers the cervix.
Spermicide provides additional contraceptive protection.
A pelvic examination is needed before starting use. The provider must select a
diaphragm that fits properly.
3.3.6. Oral Contraceptive Pills
Oral contraceptive pills include combined oral contraceptive pills (COCs) and progestin
only pills (POPs) are contraceptive methods that contain either two or one female sex
hormones. The hormones are synthetic estrogens and synthetic progesterone.
The estrogen hormones include:
 Ethinyl estradiol
 Mestranol
The progestins include
Norethindrone
Norgestimate
Gestodene
Desogestrel
In addition to their contraceptive effect, OCPs provide other non-contraceptive
health benefits. OCPs are not expensive and are widely used all over the world. OCPs
can be used as emergency contraceptives where a dedicated product is not
available. Oral contraceptive pills can be used in settings where clinical judgment is
limited. Hormonal methods do not protect against STIs, including hepatitis B and
HIV. Therefore, individuals with risky sexual behavior should use a barrier method
(condom) for dual protection against pregnancy and STIs.
Combined contraceptive pills (COCs)
Pills that contain low doses of two hormones – a synthetic progestin and a
synthetic estrogen –like the natural hormones progesterone and estrogen in a woman’s
body. Combined oral contraceptives (COCs) are also called “the Pill,” low-dose
combined pills, OCPs, and OCs. Over the years the doses of hormone in the pill
have decreased to lower and safer levels, with consequent decrease in
occurrence of side effects.
High-dose COCs are now defined as those containing 50 micrograms or more of

