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Family planning is far more than simply birth control, and aims at improving the quality of life for everybody. Family planning is an important part of primary health care and includes:
While the best time to advise a woman on contraception is before the first coitus, the antenatal and postdelivery periods provide an excellent opportunity to provide contraceptive counselling. Some patients will ask you for contraceptive advice. However, you will often have to first motivate a patient to accept contraception before you can advise her about an appropriate method of contraception. All women should be offered contraceptive counselling after delivery.
A good way to motivate a patient to accept contraception is to discuss with her, or preferably with both her and her partner, the health and socio-economic effects further children could have on her and the rest of the family. Explain the immediate benefits of a smaller, well spaced family.
It is generally hopeless to try and promote contraception by itself. To gain individual and community support, family planning must be seen as part of total primary health care. A high perinatal or infant mortality rate in a community is likely to result in a rejection of contraception.
There are five important steps which should be followed:
Ideally a woman should consider and plan her family before her first pregnancy, just as she would have considered her professional career. Unfortunately in practice this hardly ever happens and many women only discuss their reproductive careers for the first time when they are already pregnant or after the birth of the infant. When planning her family the woman (or preferably the couple) should decide on:
Very often the patient will be unable or unwilling to make these decisions immediately after delivery. However, it is essential to discuss contraception with the patient so that she can plan her family. This should be done together with her husband and, where appropriate, other members of her family or friends.
The patient should always be asked which contraceptive method she would prefer as this will obviously be the method with which she is most likely to continue.
You must decide whether the patient’s choice of a contraceptive method is suitable, taking into consideration:
If the contraceptive efficiency of the preferred method is appropriate, if there are no contraindications to it, and if the patient is prepared to accept the possible side effects, then the method chosen by the patient should be used. Otherwise help her to choose the most appropriate alternative method.
The selection of the most suitable alternative method of contraception after delivery will depend on a number of factors including the patient’s wishes, her age, the risk of side effects and whether or not a very effective method of contraception is required.
Virtually every contraceptive method has its own side effects. It is a most important part of contraceptive counselling to explain the possible side effects to the patient. Expert family planning advice must be sought if the district hospital is unable to deal satisfactorily with the patient’s problem. If family planning method problems are not satisfactorily solved, the patient will probably stop using any form of contraception.
After delivery the reproductive career of each patient must be discussed with her in order to decide on the most appropriate method of family planning to be used.
Breastfeeding, spermicides alone, coitus interruptus and the ‘safe period’ are all very unreliable. All women should know about postcoital contraception.
Breastfeeding cannot be relied upon to provide postpartum contraception.
Contraceptive methods for use after delivery may be divided into very effective and less effective ones. Sterilisation, injectables, oral contraceptives and intra-uterine contraceptive devices are very effective. Condoms are less effective contraceptives.
The effectiveness of a contraceptive method is given as an index which indicates the number of women who would be expected to fall pregnant if 100 women used that method for one year. The ideal efficacy index is 0. The higher the index, the less effective is the method of contraception. The efficacy of the various contraceptive methods for use after delivery is shown in table 8-1.
The tablets for postcoital contraception often cause nausea and vomiting reduce their effectiveness. These side effects are less with Norlevo which contains no oestrogen. Therefore Norlevo is a more reliable method and should be used if available. Norlevo as a single dose method will soon be available in South Africa.
Female (Reality female condom)
*The safety of condoms depends on the reliability with which they are used.
The following are the common or important conditions where the various contraceptive methods should not be used:
A menstrual abnormality is a contraindication to any of the hormonal contraceptive methods (injectables, combined pill or progestogen-only pill) until the cause of the menstrual irregularity has been diagnosed. Thereafter, hormonal contraception may often be used to correct the menstrual irregularity. However, during the puerperium a previous history of menstrual irregularity before the pregnancy is not a contraindication to hormonal contraception.
If a woman has a medical complication, then a more detailed list of contraindications may be obtained from the standard reference books such as J Guillebaud, Contraception: Your questions answered. Fifth edition. London: Churchill Livingstone 2008.
The World Health Organisation (WHO) medical eligibility criteria for contraceptive use is also available on the WHO website (www.who.int/reproductive-health/publications/mec/).
Most contraceptive methods have side effects. Some side effects are unacceptable to a patient and will cause her to discontinue the particular method. However, in many instances side effects are mild or disappear with time. It is, therefore, very important to counsel a patient carefully about the side effects of the various contraceptive methods, and to determine whether she would find any of them unacceptable. At the same time the patient may be reassured that some side effects will most likely become less or disappear after a few months’ use of the method.
The major side effects of the various contraceptive methods used after delivery are:
Tubal ligation and vasectomy have no medical side effects and, therefore, should be highly recommended during counselling of patients who have completed their families. Menstrual irregularities are not a problem. However, about 5% of women later regret sterilisation.
With Nur-Isterate there is a quicker return to fertility, slightly less weight gain and a lower incidence of headaches and amenorrhoea than with Depo-Provera or Petogen.
