Effectiveness of Family Planning Methods

Module III: Family Planning
Learning Objectives
Medical Eligibility Criteria
Hormonal Methods and Drug Interactions
Family Planning Methods
Breaking Family Planning Barriers
53
Learning Objectives
By the end of this module, participants

should be able to:
List the various types of FP methods
Explain the benefits of FP
Describe the effectiveness of contraceptives
(perfect and typical use)
Demonstrate an understanding of the medical
eligibility criteria
Describe hormonal methods and drug interactions
Back to Module III Table of Contents
54
Definition (1)
Family Planning: The ability of individuals and

couples to anticipate and attain their desired
number of children, as well as the spacing and
timing of their births.*
Safer Pregnancy: The safer times and ways for
individuals to get pregnant
*Source: Working definition used by the WHO Department of Reproductive Health and Research
55
Benefits of Family Planning
Protects against unwanted pregnancies

Saves the lives of children by helping women space births
Helps men and women provide a better life for their families
Some FP methods have health benefits for their clients
▬ Some pills reduce menstrual flow, pre-menstrual syndrome, cancer risk
▬ Condoms prevent STIs, including HIV/AIDS
FP helps promote national development
56
Benefits of Family Planning for
HIV-Infected Clients
For women and couples with HIV:

Improves health/well-being of families
and communities
▬ spacing/limiting births
Prevents unintended
pregnancies, thus reducing:
▬ number of infants born
HIV-positive
▬ number of future orphans
57
Pregnancy Rates by FP Method
Spermicides
Female condom
Standard Days Method
Male condom
Oral contraceptives
DMPA
IUCD (TCu-380A) Rate during perfect use
Female sterilization
Rate during typical use
Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use
Source: CCP and WHO, 2007.

58
Comparing Effectiveness of FP Methods
More
effective How to make your method
Less than 1 more effective
pregnancy per Implants, IUCD, female sterilization:
100 women in
After procedure, little or nothing to do
1 year
or remember.
Implants IUCD Female Vasectomy: Use another method for

Sterilization Vasectomy first 3 months.
Injectables: Get repeat injections on time.

Lactational Amenorrhea Method (for 6
months): Breastfeed often, day and night.
Pills: Take a pill each day.
Injectables LAM Pills Patch Vaginal
Ring Patch, ring: Keep in place, change on time
Condoms, diaphragm: Use correctly

every time you have sex.
Fertility awareness-based methods:
Abstain or use condoms on fertile days.
Male Diaphragm* Female Fertility Awareness- Newest methods (Standard Days Method
Condoms Condoms Based Methods and Two Day Method) may be easier to
use.
Withdrawal, spermicides: Use

Less correctly every time you have sex.
effective
Withdrawal Spermicides* * Spermicides and diaphragms with
About 30
pregnancies per spermicide should not be used by
100 women in Source: CCP and WHO, 2007. women with HIV or at risk of HIV. 59
1 year 59
Medical Eligibility Criteria

60
WHO Medical Eligibility Criteria
When clinical judgment is

Category Description
available
Use the method under any

1 No restriction for use
circumstances
Benefits generally
2 Generally use the method
outweigh risks
Use of method not usually

Risks generally outweigh recommended, unless other
3
benefits methods are not
available/acceptable
4 Unacceptable health risk Method not to be used
Source: WHO, 2004.

61
WHO Eligibility Criteria
When clinical judgment is

Category
limited
1
Use the method
2
3
Do not use the method
4
Source: WHO, 2004.

62
WHO Eligibility Criteria: Examples
Medical Condition/ Contraceptive

Category
Characteristic Method
Uterine fibroids COCs 1
Anaemia IUCD 2
Breastfeeding a baby less

DMPA 3
than 6 weeks postpartum
Current
Hormonal implants 4
breast cancer
Source: WHO, 2004.

63
Medical Eligibility for Contraceptive Methods
for Clients with HIV and AIDS
Summary Chart Condition
ARV therapy
Contraceptive Method HIV-infected AIDS
NRTIs NNRTIs Ritonavir
DMPA 1 1 1 1 1
NET-EN 1 1 1 2 2
Implants 1 1 1 2 2
Oral contraceptives 1 1 1 2 3
initiation 2 3* 2/3* 2/3* 2/3*
IUCD
continuation 2 2 2 2 2
Condoms No restrictions; use is encouraged to prevent STI/HIV transmission.
ECPs No restrictions.
Source: WHO, 2004; updated 2008.

Sterilization No reasons to deny. Delay in case of acute HIV-related infection.
Can use if menstrual cycle is regular. Encourage to continue using condoms outside the fertile
FAB methods
window to prevent STI/HIV transmission.
Advise on the risk of transmission; exclusive breastfeeding reduces risk compared to mixed
LAM
feeding.
Spermicides and diaphragm Use is not recommended, may increase risk of HIV transmission/superinfection.
* Category 2 if client with AIDS is clinically well on ARV therapy; otherwise category 3. 64
Hormonal Methods and
Drug Interactions

65
Theoretical Concerns about
Hormonal Methods
For women with HIV:
ARVs may reduce method effectiveness or increase

side effects
Contraceptives may affect ARV efficacy
Hormonal methods may possibly affect
▬ infectivity
▬ disease progression
? ? ?
??
NOTE: More research is needed before reviewing clinical practices. 4
Source: Leitz, 2000; Piscitelli, 1996.

66
How ARVs Interact with COCs
May cause an increase or decrease of hormone levels

Some ARVs speed up liver metabolism and could lower
oestrogen blood levels; may reduce method
effectiveness
Not all ARV classes interact with contraceptive
hormones (e.g., NRTIs)
67
Interactions between COCs and PIs
Contraceptive
ARV levels
Protease inhibitors hormone levels
in blood
in blood
Nelfinavir (NFV) Ð No data
Ritonavir (RTV) Ð No data
Lopinavir (LPV)/Ritonavir
(RTV) Ð No data
Atazanavir (ATV) Ï No data
Indinavir (IDV) Ï No data
Saquinavir (SQV) No data No change
Source: WHO, 2004; Ouellet, 1998.

68
Interactions between COCs and NNRTIs
Non-nucleoside reverse Contraceptive ARV levels

hormone levels
transcriptase inhibitors in blood in blood
Nevirapine (NVP) Ð No change
Efavirenz (EVF or EFZ) Ï No change
teratogen
No significant interaction was found between ARV drugs

and progestin-only injectables, particularly DMPA.
Source: WHO, 2004; Cohn, 2005.

