Family planning options

Planning the family by using a method of contraception helps couples to time, space and limit the number of births to achieve the desired family size.

Benefits of planning a pregnancy according to the desires of the couple are as follows;

  1. Reduces the problems of unintended pregnancies
  2. Enhances chances of healthy pregnancy outcomes and reduces birth related disability and death

‘Women with five or more children are 1.5 to 3 times more likely to die from complications of pregnancy and child birth than women with two or three children’

  1. Improves survival of the newborn and reduces child disability

‘With spacing (3 – 5 years) children are more than twice as likely to survive infancy and are healthier’

  1. Reduces the risks of adolescent/ teenage pregnancies

‘Girls aged 10 – 14 years are five time more likely to die of pregnancy related causes than women aged 20 – 24 years’

  1. Helps to regulate the menstrual cycle in women with irregular cycles (Combine Oral Contraceptive Pill)
  2. As there is less bleeding with the use of the OCP, DMPA, Implant and the Hormone Loaded IUD (IUS) this prevents anaemia due to blood loss
  3. Reduces cancer risks

Eg: Hormonal contraceptives (OCP, DMPA and Implants) reduces the risk of ovarian and endometrial (womb) cancer

  1. Reduces the risk of contracting STI/ HIV – protection by the use of Condoms

What is the suitable method?

  1. An adolescent: Effective contraceptives are strongly recommended

    Consider the following before a method of contraception is selected

Non – medical Features                                                                Medical Features

Religious compatibility                                                                   Safe

Cultural & social acceptance                                                        Easy to use

Easy availability                                                                                 Less side effects

Affordability                                                                                       No effect on Future Reproduction

Having considered individual situations, all methods of contraception can be used by an adolescent or young adult. This may depend on the duration of time they wish to avoid a pregnancy.

For long-term protection – Implants (both Jadelle and Implanon) are suitable

For short term protection – Oral contraceptive pill and condoms are sufficient

The following should be used cautiously after serious consideration of social & health issues –

                 Intra Uterine Device (eg: Cu T device Mirena IUS and LNG IUS)

                Depo Progestrone – DMPA 3 monthly injection

Sterilization may be considered in special cases where the girl may be incapacitated. Extensive analysis of the medical, social and other relevant issues should be performed before deciding on the method. Further, alternative long-term temporary methods should be considered. Legal opinion and counseling of client and family is a necessary of care provision.

To have a gap (Space) between pregnancies

It is both beneficial for the mother and the new born child. For the new born baby the chance of protection and feeding is enhanced. For the mother the opportunity to recover from pregnancy and delivery is increased. It also provides the couple to enjoy parenthood. The WHO recommends 2 – 3 years of spacing between two pregnancies. But the duration may depend on the age of the mother. If mother is older discuss with her to try for a pregnancy early.

Up to 6 months

After 6 months

Condom –from  immediately after delivery

Condoms

DMPA (3 month injection) – to be taken from 6 weeks after delivery

Oral Contraceptive Pill (OCP)

IUD/ IUS – to be inserted within 48 hours of delivery or 6 weeks after delivery

DMPA (3 month injection)

Implants – to be taken from 6 weeks after delivery

Implants

Female Sterilization –  to be done within 7 days or 42 days after delivery

IUD/IUS

Lactational Amenorrhoea Method (LAM) May be supported by condoms

Female Sterilization

Progestron Only Pill (POP) – to be taken from 3 weeks after delivery (Not available in SL at the moment)

Progestron Only Pill  (POP)

 

To limit the number of pregnancies when the desired number is achieved

All contraceptive methods are suitable if used in the proper manner

  • Long Acting Reversible Methods (LARCs) – Implants, Copper containing Intra Uterine Device (IUD) or Hormone loaded Intra Uterine System (IUS)
  • DMPA 3 monthly injection, Oral Contraceptive Pill or Condom

Sterilization (Male/ Female) – as this is a PERMANENT method, a firm decision must be taken not to have any more children. Therefore discuss thoroughly with partner before deciding on surgery.                

Women over 40 years

This group is a very vulnerable group as they may not want to start or continue a method. They cite many reasons like not having as much sexual exposure as before, now in middle age and risk of pregnancy less, not good for health, side effects, etc. These reasons are often given without much consideration or knowledge of this period of life and are impression of hearsay.

But these women are a major group who are at risk of unplanned pregnancies. This is because ovulation time is often unpredictable after 40 years of age.

They should be always advised to be on a regular reliable method rather than on fertility awareness methods as they may experience irregular cycles any time after 35 years

Although all methods can be prescribed to women over 40 years, the choice may depend on other factors such as risk of illnesses that the woman may have (DM, HT, High Cholestrol levels, cancer, etc). Therefore a general health screening is advisable as a part of the preliminary screening.

Long Acting Reversible Methods (LARCs) – Implants, Copper containing Intra Uterine Device (IUD) or Hormone loaded Intra Uterine System (IUS) are the most suitable methods. They also have other co-benefits such as reduced menstrual problems and prevention of some cancers.

DMPA 3 monthly injection, Oral Contraceptive Pill or Condom are useful for short term use.

Sterilization (Male/ Female) – as this is a PERMANENT method, a firm decision must be taken not to have any more children. Therefore discuss thoroughly with partner before deciding on the surgery.                         

Discontinuation in the elderly

OCP/ DMPA can be used continuously till the woman has reached 50 years of age.

Implants can be kept till the woman reaches 55 years of age.

