Counseling for

Postpartum Family Planning

and
Postpartum IUCD

Reference Manual
(Draft)
 COUNSELING FOR
POSTPARTUM FAMILY PLANNING
AND
POSTPARTUM IUCD

REFERENCE MANUAL

April 2011
This manual was developed through technical assistance from USAID under the MCHIP program and
printed with support from the Bill & Melinda Gates Foundation. The views expressed herein do not
necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation.
 PREFACE

The overarching strategy of family planning programs is to offer clients easy access to a wide
range of affordable contraceptive methods in a good-quality and reliable fashion. Effective
counseling is one of the cornerstones for increasing acceptance and use of family planning and
addressing the unmet need. The best decisions about family planning are those that people make
for themselves, based on accurate information and a range of contraceptive options. Effective
counseling empowers people to seek what is best for them and to exercise their right to good-
quality family planning care. These facts suggest the need to reorient and refocus the family
planning counseling to offer a tailored approach to meet individual needs of clients.

This reference manual includes essential knowledge and tools to develop skills that are required
to provide effective family planning counseling. The content of this reference manual can be used
and adapted by trainers in the training for strengthening the counseling skills of family planning
providers and counselors. The family planning providers and counselors can use and refer to the
content of this manual to do effective counseling and share the up-to-date and correct
information with clients, using appropriate communication skills and approach in a culturally
appropriate manner, at their work-sites.

The manual addresses the following:

- Benefits of family planning and importance of postpartum family planning
- Technical overview of family planning methods and contraception for postpartum women
- Family planning counseling approach and communication skills
- Elements of family planning counseling and immediate postpartum IUCD counseling
- Checklists to ensure standard counseling on postpartum family planning and immediate
postpartum IUCD

The manual is adapted from and built on existing materials listed in the reference and previous
work on family planning counseling. At the same time, it includes newer and critical areas of
family planning like postpartum family planning and IUCD counseling and responds to the
needs expressed by those in the field.

We hope that the family planning providers and health workers find the manual useful and we
request them to provide their inputs to further evolve the document to better suit their needs.

______________________________
Principal Secretary
Department of Health and Family Welfare
Government of _________________
 ACKNOWLEDGEMENT

This reference manual was developed with active contribution from Dr. M.K. Sinha, General
Manager, Public Sector, SIFPSA, Dr. Rinku Srivastava, Project Coordinator, Public Sector,
SIFPSA; and Dr. Saswati Das, Dr. G. V. Rashmi and Dr. Dinesh Singh of JHPIEGO/ACCESS
FP. We acknowledge the contributions of JHPIEGO/ACCESS FPs Dr. Rashmi Asif, Holly
Blanchard, Jeffery Smith for reviewing the manual and Dr. Vineet Srivastava, Dr. Kailash Saran
for Hindi translation and Celine Gomes for designing and formatting. We are thankful to Dr.
Bulbul Sood, Country Director, JHPIEGO, who led the India ACCESS FP team and provided
valuable guidance for developing this notebook.

We extend our warmest thanks to Dr. Kiran Ambwani, Deputy Commissioner Family Planning,
Ministry of Health and Family Welfare (MOHFW), and her team, who encouraged the
development of this manual and provided very pertinent inputs.

We extend our special thanks to Dr. Loveleen Johri, Senior Reproductive Health Advisor, Office
of Population, Health and Nutrition, United States Agency for International Development
(USAID) for her overall support and encouragement.

We are thankful to the experts in Technical Advisory Group (TAG) meeting, who made valuable
contributions to give the final shape to the notebook.

Finally, we thank the trainers and family planning counselors, who participate in the training,
share their insights and use this manual.
 TABLE OF CONTENTS

Introduction -------------------------------------------------------------------------------------------------- 1
Chapter 1: Benefits of Family Planning and Importance of Postpartum Family Planning ------- 2
Chapter 2: Technical Overview of Family Planning Methods and Contraception for Postpartum
Women ----------------------------------------------------------------------------------------- 9
Chapter 3: Family Planning Counseling Approach and Communication Skills------------------ 21
Chapter 4: Elements of Counseling on Postpartum Family Planning and Immediate Postpartum
IUCD ------------------------------------------------------------------------------------------ 35
Chapter 5: Roles and Responsibilities of Counselor and Performance Standards for
Counseling ------------------------------------------------------------------------------------ 41
References --------------------------------------------------------------------------------------------------- 59
 ACCRONYMS AND ABBREVIATIONS