69
Ritonavir with COC
Evidence from WHO has shown that a ritonavir-boosted

ARV regimen reduces the oestrogen levels significantly
such that it may affect the effectiveness of the COC pill.
Thus, it is put at grade 3 – WHO MEC (2008).
70
Hormonal Contraceptive Use and HIV:
What Providers Should Do
Counsel clients that certain ARV drugs reduce blood

levels of contraceptive hormones, which in theory may
reduce method effectiveness (except DMPA).
When prescribing ARV drugs encourage correct and
consistent use of contraceptives and emphasize dual
method use.
Keep up to date with new technology
and additional information in policy
and guidelines.
71
72
Barrier methods
Oral contraceptive pills
Injectables
Implants
Intrauterine Contraceptive Devices (IUCD)
Voluntary Surgical Contraception (VSC) Kupanga Jamii Yako
Lactational Amenorrhea Method (LAM)

Fertility awareness-based methods, including Standard Days
Methods (SDM)

73
Barrier Methods
Male condoms
Female condom
Back to Family Planning Methods

74
Barrier Methods: Learning Objectives
Define male and female condoms

Describe the mechanism of action of condoms
Identify contraceptive and non-contraceptive benefits
of condoms
List limitations of condoms
Describe client instructions for use of condoms
75
Barrier Methods
These methods create a barrier that prevents the sperm

from gaining access to the upper reproductive tract,
preventing it from meeting the egg.
The most common barrier methods are the male and
female condoms.
Condoms offer the best protection against HIV and STI.
They also can prevent pregnancy and be used for dual
protection.
76
Condoms: Mechanism of Action
Prevent sperm from

gaining access to female
reproductive tract
Prevent STIs from

passing from one partner
to another (latex and
vinyl condoms only)
77
Use of Condoms by HIV-Infected Person
The rationale for promotion:

HIV-infected persons are still sexually active
Condom use helps stop transmission of HIV to other
partner
Condoms protect against STIs
Condoms protect from unintended pregnancy
Condoms prevent re-infection, which could increase the
“viral load” and the acquisition of new strains of HIV
78
The Male Condom
A thin sheath made of latex rubber designed to

fit over the man’s erect penis before intercourse
79
Male Condoms: Contraceptive Benefits
Effective immediately
Do not affect breastfeeding
Can be used as backup to other methods
No known method-related health risks
No known systemic side effects
Widely available
No prescription or medical assessment is required
Inexpensive (in the short term)
80
Male Condoms: Non-Contraceptive Benefits
Promote male involvement in family planning

The only family planning method that provides protection
against STIs (latex rubber and vinyl condoms only)
May prolong erection and time to ejaculation
May help prevent cervical cancer by preventing an STI
(Human Papilloma Virus infection) which is associated
with cervical cancer
81
Male Condoms: Limitations (1)
Moderately effective (3-14 pregnancies per 100 women

during the first year1).
Effectiveness as contraceptives depends on willingness
to follow instructions. Most effective when used correctly
and consistently.
User-dependent (requires continued motivation and use
with each act of intercourse).
May reduce sensitivity of penis.
Trussell et al. 1998.

82
Male Condoms: Limitations (2)
Disposal of used condoms may be a problem. If not

properly disposed of, may be a source of infection to
others, especially children.
Adequate storage must be available at client’s home.
Supplies must be readily available before intercourse
begins.
Resupply must be available.
83
Male Condoms: Need for
Additional Counselling
Couples:
Who need a highly effective method of contraception
For whom pregnancy would pose a serious health risk to the woman
Who are allergic to the materials from which condoms are made
Who want a long-term contraceptive method
Who want a method not related to intercourse
Not willing to use correctly and consistently with each act of
intercourse
Who have reservations about condoms
84
Male Condoms
Client Instructions (1)
Use a new condom every time you have intercourse.

Use of spermicides (with or without condoms) in the HIV setup is
strongly discouraged.
Do not use teeth, knife, scissors, or other sharp utensils to open
package.
The condom should be unrolled onto erect penis before penis
enters vagina, because pre-ejaculatory semen contains active sperm.
85
Male Condoms

If the condom does not have an enlarged end (reservoir
tip), about 1-2 cm should be left at the tip for the ejaculate.
While holding on to the base (ring) of the condom,
withdraw penis before losing erection. This prevents
condom from slipping off and spilling semen.
Dispose of used condoms by placing in a waste container,
in latrine, or burying.
86
Male Condoms
Keep an extra supply of condoms available. Do not store them in

a warm place or they will deteriorate and may leak during use.
Check date on condom package to ensure that it is not out of date.
Do not use a condom if the package is broken or the condom
appears damaged or brittle.
Do not use mineral oil, cooking oils, baby oil, or petroleum jelly
as lubricants for a condom. They damage condoms in seconds. If
lubrication is required, use saliva or vaginal secretions.
87
The Female Condom
88
Female Condom
Thin sheath of polyurethane

plastic with polyurethane
rings at either end. They
are inserted into the vagina
before intercourse.
Female condom
89
Female Condoms: Contraceptive Benefits
Do not affect breastfeeding
Do not interfere with intercourse (may be inserted up
to 8 hours before)
Can be used as backup to other methods
No method-related health risks
No systemic side effects
No prescription or medical assessment necessary
Controlled by the woman
90
Female Condoms:
Non-Contraceptive Benefits
:
Provide protection against STIs

May help prevent cervical cancer
91
Female Condoms: Limitations (1)
Moderately effective (5-21 pregnancies per 100 women during the

first year1)
Effectiveness as contraceptives depends on willingness to follow

instructions
User-dependent (require continued motivation and use with each act

of intercourse)
Trussell et al. 1998.
92
Female Condoms: Limitations (2)
Disposal of used condoms may be a problem
Adequate storage must be available at the client’s home
Supplies must be readily available before intercourse begins
Resupply must be available
Some users complain of irritating friction sounds when used
93
Female Condom: Who Can Use (1)
Women:
Who prefer not to use hormonal methods or cannot
use them
Who prefer not to use IUCDs
Who are breastfeeding and need contraception
Who want protection from STIs and whose partners
will not use male condoms
94
Female Condom: Who Can Use (2)
Couples:
Who need contraception immediately
Who need a temporary method while awaiting another
method (e.g., implants, IUCD, or voluntary sterilization)
Who need a backup method following missed pills
Who have intercourse infrequently
In which either partner has more than one sexual
partner (at high risk for STIs, including HBV, HPV, and
HIV/AIDS), even if using another method
95
Female Condoms: Who Should Not Use
Women:
With uterine prolapse (uterus protruding into the vagina)
With severe cystocoele or rectocele (bulging of the walls
of the bladder or rectum into the vagina)
With vaginal stenosis (narrowing of the vaginal canal)
With genital anomalies (e.g., septated vaginal canal)
96
Female Condom: Who May Need
Additional Counselling
Couples:
To whom pregnancy would pose a serious health risk
to the woman
Who are allergic to polyurethane
Who need a highly effective method of contraception
Who want a long-term contraceptive method
Who want a method not related to intercourse
Not willing to use correctly and consistently with each
act of intercourse
97
Female Condoms
Use a new condom every time you have intercourse.

The female condom can be inserted up to 8 hours before
intercourse.
Wash hands with soap and water.
Remove the condom from the package. DO NOT use teeth,
knife, scissors, or other sharp utensils to open package.
98
Female Condoms
DO NOT use the female condom with a male condom.