estrogen and they are not used for ongoing contraception any longer, just for
emergency contraception. Low-dose pills contain less than 50 micrograms of estrogen.
The most common available COCs in Ethiopia contain 30-35 micrograms.
Mechanism of action
Work primarily by preventing the release of eggs from the ovaries (ovulation).
COCs prevent synthesis of gonadotropins from the pituitary. Hence, ovarian follicles do
not mature and ovulation does not occur.
Characteristics
 In almost all clients, fertility returns following COC discontinuation.
 Can be stopped at any time without a provider’s help
 Do not interfere with sex
 COCs are controlled by the woman.
 Must be taken every day, whether or not a woman has sex that day.
 Reduce the risk of ectopic pregnancy.
 Side effects include lighter bleeding and fewer days of bleeding, irregular
bleeding, infrequent bleeding, amenorrhea, dizziness, headache, nausea,
abdominal pain, mood changes, breast tenderness, acne and weight changes.
 Other physical changes include slight increases in blood pressure. When the
increase in BP is due to COCs, blood pressure declines quickly after use of
COCs stops.
 Help protect against:
Risks of pregnancy
Cancer of the lining of the uterus (endometrial cancer)
Cancer of the ovary
Symptomatic pelvic inflammatory disease
Ovarian cysts
Iron-deficiency anemia
 Reduce:
Menstrual cramps (dysmenorrheal)
Menstrual bleeding problems
Ovulation pain
Symptoms of endometriosis
Excess hair on face or body
 The three forms of low-dose COCs:
 Monophasic - each active pill contains the same amount of estrogen and
progestin, e.g., Microgynon, Prudence, Nordette.
 Biphasic - the active pills in the packet contain two different dose-combinations
of estrogen and progestin. For example in a cycle of 21 active pills, 10 may
contain one combination while 11 contain another.
 Triphasic - the active pills contain three different dose combinations of estrogen
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.
 Do not provide COCs if a woman:
 If a woman is less than three weeks after delivery of a baby. In this case, you can
give her COCs and tell her to start taking them 3 weeks after childbirth (if she is
not breastfeeding)
 If she is breastfeeding a baby less than 6 months old, delay COC initiation until
baby is 6 months old, or when breast milk is no longer the baby’s main food –
whichever comes first.
 Takes anti-epileptic drugs and rifampicin. Effectiveness may be lowered when
these drugs are taken concurrently. The anti-epileptic drugs include
barbiturates,carbamazepine, oxcarbazepine, phenytoin, primidone or topiramate.
The drugs can make COCs less effective. Help the woman choose another
method without hormones.
 Ever had heart attack, heart disease due to blocked or narrowed arteries, or
stroke, do not provide COCs. Help her choose a method without estrogen but not
progestin-only injectables. Also if she ever had or currently has a blood clot in the
deep veins of the legs or lungs (not superficial clots), do not provide COCs and
help her choose a method without hormones.
 Has serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver
tumor), do not provide COCs. Help her choose a method without hormones (She
can use monthly injectables if she has had jaundice only with past COC use.).
 Is 35 years of age or older and smokes, do not provide COCs. Urge her to stop
smoking and help her choose another method.
 Has high blood pressure and
o If you cannot check blood pressure and she reports a history of high blood
pressure, or if she is being treated for high blood pressure, do not provide COCs.
Refer her for a blood pressure check if possible or help her choose a method
without estrogen.
o Check blood pressure if possible:
 If her blood pressure is below 140/90 mm Hg, provide COCs.
 If her systolic blood pressure is 140 mm Hg or higher or diastolic blood pressure
is 90 or higher, do not provide COCs. Help her choose a method without
estrogen, but not progestin-only injectables if systolic blood pressure is 160 or
higher or diastolic pressure is 100 or higher.
 COCs for women with HIV:
 Women who are infected with HIV and/or have AIDS can safely use
COCs.
 Women who are on antiretroviral (ARV) therapy generally can safely use
COCs, unless their ARV regimen contains ritonavir or ritonavir-boosted
protease inhibitors. In such cases do not provide COCs and help her
choose another method.
 Urge these women to use condoms along with COCs. Used consistently
and correctly, condoms help prevent transmission of HIV and other STIs.
Condoms also provide extra contraceptive protection for women on ARV
therapy. Some ARV medications reduce the effectiveness of COCs.
 Explain how to use COCs
 Give pills: Give as many packs as possible—even as much as 3 months’supply
(3 packs).
 Explain pill pack: Show which kind of pack –21 pills or 28 pills. With 28-pill
packs, point out that the last 7 pills are a different color and do not contain
hormones.
o Show how to take the first pill from the pack and then how to follow the
directions or arrows on the pack to take the rest of the pills.
 Give key instruction:
Take one pill each day —until the pack is empty.
Discuss cues for taking a pill every day. Linking pill-taking to a daily
activity may help her remember.
Taking pills at the same time each day helps to remember them. It also
may help reduce some side effects.
 Explain starting next pack:
28-pill packs: When she finishes one pack, she should take the first pill
from the next pack on the very next day.
21-pill packs: After she takes the last pill from one pack, she should wait 7
days and then take the first pill from the next pack.
It is very important to start the next pack on time. Starting a pack late risks
pregnancy.
 Provide backup method and explain use
Sometimes she may need to use a backup method, such as when she
misses pills.
Backup methods include abstinence, male or female condoms,
spermicides, and withdrawal. Tell her that spermicides and withdrawal are
the least effective contraceptive methods. Give her condoms, if possible.
 Managing missed pills
Take a missed hormonal pill as soon as possible.
Keep taking pills as usual, one each day. (She may take 2 pills at the same time
or on the same day.)
 Key points:
Take one pill every day: For greatest effectiveness a woman must take pills daily
and start each new pack of pills on time.
Side effects may occur but they are not harmful: Some women will experience
irregular bleeding for the first few months and then lighter and more regular
bleeding.
Other side effects also diminish after the first three months.
Take any missed pill as soon as possible: Missing pills risks pregnancy and may
make some side effects worse.
Can be given to women at any time to start later: If pregnancy cannot be ruled
out, a provider can give her pills to take later, when her monthly bleeding begins.
Progestin-only pills (POPs)
POPs are pills that contain very low doses of a progestin like the natural
hormone progesterone in a woman’s body.
POPs do not contain estrogen, and so can be used throughout breastfeeding and
by women who cannot use methods with estrogen.
Progestin-only pills (POPs) are also called “minipills” and progestin-only oral
contraceptives.
POPs contain 0.025 mg –0.030 mg progesterone of different chemical
composition.
Mechanism of action
POPs primarily prevent pregnancy by:
Thickening cervical mucus. Thick cervical mucus blocks passage of sperm
through the cervical canal and meeting the ovum (egg).
Disrupting the menstrual cycle, including preventing the release of eggs
from the ovaries (ovulation).
Characteristics
POPs do not contain estrogens. Therefore, they do not cause many of the side
effects associated with COC use. Progestins do not suppress production of