Progesterone containing intra-uterine contraceptive devices (Mirena) have lesser side effects and reduce menstrual blood loss. These devices are expensive and not generally available in the public health sector.
If a couple have completed their family the contraceptive method of choice is tubal ligation or vasectomy.
Additional contraceptive precautions must be taken when the contraceptive effectiveness of an oral contraceptive may be impaired, e.g. diarrhoea or when taking antibiotics. There is no medical reason for stopping a hormonal method periodically to ‘give the body a rest’.
The main objective of all contraceptive methods is to prevent pregnancy. In developing countries pregnancy is a major cause of mortality and morbidity in women. Therefore, the prevention of pregnancy is a very important general health benefit of all contraceptives.
Various methods of contraception have a number of additional health benefits. Although these benefits are often important, they are not generally appreciated by many patients and health-care workers:
The condom is the only contraceptive method that provides protection against HIV infection.
The most suitable methods for the following groups of women are:
The puerperium is the most convenient time for the patient to have a bilateral tubal ligation performed.
Every effort should be made to provide facilities for tubal ligation during the puerperium for all patients who request sterilisation after delivery.
Remember that sperms may be present in the ejaculate for up to three months following vasectomy. Therefore, an additional contraceptive method must be used during this time.
The risk of cardiovascular disease increases markedly in women of 35 or more years of age who have one or more of the following risk factors:
Smoking is a risk factor for cardiovascular disease.
It should not be inserted before six weeks as the uterine cavity would not yet have returned to its normal size. At six weeks or more after delivery there is the lowest risk of:
Postpartum patients choosing this method must be discharged on an injectable contraceptive or progestogen-only pill until an intra-uterine contraceptive device has been inserted.
Insertion of an intra-uterine contraceptive device immediately after delivery may be considered if it is thought likely that a patient will not use another contraceptive methods and where sterilisation is not appropriate. However, the expulsion rate will be as high as 20%.
A 36-year-old patient has delivered her fourth child in a district hospital. All her children are alive and well. She is a smoker but is otherwise healthy. She has never used contraception.
Yes. Every sexually active person needs contraceptive counselling. This patient in particular needs counselling as she is at an increased risk of maternal and perinatal complications, should she fall pregnant again, because of her age and parity.
Tubal ligation or vasectomy would be the most appropriate method of contraception if she does not want further children. Should she not want sterilisation, either an injectable contraceptive or an intra-uterine contraceptive device would be the next best choice.
The most convenient time for the patient and her family is the day after delivery (postpartum sterilisation). Every effort should be made to provide facilities for postpartum sterilisation for all patients who request it.
Assessing the risk for pelvic inflammatory disease will determine which of the two methods to use. If the patient has a stable relationship, an intra-uterine contraceptive device may be more appropriate. However, if she or her husband (or boyfriend) has other sexual partners, an injectable contraceptive would be indicated.
The patient must insist that her partner wears a condom during sexual intercourse. This will reduce the risk of HIV infection.
A 15-year-old primigravida had a normal delivery the previous day in a district hospital. She has never used contraception. Her mother asks you for contraceptive advice for her daughter after delivery. The patient’s boyfriend has deserted her.
Yes, she will certainly need contraceptive counselling and should start on a contraceptive method before discharge from hospital. She needs to learn sexual responsibility and must be told where the nearest clinic to her home is for follow-up. She also needs to know about postcoital contraception.
An injectable contraceptive would probably be the best method for her as she needs reliable contraception for a long time.
Because she should only have her next child when she is much older and has a stable relationship.
No. A method which she is more likely to use correctly and reliably would be more appropriate. Oral contraceptives are only reliable if taken every day.
Injectable contraception is extremely safe and, therefore, is an appropriate method for long term use. This method will not reduce her future fertility.
You have just delivered the first infant of a healthy 32-year-old patient. In discussing contraception with her, she mentions that she is planning to fall pregnant again within a year after she stops breastfeeding. She is a school teacher and would like to continue her career after having two children.
Injectable contraception would not be appropriate as she plans her next pregnancy within a year, and there may be a delayed return to fertility.
Any of the injectables can be used (Depo Provera/Petogen or Nur-Isterate) as there is no proven advantage of the one above the others.
No. As she plans to breastfeed, she should be given a progestogen-only pill. Combined oral contraceptive pills may reduce milk production while breastfeeding is being established. Progestogen-only pills have no effect on breastfeeding.
A married primipara from a rural area has just been delivered in a district hospital. She has a stable relationship with her husband and they decide to have their next infant in five years time. The patient would like to have an intra-uterine contraceptive device inserted.
Yes, as the risk of developing pelvic inflammatory disease is low.
Six weeks or more after delivery as there is an increased risk of expulsion if the device is inserted earlier.
No. The risk of pregnancy is too high. She should use reliable contraception, such as injectable contraception or the progestogen-only pill, until the device is inserted.
The expulsion rate and, therefore, the risk of contraceptive failure is much higher if the device is inserted soon after delivery. Therefore, it would be far better if she were to return six weeks later for insertion of the device.