Keep an extra supply of condoms available. DO NOT
store them in a warm place or they will deteriorate and
may leak during use.
Check date on condom package to ensure that it is not
out of date.
DO NOT use a condom if the package is broken or the
condom appears damaged or brittle.
99
Condoms!
Condoms!
Condoms!
100
Exercise: Condom Lineup
Purpose: For participants to know the

steps in using condoms and to be at
ease presenting condoms to clients.
Instructions:
▬ Volunteer participants stand up.
▬ Each picks a strip of paper with a
condom step.
▬ All volunteers discuss the steps and
decide the sequence of the steps.
▬ Volunteers hold up the strips of paper
and line up according to the sequence
of the steps.
101
How to Use a Male Condom
n o p q r
Use a new Before any Unroll the After Throw the

condom for contact, pinch condom all the ejaculation, used condom
each sex act. tip of condom way to the hold the rim of away safely.
and place it on base of the the condom in
the erect penis penis. place and
with the rolled withdraw the
side out. Continue penis while it
If not pinching tip is still erect.
circumcised, while unrolling
pull foreskin condom to
back. base of penis.
102
How to Use a Female Condom
n o p q
Inner Inner
ring ring
Open
end
Outer
ring
• Gently insert the inner

• Make sure the • Squeeze the • Choose a ring into the vagina.
condom is well- inner ring at the comfortable position • Place the index finger
lubricated closed end of – squat, raise one inside the condom and
inside. condom. leg, sit, or lie down. push the inner ring up
• With the other hand, as far as it will go.
separate the outer • Make sure the outer
r lips of the vagina. ring is outside the
vagina and the condom
is not twisted.
• To remove, twist outer ring and pull gently. • Be sure that the penis
• Reuse is not recommended. enters the condom and
• Throw used condom away safely. stays inside it during
intercourse.
103
Resolution
I am going to devote myself to

promoting safer sex and condom use!
104
Dual Protection
Learning objectives:
Define dual protection
Describe dual method use
Explain the key strategies used in promoting dual
protection and educate/counsel clients about dual
protection
105
Dual Protection
Protection from unwanted pregnancy and STI/HIV

through:
Abstinence
Correct and consistent use of condoms
Dual-method use
▬ Use of condom and another contraceptive method
▬ Selective condom use plus another FP method (e.g., using the pill with
primary partner, but the pill plus condom with secondary partner)
Avoidance of risky sex

▬ Mutual monogamy between uninfected partners combined with contraceptive
method for those wishing to avoid pregnancy
▬ Delaying sexual debut (for young people)
DUAL METHOD USE IS A KEY COMPONENT OF DUAL PROTECTION!!!

Dual-method use addresses the limitations of single-method approach.
106
Dual Protection
Key strategies used in promoting dual protection:

Work with clients on partner communication and
condom negotiation skills
Involve men in counselling and education and
address their concerns about condoms
Eroticize condom use and make it acceptable to both
partners
Help women consider the ramifications of their
decisions (need for condom negotiation, possibility of
invoking violence)
Promote female condom as a viable method (where it
is available)
107
Dual Protection
Is particularly important for:

Sexually active adolescents
Men and women who put themselves and their partners
at risk because of their sexual behaviour
Commercial sex workers
Women or men who are at risk because of the high-risk
sexual behaviours of their partners
Individuals, or partners of individuals, who have an STI
and/or HIV
Sexually active people in settings where the prevalence
of STIs and/or HIV is high
108
Dual Protection for Young People
Is particularly important because youth:
Feel invulnerable and don’t believe it could happen

to them
Have multiple partners or partners with other
partners
Often do not use condoms or, if they do, use them
inconsistently or incorrectly
Easily succumb to peer/partner pressure
Experiment with drugs and alcohol
109
Dual Protection
Requirements
Acceptance by family planning providers of the condom
as an effective method of contraception
Assurance that condoms are available, affordable, and of
good quality
Counselling on the importance of correct and consistent
condom use
Consider limitations of single-method approach and
introduce aspect of dual-method use
110
Dual Methods
Condom added
Primary method for pregnancy prevention for HIV/STI prevention
1 +
Primary method for HIV/STI Emergency contraceptive pills if condom
and pregnancy prevention not used, or if it breaks or slips
2 OR
if needed
111
Resolution
I am going to devote
myself to promoting dual
protection, including dual
method use.
112
113
Hormonal Contraceptives
These methods contain synthetic hormones (oestrogen,

progestin, or a combination of both hormones), which
primarily work through prevention of ovulation or by
making the cervical mucus too thick for sperm penetration.
Hormonal methods do not protect against STIs, including
Hepatitis B and HIV.
They include:
– Oral contraceptive pill
– Injectables
– Implants
– Emergency contraception
114
Types of Oral Contraceptive Pills
Combined Oral Contraceptive Pills (COCs):

Pills which contain oestrogen and progestin
– for example, Chaguo Langu (Microgynon) and Nordette
Progestin-Only Pills (POPs) or Minipills:

Pills that contain only progestin (no oestrogen)
– for example, Microlut and Microvale

115
COCs: Mechanisms of Action
Suppress ovulation
Reduce sperm transportation

in upper genital tract
(fallopian tubes)
Change (thin) endometrium,

making implantation less
likely
Thicken cervical mucus
(preventing sperm
penetration)
116
117
COCs: Contraceptive Benefits
Highly effective when taken daily (0.1–8 pregnancies

per 100 women during the first year of use)
Pelvic examination not required prior to use
Do not interfere with intercourse
Few side effects
Convenient and easy to use
Client can stop use
Can be provided by trained nonmedical staff
118
Non-Contraceptive Health Benefits of
COCs: Overview
Reduced risk of: Improvement of:
Ovarian and endometrial Menstrual problems
cancer
Some gynecologic
Functional ovarian cysts conditions
Ectopic pregnancy
Symptomatic PID

119
Non-Contraceptive Health Benefits of COCs:
Menstrual and Other Improvements
Decreased amount of flow and days of bleeding

Reduced risk of anaemia
Decreased symptoms of dysmenorrhea
Decreased symptoms of endometriosis
Reduced symptoms of premenstrual syndrome
Source: Belsey, 1988; Davis, 2005; Davis, 2007.

120
COCs: Limitations
User-dependent
▬ Require continued motivation and daily use
Effectiveness may be lowered when certain drugs are

taken, e.g.:
▬ Epilepsy medication (phenytoin and barbiturates) or
▬ Tuberculosis medication (rifampin)
Can delay return to fertility

Forgetfulness increases failure
Resupply must be available
Do not protect against STIs (e.g., HPV, HIV/AIDS)
121
COCs: Common Side Effects
Nausea Breakthrough light bleeding

and spotting
Weight change
Amenorrhea
Dizziness
Mild headaches
Breast tenderness
Mood changes
Side effects are not experienced by all users. They are

not harmful but may be unpleasant.
Source: Ory, 1982; CCP and WHO, 2007.

