Prof. Roshan Ara Qazi
Chairperson
Obstetrics & Gynaecology
LUMHS, Jamshoro
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The student will be able to:
Describe contraception, importance of family
planning & concept of “healthy timing &
spacing of pregnancy” (HTSP)
Describe major family planning methods
including mechanism of action, benefits &
limitations
Contraception:
 Intentional prevention of conception or
impregnation through use of various devices,
agents, drugs, sexual practices or surgical
procedures.
Family Planning:
 It allows people to attain their desired
number of children and determine the
spacing of pregnancies. It is achieved through
use of contraception
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1)
2)
In June 2005, WHO brought together more
than 30 technical experts to review the global
scientific evidence regarding optional birth
spacing & answer the following questions
Does pregnancy spacing affect the health
of mothers and newborn?
How long should a woman wait to get
pregnant after childbirth?
3)
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How long should a woman wait to get
pregnant after miscarriage or induced
abortion?
The set of recommendation called healthy
timing & spacing of pregnancy is based on
the results of this technical consultation.
Ref: WHO 2006; Report of a WHO technical consultation on birth spacing,
Geneva, Switzerland, 13-15 June 2005, WHO Geneva
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Short birth intervals are associated with
multiple adverse outcomes for mothers &
newborns
An infant born after short birth interval is at
increased risk of
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Preterm birth
Low birth weight
Small for gestational age
Death
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A women who becomes pregnant too quickly
following previous birth/miscarriage or
induced abortion faces higher risks of
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Anemia
Pre rupture of membranes
Abortion
Death
AFTER LIVE BIRTH
The recommended interval before attempting the next
pregnancy is at least 24 months in order to reduce the
risk of advise maternal perinatal & infant outcomes
AFTER MISCARRIAGE OR INDUCED ABORTION
The recommended minimum interval to next pregnancy
should be at least 6months in order to reduce the risk
of adverse maternal and perinatal outcomes
DELAY ADOLESCENCE PREGNANCY
Delay timing of the first pregnancy until age 18 to
reduce risks of adverse maternal, perinatal & infant
outcomes
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6th most populous country of Pakistan with
high unmet need of family planning about
25%
Approximately 1 in 3 births occurs less than
24 months after a previous birth
The shortest birth intervals occurs in women
ages 15 – 19 who are already at highest risk
of pregnancy related complications
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The client will be given full information about
optimal pregnancy spacing and the benefits
of HTSP as a part of FP health education and
counseling. The importance of timely
initiation of an FP method after childbirth,
miscarriage, or abortion will be emphasized
The client’s right to make a free and informed
choice regarding eventual family size and
fertility will be respected.
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Combined hormonal contraception
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Progestogen – only preparations
◦ The pill, patches, the vaginal ring
◦ Progestogen-only pills, injectables, subdermal implants
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Hormonal emergency contraception
Intrauterine contraception
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Barrier Methods
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Sterilization (Voluntary Surgical Contraception)
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◦ Copper intrauterine device (IUD), hormone-releasing
intrauterine system (IUS)
◦ Condoms, female barriers, coitus interruptus, natural
family planning
◦ Female sterilization, vasectomy
Method of contraception
Combined oral contraceptive pill
Progestogen – only pill
Depo – Provera ®
Implanon
Copper IUD
Mirena
Male condom
Diaphragm
Failure rate per
100 woman
years
0.1 – 1
1–3
0.1 – 2
0.1
1–2
0.5
2–5
1 – 15
Natural family planning
2–3
Vasectomy
0.02
Female sterilization
0.13
A)
B)
Lactational Amenorrhea Method (LAM or
Breastfeeding)
Fertility awareness-based method
1) Calendar Based Method
• Calendar based method
• Standard days method (SDM)
2) Symptoms Based Methods
• Ovulation method / cervical mucus method
• Basal Body Temperature (BBT) method
3) Withdrawal Method
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Helps a couple know which days they should
not have unprotected intercourse
For women with menstrual cycles between 26
and 32 days long
Couples who can avoid unprotected
intercourse from day 8-19
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Keeping a record of at least 6 menstrual
cycles.
Find the longest and shortest of the
menstrual cycle
Subtract 18 from the number of days in the
shortest cycle to find the first fertile day of a
current cycle. (e.g. 28-18=10days)
Subtract 11 from the number of days in the
longest cycle to find the last fertile day of a
cycle. (e.g. 30-11=19days)
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Preventing pregnancy by breast feeding
Mechanism of action: ovulation prevention
Very effective: 1-2 pregnancies / 100 women
in firs 6 months
No side effects or health risks
Health benefits for the baby
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Women who:
◦ Are fully or nearly fully breastfeeding
◦ Have not had return of menses
◦ Are less than 6 months postpartum
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Shift in BBT to identify
post ovulatory infertile
(safe) days
Take temperature every
morning before any
activity
Recorded daily on a
graph paper
Within twelve hours of
ovulation , the BBT will
rise (0.4 to 1 F) until start
of next cycle
Based Body Temperature
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Presence or absence of
cervical mucus
◦ Dry (safe) days
◦ Wet (fertile) days
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Note mucus for:
◦ Color (yellow, white,
clear, cloudy)
◦ Consistency (thick, sticky,
stretchy)
◦ Feel (dry, wet, slippery,
stretchy)
Cervico Mucus
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Condoms are commonly made of thin sheaths
of rubber (latex) or vinyl. They differ in, color,
lubrication, thickness, texture and addition of
spermicide.
