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DEPARTMENT OF COMMUNITY MEDICINE

FACULTY OF MEDICINE
A.B.U. ZARIA
TOPIC: FAMILY PLANNING-
RANGE/CHOICE OF METHOD
PRESENTERS:
HAMZA AHMED TIJANI
MPH/MED/19604/2007-08
IBRAHIM NA’ALLAH
MPH/MED/ /2007-08

FEBRUARY, 2009
PRESENTATION OUTLINE
INTRODUCTION
DEFINITIONS
CONTENTS
• Global/ African / Nigerian FP Situation
• Attention to unmet needs
• FP range/ methods
• Safety / side – effects
• Implant removal/ sterilization reversal
• FP Counselling / informed Choice of
method
PRESENTATION OUTLINE (Cont’d)
• Delay child birth in Adolescence,
male responsibility, FP in post-
abortion care, post-partum period,
violence against women
• Quality of FP services
• FP and MDG’s
• Role of NGOs in FP
• Challenges of FP in Nigeria
RECOMMENDATIONS
CONCLUSION
REFERENCES
INTRODUCTION
 Family planning is arguably considered
the most important component of
reproductive health as the outcome of other
components of RH largely depend on the
effectiveness of family planning .
FP first became the focus of international
concern as a basic human right in the United
Nations conference on Human Right
Teheran
INTRODUCTION (Cont’d)
This view was further endorsed at the Bucharest
Conference on world population in 1974 and re-
echoed at ICPD Cairo in 1994.
Bucharest Conference /ICPD Cairo emphasized
in their plan of action that ”All couples and
individuals have the basic human right to decide
freely and responsibly the number and spacing
of their children and to have information,
education and the means to do so”.
DEFINITIONS
FP is a preventive Health Service that provides
quality affordable and easily accessible RH care to
women and men during their reproductive years.
FP also refers to practices that help individuals or
couples to attain certain RH objectives namely:
 To avoid unwanted pregnancies.
 To achieve wanted pregnancies
 To regulate the intervals between pregnancies
 To control the time of pregnancy
 To determine the number of children in the
family
GLOBAL / AFRICAN FP OVERVIEW
 350 million eligible people do not have
access to FP services worldwide.
 Low contraceptive prevalence mostly
in African Region
 Most countries worldwide have
achieved birth control (one-child
family in china; 2 – child family in
India, etc).
 Low utilization of contraception
among adolescents in sub-Saharan
Africa.
GLOBAL / AFRICAN FP OVERVIEW (Cont’d )

African region has a population of 869


million (14% of world population)
Highest fertility rate of 5-6 births per
woman
Highest incidences of unwanted
pregnancies among adolescents
Unsafe abortion of 4.02 million annually
Maternal mortality rate of about – 1000/
100,000 livebirths
¾ of women needing birth control in Africa
do not have access to FP.
NIGERIAN RH SITUATION
Population of Nigeria – 140 million (2006
census)
Population growth rate – 2.8%
Young population (10 – 24 years) – 32%
Total fertility Rate – 5.2 (Regional variation)
Adolescent fertility Rate - 29.3% of births
Contraceptive prevalence Rate - 8.6%
NIGERIAN RH SITUATION (Cont’d)

Unmet need for family planning - 18%


Teenage pregnancy – 22%
Girls married before age 15 years – 25.0%
Maternal mortality Rate – 800/100,000 live
births
Infant mortality rate – 103/100 live births
FP SITUATION IN NIGERIA
Contraceptives Knowledge and Use in Nigeria (1990 &1999)

64 65
63
70

60

50

40 1990
29
1999
23 1999 modern
30
17 18
14 15
20
9
6

10

0
Know method Ever Used Currently Using Unmet need
REASONS FOR HIGH FERTILITY IN NIGERIA
Socio-cultural barriers
Lack adequate information and Health
Education
Poor access to FP services
Low level of utilization of services
Inadequate skills on the part of providers
Increased teenage pregnancy
Lack of male involvement
Low educational level
Poverty, high rate of unemployment
Inadequate/ irregular supply of contraceptives
Low status of women
UNMET NEEDS FOR FP
Refers to a situation where women or men who
are sexually active would prefer to avoid
pregnancy but nevertheless are not using any
contraceptive methods
About ¼ of women want to stop having children
or delay pregnancy but are not using
contraceptives
Unmet need is highest among adolescents,
among rural women and women with low
educational level
Unmet need for FP in Nigeria – 18.0%
REASONS FOR UNMET NEEDS