122
COCs: Conditions Requiring Precautions
CONDITION RECOMMENDATION
High blood Initiate and resupply after careful evaluation
pressure of condition. Women with BP <140/90 can
use COCs.
Diabetes COCs can be used with uncomplicated
diabetes or diabetes of less than 20 years
duration.
Migraines Women who have migraine with aura and
women with migraine without aura but less
than 35 years of age should not use COCs.
Taking drugs for Help client choose another method.
epilepsy or
tuberculosis
123
Category 1 and 2 Examples (Not Inclusive):
Who Can Use COCs
WHO Category Conditions
Category 1 menarche to 39 years; endometriosis; endometrial or

ovarian cancer; uterine fibroids; family history of breast
cancer; varicose veins; irregular, heavy, or prolonged
bleeding; anaemia; STI/PID; hepatitis (chronic/carrier)
Category 2 ≥40 years; breastfeeding ≥6 months postpartum;

superficial thrombophlebitis; uncomplicated diabetes;
cervical cancer; unexplained vaginal bleeding;
undiagnosed breast mass

124
Who Should Not Use COCs
Category 3 breastfeeding between 6 weeks and 6 months postpartum;

non-breastfeeding <21 days postpartum; hypertension
(140–159/90–99); migraine without aura (<35
years/continue use); gall bladder disease; use of
rifampicin, rifabutin
Category 4 breastfeeding <6 weeks postpartum; hypertension

(≥160/≥100); migraines with aura; deep venous
thrombosis (history or acute); ischemic heart disease or
stroke; complicated diabetes; breast cancer; acute/flare
hepatitis; severe liver disease and most liver tumours

125
COC Use by Women with HIV
WHO Eligibility Criteria Women with HIV or AIDS can use

without restrictions
Condition Category
Women on ARVs other than ritonavir

HIV-infected 1 can use COCs safely
AIDS 1
Should not be used by women who
ARV therapy take ritonavir
(which does not contain
ritonavir)
2
Using low-dose COCs is appropriate
Ritonavir/
ritonavir- Dual-method use should be
boosted PIs 3 encouraged
(as part of ARV regimen)
Source: WHO, 2004, updated 2008; Sekar, 2008.

126
COCs: When to Initiate
Anytime provider is reasonably sure woman is not pregnant
First 5 days of menstrual cycle
After 5th day, use backup method for 7 days
Postpartum:
▬ Not breastfeeding: delay 3 weeks
▬ Breastfeeding: delay 6 months or until breastfeeding is discontinued
Source: WHO, 2004.

127
Key Counselling Points on COCs
COCs can be used by women of any age, whether or

not they have had children.
COCs can be started anytime it is reasonably certain a
woman is not pregnant, not only when she has a
period.
Spotting and nausea may occur, especially in the first
few months. These side effects are not dangerous and
generally lessen or stop in a few months.
Clients should have access to condoms to use as a
backup method for missed pills or for dual protection.
COCs DO NOT PROTECT AGAINST STI/HIV/AIDS
128
When to Return:
Warning Signs of COC Complications
Return immediately if experiencing ACHES:

Abdominal pain (sharp)
Chest pain (severe)
Headache (severe)
Eye problems (blurred vision, brief loss of vision)
Sharp leg pain
Advise to stop taking pills, use a backup method,

and return to the clinic immediately.
Source: Pathfinder International, 2006.
129
Progestin-Only Pills (POPs)
Progestin-only pills (POPs), unlike COCs, do not

contain any oestrogen.
130
Progestin-Only Pills (POPs)
Mechanism of action:
Thicken cervical mucus (make it hard for sperm
to penetrate)
Change endometrium (make implantation less
likely)
Partially inhibit ovulation (in 60% of cycles)
131
Who Can Use POPs
Women of any reproductive age or parity who:

Want to use this method of contraception
Cannot or should not take pills containing oestrogen
Are breastfeeding (POPs do not affect the amount or
quality of breast milk)
132
POP Use by Women with HIV

Condition Category
Women on ARVs other than ritonavir
HIV-infected 1 can use POPs safely
Should not be used by women who
AIDS 1
take ritonavir
ARV therapy
(which does not contain 2 Dual method use should be
ritonavir)
encouraged
Ritonavir/
ritonavir- Breastfeeding status provides
boosted PIs 3 additional protection from
(as part of ARV regimen) pregnancy
Source: WHO, 2004, updated 2008; Sekar, 2008.

133
Who Should Not Use POPs
Women who have the following conditions

(contraindications):
Current breast cancer: Most breast cancers are
hormone sensitive to oestrogen and progestin. Use
of these may accelerate the progression of tumours.
134
POPs: Advantages
Safe
Effective, especially for breastfeeding women
Easy to discontinue
Immediate return to fertility
Have beneficial non-contraceptive effects
135
POPs: Disadvantages
Require very strict pill taking schedule (must be

taken at the same time every day)
Incorrect use is common
Require resupply
Have common side effects
No protection against STIs/HIV
136
POPs: Possible Side Effects
More common: Less common:
Breakthrough bleeding Nausea

Headache
Spotting
Breast tenderness
Irregular cycles
Mood change
Weight gain
Acne
Amenorrhea
137
Key Counselling Points on POPs
POPs are usually used by women who have had a baby

and are breastfeeding.
POPs can be used by other women, such as women who
cannot use oestrogen (e.g., women with heart disease
and older women who smoke).
POPS are not as effective as COCs in preventing
pregnancy.
Counsel that irregular periods are common with POP
users, especially non-breastfeeding women. These
periods can range from normal periods to very light
bleeding, to none at all.
POPs DO NOT PREVENT STI/HIV/AIDS
138
Emergency Contraception
What Is Emergency
Contraception?
139
Safe ways to prevent pregnancy soon

after unprotected sex
Two options:
▬POP regimen
▬COC regimen
140
Emergency contraception (EC) is a safe and effective way to prevent

pregnancy after unprotected intercourse. It can be started up to five
days (120 hours) after unprotected intercourse.
EC may be necessary if:

A condom broke or slipped off, and ejaculation occurred inside the
vagina
A woman forgot to take birth control pills
A diaphragm or cap slipped out of place, and ejaculation occurred
inside the vagina
Sexual partners miscalculated the “safe” days
Withdrawal was not done in time
Sexual partners were not using any birth control
A person was forced to have unprotected vaginal sex, or was raped.
141
How to Use EC
Take as soon as possible
Will not cause abortion

5 days to use EC
May cause nausea and vomiting after unprotected sex
Next period may come a few days

earlier or later
142
Emergency Contraception Flow Chart
The effectiveness of emergency contraception is highest when taken within 12 hours of intercourse
and declines over time. Reasonable effectiveness continues for up to 120 hours (5 days).
Take anti-nausea medication (Meclizine hydrochloride)
One hour later take the first dose of the ECPs such as (1) tablet of Postinor or
(20) tablets of Microlut or (2) tablets of Eugynon or (4) tablets of Microgynon
Counsel to abstain or use condoms until next menstrual period
12 hours later repeat the same dose
Menstrual period within 21 days?
NO
YES Advise to see clinician
Counsel to start a contraceptive she will and have pregnancy test
use consistently and correctly
143
Mechanism of Action of ECPs
Mainly stops ovulation (release of egg from ovary)

Interferes with the movement of ovum and spermatozoa
in the fallopian tube
ECPs do not disrupt existing (established)
pregnancy and they are not effective once
the zygote is attached to the uterus.
144
Uses of ECPs for HIV-Positive Women
As a backup method to unprotected sex

Therefore, tell your HIV-positive patients about when
to use emergency contraception and where to obtain
emergency contraceptives.
145
ECPs Key Counselling Points
Emergency Contraceptive Pills should not be used as a

regular contraceptive method.
ECPs will not cause abortion in pregnancy.
Tell clients at routine family planning visits that ECPs are
available at your facility. Ask them to share this
information with their friends and family members.
Providers should think of ECP if they see victims of rape.
▬ Given within 120 hours of the assault, ECPs can ease some of
the trauma of sexual assault by offering a chance of preventing
pregnancy.
ECPs DO NOT PROTECT AGAINST STIS/HIV/AIDS

