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Family Planning

 Overview/Lessons Learned | Contraceptive Methods | Key Issues
Annotated Bibliography | Program Examples | Links | Presentations

Overview/Lessons Learned

 

Introduction

Family planning programs and modern contraceptives enable millions of couples and individuals throughout the world to plan the number and spacing of their children -- or to avoid pregnancy altogether. Today almost 60 percent of couples use some form of contraception and over 50 percent use modern methods - well on the way to the 70 percent use that demographers call the "fully contracepting society." The large variety of new and improved contraceptive methods developed over the past 30 years now permits clients to select the method most appropriate for their medical and personal needs.

Experience in developing countries has also led to improvements in the way that family planning services reach clients. Conveniently located family planning organizations, integration of family planning with other government health services, community-based distribution, worksite programs, and social marketing of contraceptives through retail outlets have made access to contraception widely but not universally available. Large numbers of people are underserved in terms of services or access to a wide range of methods, particularly the rural poor.

Research reveals other obstacles. Responsibility for contraception is not borne equally: worldwide more than two-thirds of family planning users are women. Not surprisingly, use of modern methods is lowest among rural, less educated, and poorer women. Demographic and Health Surveys in developing countries found over 120 million women in an "unmet need category"-- those who report wanting to space or end childbearing but who do not use any contraception. Availability and cost of methods were not major problems; the single greatest reason for non-use or discontinuation was fear of side effects and health complications.

All of these obstacles are complicated by the low status of women and their lack of power to make independent decisions about using contraceptives or accessing services. In some settings, family planning clients also are discouraged by the rude behavior of clinic staff, long waits, stockouts and unreasonable restrictions on certain methods. In addition, the needs of unmarried women, men, and adolescents are largely ignored. For more information, see RHO's Information Summaries on Gender and Sexual Health, Men and Reproductive Health, and Adolescent Reproductive Health.

Today's family planning programs increasingly address these obstacles and strive to improve their quality of care. Research on these programs shows that improvements in client-provider interactions -- courtesy, counseling tailored to the individual, clear information on how to use the method and common side effects, and respecting the client's choices of methods--lead to higher rates of adoption, effective use and continuation. (see Murphy, "Implications of Research and Program Experience for Client-Provider Interactions." in Technical Guidance/Competence Working Group, Volume II 1997).

More programs include STD/HIV counseling, treatment for STDs, and other reproductive health care. Many are launching services for adolescents and men. Training of family planning providers reflects the evolving nature of programs; new training curricula include topics such as re-orienting services to be client-centered, sexuality issues relevant to method choice, gender-related constraints, domestic violence, vulnerability to STD/HIV, and post-abortion family planning counseling.

This overview discusses several topics. Click on a title to go directly to that topic. The Contraceptive Methods discussion includes links to tables outlining specific method characteristics.

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Revised WHO eligibility criteria

The World Health Organization, in collaboration with medical experts and women's reproductive health advocates from around the world, has developed revised medical eligibility criteria that give sound guidance on the safety of contraceptive methods for various categories of users. These evidence-based criteria are designed to increase access to contraceptive use for appropriate candidates, while maintaining required levels of safety.

The new eligibility criteria classify the suitability of different contraceptive methods for individuals with specific illnesses or health conditions, those at later ages, and those whose behavior poses added risks (for example women who smoke or women and men with multiple sex partners). The eligibility criteria aim to ensure an adequate margin of safety to protect women and men from the potential adverse effects of contraceptives, while ensuring that they are not denied suitable choices.

The WHO Eligibility Criteria classify health conditions according to four categories:

    Category A   Always usable
    Category B   Broadly usable
    Category C   Use with caution
    Category D   Do not use

For a complete review of eligibility criteria for various methods, see the WHO guidelines (WHO, 1996) or a summary of the guidelines in Outlook 13(4) and 14(1).