IUD/IUS can be kept till the woman reaches menopause. Prolonged, continuation of IUD/IUS beyond its lifetime is inadvisable as the device becomes brittle and also tends to attract fungal infections.

Menopause can be confirmed by the following;

If woman is less than 50yrs – there should be Two years of absent periods (amenorrhoea)

If woman is more than 50yrs – there should be One year of absent periods (amenorrhoea)

OR

Confirm with 2 FSH (hormone responsible for egg/follicle maturation) levels 6 weeks apart, which should be more than 30 mIU/L

 

In the presence of Diabetes;

All methods can be used if there is only a history of gestational diabetes (GDM) or uncomplicated diabetes

But if vascular or other organ involvement is present the Oral Contraceptive Pill is not recommended

Condition

Method

COCP

DMPA

Implants

IUD/ IUS

Sterilization

History of GDM

ü   

ü   

ü   

ü   

ü   

Non vascular DM (Insulin dependent or not)

ü   

ü   

ü   

ü   

ü   

With vascular and organ involvement

   x

ü   

ü   

ü   

ü   

 

In the presence of High Blood pressure (Hypertension);

All methods of contraception are permitted if Systolic Blood Pressure is between 140 – 159 and/or Diastolic Blood Pressure is between 90 – 99 mmHg (The combined oral contraceptive pill should be used very carefully)

Similarly, if Systolic blood Pressure is more than 160 and Diastolic Blood Pressure is more than 100 mmHg, DMPA three monthly injection, Intra Uterine Device (IUD), Intra Uterine System (IUS), Implants or sterilization are suitable methods, but the Combined Oral Contraceptive Pill is not recommended for use.

Method

Blood Pressure

 

BP 140 – 159/ 90 – 99 mmHg

BP >160 / 100 mmHg

Combined Oral Contraceptive

ü   

                       x

DMPA

ü   

ü   

Implants

ü   

ü   

IUD/ IUS

ü   

ü   

Sterilization

ü   

ü   

 

 

Contraceptive use in situations of high risk of Sexually Transmitted Infections (STI’s)

STI’s involve many clinical, emotional and social issues. While contraceptive use is necessary to avoid a pregnancy it is also necessary that spread of disease is prevented.

Accordingly both male and female barrier methods (condoms) would offer the best chance of controlling disease transmission.

The STI’s are;

  1. Lower Genital Tract infection (Vaginitis) due to Trichomoniasis and Candida Albicans (Thrush). While treatment of these conditions to both partners is effective further protection is provided by the condom.
  2. Cervical infection with Gonococcus. Main management is to diagnose and treat with suitable antibiotics. Condoms offer some protection from spread.
  3. Overall genital herpes and Human Papiloma Virus (HPV) Infection receives protection from spread by the use of the condoms.
  4. HIV/ AIDS – Use of condoms especially those impregnated with Naloxone is strongly recommended to avoid spread

All hormonal methods (OCP, Injectables, and Imlants) would be effective for contraception in the presence of STI’s

A symptom often attributed to STIs is vaginal discharge. However physiological discharges are very common and are noticed to be without itching or irritation and may be of different consistency, such as thin and watery in the early part of the period cycle (due to oestrogen effect) and thick and sticky just before the menstrual period (due to progesterone effect). Such discharges occur as a part of normal activity of the reproductive cycle and all contraceptives are acceptable for use in their presence.

Continuous clear and sometimes blood streaked vaginal discharge could occur in genital track polyps (which are small, harmless, fleshy masses and are unrelated to STIs). Although all methods of contraception could be used in their presence it is advisable to treat polys soon, preferably prior to the use of the contraceptive method.

Lower genital tract STIs are usually associated with itching and soreness. The discharge is then purulent (yellow coloured) and has an offensive smell (Trichomoniasis infection has a greenish yellow discharge with a fishy odour and has small froth bubbles). These may be due to bacterial, fungal (yeast) and viral infections. The use of barrier methods (male and female condoms) is strongly recommended. The use of intra uterine contraceptive devices could lead to spread of the infection to the upper genital track and are therefore to be avoided. Other methods of contraception do not affect the infection and are acceptable for use to prevent pregnancies. Urgent diagnosis and treatment of the infection is essential.

Upper genital infections (Pelvic Inflammatory Disease – PID) are usually associated with fever and abdominal pain. Except for intra uterine devices other contraceptives are acceptable for use.

As in all STIs those with higher risk of HIV infection, the use of condoms is a priority to reduce chances of disease spread. All the other contraceptive methods are acceptable for family planning.

In the presence of STIs male and female sterilization should be performed taking in to account the risk of spread of the disease to other sites as well as infection transfer to other patients and the care providers.

When an offensive smelling blood stained discharge occurs especially in the older age groups, lower and upper genital tract malignancies should always be excluded by clinical examination, cytological evaluation (Pap smear test) and ultra-sound scanning.

In the presence of Valvular heart Disease;

Till recently the only method of contraception that was considered for use in the presence of heart disease was the condom

The World Health Organization (WHO) has recommended all methods of contraception for patients with heart disease without any complications and if with complications (pulmonary hypertension, etc) all hormonal methods containing only progesterone (implants/ DMPA), IUD/IUS and sterilization are permitted. The Combined Oral Contraceptive Pill (COCP) is not recommended.

Method

Uncomplicated Heart Disease

Complicated Heart Disease

COCP

ü   

   x

DMPA

ü   

ü   

Implants

ü   

ü   

IUD/IUS *

ü   

ü   

Sterilization *

ü   

ü   

*Need to start prophylactic antibiotics a day prior to procedure and continue for 3 days after