146
Injectable Hormonal Contraceptive Methods
DMPA or Depo Provera

NET-EN or Noristerat

147
DMPA: Mechanisms of Action
Suppress ovulation
(release of eggs)
Decrease tubal motility
Change endometrium
Thicken cervical mucus

(to prevent sperm from
going into uterus)
148
DMPA checklist
149
Characteristics of DMPA:
Advantages
Safe Can be provided outside

of clinics
Highly effective
Requires no action at
Easy to use time of intercourse
Long acting Use can be private
Reversible Has no effect on lactation
Can be discontinued Has non-contraceptive
without provider’s health benefits
help
150
Non-Contraceptive Health Benefits
DMPA use may reduce:
Risk of endometrial cancer
Risk of ectopic pregnancy
Risk of symptomatic pelvic inflammatory disease
Uterine fibroids
Frequency and severity of sickle cell crises
Symptoms of endometriosis

151
Disadvantages
Causes side effects, particularly menstrual

changes
Action cannot be stopped immediately
Causes delay in return to fertility
Provides no protection against STIs/HIV
152
DMPA – Common Side Effects
Menstrual changes
▬ prolonged or heavy bleeding
▬ irregular bleeding or spotting
▬ amenorrhea (absence of menses)
Weight gain
Headaches, dizziness, changes in mood and

sex drive
One third of users discontinue during the first

year because of side effects.
Source: WHO, 1983.

153
DMPA – Return to Fertility
Does not permanently reduce fertility.

Length of time DMPA was used makes no difference.
Return to fertility depends on how fast woman fully
metabolizes DMPA.
▬ On average, it takes 9 to 10 months for women to become
pregnant after their last injection.
Source: Pardthaisong, 1984; Schwallie, 1974.

154
Infant Exposure to DMPA
through Breastfeeding
DMPA has no effect on:

▬ onset or duration of lactation
▬ quantity or quality of breast milk
▬ health and development of infant
When to initiate:
▬ after child is 6 weeks old (preferred)
Source: Koetsawang, 1987; WHO Task Force for Epidemiological Research on Reproductive Health, 1994;
WHO, 2004. 155
Effect of DMPA on Bone Density
DMPA users have lower bone density than

non-users
Women initiating use as adults regain most
lost bone
Long-term effect in adolescents is unknown
▬ Concern that osteoporosis may develop later
▬ Generally acceptable to use
Source: Cromer, 1996; Cundy, 1994; WHO, 2004.

156
Who Can Use DMPA
WHO
Conditions
Category
Category 1 heavy smoking, breastfeeding after

six weeks postpartum, thyroid disorders,
severe dysmenorrhea, uterine fibroids, STIs/PID, use
of rifampicin or rifabutin, anticonvulsants, or any type
of ARV drug
Category 2 ≤18 years, adequately controlled hypertension,

uncomplicated diabetes, gall-bladder disease

157
Who Should Not Use DMPA
WHO
Conditions
Category
Category 3 breastfeeding before 6 weeks postpartum, severe

hypertension (≥160/≥100), vascular disease, acute
DVT/PE, current or history of ischemic heart disease
or stroke, complicated diabetes, severe liver disease
and most liver tumours
Category 4 current breast cancer

158
DMPA Use by Women with HIV

Condition Category Nevirapine reduces blood progestin
level by ~20%
HIV-infected 1 DMPA dose provides wide margin of
effectiveness
AIDS 1 On-time injections emphasized
ARV therapy Dual-method use should be

1 encouraged
Source: WHO, 2004, updated 2008; Mildvan, 2002; Said, 1986.

159
How to Take DMPA:
When to Initiate
Any time during menstrual cycle if provider is
reasonably sure woman is not pregnant
Postpartum:
▬ not breastfeeding: immediately
▬ breastfeeding: delay 6 weeks
Postabortion: immediately
Source: WHO, 2004.

160
Management of DMPA Side Effects:
Counselling about Bleeding
Counselling is the most important tool

for managing bleeding irregularities.
Before first injection, counsel that bleeding
changes are normal and expected.
Provide ongoing counseling and reassurance.
If client is concerned or bleeding is severe,
treatment or discontinuation may be
necessary.
161
Treatment of Bleeding
Treatment options:
Combined oral contraceptives (COCs)

for 7 to 21 days
Ibuprofen (800 mg 3 times/day for 5 days)
With very heavy bleeding, rule out pregnancy

or gynecological problems (uterine evacuation
not indicated)
Iron supplements can help prevent anaemia.

Source: CCP and WHO, 2007; WHO, 2004.
162
Amenorrhea
Medical treatment not required

If no reason to suspect pregnancy, counsel
and reassure that amenorrhea is normal
Pregnancy may need to be ruled out in
some cases
163
Counseling about DMPA
Factors for clients to consider:

Other available contraceptive options
Characteristics (advantages and disadvantages)
Side effects, including menstrual changes
Timing of return to fertility
Need for regular, timely injections
164
Counselling about DMPA
continued ...
Messages after choosing DMPA:

Do not massage injection site
Expect bleeding 12–15 days
after injection
Return with problems or
concerns
No protection from STIs/HIV
Return for re-injection every 13 weeks
(can be up to 2 weeks early or 4 weeks late).
Back up needed after seven days.
165
Implants
Back to Family Planning Methods 166

Subdermal Implants
Progestin-filled rods or capsules that

are inserted under the skin
Norplant: 6-capsule system,
effective for 5 years
Second generation implants:
▬ Jadelle 2-rod system,
▬ Implanon 1-rod system,
▬ Sino-implant (II) 2-rod system, effective
for 5 years
Mechanism of action similar to
injectables
167
Implants – Characteristics
Advantages Disadvantages
Safe, 99.95% effective, easy Have common side effects
to use, reversible
Cannot be initiated/
Can be used by breastfeeding discontinued without
women provider’s help
Offer health benefits, such as Provide no protection from
reducing risk of symptomatic STIs/HIV
PID and anaemia
Source: Hatcher, 2004; WHO, 2004; CCP and WHO, 2007.

168
Implants – Side Effects
First several months:

Light bleeding/spotting, prolonged irregular bleeding, infrequent
bleeding, amenorrhea
After one year:

Light bleeding for fewer days, irregular bleeding, infrequent
bleeding, amenorrhea
Other side effects: e.g., nausea, headaches, breast

tenderness, weight change, abdominal pain
▬ Less common than with progestin-only injectables
▬ Diminish after the first few months
Source: Shoupe, 1991; CCP and WHO, 2007.

169
Who Can Use Implants
WHO
Conditions
Category
Category 1 breastfeeding after 6 weeks postpartum, heavy smoking,

complicated valvular heart disease, endometriosis,
endometrial or ovarian cancer, thyroid disorders
Category 2 blood pressure ≥160/100, history of DVT/PE, diabetes with

vascular complications, heavy or prolonged vaginal bleeding
patterns, multiple risk factors for CVD

170
Category 3 and 4:
Who Should Not Use Implants
WHO
Category Conditions
Category 3 breastfeeding before 6 weeks postpartum, acute DVT/PE,

unexplained vaginal bleeding, history of breast cancer,
severe liver disease and most liver tumours, systemic lupus
disease
continuation only: ischemic heart disease, stroke, migraine
with aura
Category 4 current breast cancer

171
Implant Use by Women with HIV
Women with HIV or AIDS can use

WHO Eligibility Criteria without restrictions
Condition Category Some ARV drugs reduce blood
progestin level
HIV-infected 1 Efficacy is not affected because
implants provide consistent dose of
hormone over time
AIDS 1
Dual-method use should be
ARV therapy encouraged
2
Source: WHO, 2004, updated 2008; Mildvan, 2002.

