Family Planning Ayşe Arzu Akalın, MD
Aim: The aim of this lecture is to convey general information on Family Planning Services and Contraceptive Method use Objectives: At the end of this lecture students should be able to; • tell the definition of family planning • differentiate between population planning and family planning • tell the history of birth control in Turkey • give statistical data on family planning • list contraceptive methods according categories • explain the main features of contraceptive methods
Definitions • History • Legal Background • Statistics on Contraceptive Method Use • Principles of Family Planning Counselling • Methods
Definition • Birth control, also known as contraception and fertility control, are methods or devices used to prevent pregnancy. • Family planning is the planning of when to have children and the use of birth control and other techniques to implement such plans. • Family planning is applied by individuals
Definition Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved".
Definition • Population planning or control is the practice of artificially altering the rate of growth of a human population. • Population planning or control is applied by governments.
Population Planning orControl may use one or more of the following practices although there are other methods as well: • Contraception • Abstinence • Reducing infant mortality so that parents do not increase their family size to ensure at least some survive to adulthood. • Abortion • Infanticide • Improving status of women causing departure from traditional sexual division of labour. • Emigration • Immigration reduction • Sterilization • Legislation
History • The oldest claimed representation of condom use is a painting in the French cave Grotte des Combarrelles; the paintings in this cave are 12,000–15,000 years old • EarliestdocumentareChiniesrecepts of contraceptionandabortion (BC 2700) • In the EgyptianEbersPapyrus 1550 BCE and theKahunPapyrus1850BCE: the use of honey,acacialeaves and lint to be placed in the vagina to block sperm. • In Ancient Greecesilphiumwas used as birth control which, due to its effectiveness and thus desirability, was harvested into extinction.
History • In BC periodArabiccommunitiesusedpebblelikestones as IUD’sforcamelstopreventpregnancywhilepassingthedesert. • In medieval Europe women used a number of birth control measures, such as coitusinterruptusand inserting lily root and rue into the vagina (and, in addition, infanticide after birth), orusingamulets. • Casanovaliving in 18th centuryItalydescribed the use of a lambskin covering to prevent pregnancy; however, condoms only became widely available in the 20th century.
PopulationPolicies in Turkey Between 1923 and 1965 pronatalist population policies. population in 1927: 13 million Importation of contraceptive material restricted, induced abortion illegal, promotion of contraception inhibited, big families promoted (tax exception, medals and gratifications) leading to high population growth, high maternal, infant and child mortality In 1959 in Rural Turkey infant mortality ratio was about 165 in 1000 live births and maternal mortality ratio was 280 in 100.000 live births.
PopulationPolicies in Turkey • after 1965 antinatalistpopulationpolicies. A newlegislation on populationplanning (1965). A newdefinitionforpopulationplanning: people can decidefreely on thenumber of theirchildren Contraception can be usedfreely Inducedabortionandsterilizationsareonlyallowedifbased on medicalcauses.
PopulationPolicies in Turkey 2827 sayılı Nüfus Planlaması Yasası (1983) (Law on Population Planning Nr 2827) (still in force) • Inducedabortion is legal untill 10 weeks of pregnancy • Trainednursesandmidwivesarelicencedfor IUD (Intrauterin Device) insertion • TrainedGP’sarelicencedforpregnancytermination • Male andfemalesterilization is legal Infantmortality rateisabout 17in 1000 live births and maternal mortality ratiois 28,5in 100.000 live births. (2008, TurkeyHealthandDemographicSurvey) Population size: over 76.5 million
TurkeyDemographicandHealthSurvey • is conductedby Hacettepe UniversityInstitute of PopulationStudiessince 1983 every 5th year • Gathersinformation on levelsandtrends of fertility, infantandchildmortality, familyplanning, maternalandchildhealthandnutrition.
Thefertility rate 2.1 is a limit forpopulationgrowth. • Iffertility rate of Turkeywillstay in thisvalueTurkeywillhave a population of 96-98 millions in 2050 andbecomefirststaedyandwillbegintodiminishlater.