breast milk, which makes them an ideal contraceptive method for breastfeeding
women.
Return of fertility after stopping POPs is immediate.
Does not provide protection against sexually transmitted infections (STIs)
including hepatitis B and HIV/AIDS and, therefore, individuals at risk should
practice ‘dual method use’ (a barrier method in addition to POPs) to ensure
protection against STIs/HIV/AIDS.
Can be stopped at any time without a provider’s help
Do not interfere with sexual intercourse
POPs are controlled by the woman.
Must be taken every day, whether or not a woman has sexual intercourse that
day.
Reduce the risk of ectopic pregnancy.
Side effects include spotting or bleeding between periods (more common),
amenorrhea, headaches and breast tenderness, nausea, abdominal pain and
mood changes
POPs are safe and suitable for nearly all women.
Nearly all women can use POPs safely and effectively, including women who:
o Are breastfeeding (starting as soon as 6 weeks after childbirth)
o Have or have not had children
o Are not married
o Are of any age, including adolescents and women over 40 years old
o Have just had an abortion, miscarriage, or ectopic pregnancy
o Smoke cigarettes, regardless of woman’s age or number of cigarettes
smoked
o Have anemia now or had in the past
o Have varicose veins
o Have goitre
o Are infected with HIV, whether or not on antiretroviral therapy
Do not provide POPs if a woman:
 Takes anti-epileptic drugs and rifampicin. The anti-epileptic drugs include
barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone or
topiramate. The drugs can make POPs less effective.
 Reports a current blood clot in legs (deep vein thrombosis) or lungs do not
provide POPs.
 Has serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver
tumor), do not provide POPs. Help her choose a method without hormones.
 Has history of breast cancer.
Explain how to use POPs
 Give pills: Give as many packs as possible.
 Explain pill pack:
o Show which kind of pack—28 pills or 35 pills.
o Explain that all pills in POP packs are the same color and all are active
pills, containing a hormone that prevents pregnancy.
o Show how to take the first pill from the pack and then how to follow the
directions or arrows on the pack to take the rest of the pills.
 Give key instruction:
o Take one pill each day —until the pack is empty.
o Discuss cues for taking a pill every day. Linking pill-taking to a daily
activity may help her remember.
o Taking pills at the same hour each day helps to remember them.
 Explain starting next pack
o When she finishes one pack, she should take the first pill from the next pack on
the very next day.
o It is very important to start the next pack on time. Starting a pack late risks
pregnancy.
 Provide backup method and explain use
o Sometimes she may need to use a backup method, such as when she misses
pills.
o Backup methods include abstinence, male or female condoms, spermicides, and
withdrawal. Tell her that spermicides and withdrawal are the least effective
contraceptive methods. Give her condoms, if possible.
 Explain that effectiveness decreases when breastfeeding stops
o Without the additional protection of breastfeeding itself, POPs are not as effective
as most other hormonal methods.
o When she stops breastfeeding, she can continue taking POPs if she is satisfied
with the method, or she is welcome to come back for another method.
 Key message :
o Take a missed pill as soon as possible.
o Keep taking pills as usual, one each day (this means that the woman may have
to take 2 pills at the same time or on the same day.)
 If the woman has regular monthly bleeding:
o The woman should also use a backup method for the next 2 days.
o Also, if she had sex in the past 5 days, can consider taking ECPs:
 Emergency Contraceptive Pills.
 Key points:
Take one pill every day. No breaks between packs. All pills are active pills.
Safe for breastfeeding women and their babies. Progestin only pills do not affect
milk production.
Add to the contraceptive effect of breastfeeding. POP use and breastfeeding
together provide effective pregnancy protection.
Bleeding changes are common but not harmful. Typically, pills lengthen the time
where breastfeeding women have no monthly bleeding. For women having
monthly bleeding, frequent or irregular bleeding is common.
Can be given to a woman at any time to start at a later date. If pregnancy cannot
be ruled out, a provider can give her pills to take later, when her monthly
bleeding begins.
Progestin Only Injectables
The contraceptive injection, also known as ‘the shot’, contains progestogen or a
combination of estrogen and progestogen. The injectable contraceptives depot
medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) each
contain a progestin like the natural hormone progesterone in a woman’s body. In
contrast, monthly injectables contain both estrogen and progestin.
 Injectables that do not contain estrogen can be used throughout breastfeeding
and by women who cannot use methods with estrogen. DMPA, the most widely
used progestin-only injectable, is also known as Depo or Depo Provera.
Mechanism of action
 Inhibits Ovulation- After a 150 mg injection of DMPA, ovulation does not occur
for at least 13 to 14 weeks. Levels of the follicle stimulating hormone (FSH) and
luteinizing hormone (LH) are lowered and a LH surge does not occur.
 Thickens the Cervical Mucus - the cervical mucus becomes thick, making
sperm penetration difficult.
 Thins the Endometrial Lining- because of the high progestin and low estrogen
levels, the endometrium changes, making it unfavorable for implantation.
However, due to the changes in the cervical mucus and an ovulation, fertilization
is extremely unlikely to occur.
Characteristics of DMPA
 Highly effective.
 Safe.
 Long acting (three months).
 Completely reversible (an average of 4 months’ delay in return to
fertility after discontinuing DMPA).
 Suitable for women who are not eligible to use an estrogen-
containing contraceptive.
 Suitable for breastfeeding women (after 6 weeks postpartum).
 Provides immediate post partum (in non-breastfeeding women) or post-
abortion contraception.
 The prolonged absence of menses is an advantage for many women.
 Protects against ectopic pregnancy since ovulation does not occur.
 There are menstrual changes for almost all women.
 Increased appetite causing weight gain for some women (0.5 kg, on the
average, in the first year).
 Women who stop using DMPA take an average of four months longer than
usual to get pregnant (compared to discontinuing other contraceptives
such as oral contraceptives or IUCDs).This is because residual levels
of DMPA exist for several months after the end of contraceptive
protection from the last injection.
 DMPA is completely reversible and does not cause infertility.
 Since DMPA is long acting, it cannot easily be discontinued or removed
from the body if a complication occurs or if pregnancy is desired
immediately.
Progestin-only injectables safely and effectively, including women who:
o Are breastfeeding (starting as soon as 6 weeks after childbirth)
o Are infected with HIV, whether or not on antiretroviral therapy
Women who Should Not Use Injectables (DMPA)
Breastfeeding a baby less than six weeks old.
Severe decompensate cirrhosis
Blood pressure higher than 160/100 mm Hg.
Diabetes more than 20 years of duration or diabetes with vascular
complications.
History or current heart attack or stroke
Current blood clot in leg (deep venous thrombosis) or lungs (pulmonary
embolism)
Undiagnosed abnormal vaginal bleeding (postpone injection until bleeding can be
evaluated)
History or current breast cancer
Timing of the First Injection
