WHO Hanbook On Family Plannig

Maternal health and
family planning
A handbook for health and

family planning projects
Guenther Dietz and Assia Brandrup-Lufcanow

© Copyright illustrations The Macmillan Press Ltd, 1993
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First published 1993
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ISBN 0-333-58759-6
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British Library.
Gontents
Preface v
Foreword vi
Introduction vii
Part One Human fertility and health 1

1 Determinants of fertility 1
Menarche, climacterium and menopause 1
Social determinants of fertility 2
Widowhood and dissolution of marriages 3
Infertility and sterility 4
2 Maternal health 6
Risks for pregnant women 7
Maternal death 8
Hemorrhage 8
Infection 10
Hypertension and toxemia
1
1
Obstructed labour
1
1
Abortion 12
3 Maternal and child health 13
Age, parity and child mortality 13
Low birth weight and intrauterine growth retardation 16
Part Two Methods of fertility control

1
7
The ideal contraceptive method 17
4 Contraceptives - measuring their effectiveness 18
Pearl Index 18
Life Table method 19
Natural fertilitity rate 19
5 Contraceptives and the female reproductive cycle 19
Mode of action of Contraceptives 20
6 Classification of contraceptive methods 20
7 Contraceptive methods 22
Natural family planning methods (NFP) 22
Rhythm or calendar method 24
Basal body temperature method 24
Cervical mucus (ovulation or Billings method) 27
Lactation (or breast-feeding) 27
iii
Non-clinical methods 29
Spermicides 29
The condom 33
Contraceptive intravaginal sponges 36
Semi-clinical methods 38
Hormonal contraception 38
Combined oral contraceptives (COC) 40
Progestogen-only pill (POP) 60
Long-term Progestogen-only contraception, Injectalbles
6
2
NQRPLANT subdermal implants 66
Intrauterine contraception (IUD) 69
Vaginal barrier methods 76
Vaginal diaphragm 77
Cervical caps 82
Post-coital contraception 86
Clinical methods 88
Female Sterilisation 88
Male Sterilisation 93
8 Family planning counselling 93
Counselling risk groups for contraception 94
Women over 35 years of age 94
Teenage girls or young mothers 96
After childbirth and during breast-feeding 97
After abortion 98
Women with anemia 99
Women with diabetes 100
Women with hypertension 101
Women with cardiac or cerebrovascular disease 102
Women with superficial varicosis 103
Women with history of deep venous thrombosis 104
Women with liver disease 105
Physically handicapped women 106
Mentally handicapped women 107
Women under tuberculostatic drug treatment 108
Women under anti-epileptic drug treatment 109
Women suffering from migraine/headache 110
Women suffering from depression 111
Women with acne 112
Part Three Organising and managing a community-
based family planning Programme113
9 Preparing a family planning Programme 113
10 Setting up a community-based family planning Service 114
11 Effects of family planning Services 118
Bibliography 119
iv
Preface
The period from 1980 onwards is often described as the lost development decade.
Economic crises and the efforts to counteract the worsening economic Situation by
so-called 'structural adjustment programmes' initially led to a decline of
interest in the social sector. The United Nations Children Fund (UNICEF),
recognizing the social needs of populations therefore demanded 'adjustment
with a human face'. This resulted in a renewed interest in the social sector and
the development of health Services. Even though the social and health needs
are still largely unmet, it is now recognized that human resources are a
prerequisite for development. Basic needs including health should not be a
development goal but must be clearly recognized as an essential precondition
for any development effort.
In the past, development strategies were largely focused on men as the key
actors at the political decision-making level. The role of women was only
recognized relatively late.
These overall developmental issues are reflected strongly in the health sector
which is always at danger of being neglected in comparision to various other
sectors that promise earlier returns of Investment. National budget allocations to
health are often below one or two dollars per capita per annum, especially in
rural areas. But rather than deploring the plight of the health sector it is at
times surprising that even with these very limited funds rudimentary Services
can be maintained.
It must be a clear objective of development in the health sector to increase
budgets again to pre-crisis levels in the 1970s, i.e. approximately 10 per cent of
national budgets. Within the health sector, the care of women and the
Provision of family planning play a crucial role not only for the health Status
but for overall sustainable development.
We hope that this handbook, which aims at providing better maternal and
child health Services including family planning, will make a contribution to this
noble goal.
PD Dr med. Rolf Korte, DTPH

Head of GTZ Division for Health, Population and Nutrition and
WHO Collaborating Centre for Health Systems Development
Foreword
To date; developing countries have profited very little from technological and
medical progress in industrialized countries. Very few medical centres in the
Third World have special diagnostic and surgical facilities; these are generally
open only to a privileged few, while the majority of the population has no access to
good quality health care.
Especially in rural areas, only a small percentage of births is attended
professionally by medical or paramedical staff. Maternal and infant mortality
rates in developing countries are therefore still unacceptably high. The risk of
maternal mortality is further increased by too many and too frequent births.
In the long term, the vicious circle of increasing poverty and uncontrollable
population growth can only be interrupted by sustainable economic and social
development in ThirdWorld countries.
The Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ) GmbH
(German Agency for Technical Cooperation) has accepted the challenge and is
doing excellent work in promoting social development as well as offering
preventive health care.
This book is a valuable contribution towards the improvement of maternal
and child health. Factors influencing fertility are described clearly and
understandably and an important part of the book is dedicated to methods of
fertility regulation, paying special attention to possible problems and side-effects of
the various contraceptive methods. It thus gives essential Information for
adequate counselling of couples and individuals. This book will be of practical
help for those working in health and family planning projects in the field.
Prof. Dr Wolfgang Kunzel

Chairman of the Dept. Obstetrics and Gynaecology
University of Gießen, Germany Chairman of the
Standing FIGO Committee on Perinatal Mortality
and Morbidity
VI
Introduction
Thanks to the development of functioning health care Systems and medical
technology, pregnancy- and childbirth-related complications have become a rare
cause of maternal deaths in industrialised countries today, but in many
developing countries they range among the most frequent causes of mortality in
women of childbearing age. Each year, about half a million women die from
causes related to pregnancy and childbirth worldwide. Only about one per cent of
these deaths occur in developed countries, the rest - about 99 per cent - occur in
Asia, Latin America and Africa.
The risk of dying from a pregnancy is highest in Africa, where maternal
mortality rates between 400 per 100 000 live births and 1000 per 100 000 live
births still prevail in rural areas. The maternal mortality rate bf girls and young
women between 15 and 19 years of age is twice as high as that in the 20 to 24
age group. Teenage pregnancies in girls under 15 years of age are even more
dangerous, with a five to sevenfold risk. Women at the other end of the age
scale, are at a higher risk as well. Having too many and too frequent births
endangers both the health of mother and infant and increases the infant mortality
rate.
Unwanted pregnancies have dramatic physical, social and psychological
consequences, usually more for the mother than the father of the child. Many
women thus resort to clandestine abortions causing another estimated 300 000
deaths worldwide.
Despite these well-known facts, primary health care projects in developing
countries have tended to concentrate on preventive care for frequent infectious
diseases and basic curative care. Offering family planning Services was seen as a
luxury asset and certainly not as an integral part of preventive health care.
Family planning activities are often left to small volunteer organisations,
which, despite all their involvement and goodwill, frequently face
unsurmountable financial problems, problems concerning shortage of
contraceptive supplies and a rapid turnover of volunteer staff. The lack of
integration of family planning Services into a functioning health care System
"creates additional difficulties when it comes to the follow-up of possible
complications of contraception or to the appropriate training and supervision of
non-medical family planning staff.
During the past 10 years, the importance of family planning as an integral
part of health care has been increasingly recognised and accounted for by many
organisations working in developing countries. However, one of the problems
which remains is that medical and paramedical staff working in health projects
have rarely been trained in family planning and modern contraception - this
vii
makes many people shy back from offering comprehensive family planning
Services.
This handbook is intended for nurses, midwives and doctors who have begun
setting up family planning Services or would like to Start training medical and
non-medical staff in family planning and counselling. Part One deals
physiological and social determinants of fertility, with major issues of maternal
health risks, and with the link between maternal and child health in developing
countries.
In Part Two, we have put together relevant facts on the mode of action,
advantages, disadvantages and possible side-effects of prevailing modern
contraceptives and have summarised many of these facts in the form of short
tables so that they can easily be referred to or copied on to transparencies
(overheads) for teaching purposes. We have given much space to practical
issues such as instructions for the users of each method of contraception, how to
start on a certain method and how to deal with possible complications or side-
effects; We believe that the latter is important not because side-effects occur so
frequently - they are actually quite rare - but because knowing how to deal with
them if they occur may increase the confidence of medical or non-medical family
planning staff.
For the same reason, we have included material on counselling major risk
groups which may require special attention and care in contraceptive counselling
and follow-up. In women with manifested health problems, medical attention
usually centers around curative care and contraceptive counselling is often
forgotten, even though a pregnancy may seriously endanger these women's lives. In
this respect, such information is not only intended for staff involved in family
planning Services, but also for medical staff in curative care.
Part Three deals with some practical issues of setting up family planning
programmes and community based family planning Services, (although not dealt
with in great detail, since they have been excellently documented elsewhere).
Finally, we hope that this handbook will be a useful tool for all those
interested, and we shall be grateful for any comments or suggestions for
improvement.
Assia Brandrup-Lukanow
Guenther Dietz
vin
Part One
Human fertility and health
1 Determinants of fertility
2 Maternal health
3 Maternal and child health
1 Determinants of fertility Menarche,

climacterium and menopause
The natural reproductive period of a woman is determined by the age at

first menstruation and the age at the beginning of the climacterium, and
fertility is naturally decreased at both ends of reproductive life.
Menarche is defined as the first period. In young teenage girls, the
menstrual cycle is often irregular and an ovulatory. The age at menarche
varies considerably, depending on social, environmental and cultural
factors. Normally, menarche occurs between the ages of 12 and 16. In
industrialised countries, there is a marked shift towards a younger age at
first menstruation.
The reproductive period is characterised by normal fertility. It usually
lasts about 25 —30 years. The natural fertility rate corresponds to 10 -12
live born children in 25 years. Very early menarche and a late menopause
extend the period of reproduction, potentially increasing the number of
further pregnancies.
Climacterium is the period during which profound changes in the
production of hormones take place. It usually occurs between the age of
45 and 55 and generally lasts several years (3 - 5) during which mainly
ovarian function is affected. The climacterium is marked by a steady
decline in ovulation episodes, hormonal levels (especially estrogen and
progesterone) and fertility. Natural infertility thus precedes menopause
by several years, usually starting at the beginning of the climacterium.
2 Human fertility and Health
The age at which a women reaches complete natural infertility varies
considerably among individuals. A woman at the age of 40 still has a 60
per cent chance of normal fertility, while 80 per cent of women aged 45
are naturally infertile (amenorrhea is not always a reliable indicator of
cessation of ovulation).
At the end of this transitional period no further ovulation takes place,
the ovaries are at final rest, indicating the end of a woman's reproductive
life (menopause).
Menopause is characterised by a complete cessation of the ovarian
function with no ovulation, no hormonal production and no further
menstruation. Women tend to be menopausal by the middle or end of
their fifties.
Social determinants of fertility

The effect of age at marriage on fertility
The age at marriage and the proportion of women marrying at a certain

age affects considerably the fertility rate of a society. The age at first
marriage usually determines the age at first childbirth, and possibly the
number of future children.
The age at which a woman first enters into a marital union varies widely
among different countries and according to culture, rural or urban
residence, religion, education and many other factors. In industrialised
countries, individuals or couples are often more free to choose the age at
which they wish to marry, and whether and when they want to have
children. In traditional societies, however, individuals often have less
room for decision making. Cultural norms which are enforced by very
close family ties may decide whom, how, and when to marry.
Marriage in most societies is seen as a reproductive union. It is expected
that those who marry want children and will have children. In almost all
societies childbearing is an essential part of marriage, and childlessness may
even lead to the dissolution of the marital union. Usually, unwanted
childlessness is regarded as the woman's inability of bearing a child.
In most societies, there is a legal minimum age for marriage and a
socially acceptable range of age. Each society has its own rules, often
very much influenced by tradition, religion and family clans. The average
age at first marriage varies from puberty to the late twenties.
The main reason for early (teenage) marriages are socio-cultural.
Marriages are often arranged by the parents, sometimes even before the
girls reach puberty, and pregnancy and childbearing of the young wife is
then enforced by the family clan. Early marriages fundamentally affect
Determinants of fertility 3
fertility and have a great impact on maternal and child health. Maternal
mortality and morbidity is raised in teenage women just like the risk of
the child dying before birth, during labour or in its first year of life. A
teenage wife therefore requires special attention concerning
contraception and extensive counselling is necessary to avoid unplanned
and possibly harmful pregnancy outcomes. In later years of her
reproductive life, the same woman will be at risk again as a consequence of
many pregnancies and childbirths.
Widowhood and dissolution of marriages

The effect of widowhood on fertility largely depends on the position of a
widow in her society and her chances of remarriage. This can vary widely
from absolute prohibition to remarriage after a certain acceptable period of
mourning and widowhood, but even in societies where remarriage is
tolerated, a period of some years usually passes before a new marriage
and further childbearing.
Dissolution of marriages and Separation often take place when the woman is
still in her reproductive period. Therefore, dissolution of marriages due
to divorce or Separation also affects fertility rates. Customs and legal
aspects of divorce vary considerably among societies.
In some mostly Catholic countries, there is no legal divorce at all. The
impact of divorce on fertility largely depends on the frequency of
remarriage.
Non-marital sexual unions
In some countries, for example in the Carribean, a considerable number of

women live in non-marital unions, and this group shows a different
reproductive behaviour from married women, usually with a smaller
number of children.
Frequency of intercourse, periods of abstinence and their effect

on fertility
Marriage is not necessarily the exposure to constant sexual intercourse

and pregnancy. Even when marriage occurs at very early ages and
continues without interruption, there is considerable Variation in the
amount of exposure to sexual intercourse. In many societies, there are
beliefs about certain intervals during marriage when intercourse should be
avoided.
4 Human fertility and Health
Socially prescribed periods of sexual abstinence are often periods closely
related to reproduction, most often following childbirth (postpartum
abstinence). This period can play an important role in fertility regulation,
especially in conjunction with breast-feeding customs. Social and
environmental factors which can influence the frequency of intercourse
can also be lack of privacy in big family households, traditional opinions
about moderation, etc.
Personal factors leading to periodic abstinence may be illness of the
Partner, or in many countries, migration of the husband for work
purposes.
Infertility and sterility
During the reproductive life of a woman, there are periods of naturally

decreased fertility and temporary sterility, for example after delivery,
after fetal loss or still-birth, and during breast-feeding periods. These
are physiologically protective periods and not pathological.
Infertility is defined as the pathological inability to carry out a normal
pregnancy. Common causes of infertility are genetic disorders or
malformations of the female reproductive organs.
In countries with a high prevalence of sexually transmitted diseases
(STDs) and pelvic inflammatory disease (PID) affecting and obstructing
the Fallopian tubes, these may be a major cause of infertility.
Sterility is defined as the inability to conceive. In practice, a marriage is
considered sterile if no pregnancy has occurred after two years of
unprotected intercourse. In a sterile couple, as opposed to an infertile
couple, no egg fertilisation takes place at all.
It is useful to differentiate between a primary pathological sterility and a
secondary pathological sterility. Primary sterility of a woman means that
no pregnancy ever occurred despite regular unprotected intercourse. In
secondary sterility, a pregnancy has occurred, but conception is now
impossible. Similarly, primary sterility in men is often associated with
congenital or developmental abnormalities, whereas secondary sterility
occurs due to genital tract infections, drugs, alcohol or smoking and is
sometimes reversible by treatment or abstinence from alcohol and
tobacco. There are as many male as female pathologies leading to a sterile
marriage. Data from industrialised countries show that 40 per cent of
the sterile partnerships are due to male pathologies, 45 per cent are due to
female pathologies, and in 15 per cent of all sterile couples no cause is
found at all (unexplained sterility).
Unwanted sterility can lead to major social complications, such as
Determinants of fertility 5
Table 1 Factors leading to female pathological sterility
Disorder Examples
Hormonal disorders - affect Ovarian disorders (aplasia or hypoplasia)

mainly egg maturation and Central ovarian dysfunction
ovulation Hyperprolactinemia
Hyperandrogenemia Corpus
luteum insufficiency
Cervical disorders - affect Anatomical changes (tears, lacerations or
uterine neck (cervix) polyps)
Functional disorders (loss of secretion or
sperm antibodies, hormonal factors) Infection
leading to tissue damage
Uterine disorders Congenital malformations of Uterus
Fibroids Intrauterine changes due to
adhesions
Disorders of Fallopian tubes Adhesions and obstruction due to pelvic
inflammatory disease or previous ectopic
pregnancies Endometriosis
Other factors Generalised infection (malaria,
toxoplasmosis, rubella, listeriosis,
cytomegaly and others)
Intoxication due to nicotine, drugs, alcohol
or environmental intoxication
Malnutrition
Vitamin deficiency
Chronic diseases
Psychological factors and stress
Table 2 Causes of female sterility and their frequency

Cause Frequency (%) Mean (%)
Hormonal and ovarian 21-39 33

Cervical 3-15 5
Uterine 4-19 10
Fallopian tubes 12-30 20
Vaginal 6 6
Endometriosis 12-33 23
Unexplained 4-27 15
Psychological 5 5
6 Human fertility and health
Separation of partners, dissolution of marriage and possibly severe
psychological disorders such as depression.
Table 3 Factors leading to male infertility
Cause Frequency (%)
Infections
gonorrhea, Syphilis, tuberculosis, filariasis, chlamydia,
mycoplasmas, schistosomiasis, 40-50
Varicocele (varicose spermatic vein)
Hydrocele (effusion around the testicle) •
leading to inadequate sperm production if not treated
surgically 20-30
Cryptorchidism (testicles not descended)
leading to inadequate sperm production if not corrected
surgically by the age of five 5
Congenital abnormalities
leading to hypogonadism and lack of sperm production ?
Endocrine causes
including diseases of the pituitary and adrenal glands 5-10
Drugs/Alcohol/Smoking
leading to inadequate sperm production 10
Psychological factors/stress ?
2 Maternal health
In Part One we shall discuss special health risks for mothers and children in
the context of pregnancy and childbirth and their implications for
family planning Services. The risks for pregnant women may be divided
into three groups:
1 Pre-existing risks before pregnancy
2 Risks emerging during pregnancy
3 Risks of labour and delivery.
This three-step classification of risk factors is important for the detection of
women at risk, their subsequent follow-up, and treatment to prevent
maternal morbidity and mortality.
Maternal health l
Risks for pregnant women
Pre-existing risks
These can easily be detected through a normal medical history. It is

necessary to check for:
- age - degree of malnutrition
- parity - degree of anemia
- physical stature , - social and environmental factors
- pre-existing diseases -marital Status.
Risk groups within this category are as follows:

-age: under 18 and over 35 years of age
- parity: first child and 5 or more children
- birth interval: short birth space of less than 2 years
-anemia: less than 10 g%
-height: less than 145 cm
-weight: malnutrition or gross obesity
-hygiene: poor
- social: low socio-economic Status
-marital: unmarried
- education: illiterate
- neighbourhood: rural or urban in slums.
Pre-existing diseases that are risk factors for pregnant women are:
- diabetes - cardiovascular diseases
- hypertension -skeletal anomalies rachitis
-STD/AIDS - history of fetal loss
-liver disorders (hepatitis, -history of obstetrical
cirrhosis) complications
- renal disorders -drug abuse.
- chronic infections (parasitic,
Risks emerging during pregnancy can either be induced by pre-existing

pathology or emerge inexpectedly. They are:
- anemia of pregnancy -threatening abortion
- antepafturn hemorrhage - infections
-hypertension -cervical incompetence
-proteinuria -premature labour
-edema -gestational diabetes
- intrauterine growth retardation — suspected cephalopelvie
(IUG) disporportion
-poor pregnancy weight gain -pathological fetal lie.
Any of these must be referred to a health center or hospital where
adequate medical skills and equipment (blood transfusion, anesthesia,
theatre for surgical delivery, pediatric care, etc.) are available.
Risks of labour and delivery that may lead to maternal death are:
- premature rupture of membranes -obstructed labour
- amniotic infection - intrapartum hemorrhage
- fetal malpresentation - postpartum hemorrhage
-prolonged labour - pre-existing anemia.
- cephalopelvic disproportion
Teenage mothers and women who have born rnany children are
particularly prone to develop these complications: teenage mothers have a
high incidence of cephalopelvic disproportion leading to obstructed
labour; in the gross multipara, obstructed labour is due to a higher
incidence of fetal malpresentation and decreased uterine strength.
Premature rupture of membranes with pre-term delivery and possible
infection is also more frequent in very young girls or gross multipara. The
rate of low birth weight is elevated in teenage girls and gross multiparity.
Maternal death
Maternal death is defined as the death of a woman while pregnant or

within 42 days of termination of pregnancy, irrespective of the duration
and the site of pregnancy, from any cause related to or aggravated by
the pregnancy or its management but not from accidental or incidental
causes.
Patients belonging to any of the three risk groups described above are at
a higher risk of:
- hemorrhage - hypertensive disease and toxemia
- anemia - obstructed labour.
- infection
These are the major causes of maternal death.
Hemorrhage
Hemorrhage during pregnancy can be classified in bleeding:

1 before delivery (antepartum)
2 during delivery (intrapartum)
3 after delivery (postpartum).
Maternal Health 9
Any of these can cause serious danger to maternal and fetal health,
especially when anemia is already present.
Any bleeding during pregnancy is a serious condition, mostly putting at
least the child at risk. If possible it should always be treated by a
doctor, especially if other risk factors are present. An emergency Situation
can arise suddenly leading to disseminated intravascular coagulation
(DIC), shock and death of the mother and child.
First tri mester hemorrhage

Bleeding during the first 3 months of a pregnancy is usually a sign of an
impending or inevitable abortion.
Second trimester hemorrhage

Bleeding in the months 4 to 7 is an alarm sign of an abnormal placenta
locatiori such as placenta previa, and is often due to pre-term labour
with opening of the Uterus.
Third trimester hemorrhage

Bleeding in the months 7 to 9 is usually due to abnormal placenta location,
premature Separation of the placenta, or premature labour with rupture of
the membranes.
Hemorrhage at delivery
There are many possible reasons for blood loss at delivery. The most
common origin of bleeding is the Uterus and placenta, but often traumatic
damage of the vagina or other tissue can lead to a major blood loss.
Postpartal hemorrhage
Life-threatening bleeding can occur after delivery due to non-involution of
the Uterus - especially in twin deliveries or gross multiparity. Retained parts
of the placenta in the uterine cavity and major blood loss leading to
coagulation disorders (anemia, bleeding, DIC) can be the cause of a
persisting watery bleeding-a nightmare for all persons involved in
obstetrical care. Injuries due to operative delivery or cephalopelvic
disproportion can also lead to major postpartum blood loss.
Maternal mortality due to hemorrhage

Hemorrhage is the leading cause of maternal mortality in developing
countries.
Table 4 Maternal deaths due to hemorrhage
Country Maternal death - hemorrhage

(estimated %)
Bangladesh 20
Colombia 22
Egypt 38
Jamaica 23
Papua New Guinea 33
(Adapted from WHO, 1990)
The mortality risk depends on:

- the amount of blood loss
- the state of general health
- the degree of pre-existing anemia
-access to medical (hospital) care.
Infection
The normal intact pregnancy with a closed amniotic sac is not at risk of
infection. However, any condition which facilitates the access of
bacteria into the cervical canal and the Uterus seriously endangers fetal
and maternal health.
In these cases, a vaginal infection may be followed by amnionitis.
Amnionitis is life threatening: it almost always causes premature labour
and delivery that often lead to septicemia with fetal and maternal death.
Children born to women with premature rupture of membranes and
amnionitis usually need intensive pediatric care due to problems related to
infeqtion.
Table 5 Maternal mortality rate due to infection

Country Maternal death -infection (%)
Bangladesh 3-12
Cuba 19
Egypt 11-18
Indonesia 8
Jamaica 9

Maternal health 11
Hypertension and toxemia
Toxemia is a major cause of maternal death in both industrialised and

developing countries. Its exact etiology is still unknown and treatment is
therefore mostly symptomatic.
The recognition of early signs of toxemia such as hypertension, edema
and proteinuria is essential. They can appear alone or in combination,
and if these early signs are neglected, they may rapidly progress into a
life threatening state (eclampsia) which is characterised by seizures and
organ failure. Fetal death rate at this eclamptic stage of toxemia is almost
100 per cent and the maternal death rate is also very high.
Risk groups for toxemia

Toxemia is more common during the first pregnancy especially in very
young teenage mothers and in women over 35. The incidence of toxemia in
black people is higher than in Caucasians.
Low socio-economic Status, lack of public health care and pre-natal
care are conditions which increase the rate of maternal deaths due to
unrecognised toxemia.
Table 6 Maternal mortality rates due to toxemia
Country Maternal death - toxemia (%)
Bangladesh 15-24
Colombia 34
Egypt 11-18
Indonesia 7
Jamaica 30
Obstructed labour
Risk factors for obstructed labour are:
- young teenage girls with small pelvis
-low body height less than 145 cm
-skeletal anomalies due to malnutrition or vitamin D deficiency
(rachitis)
- cephalopelvic disproportion
- fetal malpresentation
- fetal anomalies (hydrocephalus, etc.)
- multiple pregnancy (twins)
- multiparity.
Obstructed labour is always at danger of infection due to prolonged
labour and at risk of hemorrhage due to premature Separation of the
placenta or uterine rupture. Obstructed labour requires medical attention,
and surgical deliveries (e.g. forceps, Caesarean section) are often
necessary. The most serious complication resulting from obstructed labour is
uterine rupture with inevitable fetal death and extreme danger for the
mother.
Fetal morbidity rates resulting from obstructed labour are high with
fetal brain damage due to intrauterine asphyxia. Maternal morbidity due to
obstructed labour includes fistulas, cervical lacerations and scars, with a
subsequent higher risk for the next pregnancy.
Abortion
Despite the illegality of abortion in many societies, it has been a widely

used method of birth limitation throughout history. Medical and ethical
considerations of pregnancy termination have provoked enormous
discussions through all societies, political parties and religious groups.
Trying to assess the extent of illegal abortion in a society and its
contribution to maternal mortality and morbidity is almost always a
matter of guesswork.
Complications resulting from unsafe, unclean and unprofessional
abortion are commonly life-threatening and, due to a feeling of shame
of the women involved or inaccessibility of health Services, delayed
admission and delayed medical treatment are common. The most
commonly found complications of unprofessional abortion are:
- retained fetal and placental products
- uterine Perforation
- cervical laceration
- infection and pelvic inflammatory disease (PID)
-hemorrhage
- undiagnosed ectopic pregnancy.
The major causes of death from unsafe abortions are infection and
hemorrhage usually due to unsterile Instruments and retained fetal parts.
Post-abortional infections are frequent especially if infections of the
vagina are present. In some countries with a high prevalence of sexually
transmitted diseases such as gonorrhea, pelvic inflammatory disease
following abortion is a common complication. It is often associated with a
high degree of damage of the Fallopian tubes and subsequent sterility.
Infection can become life threatening, especially if fetal parts have
remained in the uterine cavity (retained products). Retained fetal and
placental tissue is an ideal environment for bacterial growth. Infection
Matemal Health 13
can be either confined to the uterine cavity (endometritis) or spread
through the muscle (myometritis). In the most serious cases, infection
enters the abdominal cavity leading to peritonitis and septicemia.
A major factor influencing the outcome of an abortion is the age of
the pregnancy. Excessive bleeding may occur especially if abortion takes
place in later stages of pregnancy (second trimester). Retained products
are often the cause of persistent uterine bleeding after abortion. Especially in
young girls, damaging the cervix due to manipulation can cause
lacerations and scars which later on may either lead to cervical
incompetence with premature birth or dysfunctional, prolonged and
obstructed labour.
In general, complication rates of safe abortions performed by skilled
medical practitioners and with sterile Instruments in the first three months of
pregnancy are very low.
3 Maternal and child health
Many of the risk factors for child health are identical with those for
maternal health:
- very young teenage mother - infectious diseases
- high maternal age - low socio-economic Status
- multiparity of the mother - malnutrition of the mother
- short birth interval - low birth weight of the child.
It is obvious that maternal and fetal health are closely related to each
other. Poor maternal health, pre-existing maternal diseases, and other
general risk factors strongly influence the outcome of the pregnancy.
Age, parity and child mortality
The risk for the child is increased with multiparity of the mother. Studies in
various countries have consistently shown that child mortality is closely
related to maternal age, parity and birth order.
Mortality is lowest among infants born to women aged 20 - 29 and
highest among those born to women at either end of childbearing age
(under 18 and over 35).
Fig 1 Risk of child mortality in relation to mother's age at birth
Mortality is especially high for the first child of very young mothers
(see Figure 3). Young mothers tend to have a higher incidence of pre-
term deliveries, complications at birth, toxemia, puerperal complications
and neonatal deaths.
Children born to older mothers (over 35) have a greater risk of birth
defects and malformations. The risk of malformations rises steadily
among children born to women in their late thirties. Frequent
malformations are Down's syndrome, cleft palate and heart defects.
A short birth interval adversely affects the preceding child and the
succeeding child. When two children are separated by only a critical short
birth interval of less than one year, both will suffer. Short birth intervals
are also associated with a higher risk of poor pregnancy outcome,
followed by poor physical and intellectual development of the child.
Family size and child health
Studies have shown that large family size and short birth spasms interact
with poor nutrition and represent a risk for both the unborn child and
the older children with a marked increase in morbidity and death. A high
rate of malnourished children is found in large families. Family size and
poor nutrition also interact closely with child development.
In children of large families and with short birth intervals, growth and
mental and physical development are affected. In addition, the lack of
material resources, overcrowded housing with unsatisfactory hygiene and
sanitation leading to infection contribute to the poor health Status and
high health risk for the child.
Fig 3 Mortality in relation to parity and birth order
16 Human fertility and health Child
mortality and birth order
Mortality is highest for the first child of a very young mother, lowest
among the second and third children and then increases again steadily.
Low birth weight

Data from developing countries show that 30-40 per cent of all infant
deaths are associated with LBW. Low birth weight is a major contributing
factor to infant and child mortality. LBW can be due to:
1 pre-term delivery .
2 intrauterine growth retardation (at term delivery).
Pre-term delivery is often associated with the maternal risk factors

(already mentioned) such as a teenage mother, multiparity, short birth
interval or social problems.
Risk factors for pre-term delivery are:

- age: under 18 and over 35 years
-parity: first child and fifth and over
-birth interval: short birth space of less than 2 years
- social: low socio-economic Status
-marital: unmarried
- hygiene: poor with recurrent infections
-work: heavy physical work.
Intrauterine growth retardation (IGR)

Factors leading to IGR are:
1 placenta insufficiency
2 fetal malformations
3 maternal diseases.
Mothers who have failed to achieve the Optimum growth and
development due to undernutrition, recurrent illness in their childhood
and chronic diseases in adulthood are more likely to give birth to a low
birth weight child.
This applies particularly if they suffer from malnutrition during
pregnancy, are not protected against anemia and parasitic diseases, suffer
from low social Status, heavy physical work and have no access to pre-
natal care.
Part Two
Methods of fertility control
4 Contraceptives - measuring their effectiveness
5 Contraceptives and the female reproductive cycle
6 Classification of .contraceptive methods
7 Contraceptive methods
Natural family planning methods (NFP)
Non-clinical methods Semi-clinical
methods Clinical methods
8 Family planning counselling
The ideal contraceptive method

To date, the ideal contraceptive method is unknown. If it was available it
should have the following attributes:
1 be 100 per cent effective
2 have no side effects
3 be simple, painless and esthetic
4 be independent of intercourse
5 not depend on the user’s memory
6 be fully and immediately reversible
7 be cheap
8 be acceptable by religion, culture and society
9 be easy to distribute
10 require no major medical knowledge
11 require no follow-up
12 be easily accessible and available
13 be accepted by both partners.
17
18 Methods of fertility control
4 Contraceptives - measuring their effectiveness Pearl
Index
The effectiveness of a contraceptive method is not measured in success

rates but in failure rates (unwanted pregnancies). Usually, a certain
amount of time has to go by before judging the effectiveness. The Pearl
Index is calculated on a basis of 1200 user months, which corresponds to
100 women using the method for one year (100 women x 12 months =
1200 user months). The Pearl Index calculates the failure rate as
follows:
Failure Rate total accidental pregnancies x 1200 months of use

(Pearl Index)" total months of exposure
When calculating the failure rate with this formula, every known
conception (=failure) must be included. By convention, 10 months are
deducted from the denominator for a full pregnancy and 4 months for
any kind of abortion.
However, the Pearl Index has some disadvantages and represents a
more theoretical than practical figure. For example, if 10 women use a
contraceptive method for 10 years, they will achieve different failure
rates than 100 women using this method for only one year. Both groups
have used the method for 1200 months, but the long-term user s tend to
be more accurate using the method, so they will achieve better results
(that is, lower failure rates).
Also, the Pearl Index does not include some others factors which may
influence the effectiveness of a method, such as the decline of fertility
with age, frequency of sexual intercourse, etc.
Life table method
Common among insurance companies when calculating the risk of death of

a person the Life Table method is also the basis for the calculation of
individual insurance rates.
This method has been adopted to measure contraceptive failure,
especially to overcome such difficulties as:
- discontinuation rate of a method
- failure rate differences in short and long term users
- number of drop-outs
-lost follow-ups.
Contraceptives - measuring their effectiveness 19
Natural fertility rate
When judging the efficacy of a contraceptive method, the failure rate

must be compared to the natural fertility rate (i.e. number of pregnancies
when no contraceptives were used at all). In the complete absence of
any contraceptive protection and including the times of natural infertility
such as puberty, climacterium, pregnancy, postpartum lactational
amenorrhea, abortion, etc.) the total fertility rate is as high as 40 per
100 women years. This corresponds to 10-12 live born children in
approximately 25 years of normal reproductive life.
5 Contraceptives and the female reproductive cycle
The natural reproductive cycle is divided into 3 phases:

1 maturation of the egg (oocyte) and ovulation
2 fertilisation of the egg in the Fallopian tubes and transport to the Uterus
3 successful Implantation of the fertilised egg (blastocyst) in the Uterus.
Mode of action of contraceptives
A contraceptive method can exert its effect by interfering with one or
more phases of the reproductive cycle. It can:
- suppress the maturation and ovulation of the egg
-interfere with fertilisation of the egg in the Fallopian tubes
-impair the egg Implantation in the Uterus.
Some contraceptive methods, especially the hormonal contraceptive
methods, may act at different levels at the same time. the combination of
t wo different methods affecting different phases increases the
contraceptive effect.
Table 7 Mode of action of contraceptives
Mode of action Methods
Suppression of ovulation combined oral contraceptives (COC)

(hormonal contraceptives) progestogen only contraceptives (POP)
implants
injectables
Impairment of egg fertilisation barrier methods (condom, IUD)
Chemical (spermicides)
hormonal methods natural
methods
Impairment of egg Implantation intrauterine device (IUD)
hormonal methods
6 Classification of contraceptive methods
There are many possible ways of classifying the whole range of

contraceptive methods available. One way is the mode of action, as it is
commonly done in medical handbooks. Another possibility is to classify the
contraceptives by their effectiveness or failure rate. Costs of the
method could be a worthwhile classification, especially considering family
planning programmes in developing countries.
In family planning programmes, one key issue is related to all methods,
'How can the method be distributed ensuring its maximum effectiveness
and safety for the patient?' Therefore, contraceptives may be classified
according to their mode of distribution:
1 non-clinical methods
2 semi-clinical methods
3 clinical methods.
Classification of contraceptive methods 21
There may be differences in the classification of these three methods due to
logistics or country-specific legislation.
Non-clinical methods
Non-clinical methods include natural family planning methods and so-
called 'over the counter sales methods'. They usually do not require
intensive medical or paramedical attention. One counselling session or
simple written instructions may be sufficient due to the simplicity and
low risks of the methods:
-condoms
- spermicides (suppositories and creams).
Semi-clinical methods
Semi-clinical methods require medical or paramedical attention and a

considerable amount of counselling. Distribution of any semi-clinical
method usually involves history taking (past medical history, obstetric
and gynecological history) and sometimes pelvic examination. In some of
the semi-clinical methods such as IUD or implants, minor surgery under
sterile conditions is necessary.
Follow-up visits are required to ensure maximum effectiveness and
medical safety. Semi-clinical methods are:
-hormonal contraceptive pills -implants
(COC, POP) . - IUD (intrauterine device)
- injectables - diaphragm, cervical cap.
*•
Note There is a considerable amount of controversy and dispute over

hormonal contraceptive pills (COC/POP): should they be 'sold over the
counter', distributed by non-medical persons or do they require a clinical
setting? There is no international rule or final Statement on this issue.
So far, country-specific legislation determines the classification in this
respect.
Clinical methods
Strictly clinical methods are methods which need special medical attention
and care. They require a considerable amount of counselling, medical
examination, sometimes surgery, and follow-up. Clinical methods
comprise:
-female Sterilisation
-male Sterilisation.
7 Contraceptive methods
Natural family planning methods (NFP)
Fertility awareness methods also called 'natural family planning methods'

are based on the following physiological conditions:
- life span of a sperm is 48 hours
- life span of an egg is at maximum, 24 hours
-ovulation takes place between 12-16 days before the next
menstruation.
The basic concept of all natural family planning methods is to help
couples and especially women to be aware of their own fertility. The
most common methods used are:
-rhythm method (also called calendar method)
-basal body temperature method
- cervical mucus method (also called ovulation or Billings method)
- symptothermal methods (combination of the above).
The effectiveness ranges between a Pearl Index of 2.0 and 20.0
depending on the study or the methods employed (see Table 8).
Advantages of natural methods

Safety.
No physical side-effects.
Cheap.
Acceptable to many groups and religions which oppose modern
contraceptive methods.
Teaches women about their own menstrual cycle and fertility.
Couple has control over the method.
Helpful for planning a pregnancy.
Disadvantages of natural methods

D Some methods require substantial initial teaching.
D Records on several cycles must be kept before the method can be used.
D Some women may be unable to recognise natural fertility.
D Women with an irregular cycle may have difficulties with these
methods
D Adjustment of sexual behaviour necessary.
D Requires co-operation of the male partner.
Rhythm or calendar method
Before using this method, an accurate menstrual calendar has to be kept

for a period of 6-8 months.
Calculation of the fertile period

1 Record the length of each cycle.
2 First fertile day: subtract 18 days from the shortest cycle (16 days
plus 48 hours for sperm survival).
3 Last fertile day: subtract 11 days from the length of the longest cycle.
For the beginning and end of the fertile period

Example A Woman with a regular cycle of 28 days duration
first fertile day: 28 minus 18 = 10 last
fertile day: 28 minus 11 =17
Recommendation: avoid intercourse between the lOth and the 17th day of
the cycle.
Example B Woman with an irregular cycle, shortest cycle is 25 days and

longest cycle is 32 days.
first fertile day: 25 minus 18 = 7
last fertile day: 32 minus 11=21
Recommendation: avoid intercourse between 7th and 21 st day of the

cycle.
Both Examples A and B show that, especially in women with an irregular

cycle, the period of abstinence can be unacceptably long for both partners.
Basal body temperature method

A woman can determine her time of ovulation by recording her
temperature daily. The basal body temperature (BBT) of a woman drops
slightly before ovulation, rises by 0.2 - 0.4°C after ovulation, and then
remains at this level (see Figure 5).
Interpretation and calculation of the infertile days

The infertile days Start on the morning of the third day after the plateau
(temperature increase of at least 0.2°C). The couple can have unprotected
intercourse from the morning of this day until the next menstruation.
9
3
I
».
3
I
I
ts)
Fig 6 Example of chart for detection of ovulation by cervical mucus method