AIDS Acquired Immuno Deficiency Syndrome

ANC Antenatal Care
ARV Anti Retro Viral
COC Combined Oral Contraceptive
CNS Central Nervous System
DMPA Depot Medroxy Progesterone Acetate
DVT Deep Vein Thrombosis
EBF Exclusive Breast feeding
EC Emergency Contraception
ECP Emergency Contraceptive Pill
FP Family Planning
HIV Human Immuno Deficiency Virus
HTSP Healthy Timing and Spacing of Pregnancy
IEC Information, Education and Communication
IPPF International Planned Parenthood Federation
IUCD Intrauterine Contraceptive Device
JSY Janani Suraksha Yojna
LAM Lactational Amenorrhea Method
NSV No Scalpel Vasectomy
OCP Oral Contraceptive Pill
PID Pelvic Inflammatory Disease
PNC Postnatal Care
POP Progestin Only Pill
PPFP Postpartum Family Planning
PPIUCD Postpartum Intrauterine Contraceptive Device
RH Reproductive Health
SDM Standard Days Method
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
TB Tuberculosis
WHO World Health Organization
Introduction
 CHAPTER 1
BENEFITS OF FAMILY PLANNING
AND
IMPORTANCE OF POSTPARTUM FAMILY PLANNING

Table 1: Benefits of Family Planning and Risks if family planning is not practiced

Benefits Risks
1.1 Postpartum Family Planning

1.2 Rationale for Postpartum Family Planning (PPFP)

1.
2.

3.

4.

5.

1.3 Importance of Postpartum Family Planning

1.4 Contraception for Postpartum Women

Table 2: Timing of Method Use in the Postpartum Period

FAMILY PLANNING FULLY BREAST FEEDING PARTIALLY BREASTFEEDING OR

METHOD NOT BREASTFEEDING
 SAFE TIMES FOR POSTPARTUM INITIATION
OF VARIOUS METHODS OF FAMILY PLANNING

Delivery 48 hr 3 weeks 4 weeks 6 weeks 6 month 12 month

CONDOMS

IUCD IUCD

All FEMALE FEMALE STERILIZATION

STERILIZATION
Women
EMERGENCY CONTRACEPTIVE PILL*

MALE STERILIZATION

LACTATIONAL AMENORRHEA METHOD (LAM)

Breast-
PROGESTIN ONLY
Feeding PILL/INJECTION **
Women
COMBINED
ESTROGEN.-
PROGESTIN PILL
(COCs)

Non-breast PROGESTIN ONLY METHODS (PILLS/INJECTIABLES) **

Feeding Women
COMBINED ESTROGEN-PROGESTIN PILL (COCs)

fdfdf

*This is to be used only in emergency. For a regular contraceptive use, take advice from ANM/Doctor at government health centre.
**This is available in private sector.
1.5 Family planning information to pregnant and new mothers

1.5 (A) During antenatal period

1.5 (B) During immediate postpartum (within 48 hours of delivery)

o
o
o

1.5 (c) During postnatal care contact (within six weeks)

1.5 (D) Child health contacts during the first year/Immunization sessions
 Table 3: Family Planning Messages

1.6 Return to Fertility (chances of becoming pregnant)

Return to Fertility: A Distinction Between Postabortion and Postpartum Women

 CHAPTER 2
TECHNICAL OVERVIEW OF FAMILY PLANNING METHODS
FOR POSTPARTUM WOMEN
2.1 Basket of Contraceptives

2.2 Method Characteristics

Checklist to be reasonably sure a woman is not pregnant
 Condoms

MECHANISM OF ACTION FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE WHO SHOULD
(expressed in no. BENEFITS SIDE EFFECTS THE METHOD NOT USE THE
of pregnancies per METHOD
100 women using
the method over
the first year)
 Lactational Amenorrhea Method (LAM)

MECHANISM OF FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE WHO SHOULD
ACTION (expressed in no. of BENEFITS SIDE EFFECTS THE METHOD NOT USE THE
pregnancies per 100 METHOD
women using the method
over the first year)
 Oral Contraceptive Pills (OCPs) or Combined Oral Contraceptives (COCs)

MECHANISM OF FAILURE RATE EFFECTIVENESS LIMITATIONS/ WHO CAN USE WHO SHOULD NOT USE
ACTION (expressed in no. of AND BENEFITS SIDE EFFECTS THE METHOD THE METHOD
pregnancies per 100
women using the
method over the first
year)

 Intrauterine Contraceptive Device (IUCD)

MECHANISM OF FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE THE WHO SHOULD NOT USE
ACTION (expressed in no. of BENEFITS SIDE EFFECTS METHOD THE METHOD
pregnancies per 100
women using the
method over the first
year)

MECHANISM OF FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE THE WHO SHOULD NOT USE
ACTION (expressed in no. of BENEFITS SIDE EFFECTS METHOD THE METHOD
pregnancies per 100
women using the
method over the first
year)
 Female Tubal Ligation
MECHANISM OF FAILURE RATE EFFECTIVENESS LIMITATIONS/ WHO CAN USE WHO SHOULD NOT USE THE
ACTION (expressed in no. of AND BENEFITS SIDE EFFECTS THE METHOD METHOD
pregnancies per 100
women using the
method over the first
year)