172
Key Counselling Points about Implants
Implants are effective in preventing pregnancy!
Irregular menses and vaginal bleeding are common
Implants can be removed by any trained health provider
Women with HIV can use implants while on ARV therapy
IMPLANTS DO NOT PROTECT AGAINST STI/HIV/AIDS
173
Intrauterine Contraceptive Devices (IUCDs)

174
Types of IUCDs
Most common:
▬ T-shaped, copper bands on
plastic stem/arms
Inserted in uterus through Copper T-380A

vagina and cervical opening
Strings:
▬ Assure IUCD is in place; facilitate removal
Most common copper IUCD: TCu-380A

Less common: hormonal IUCDs
175
Mechanism of Action of Copper IUCDs
Prevent fertilization by:

Impairing the viability of the sperm
Interfering with sperm movement
Source: Ortiz, 1996.

176
177
IUCD Use by Women with HIV
Safe for majority of women

WHO Eligibility Criteria
with HIV
Category Initiation not recommended if

Condition woman has AIDS and is not on
Initiate Continue ARV therapy
Dual-method use should be
HIV-infected 2 2 encouraged
AIDS 3 2
(without ARVs)
ARV therapy 2 2
(clinically well)

178
Who Can Use Copper IUCDs
Category 1 ≥20 years, hypertension, deep venous thrombosis,

ischemic heart disease, migraine headaches, cervical
ectopy, breast disease (including breast cancer)
Category 2 menarche to <20 years, nulliparous, heavy or prolonged

bleeding, severe dysmenorrhea, endometriosis, anaemia,
high risk of HIV

179
Who Should Not Use Copper IUCDs
Category 3 48 hours to <4 weeks postpartum, ovarian cancer/if

initiating use, high individual risk of STIs, AIDS (no ARV
treatment or not well on ARVs)
Category 4 pregnancy, postpartum/postabortion sepsis, unexplained

vaginal bleeding (prior to eval.), uterine fibroids with cavity
distortion, current PID, purulent cervicitis, endometrial
cancer, cervical cancer, or pelvic TB/if initiating use

180
Relationship of IUCD and HIV
No increase in infection-related complications noted in

HIV-positive women
No increase in cervical HIV shedding (4 months after
IUCD insertion)
Increased menstrual flow with non-progesterone
containing IUCDs. This may increase risk of anaemia
and possibility of HIV transmission
Not recommended for HIV-positive women with:
▬ Recent (within 3 months) STI
▬ Recurrent pelvic infection
▬ Risk of STI
181
Characteristics of Copper IUCDs:
Advantages
Highly effective and very safe

Easy to use
Long lasting
Easily reversible
Quick return to fertility
No systemic effects
Complications are rare

182
Characteristics of Copper IUCDs:
Disadvantages
Side effects, including cramping and increased

or prolonged bleeding
Rare complications include perforation and
pelvic inflammatory disease
Method failure can lead to ectopic pregnancy
(extremely rare)
Insertion and removal require trained provider
No STI/HIV protection

183
Copper IUCDs – Common Side Effects
Cramping and increased or

prolonged menstrual bleeding
Possible bleeding between

menstrual periods
Side effects are most common during the

first 3 months.
Source: CCP and WHO, 2007; Larsson, 1993; DeMaeyer, 1989; WHO, 2004; WHO Special Programme
of Research Development and Research Training in Human Reproduction, 1997. 184
IUCDs – Pelvic Inflammatory Disease (PID)
PID is an infection of a woman’s upper genital tract.

Risk of PID in IUCD users:
Low overall
▬ Risk of PID attributable to IUCD is 0.15% to 0.30%
Higher during first 20 days after insertion

Due mostly to presence of gonorrhea or chlamydia at time
of insertion
Similar to risk of PID in women with gonorrhea and
chlamydia who are not using IUCD
Source: Shelton, 2001. 185

IUCDs – Reducing the Risk of PID
Do not insert IUCD if:

▬ at high individual risk of STIs, or
▬ clinical symptoms and signs of an STI are present
Counsel about risk of PID

Follow infection prevention procedures during insertion
Recommend follow-up visit at 3 to 6 weeks to check for
infection
▬ Return immediately if any symptoms of PID develop
Source: WHO, 2004. 186

Timing of IUCD Insertion
Interval insertion
▬ Anytime during menstrual cycle if woman is not pregnant
Postpartum insertion
▬ Immediately after vaginal or cesarean delivery if no infection or
bleeding (within 48 hours or delay 4 to 6 weeks)
Insertions after abortion

▬ Immediately if no infection
Source: WHO, 2004

187
IUCD Counselling Topics
Characteristics of IUCDs
Effectiveness and how IUCDs work
Common side effects
Client’s risk of STIs
Insertion and removal procedures
Instructions for use and follow-up visit (including
signs of complications that require immediate return
to the clinic)
188
Counselling about IUCD Side Effects:
What to Expect
During insertion:
Some pain and cramping
First few days:

Light bleeding and mild cramping
First few months:

Heavier and/or prolonged menstrual bleeding
Menstrual cramping
Spotting between periods

189
IUCD Use and Follow-up
Teach client how to check for strings:

▬ With clean fingers
▬ After each menses
(Expulsion most likely in first 6 months)
Schedule follow-up visit at

▬ 3 to 6 weeks
Counsel to return immediately if any signs of

complications
Source: CCP and WHO, 2007; WHO, 2004.

190
Signs of Possible IUCD Complications
Advise to return immediately if experiencing:
Bleeding and severe abdominal cramping

3 to 5 days post-insertion perforation
Irregular bleeding or pain every cycle
partial expulsion, perforation
Fever, unusual vaginal discharge, low abdominal
pain infection
Missing IUCD strings, missed period

expulsion, pregnancy

191
Voluntary Surgical Contraception
Includes
▬Female sterilization
▬Male sterilization
Is intended to provide permanent

contraception

192
Female Sterilization
Female sterilization is a safe,

highly effective, relatively
simple surgical means of
contraception
It can usually be provided in
an outpatient setting
It is intended to be
permanent
193
Method-specific characteristics and considerations

Convenience/Timing:
Female sterilization is immediately effective, coitally
independent, and does not require routine follow-up. It
can be provided safely under light sedation in an
outpatient facility:
▬ Postpartum,
▬ Postabortion, or
▬ As an interval procedure (unrelated to a pregnancy)
The postpartum and postabortion periods are good times

to provide sterilization, as it is then technically easier, less
expensive, and more convenient for many clients
194

Effectiveness:
Female sterilization is highly effective. Risk of failure
(pregnancy), while very low, persists after the procedure,
does not diminish with time, and is higher in younger
women.
Cumulative pregnancy rates of 5.5/1000 procedures at
one year, 13/1000 at five years, and 18.5/1000 at ten
years have been reported;
One-third of such uncommon pregnancies are ectopic.
195