DMPA may be given at any time when it is reasonably certain the woman is not
pregnant:
o During the first seven days after the start of menses.
o Immediately or within 7 days following a spontaneous or induced abortion.
o Immediately postpartum or up to 28 days after delivery if the woman is
not breastfeeding (because postpartum women don't ovulate for at least 28
days). Between six weeks and six months for fully breastfeeding women whose
menses have not returned postpartum. (Full breastfeeding is a reliable method
of contraception up to six months postpartum if a woman has not menstruated.)
Full breastfeeding means: Intervals between feeds should not exceed 4 hours
during the day, 6 hours at night, and supplementation should not exceed 5 - 15%
of all feeding episodes, preferably fewer. (DMPA is generally not given before an
infant is six weeks old, because of the theoretical concern that the liver of the
neonate may not be mature enough to metabolize DMPA.)
o When a woman has not had intercourse since her last menses and
cannot, therefore, be pregnant.
o When a woman is reliably using another effective method of contraception
(COCs, IUCD, and barrier).
 Key points:
 Bleeding changes are common but not harmful. Typically, irregular bleeding for
the first several months and then no monthly bleeding
 Return for injections regularly. Coming back every 3 months (13 weeks) for
DMPA or every 2 months for NET-EN is important for greatest effectiveness.
 Injection can be given as much as 2 weeks early or 4 weeks late. Client
should come back even if later.
 Gradual weight gain is common.
 Return of fertility is often delayed. It takes several months longer on average
to become pregnant after stopping progestin only injectables than after other
methods
Contraceptive implants (Norplant)
Hormonal implants are thin, flexible, matchstick-sized rods made of soft plastic.
The rods contain hormone progestin (similar to the natural hormone progesterone
in a woman’s body) and are surgically placed beneath the skin of client’s upper arm by
a trained provider. They are highly effective, very safe, simple, convenient, and
quickly reversible forms of contraception that are provided easily in an outpatient
setting. Three new implants, Jadelle® (a two-rod system labeled as effective for
five years), SinoImplant (II)® (a two-rod system labeled as effective for five years)
and Implanon® (a one-rod system labeled as effective for three years), are even
easier to insert and remove than the previously available implant, Norplant ®(a six-
capsule system no longer in production that was labeled as effective for 7 yrs).
The Norplant implant system consists of a set of 6 small, plastic capsules. Each capsule
is about the size of a small matchstick. The capsules are placed under the skin of a
woman’s upper arm. Norplant capsules contain a progestin (called levonorgestrol),
similar to a natural hormone that a woman’s body makes. It is released very slowly from
all 6 capsules. Thus the capsules supply a steady, very low dose of progestin. Norplant
contains no estrogen.
Mechanism of Action:
o Implants continually release a small amount of progestin steadily into the blood.
o Increased viscosity of the cervical mucus making it harder for sperm to swim
through (effect starts within48-72 hours after insertion of implants). Inhibition of
ovulation in about 50% of menstrual cycles.
o Suppression of endometrial growth so that it is less receptive to implantation.
Precautions
Category -4: Because the combination of this method with certain conditions poses a
health risk, do not use implants in the presence of the following conditions:
o Current breast cancer.
o Serious liver disease
o Current DVT
o Unexplained vaginal bleeding
Category -3: A condition where the theoretical or proven risks usually outweigh the
advantages of using the method. Use of method not usually recommended unless other
more appropriate methods are not available or not acceptable. These conditions are:
o Breastfeeding less than 6 weeks postpartum
o Acute deep venous thrombosis (DVT)
o Unexplained vaginal bleeding
o Severe cirrhosis
o Hepato-cellular adenoma
o Hepatoma
o Women with a history of breast cancer and no current evidence of disease
Side effects:
 Most side effects and other problems associated with the use of implants
are not severe. The most common side effect is that of changes in menstrual
bleeding patterns.
 Some users report changes in bleeding patterns including:
 First several months:
Lighter bleeding and fewer days of bleeding
Irregular bleeding that lasts more than 8 days
Infrequent bleeding
No monthly bleeding
After about one year:
Lighter bleeding and fewer days of bleeding
Irregular bleeding
Infrequent bleeding
 Key Points for Providers and Clients
Implants are small flexible rods that are placed just under the skin of the upper
arm.
Provide long-term pregnancy protection. Very effective for 3 to 5 years,
depending on the type of implant. Immediately reversible.
Require specifically trained provider to insert and remove.
A woman cannot start or stop implants on her own.
Little required of the client once implants are in place.
Avoids user errors and problems with resupply.
Bleeding changes are common but not harmful. Typically, prolonged irregular
bleeding over the first year, and then lighter, more regular bleeding, infrequent
bleeding, or no bleeding.
o Equipment and Instruments for Implanon Insertion:
Examining table for the client to rest her arm on
Marker pen/optional/.
Soap for washing the arm.
Gloves.
One bowl for antiseptic solution
Antiseptic solution (iodine).
Sterile syringe with needle.
2ml of lidocaine (1% without adrenaline)
Preloaded sterile Implanon and applicator containing a single rod
Ordinary band-aid or bandage.
Gauze/cotton ball.
Safety box
IUCDs
Common types of IUCDs available worldwide are:-
 Copper - bearing, which include the Cu-T 380A, Cu-T 380A with safe load, Cu-T
200C, Multiload (MLCu 250 and 375), and the Nova T
 Medicated with a steroid hormone, such as the levonorgestrel containing
MirenaI US (intrauterine system)
Fig. Intrauterine device
 Mechanism of Action:
The copper bearing IUCDs’ principal mechanism of action (MOA) is to interfere
with fertilization. Normally the uterine cavity and fallopian tubes are a good environment
for sperm to swim and fertilize the egg. But, the IUCD creates a “spermicidal
environment.” This environment becomes inhospitable to sperm cells. The sperms are
killed or damaged, so they cannot swim and reach the egg. The IUCDs, which
contain progesterone, also cause the thickening of cervical mucus, which stops the
sperm from entering the uterus. IUCDs’ contraceptive effect is not abortificient.
IUCDs are an appropriate choice for a client who:
Has a healthy reproductive tract (the client does not have any signs of infection
or cancer, or reproductive tract abnormalities that would make insertion difficult).
Wants to delay first pregnancy or space her children.
Also very appropriate for women that have completed childbearing and do not
want
Voluntary Surgical Contraception/VSC (IUCDs are highly suitable for older
women until menopause).
Wants an effective method, but precaution (s) exist for hormonal methods such
as COCs. (IUCDs have little or no effect on body systems other than
reproductive tract.)
Is breastfeeding. ( IUCDs do not affect lactation)
Is immediately postpartum (from delivery of placenta to 48 hours) and wants an
effective method that won’t interfere with breastfeeding.
Common IUCD (CU-T 380A) side effects and complications
Side effects may include:
Cramping.
Prolonged and heavy menstrual bleeding
Irregular bleeding.
1. All natural family planning methods are requiring partners’ cooperation except.
A. calendar method C. Lactation amenorrhea