FP Counselling • General Counselling (information on reproductivesystemandcontraceptivemethods) • MethodSpesificCounselling (detailedinformation on thechoosenmethod, historytakingandphysicalexam) • Follow-upCounselling (satisfaction, appropriateuse, anyproblems)
Basic Principlesfor FP Counselling • Welcome and greet • Show interest and ask questions • Provide information on FP methods • Help to choose a method • Explain how to use the chosen method • Ask to come back for follow-up visit
Delivery of FP Services Before Family Medicine System: • Health Units, Health Centers, Mother and Child Health/ Family Planning Centers, Family Planning Departments in State Hospitals, Ob/Gyn Outpatient Clinics in Hospitals and Private Health Facilities, Private offices After Family Medicine System: Family Physicians, Reproductive Health Centers ?, Mother and Child Health/ Family Planning Centers, Family Planning Departments in State Hospitals ?, Ob/Gyn Outpatient Clinics in Hospitals and Private Health Facilities, Private offices
ContraceptiveMethods Classificationaccordingto • Action (Hormonal, Barrier, IUD’s, Surgical, LAM, FertilityAwarenessBasedMethods, CoitusInterruptus) • Effectiveness (High, moderate, low) • Traditional / Modern • Gender (Male/Female) • Service provision (A: Pills, condom, diaphragmandspermiside, B: IUD, enjectablesandimplants,+A, C: surgicalsterilization+A+B)
HormonalContraceptives Combined Hormonal Contraceptives • Combined Oral Contraceptives (COC’s) (pills) • Combined Injectable Contraceptives (Monthly) • Combined Patches • Combined Vaginal Rings Progestin-only Contraceptives • Progestin-OnlyPills (Minipills) • Progestin-OnlyInjectableContraceptives • Implants
Combined Hormonal Contraceptives Combined Oral Contraceptives (COC’s) (Pills) • Pills that contain low doses of 2 hormones—a progestin and an estrogen—like the natural hormones progesterone and estrogen in a woman’s body. • Work primarily by preventing the release of eggs from the ovaries (ovulation). Should be takeneveryday, should be started in first 5 days of menstrualperiod
Effectiveness • As commonly used, about 8 pregnanciesper 100 womenusing COCs over the first year. This means that 92 of every100 women using COCs will not become pregnant. • When no pill-taking mistakes are made, less than 1 pregnancy per 100 women using COCs over the first year (3 per 1,000women). • Return of fertility after COCs are stopped: No delay • Protection against sexually transmitted infections (STIs): None
Side Effects, Health Benefits, and Health Risks Side Effects • Changes in bleeding patterns including:Lighter and fewer days of bleeding, Irregularbleeding, Infrequentbleeding, No monthlybleeding • Headaches • Dizziness • Nausea • Breasttenderness • Weight change • Moodchanges • Acne (can improve or worsen, but usually improves) • Blood pressure increases a few points (mm Hg). When increase is due toCOCs, blood pressure declines quickly after use of COCs stops.
Known Health Benefits Help protectagainst: • Risks of pregnancy • Cancer of the lining of the uterus(endometrial cancer) • Cancer of the ovary • Symptomaticpelvic inflammatory disease • May help protect against: • Ovarian cysts • Iron-deficiency anemia Reduce: • Menstrual cramps • Menstrual bleeding problems • Ovulation pain • Excess hair on face or body • Symptoms of polycystic ovariansyndrome (irregular bleeding,acne, excess hair on face or body) • Symptoms of endometriosis(pelvic pain, irregular bleeding
KnownHealthRisks Very rare: • Blood clot in deep veins of legsor lungs (deep vein thrombosisor pulmonary embolism) Extremely rare: • Stroke • Heartattack
MedicalEligibility Do not provideCOC’sifshe • is breastfeeding a baby less than 6 months old • had a baby in the last 3 weeks and notbreastfeeding • is 35 years of age or older and smokes • hascirrhosis of the liver, a liver infection, or livertumor, jaundice. Has ever had jaundice when using COCs • systolic blood pressure is 140 mm Hg or higher ordiastolic blood pressure is 90 or higher, • had diabetes for more than 20 years or damageto her arteries, vision, kidneys, or nervous systemcaused by diabetes • hasgallbladder disease now or take medicationfor gallbladder disease • ever had a stroke, blood clot in legs orlungs, heart attack, or other serious heart problems
MedicalEligibility Do not provideCOC’sifshe • hasor has ever had breast cancer • has migraine aura at any age, orhas migraine headaches without aura and isage 35 or older • taking barbiturates, carbamazepine,lamotrigine, oxcarbazepine, phenytoin, primidone,topiramate, rifampicin, rifabutin, or ritonavir.They can make COCs less effective. • planning major surgery that will keep her fromwalking for one week or more • hasseveral conditions that could increase her chances of heart disease (coronary artery disease) orstroke, such as older age, smoking, high blood pressure,or diabetes • has thrombogenicmutations or lupus with positive (or unknown)antiphospholipidantibodies
Managing Missed Pills Making Up Missed Pills With 30–35 μg Estrogen‡ • Key message:Take a missed hormonal pill as soon aspossible. • Keep taking pills as usual, one each day. (She maytake 2 pills at the same time or on the same day.)
Managing Missed Pills Missed 1 or 2 pills? Started new pack1 or 2 days late? • Take a hormonal pill as soon as possible. • Little or no risk of pregnancy. Missed pills 3 ormore days in arow in the firstor second week? Startednew pack3 or more days late? • Take a hormonal pill as soon as possible. • Use a backup method for the next 7 days. • Also, if she had sex in the past 5 days, can considerECPs
Managing Missed Pills Missed 3 or morepills in the thirdweek? • Take a hormonal pill as soon as possible. • Finish all hormonal pills in the pack. Throw awaythe 7 nonhormonal pills in a 28-pill pack. • Start a new pack the next day. • Use a backup method for the next 7 days. • Also, if she had sex in the past 5 days, can considerECPs
Managing Missed Pills • Missed any nonhormonalpills? (last7 pills in 28-pill pack) • Discard the missed nonhormonal pill(s). • Keep taking COCs, one each day. Start the newpack as usual. • Severe vomiting ordiarrhea • If she vomits within 2 hours after taking a pill, sheshould take another pill from her pack as soon aspossible, then keep taking pills as usual. • If she has vomiting or diarrhea for more than 2 days,follow instructions for 3 or more missed pills, above.