Safety:
Female sterilization is safe, with few medical restrictions.
Death is rare: estimated at 5/100,000 in developing
countries (usually related to general anaesthesia).
Overall complication rates are generally low, estimated
to be between 9–16/1000 procedures.
The use of mini-laparotomy with local anaesthesia and
light sedation has allowed wider provision of services.
196

HIV/AIDS:
Female sterilization does not protect against HIV
infection. Being HIV-positive is not a reason to be
denied sterilization.
A woman with AIDS who is clinically stable may receive
sterilization in settings with experienced staff and the
needed equipment and support.
197

Regret:
Most women who choose sterilization do not regret their
decision.
There are clear correlates of subsequent regret, however:

young age, marital instability, decisions made in the
absence of other long-term options, and decisions made
under pressure.
Thus pre-sterilization counselling is critical.
198
Female Sterilization (1)

Counselling:
Free and informed choice calls for “two-way” counselling,
which should address:
Sterilization’s intended permanence
The availability and characteristics of alternative methods
The client’s reasons for her choice
199
Female Sterilization (2)

Screening and discussion of risk indicators for regret;
details of the procedure; the possibility of failure
Younger women may need extra time to consider their
future life goals and other options for long-term
contraception, such as implants or the IUCD.
200
Vasectomy
Vasectomy is a very safe,

convenient, highly effective,
and simple surgical form of
contraception for men
It is provided under local
anaesthesia in an outpatient
setting
It is intended to be permanent
201
Vasectomy

Effectiveness:
Vasectomy is highly effective, comparable to female sterilization and
to long-term, reversible female methods such as implants and IUCDs.
Vasectomy is not effective immediately, however. WHO recommends
that the couple use alternative contraception for 3 months after the
procedure.
Risk of failure (pregnancy) is commonly quoted as from 2/1000 to
4/1000, but failures rates as high as 3–5% have been reported.
Failure may be due to client behaviour (when alternative
contraception is not used after the procedure) or may be due to
technical failure from the procedure.
202
Vasectomy

Safety:
Vasectomy is very safe, with few medical restrictions.
Major morbidity and mortality is rare and adverse long-term effects
have not been found.
Minor complications such as post-operative infection,
bleeding/hematoma formation, and short- or long-term pain occur at
reported rates of 5–10%.
HIV/AIDS:
Vasectomy does not protect against HIV infection.
Being HIV-positive is not a reason to be denied vasectomy.
A man with AIDS who is clinically stable may also receive vasectomy.
203
Vasectomy

Regret:
Most men who choose vasectomy do not regret their decision.
Correlates of subsequent regret include young age, marital instability,
and decisions made under financial or other pressure.
Counselling:
Address fears (e.g., about post-procedure sexual functioning or pain)
Correct myths (e.g., “vasectomy equals castration,” or “it makes you
weak”).
Emphasize that vasectomy does not protect against STIs/HIV.
Advise that vasectomy does not take effect immediately after the
procedure, hence alternative contraception must be used.
204
Medical Eligibility for VSC
DEFINITIONS
A= Accept: There is no medical reason to deny sterilization to a
person with this condition.
C= Caution: The procedure is normally conducted in a routine
setting, but with extra preparation and precautions.
D= Delay: The procedure is delayed until the condition is evaluated
and/or corrected. Alternative temporary methods of contraception
should be provided.
S= Special: The procedure should be undertaken in a setting with
an experienced surgeon and staff, equipment needed to provide
general anaesthesia, and other back-up medical support.
205
Medical Eligibility for VSC
Sterilization procedures should only be

performed by well-trained providers in
appropriate clinical settings using proper
equipment and supplies.
The following classification of conditions in the
four different categories is based on an in-depth
review of the epidemiological and clinical
evidence relevant to medical eligibility.
206
Proceed with Caution or Delay in the
Following Situations
Source: FAMILY PLANNING GUIDELINES FOR SERVICE PROVIDERS, March 2005. 207
Source: FAMILY PLANNING GUIDELINES FOR SERVICE PROVIDERS, March 2005 209
Management of Common Side Effects in VSC
Lactational Amenorrhea Method and
Infant Feeding Options

211
Lactational Amenorrhea Method
Temporary contraceptive option

Used by postpartum women who:
▬Are less than six months
postpartum
▬Are fully or nearly fully
breastfeeding
▬Have no menses
Safe, convenient, effective
Source: Hatcher, 2004.

212
Characteristics of LAM:
Advantages
Universally available
At least 98% effective; no side effects
Begins immediately postpartum
Health benefits for mother and child
No direct cost for family planning or feeding
the baby
No commodities/supplies required
Bridge to other contraceptives
213
Characteristics of LAM:
Disadvantages
Breastfeeding pattern may be difficult to maintain
No STI or HIV protection
Risk of HIV transmission to baby
Duration of method limited
Only useful for breastfeeding women
214
Recommended Breastfeeding Behaviors
A mother should breastfeed:

Soon after delivery
Without supplementation up to
six months
Frequently, upon request, not
on schedule
Without long intervals between
feeds both day and night
Without pacifiers or bottles
215
LAM Use by Women with HIV
Advise that children can become infected

▬ Risk of acquisition through breast milk ~16%
Exclusive breastfeeding during first 6 months may

reduce risk of acquisition by infant (compared to mixed
feeding)
Exclusive use of formula or other substitutes eliminates
risk of transmission through breast milk (often not
possible)
Source: WHO, 2004; Nduati, 2000; De Cock, 2000; WHO, 2006.

216
Factors That Increase Transmission of
HIV to Infant During Breastfeeding
High maternal viral load
Duration of breastfeeding
Mixed feeding
Breast abscesses, nipple fissures, mastitis
Poor maternal nutrition status
Infant oral sores
Source: WHO, 2004.

217
Infant Feeding Options for
Women with HIV
Up to six months:
Exclusive breastfeeding
OR
Replacement feeding
▬ Expressed, heat-treated breast milk
▬ Commercial infant formula
▬ Breastfeeding by an HIV-negative wet nurse
▬ Breast-milk banks

Infant Feeding Options for
Women with HIV
Beyond six months:

Switch to replacement feeding if acceptable,
feasible, affordable, sustainable, safe (AFASS)
If not AFASS, continue breastfeeding along with
complementary foods
All breastfeeding should stop if adequate and
safe diet without breast milk can be provided
If a child is known to have HIV, the mother should

be strongly encouraged to continue breastfeeding.
Summary of Contraceptive Choices
Use two methods concurrently

(condoms plus another contraceptive method)
Use one method and understand its limitations
(prevent pregnancy versus prevent transmission)
▬ Effective pregnancy prevention but no STI/HIV protection
▬ Condoms protect from STIs/HIV but typically are less effective
preventing pregnancy than some other methods
Use no method and abstain from sexual

intercourse
220
Contraceptive Options for Women and
Couples with HIV
Fertility awareness-based methods include:

▬ Cervical Mucus [Billings]
▬ Basal Body Temperature [BBT]
▬ Standard Days Method [SDM]
▬ Symptothermal Method
▬ Calendar [Rhythm Method]
221
Fertility Awareness-Based Methods
Identify fertile window of the menstrual cycle