Contraceptive methods 27
After menstruation, there should be no unprotected intercourse until the
third day of the next temperature increase.
Instructions before starting to use the BBT method
* Record the BBT for at least 3-4 consecutive months.
* Record the temperature at the same time each day (preferably in the
early morning = waking-up temperature).
* Record the temperature on a special chart.
* Record any illness with fever, such as influenza or malaria, and lack of
sleep.
* Begin a new chart for each new menstrual cycle.
Cervical mucus (ovulation or Billings method)

Another method to detect the time of ovulation is the mucus method,
which was first described by Billings. This method is based on changes
that occur in the quality and quantity of cervical mucus. Under the
influence of estrogen, and later progesterone, several changes in the
secretion of cervical mucus take place during the menstrual cycle:
1 After menstruation, there is almost no secretion (dry day s).
2 In the early pre-ovulatory days, the dryness of the vagina disappears
and a cloudy, white mucus is discharged by the cervix (wet days).
3 Shortly prior to ovulation, the mucus becomes clear and slippery (
= peak of fertility, very wet days).
4 After ovulation, the quantity of mucus decreases under the influence of
progesterone and becomes sticky and cloudy again (dry days)»
Instructions for a woman wanting to use this method
* Observations should be made every day.
* Feel the mucus at the entrance and the inside of the vagina.
* Record subjective findings such as feeling of dryness or wetness.
* Record the appearance of the mucus, such as color or viscosity.
* Record the peak mucus day ( = prior to ovulation).
* Do not per form a vaginal douche when recording.
* Remember: semen may interfere and disturb proper recordings.
Lactation
Immediately after childbirth, there is a period of naturally decreased
fertility, which can be prolonged by regular breast-feeding. The hormone
responsible for the suppression of fertility is prolactin (PRL), that controls
milk production.
PRL is produced in the anterior pituitary gland and released into the
blood stream. Already during pregnancy, PRL-producing cells in the
anterior pituitary gland proliferate and Start slowly releasing PRL into
the bloodstream in rising quantities. After childbirth, PRL levels reach
their peak and milk production Starts immediately, even before any
sucking Stimulation from the newborn. Later on, Stimulation of the
nipples is necessary to maintain PRL production and subsequent milk
production. In non-breast-feeding women, PRL gradually decreases in
the weeks following delivery, reaching low and normal levels
approximately four weeks postpartum.
It is important for women who are breast-feeding to realise that regular
nipple Stimulation is necessary to maintain milk production and
lactational amenorrhea with a partial contraceptive effect. In this respect,
lactational amenorrhea is not equivalent to postpartum amenorrhea.
Every woman goes through a period of amenorrhea usually lasting 6-
12 weeks after childbirth (postpartum amenorrhea), during which she is
practically infertile. Lactational amenorrhea may last from four up to
24 months, during which regular PRL release from the anterior
pituitary gland inhibits ovarian function.
There are indications that the release of other hormones (gonadotropins
(follicle stimulating hormone (FSH) and luteinising hormone (LH)) which
stimulate the ovaries, is also altered during the lactational period, leading to
a lack of ovarian Stimulation.
Return of fertility is usually indicated by the re-occurrence of the
menstrual period, indicating normal ovarian function and ovulation. The
restart of menstruation is, however, not a very reliable indicator for the
exact time of return of fertility. The first postpartal menstruation often
follows initial ovulation with two or three weeks of delay. In other words,
ovulation can occur two to three weeks prior to menstruation.
This means that /'/ is not possible to predict when the first ovulation
will occur after childbirth. It is therefore risky to rely on breast-feeding
alone as a contraceptive method and it is advisable to recommend
additional contraceptives during breast-feeding. Since natural fertility is
reduced, contraceptive methods with normally higher failure rates are
generally acceptable and effective.
Factors affecting duration of lactational amenorrhea

The duration of lactational amenorrhea differs widely among individuals.
There are, however, some major influencing factors:
- duration of breast-feeding
- demand feeding versus scheduled feeding
- timing of the addition of supplementary food
- maternal age and parity.
All of these factors should be taken into account when counselling a
breast-feeding woman on contraception.
Duration of breast-feeding
The duration of breast-feeding affects the delayed return to fertility by
continuous suppression of ovulation. Decline in sucking Stimulus
(weaning) leads to an earlier return of fertility.
Demand feeding versus scheduled feeding

Decline in PRL levels is closely associated with the frequency of breast-
feeding per day. Demand breast-feeding raises the frequency of sucking
and it is more likely to sustain high PRL levels necessary for ovarian
inhibition. More rapid declines are seen in mothers breast-feeding only
three times per day.
The length of intervals between breast-feeding episodes also affects
PRL levels. Long intervals between nursing (working periods of the
mother) or cessation of nursing at night are unfavorable factors for
sustaining lactational amenorrhea.
Addition of supplementary food

Supplementary food decreases the infant's needs and frequency of
sucking. A drop in PRL levels occurs, leading to decreased milk
production and less ovarian inhibition. The earlier supplementation is
started, the earlier fertility returns to normal levels.
Maternal age and parity

Studies have shown that maternal age and the number of children (parity)
influence the duration of lactational amenorrhea. It is increased in older
women (over 30 years of age) and in multiparous women. Younger women
(under 30 years of age) tend to have shorter periods of lactational
amenorrhea.
Non-clinical methods
Spermicides
The application of chemical substances into the vagina to avoid pregnancy is
one of the oldest contraceptive methods dating back to ancient Egypt.
Substances used comprised anything from honey to dry animal feces or
tree leaves. Most of the methods employed worked by application of
sour (acid) substances. In 1907, the first commercially available spermicide
was developed. Many different types of spermicides followed, but most of
them had to be withdrawn from the market due to minor or major side-
effects or unacceptably high failure rates.
One old and simple but remarkable idea of a spermicide is a lemon
cut in half, which is used as a barrier around the cervix (like a cap) with
the sour lemon juice acting as a built-in spermicide. Another popular
cheap and simple spermicide is a sponge full of water and lemon juice
inserted into the vagina prior to intercourse: of course, the failure rates of
this home made method of contraception are high!
Ingredients and mode of action of spermicides

Spermicides generally consist of two components:
1 the spermicide itself
2 an inert base as the medium.
The inert bases can be manufactured in many different forms, such as
jellies, foams, creams and suppositories. Of the many spermicide
substances tested in the past, only one major group survived and is now
recognised as an effective and safe substance. This is the group of
surfactants, and the most popular substances are Nonoxynol-9,
Menfengol, Octoxynol.
Surfactants act by altering the sperm surface. When a surfactant comes in
close contact with the sperm, the cell membrane is damaged, causing
many intracellular components, such as proteins and enzymes to flow
out from the sperm. These changes lead to an instant devitalization of
the sperm. It loses its mobility and, what is even more important, its
ability to fertilise an egg.
To be effective, the spermicide must disperse quickly in the vagina,
but still remain more concentrated around the cervix, where a higher
sperm count occurs after ejaculation.
Types and application forms of spermicides

There are several forms of spermicide application:
- jellies - foaming tablets
- creams - soluble film
- foams (aerosol) as condom lubricants
-melting suppositories as ingredients in vaginal sponges.
Foams
Foam containing spermicide is filled from a pressurised bottle into an
applicator and then placed deeply into the upper part of the vagina, close
to the cervix. The main advantage of these foam spermicides is that tljey
can be applied just prior to intercourse since no melting has to occur.
Tablets and suppositories

There are many brands of tablets and suppositories available 'over Ijhe
counter'. They dissolve or melt in approximately 10 to 30 minutes, tljus
requiring a waiting period before intercourse.
Creams and jellies

This group of spermicides is inserted into the vagina with the help of an
applicator. The couple may have intercourse as soon as the spermicide has
been introduced. Creams or jellies are often used in combination with
vaginal barrier methods such as the diaphragm or cervical caps.
C-Film
This is a water soluble film which disappears rapidly in the vagina.
Waiting time for C-film to be active is 3 - 5 minutes.
Effectiveness of spermicides
There are great variations in the failure rate data on spermicides, wfch
rates ranging from 3 - 28 per 100 women years of use. The main problem of
this 'over the counter' sold contraceptive method is the lack pf
instruction and failure often occurs due to incorrect application. The
effectiveness of spermicides is significantly improved with proper
counselling and once the user is familiar with the method and fee^ls
comfortable applying it.
The use of a spermicide in combination with other contraceptive
methods, such as the diaphragm, cervical caps or condoms, improves
contraceptive effectiveness considerably, therefore spermicides should be
recommended as an additional method.
Advantages of spermicides
• Available without prescription.
• Fairly effective if used correctly and consistently.
• Very effective in conjunction with other methods, such as diaphragm or
cervical cap.
• Can increase the effectiveness of other methods, such as natural family
planning (NFP), when used at time of ovulation.
• Use in female hands.
• Needs to be used only when required.
• Limited toxicity or systemic absorption.
|
• As a back up method.
• Provides extra vaginal lubrication if dryness is a problem.
• Easy transport.
O Good protection against sexually transmitted diseases (STDs) and
pelvic inflammatory disease (PID).
Spermicides and protection against STDs
One of the most important non-contraceptive benefit^ of Spermicides is
their protection against many STDs. They are effective against
gonorrhea, trichomoniasis, herpes genitalis and others. Spermicides
reduce the risk of ascending infections and pelvic inflammatory disease.
Spermicides also have and-viral properties, but how they are effective
against HIV (AIDS) is still not known.
Disadvantages of Spermicides
D Not highly effective when used alone or infrequently.
D Not effective if inserted over 60 or less than 20 minutes before
intercourse.
D Some couples find the method 'messy'. D May produce allergic
reaction, irritation or heat sensatipn in the woman
or man. D Foaming tablets or suppositories must be stored in adequate
conditions
(problem in tropical countries). D Sexual
activities may have to be interrupted.
Indications for the use of Spermicides
• !
* As a method while waiting to begin the first pack 0f pills.

* As a back up method while starting another contraceptive method (pill,
IUD or POP).
* As a mid-cycle contraceptive to increase the effectiveness of methods,
such as natural family planning.
* As an additional method to diaphragm or cervical cap.
* As a lubricant if vaginal dryness is a problem.
* For protection against STDs.
* If sexual intercourse is infrequent.
Important instructions for use of spermicides
Waiting time after insertion
-Suppositories 15-30 minutes
-Foaming tablets 3-10 minutes
- Creams and jellies 2-3 minutes (2 g minimun} dose)
- Foams no waiting time
-C-film 3-5 minutes
i
j
Spermicides have to be taken before every intercourse; a second
intercourse means a second dose. If a spermicide was inserted more t tian
two hours before intercourse takes place, a new dose has to be applied.
All spermicides should be placed as high as possible into the vagina
and close to the cervix. To achieve maximum contraceptive safety, the
combination of the spermicides with other contraceptive methods is
recommended.
Especially in tropical countries, where heat may affect spermicides,
suppositories and other melting preparations, these should only be
recommended if adequate storage facilities are available.
The condom
The condom is by far the most popular and oldest barrier method. It is
known that in 1200 B.C., fish bladders were used to cover the penis
during intercourse. In the Middle Ages, the physician Gabriele Fallopio
suggested the use of a linen sheath for protection against STDs £nd
unwanted pregnancy. The English doctor Contom described the us? of
lamb gut as a sheath for the penis.
The real breakthrough came with the discovery of latex and rubber.
Thanks to the vulcanisation process, a new dimension in the
manufacturing and quality of the condom emerged. The safety and quality of
condoms was steadily improved, resulting in a greater acceptability and
availability of this male method of contraception.
Condoms have been excessively promoted in 'safe sex' campaigns to
prevent the spread of STDs and AIDS. Condoms now play an important
role in family planning programmes due to their easy distribution, simple
usage, and their effective protection against STDs and AIDS.
Mode of action
The condom, when correctly used, prevents the entrance of sperms into the
cervical canal. There is a small but very important difference to other
barrier methods: when using the condom, there is no contact of the
ejaculation fluid and the vagina at all.
When the cap, diaphragm, spermicides, etc. are used, there is always
contact between the ejaculation fluid and the vagina, even if the cervix
remains well protected. This unique property of no contact of genital
body fluids (ejaculation, secretion or blood) between the sexual partners,
makes the condom the most protective method against STDs ^nd
especially AIDS.
i
j,

Types of condoms
There are many types and brands of condoms. Commonly they are
transparent, made out of latex with a smooth surface, 4 cylindric form
and a little reservoir for the ejaculation fluid at the closed end. Despite
differences in colour and surface properties, the only Substantial and
important differences between latex condoms are:
-the presence or absence of a lubricant on the outside
-the presence or absence of a spermicide on the inside.
The spermicide applied to the inner side of condoms is usually the
surfactant Nonoxynol - 9. Tests of the spermicide effect on sperms
showed that already 60 seconds after ejaculation into a condom covered
with spermicide only 4.3 per cent of the sperms remaih active.
Effectiveness
The effectiveness of condom use depends highly on the ftiotivation and
experience of the user. Failure rates therefore vary from Q.4 - 32 per 100
women years of use. A mean failure rate of approximately 4.8 per 100
women years seems to be realistic.
Reasons for failure

Condom failure can be due to a variety of reasons, including:
-vaginal penetration before the condom is applied
-failure to unroll the entire condom over the erected penis and not
leaving sufficient place for the ejaculate at the tip of the condom
-withdrawal failure
-condom breakage during intercourse
- tearing and damaging the condom while unrolling
- weakening of the latex rubber due to supplementary lubricants, such as
oil or cream.
Advantages of condom use

There are many advantages of condom use, including contraceptive and
non-contraceptive benefits. They include:
No health risk, systemic side-effects or complications.
Effective contraceptive method if used correctly.
Can increase the effectiveness of other methods, for bxample IUD,
NFP and POP.
Easy to use.
Acceptable in many cultures.
Needs to be used only when required.
Generally good availability and affordability.
Can be distributed by non-medical personnel.
No medical supervision required.
By preventing STDs and PID, condoms reduce the likelihood of
subsequent infertility.
* Condoms may help pregnant women to avoid certain infections which
may damage the unborn child, such as gonorrhea, herpes, syphilis
and chlamydia..
* Convenient to carry and store.
* Involves the male in sharing responsibility.
* Minimises postcoital discharge or odour.
Indications for condom use

* Short term contraception, for example before starting a new method.
* As a back up method.
* To increase security of other methods, such as IUD, NFf* and
spermicide.
* For persons with a high risk of STDs.
* When intercourse takes place infrequently.
Disadvantages of condom use

D Sexual activities need to be interrupted.
D Loss of spontaneity.
D Decreases sensitivity especially for the male.
D Requires a high degree of continuous motivation.
D Requires male responsibility.
D May increase erectile difficulties.
D May rupture or loose its position during intercourse when not applied
correctly.
D May be seen as unaesthetic.
D Condoms are often associated with extramarital sex and STDs in
people's perception.
D Possible (but very rare) allergic reactions. D Need
to be stored properly (affected by heat). O Some
lack of privacy when purchasing. D Problems of
disposal of used condoms. D Not suitable for
poorly motivated persons.
important instructions for condom use:

* Condoms should never be re-used.
* Use condoms containing spermicides on their inner part.
.
I

* Use only those condoms manufactured to approved standards.
* Store condoms in a dry and cool place.
* Use the condom every time you have intercourse.
* Condoms should be handled with care to prevent damage.
* Do not test the condom by inflating or stretching it.
* Keep the condom away from sharp fingernails.
* The condom should be put on the penis before any genital contact
takes place.
* Hold the tip of the condom (reservoir) and unroll it over the erected
penis.
* Roll the rim of the condom all the way down to the iase of the penis,
and |
i
* leave a space at the tip to collect the semen, and

* make sure that no air is trapped in the condom i
* Only use water based lubricants if necessary.
* After ejaculation, the base of the penis should be held at withdrawal.
* The penis should be withdrawn while still erect.
* Check the condom for tears or leakage before discarding.
* After you have used the condom, discard it out of rbach of children
and animals.
Contraceptive intravaginal sponges

Types and ingredients
The contraceptive sponge commonly used today is a soft, round
polyurethane sponge with a size of approximately 5.5 X 2.5 cm. In the
middle of the sponge, there is a circular cavity for the cervix. This cavity
ensures close contact of the sponge with the cervix an<l also decreases
the chance of dislocation during intercourse.
The sponge is filled with a spermicide, usually the surfactant
Nonoxynol-9. The sponge is inserted before intercourse to the upper part of
the vagina and to cover the whole cervix.
Its mechanism of action is based on a combination $f chemical and
mechanical barriers and it also absorbs a great part of th|e ejaculate. The
sponge is disposable and should never be used twice.
Effectiveness of sponges
Multicentre studies have reported failure rates as high as 9 - 25 per 100
women years of use. The sponge seems to be less reliable than other
vaginal barrier methods, such as the diaphragm or cervical cap.
Advantages of sponges
Easy to use.
No systemic side effects.
Uses both spermicide and barrier mode of action.
Can be inserted very shortly before intercourse.
Can be inserted up to 24 hours prior to intercourse.
Sexual intercourse can take place more than once.
Protection lasts for up to 24 hours.
Convenient and simple use (same method as a tampon).
No special fitting required.
Not felt by the male partner.
Method under woman's control.
No discharge after intercourse (ejaculate is absorbed).
Protection against STDs and PID.
No additional spermicide is needed before intercourse.
Easily available (over-the-counter sales).
Disadvantages of sponges
D Higher failure rates than other vaginal methods.
D Possible allergic side-effects against the spermicide.
D Removal may be forgotten (risk of toxic shock syndrome developing).
D May dislocate during intercourse.
D Manipulation of the genitals necessary.
Instructions for use of sponges

* Plan to insert the sponge well before intercourse.
* Make sure that water is available (a dry sponge is less active}.
* Rinse and squeeze the sponge in 2 tablespoons of clean watei[.
* Locate your cervix with the index finger tip before insertion of the
sponge.
* Insertion must be as high as possible.
* Slide the index finger around the sponge after insertion.
* Check that the cervix is covered.
* Intercourse can take place several times with the same sponge.
* Keep the sponge in place at least 6 hours after intercourse, up to a
maximum of 24 hours.
* Use the sponge whenever you have intercourse.
* After intercourse, re-check position to make sure that the cervix is
still covered entirely by the sponge,
* To remove the sponge, gently pull the loop dowriwards with your
finger.
* Never re-use a sponge.
Semi-clinical methods Hormonal

contraception Effect of hormones on female
reproductive tract
Hormones are very effective substances and can induce profound changes in
the female reproductive organs and breasts. But other organs such as
the liver, blood, digestive System, cardiovascular sys^tem and skin are also
affected by hormones. The most important sexual hormones
produced by the ovaries are:
1 estrogen
2 progesterone.
These two hormones can now be produced synthetically. Hormones can be
either administered for contraceptive purposes alone or applied in the
treatment of some hormone-dependent.diseases. Eveji some types of
cancer are successfully treated with high dosages of female hormones.
Hormone receptors
Usually hormones can only be effective in organs with s^pecific hormone
receptors. The existence of hormone receptors, either estrogen or
progesterone, determines whether the organ may be affected by hormones or
not. Hormone receptors are found in very large numl}ers in the female
reproductive organs: the ovaries, Fallopian tubes, Uterus, endometrium,
cervix and vagina.
Estrogen
Estrogen induces cell proliferation and cell activity. The production of
new cells is stimulated and the activity of already existing cells is
promoted. In the cervix, for example, the secretion of fluid or mucus in
the first half of the cycle and the opening of the cervical canal is mainly due
to an estrogen effect.
Progesterone
Progesterone is only effective in conjunction with estrogen. Once a cell
has developed under the influence of estrogen, progeslierone continues
Contraceptive methods} 39
to monitor the further development of this cell (e.g. secretory
transformation of the epithelium).
Progesterone, as opposed to estrogen, reduces cell activity. Inj the
cervix, for example, less fluid is produced under the progesterone effect
and the cervical canal is closed, thus forming a natural barrier against
sperm penetration.
Hormones used as contraceptives

Hormones can have a contraceptive effect by
either suppressing ovulation
or impairing egg fertilisation and interrupting sperm transport
through the cervical canal or creating unfavourable
conditions for egg transport and
implantation in the uterus.
Combined oral contraceptives (COC)