Key conclusions from the Revised Medical Eligibility Criteria are:

  • Many of the common recommendations that have restricted method use among women with specific medical conditions or histories are unfounded or based on outdated information.
  • Criteria that restrict use of older high-dose OCs should not be applied to newer low-dose OCs. Many of these restrictions do not apply to formulations containing lower doses of estrogen.
  • Nulliparous women should not be denied access to injectable contraceptives for fear it may affect future fertility. Medical evidence suggests that there is no basis for this restriction.
  • The eligibility criteria for progestin-only contraceptive methods generally are less restrictive than for methods containing both estrogen and progestin. Age should not restrict access to a contraceptive method.
  • Concerning age, the advantages of using a contraceptive method generally outweigh the theoretical or proven risks associated with method use at younger or older ages.
  • Eligibility criteria for women with vaginal bleeding differ for women with irregularmenstrual bleeding and women withunexplained vaginal bleeding. Irregular menstrual bleeding generally is a Category A condition (always usable). Unexplained vaginal bleeding that could be related to pregnancy or pelvic malignancy is considered a Category B or C condition (broadly usable or use with caution) for all hormonal methods and IUDs.
  • For many specific medical conditions, such as thyroid disease and epilepsy, there are no restrictions on the use of any of the methods discussed.
  • As long as the client's history is taken correctly, clinical and laboratory diagnostic and screening tests generally are not considered mandatory for safe use of contraceptive methods.
  • Women using a hormonal method or IUD who are at risk of STDs should be advised to use condoms in addition to their primary contraceptive method to protect themselves.
  • Access to tubal ligation or vasectomy should not be based on the client's age or parity; there is no medical basis for restricting access based on these factors.
  • Informed choice is at the foundation of the revised eligibility criteria for contraceptive methods. Informed choice means that a client can freely make an informed decision based on (1) accurate, useful information; (2) an understanding of their own needs; and (3) selecting from a range of family planning methods.
  • The eligibility criteria will be revised periodically to update the recommendations as new information becomes available.

Most of the review findings resulted in eliminating unnecessary prescribing criteria. In a few cases, however, eligibility criteria were added or strengthened to ensure adequate client safety during method use. For example, the expert committee recommended that:

  • Women who have any risk of STDs should not use an IUD unless no other options are available to her.
  • Anyone with a risk factor for STDs should use dual protection: condoms to protect against STDs/HIV in combination with another effective method to protect against pregnancy.

In programs where clinical training and experience are limited, as in a community-based distribution system, the original WHO four-category system can be simplified to a two-category system. In this scenario field workers generally could provide a method to a woman with Category A and B conditions, but not provide the method to women with Category C or D conditions.

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Controlling sexually transmitted diseases

As the magnitude and consequences of STDs become more widely recognized, especially among women, integrating STD control and prevention strategies into primary care facilities that target women becomes critical. Integrating STD services with family planning or other women-centered programs is an attractive option since family planning clients often need STD control and prevention services, and STD clients often need family planning services.

Integrating STD services into a family planning health setting also provides continuity of care and services, and it can simplify logistical hurdles such as lack of providers, supplies, and space. Most family planning programs can undertake primary prevention activities, particularly counseling and provision of condoms and other barrier contraceptive methods. Most also can refer clients for STD case management. Some also can offer secondary prevention services, such as case management or even simple laboratory testing.

Male and female condoms provide the most effective protection against STDs other than abstinence or sexual relationships between mutually monogamous, uninfected partners. Female barrier contraceptives provide modest protections against STDs. Nonoxynol-9 (N-9), a spermicide, protects against bacterial STDs, but its effects on viral STDs are less clear. Oral contraceptives, other hormonal contraceptives, and IUDs do not provide any protection against STDs and should not be recommended for women at risk of STDs unless used in conjunction with condoms. Women who have IUDs inserted when they have a gonococcal or chlamydial infection are at increased risk of developing PID within a few weeks of insertion; provision of IUDs in populations where STDs are common requires special precautions.

Women and men who are at risk of STDs, and who rely on a method that does not protect against STDs, should strongly be encouraged to consider using of a barrier method in addition to their preferred method. Hormonal methods, IUDs, sterilization, LAM, and Natural Family Planning can provide good protection against pregnancy, but they do not protect against STDs. Clients who rely on these methods or on withdrawal need to use a male or female condom to protect themselves and their partners from the serious health consequences of STDs. These include infertility, chronic pain, and death since STD infection may make a client more susceptible to infection by HIV.

The following list describes the protective effect (or lack thereof) of specific methods.