▬ Includes several days before ovulation and one day after
▬ Timing of ovulation varies from woman to woman and may vary
from cycle to cycle
Methods use different means to identify the window
▬ Observe fertility signs (symptothermal method, cervical mucus
method)
▬ Monitor cycle days (calendar method, standard days method)
Abstinence or barrier methods should be used

during the fertile time
Pregnancy rates:
▬ Perfect use 1% to 9%; typical use up to 25%
Source: CCP and WHO, 2007. Back to Family Planning Methods 222
Standard Days Method (SDM)
SDM users rely on CycleBeads to:

▬Track the days of their cycle
▬Identify when they may be fertile so
they can avoid sex or use condoms
Appropriate for women with regular cycles

between 26 and 32 days long
▬Fertile window of shortest and longest cycles
combined into one longer window (days 8–19 of
the cycle)
223
Characteristics of SDM
Effectiveness is similar to barrier methods:

▬ Correct use, 95% effective
▬ Typical use, 88% effective
Low cost; no resupply needed; requires partner

cooperation; no STI protection
For couples who desire children, SDM can be used

to plan which days to have sex
224
FAB-Method Use by Women with HIV
Women who are HIV-positive with or without AIDS

and those on ARV therapy:
Can use without restrictions
(SDM and calendar method
rely on regular menstrual
cycles)
Should be encouraged to
use condoms
If the client does not want more children, other methods

that are less client-dependent should be considered.
Source: WHO, 2004.
225

226
FP providers are now trying to break through the

barriers that have prevented women from
receiving services in the past
These barriers are
▬Age
▬Parity
(number of children)
▬Menses (monthly periods)
227
Age-Parity-Menses: (A-P-M)
Clients do not get FP because some providers, mistakenly,

think:
▬ The woman is too young or too old
▬ The woman has never had a child or has too few children
▬ The woman is not having her monthly period at that time
Remember that it is a client’s right to get FP if he or she

wants and if there is no danger in his or her obtaining it
Remember the abbreviation A-P-M to increase your
awareness of these unnecessary barriers
228
Unmet RH Needs of Youth
Evidence:
High STI/HIV rates
Unintended pregnancy
Mortality/morbidity from unsafe abortion
Causes include lack of:

Information/education/ communication skills
Access to youth-friendly RH services
Source: Ross, 2002. 229

Don’t Be an A-P-M Barrier
No missed opportunities!
Dual protection
Condoms
Condoms
Condoms!
Emergency contraception
230
HIV and Contraception
Have we said that HIV-positive

women cannot use a particular
modern method of contraception?
No! No!! No!!!

They can use virtually any method,
but remember,
DUAL PROTECTION is usually
indicated to prevent HIV and
pregnancy.
231
Resolution (1)
I am going to inform
patients/clients at the HIV clinic
about all methods of family
planning and help them make an
informed choice!
232
Resolution (2)
I am going to refer my
clients/patients who
request services that I
cannot provide! My
patient/client’s informed
choice must be respected!
233
Referrals
Family Planning
Clinic
234

Effectiveness of Family Planning Methods

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Module III: Family Planning

By the end of this module, participants

Family Planning: The ability of individuals and

 Protects against unwanted pregnancies

 FP helps promote national development

For women and couples with HIV:

Source: CCP and WHO, 2007.

Implants IUCD Female Vasectomy: Use another method for

Injectables: Get repeat injections on time.

Condoms, diaphragm: Use correctly

Withdrawal, spermicides: Use

Back to Module III Table of Contents

When clinical judgment is

Use the method under any

Use of method not usually

4 Unacceptable health risk Method not to be used

Source: WHO, 2004.

When clinical judgment is

Source: WHO, 2004.

Medical Condition/ Contraceptive

Uterine fibroids COCs 1

Breastfeeding a baby less

Source: WHO, 2004.

Source: WHO, 2004; updated 2008.

Back to Module III Table of Contents

 ARVs may reduce method effectiveness or increase

NOTE: More research is needed before reviewing clinical practices. 4

Source: Leitz, 2000; Piscitelli, 1996.

 May cause an increase or decrease of hormone levels

Nelfinavir (NFV) Ð No data

Ritonavir (RTV) Ð No data

Atazanavir (ATV) Ï No data

Indinavir (IDV) Ï No data

Saquinavir (SQV) No data No change

Source: WHO, 2004; Ouellet, 1998.

Non-nucleoside reverse Contraceptive ARV levels

Nevirapine (NVP) Ð No change

Efavirenz (EVF or EFZ) Ï No change

No significant interaction was found between ARV drugs

Source: WHO, 2004; Cohn, 2005.

 Evidence from WHO has shown that a ritonavir-boosted

 Counsel clients that certain ARV drugs reduce blood

 Lactational Amenorrhea Method (LAM)

Back to Module III Table of Contents

Back to Family Planning Methods

 Define male and female condoms

 These methods create a barrier that prevents the sperm

Prevent sperm from

Prevent STIs from

The rationale for promotion:

A thin sheath made of latex rubber designed to

 Promote male involvement in family planning

 Moderately effective (3-14 pregnancies per 100 women

Trussell et al. 1998.

 Disposal of used condoms may be a problem. If not

Client Instructions (1)

 Use a new condom every time you have intercourse.

Client Instructions (2)

Client Instructions (3)

 Keep an extra supply of condoms available. Do not store them in

 Thin sheath of polyurethane

 Provide protection against STIs

 Moderately effective (5-21 pregnancies per 100 women during the

 Effectiveness as contraceptives depends on willingness to follow

Protects against unwanted pregnancies

FP helps promote national development

ARVs may reduce method effectiveness or increase

May cause an increase or decrease of hormone levels

Evidence from WHO has shown that a ritonavir-boosted

Counsel clients that certain ARV drugs reduce blood

Lactational Amenorrhea Method (LAM)

Define male and female condoms

These methods create a barrier that prevents the sperm

Promote male involvement in family planning

Moderately effective (3-14 pregnancies per 100 women

Disposal of used condoms may be a problem. If not

Use a new condom every time you have intercourse.

Keep an extra supply of condoms available. Do not store them in

Thin sheath of polyurethane

Provide protection against STIs

Moderately effective (5-21 pregnancies per 100 women during the

Effectiveness as contraceptives depends on willingness to follow

User-dependent (require continued motivation and use with each act

Disposal of used condoms may be a problem

Adequate storage must be available at the client’s home

Supplies must be readily available before intercourse begins

Resupply must be available

Some users complain of irritating friction sounds when used

Use a new condom every time you have intercourse.

DO NOT use the female condom with a male condom.

Purpose: For participants to know the

Avoidance of risky sex

Feel invulnerable and don’t believe it could happen

These methods contain synthetic hormones (oestrogen,

Highly effective when taken daily (0.1–8 pregnancies

Decreased amount of flow and days of bleeding

Effectiveness may be lowered when certain drugs are

Can delay return to fertility

Nausea Breakthrough light bleeding

WHO Eligibility Criteria Women with HIV or AIDS can use

Women on ARVs other than ritonavir

Anytime provider is reasonably sure woman is not pregnant

First 5 days of menstrual cycle

After 5th day, use backup method for 7 days

COCs can be used by women of any age, whether or

Progestin-only pills (POPs), unlike COCs, do not

WHO Eligibility Criteria Women with HIV or AIDS can use

Require very strict pill taking schedule (must be

Breakthrough bleeding Nausea

POPs are usually used by women who have had a baby

Safe ways to prevent pregnancy soon

Take as soon as possible

Will not cause abortion

Next period may come a few days