All the effects mentioned above can be achieved by combining both the
sexual hormones estrogen and progestogen (closely related to
progesterone) in one pill.
The application of estrogen leads to suppression of ovulation.
Progestogen creates unfavorable conditions for egg transport and
nidation, and also impairs sperm entrance into the cervical canal.
Progestogen alone
It is also possible to achieve a good contraceptive effect by giving
progestogen alone. This leads to the impairment of egg fertilisation by
creating unfavorable conditions for sperm penetration through the cervix.
Even if a sperm manages to pass the cervical canal, the conditions in
the uterus for successfull egg implantation would be adverse. Ovulation is
not necessarily suppressed while taking estrogen-free hormonal
contraception.
REMEMBER:
COC = Suppression of ovulation

Progestogen only = Impairment of egg fertilisation due to unfavorable condi-
tions in the uterus and sperm transport block at the cervix.
j
40 Methods of fertility control Combined

oral contraceptives (COC) Ingredients
and dosages
COC
Made in the form of a mixture of synthetic estrogens and progestogens,
either fixed (monophasic) or phased (biphasic or triphasic. Monophasic
COC have a fixed ratio of estrogen and progestogen components, while in
phased COC, the ratio of the two hormones is changed step wise. The steps
can be either biphasic or triphasic and mainly affect the progestogen dosage.
i . , .
Ethinylestradiol (EE)
This is the most important synthetic estrogen used in C0C. Basically
there are three different dosages of EE in COC:
-low dose EE COC containing 30 or 35 jug EE
- medium dose EE COC containing 50 jtg EE
- high dose EE COC containing more than 50/^,g EE.
Progestogens
The commonly used protestogens in COC are:
- Levonorgestrel
-Desogestrel
- Norgestimat
- Gestodene.
Their dosage can also vary from low-dose, medium-dose and high-dose.
COC-TYPES
Monophasic COC
This type of COC is the oldest known combination. It has gradually been
replaced by other COC which are better tolerated and mMic the normal
physiologic female cycle better. Monophasic COC usually contain a fixed
ratio of EE (30-50 ug and a derivative of progestogeit
Phased COC
Their composition reflects the normal hormonal changes during the
female cycle better. First, there is estrogen dominance, followed by an
increasing amount of progestogen. There are two types of phased COC:
Biphasic COC has an increase of progestogen at the end of the packet. It

reflects the physiological hormonal blood levels found during the
menstrual cycle, however not as accurately as the triphasic CO(t.
Triphasic COC has a combination of EE and progestogen that imitates the

hormonal blood level changes during the menstrual cycle as closely as
possible. It is mainly the progestogen dose that changes gradually during
the 21 days of intake. Almost all triphasic COC contain very low ddsages of
EE (only 30-35 /ig), thus causing less estrogen-related side effects.
COC packet types

A packet of COC can contain either 21 or 28 tablets. In either case, only
the tablets for days 1-21 inclusive contain hormones.
21 days packet.
Using a 21 packet of COC means 21 days of pill intake, followed by a
7 day pill-free interval.
28 days packet.
In a 28 packet, the last 7 tablets (days 22 - 28) contain no hormones (they
may contain either iron or sugar). The advantage is that no interruption of
pill intake is necessary, so that the user does not have to memorise
when to stop or restart a new packet.
Intake
It is very important that the instructions on the packet are strictly
followed, especially in phased COC. In triphasic COC for example, each
packet contains 21 tablets, each of different strength (step-by-step increase of
protestogen). Usually, the different strength is visualised by different
colours.
Beneficial effects of COC

COC have been widely used by millions of women for over 30 years.
The majority of women who use COC are well-protected against
pregnancy and free of major side-effects.
The contraceptive benefit outweighs by far the risk of an unwanted
pregnancy. Side-effects are infrequent and occur only in a minority of
the users.
Apart from the contraceptive benefit, COC may have a non-
contraceptive beneficial aspect as well, especially in case of malfunction
related to the female endocrine cycle.
Contraceptive benefits
highly effective method
not intercourse related
fully reversible
reliable
convenient use
under woman's control.
Non-contraceptive benefits
D beneficial effect on menstrual irregularities
D less blood loss and anemia
D less dysmenorrhea
D regular menstruation
D good cycle control
D less pre-menstrual symptoms
D less PID
D less pain at ovulation
D less ectopic pregnancies
D less mastopathy
D less functional ovarian cysts
D less endometriosis
D less sebaceous skin disorders
D possible protection against ovarian cancer.
Therapeutic indication for use of COC

Many gynecological problems are closely related to the blood levels of
the hormones estrogen and progestogen. Some disorders occur due to an
imbalance between these two natural hormones. Regular hormonal
intake in form of COC creates constant hormonal levels which may
improve the disorder.
Table 9 Therapeutic indications for combined oral contraceptive
(COC)use
Disorder COC effect
Hypermenorrhea/ Reduces blood loss

menorrhagia
Polymenorrhea Stabilises and turns menses regular
Dysmenorrhea Positive effect due to interaction with prostaglandin
synthesis
Pre-menstrual syndrome Substitution of progestogen relieves symptoms
Delay of menses Possible when necessary
Pain at ovulation Reduction by suppression of ovulation
Anemia Reduction of blood loss
Functional ovarian cysts Induces shrinking
Endometriosis Reduces pain and growth of endometriosis
Sebaceous/androgenic Reduces androgen production in ovaries
disorders
Mastopathy Less pain and premenstrual symptoms
Risks and side-effects of COC use

Extensive research has shown that, under certain conditions, there may be
a health risk for a women using a hormonal contraceptive (especially
estrogen-containing pills)
Multifactorial etiology of a disease

The etiology of many diseases is often due to the combination of two or
more unfavorable conditions. This must be taken into consideration when
discussing the risks involved in taking COC. If certain unfavourable
conditions are combined, a woman's health may be at risk.
It is not the COC which causes a disease, but its combination with
several other risk factors may promote the outbreak of certain diseases.
Example Possible future cardio-vascular disorder

An obese women, aged 38, heavy smoker, with elevated blood pressure
wishes to take COC.
- Risk factor 1 = obesity
- Risk factor 2 = age
- Risk factor 3 = elevated blood pressure
- Risk factor 4 = heavy smoker
- Risk factor 5 = COC (estrogen)
If this women develops a myocardial infarction, it is not because she
takes COC, but the addition of every risk factor contributes to her overall
risk of developing a cardio-vascular disorder.
It is the responsibility of every doctor or para-medic involved in the
distribution of COC to know about risk factors which may be enhanced by
COC use.
Risk factors for COC use

Cardio-vascular system:
- family history of cardio-vascular disease
-hypertension
-obesity
- smoker over 35 years of age
-age over 45 years
-diabetes
- hyperlipidemia.
The prevalence of these risk factors increases with age. Older women
are likely to have a longer average duration of exposure to each of the
risk factors mentioned above.
Venous thromboembolism
Female hormones, especially estrogen, can lead to changes in the blood
clotting factors, and increased coagulability and clot formation. Blood
clots may obstruct the venous blood vessels, epecially in the legs if
varicosis is present. Blood clots can also become infective or, even worse,
lead to thromboembolism. Risk factors for venous thrombosis are:
- history of thrombosis - age over 35 years
- varicose veins — immobilisation
- history of phlebitis - puerperium
-obesity -high estrogen-dose.
Liver and COC

The liver plays a very special role in hormonal contraception.
Metabolic changes due to the 'first pass effect'
When a pill is resorbed in the intestine, the hormones are bound to blood
proteins and first carried to the liver. Some metabolic changes of the
hormones occur in the liver before the hormones reach their final site of
action - the female reproductive organs. Because of the passage of
hormones through the liver, liver enzymes are induced and other blood
substances such as clotting factors which are produced by the liver can be
affected. This fact is particularly important if a woman is taking other
drugs which may also affect the liver.
Research has been carried out on how to avoid this 'first pass effect' of
the liver by application of hormones through the skin. This form of
hormone application has so far only been used for therapeutic, and not
for contraceptive, purposes.
Benign Liver Tumors

Benign liver tumors (adenomas) have been observed in women using
COC. Several results emerged from research:
1 Adenoma occurred in young women aged 20 - 35 years (this young
age is rather uncommon for the appearance of liver adenoma).
2 About 60 per cent of the women affected had used COC containing
mestranol.
3 In 85 per cent of the cases, the COC had been used for more than
four years.
These findings suggest an extrinsic origin of liver adenomas observed -
possibly the long-term intake of COC containing mestranol.
Symptoms of liver tumors are upper abdominal pain, nausea and
vomiting. In 50 per cent of all tumors there was a palpable enlargement of
the liver (hepatomegaly). Benign liver tumors (adenoma) can be very
well vascularized and massive hemorrhage may occur due to liver
rupture.
Hepatitis
Hepatitis can seriously affect the metabolic performance of the liver by
cell destruction. Elevated liver enzymes are an indicator for liver cell
destruction (necrosis). Cell destruction of the liver can be the result| of
an infectious disease such as hepatitis, or due to other reasons such as
alcohol, drugs and other toxic substances. As mentioned above, hormones of
COC have a 'first pass' through the liver. This can have a damaging
effect if the liver is already affected. Consequently it is strongly
recommended that: no hormonal contraception should be used when there is
an indication of liver disease (elevated enzymes).
Absolute contraindications for COC use:
Fast or present circulatory diseases
- arterial or venous thrombosis
- ischemic heart disease (angina)
-hypertension (>95 mm Hg diastolic)
-atherogenic lipid disorder
- focal migraine
-transient ischemic attacks
-past cerebral hemorrhage
-valvular heart disease
- family history of cardio-vascular disease.
Diseases of the liver

- acute liver disease with elevated liver enzymes
-liver adenoma
-gall stones
- porphyria.
Other conditions
-chorea
- otosclerosis
- Stevens-Johnson Syndrome
- trophoblastic disease (until normal HCG* levels are seen)
-pregnancy
- unclear genital tract bleeding
-estrogen dependent cancer (breast, cervix,etc.).
- HCG = human chorionic gonadotrophic Hormone
Relative contraindications for COC use:

- family history of cardio-vascular disease
-diabetes mellitus
- ciCarette smoking (more than 10/day)
-age above 35 and ciCarette smoking
- excess weight
-migraine (uncomplicated)
- long term immobilisation
- severe depression
- long term treatment with drugs possibly interacting with COC (epilepsy,
tuberculosis).
Chronic systemic diseases
- autoimmune disorders
- vascular malformations
- Raynaud phenomenon
-sickle-cell anemia
- systemic lupus erythematodes
- cervical intraepithelial neoplasia.
Prevalence of risk factors in developing countries

Not enough studies about the prevalence of cardio-vascular risk factors
have been carried out so far. Some studies, however, suggest that the
same risk factors typical for industrialised countries are becoming relevant
for developing countries as well. This might be due to a strong tendency of
urbanisation, as well as changing life-styles and eating habits.
Hypertension
In contrast to other risk factors, the prevalence of hypertension in
developing countries seems to be similar to the figures found in
industrialised countries.
Hypercholesterinemia
Studies carried out in developing countries suggest that serum cholesterol
levels are lower than in industrialised countries, and higher levels are
correlated with increased contact with urban cultures.
CiCarette smoking
The highest prevalence rates of ciCarette smoking in women in developing
countries occur in urban areas (7-26 per cent). In traditional
communities, the number of female smokers tends to be much lower (0-7
per cent).
Liver disease
Primary hepatocellular carcinoma is frequent in developing countries,
especially in Asia, and hepatitis B is also more frequent than in
industrialised countries.
Sickle-cell anemia
Sickle-cell anemia is among the most common hemoglobinopathies in
Africa. Since it predisposes to gallstone formation, puls containing
estrogen are not indicated. However, in homozygous sickle-cell disease,
contraception is essential, since a pregnancy may be severely life-
threatening.
Diabetes
Epidemiological data on diabetes in developing countries is scarce, but
there are no indications pf essential epidemiologic differences between
the continents.
Malabsorption
Malabsorption syndromes are frequent, particularly in rural areas, mainly
due to gastrointestinal parasites such as giardia and ascaris.
Malaria and other parasitic diseases

Millions of people in developing countries are affected by malaria and
other parasites, many of them causing anemia which particularly affects
women in their reproductive period. Contraceptives which may enhance
anemia by prolonging menstrual bleeding (such as lUDs) are relatively
contraindicated in such regions but COC and POP have a beneficial effect
on anemia.
Management of COC patients

Rules on prescription of hormonal contraceptives
Rules and regulations in industrialised countries concerning the
prescription of hormonal contraceptives such as COC are relatively strict.
Usually:
1 Only a doctor is allowed to prescribe the pill.
2 Every woman must be examined before the first pill prescription.
3 Prescriptions must be dated and include the patient's name.
4 Prescriptions are restricted to 3-6 months.
In practice, however, the rules mentioned above are not always
followed, but often neglected due to daily routine and work load.
It seems logical that the prescription of a drug (COC) requires different
regulations than simple contraceptive methods such as condoms and
spermicides, but provided that important risk factors are ruled out, and
high-risk patients referred to a doctor, the first prescription may just as
well be done by a nurse or trained non-medical staff.
Selection of patients for COC

Checking the patient before prescribing a COC usually involves history
taking and, in case of the slightest doubt, physical examination. Basically,
the risk factors for COC use (see page 46) should be taken into
consideration.
Maximum check up
1 History taking
Family history and past medical history concerning:
- age - nicotine
- cardio-vascular disorders -obesity
-thrombosis -diabetes
- hematologic disorders - drug intake
- liver disorders - gastrointestinal disorders
-gall bladder problems (malabsorption).
2 Physical examination
-Heart: rhythm, size
- Blood pressure: elevated(> 140/95)
-Liver: enlargement, pain
-Weight: obesity
-Veins: varicosis
- Breasts: lumps
-Pelvic: fibroids, ovarian cysts, cervical smear.
3 Laboratory (facultative)
-Urine: glucose (diabetes?)
protein (nephropathy?)
- Blood: liver enzymes (hepatitis?),
glucose (diabetes?) lipids (if
risk factors exist).
Choosing the right dosage

Estrogen dosage
Side-effects of COC are mostly related to the effect of estrogen. It is
therefore advisable to pay special attention to the levels of estrogen in a
COC. There are three different dosages of estrogen in available COC (see
also Tables 10 and 11).
/ Low-dose EE- COC containing 30 or 35 jug EE Most physicians

start a woman on a low-dose pill containing 30 - 35 /xg of EE. Due to low
estrogen intake, possible short- or long-term estrogen side-effects are less
common. Disadvantages of low-dose estrogen pills are the increased
frequency of spotting, breakthrough bleeding and missed
Table 10 World directory of low-dose estrogen combined oral
contraceptives (COC) (30 - 35 /*g)
Binovum Microdiol Qvacon
Brevicon Microginon Ovamezzo
Brevicon -1 + 35 Microgyn Ovoplex 30/150
Brevinor Microgynon 30 Ovoplexin
Brevinor-1 Microvlar Ovoresta M
Ciclo Milli-Anovlar Ovoresta Micro
Conceplan mite Min-Ovral Ovral L
Conova 30 Minestril - 20 Ovran 30
Conova Minestril-30 Ovranet
Contraceptive LD Minetrin 1/20 Ovranette
Demulen 30 Minidril Ovysmen 1/35
Desolett Minigynon 30 Ovysmen
Econ 30 Minilyndiol Ovysmen 0.5/35
Econ mite Minipregnon Ovysmen
Egogyn Ministat Perle LD
Eugynon 30 Minivlar Planum
Femodeen Minulet Practil
Femodene Minulet Pregnon
Femodene ED Minulette Prevenon
Femovan Mithuri Green Primovlar 30
Fironetta Moda Con Restovar
Follimin Modacon Rigevidon
Frilavon Modicon Stediril-d
General+35 Myralon Stediril-M
Ginoden Myvlar Suginor
Ginotex Nelova 1 + 35E Synfase
Gynatrol Nelova 0.5/35E Synfasic
Gynera , Neo - Gentrol 150/30 Synphase
Gynex 1/35E Neo-Norinyl Synphasec
Gynex 0.5/35E Neo - Ovopausine Synphasic
Gynovian Neocbn 1/35 Trentovlane
Levlen Neocon Tri-Levlen
Lo - Femenal Neomonovar Tri - Norinyl
Lo-Gentrol Neovletta Triagynon
Lo-Ovral Nilocon Triciclor
Loestrin Fe 1/20 Nogest Triella
Loestrin 1.5/30 Nordet Trigynon
Loestrin Fe 1.5/30 Nordette 150/30 Trikvilar
Loestrin 20 Nordiol 30 Trinordiol
Loestrin 30 Norethin 1/35 TriNovum
Loestrin 1/20 Norimin TriNovum ED
Loestrin Norinyl 1 + 35 Trionetta
Logynon Norminest-Fe Triphasil
Logynon ED Norquest-Fe Triquilar ED
Lostrin 1/20 Ortho 777 Triquilar
LynodiolO.75 Ortho 10/11 Trisiston
Marvelon Ortho 1+35 Triviclor
Marviol Ortho-Novum 10/11 Varnoline
Mercilon Ortho-Novum 1/35 Zorane 1/20
Micro Plan Orthonett - Novum Zorane 1.5/30
Micro-Ovostat_______________________________
menses. Women should be informed that these side-effects may occur,
otherwise they may lead to pill discontinuation and to unwanted
pregnancy.
2 Medium-dose EE- COC containing 50 ng EE If the amount of
estrogen (in low estrogen pills) is insufficient, occasionally
irregular bleeding or spotting may occur. In this case, a medium-dose
COC might be more appropriate. Some gynecological disorders closely
related to the endocrine cycle may even suggest the prescription of a
pill with higher estrogen content. Examples of such disorders are:
- hirsutism
-acne
-seborrhea
- alopecy
-functional ovarian cysts
- uterine hypoplasia
- breast hypoplasia
-irregular cycle with breakthrough bleeding
- rare and very light periods (hypo-oligomenorrhea).
Also, some drugs, such as broad spectrum antibiotics or drugs used in
the treatment of tuberculosis (rifampicin) may accelerate the
metabolism of estrogen, so that a higher amount of estrogen is necessary to
ensure its contraceptive effectiveness.
In summary
1 If menstrual irregularities occur during the use of a low-dose COC,
change to medium-dose COC.
2 Some gynecological conditions may improve due to the application of
higher dosages of estrogen.
3 Some drugs may decrease the security and effectiveness of COC,
higher dosages of estrogen are therefore necessary in this group of
patients.
3 High-dose COC containing more then 50 pg EE
These COC should not be prescribed for contraceptive purposes alone.
High-dose COC are only justified in combination with other medical
indications.
High-dose progestogen COC

Several gynecological problems of the reproductive organs may
substantially improve under the application of progestogen. This can
Table 11 World directory of medium-dose estrogen combined oral
contraceptives (COC) (50 /*g)
Alovlan Maya Norlestrin 1/50

Anfertil Microgynon 50 Norlestrin Fe 1 mg
Anogenil Milli - Anovlar Norlestrin 1 mg
Anovlar Minigynon 50 Normanor
Anovlar 1 mg Minovlar ED Novogyn
Anovulatorio Minovlar Novulon 1/50
Anovulatorio MK Minutes Driest 1 mg
Anulit Mithuri Driest 21
Arona Mithuri Red Driest
Berligest Monovar Ortho-Novin 1/50
Celapil Mycrogynon Ortho - Novin
Combiginor Neo - Gentrol 125/50 Ortho - Novum 1 + 50
Conceplan Neo - Gentrol 250/50 Ortho-Novum
Conlumin Neo - Promovlar Ortho-Novum 1/50
Contraceptive HD Neo - Stediril Orthonett
D-Norginor Neogentrol Orthonett 1/50
Denoval Neogynon Ovadon
Duoluton Neogynona Ovcon 50
Duotone Neovlar Ovidon
Ediwal Nodiol Ovoplex
Estrinor Non - Ovlon Ovral 0.25
Eugynon 50 Non - Ovlon Ovral
Eugynon Nor-50 Ovran
Eugynon 0.25 Noral Perle
Eugynona Nordet 50 Pil KB
Evanor Nordiol Plan mite
Evanor-d Norethin 1/50 Planovlar
Femenal NorFor Primovlar
Floril Norginor Prolestrin
Follinet Noriday Promovlar 50
Follinyl Noriday 1+50 Regovar 50
Genora 1+50 Norimin Regovar
Gentrol Norinyl 1 + 50 Regunon
Gravistat Norinyl 1/28 Rosanil
Gravistat Norinyl Stediril 50
Gravistat 250 Norinyl -1 Stediril
Gulaf Norit Stediril-d
Gynophase Norit Ultra - Novulane
Logest 1/50 Norlesterire Zorane 1/50
Mithuri Blue Ovlar
either be done by prescribing a higher progestogen COC or prescribing a
'progestogen only* method (POP, injectables or implants). Indications are:
-excess cervical secretion -premenstrual syndrome
-marked cervical ectopia -hypermenorrhea
-fibroids -menorrhagia
-endometriosis -premenstrual spotting.
- mastopathia cystica
Hormonal effects:
Under a regime of either excess or lack of estrogen or progestogen, one or
more effects may become visible.
Estrogen excess Estrogen deficiency