Inadequate or unsatisfactory services


Lack of adequate information
Fears about contraceptive side
effects
Resistance from sexual partner or
relatives.
Poor accessibility to FP services
INCREASING DEMAND FOR FP
SERVICES
Adequate information on FP services
Accessibility to FP services
Emphasis on Quality of services
Emphasis on counselling and
informed choice of FP services
 male involvement in FP services
RANGE / SCOPE OF FP
SERVICES
FP not synonymous with Birth control
FP include in its purview the
following:
• The proper spacing and limitation of
births
• Marriage/ parenthood counselling
• Preparation of couples for the arrival
of their 1st child
• Genetic counselling
RANGE / SCOPE OF FP
SERVICES (Cont’d)
Providing services for unmarried
mothers
Sex Education for adolescents
Screening for pathological
conditions of the reproductive
system e.g. ca-cervix
Teaching Home Economics and
Nutrition
Providing adoption services
METHODS OF FAMILY
PLANNING
 Natural Family Planning (NFP)
 Contraceptive (Fertility Regulating)
methods
 Post – Conceptional Methods
(termination of Pregnancy )
 Terminal (Sterilization) methods
 ?Family planning vaccine
NATURAL FAMILY PLANNING METHODS
 Sexual Abstinence
• The only completely effective
method
• Only theoretical
 Coitus interruptus (withdrawal) method
 Safe period (calendar/ Rhythm) method
 Basal body temperature (BBT)
 Cervical mucus (Billings) method
 Breast feeding (lactational
Amenorrhoea)
HORMONAL CONTRACEPTIVES

 Combined pill
 Progestogen - only
 Post – coital pills (ECPs)
 ?Male pill (Gossypol)
 Injectables
 Subcutaneous Implants
 Vaginal rings
TERMINAL METHODS

 Male sterilization (vasectomy)


 Female sterilization (Tubal ligation)

BIRTH CONTROL VACCINE-


 Under Research
 Clinical trials very soon
CONTRACEPTIVE METHODS

 Barrier methods – Condoms,


Spermicides, diaphragm
 Intrauterine contraceptive
Devices (IUCD)
BENEFITS OF FAMILY PLANNING METHODS

Prevention of unwanted pregnancies


Adequate spacing between pregnancies
Improves General and Reproductive
Health of the mother
Decreases incidence of adolescent
pregnancy
Decreases incidence of unsafe abortion
Variety of options for users
Generally safe in Healthy individuals
Happy couple, Happy family, Happy
community.
SAFETY OF FP METHODS
 Natural family planning  Absolutely safe but
less effective
 Barrier methods- Safe except
 Allergic to latex
 Combined oral
contraceptives- Safe in young women
relatively safe in older women
 Not safe in the first 6 months
of delivery if breast feeding.
 Progestin- Only pills (Mini-pills)
 Generally safe except in medical conditions
 Safe while breast feeding
 d. Emergency contraceptive pills (ECP)
 Generally safe even with medical condition
due to their short – term nature.
SIDE EFFECTS
Irregular vaginal bleeding
Pain – lower abdominal backache
Pelvic inflammatory diseases
Uterine perforation – (IUCD)-Rare
Ectopic pregnancy
Expulsion of IUCD
SIDE EFFECTS (Cont’d )
Cardiovascular -
Myocardial
infarction
hypertension,
venous thrombosis
Metabolic - Hyperlipidaemia,
hyperglycaemia
Weight gain
Liver disorders - Adenoma,
cholecystitis
IMPLANTS REMOVAL
Removal is necessary when requested by
the woman for whatever reason.
INDICATIONS FOR REMOVAL
need for another pregnancy
Medical conditions
Severe side effects
Replacement after expiration of implant
Personal reasons
Aseptic technique is used
Fertility is regained within one year of
removal.
STERILIZATION REVERSAL
Fertility does not return because
sterilization generally can not be reversed
The procedure is intended to be
permanent
Reversal surgery is difficult, expensive
and not available in most areas
Reversal surgery when performed does
not lead to pregnancy
Greater risk of ectopic pregnancy when
reversal is done in women
Adequate counselling and informed
consent are therefore necessary.
FP METHODS – FAILURE RATES
FP Method Perfect Typical Use
Use (%) (%)
No contraception used 85 85