-
-
-

-
-

-
-

-
-
-
-

-
 Vasectomy

MECHANISM OF FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE THE WHO SHOULD NOT USE
ACTION (expressed in no. of BENEFITS SIDE EFFECTS METHOD THE METHOD
pregnancies per 100
women using the
method over the first
year)

-
-
-
-
-

-
-

-
- -
-
2.3 Options for Emergency Contraception (EC)
 Emergency Contraceptive Pill (ECP)
(Can be used anytime after 4 weeks of childbirth)

MECHANISM OF ACTION FAILURE RATE EFFECTIVENESS AND LIMITATIONS/ WHO CAN USE WHO SHOULD
(expressed in no. BENEFITS SIDE EFFECTS THE METHOD NOT USE THE
of pregnancies METHOD
per 100 women
using the method
over the first year)
- -

-
-

-
-

-
-

-
 Comparing Effectiveness of Family Planning Methods
How to make your
More effective method more effective
Less than 1 Implants, IUD, female
pregnancy per 100 sterilization: After
women in 1 year procedure, little or nothing
to do or remember
Vasectomy: Use another
Implants IUD Female Sterilization Vasectomy method for first 3 months
Sterilization
Injectables: Get repeat
injections on time
Lactational Amenorrhea
Method, LAM (for 6
months): Breastfed often,
day and night

Injectables LAM Pills Patch Vaginal ring

Pills: Take a pill each day
Patch, ring: Keep in place,
change on time

Condoms, diaphragm: Use

correctly every time you have
sex.
Fertility awareness
methods: Abstain or use
condoms on fertile days.
Newest methods (Standard
Male condoms Diaphragm Female Fertility awareness Days Method and Two Day
Method) may be easier to use.
Condoms methods

Withdrawal, spermicides:
Less effective Use correctly every time
About 30 pregnancies per you have sex.
100 women in 1 year
Withdrawal Spermicides

Sources:
Steiner MJ, Trussell J, Mehta N, Condon S, Subramaniam S, Bourne D. Communicating contraceptive effectiveness: a randomized conrolled trial to inform a
World Health Organization family planning handbook. Am J Obstet Gynecol 2006; 195(1):85-91
World Health Organization/Department of Reproductive Health and Research (WHO/RHR), Johns Hopkins Bloomberg School of Public Health
(JHSPH)/Center for Communication Programs (CCP). Family Planning: A Global Handbook for Providers. Baltimore, MD and Geneva: CCP and WHO, 2007.
Trussell J. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Stewart F, Nelson AL, Guest F, Kowal D, eds.
Contraceptive Technology, Nineteenth Revised Edition. New York: Ardent Media, Inc., in press.
 CHAPTER 3
FAMILY PLANNING COUSELING APPROACH AND
COMMUNICATION SKILLS
3.1 Counseling
3.2 Key points of Counseling

3.3 General Counseling

3.4 Method-specific Counseling

3.5 Return/Follow up counseling

3.6 Counseling the four types of FP clients

ESSENTIAL COUNSELING TASKS FOR

NEW CLIENTS WITH NO NEW CLIENTS RETURNING RETURNING
METHOD IN MIND WITH A METHOD IN CLIENTS WITH NO CLIENTS WHO ARE
MIND PROBLEMS OR EXPERIENCING
CONCERNS PROBLEMS OR
HAVE CONCERNS
3.7 Principles and Quality Issues of Counseling

3.8 Adapting the Counseling Process

3.9 Informed Choice
3.10 Rights of Clients

Introduction to Rights of the Client

Clients Rights

The Rights of Family Planning Clients

3.11 Three Kinds of Communication in Family Planning

Comparison of motivating, informing and counseling

Motivating Informing Counseling

3.12 Effective Counselor and Communication Skills

3.12.1 Effective Counselor

3.12.2 Qualities

3.13 Knowledge needed by FP providers

About clients
About contraception and family planning methods

About counseling for family planning

About the family planning program

FP service delivery centre requirements

3.14 Skills of Counselor

3.15 Communication Skills

3.15.1 Difference between verbal and non-verbal communication

Verbal Communication Nonverbal Communication

3.15.2 Non-verbal Communication

3.15.2 (A) Positive nonverbal cues include:

3.15.2 (B) Negative nonverbal cues include:

3.15.3 Verbal Communication

3.15.3 (A) Active Listening

3.15.3 (B) Verbal Encouragement

3.15.3 (C) Tone of Voice

3.15.3 (D) Using Simple Language

3.15.3 (E) Giving feedback

3.15.3 (F) Empathy

3.15.3 (G) Being Non-judgmental

3.15.3 (H) Asking open-ended and close-ended questions

 o
o
o

o
o
o
o

3.16 Some acronyms to help communication

 CHAPTER 4
ELEMENTS OF COUNSELING ON POSTPARTUM FAMILY PLANNING
AND IMMEDIATE POSTPARTUM IUCD
4.1 The GATHER Approach for Family Planning Counseling

Tasks conducted under GATHER approach

4.2 Elements of postpartum counseling

4.3 Elements of Immediate Postpartum IUCD (PPIUCD) Counseling

4.4 Immediate Postpartum IUCD Counseling

4.5 Antenatal Counseling

Textbox: Client Messages about Basic Attributes of the PPIUD

4.6 If not counselled in antenatal period, when else can women be counseled
for PPIUCD insertion?

4.7 Post Insertion Counseling

 CHAPTER 5
ROLES AND RESPONSIBILITIES OF COUNSELOR
AND
PERFORMANCE STANDARDS FOR COUNSELING

5.1 Following are the suggested roles and responsibilities of the counselor
with respect to PPFP and PPIUCD services:
 POSTPARTUM IUCD FOLLOW-UP (FU) REGISTER FORMAT

Type of PPIUCD Type of FU

Time of FU
insertion (Tick Finding of FU
(Tick
(Tick appropriate appropriate (Tick appropriate column)
appropriate
column) Name of column)
column) Action
provider Due Actual Reason
S. Indoor Phone Date of taken for

(within 10 min.)

(within 48 hrs.)
Name Age who date of date of for Remarks

Missing Strings
Immediate PP

Intracesarean

Up to 6 weeks

After 6 weeks

No Complaint
No Reg No No insertion complica

-Telephonic
Postpartum

Complaints
Clinic Visit
inserted FU FU removal

Expulsion

Infection

(Specify)
-tions

Other
PPIUCD
5.2 Checklists and Performance Standards

Using the Checklists for Learning

Using the Checklist for Assessment

Trainers: Use this tool when the learner is ready for assessment of competency in the counseling skill.
Place a in case box if step/task is performed satisfactorily, an X if it is not performed
satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by participant during evaluation by trainer
 CHECKLIST 1: FAMILY PLANNING COUNSELING
(To be used for practicing and assessment of the FP counseling skill)
This checklist is for counseling woman/couple at any time on various methods of family planning

Place a in case box if step/task is performed satisfactorily, an X if it is not performed

satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by participant during evaluation by trainer

Participant_________________________________ Date Observed _________

CHECKLIST FOR FAMILY PLANNING COUNSELING

(Some of the following steps/tasks should be performed simultaneously)

STEP/TASK CASES

PREPARATION FOR COUNSELING

GENERAL COUNSELING SKILLS

 CHECKLIST FOR FAMILY PLANNING COUNSELING
(Some of the following steps/tasks should be performed simultaneously)

STEP/TASK CASES

SPECIFIC FAMILY PLANNING COUNSELING

METHOD-SPECIFIC COUNSELING once the woman has chosen a method

 CHECKLIST FOR FAMILY PLANNING COUNSELING
(Some of the following steps/tasks should be performed simultaneously)

STEP/TASK CASES

FOLLOW-UP COUNSELING
 CHECKLIST FOR FAMILY PLANNING COUNSELING
(Some of the following steps/tasks should be performed simultaneously)

STEP/TASK CASES
 CHECKLIST 2: POSTPARTUM IUCD COUNSELING IN THE WARD
(To be used for practicing and assessment of the FP counseling skill)

This checklist is for counseling woman, who has just delivered, for postpartum family planning. This
counseling can be done in postpartum ward. After getting information on all the methods of family
planning, if the woman shows interest in IUCD (CuT), she should be counseled on PPIUCD according
to the steps given in this checklist

Place a in case box if step/task is performed satisfactorily, an X if it is not performed satisfactorily, or

N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by participant during evaluation by trainer

Participant_________________________________ Date Observed _________

CHECKLIST FOR POSTPARTUM FAMILY PLANNING (PPFP) COUNSELING IN THE WARD

(Some of the following steps/tasks should be performed simultaneously)

STEP/TASK CASES
PERFORMANCE STANDARDS FOR IMMEDIATE POSTPARTUM INTRAUTERINE DEVICE (PPIUCD) COUNSELING

PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS

AREA 1: INITIAL CLIENT ASSESSMENT AND COUNSELING DURING ANTENATAL CARE; RETURN VISIT
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS

-
-

-
PERFORMANCE STANDARDS VERIFICATION CRITERIA Y/N, N/A1 Y/N, N/A COMMENTS
References