- nausea plus vomiting - spotting
- fluid retention -- breakthrough bleeding
-weight gain -hot flushes
- cyclic headaches - dry vagina
- breast tenderness - hypomenorrhea
-dizziness -amenorrhea
-irritability
-discharge
-hypermenorrhea
Progestogen excess Progestogen deficiency

-oily skin and scalp -premenstrual spotting
- acne - late breakthrough bleeding
-chloasma -hypermenorrhea
-increased appetite
- weight gain
-depression
- tiredness
- decreased libido
- dry vagina
-breast fullness
-hypomenorrhea
Starting the pill

Before starting the patient on a pill an accurate history taking and if
necessary a physical examination (see page 49) should be performed.
When starting a new patient, the first choice should be a low-dose
estrogen brand, containing not more than 30- 35 jtig EE. If the patient
already has a history of irregular periods, a medium-dose brand (50 /*g
EE) can be chosen.
The patient must be instructed to start on the first day of menstruation, to
ensure maximum effectiveness from the first cycle on.
It is advisable to use barrier methods (such as condoms) in the first
cycle to avoid failure and unwanted pregnancy. This applies especially to
all cases where the pill is started later than the first day of menstruation.
Starting routines for COC

- Menstruation first day
-Postpartum
not breastfeeding 4 weeks after delivery
breastfeeding COC not advised
- Postabortion the same day
Changing method of contraceptive

- after low-dose EE usually 7 days break
- after higher dose EE instant switch, no break
- after POP first day next menstruation or instant
switch
- after IUD first day next menstruation
- after injectable instant switch
-after implant instant switch
Systems of pill intake

The most common method is the 21 days intake followed by a break of
7 days. For women who do not want to remember when to stop and
restart the pill the 28 day packet (everyday packet) may be more
convenient; the pills are taken continuously without a break. Both the
21 and the 28 day intake will maintain a regular menstruation (every 4
weeks).
For some special reasons, such as anemia due to very heavy periods,
dysmenorrhea or migraine during periods, it may be recommendable to
reduce the frequency of menstrual bleeding. This is possible with the 3-
months intake of 3 x 21 tablets without break. Only after 63 days the user
will have her period.
1 21-day packet
One pill every day for 21 days, followed by a break of 7 days (during
which menstruation will normally occur).
2 28-day packet
Pill intake every day for 28 days, no break. The last 7 puls are placebos.
Menstruation will occur during the intake of the last 7 tablets.
3 3-months intake
Three packets of 21 pills are taken without break; a continuous intake of
3 x21 tablets for 63 days. After these 63 days there is a break of 7 days,
in which menstruation will occur. Restart again with three new packets
of 21 pills after the 7 day pill-free interval.
Follow-up visits for COC users
After the first 3 months of pill intake, a follow-up visit may be useful
since menstrual irregularities in the first months of intake are likely (about
30 per cent). This is especially the case with low-dose brands. Counselling
may be necessary to avoid drop-out or failure. Follow-up should be
performed during subsequent visits for purposes of check-up and cervical
(PAP) smear (every 6 months or yearly). If risk faetors are present, close
and regular follow-up should be ensured (in older women, diabetes or
hypertension). During the follow-up visit, possible side-effects should be
recognised and discussed. Further action or pill change may be necessary.
Indications for stopping the pill at a follow-up visit

P Repeated recording of BP systolic >140 and diastolic >95.
D Unexplained new chest pain.
D Unexplained shortness of breath.
D Recurrent fainting or collapse.
D Weakness of a limb.
D New headache or migraine attacks.
D Swelling or pain in the calf.
D Onset of jaundice.
D Planned surgery or immobilisation.
D Age now over 35 years.
D New additional risk factors emerging, such as hyperlipidemia or
diabetes.
D Severe depression.
D Pathological cervical smear (cervical intraepithelial neoplasia).
Practical management of pill related side-effects

Irregular bleeding
Normally, bleeding abnormalities in the first 3-6 months of COC use
may be treated by the method 'wait and see', because they tend to
disappear with regular pill intake. Counselling a patient with irregular
bleeding at a follow-up visit should always include the following questions:
- duration and amount of irregular bleeding
- timing of irregular bleeding (midcyclic, premenstrual)
- most recent period
- duration of pill use
-dosage
- mode of intake
- regularity of intake
-exclude onsets of vomiting, diarrhea or drug interaction.
Recommended procedure
If Symptoms persist, or the patient is afraid and wants treatment:
Depression
It may be difficult or impossible to diagnose the cause of depression as
uniquely pill related, since many underlying conditions may lead to
depression as well. A careful social and personal history should be taken to
exclude external events as the cause of depression. Some data suggest that
alteration of the blood chemistry levels, especially of Vitamin B6
(piridoxine) may induce depression.
Migraine and headache
Headache is a very common symptom when taking drugs, and about
10-15 per cent of women even develop headaches when using placebo
instead of COC. In women with pre-existing problems of headache and
migraine, the condition may worsen under COC intake.
A woman on COC complaining about severe headache or migraine
must always be taken seriously because it could be the first symptom of
a cardio-vascular disorder affecting the central nervous sytem.
The most common patterns of headache occur during the 7 days break
(hormone-free interval) due to the sudden drop in hormonal blood levels.
A possible solution could either be reducing the frequency of
menstruation by switching to the three monthly intake (3x21 tablets), or
the replacement with 20 fig EE/daily during the pill-free interval.
Nausea and vomiting

Nausea and vomiting occur frequently when people have to take drugs. It
is hard to tell whether the causes are drug-related or psychological.
Studies have shown that nausea and vomiting occur as often under
placebo intake as under COC.
Nausea and vomiting are one of the main reasons for pill
discontinuation. If the cause is drug-related, it is usually due to the
estrogen level, therefore it may be useful to lower the EE dose if possible.
Changing the timing of pill intake, taking the pill with meals or before
sleeping, may also improve the symptoms.
Weight gain
Often patients do not want to take the pill because they are afraid of
gaining weight. Despite a possible minor weight gain (1 -2 kg) due to
fluid retention (= estrogen effect), weight gain is usually not COC-related.
Some increase in appetite may occur due to the effect of progestogen in
the COC. If there is a subtantial weight gain, change to a COC
containing the lowest dose possible of EE and PG.
Progestogen-only pill Effects
and mode of action
The POP exerts its effects in the following ways:
1 alteration of cervical mucus
2 endometrium changes (unreceptive for fertilised egg)
3 ovarian suppression (but not in every cycle)
4 decreased tubal motility.
In contrast to the COC effect, the contraceptive effect of progestogen-
only methods is not due to a suppression of ovulation. The most
important factor for its contraceptive effect is the alteration of the cervical
mucus and blockade of sperm entrance into the cervical canal. The
effects of POP on the reproductive cycle and as a contraceptive are:
-FSH-inhibition
- LH-inhibition +
- anti-ovulatory effect +
- hostile cervical mucus +++
-endometrium changes atrophic
-failure rate 0.5-4.0
-contraceptive efficacy +++
At the time of ovulation, the cervical canal is usually open and there is
a very clear mucus, which is easily penetrable by sperms. Under the
influence of progestogen, the mucus becomes thicker and unfavorable to
sperm penetration. Also, the endometrium (inner layer of the Uterus and
site of egg Implantation) changes under progestogen. Due to these
unfavorable and hostile changes of the endometrium, there is hardly a
chance for Implantation even of a fertilised egg.
In summary, POP acts by impairment of egg fertilisation and
impairment of egg implantation.
The Pearl Index of POP is good, only 2 - 4 per 100 women years. The
reason for the higher Pearl Index (compared to COC) is mainly due to
incorrect pill intake. The fact that almost 50 per cent of pregnancies under
POP occur because of incorrect pill intake indicates the importance of
counselling for POP use.
The efficacy of POP is very good in women with already decreased
fertility, such as older women at the end of their reproductive period or
after delivery and during lactation.
POP intake
More than any other hormonal contraceptive, the POP requires a very
regular intake. Progestogen has its strongest effect on the cervical mucus
approximately 3 hours after intake. The effect lasts for 16 to 19 hours.
The POP should be taken at the same hour every day.
The best time is the evening because the protective effect will be
strongest at night, when intercourse commonly occurs. Very accurate
pill intake may be a problem for many women and restrict the number of
potential users. Frequent travellers, night-shift workers, and other
women with an irregular lifestyle may have problems with an accurate to
the hour intake. In the following cases, additional precautions (e.g.
condoms) should be taken:
if the POP was taken more than 3 hours late
if one POP pill was missed
in case of vomiting and diarrhea.
Advantages with the use of POP
* Has minimal side-effects and cause no severe morbidity. The major
group of users are women with risk factors and contraindications for
COC listed above.
* Is not associated with any incidence of carcinoma.
* Does not affect blood lipid levels, liver function, blood pressure and
coagulation.
* Does not interfere with the amount and the composition of milk during
lactation, so they are an ideal contraceptive for breast-feeding women.
* If a pregnancy occurs during POP intake (possibly due to incorrect
intake), the fetus is not at risk.
* The contraceptive effect of POP is fully and immediately reversible.
Indications for use of POP
* During lactation.
* Women over 35 years of age.
* Smoker.
* Women unable to tolerate COC.
* History of thromboembolic problems.
* History of cardiovascular problems.
* History of metabolic disorders.
* Controlled hypertension.
* Diabetes.
* Sickle-cell anemia.
* Migraine.
* Liver disorders.
* Women with premenstrual tension.
Disadvantages and possible side-effects of POP
No major morbidity has been observed in POP users. Progestogen-only
contraceptives may interfere with the normal menstrual cycle leading to
bleeding irregularities, such as spotting, breakthrough bleeding and
amenorrhea. The duration and amount of blood loss during menses may
change. This happens especially in women with pre-existing menstrual
irregularities. Amenorrhea is a major problem because the woman might
think she is pregnant.
POP should not be given to very young women because the occurrence of
amenorrhea is more likely soon after menarche. The main side-effects are
menstrual irregularities.
The incidence of functional ovarian cysts is increased under POP intake
and breast tenderness may occur as well. The incidence of ectopic
pregnancies is increased: this might be due to alterations in tubal motility
and subsequent slower passage of an egg through the Fallopian tube.
Women with a history of recurrent PID with possible adhesions of the
Fallopian tubes should therefore not be given POP.
POP is not suitable for women known, or assessed, to be, or to have:
D Poorly motivated.
D Unreliable.
D Irregular life style.
D Irregular periods.
D Previous ectopic pregnancies.
D Malabsorption syndrome.
D History of breast or genital tract cancer.
D Previous functional ovarian cysts.
D Liver tumors.
D To need maximum contraceptive effect (high risk women).
POP and family planning activities in developing countries
In family planning programmes, POP should be part of the method-
mix, indicated especially for women immediately after delivery and during
lactation. The contraceptive security of POP is very good in women with an
already decreased level of fertility, such as older women at the end of
their reproductive period (over 35 years).
A major effort in counselling is necessary, especially with respect to
intake and the common side-effects such as erratic bleedings and possible
amenorrhea.
POP should be prescribed to women with risk factors for COC.
Special programmes for postpartal women including counselling and
follow-up visits, may improve the popularity of the method.
Long-term progestogen-only contraception
Injectables
Two synthetic progestogen derivatives have been widely used and are
available for deep intramuscular injection:
- Medroxy progesterone acetate (DMPA) 150 mg
- Norethisterone oenanthate (NET-OEN) 200 mg
Both are in a crystalline suspension from which the hormones are steadily
released ensuring continuous blood levels.
Mode of action
After progestogen injection (DMPA or NET-OEN), no more
gonadotrophins are released from the anterior pituitary gland and
ovulation is inhibited. Injectables also have intense effects on the
endometrium leading to atrophia and subsequent amenorrhea. The
cervical mucus becomes hostile and impermeable for sperms. Injectables
act on three levels:
level I by inhibition of ovulation
level II by endometrial changes
level III by hostile cervical mucus
Effect on menstrual cycle

Under injectables, the cycle usually becomes irregular. If menstrual
bleeding occurs, it is not cyclic and looses its typical pattern and character. In
the beginning, bleeding may increase (metrorrhagia) and irritate the
patient. Later, oligomenorrhea and amenorrhea are common. Erratic
bleeding is the main reason for discontinuation of the method.
Application, dosage and time intervals

DMPA 150 mg (= 1 ml) in the first 5 days of the menstrual cycle, repeated
every 90 days.
NET-OEN 200 mg (= 1 ml) in the first 5 days of the menstrual cycle,

repeated every 8 weeks for 3 - 6 months, and then in intervals of 12 weeks.
Application at shorter intervals (8 weeks) in the first cycles improves
safety.
Return to fertility
Due to the depot action of DMPA, it usually takes up to 9 months after
the last injection of DMPA before fertility returns to normal. After one
year, fertility is equal to that of non-users.
Return to fertility after NET-OEN injection is faster than after DMPA.
Normal fertility is restored approximately four months after the last NET-
OEN injection.
Because of this slow return of fertility after DMPA, it is advisable to
give:
- DMPA to long-term users
- NET-OEN to shorter-term users, when the return of fertility is desired in
the nearer future.
Advantages of injectables
The application of injectables can have major advantages in family
planning programmes in developing countries. They can be administered by
trained health workers. In order to avoid the risk of an HIV infection due
to contaminated needles, the administration must take place under strictly
sterile conditions.
Once a patient is familiar with the method and has experienced no
side-effects, the application can take place without any medical or
paramedical supervision.
The advantages of using long-term progestogen-only injectables as a
method of contraception are as follows:
Highly effective method.
Not coitus-related.
Easy to use (no daily intake).
No continuous motivation necessary.
No estrogen side-effects.
Amenorrhea may be an advantage from the medical point of view
(reduction of anemia).
Possible reduction of ascending infections.
No effect on blood pressure.
No effect on liver metabolism.
No effect on blood coagulation.
Less risk of ectopic pregnancies (compared to POP).
Pre-existing breast lumps and ovarian cysts may shrink.
Improvement of hematological picture in sickle-cell anemia.
Accepted in many cultures.
Trained health workers can prescribe and administer injectables.
Patients especially suitable for injectables:

- estrogen intolerance or contraindications
- lack of reliability
- desired family size achieved
- postpartal contraception in breast-feeding women
- women with irregular life style
- women with pre-menstrual or menstrual problems
-anemic women
-women with uterine fibroids
-women with endometriosis
- women with sickle-cell anemia
- women with mastopathy.
Disadvantages of injectables
The main disadvantage and cause of discontinuation are bleeding
disorders, especially during the first month of intake. Bleeding
irregularities occur in approximately 30 - 50 per cent of all patients. There is
no control of the menstrual cycle after application of an injectable. This
lack of control of the cycle may be distressful! for some women,
especially if periods of amenorrhea are wrongly interpreted as pregnancies.
The delayed return of fertility, particularly after the application of
DMPA (9 months) may last longer than desired by the user, leading to
false interpretations and possible conflicts between partners. Depression
may occur more often due to progestogen dominance of this estrogen-
free method.
The possible disadvantages and side-effects of injectables can be
summarised:
D Erratic bleeding (30-50%).
D Delayed return of fertility.
D Depression.
D Weight gain.
D No cycle control.
Practical management of injectables
/ Patient counselling
The initial and follow-up counselling should include:
- information on advantages and disadvantages
- long- and short-term effects
-mode of administration
-side effects, particularly erratic bleeding and amenorrhea
- handling of common side-effects
- importance of repeating the injections on scheduled days
- delayed return of fertility.
2 Choice of type of injectable
DMPA is for long-term users (where no short-term return to fertility
is desired).
NET-OEN is for short-term users.
3 Route of administration
Injections should be deep intramuscular, preferably in the gluteal region.
4 Time of administration
During the first days of menstruation, DMPA is given every 12 weeks.
NET-OEN is first administered every 8 weeks for 6 months, then later
every 12 weeks.
5 Equipment required by staff
- one dose of injectable
-skin disinfectant
- sterile syringe and needle
-needle length 3 - 4 cm for deep intramuscular injection.
Always use sterile Instruments to prevent HIV infection.
NORPLANT® subdermal implants

The NORPLANT implant consists of six silastic capsules which are filled
with levonorgestrel (LNG). One capsule has a length of approximately 3
cm and a diameter of 2.4 mm. Levonorgestrel is especially suitable
because it is released on a very slow basis after subdermal Implantation.
The total amount of LNG in one capsule is 36 mg.
During the first 18 months, 80 fig are released on a daily basis, later, 30
jug are released daily on a constant basis up to the fifth year.
Mode of action
Like all other estrogen-free hormonal contraceptives, NORPLANT
subdermal implant has two main modes of action:
1 alteration in cervical mucus causing impermeability of the sperms
2 endometrial changes.
Implants effect ovulation and menstruation. During the first year, 90
per cent of users have a total ovarian suppression due to the high
concentration of LNG. No ovulation takes place and there is no
menstruation. Later, there is less ovarian suppression (only in about 50
per cent of users), but the contraceptive effect is still prevalent due to
cervical and endometrial changes.
Effectiveness of implants
The effectiveness of NORPLANT is very high: pregnancy rates are
0.2-1.3 per 100 women years of use. The cumulative pregnancy rate
after 5 years is lower but still very good with 2.6 per 100 women years.
Acceptability and discontinuation rates

Acceptability for NORPLANT is very good especially compared to other
estrogen-free methods of contraception. In the fifth year, 50 per cent of
patients are still using NORPLANT.
The main reasons for discontinuation are erratic bleeding and loss of
cycle control.
Reversibility
The reversibility of NORPLANT has been demonstrated: within 24
months after removal the cumulative pregnancy rate was found to be
95 per cent (see Figure 12).
Factors influencing the failure rates of NORPLANT

Time: the failure rate increases after the 6th year of constant use due
to the decline in hormonal blood levels.
Obesity: the contraceptive security of NORPLANT can be lowered due
Fig 13 Relationship between body weight and contraceptive effectiveness of
NORPLANT
to metabolic changes of levonorgestrel and increased production of

estrogen in fat tissue.
Advantages of implants
Long-term highly effective method.
No estrogen-related side effect.
Not coitus-related.
Not depending on user's memory or compliance.
Amenorrhea may be beneficial when strong anemia is present.
May be administered by trained paramedical personnel.
No frequent application necessary.
Acceptable return to fertility after removal.
Low discontinuation rate.
Less frequent vaginal mycosis and PID.
Disadvantages of implants
D No menstrual cycle control.
D Menstrual irregularities.
D Amenorrhea may be distressful.
D Possible infection and expulsion of the capsule.
D Needs sterile working.
D Removal may be forgotten.
D Higher incidence of ectopic pregnancies.
Practical NORPLANT application
1 Timing of Implantation
The Implantation of the capsules should take place in the first week of
the menstrual cycle (first 7 days after the beginning of menstrual bleeding).
The woman must make sure that she is not pregnant at the time of
implantation. (Physical examination is recommended.)
Implantation can also be carried out after abortion and delivery in
non-breast-feeding women. (Since little evidence is available to date about
the effect of NORPLANT in breast-feeding women, at present this
contraceptive should not be inserted during breast-feeding).
2 Implantation and removal procedure