B. Standard days method method
D. Withdrawal method
2. W/c one is the temporary family planning method based on effect of
breastfeeding
A. Spermicidal
B. Oral contraceptive pills
C. Progestin-only pills
D. Lactation amenorrhea method
3. One of the following is Notcontains estrogen hormone
A. Combine oral contraceptives
B. Depo- perovera contraceptive injection
C. Contraceptive implants
D. Emergency Contraceptive Pills
ANSWER SHEET
Name: ________________ Date: _______
1._________________________
2. _________________________
3. _________________________
3.3.3. Permanent Family Planning Methods

Permanent FP methods, also called voluntary surgical contraception (Bilateral
Tubal Ligation and Vasectomy), are among the most effective, popular and well-
established contraceptive method options available for men and women who
desire no more children. For individuals and couples desiring no more children, it
provides the most effective protection against pregnancy. The risk of
complications is small if the procedure is performed according to accepted
medical standards. It offers the advantage over other contraceptive methods that it is a
once-only procedure.
Mechanism of action
The voluntary surgical contraception (VSC) procedure blocks either the sperm
ducts (Vasa deferentia) or the oviducts (fallopian or uterine tubes) to prevent the
meeting of sperm and ovum, which makes fertilization and pregnancy impossible.
Types of Permanent FP methods
A. Bilateral tubal ligation/Minilaparotomy
B. Male Sterilization/Vasectomy
Bilateral tubal ligation with Mini laparotomy (BTL/ ML)
Bilateral tubal ligation with Mini-laparatomy (BTL/ML), generally referred to as “minilap,”
is a permanent contraception method for females done through an abdominal surgical
approach to the fallopian tubes by means of an incision less than 5cm/mostly 3cm/ in
length under local anesthesia. The fallopian tubes (oviduct) are permanently occluded
so that the egg cannot travel through them to meet the sperm. Bilateral tubal ligation is
the world’s most widely used modern family planning method and one of the
fastest growing, including in developing regions and in many developed countries such
as theUnited States. It is safe, highly effective, relatively simple, surgical means
of contraception that can usually be provided in an outpatient setting and is intended to
be permanent.
Surgical approaches for bilateral tubal ligation
a. Mini-laparatomy: A simplified laparatomy approach using an incision of 2 cm - 5 cm
in length.
b. Laparoscopy: uses endoscopic equipment through a tiny incision under the
umbilicus.
c. Laparotomy is an incision of the abdominal wall that extends over 5 cm in length to
be used when BTL is performed in conjunction with caesarean section or another
gynecological operation.
Timing of procedure
The following timings are all equally acceptable when performed according to
Guidelines:
Interval bilateral tubal ligation
This implies BTL which is done any time when one is sure that the client is not
pregnant, or beyond four weeks of delivery or abortion
Postpartum bilateral tubal ligation
This implies BTL which is done within the first seven days postpartum, at which time the
uterus is still an abdominal organ
Post-abortion bilateral tubal ligation
This implies BTL which is done within the first seven days post-abortion
NB. There is no medical reason that would absolutely restrict a woman’s eligibility for
bilateral tubal ligation.
Vasectomy:
Vasectomy is a permanent method of contraception for men involving a minor surgical
procedure whereby both tubes are cut and tied. The procedure usually takes 5 to 20
minutes to perform.
Mechanism of action
The Vas deferens through which sperm travel from the testes to the penis are cut or
blocked so that sperm can no longer enter the semen that is ejaculated.
Safety
Vasectomy is very safe if done using a strict aseptic technique.
Advantages:
Vasectomy is one of the most effective contraceptive methods. It is over 99%
effective; in the first year, 1 failure would occur in 700 men.
Vasectomy is meant to be permanent.
Vasectomy can be performed at any time
Vasectomy is simple and safe.
Vasectomy can be performed quickly.
Vasectomy has very low mortality and morbidity.
A man who has Vasectomy no longer has to worry about causing a
woman to become pregnant. The man and his partner do not have to use
other family planning methods.
Disadvantages:
Does not protect against STI including HIV/AIDS.
Vasectomy is a minor surgical procedure, with risk similar to any minor
surgical procedure.
Some men have a little pain, soreness, bruising, or swelling after vasectomy.
These problems usually go away by themselves or with simple treatment or pain
medicine. There is a small chance that the operation will not succeed and the
man’s partner may become pregnant.
It is considered irreversible.
Requires specialized training, aseptic conditions, medications, and clinical
assistance.
Is not immediately effective; must use another contraceptive method for the first
20 ejaculations or the first 3 months—whichever comes first.
Side effects and complications occasionally occur:
Bleeding at the incision site or internal
Infection at the incision site or internally
Injury to abdominal organs
Pain and skin discoloration in area of incision
Swelling and discoloration of scrotum
Blood clots in scrotum
3.3.5. Emergency family planning methods
Despite the availability of highly effective methods of contraception, many pregnancies
are unplanned and unwanted. Many of these unplanned pregnancies can be avoided by
using family planning. Family planning is the use of either hormonal pills (estrogen and
progestin or progestin alone) or a copper-bearing IUCD to prevent an unintended
pregnancy following exposure to unprotected intercourse.
Emergency contraceptive pills (ECPs) are hormonal methods of contraception that
can be used to prevent pregnancy following an unprotected act of sexual intercourse.
ECPs are sometimes referred to as “morning after” or “postcoital” pills.These terms
have been replaced by the term “emergency contraceptive pills” because they do not
accurately convey the correct timing of use. ECPs can be used up to five days following
unprotected intercourse (120 hours). ECPs should not be used as a regular or on-going
method of contraception. They are intended for “emergency” use only.
Two types of emergency contraceptive pills:
Pills containing a combination of a progestin (levonorgestrel or norgestrel) and an
estrogen (ethinyl estradiol).
Pills containing a progestin only (levonorgestrel or norgestrel).
ECPs are thought to prevent ovulation, fertilization, and/or implantation.
ECPs are not effective once the process of implantation of a
fertilized ovum has begun.
ECPs will not cause an abortion and have no known adverse effects
on (the growth and development of) an established pregnancy.
Overall, ECPs are less effective than regular contraceptive methods. Because the ECP
pregnancy rate is based on a onetime use, it cannot be directly compared to
failure rates of regular contraceptives, which represent the risk of failure during a full
year of use. If ECPs were to be used frequently, the failure rate during a full year of use
would be higher than those of regular hormonal contraceptives. Therefore, ECPs are
not recommended for regular use. Additional factors determining effectiveness are
timing of the two doses and exposure to repeated unprotected intercourse following
ECP therapy before the return of menses.
IUCD
IUCDs are highly effective as ECs. After unprotected sexual intercourse, less than
1% of women are reported to become pregnant if they use a copper releasing
IUCD as an EC.
Safety:
The short exposure to estrogens and/or progestins does not appear to
increase
women’s risk for blood clots as may occur with longer use of combined
oral contraceptives (COCs).
Hormones in ECPs (as well as in other COCs or POPs) have not been
associated
with any fetal malformations or congenital defects, so if woman who is
already pregnant accidentally uses ECPs, it is not harmful.
ECPs do not increase woman’s risk for ectopic pregnancy.
When to Use Emergency Contraception:
ECPs are indicated to prevent pregnancy within five days (120 hours) of
unprotected sexual intercourse, including:
o When no contraceptive has been used.
o When there is a contraceptive accident or misuse, including:
Condom rupture, slippage, or misuse.
Diaphragm or cap dislodgment, breakage or tearing, or early removal.
Failed coitus interruptus, withdrawal, (e.g. Ejaculation in vagina or on external
genitalia).
Miscalculation of the periodic abstinence method.
IUCD expulsion.
Returned for DMPA injection later than four weeks
After sexual assault.
IUCD as an EC is indicated when:
Within 7 days of unprotected intercourse. .
When the time of ovulation can be estimated, she can have an IUCD inserted up
to 5 days after ovulation, even if it is more than 5 days after unprotected
intercourse.
The client prefers using an IUCD for continuous, long-term contraception.
Eligible Clients to Use IUCD as an EC
Screening
Check if woman is within 12 days from the start of her monthly bleeding.
If more than 12 days have passed, check if her only unprotected intercourse was
not more than 7 days ago.
Screen for conditions which may preclude safe IUCD insertion (as described in
the section on IUCD)
Record the medical and gynecological history.
Record present illnesses, including history of STIs and risk factors for STIs,
suchas multiple sexual partners.
Common side effects and their management
Nausea:
To minimize nausea and vomiting, use progestin-only ECPs whenever possible,
instead of COCs. Progestin-only regime is also more effective as well as better
tolerated.
Vomiting:
If vomiting occurs within one hours of taking ECPs, the dose should be repeated. In
cases of severe vomiting, vaginal administration of the pills can be used.
Irregular uterine bleeding:
Inform women that ECPs do not bring on menses immediately. Her next menstrual
period may start a few days earlier or later than expected. If there is a delay
in menstruation of more than one week, a pregnancy test should be performed.
Other side effects of ECP use include breast tenderness, headache, abdominal
pain, dizziness, and fatigue. These side effects usually do not last more than a few days
after treatment and most do not last more than 24 hours.
Instructions to client using IUCD:
 Advise the client that cramping or pain may occur for the first 24-48
hours after insertion of the device. If she experiences this, she should take
pain-relief tablets such as aspirin, ibuprofen or paracetamol.
 If the client does not plan to keep the IUCD for regular contraception, instruct her
to come back during or soon after menstruation for removal of IUCD and initiation
of her preferred contraceptive method.
 If the client plans to keep the IUCD for regular contraception, inform her that:
some bleeding or spotting may occur immediately after insertion and spotting
may continue for the next few months.
 Vaginal discharge may occur during the first few weeks. This should not be
cause for concern.
 She should return to the clinic, if she is experiencing any of the following signs
and symptoms which might, indicate possible complications: fever and/or
chills; pelvic pain or tenderness; purulent vaginal discharge, excessive
abnormal bleeding absence of menses, or if the IUCD thread cannot be felt.
 She should use condoms to protect herself from the risk of STIs,
including HIV.
1. One of the following is very safe if done using a strict aseptic technique
A. Vasectomy
B. Tubal ligation
C. Female Sterilization
D. All
2. W/c one of the following is Not advantages of vasectomy
A. Vasectomy has very low mortality and morbidity
B. Vasectomy can be performed at any time
C. Vasectomy is simple and safe.
D. It is considered irreversible
ANSWER SHEET
Name: ________________ Date: _______