  • Male condoms: Protective against both bacterial and viral STDs.  Only provides protection when used correctly and consistently.
  • Female condoms: Limited data suggest they protect against both bacterial and viral STDs.  Only provides protection when used correctly and consistently.
  • Diaphragm: Moderately protective against many cervical STD infections, including HIV.  Only provides protection when used correctly and consistently, with a spermicide.
  • Spermicide: Moderately protective against gonorrhea and chlamydial infection; probably not protective against HIV. Only provides protection when used correctly and consistently                   
  • Hormonal methods: Not protective.  If they are at risk of STDs, women relying on these methods should consider dual method use.
  • IUDs: Not protective; insertion of an IUD in a woman with an STD increases the risk of PID.  Use of IUDs among women at risk of STDs generally is not recommended.
  • Male and female sterilization: Not protective.  If they are at risk of STDs, women and men relying on these methods should consider dual method use.
  • Natural family planning, LAM, withdrawal: Not protective.  If they are at risk of STDs, women and men relying on these methods should consider dual method use.

For more information, see RHO's Reproductive Tract Infections section.

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Effective counseling

Counseling is an essential element of all family planning services. Effective counseling helps family planning clients choose a method that meets their needs, identify health conditions that would prevent their safe use of the method, and use the method effectively. The overall goal of counseling is to help clients feel well informed, reassured, and comfortable with their decisions about contraception. Effective counseling also contributes to the success of a program.  Research has shown that the way in which a family planning worker interacts with and provides information to a family planning client can have an important impact on that client's satisfaction and success using contraception.

Counseling is an interactive process between a family planning worker and a client that helps the clients make and carry out his/her own reproductive health choices. Counseling involves more than just providing information. Depending on a client's needs, counseling may include discussing concerns about using a method as well as other personal issues that influence contraceptive choice and use. A client's child-bearing intentions, feelings about sexuality, relationship to his/her partner, and risk-taking behavior related to STDs all affect method selection and use and should be discussed as part of good counseling (PATH/Outlook, 1995; PATH/Outlook, 1999).

The following six principles help promote a positive interaction between the client and provider. These principles apply to all staff who come in contact with the client.

  • Treat the client well. Treat clients with friendliness and respect. Ensure that information will be kept confidential. Encourage clients to ask questions. Answer questions patiently and fully.
  • Interact with the client. Listen to the client describe his/her needs or concerns. Ask questions to clarify the situation. Pay attention to your client's and your own body language (such as posture and facial expressions). Adjust your body language to make the client feel more comfortable.
  • Tailor information to the client's needs. Use information provided by the client to tailor the counseling session to the individual client's health and personal needs. Consider the client's stage in the reproductive life cycle. Give examples to help the client understand how information applies to the client's personal situation. Use language the client can easily understand.
  • Provide the method the client wants. If there is no medical reason against it, give the client the method he/she wants. Help the client understand that there are other methods available if the preferred method is unsatisfactory or if it later needs to be changed. When clients get the method they want, they use the method longer and more effectively.
  • Avoid giving too much information. Provide only essential information about the selected method. Too much information leads to confusion and forgetfulness. Leave time for the client to ask questions.
  • Help the client understand and remember. Use contraceptive samples, flip charts, posters, and brochures during counseling to help describe the method and how to use it. Ask the client to summarize key points to check for comprehension. Allow the client to demonstrate correct use when possible. Provide a written summary of key information for the client to take home to reinforce the information provided during counseling.

Good counseling provides accurate information to the client to help them choose methods that meet their needs. Once the client has selected a method, he/she needs the following information to use the method safely and effectively.

  • Method effectiveness
  • Side effects and complications
  • Important method features
  • How to use the method
  • When to return
  • STD/HIV prevention

For more information on counseling, see the Family Planning Annotated Bibliography.

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Chronic health problems

Women and men with chronic or serious health problems still need access to safe and effective contraception. Providing an appropriate contraceptive method for these clients can be complicated since their health condition may limit their contraceptive choices. Providers must know about possible interactions been medical conditions, drugs, and contraceptives to provide appropriate counseling. Women who have chronic or serious medical conditions may need medical follow up and monitoring more often than other women. In balancing the needs and desires of the client, providers need to consider that, for women with serious health conditions that make pregnancy dangerous, providing no contraceptive method would be even more dangerous than providing a method with some health risks.