The implantation of the 6 capsules is superficially subdermal. The
preferred part of the body for insertion is usually the upper arm. It is
important to avoid deep implantation into the muscle tissue because
removal may be much more difficult and time-consuming.
It is essential to work under sterile conditions to avoid infection and
possible expulsion of the capsules. The implant should be removed after a
maximum of 5 years.
Implantation and removal require local anesthesia. Removal is more
time consuming and takes approximately 15-30 minutes (three times
longer than implantation), due to fibrosis which has meanwhile developed
around the capsule.
Intrauterine contraception (IUD)

Prevalence
The intrauterine contraceptive device (IUD) is a method of contraception
used throughout the world. In industrialised, western countries, an
estimated 4 per cent of the female population of reproductive age use
an IUD. In China almost 40 million women use an IUD.
Mode of action
IUD are approximately 3 - 6 cm long devices of different shapes which
are inserted into the uterine cavity. There have been a number of studies
on the best shape and material for an IUD. Unfortunately, improving
one aspect of the IUD may worsen another. For example, increasing the
surface area leads to more safety, but also to an increase of side-effects
such as pain and erratic bleeding.
When an IUD is placed into the uterine cavity, a foreign body reaction
occurs, characterized by specific changes in the inner layer of the uterus
(endometrium) such as edema and infiltration of leucocytes. It has been
suggested that the mode of action of the IUD is directly related to these
changes, especially the leucocyte and macrophage reaction. It is thought
that egg transport and fluid secretion in the Fallopian tubes are also
altered by an IUD in the uterus. The IUD interferes with implantation by
producing unfavorable endometrial changes.
Types of IUD
Inert devices
Made of stainless steel, inert devices are very common in China.
Copper-bearing devices
Copper-bearing lUDs dramatically reduce the number of egg
implantations in the Uterus. The inclusion of copper into the IUD allows
smaller devices without loss of efficiency and with fewer side-effects.
Because of their smaller size, they are easier to apply in women with a
small Uterus. Copper also has a bacteriostatic effect, reducing the number of
possible infections due to lUD-use. A copper-bearing IUD is effective for 3
- 5 years. They all carry a monofilament thread.
P copper-bearing part
Fig 15 Examples of copper-bearing lUDs.
Hormone releasing IUD

Because of their complementary effects, the combination of IUD and
the hormone progestogen is beneficial. lUDs with progestogen have a
core containing microcrystals of progestogen (PG) suspended in a fluid
medium and surrounded by a membrane.
The disadvantage is that, due to its relatively short life-span of only
two years, frequent removal is necessary. One positive aspect of PG-
bearing devices is the significant reduction in menstrual blood loss.
Women complaining of severe dysmenorrhea tend to experience relief
after insertion of a PG-containing IUD. The effect of PG on the cervical
mucus, which becomes inpenetrable and hostile for sperms, improves
the contraceptive safety of the method.
Fig 16 Examples of progestogen-bearing (PG) lUDs
Effectiveness of IUD
The failure rates of IUD are influenced by various factors including:
- type of IUD (inert, copper or PG)
-shape, especially surface area of the IUD
- competence of the doctor/nurse inserting the IUD
- intrauterine position
- age of the user
- duration of usage.
Failure rates for copper-IUDs reach approximately 2 per 100 and failure
rates for progestogen-IUDs reach approximately 2 - 2.9 per 100. Failure
rates largely depend on the age of the user and duration of IUD use.
Table 12 Failure rates for copper-IUDs

Age Year 1 (%) Year 3 (%)
20 4.1 2.7
25-29 2.6 1.8 30-
34 2.1 2.9 35
0.3 1.9
The reasons for failure are:

- expulsion
- dislocation (intracervical position)
- time factor in hormone releasing lUDs.
Reversibility
Normal return to fertility after lUD-removal can be expected. Studies
have revealed that women who did not continue the use of an IUD became
pregnant at a rate of 85 per cent (Life Table analysis) within one year of
removal. This approximately corresponds to values found in a non-
contraceptive user group.
Benefits of IUD use

i
JUDs are highly effective.

No systemic metabolic effects occur.
Use independent of coitus.
Under the woman's control.
Normal return to fertility after removal.
Relatively cheap and easy to distribute.
No frequent application necessary.
Not depending on user's memory or compliance.
No interaction with milk production (lactation).
PG-IUDs may reduce dysmenorrhea.
Patients
Those suitable for IUD are:
-women with complete family or at least one or two children
- unreliable patients
-women with risk factors for COC use
- postabortion
-postpartum
-postcoital insertion.
Risks and disadvantages of lUDs

There are some risks involved in the use of lUDs. There is a higher
incidence of infections with subsequent PID, likely to lead to adhesions in
the Fallopian tubes and infertility in IUD patients. Other complications are
often related to the insertion procedure, where damage to the Uterus,
especially Perforation, may occur. This is particularly likely to happen
when the Uterus is soft and fragile, for example after abortion or
postpartum. Excessive blood loss during menstruation and pain can be
another irritating side effect.
The pelvis and genital organs need to be examined, and trained
personnel are needed for lUD-insertion. If the patient becomes pregnant
while using an IUD, the risk of an ectopic pregnancy is high.
Disadvantages of IUD
G Painful insertion.
G Menstrual bleeding may increase.
G Higher risk of pelvic inflammatory disease (PID).
G Pelvic examination necessary
G Trained personnel necessary.
G Risk of uterine Perforation.
G Expulsion.
Q Risk of ectopic pregnancy increased.
G Risk of abortion increased when pregnancy occurs (even after
IUD removal).
Contraindications
Signs and Symptoms against the use of IUD are:
-pregnancy
- acute or chronic pelvic inflammatory disease (PID)
- any vaginal infection
- purulent cervical discharge
- symptomatic uterine fibroids
-uterine cavity incompatible for IUD use
-abnormal uterine bleeding.
IUD insertion
Importance of correct insertion
The correct insertion of an IUD is the precondition for its successful
use. Uterine Perforation, infection with pelvic inflammatory disease, pain,
bleeding, expulsion and unwanted pregnancy are some of the
consequences of incorrect applications of an IUD. Normally IUD
insertion is performed in clinics or semi-clinical institutions.
The most important factors contributing to successful insertion and
use are:
- training of inserting personnel
- experience of inserting personnel
- insertion technique
- timing of insertion
- quality of follow-up and care.
According to the experiences made in many countries, well trained
paramedics can successfully perform the insertion. A gynecological
examination is essential to select suitable patients for IUD use and risk
patients with uterine or cervical pathologies have to be excluded from
the IUD contraceptive method: therefore, a certain amount of experience in
pelvic examination is necessary.
Timing of insertion
Insertion of the IUD during or shortly after menstruation is preferable,
because the cervical canal is slightly open, which facilitates insertion
procedure. Another advantage is that during this time, the application is
less painful and the patient experiences less foreign body discomfort.
However, several studies have shown that the IUD may be inserted equally
well on the day it is requested with a relative amount of safety.
Best time
From the ending phase of menstruation up to day 19 is the best period.
Note that an insertion during any days of heavy menstruation has a higher
expulsion rate. About 40 per cent of the patients are unaware of the loss of
the IUD when it occurs during menstrual bleeding. lUDs should not be
inserted after day 19 of a 28-day cycle, unless a pregnancy can be ruled
out.
Postpartum insertion
Before 6-8 weeks postpartum expulsion rates are doubled if inserting

before 8 weeks postpartum (i.e. not recommended). lUDs do not interfere
with milk production or composition, so they are a suitable contraceptive
method for breast-feeding women.
Postabortion insertion
lUDs can be inserted immediately after flrst trimester abortion. Insertion
after abortions in later pregnancy stages (second trimester) lead to a higher
expulsion rate.
Insertion technique
Before insertion, an inspection of the vagina and the cervix should take
place, followed by a basic gynecological examination to estimate uterine
size and configuration and check for conceivable pathology (pelvic
inflammatory disease or tumor) in both adnex regions. The cervix should
then be cleaned with a disinfectant. After disinfection, it is recommended to
measure the length of the uterine cavity to estimate the size of the
suitable IUD. It is extremely important that all Instruments are sterile.
lUDs are usually applied by means of an applicator. The
introducer/applicator should be carefully passed through the cervical
canal, then the IUD should be released according to the manufacturer's
instructions.
Perforation may occur when pushing the IUD out of the applicator,
especially in a soft Uterus after an abortion. It is very important to achieve a
good intracavitary (fundal) placement of the IUD.
Follow-up
A follow-up examination of the patient 3 months after IUD insertion is
recommended.
Complications of IUD insertion

Perforation
•
The danger of Perforation is greatest at insertion postabortion when the

uterus is soft and vulnerable. In case of Perforation, the IUD enters the
abdominal cavity, possibly damaging beweis, bladder and other intra-
abdominal organs.
If possible, the IUD should be removed immediately, especially if it is
a copper-bearing one. Location of the IUD is best performed with the
help of an X-ray or ultrasound and removal by laparoscopy, if
available.
Pain
Bleeding or pain can occur immediately after insertion of the IUD or
after several days, particularly during the first menstrual periods. If pain is
very strong immediately after insertion and the patient in danger of
collapse, the IUD has to be removed. If pain is moderate and tolerable,
some pain killers should be prescribed and the patient should be given a
follow-up appointment. If complaints persist or an infection with fever
occurs, the IUD has to be removed.
Infection
When inserting an IUD, the vagina and cervix have to be examined
carefully. Should there be any indication of infection such as as offensive
purulent cervical discharge, an IUD is contraindicated.
Because of the increased risk of infection during IUD use, the life style
and sexual habits of the woman must be taken into consideration. Women
with an increased risk of sexually transmitted diseases should not use an
IUD.
Erratic or increased uterine bleeding

An IUD can lead to erratic bleeding due to the foreign body reaction in
the uterine cavity. This may especially be the case if an infection is
present or uterine fibroids alter the configuration of the cavity. Increased
menstrual bleeding may also occur with lUDs. If the woman is already
anemic and menorrhagic episodes are frequent, IUD removal must be
considered to avoid further blood loss.
IUD expulsion
Spontaneous IUD expulsion or loss may occur without Symptoms and
may not be noticed. Expulsion is more frequently seen in the first months
after insertion especially after postabortion or postpartum insertion or if
the IUD is too large.
Vaginal barrier methods

There are three types of mechanical or chemical vaginal contraceptive
methods:
1 diaphragm
2 cervical caps
3 spermicides.
While spermicides are readily available and an easy to apply method
(see page 29), the diaphragm and caps need medical or paramedical
counselling and fitting. A gynecological examination is necessary to
choose the adequate size and shape.
The diaphragm and caps should always be used with spermicides to
increase their effectiveness. Vaginal barrier methods in combination with
spermicides are highly efficient in preventing sexually transmitted diseases
and upper genital tract infections leading to pelvic inflammatory disease.
Failure rates are lowest in older women (aged 35 years and above) because of
their already decreased fertility rates. Long-term use decreases failure rates
further and correct fitting by a skilled medical or paramedical person
influences the effectiveness of these methods considerably.
Vaginal diaphragm
History
The vaginal diaphragm was first introduced by a German doctor, Hasse, in
1882 under the pseudonym 'Mensinga'. The original model of Hasse was
developed further by a Dutch doctor, Aletta Jacobs. Her scientific
publications led to the name of 'dutch cap', which became very popular in
the USA and was widely accepted by the American female population.
After the introduction of hormonal contraception in the 1960s, the
diaphragm lost some of its original popularity. Today, knowledge about
risk factors and complications resulting from hormonal contraception
and under the impact of an increasing risk of sexually transmitted diseases,
this method is regaining new popularity and acceptance.
The main advantage of the arcing diaphragm is that it can easily be
folded and inserted into the vagina, furthermore it exerts a strong pressure
on the vaginal walls. This can be particularly important in women with
poor pelvic floor tone or with anatomical changes such as cystocele or
rectocele formation.
Choosing the adequate diaphragm is often a matter of personal taste
and may depend on the fitting ability of the user.
Mode of action
Like all other vaginal barrier methods (occlusive cap, etc.), the diaphragm
should only be used in combination with spermicides, thus ensuring double
action of a mechanical and a chemical barrier, with the diaphragm acting
mainly as a large reservoir for spermicides around the cervix.
The correct position of the diaphragm in the vagina should be extending
from behind the pubic bone to the posterior upper part of the vagina
(posterior vaginal fornix).
Before intercourse, the user must check that the diaphragm is covering
the cervix and the cervical canal completely.
Effectiveness
The effectiveness of this contraceptive method is best in long-term users
and women over 35 years of age. The overall failure rates range from 2-
15 per 100 women years.
Compared to other vaginal barrier methods or the use of spermicides
alone, the diaphragm has the lowest failure rates. The main cause of
failure is incorrect size (fitting), incorrect insertion by the user or
displacement during intercourse.
Advantages of the diaphragm
Effective method when used correctly.
No systemic side-effects.
Reduction of risk of sexually transmitted diseases (STDs).
Not felt by the male partner.
In female hands and under the woman's control.
Extra lubrication when used with spermicide.
Less disruptive than condom use.
Disadvantages of the diaphragm

D Must be initially fitted by a trained health worker.
D Vaginal manipulation and examination necessary.
D Possible discomfort during intercourse.
D Diaphragm and spermicide more expensive than other methods.
D Some loss of vaginal sensation possible.
D Vaginal irritation due to spermicide may be experienced.
D Can be messy due to spermicide.
D Possible increased incidence of urinary tract infections (due to the
obstruction of the urethra/bladder neck by the diaphragm).
Fitting the diaphragm

The selection and fitting of a diaphragm can either be done by a doctor or
a trained health worker, but the ability to perform a basic gynecological
examination is essential. The size of the diaphragm should correspond
roughly to the distance between the posterior upper part of the vagina
(posterior fornix) and the pubic bone (symphysis).
Fitting a diaphragm means selecting the largest possible size which is
tolerated by the user without discomfort.
If the diaphragm is too small, there will either be a gap behind the
symphysis or the upper part of the diaphragm will not cover the cervix
completely, and dislocation of the diaphragm may occur during
intercourse.
If it is too large, discomfort may arise due to excessive pressure on
the vaginal walls.
Teaching the user

First, the woman should be taught to identify her own cervix (it may
feel similar to the tip of a nose). Then she is taught to insert the diaphragm
herself and remove it afterwards. Insertion takes place either in a squatting or
lying position, or with one foot on a chair (see Figure 20).
Before insertion, the diaphragm must be filled with spermicide. During
insertion into the vagina, the diaphragm should be compressed with two
fingers to reduce its size. If this is too difficult, an introducer may be
used. It is very important to check that the cervix is completely covered
after insertion.
After intercourse, it should remain in place for at least 6 hours. For
removal, the index finger is inserted into the vagina under the anterior
rim (behind the pubic bone) and the diaphragm is gently pulled
downwards.
Important instructions for users of diaphragms

* Use your diaphragm every time you have intercourse.
* Put spermicide cream or jelly into your diaphragm before use.
* To apply the spermicide, hold the diaphragm like a cup.
* Before inserting the diaphragm, locate your cervix with the index
finger.
* After insertion, make sure that your cervix is completely covered, and
that the front rim is in place behind the pubic bone.
* Insert the diaphragm at any time before intercourse (up to 6 hours
earlier).
* If no intercourse has taken place within this time, spermicide should be
applied again into the diaphragm.
* If repeated intercourse takes place, it is advisable to apply additional
spermicide to the vagina without removing the diaphragm.
* The diaphragm should be left in place for at least 6 hours after
intercourse.
* You can shower or bath with the diaphragm in place.
* To remove the diaphragm, hook your index finger behind the frontal
rim and pull gently.
* After removal, wash the diaphragm with water and a mild soap and
let it dry.
* Store the diaphragm in a dry, clean box.
* After about 2 years of use, it may be necessary to use a new diaphragm
(check with the manufacturer's advice).
Difficulties and contraindications for use of the diaphragm

It may be impossible to use a diaphragm in the following conditions:
- extreme dislocation of the cervix (commonly seen in marked retro-
version or anteflexion of the Uterus)
-genital prolapse
-poor pelvic floor tone
- previous surgery of the vagina or perineum with scars
- vesico-vaginal or recto-vaginal fistula
-vaginal infection
- recurrent urinary tract infection
- allergy against rubber or spermicide
-user reluctant to touch own genitals.
It is recommended to have the diaphragm checked for size:

- after a pregnancy
- after any kind of vaginal surgery
- if the diaphragm causes pain or irritation
- after 2 years of use (life span of diaphragm).
Cervical caps
History
In 1838, a German gynecologist, Wilde described an occlusive cap for
the cervix which could be used for contraceptive purposes. This new
method became very popular and early this Century, caps were the most
common contraceptive method used. The first material used was rigid, of
gold or silver. Later latex/rubber caps where introduced.
Mode of action
The cervical cap is a small cup-shaped device made out of latex, which
lies around the cervix obstructing the cervical canal. It is held in place by
adhesive forces (suction) due to its specific construction with a groove at the
inner part (in contrast to the diaphragm which is held in place by the
vaginal walls and the pelvic floor muscles). The main mode of action
of the cervical cap is:
1 holding sperms away from the entrance of the Uterus, and
2 when used with spermicides, it ensures a higher concentration of
spermicides around the cervix and the cervical canal than if
spermicides are used alone.
To ensure maximum effectiveness, caps should always be used in
combination with spermicides.
Types and sizes of cervical caps

Three types of cervical caps are currently available:
1 vimule cap
2 vault cap
3 cavity rim cap.
Vimule cap
The vimule cap is a bell shaped cap with the open upper part wider than the
body (see Figure 21).
It is available in three sizes-42, 48 and 52 mm. Due to its thickened

rim, it covers the whole cervix and parts of the vaginal fornices as well. In
the inner part of the vimule, there is a groove for adhesion of the cup
to the cervix. The vimule cap is especially suitable for an irregularly shaped
cervix that often occurs after childbirth, such as tears, lacerations or scars.
A very long cervix can be completely covered by this cap.
Vault cap (Dumas)

The vault cap is similar to the diaphragm (see Figure 22). It is a
hemispherical bowl with sizes ranging from 50 mm to 70 mm in diameter
(usually in 5 mm steps).
Once in place, the vault cap covers not only the cervix but also the upper
part of the vagina. It stays in place by suction (adhesive forces),
but it is also partly held by the vaginal walls. If there is any condition of
the cervix which may impair proper fitting of a cap, such as extreme
shape or position, the vault cap may be ideal.
Cavity rim cap

This type of cap is the one most commonly used. It has a thick rim at its
upper part with an incorporated groove ensuring suction to the cervix (see
Figure 23). Sizes from 21 mm to 31 mm are available. This cap fits
directly over the cervix and adheres to the cervical side walls.
Patients suitable for this type of cap, should have a normal cervix
without irregularities. Furthermore, the cervix should be easily reached
for correct positioning of the cap by the user.
Fig 23 Cavity rim cap
Effectiveness of cervical caps

Data concerning failure rates vary between 8-26 per 100 woman years of
use. In comparison to other vaginal barrier methods such as the
diaphragm, cervical caps seem to have a higher failure rate. Difficulties in
correct positioning of the cap around the cervix are mainly responsible. The
lowest failure rates are seen in women over 35 years of age and long-term
users. Cervical caps have a rather high discontinuation rate of
approximately 50 per cent of users.
Advantages of use of cervical caps
* When used with spermicides, caps are an acceptable and safe
contraceptive method. Under woman's control.
Can combine barrier and spermicide methods of action.
No systemic effects.
Makes a woman more aware of her reproductive anatomy.
Only a very small amount of spermicide necessary. Not felt by
the male partner. No reduction in vaginal sensation.
Protection against sexually transmitted diseases and ascending
infections with pelvic inflammatory disease. More independent of
intercourse than the condom. May be left in place for 24 hours.
Useful for intercourse during menstruation. May be used by women
not suitable for the diaphragm due to poor pelvic floor tone, cystocele
or rectocele formation.
Indications for use
* Women over 35 years of age.
* Patient with contraindications for hormonal contraception.
* Reliable women.
* Women aware of their reproductive organs.
* Women with increased risk of sexually transmitted diseases.
Disadvantages
D Fitting the cap and instructions are time consuming and require a
specially trained person. D Vaginal manipulation and gynecological
examination necessary which
may be unacceptable to some women.
D Self insertion and removal are more difficult than with the diaphragm. D
Loss of spontaneity may occur if not inserted well in advance of
intercourse.
D May dislocate during intercourse.
D Unpleasant odour and discharge may occur if left in place for too long. D
Irritations possible due to spermicide action. D Fairly expensive. D
Possible unknown effects of prolonged cervical exposure to
spermicide, cervical secretion and other material trapped inside the cap.
Contraindications
Cervical caps should not be used when the following signs and symptoms
are present.
-unhealthy cervix
-purulent cervical discharge
- acute infection of the vagina
-marked cervical ectopia
- inability to reach the cervix with the finger
- aversion of touching and manipulating genital organs
- inability to learn the insertion technique
-lack of hygiene or privacy.
Important instructions for use of cervical caps