Consistent abstinence 0 0

Tubal ligation 0.2 0.4

Vasectomy 0.1 0.15


FP METHODS – FAILURE RATES (Cont’d)
FP Method Perfect Typical Use
Use (%) (%)
Injectable contraceptive 0.3 0.3

Oral contraceptive 0.1 5

IUCD 0.6-1.5 0.8-2

Condom (Male) 3 14

Condom (Female) 5 21
FP COUNSELLING/ INFORMED
CHOICES
Aims to help the client make informed
choice.
Involves
• Effectiveness of FP method
• Advantages and disadvantages
• side effects and complications
• How to use the chosen method
• When to return
FP COUNSELLING/ INFORMED
CHOICES (Cont’d)
• Principle of “GATHER” is
employed
• Allow client to make a choice
• Non- judgemental
• Couple – counselling is important
to encourage male involvement
MEDICAL ELIGIBILITY CRITERIA FOR
FP METHODS
Category With Limited Clinical With Limited
Clinical

1 Use method in any circumstances Yes


2 Generally use method
(Use the
method)
3 Use of method not usually No
recommended unless other
more appropriate methods (Do not use
are not available or not the method)
Acceptable
4 Method not to be used
FP SERVICES FOR DIVERSE
GROUPS

Adolescents
Men
Post – abortion care
Violence against women
Post – partum period
Pre-menopausal women
ADOLESCENTS
Adolescents – Age 10 – 19 years
Constitute 1/6th of world’s population
85% of adolescents in developing
countries
Girls age 15 – 19 years give birth to 15
million babies yearly
About 4 million abortions yearly
Girls age 15 – 19 years die from
pregnancy- related causes than any other
cause
In Nigeria – young people age 10 – 24
years – 32% teenage pregnancy – 25%.
ADOLESCENTS (Cont’d)
8.3% of males age 15 – 19 years
have had sex by age 15 year
16.2% of girls in the same age –
group have had sex by 15 years
WHY FP / DELAY BIRTH IN
ADOLESCENTS?
Women less than 20 years are more
likely to suffer from complications of
pregnancy
Young women often seek for unsafe
abortion with its attendant
complications
STI`s higher among adolescents –
33% under 17 years
High prevalence of preterm delivery
and infant mortality in teenage
BENEFITS OF FP IN
ADOLESCENTS
Protection against unwanted
pregnancies
Protection from STI`s/HIV- AIDS
Prevention of Unsafe abortion
Increased Employment opportunities
Increased Educational opportunities
METHODS OF FP IN
ADOLESCENTS
• All contraceptives are safe for young
people
• Barrier methods (condom) are better for
young males  contraception and
protection against STI`s
• ECP`s and Injectables are better for young
girls because they have less control over
sex.
• Young women are less tolerant to OCP`s.
• IUCDs, sterilization not desirable
MALE RESPONSIBILITY IN FP
Men are important supporters,
important clients
They have influence on women
They can use condoms and
vasectomy
Couple – counselling/ Joint –
decision-making about sexual and
reproductive health should be
encouraged.
MALE RESPONSIBILITY Cont’d
MALE RH SERVICES
Condom, vasectomy and counselling
about other methods
Conselling and help in other sexual
problems e.g Erectile Dysfunction
STI/HIV counselling, Testing and treatment
Infertility counselling
Screening for penile, testicular or prostate
cancer.
OBSTACLES TO MALE
INVOLVEMENT IN FP
1. Feminists’ extreme stance on
Gender equality -“It is my body !”
slogan.
2. FP service providers resistance in
providing male RHS
3. No clear definition of male RHS
4. Marginalization of males in RHS–
Emphasis is on women.
FP IN POST – ABORTION CARE
Fertility returns quickly within 2 weeks (1st
trimester abortion) and 4 weeks (2nd trimester
abortion).
Need for immediate access to FP services.
FP services to be integrated into PAC
COC’s, Injectables, Implants can be started
immediately
IUCDs, sterilization can be started when
infection is ruled out
FP IN VIOLENCE AGAINST
WOMEN (VAW)
Women experiencing violence have
special Health needs, many of them
related to sexual and Reproductive Health
Violence can lead to injuries, unwanted
pregnancy, STI`s etc
Counsel client with empathy, compassion
and non – judgmental manner.
Provide ECP`s if appropriate and wanted
Offer ECP pills for future use
QUALITY OF FP SERVICES
Refers to degree of excellence and
standards in FP services delivery, in order
to satisfy needs of clients
Adequate information on scope and
benefits of FP services to stakeholders
Adequate and regular supply of
contraceptives
Improved accessibility to FP services.
Technical competence in FP service
delivery
QUALITY OF FP SERVICES
(Cont’d)
Improving staff attitude and interpersonal
relationship
Provision of wide range of FP choices to
meet diverse groups
Appropriate mechanism for sustainability
of FP programmes
Collaboration with development partners
in FP services
FAMILY PLANNING AND
MDG’S
Strong relationship exists between
family planning and MDG’s.
MDGs 1, 2 and 3
Eradicating poverty, achieving
female education and promotion of
gender equality and equity are the
best strategies to uptake of FP
services
FAMILY PLANNING AND
MDG’S (Cont’d)
MDGs 4, 5 and 6
Effective family planning will reduce
incidence of unwanted pregnancies,
unsafe abortions, complications of
pregnancy and STIs/ HIV – AIDS.
Consequently there will be reduction of
child mortality, improvement in
maternal Health and reduce prevalence
of STIs / HIV-AIDS
FAMILY PLANNING AND MDG’S
(Cont’d)
MDG 8