1._________________________
2. _________________________
3.3.5. Postpartum and post- abortion family planning

Post partum family planning is the initiation and use of family planning methods in the
first year after delivery to prevent unintended pregnancy particularly in the first 1-2
years after childbirth, when another pregnancy can be harmful to the mother or a
breastfeeding baby.
The initiation of family planning during the period following delivery includes:
Post-placental insertion of IUCD- within 10 minutes following delivery of the
placenta.
Immediate post partum -within 48 hours after delivery (usually performing VSC or
inserting an IUCD)
Postpartum before discharge(PPBD) –within 48 hours after delivery and
beforethe woman leaves the facility where she delivered
Early postpartum period – 48 hours to 6 weeks after delivery
Extended postpartum – beyond the 6 weeks after delivery up to one year
Post-abortion family planning
Post-abortion family planning is the initiation and use of family planning methods,
most often immediately after treatment for abortion - within 48 hours, or before fertility
returns (2 weeks post abortion).
The aim is to prevent unintended pregnancies, particularly for women who do not want
to be pregnant and may undergo a subsequent unsafe abortion if contraception is not
made available during this brief and vulnerable interval.
Postpartum Infertility
During pregnancy, ovulation is suppressed.
After the delivery of the placenta, the inhibiting effects of estrogen and progesterone are
removed so that levels of Follicle Stimulating Hormone and Luteinizing Hormone
gradually rise and ovarian function begins again.
Most non-lactating women resume menses within four to six weeks of delivery;
however, approximately 33% of first cycles are an ovulatory and a high proportion of
first ovulatory cycles have luteal-phase defects; therefore pregnancy is less likely
than with normal cycles. In non-lactating women, the first ovulation occurs on
average around 45 days postpartum.
Postpartum:
During the early postpartum period, a combination of abstinence and/or lactational
amenorrhea may prevent the woman from conceiving. However, many women at risk
for pregnancy are not using contraception.
Despite the documented demand for postpartum contraception, many postpartum
women do not receive the family planning information or services they need to
delay or prevent subsequent pregnancies. About half of the postpartum women who
want family planning do not succeed in starting a method in the first year after delivery,
clearly an unmet need that puts women and their babies at risk due to unintended,
untimely pregnancy.
Post-abortion
Many women are trapped in a cycle of repeated unwanted pregnancy and
abortion (either safe or unsafe). Although the importance of linking the treatment of
incomplete abortion care and family planning services is well documented, in many
countries they are not offered together. This results in:
Women being denied convenient access to the means of preventing future
unwanted pregnancies.
A lack of comprehensive reproductive health services linking family planning,
post abortion care, and treatment for infertility and sexually transmitted infections.
3.9. Managing side effects
Side-effect & its management of spermicidal

Vaginal irritation  Check for vaginitis and GTIs. If caused by spermicide,
switch to another spermicide with a different chemical
composition or help client choose another method.
Penile irritation and  Check for GTIs. If caused by spermicide, switch to
discomfort another spermicide with a different chemical
composition or help client choose another method.
Side-effect & its management of diaphragm

Urinary tract infections  Treat with appropriate antibiotic. If client has frequent
(UTIs) UTIs and diaphragm remains her first choice for
contraception, advise emptying bladder (voiding)
immediately after intercourse.
Suspected allergic  Allergic reactions, although uncommon, can be

reaction (diaphragm) uncomfortable and possibly dangerous. If symptoms of
vaginal irritation, especially after intercourse and no
evidence of GTI, help client choose another method.
Suspected allergic  Allergic reactions, although uncommon, can be
reaction (spermicide) uncomfortable and possibly dangerous. If symptoms of
vaginal irritation, especially after intercourse and no
evidence of GTI, provide another spermicide or help
client choose another method.
Vaginal discharge  Check for GTI or foreign body in vagina (tampon, etc.). If
and odor if left in no GTI or foreign body is present, advise client to
place for more than remove diaphragm but not less than 6 hours after last
act. (Diaphragm should be gently cleaned with mild
24 hours soap and water after removal.
Side-effect & its management of COCs
Nausea and dizziness  Assess for pregnancy; counsel about side effects,
advise to take pills with meals or at a bed time.
Irregular bleeding  If irregular bleeding continues beyond the first three
months or starts after several months of regular cycles,
assess for other possible causes (infection, cancer, or
other gynecological conditions)
 Encourage to take pills at the same time each day.
 For modest short-term relief, use 800 mg ibuprofen 3
times daily after meals for 5 days or other non-steroidal
anti-inflammatory drug (NSAID), beginning when
irregular bleeding starts.
Amenorrhea  Assess for pregnancy; if negative, counsel that this is
one of the side effects of COC use.
Breast tenderness  Recommend that the woman wear a supportive bra
(including during strenuous activity and sleep).
 Try hot or cold compresses.
 Suggest aspirin (325–650 mg), ibuprofen (200–400
mg),paracetamol (325–1000 mg), or other pain
reliever.
Side-effect & its management of POPs
Amenorrhea:  Reassure that amenorrhea is a common side effect of
POPs, especially if she is breastfeeding. If she is not
breastfeeding and there are reasons to suspect
pregnancy (e.g. she missed pills), assess for pregnancy.
If pregnant, stop use of POPs and discuss on
subsequent actions; if not pregnant, reassure and
continue POPs.
Abnormal vaginal  Client should be evaluated (refer as necessary),
Bleeding: including VIA/ VILI and Pap Smear; refer as necessary
for management.
Headache&  Painkillers can be taken for pain relief. If developed, or
dizziness: worsened while taking POPs, determine cause. If no
cause, counsel; if severe and no cause help client select
alternative method; refer if persistent.
Mood changes or  Counsel; if it worsens, help client select alternative
nervousness: methods.
3.10. Misconceptions and compliance