Prevent sperm from gaining access to female
reproductive tract.
Prevent microorganisms (STIs) passing from
one partner to other.
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BENEFITS
No systemic side effects
Widely available
No prescription or medical assessment necessary
Only FP method that provides protection against
STIs
LIMITATIONS
Effectiveness depends on willingness to follow
instructions
User-dependent (require continued motivation
and use with each act of intercourse)
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Containing both estrogen and progestin
(COCs)
Prevents the release of the ovum or egg from
ovaries
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Highly effective when taken daily (0.1 to 1)
pregnancies per 100 women during the first
year of use)
Client can stop use
Fertility returns soon after stopping
Decrease menstrual flow (lighter, shorter
periods)
Decrease menstrual cramps
Protect against ovarian and endometrial
cancer
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Some nausea, dizziness, mild breast
tenderness, headaches or spotting may occur
Effectiveness may be lowered when certain
drugs are taken barbiturates, carbamazetine,
phenytoin and rifampicin
Rare serious side effects possible
Resupply must be readily and easily available
Do not protect against STIs (e.g., HBV,
HIV/AIDS)
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Women:
◦ Of any reproductive age or parity who want highly
effective protection against pregnancy (within first 5
days of the menstrual cycle or any time if the client is
not pregnant)
◦ Who are breastfeeding (6 months or more postpartum)
◦ Who are postpartum and are not breastfeeding (begin
after third week)
◦ Who are post abortion (start immediately or within 7
days)
◦ With severe menstrual cramping or with irregular
menses
◦ In need of emergency contraception
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Contains only progestin (single hormone)
Mechanism of action
◦ Inhabits ovulation
◦ Thickness cervical mucous
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Used less often in Pakistan than COCs
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Contains both estrogen
and progesterone
Mechanism of action:
preventing ovulation
Given every 1 month
Very effective at < 1
pregnancy / 100
women
Health benefits and
risk similar to COC
Combined injectable
contraceptive
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Only progestin:
◦ DMPA
◦ NET-EN
Mechanism of action:
preventing ovulation /
thickness cervical
mucous
Given
◦ DMPA – every 3 months
◦ mNet-EN - every 2
months
Very effective at < 1
pregnancy/100 women
Progestin injectable
contraceptive
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Very effective
Reversible
Do not affect breastfeeding
Few side effects
Protect against endometrial cancer and
fibroids
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Return to health clinic for an injection every 3
months (DMPA) or every 2 months (NET-EN)
Changes in menstrual bleeding patterns are
common
If using DMPA, return of fertility is
temporarily delayed, but does not decrease
fertility in the long term
If using DMPA, 50% of women will stop having
any bleeding by end of first year of use
PICs do not provide protection against STIs,
(e.g., HBV, HIV/AIDS).
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1)
2)
EC should be considered if unprotected
intercourse has occurred, if there has been
failure of a barrier method for example a
burst condom or if hormonal contraception
has been forgotten.
Hormonal emergency contraception: single
dose levonorgestrel 1.5mg within 72hours of
unprotected intercourse
IUD for emergency contraception: upto
5days of unprotected intercourse.
Intrauterine Contraceptive
Devices (IUCDs)
Copper
containing
IUCD
Hormone
releasing intra
uterine system
(Levonorgestr
el)
Copper T 380
A
Mirena
Multiload Cu
375
LNG - IUCD
Types of IUCDs
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Prevents Fertilization by:
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Changing endometrial lining
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Interfering with ability of sperm to pass
through uterine cavity
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Highly effective and economical
Does not interfere with intercourse
Long lasting (Multiload up to 5 years and CuT
up to 12 years)
Quick return of fertility after removal no
systemic effects
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Minor voluntary surgical procedure for
permanently terminating fertility in men
(vasectomy) and women (mini-laparotomy
and laparoscopy)
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Vasectomy (no-scalpel or incisional):
◦ By blocking the vas deferens, sperm are no longer
present in the ejaculate
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Minilaparotomy or laparoscopy:
◦ By blocking the fallopian tube (tying the cutting,
rings, clips or electrocautery) ovum is prevented
from meeting with sperm
BENEFITS
◦ Highly effective, Permanent
◦ Simple surgery usually performed under local
anesthesia
◦ No change in sexual functin
LIMITATIONS
◦ Must be considered permanent (not reversible)
◦ Client may regret later
◦ Short-term discomfort/pain following procedure