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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 healthcare and includes:
It is essential to obtain prior community acceptance of, and promote community participation in, any family planning programme if the programme is to succeed in that community.
Because family planning aims at improving the quality of life for everybody, every person, female or male, requires family planning education. Such education should ideally start during childhood and be given in the home by the parents. It is then continued at school and throughout the rest of the individual’s life.
Every person who is sexually active, or who probably will soon become sexually active, needs contraceptive counselling (i.e. information and advice about birth control). While the best time to advise a woman on contraception is before the first coitus, the antenatal and post-delivery periods are 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.
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 healthcare. 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.
Step 1: Discussion of the patient’s future reproductive career
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 partner and, where appropriate, other members of her family or friends.
Step 2: The patient’s choice of contraceptive method
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.
Step 3: Consideration of contraindications to the patient’s preferred method
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 proceed to step 4.
Step 4: Selection of the most appropriate alternative method of contraception
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.
Step 5: Counselling the patient once the contraceptive method has been chosen
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 local clinic is unable to deal satisfactorily with the patient’s problem. If family planning 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.
Oestrogen increases the risk of thombo-embolism during the puerperium and reduces milk production while lactation is being established. Combined pills should not be used in the first 3 months after delivery.
The most effective permanent contraceptive methods are female sterilization or male vasectomy. The most effective reversible methods are the intra-uterine contraceptive devices and progesterone implants.
Methods that are effective if carefully used are injectable and oral contraceptives. Condoms are less effective and if used for contraception require very careful use.
The tablets for postcoital contraception often cause nausea and vomiting, which reduces their effectiveness. These side effects are less with levonorgestrel (Norlevo and Escapelle) which contains no oestrogen. Therefore levonorgestrel (Norlevo and Escapelle) is a more reliable method and should be used if available. Norlevo and Escapelle as a single dose method is available in South Africa.
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, implants, 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.
The World Health Organisation (WHO) medical eligibility criteria for contraceptive use is also available on a 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:
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 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 healthcare workers.
The condom is the only contraceptive method that provides protection against HIV infection.
The most suitable methods for the following groups of patients 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 3 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.
Within 48 hours of birth but always as soon as possible, ideally within 15 minutes after completion of the third stage of labour. Although the expulsion rate is higher as compared to insertion 6 weeks postpartum, the method is immediately effective and loss to follow-up is ruled out.
If not inserted within 48 hours after birth 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.
You have delivered the fourth child of an unbooked 36-year-old patient. 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 intra-uterine contraceptive device, implant or injectable contraceptive 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 partner has other sexual partners, an implant would be indicated. A contra-indication for an implant will be a HAART regimen that contains efavirenz, rifampicin for TB and anti-epileptic drugs.
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 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 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 family planning clinic to her home is for follow-up. She also needs to know about postcoital contraception.
An intra-uterine contraceptive device or implant be the best method for her as she needs reliable contraception for a long time. An injectable contraceptive could be offered as a third choice as it would be a more reliable method than oral contraceptive pills.
Because she should only have her next child when she is fully grown up and able to take care of her children by herself.
No. A method that does not depend on her reliable and correct use would be more appropriate. Oral contraceptives are only reliable if taken every day.
Implants and injectable contraception are extremely safe and, therefore, appropriate methods for long-term use. These methods 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 schoolteacher 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.
An injectable such as Nur-Isterate is preferable, as the return to fertility may be quicker.
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.
There are 2 options:
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.
Yes, although the expulsion rate is higher as compared to insertion 6 weeks postpartum, the method is immediately effective and loss to follow-up is ruled out.