4. Misconceptions can lead to discontinuation of FP methods. Thus, correcting
misconceptions is an important step in ensuring continued use.
If clients understand why misconceptions are untrue, they are more likely to
believe the correct information.
A Client’s Misconception:
Ask clients what they have heard about FP methods and what concerns they
have about the methods.
Take the client’s concern or misconception seriously.
Try to find out where the client heard the misconception or rumor.
Explain tactfully why the misconception or rumor is not true.
Find out what the client needs to know to have confidence in the FP method.
Find out who the client will believe.
Give the correct information. Be aware of traditional beliefs about health
because they can help you both understand rumors and explain health matters in
ways that clients can more easily understand and accept.
Encourage clients to check with a service provider if they are not sure about what
they hear about their method of choice or other methods after they leave the
health care facility.
3.11. Counseling and follow ups
Family planning counseling is defined as a continuous process that you as the

counselor provide to help clients and people in your village make andarrive at informed
choices about the size of their family i.e. the number ofchildren they wish to have.
In order to allow people to make an informed choice about family planning, you must
make them aware of all the available methods, and the advantages and disadvantages
of each. They should know how to use the chosen method safely and effectively, as well
as understanding possible side-effects.
Information should be provided regarding all available methods of contraception,
advantages of each method, and expected contraceptive side effect, as well as the
steps to be taken if and when the clients have side effects. Knowledge of the common
misconceptions about each method is an added advantage to the counselor and efforts
should be made to address clients concerns and fears about specific methods.
FP workers should ensure confidentiality and privacy to potential clients. After
counseling on all available methods, clients should be helped to make an
informed decision.
There are the important principles and conditions necessary for effective counseling:
Privacy — find a quiet place to talk.
Take sufficient time.
Maintain confidentiality.
Conduct the discussion in a helpful atmosphere.
Keep it simple — use words people in your village will understand.
First things first — do not cause confusion by giving too much information.
Say it again — repeat the most important instructions again and again.
Use available visual aids like posters and flip charts, etc.
Follow-up counseling is to discuss and manage any problems and side effects related to
the given contraceptive method. This also gives you the opportunity to encourage the
continued use of the chosen method, unless problems exist.
Operation sheet -1 Implanon insertion
Procedure:
Step 1: Greet client respectfully and with kindness.
Step 2: Review Client Screening Checklist and further evaluate client,
Step 3: Tell client what is going to be done and encourage her to ask questions.
Step 4: Ask about allergies to antiseptic solution and local anesthetic agent.
Step 5: Check to be sure client has thoroughly washed and dried her entire arm.
Step 6: Help position and allow the client on table to lie on her back with her
non-dominant arm (the arm, which the woman does not use for carrying pitcher
or for writing) on the arm rest of the table turned outwards and bent at the elbow.
Step 7: Determine insertion site at the inner side of the upper arm (non-dominant
arm) about 6-8 cm above the elbow
Step 8: Mark the insertion site on arm with a marker/pen (optional)
Step 9: Open sterile Implanon package by pulling apart sheets of the
pouch completely without touching the preloaded applicator and place on the
work table.
10: Carefully remove the sterile disposable applicator carrying Implanon rod
from the sterile blister and remove the needle cap/shield.
Step 11: Always hold the applicator in the upward position (i.e. with the
needle pointed upwards) until the time of insertion. This precaution is to prevent
the implant from dropping out.
Step 12: Visually verify the presence of the implant inside the metal part of the
cannula (the needle). The implant can be seen as a white tip inside the
needle. If the implant protrudes from the needle, return to its original
position by tapping against the plastic part of the cannula.
Note: Keep the needle and the implant sterile. Do not touch the needle of
the cannula or the implant inside the applicator with anything, including
client skin before insertion. If contamination occurs, a new package with a new
sterile applicator must be used.
Step 13: Stretch the skin around the insertion site with thumb and index
I- Multiple Choices: Choose the best answer (more than one answer
may be correct)
1. Which of the following is/are traditional family planning method(s):
A. Lactational ammenorrhea
B. Calendar method
C. Rhythm method
D. Basal body temperature method
E. Abstinence?
2. The common types of combined oralcontraceptive pills in Ethiopia:
A. Have 21 hormonal pills in each pack
B. Are biphasic
C. Are monophasic
D. Are multiphase
E. Have the same amount of progesterone and estrogen.
3. Advantage/s of COCs include:
A. Trained non medical person can provide them
B. They are user dependant
C. They are highly effective when used correctly
D. They do not protect against STDs
E. They are convenient and easy to use.
4. Minipills contain:
A. Only estrogen
B. Only progesterone
C. Both estrogen and progesterone equally
D. More progesterone than estrogen
E. More estrogen than progesterone.
5.The preferable contraceptive method for breast feeding mother is:
A. Depo-provera
B. IUCD
C. Progesterone only pills
D. High estrogenic pills
E. Combined oral contraceptive pills.
ANSWER SHEET
Name: ________________ Date: _______

1. ________________
2. ________________
3. ________________
4. ________________
5. ________________
LO4. Monitor family planning services

Instruction sheet # 1 learning guide #
1
 HMIS standards of FMOH

 Preparing action plan
 Monitoring family planning practice
 Documentation and reporting
Preparing registration book for family planning services according to HMIS

standards of FMOH
Collecting, updating and sustaining Family planning services data on the basis
of HMIS guideline of FMOH
Reporting and communicating family planning activities to the higher level and
relevant body on the basis of HMIS procedure of the FMOH
Revising plan on family planning for the catchments for a specific period of time
Monitoring family planning practice at kebele is against plan
understanding them.
26. If you earned a satisfactory evaluation proceed to “Information Sheet next”.
However, if your rating is unsatisfactory, see your teacher for further instructions.
unsatisfactory. If unsatisfactory, your teacher shall advice you on additional work. .
Information Sheet-1 HMIS standards of FMOH
4.1. HMIS standards of FMOH

Family planning records and reports are important tools for strategic planning,
supervision and monitoring.
4.1.1. Client Card

4.1.2. All clients seeking family planning services need to have client card. The client
card records the socio-demographic and health history, physical examination
findings and current method of use. The follow up section of the card records the
history and physical examination findings at the time of the visit (client card insert
copy of client card). The client card provides information on past and current use
of a FP method and method switch (if any). It is an important tool for monitoring
the quality of services as it provides information on whether the client has been
screened for eligibility to use the method. It is useful for follow up of clients.
When the client cards are organized in a systematic way, it helps to track
defaulters.
4.1.2. Family Planning Register
This register records relevant information of all the clients who got service from a health
facility. The family planning register is kept in the family planning room of the facility.
Family planning register should be completed by the provider at the time of service
provision. The register includes information on the medical record number, sex, date of
visit, counseling services , contraindication for methods, method provided and number
of visit , FP method used and the date of last visit (in case of condoms, combined oral
contraceptives and injectables).
The register:
o Provides information on the contraceptive use in a specified geographical