Development of Global partnership


especially with UN Agencies and NGO’s
has strengthened FP services in Nigeria.
ROLE OF NGOs IN FP
Several International Voluntary agencies and
NGO’s are actively involved in FP activities in
Nigeria
Agency – UNFPA
Unilateral Agencies – USAID DFID, SIDA, IPPF
International NGOs – FHI, Pathfinder, Compass,
SFH. etc
Local NGOs – WIN, PPFN, FOMWAN, NCWS
etc
FUNCTIONS OF NGOs IN FP
Community mobilization / advocacy
Mass media campaign on FP issues
Distribution of IEC materials/Contraceptives
SFH distributes about 74% of Contraceptives in
Nigeria
Support for Religious Leaders Forum on
maternal mortality rate reduction
 Research  SFH was involved in the National
AIDS and Reproductive Health survey in 2005
CHALLENGES OF FP IN NIGERIA
 Low contraceptive prevalence rate in
Nigeria.
 High proportion of unmet needs.
 Large proportion of young population
requiring FP services
 Lack of community awareness on scope
and methods of FP
 Low Educational, Economic and social
status of women.
CHALLENGES OF FP IN NIGERIA
(Cont’d)
Lack of male involvement in FP
services
Inadequate and irregular supply of
FP commodities
Heavy reliance on donor agencies for
FP activities
RECOMMENDATIONS
Community mobilization on FP
services and relevance of condoms
for dual protection
 promotion of behavioural changes
and safer sex practices through
behavioural change modification.
Expanding access to FP services
especially for adolescents (in –
school and out – of – school),
refugees etc
RECOMMENDATIONS (Cont’d)
Updating operational guidelines and
standards of practices
Strengthening commodities supply and
logistics.
Ensuring client satisfaction through quality
of services
Expanding contraceptive services to
include ECPs, implants, sterilization and
NFP methods
Promoting educational and employment
opportunities for girls and women
Promoting male involvement in FP
services.
CONCLUSION
Family planning remains one of the most
important cornerstones of reproductive
health and also a veritable strategy for
achieving millennium development goals.
Low contraceptive prevalence, high
proportion of unmet needs, large
proportion of adolescents requiring FP
services and lack of community
awareness on scope of FP remain
challenging issues in FP services
delivery.
CONCLUSION (Cont’d)
There is therefore the need for
concerted effort by all stakeholders to
promote FP services in all its
ramifications for the improvement of
maternal and child health and for the
development of the family, community
and the nation at large.
REFERENCES
1. Park, K (2005). Park’s Textbook of Preventive
and Social Medicine, 18th Edition (8): 358 – 376,
2005.
2. FMOH, Abuja (2002). National strategic
Framework and Plan (2002 – 2006).
3. Sabitu, K. (2008). Concepts elements and
strategies of RH in Nigeria. MPH 2008 Lecture
services.
4. WHO (2007). Family Planning Handbook for
Providers, 2007.
5. WHO (2007). Medical Eligibility Criteria for
Contraceptive Use, 2008.
6. Society for Family Health. Improved Reproductive
Health in Nigeria (IRHIN).
THANK YOU
FOR
LISTENING

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