Managing Missed Pills • For pills with 20 μg of estrogen or less, women missing one pill should follow the sameguidance as for missing one or two 30–35 μg pills. • Women missing 2 or more pills shouldfollow the same guidance as for missing 3 or more 30–35 μg pills.
Monthly Injectables (CombinedInjectableContraceptives, CICs) • Monthly injectables contain 2 hormones—a progestin and an estrogen—like the natural hormones progesterone and estrogen in a woman’s body. Mesigyna=norethisteroneenanthate(NET-EN)/estradiol valerate. Work primarily by preventing the release of eggs from the ovaries(ovulation). Should be injectedeachmonth im.
Effectiveness Effectiveness depends on returning on time: Risk of pregnancy isgreatest when a woman is late for an injection or misses aninjection. • As commonly used, about 3 pregnancies per 100 women usingmonthly injectables over the first year. This means that 97 ofevery 100 women using injectables will not become pregnant. • When women have injections on time, less than 1 pregnancyper 100 women using monthly injectables over the first year(5 per 10,000 women). • Return of fertility after injections are stopped: An average of about onemonth longer than with most other methods • Protection against sexually transmitted infections (STIs): None
Side Effects • Changes in bleeding patterns including: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – Prolonged bleeding – No monthly bleeding • Weight gain • Headaches • Dizziness • Breast tenderness
Known Health Benefits and Health Risks • Long-term studies of monthly injectables are limited, but researchers expect that their health benefits and health risks are similar to those ofcombined oral contraceptives.
MedicalEligibility Do not providemonthlyinjectablesifshe • isfully or nearly fully breastfeeding: She can start 6months after giving birth or when breast milk is nolonger the baby’s main food—whichever comes first • had a baby in the last 3 weeks and you are notbreastfeeding • is 35 years of age or older and smokesmore than 15 cigarettes • reports serious active liver disease (jaundice,active hepatitis, severe cirrhosis, liver tumor), • if hersystolic blood pressure is 140 mm Hg or higher ordiastolic blood pressure is 90 or higher, • had diabetes for more than 20 years or damageto your arteries, vision, kidneys, or nervous systemcaused by diabetes • reports heart attack, heart disease due toblocked or narrowed arteries, or stroke,
MedicalEligibility • hasor hasever had breast cancer • has migraine aura at any age,orshe has migraine headaches without aura and is age 35 or older • is planning major surgery that will keep her fromwalking for one week or more • hasseveral conditions that could increase herchances of heart disease (coronary artery disease) orstroke, such as older age, smoking, high blood pressure,or diabetes? • is taking lamotrigine or ritonavir. Monthly injectablescan make lamotrigine less effective. Ritonavir canmake monthly injectables less effective • reports having thrombogenic mutations or lupus with positive (or unknown)antiphospholipidantibodies.
Combined Patch • A small, thin, square of flexible plastic worn on the body. • Continuously releases 2 hormones—a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body—directlythrough the skin into the bloodstream. • A new patch is worn every week for 3 weeks, then no patch for thefourth week. During this fourth week the woman will have monthlybleeding. • Also called Ortho Evra and Evra. • Works primarily by preventing the release of eggs from the ovaries(ovulation).
Effectiveness Effectiveness depends on the user: Risk of pregnancy is greatestwhen a woman is late to change the patch. • The combined patch is new, and research on effectiveness islimited. Effectiveness rates in clinical trials of the patchsuggest that it may be more effective than combined oralcontraceptives, both as commonly used and with consistent andcorrect use • Pregnancy rates may be slightly higher among women weighing 90 kg ormore. • Return of fertility after patch use is stopped: No delay • Protection against sexually transmitted infections: None
Side Effects • Skin irritation or rash where the patch is applied • Changes in monthly bleeding: – Lighter bleeding and fewerdays of bleeding – Irregular bleeding – Prolonged bleeding – No monthly bleeding • Headaches • Nausea • Vomiting • Breast tenderness and pain • Abdominalpain • Flu symptoms/upper respiratory infection • Irritation, redness, or inflammation of the vagina (vaginitis)
Known Health Benefits and Health Risks • Long-term studies of the patch are limited, but researchers expect that itshealth benefits and risks are like those of combined oral contraceptives
Combined Vaginal Ring • A flexible ring placed in the vagina. • Continuously releases 2 hormones—a progestin and an estrogen, like thenatural hormones progesterone and estrogen in a woman’s body—frominside the ring. Hormones are absorbed through the wall of the vaginadirectly into the bloodstream. • The ring is kept in place for 3 weeks, then removed for the fourth week. • During this fourth week the woman will have monthly bleeding. • Also called NuvaRing. • Worksprimarily by preventing the release of eggs from the ovaries(ovulation).