area
o Useful tool for tracking clients, especially defaulters
o Provides information on supplies of contraceptives.
4.1.3. Referral form: Records of clients referred are obtained from the referral records.
4.1.4. Reports
Family planning reports provide information on the progress of the various indicators
that have been identified by the Federal Ministry of Health. The reports shall include
complications with use of methods and are important tools for monitoring. The health
facility shall compile a monthly report and forward to the woreda health office. A woreda
health office shall compile all reports from all facilities in its catchment area monthly and
shall submit a report to the zonal health office which in turn will summarize the report
every 3 months to Regional Health Bureau. The regional health bureau will compile the
total contraceptive acceptor and the LMIS report to FMOH biannually.
Information Sheet-2 Preparing action plan
4.2. Preparing action plan
An action plan is a document developed by the manager and staff, which lists all
planned activities, the date on which they will occur or by which they will be
accomplished, the resources they will require, and the person who is responsible for
carrying the out. Such a document is a valuable tool for efficient and effective
programme implementation, and should be used regularly and consistently as a
monitoring tool at all levels.
Action plan (also known as operational plans)are distinguished from long term plans in
that they show how the broader objectives, priorities and targets of the strategic plan will
be translated into practical activities, which will then be carried out over a much shorter
time period(anywhere from a week to a year). However, there should be complete
harmony between the strategic objectives and the annual targets.
Information Sheet-3 Monitoring family planning practice
4.3. Monitoring family planning practice
Monitoring is a process by which priority data and/or information is routinely collected,

analysed, used and disseminated to see progress towards the achievement of planned
targets.This helps the managers take timely corrective actions in order to improve
performance. It includes monitoring of inputs, outputs, outcomes and impacts of health
programmes, including family planning. The most common form of monitoring is often
based on input and output indicators using routinely collected service data. Monitoring
of outcomes and impacts, on the other hand, requires the collection of target population
level data, and forth is reason is done at ahigher level and for fewer selected priority
areas only.
Common performance indicators for a family planning programme:
 Inputs (resources, activities)

Total commodities (supplies, equipment, contraceptives) received.
Training and technical assistance received by the staff.
Supplies and contraceptives expended (subtract inventory from amount
received).
Number of educational materials received, by type.
 Outputs (services, training, information, education and communication)
Number of new clients, given by choice of contraceptive method.
Number of providers trained.
Number of households covered.
Number of community meetings and number of people informed at meetings.
Number of referrals for clinical methods.
Number of contraceptives distributed, by contraceptive method.
Information Sheet-4 Documentation and reporting

4.4. Documentation and reporting
 Documentation and reporting is one way that an organization can keep track of
patterns of contraceptive use amongst its clients. Keeping records and preparing
and analyzing reports are effective ways to determine clients’ needs and their
use patterns, without doing a formal programme evaluation. Good examples of
this are stock on hand (by method and brand), and consumption/ distribution (by
method and brand), both of which can be easily collected and analyzed on a
routine basis. This information can be collected by using simple HMIS records,
forms and reports.
Types of Documentation forms:
 Inventory control card (ICC): This form should be kept at all storage facilities that
manage a significant number of inventory items. The purpose of the ICC is to
have an up-to-date and continuous record, in one location; of all transactions for
each item in the inventory .Daily activity register (DAR) The register is designed
to be used when contraceptives are dispensed to family planning clients. It
provides a daily log of the number of client visits, subdivided by the types and
quantities ofcontraceptives dispensed to each client on a monthly basis. When
anew month begins, service providers should begin anew DAR. The DAR should
be totaled on a monthly and quarterly basis .Quarterly report/ requisition: This
form serves several purposes. It provides summary information from the DAR
and ICC concerning the number and types of clients served, and quantities of
each type of contraceptive received and dispensed over a three-month period.

 Multiple Choices: Choose the best answer
1. ----- Is priority data and/or information is routinely collected, analysed and
disseminated
A. Evaluation
B. Monitoring
C. Implementation
D. All
ANSWER SHEET
Name: ________________ Date: _______

6. ________________
Reference:
1. Federal Democratic Republic of Ethiopia Ministry Of Health 2012, Participant‘s
Handout Basics in Family Planning and Short acting Family Planning Methods
2. Federal Democratic Republic of Ethiopia Ministry Of Health 2012,
Participant‘s Handout, counseling for family planning use

Providing Comprehensive Family Planning Service

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NURSING LEVEL III

Unit of Competence: Providing Comprehensive

Introduction to family planning

 Conduct resource mapping using the standard format of FMOH

 Develop plan of action to reach eligible

Read the specific objectives of this Learning Guide.

1. Follow the instructions described in number 2 to 9.

3. Accomplish the “Self-check” in page 8.

Family planning is defined as the ability of individuals and couples to anticipate

The rationale for family planning includes:

1.1.2. History of family planning

Information Sheet-2 Resource mapping

1.2. Resource mapping

Information Sheet-3 Identification of WHO medical eligibility

Categories 1 and 4 are self-explanatory. Classification of a method/condition as

For a method/condition classified as category 3, use of that method is not

Information Sheet-4 Developing plan of action

1.4. Developing plan of action

Its aim:to Increase the knowledge of individuals and couples on their

Name: ________________ Date: _______

Instruction sheet learning guide

Consultation of community representatives and voluntaries

 Identify consultative influential community representatives and voluntaries

Read the specific objectives of this Learning Guide.

8. Follow the instructions described in number 2 to 6.

Community-based family planning brings family planning information and methods to

Informed choice is defined as a voluntary choice or decision, based on the knowledge of

Information Sheet-62 Inter-sectoral collaboration

2.2. Inter-sectoral collaboration

Collaboration should be considered at all levels of health care delivery system.

o Voluntary counseling and testing:

o Education, screening and treatment of STIs:

o Delivery and postnatal care:

A woman seeks abortion or post-abortion care largely because of unwanted pregnancy.

Over a quarter of pregnant women in Ethiopia attend ANC. FP counseling should be

Furthermore, family planning programs and services should also be integrated

Information Sheet-3 Family planning promotion and

2.4. Supporting family planning practice

Date of expiry and physical characteristics of the method to be provided should

Self-Check -1 Written Test

Instruction sheet # 1 learning guide # 1

National family planning guideline

 Providing counsel on method mix for advantages, side effects, misconceptions,

Read the specific objectives of this Learning Guide.

15. Follow the instructions described in number 2 to 57.

17. Accomplish the “Self-check” in page 56.

3.1. National family planning guideline

Information Sheet-1 Describing “REDI” frame work

3.2. Describing “REDI” frame work

The REDI framework:

Phases and steps of REDI

Step 1: Rapport Building

Greet client with respect

For new clients:

Confirm correct method use

Step 3: Decision Making

Step 4: Implementing the Decision

Information Sheet-1 Family planning methods

3.3. Family planning methods

Have no side effects

Name: __________ Date: _

Name: __________ Date: _

Name: __________ Date: _

Name: __________ Date: _

Name: __________ Date: _

Name: __________ Date: _