For more detailed information about providing contraceptives to clients with chronic or serious health conditions, see the section on the WHO eligibility criteria in the Annotated Bibliography as well as the Network issue on contraception and chronic conditions.

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Infection prevention

Infection prevention measures are important to protect both providers and clients from the transmission of infectious diseases. The epidemic of bloodborne viral diseases, including hepatitis B and C and human immunodeficiency virus (HIV), adds to the importance of ensuring that family planning providers follow basic infection prevention procedures. These and other infections can be transmitted by contact with blood and body fluids and generally can be spread before symptoms are present. Family planning providers need to follow appropriate infection control procedures with all clients, treating all as if they are potentially infected.

For a more complete discussion of infection prevention procedures appropriate for family planning programs, see the article, "Preventing Infections in Health Care Workers".

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Meeting contraceptive needs through the life cycle

Most healthy women are eligible to use any method of contraception and can select a method that best meets their needs. As a woman moves through the stages of her reproductive life, her contraceptive needs and her health status may change. Not all methods are equally acceptable at each stage of a woman's life. Adolescents, post-partum and post-abortion women, breast-feeding women, and women over the age of 35 years are groups with special contraceptive and counseling needs.

Adolescents

Adolescents who are sexually active need access to safe and effective contraception. Many adolescents use no contraception or use a method irregularly, so they are at high risk of unwanted pregnancy, unsafe abortion, and sexually transmitted diseases. In general, adolescents are eligible to use any method of contraception. Adolescents need access to family planning services regardless of their marital status. Services should avoid unnecessary procedures that might discourage or frighten teens, such as requiring a pelvic exam when requesting oral contraceptives.

For more detail see the section on Other family-planning related issues in the Annotated Bibliography, especially the the FHI chart, Contraceptive Methods for Young Adults (www.fhi.org/en/fp/fppubs/network/v17-3/nt1735.html.)

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Post-Abortion and Post-Partum Women

Women who recently have had an abortion or given birth have special health needs that influence their contraceptive options. Providers should be aware of these health issues so they can provide appropriate counseling. For example, ovulation and subsequent risk of pregnancy return rapidly following an abortion, so post-abortion family planning needs to be initiated immediately. Also, any woman who has had an abortion should be advised of the warning signs for abortion-related hemorrhage, infection, or shock. In post-partum women, on the other hand, return to fertility is influenced by whether or not she is breastfeeding. In women who are not breastfeeding, the first post-partum ovulation may occur anywhere from day 30 to day 90 after delivery. Women who are not breastfeeding or who have weaned their infants are eligible to use any contraceptive method, provided that there are no delivery-related complications and they are screened for existing health conditions.

Breastfeeding women also have special health needs and concerns. They should not use a method that will affect breast milk or the health of the infant, such as a combined oral contraceptive or injectable. These methods should be delayed until after six months, unless another, more appropriate method is not available. Progestin-only methods should be delayed until after six weeks, and an IUD may be inserted either within 48 hours of delivery, or after 6 weeks post-partum. For more information see the article, "Contraception during Breastfeeding" (Anonymous 1998).

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Women Over Age 35

Although many women achieve their desired family size by the time they reach 30 years, women remain fertile until menopause which generally occurs between the ages of 45-55. Contraception is recommended until one year after menses cease. In addition women over age 35 may need protection against STDs, including HIV. Access to appropriate and acceptable contraceptives is important for women in their later reproductive years because pregnancy after age 35 carries increased health risks for both the woman and her child. A woman's choice and use of contraceptives during this time may be influenced by whether she wants more children, has existing disease conditions (such as diabetes, hypertension, anemia, or genital tract disorders) or smokes, as well as by her previous experience with contraceptives. For woman who are experiencing uncomfortable menopausal symptoms, estrogen-containing hormonal methods may be good choices as they can alleviate some symptoms. For more discussion of this issue, see Outlook Volume 14, Number 4.

Because older women are more likely to have pre-existing conditions, family planning programs should provide careful screening and counseling for these women when providing contraception. For more complete information on these recommendations, please refer to WHO's Medical Eligibility Criteria for Contraceptive Use.

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