* Always put spermicide into your cap before use.
* Spermicide cream should fill one-third of the cap.
* Use your cap every time you have intercourse.
* Before inserting the cap, locate your cervix with the tip of your index
finger.
* Insert the cap at least 30 minutes before intercourse to ensure best
suction to the cervix.
* Check that the cervix is completely covered.
* After intercourse, leave the cap in place for at least 6 hours.
* Do not leave your cap in place longer than 24 hours.
* If intercourse takes place more often, add additional spermicide
(jelly/cream/suppositories) to the vagina.
* Always re-check the position prior to new intercourse.
* To remove the cap, insert your finger between the rim of the cap and
the cervix.
* In the first cycle of usage, use a back-up method such as condoms,
until you feel familiar and comfortable with this method.
Post-coital contraception
Some patients attend the clinic after unprotected intercourse and fear a
possible pregnancy. Several methods can prevent Implantation of a
fertilised egg into the uterus. They can be either hormonal or mechanical.
Mechanical methods
'Morning after IUD insertion' or 'menstrual regulation' by evacuation of
the uterus in a woman with a previously regular period who has rm'ssed her
menstruation by up to 14 days are post-coital mechanical methods of
contraception. Legislation on menstrual regulation differs from
country to country.
Post-coital hormonal contraception
This can be achieved by:
- the 'morning after pilP (a combined pill)
-application of a high dose of progestogen only
- the anti-gestogen pill (Mefipristerone, RU 486).
Currently, the 'morning after pill' is the only widely used hormonal
post-coital contraceptive method. The application of high-dose
progestogen is not recommended because of unacceptably high failure
rates. The anti-gestogen pill, RU 486, is not yet widely available because of
unresolved legal and ethical issues. The application of RU 486 will not
be discussed here due to the present unsolved controversies in many
countries. Detailed information on the results of recent clinical surveys
may be obtained from the WHO - HRP Programme.
'Morning after pill'
The commonly used 'morning after pill' is a combined estrogen/
progestogen preparation.
Ingredients and intake
Four tablets containing 100 /^g ethynylestradiol and 500 /ng levonorgestrel
are taken within 72 hours after intercourse.
Instructions for use:
- Take the first two tablets within 72 hrs and then take two more pills
12 hours after the first dose (total = 4 puls),
- The next menstrual period should occur within two or three weeks.
- If the period has not started after three weeks of pill intake see your
doctor.
- Nausea and vomiting may occur.
- Remember: the 'morning after pill' is not a regular applicable method of
contraception. Immediately after the expected menstruation, Start with
a safe method of birth control.
Questions to be asked when prescribing 'morning after pill':
- date of last menstrual period
- details about the patient's normal cycle
- days of unprotected intercourse
- time span since the first episode of unprotected intercourse
-current method of contraception
-contraindications against the use of COC (combined oral contra-
ceptives).
Patients and conditions not suitable for 'morning after pill'
- possible pregnancy before the last unprotected intercourse
- presentation more than 72 hours after unprotected intercourse
-patients with absolute contraindications against COC
- previous ectopic pregnancy.
Follow-up recommendations
A follow-up visit is recommended 3-4 weeks after treatment.
Clinical methods
Female Sterilisation
Sterilisation is the permanent impairment of egg fertilisation. This is
usually achieved by surgical occlusion or removal of both Fallopian tubes.
Interruption of the Fallopian tubes does not interfere on a major scale
with hormonal production of the ovaries. The normal cycle continues,
ovulation and menstruation occur regularly. Sterilisation is not equivalent to
castration.
Castration means the removal of both ovaries, leading to Sterilisation and

loss of fertility.
The main difference between Sterilisation and castration is the effect
on future hormonal blood levels and the menstrual cycle. Castration leads to
the total loss of hormones, so that no regular cycle can take place.
Sterilisation is a very popular method of fertility control throughout
the world. The effectiveness and possible complications of the surgical
procedure for female Sterilisation depend on:
the route of access to the abdominal cavity
the surgical method employed
the timing of the Sterilisation procedure.
Routes of access
Laparoscopy
The endoscopic technique of laparoscopy (visual inspection of the
abdominal cavity), widely promoted by the German Professor Semm,
has revolutionised many surgical procedures especially in the field of
gynecology. The laparoscopic procedure consists of a small telescope tube,
which is inserted into the abdomen through a small cut in the umbilical
region.
First, a pneumoperitoneum needle is inserted through the skin
into the abdominal cavity and the abdomen is filled with air
(pneumoperitoneum). Subsequently, a telescope and light source are
introduced and the inside of the abdomen is inspected. The Fallopian
tubes are located, grasped with forceps and coagulated (occlusion) with
electricity. Some surgeons prefer the ligation of the tubes with rings or
clips rather than electrocoagulation.
A major advantage of this technique is that it takes only a few
minutes, there is almost no scar (less than l cm) and no patient-admission is
necessary.
However, it requires considerable surgical skills (usually at specialist
level) and the technical equipment is sophisticated and expensive.
Complications of laparoscopy
Morbidity and mortality related to laparoscopy are low. Complications
can arise either from anesthesia (especially from general anesthesia) or
due to the surgical technique used. Major surgical Complications may
arise at the very beginning of the procedure when the needle for
insufflation is placed and the tube is pushed through the abdominal wall.
This part of the procedure is 'blind': the surgeon can not yet see what is
below the surface. Damage of the bowel, stomach or blood vessels may
occur at this stage, especially if adhesions to the anterior (front)
abdominal wall are present.
Another source of possible Complications may be the use of the
electrocoagulation technique for occlusion of the Fallopian tubes. Tubal or
mesosalpingeal bleeding, and accidental burning of the bowel may
occur. The use of bipolar forceps to coagulate the Fallopian tube was a
major advance, since with bipolar forceps, the current flows only
between the prongs, thus injury of the tissue located in the surroundings of
the Fallopian tube is less common.
The use of rings and clips have reduced the number of surgical
Complications such as hemorrhages or burns.
Anesthesia and laparoscopy

In most industrialised countries, laparoscopy is perfomed under general
anesthesia with intubation. Some surgeons have now reported new
techniques for laparascopic female Sterilisation which may be performed
just in local anesthesia. These laparoscopic techniques under local
anesthesia may also be suitable for developing countries.
Mini-laparotomy
Mini-laparotomy (laparotorny = opening of the abdominal cavity) is a
minor surgical procedure requiring only basic surgical Instruments. Access to
the abdominal cavity is gained by a suprapubic incision of 2 - 3 cm. The
Fallopian tubes are carefully located manually and exteriorised
outside the abdominal cavity. Interruption of the tubes can be achieved
either by applying clips or by surgical excision of part of the Fallopian
tubes.
A major advantage of this technique is that it can be performed in a
day-clinic without admission of the patient. (Follow-up of the scar,
however, may be necessary to control the healing process).
Complications of mini-laparotomy
Morbidity and mortality due to mini-laparotomy is low. Possible
complications of mini-laparotomy are similar to all other surgical
procedures of the lower abdomen: damage to the bowel, bladder or
uterus, hemorrhage and post-operative infection.
A possible advantage of mini-laparotomy may be that if an injury has
occurred, the injury is more likely to be recognized by the surgeon
(compared to laparoscopy). Injuries usually can be repaired through the
same small incision to the abdomen.
Mini-laparotomy and anesthesia

Mini-laparotomy can be performed in local anesthesia.
Vaginal tubal occulusion

The classical vaginal way of tubal ligation (culdotomy) has become
popular in many developing countries. There is no visible scar in the
abdominal wall and in-patient admission is not necessary. The method
consists of an incision made in the posterior upper part of the vagina
(posterior fornix), thus reaching the 'cul de sac' or pouch of Douglas.
Each Fallopian tube is then located and interrupted either by surgical
methods or by rings or clips (see Figure 24).
Complications
Despite the fact that complication rates are low, they are twice as high
as in mini-laparotomy or laparoscopy. Infections and hemorrhage are
the most common complications. In countries with a high prevalence of
STD and PID intra-abdominal adhesions are frequent. This may
complicate surgical procedure and lead to failure of this vaginal technique,
especially if the tubes are fixed in adhesions and cannot be properly
located and interrupted.
Anesthesia and vaginal tubal ligation

In the same way as the other methods of female Sterilisation, this method
can be performed under general or local anesthesia.
Surgical methods of tubal ligation

Electrocoagulation
To prevent an unwanted pregnancy, the Fallopian tubes should be
coagulated more than once (3-6 times), over an extent of 2-3 cm.
Nowadays, electrocoagulation is almost uniquely performed with the
bipolar method (see page 89). Coagulation of the bowel can only occur if
it is grasped instead of the Fallopian tube.
There is a considerable amount of discussion as to whether
electrocoagulation has an effect on ovarian blood supply and therefore
possibly affects future hormonal release of the ovaries. Some women
have reported changes in their general well-being and menstrual pattern
after Sterilisation. When performing this technique, care should be taken
not to coagulate tissue other than the Fallopian tube (especially the
mesosalpinx carrying ovarian vessels).
Thermocoagulation
When using thermocoagulation, the branches of the forceps are heated to
approximately 100°C. There is no electrical current, but the very hot
prongs of the forceps may damage tissue around the Fallopian tubes, if
not haridled in the correct manner.
Clips
Modern clips for tubal ligation are made out of plastic material with
silicon on the inner parts. Popular clips are the Hulka Clip (USA) or
the Filshie Clip (UK). The clips can either be placed via laparoscopy or
mini-lapararotomy or by vaginal access. It is important to apply the clip in
a right-angle to the tube to ensure that the whole lumen is obstructed.
Rings
Rings (Silastic band or Yoon ring) have become a popular method for
tubal occlusion and are widely used in developing countries. The route of
access can be via laparoscopy, mini-laparotomy or vaginal.
The tubes are grasped and retracted into an instrument (tube)
containing the ring. This method may be more difficult if performed
shortly after delivery because the tubes are very thick and succulent
postpartum, leading to possible failure and bleeding. Some patients may
complain about pain due to ischemia in the obstructed part of the tube.
Surgical techniques for resection of Fallopian tubes

Many different techniques can be used to interrupt the Fallopian tube.
The main difference between the techniques is the amount of Fallopian
tube removed and whether the remaining ends of the tubes are 'well
hidden' (peritonealised), thus avoiding future recanalisation.
The method of tubal sterilisation chosen will depend largely on the
surgeon's experience and training. Each method is equally effective
provided that it is performed correctly.
Male Sterilisation
The procedure can be compared in many ways to female Sterilisation.

Complication rates are low and surgery can be perfprmed in local
anesthesia. The effect is usually irreversible, even though studies are being
performed with reversible procedures, such as occlusion of the vas
deferens with silicon plugs which can be removed later.
The procedure most frequently used is the one- or two-incision
technique with subsequent extoriorisation of the vas deferens and ligation or
fulgurisation of the cut ends.
Complications
Short-term Complications are mainly bleeding and post-operative infection as
well as swelling of the scrotal tissue and haematoma formation. As
far as the long-term side-effects are concerned, no adverse
physiological effects have been proven. There are no large-scale studies
on possible psychological long-term effects, which may be particularly
important if vasectomy was performed at a young age when the desired
family size had not yet been completed.
Follow-up
Ejaculation specimens must be examined after the Operation and tested
for sperms. When two sperm-free specimens have been obtained,
vasectomy may be considered successful.
8 Family planning counselling
Counselling, along with recommending the most suitable contraceptive

method, is probably the most important activity in a family planning
Programme. The quality of counselling will determine whether a woman or
a couple feel confident to come back if they experience problems with the
contraceptive method recommended, or whether contraception is
simply discontinued.
Counselling always means listening to individual problems the client
may have, particularly concerning partnership and sexuality. This is
especially important when advising young people, but should not be
forgotten in married women and couples. Counselling comprises
identifying potential risk patients and advising them appropriately.
On the following pages, we have compiled contraceptive choices and
preferences for major risk groups. For practical purposes, this
Information is presented in the form of tables, so that it can easily be
used as a reference during counselling (Tables 13 - 30). It is, of course,
not possible to list all the potential conditions of risk, and, in many cases,
several risk factors may be combined. Since all tables have the same
arrangement, it should be easy to see whether a certain contraceptive
recommended for one condition, is also recommended in the other, or if
it is contraindicated. In the latter case, a new contraceptive method
should be chosen which is compatible with both conditions.
Clients with many risk factors and potential complications should
always be referred to the nearby health center or hospital where proper
facilities for diagnosis and possibly treatment are available.
Counselling risk groups for contraception
Women over 35 years of age
Women in the age group 35-45 years, who usually already have a
complete family, deserve special attention when it comes to the choice of
the adequate contraceptive method. Women over 35 years of age
constitute about 20 per cent of women seeking contraceptive ad vice.
Fetal malformation rates, infant and maternal mortality and morbidity rates
are significantly increased in this age group (see Maternal health, pages 6
-16). It is important to realise that unwanted pregancy may be mentally
and physically very traumatic at this age. The choice of the
contraceptive method must account for this, but also for the naturally
increased incidence of already pre-existing diseases and risk factors
(hypertension, diabetes, cardiovascular disease, obesity, varicosis, etc.)
among these patients.
Family planning counselling 95
Table 13 Contraception for older women
Methods Rating Notes
Sterilisation + + + Best method if family is complete.
COC - If COC desired, use only low

dose; screen for side-effects.
POP ++ No estrogen side-effects; user

must be reliable.
Injectables ++ No estrogen side-effects; bleeding/

spotting may be troublesome.
Implants ++ No estrogen side-effects; highly

effective.
IUD ++ No systemic effects; rule out

uterine fibroids!; remove 1 year after
the last period.
Diaphragm/cap + Higher failure rates; only

recommended if cervical and vaginal
anatomy are favorable and woman is
reliable in hygiene.
Spermicide + Only in combination with barrier

method; may provide some extra
lubrication.
Sponge 0 Not recommended because of

higher failure rates.
Condom + No systemic side-effects.
Natural family planning (+) High failure rates; best with

barrier methods.
Coitus interrupts (+) High failure rates; best in

combination with NFP or barrier
methods.
96 Methods of fertility control Teenage
girls or young mothers
Especially if they are unmarried, teenagers require counselling which
accounts particularly for their special social situation and possible
sanctions by their parents and family. Care should be taken to ensure
an atmosphere of confidentiality and support rather than moralistic and
authoritarian attitudes.
Table 14 Contraception for teenagers or young mothers

Sterilisation -- Only if a pregnancy puts the
woman's life at extreme risk.
COC (combined oral + + + Best method, hardly any risk

contraceptive) factors in this age group, to
prevent STDs, use additional
condoms or spermicide.
POP (progestogen-only pill) + Not first choice, reliability may be

a problem.
Injectables 0 Amenorrhea likely.
Implants - Not recommended.
IUD (intrauterine device) (-) Risk of STDs and PID higher, use
only in women who have at least one
child.
Diaphragm/cap + Only if user reliable.
Spermicide + Best in combination with barrier

methods, helps to prevent STDs.
Sponge ++ Best in combination with other

methods.
Condom ++ In combination with spermicides.
Natural family planning - Unreliable; high failure rate in this

(NFP) ________________age group.____________
Coitus interruptus - As for natural family planning.

After childbirth and during breast-feeding
Women after childbirth require special counselling since their fertility is

naturally decreased but the return of normal fertility is not easily
recognised.
Table 15 Contraception for women after childbirth and during

breast-feeding
Sterilisation ++ Careful counselling before labour;
surgery 3 months postpartum.
COC__ - May interfere with milk production.
POP ++ No interference with milk

production or quality; start 6
weeks postpartum.
Injectables (+) As POP, but a slight amount of

hormone in breastmilk.
Implants (+) As injectables; delayed return of

fertility may be a problem.
IUD ++ No systemic effects; rule out

uterine fibroids; insert not prior to 6
weeks postpartum (risk of expulsion
at earlier time).
Diaphragm/cap + New fitting necessary after

childbirth.
Spermicide + Best in combination with other

I ________________ __________________________ _________^_________ _|__
methods.
____ :-.---—_..._....... ....._....... ——-....
Sponge + Best in combination with other

methods.
Condom ++ No systemic side-effects.
Natural family planning - Unreliable during breastfeeding.
Coitus interruptus (+) In combination with other

methods.
After abortion
Women who have just had an abortion may require particularly sensitive
counselling taking into account their individual psychological situation
and possible guilt feelings.
Table 16 Contraception after abortion

Sterilisation (-) Careful counselling necessary;
only advisable if family complete.
COC + + + Start the same day; rule out risk

factors.
POP ++ Start the same day; less reliable

______ than COC.
Injectables ++ Start the same day.
Implants + Start the same day; best if family

complete.
IUD ++ Insert same day or 5 days after
abortion; higher expulsion rate
postabortion; rule out infection.
Diaphragm/cap + New fitting necessary after

abortion.
Spermicide 0 Best in combination with other

methods; high failure rate.
Sponge 0( + ) Best in combination with other

methods.
Condom (+) Not first choice.
Natural family planning - Unreliable and high failure rate.
Coitus interruptus - As for natural family planning.

Women with anemia
Anemia, either due to multiple pregnancies or to malaria and other

parasitoses is a very frequent problem in many developing countries.
Women coming for contraceptive counselling should always be checked
for anemia and contraceptives possibly enhancing this state, such as lUDs
should not be used. When prescribing COC or POP, the 28-day packets
with 7 tablets containing ferrous sulfate should be used.
Table 17 Contraception for women with anemia

Sterilisation + Hysterectomy may be indicated if
uterine (fibroids etc.) bleeding is the
cause of anemia.
COC + + + Menstruation will become regular.

Less blood loss during
menstruation.
Rule out pathologic uterine condition
(fibroids). Change to higher dose
COC if irregular bleeding persists.
POP ++ Less blood loss, but menstruation

may become irregular.
Injectables + As POP.
Implants + As POP; amenorrhea may be

beneficial.
IUD ( -- Not recommended; may increase

blood loss.
Diaphragm/cap 0/+ No beneficial effect on anemia.
Spermicide 0/+ As above.
Sponge 07+ As* above.
Condom 0/+ As above.
Natural family planning 0/+ As above. __
Coitus interruptus______O/ + As above._____________

Women with diabetes
Patients with diabetes are at special risk of infections in general, so that

any contraceptive which gives extra protection against infections (such as
the barrier methods) is preferable. Furthermore, the contraceptive
should not affect glucose levels or interfere with anti-diabetic drugs.
Table 18 Contraception for women with diabetes

Sterilisation +( + ) Best method: if family complete
and a pregnancy puts the woman's
life at risk; or if previous pregnancies
were complicated.
COC --• Not recommended; may interfere

with glucose tolerance.
POP + May be used even in insulin-

dependent diabetes if reliability is
no problem.
Injectables (+) Reversibility may be a problem.
Implants (+) As for injectables.
IUD - Risk of STDs and PID higher.
Diaphragm/cap ++ Recommendable.
Spermicide ++ Best in combination with barrier

methods; helps to prevent STDs.
Sponge ++ Best in combination with other

methods.
Natural family planning - Often unreliable in this group.
Coitus interruptus - (+) 'n combination with other

methods.
Women with hypertension
Women with hypertension are at special risk of pregnancy complications

such as severe hypertension, toxemia and renal failure. Pregnancies should be
carefully planned in this group and should be totally avoided if
hypertension is already a severe problem. The choice of the contraceptive
method should not affect blood pressure nor increase cardiovascular risk.
Table 19 Contraceptives for women with hypertension
Sterilisation ++ Best method if family complete
and a pregnancy puts the woman's
life at risk; or if previous pregnancies
were complicated.
COC -- Not recommended; additional risk

factor.
POP +( + ) Does not affect blood pressure;

user must be reliable.
Injectables ++ Highly effective; does not affect

blood pressure.
Implants + As for injectables.
IUD ++ Recommended; no systemic

side-effects.
Diaphragm/cap ++ Recommendable with additional

spermicide.

methods.

methods.
Natural family planning + If menstruation regular and user

reliable.
Coitus interruptus -( + ) In combination with other

methods.
Women with cardiac or cerebrovascular disease
For women with a history of cardiac disease or cerebrovascular accidents, a

pregnancy is likely to be a serious health risk and may lead to death.
Therefore, it is important that the contraceptive method used has a very
low failure rate. It may be advisable to combine two contraceptive
methods. The method chosen should have little or no systemic side-effects.
For this reason, long-term hormonal contraception is not recommended.
Table 20 Contraceptives for women with cardiac or cerebrovascular

disease

Sterilisation + + + Best method if family complete.
COG -- Not recommended; additional risk

____________________________factor. _________
POP (+) Not first choice; systemic side
effects cannot be excluded.
Injectables - Not recommended; reversibility

difficult if systemic side effects
occur. __________
Implants - As for injectables. ______

side-effects.
Diaphragm/cap + Recommendable with additional

spermicide; less effective than
__________________________IUD.________________
Spermicide (+) Best in combination with barrier
methods.
Sponge (+) Best in combination with other

methods.
Natural family planning - Not recommended in this group;

risk of pregnancy too high.
Coitus interruptus - (+) In combination with other

methods. _________________
Women with superficial varicosis
Women with varicose veins are at a higher risk of superficial venous
thrombosis. It is therefore important that the contraceptive method
chosen does not interfere with blood clotting and coagulation.
Table 21 Contraception for women with varicose veins (no history of

thrombosis)

Sterilisation + Only if family complete.

factor.
POP + Does not affect blood coagulation.
Injectables + Highly effective; does not affect
blood coagulation.
IUD + Recommended; no systemic

side-effects.
Diaphragm/cap + No systemic side-effects; check

strength of pelvic floor muscles,
since varicosis is often associated
with genital prolapse.

methods.

methods.
Natural family planning + If user is reliable.

methods.
Women with history of deep venous thrombosis
In this group, prevention of thromboembolism is particularly important.

The contraceptive method chosen must not interfere with blood clotting
and should not enhance risk factors, for example by raising blood
pressure.
Table 22 Contraception for women with a history of deep venous

thrombosis or thromboembolism

Sterilisation + + + Best method if family complete.

factor.
POP + Does not affect blood coagulation.
Injectables + Highly effective; does not affect
blood coagulation.
side-effects.
Diaphragm/cap + No systemic side-effects.

methods.

methods.
Natural family planning - If user is reliable, but only in

combination with other methods.

methods.
Women with liver disease
Women with liver disease should not be given any contraceptives which
may possibly interfere with liver metabolism. At the same time, care must
be taken to ensure effective contraception, and it may therefore be
necessary to combine several non-hormonal methods.
Table 23 Contraception for women with liver disease

Sterilisation ++ Best method if family complete.

factor, may affect liver
metabolism.
POP -- Not recommended; may affect

liver metabolism.
Injectables -•- Not recommended.
Implants -- Not recommended.

side-effects.
Diaphragm/cap + No systemic side-effects;

recommended if user is reliable.

methods.

methods.
Natural family planning - Not recommended in this group.

methods.
Physically handicapped women
Physically handicapped women do not necessarily have to be treated as a

special risk group. However, counselling should account for possible
difficulties which may arise from pregnancy, childbirth and childcare.
Physically handicapped women who are immobilised are at a greater risk of
thrombosis and thromboembolism: they should not be given
contraceptives which affect coagulation.
Table 24 Contraception for physically handicapped women

(especially immobility)

Sterilisation ++ Best method if family complete.
COC -- Not recommended in immobility;

additional risk factor for
thromboembolism.
POP + If user is reliable.
Injectables ++ Recommended.
Implants ++ Recommended.

side-effects.
Diaphragm/cap + No systemic side-effects;

recommended if user is capable of
inserting.

methods.

methods. ____
Condom + In combination with spermicides.
Natural family planning 0____Only if cycle is regular._____

methods.
Mentally handicapped women
In women with a mental handicap or retardation, the degree of handicap
must be carefully assessed in order to decide on the best method of
contraception. Counselling should involve the woman's partner and/or, in
the case of young girls, a parent.
Table 25 Contraception for mentally handicapped women

Sterilisation (+) Only if legal aspects are clearly
solved.
COC -- Not recommended; intake may be

irregular.
POP -- As for COC.
Injectables ++ Recommended - not relying on
user's memory.
Implants ++ Recommended.
IUD + Recommended, if infections are

ruled out.
Diaphragm/cap - Not recommended.
Spermicide -(+') In combination with barrier

methods, if user or partner
reliable.
Sponge - Not recommended.
Natural family planning -- Not recommended.
Coitus interruptus -- Not recommended.

Women under tuberculostatic drug treatment
When counselling women who are under treatment for tuberculosis, it is

important to know that Rifampicin, (one of the drugs used in
tuberculostatic therapy), reduces the effect of oral contraceptives. At
the same time, successful treatment of tuberculosis brings the previously
depressed fertility level back to normal, which means that these patients
need careful contraceptive counselling. Oral contraception and other
hormonal contraception should not be relied upon.
Table 26 Contraception for women under tuberculostatic drug

treatment

Sterilisation + If family is complete.
COC -- Not recommended because of

drug interaction.
POP - Possible drug interaction.
Injectables - As for COC and POP.
Implants - As for COC and POP.
side-effects.
Diaphragm/cap + Recommended.
Spermicide + In combination with barrier
methods, if user reliable.
Sponge + Recommended.
Natural family planning -- Not recommended; high failure

rates.
Coitus interruptus (+) Only in combination with other

methods. ______
Women under anti-epileptic drug treatment
When counselling women with a history of epileptic seizures or under
anti-epileptic treatment, the severity of the disease should be taken into
account and all systemically active contraceptives must be used with
caution. Since many anti-epileptic drugs induce liver enzymes, the
effectiveness of hormonal contraception may be reduced.
Table 27 Contraceptives for women under anti-epileptic drug

treatment

Sterilisation + If family is complete.
COC -- Not recommended because of

drug interaction.
POP - Possible drug interaction.
Injectables - As for COC and POP.
Implants - As for COC and POP.
side-effects.
Natural family planning -- Not recommended; high failure

rates.
Coitus interruptus (+) Only in combination with other

methods.
Women suffering from migraine/headache
Severe headaches and migraine may be enhanced by some hormonal

contraceptives. However, some types of headaches, for example pre-
menstrual headaches may improve under COC or POP. It is often a
matter of trying different kinds of pills or letting some time pass before
necessarily re-adjusting and changing hormonal dosages.
i 7
Table 28 Contraceptives for women suffering from severe headaches
Sterilisation ++ If family is complete.
COC + Only low dose estrogen.
POP ++ Recommended.
Injectables - Not recommended - effect cannot

be predicted and is irreversible at
least for some months.
Implants + May be removed if headaches

persist.

side-effects.
Diaphragm/cap + Recommended.__________
Natural family planning + If cycle is regular.________
Coitus interruptus + Only in combination with other

methods.
Women suffering from depression
Depression is a severe physical and mental state and must always be taken
seriously. Counselling may help to reveal causes, but in many cases, these
can be difficult to identify. Irreversible or long-term contraceptives are
not recommended in this group, because they may physically or
psychologically enhance the problem.
Table 29 Contraceptives for women suffering from depression
Sterilisation - May worsen condition.
COC + Only low-dose estrogen.
POP ++ Recommended.
Injectables - Not recommended - effect is

irreversible at least for some
months.
Implants - Not recommended.

side-effects.
methods.
Natural family planning - -r. Not recommended; menstrual

irregularities may be more
frequent in this group.
Coitus interruptus + Only in combination with other

methods.
Women with acne
Women with acne or sebaceous skin problems are not really a risk group in
the strict sense. However, it should be kept in mind that skin problems,
particularly in the face, may be seriously distressing for a woman and
that these problems may be enhanced or improved under certain hormonal
contraceptives.
Table 30 Contraceptives for women with acne or sebaceous skin

problems

Sterilisation -/+ Depending on age, either way, it
will not affect skin problem.
COG + + + Only low-dose progestogen, and

medium- or high-dose estrogen.
POP -- Not recommended; may worsen

condition.
Injectables - Not recommended; as for POP.
Implants - Not recommended; as for POP.
IUD 0/ + No effect on skin problem.
Diaphragm/cap 0/+ As above
Spermicide 0/+ As above
Sponge 0/+ As above
Condom O/ + As above
Natural family planning 0/ + As above
Coitus interruptus 0/+ As above _________

Part Three
Organising & managing a community-
based family planning Programme
9 Preparing a family planning Programme
10 Setting up a community-based family planning Service (CBS)
11 Effects of family planning Services
9 Preparing a family planning Programme
Setting up a family planning Programme involves several Steps and

requires special attention concerning:
1 assessing family planning needs in the community
2 establishing adequate facilities and staff
3 ensuring the logistic function of the Services
4 establishing standardised patient selection criteria
5 ensuring the adequate and safe application of each method
6 staff training.
Assessing family planning needs in a community involves:

- Operational research on knowledge and use of contraceptives within
different groups of the community (married couples, single men and
women, adolescents).
-Obtainmg quantitative data on the likely amounts of various
contraceptives required.
- Identifying possible obstacles to the establishment of family planning
Services.
- Identifying needs of Information and education of various target
groups.
113
114 Organising a community-based family planning Programme
Establishing adequate facilities and statt involves:
-Providing buildings, rooms, Instruments according to needs.
-Selecting medical and paramedical staff and identifying respected
members of the community who may be involved as volunteers in
information, education and communication (IEC) activities and/or in
contraceptive distribution.
- Organising adequate training of medical and paramedical staff at
various levels.
Ensuring the logistic function of the Services offered involves:

1 monitoring of demand by record keeping
2 material management including order points, minimum stock, storage,
shelf-life, quality control
3 documentation System
4 establishing a patient referral and follow-up System.
Establishing standardised patient selection criteria involves:

- patient health screening with check-lists and simple physical
examination
-patient selection criteria for contraceptive methods
- counselling
-patient documentation.
Ensuring adequate and safe application of each method involves:

- ensuring quality of counselling
-using a standardised application System
- ensuring sterile working, if necessary
-establishing a System of continuous supervision.
10 Setting up a community-based family planning

Service (CBS)
In order to make family planning Services available and accessible to the

majority of people, it is essential to apply principles of decentralisation
beyond those of the district health centers, to put the success slogan of
many private enterprises 'don't come to us, we'll come to you!' into
practice - like many things in life, this is easier said than done. However,
community based Services have been successfully implemented in many
countries of the developing world and there are numerous experiences to
learn from.
Setting up a community-based family planning service 115
The crucial points that all CBS experiences have in common, and that
decide on whether the service will be a success or a failure, are as follows:
- selection of CBS workers
- duration and quality of CBS training
- quality of supervision of CBS work
- integration into a functioning referral System for problem cases
- incentives for CBS workers
- community participation in the selection of CBS workers and service
support by the community
-cost recovery
- supplies and logistics management
-management Information Systems.
Organisation and management factors

Selection of CBS workers
Experience shows that older (above 25 years of age), married and educated
women (Standard 7) appear to make the best distributors, but men
distributors are also becoming more and more accepted, especially in
male motivation programmes. One determining factor, independent of
age and sex, is the respect of the CBS agent by the community. Successful
CBS agents have tended to be local leaders, teachers, traditional healers,
traditional birth attendants, church eiders or respected housewives.
Duration and quality of CBS training
The initial series of CBS training tended to be very short (3-5 days)
and packed with issuing detailed information. These programmes were
generally not very successful. Evaluations after a couple of months usually
revealed that CBS workers had forgotten much of what they had learned,
passed on wrong information to the clients, become generally dissatisfied
themselves and had high client drop-out rates.
A more promising model is that of two one-week training courses*
with six to eight weeks between them. This allows trainees to gain some
experience in field work, and to come back to the second course with
unanswered questions and difficulties they came across in field work.
Course curricula should include rationales for family planning, human
reproductive anatomy and physiology, methods of family planning, com-
munication and counselling, record keeping and some management aspects.
A functioning System of continuous supervision and on-the-job training is
just as important as a good initial course, especially with respect to
motivational aspects of CBS work which is often performed by volunteers
with no or very little financial incentives.
Quality of supervision of CBS work
One of the frequently encountered problems is that the Supervisors are

nurses or more experienced health workers whose main task is curative
health care and who have not received specific training in family planning
themselves. It is therefore important that Supervisors participate in the
CBS training courses at least once, that they are additionally trained in
supervision and techniques, and that their personal attitudes are
encouraging and motivating rather than hierarchically authoritarian. In
this sense, a System of further supervision and continuous training of
Supervisors is just as important as the supervision of CBS agents
themselves.
Integration into a functioning referral System for problem cases

It is essential for CBS workers to know when they should refer a potential
client to the next level of health care for counselling, diagnosis or
treatment of complications. This presupposes that a functioning referral
System exists and the health centers are involved and informed about
family planning activities in their area - even if they are not directly
responsible for training and supervision of CBS workers.
Without this integration, family planning Services risk soon losing their
credibility in the community and are likely to come across difficulties in
recruiting new acceptors, especially if unresolved problem cases have
occurred and become publicly known.
Incentives for CBS workers

These have varied from total volunteer work, incentives in kind, to fixed
regular salaries. In many cases, paying regular salaries is not possible
due to financial limitations on health budgets especially in rural areas.
However, the highest drop-out rates of CBS workers have been found in
programmes that worked with volunteers only. At least small financial
incentives, such as proportional shares in the sales of contraceptives (in
areas where they are not distributed free of Charge) are necessary to keep up
motivation. Where this is not feasible, incentives such as the provision of a
bicycle, free health care for all family members, or the coverage of
school costs for the children of CBS workers may be an acceptable
substitute.
Setting up a community-based family plannmg Service 117
Community particlpation in the selectlon of CBS workers and
service support by the community
Sustainable and successful programmes have usually involved the

communities from the very beginning of Programme activities. This
implies that a substantial amount of Information and motivation work
must be done before the Programme is actually implemented. Care must be
taken to ensure acceptance of family planning Services in the
community, especially to identify groups within the community who may
resist these due to religious, moral and traditional convictions. These
groups should be a special target of information, education and
communication (IEC) activities.
Community participation in the selection of a trustworthy CBS worker is
one essential component of a successful Programme, and, once the
Programme has been implemented, it is important to keep the community
continuously informed about successes, shortcomings and possible
financial or other programmes. The task of informing the community
can be partly one of the CBS worker, but should also be taken on by
the supervising staff in community or group meetings.
Cost recovery
Cost recovery is a problem especially in areas where people have little or

no monetary income. Solutions must be found for each community
individually. In countries where drugs are generally free of Charge by
law, it may be possible to ask for a voluntary contribution. In some
countries, patients pay a small fee for drugs according to their income.
This model can then also be applied to the purchase of contraceptives.
Some family planning Services have asked for small membership fees to be
paid once a year; contraceptives are then distributed free of Charge.
Supplies and logistics management
A further issue which is dealt with in different ways by different family

planning Services, is the management of supplies and logistics. Usually,
CBS agents are allowed to distribute condoms, vaginal spermicides and
resupplies of oral contraceptive puls. In some countries (Zimbabwe and
Kenya) new pill clients can be given the first cycle of the pill after
completion of a checklist, but before the cycle is finished they must report to
a family planning clinic for physical examination. After this, CBS
workers may give supplies of three cycles. Experiences with this model
have been positive so far.
As far as logistics are concerned, record keeping is essential to estimate
demand and necessary supplies of contraceptives, which are commonly
brought to the CBS workers by the Supervisors on their regular visits.
Management information Systems
The importance of functioning rtianagement information Systems is

gradually being recognised by Programme planners but frequently presents a
problem largely due to the necessary paper work. In many programmes,
monthly statistics are compiled by the Supervisors after receiving the
information from the CBS agents. The completed reports are transmitted to
the overall CBS coordinator at district or headquarter level where the
statistics are analysed and compiled for Submission to the ministries of
health and to donor agencies.
This point has frequently been neglected in CBS training so far, but
should be included in all programmes to ensure future functioning and
Programme sustainability.
11 Effects of family planning Services
When designing a family planning Programme, we must keep in mind

that in most societies, family planning Services are not seen in the same
way as health Services. Care must be taken to respect religious and moral
traditions of the specific community.
Setting up family planning Services does implicitly involve changing
some aspects of traditional gender roles, especially traditional roles of
women. Because efficient family planning Services enable women to have
better and more conscious control over their fertility, they not only
contribute to their better physical well-being, but to more self-
determination of women in general, increasing their chances of education,
Professional training and economic independence.
Some of the resistance against family planning Services may be
explained by these facts. Such aspects should be accounted for in
information and education programmes linked to family planning
Services. A greater economic capacity of women does, of course,
contribute to a better well-being of men, women and children in a
community and to gender equity in a society.
Family planning programmes also have an essential role in maintaining
the balance between population density and renewable and non-renewable
natural resources and are thus an essential asset to global sustainable
development.
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Maternal health and

A handbook for health and

Guenther Dietz and Assia Brandrup-Lufcanow

All rights reserved. No reproduction, copy or transmission of

First published 1993

Published by THE MACMILLAN PRESS LTD

Printed in Hong Kong

A catalogue record for this book is available from the

Part One Human fertility and health 1

Part Two Methods of fertility control

PD Dr med. Rolf Korte, DTPH

Prof. Dr Wolfgang Kunzel

1 Determinants of fertility Menarche,

The natural reproductive period of a woman is determined by the age at

Social determinants of fertility

The age at marriage and the proportion of women marrying at a certain

Widowhood and dissolution of marriages

Non-marital sexual unions

In some countries, for example in the Carribean, a considerable number of

Frequency of intercourse, periods of abstinence and their effect

Marriage is not necessarily the exposure to constant sexual intercourse

Infertility and sterility

During the reproductive life of a woman, there are periods of naturally

Hormonal disorders - affect Ovarian disorders (aplasia or hypoplasia)

Table 2 Causes of female sterility and their frequency

Hormonal and ovarian 21-39 33

Table 3 Factors leading to male infertility

Cause Frequency (%)

These can easily be detected through a normal medical history. It is

Risk groups within this category are as follows:

Risks emerging during pregnancy can either be induced by pre-existing

Maternal death is defined as the death of a woman while pregnant or

Hemorrhage during pregnancy can be classified in bleeding:

First tri mester hemorrhage

Second trimester hemorrhage

Third trimester hemorrhage

Maternal mortality due to hemorrhage

Country Maternal death - hemorrhage

(Adapted from WHO, 1990)

The mortality risk depends on:

Table 5 Maternal mortality rate due to infection

(Adapted from WHO, 1990)

Toxemia is a major cause of maternal death in both industrialised and

Risk groups for toxemia

Table 6 Maternal mortality rates due to toxemia

Country Maternal death - toxemia (%)

(Adapted from WHO, 1990)

Despite the illegality of abortion in many societies, it has been a widely

3 Maternal and child health

Age, parity and child mortality

Family size and child health

Low birth weight

Pre-term delivery is often associated with the maternal risk factors

Risk factors for pre-term delivery are:

Intrauterine growth retardation (IGR)

The ideal contraceptive method

The effectiveness of a contraceptive method is not measured in success

Failure Rate total accidental pregnancies x 1200 months of use

Life table method

Common among insurance companies when calculating the risk of death of

When judging the efficacy of a contraceptive method, the failure rate

5 Contraceptives and the female reproductive cycle

The natural reproductive cycle is divided into 3 phases: