Birthspacing and Family Planning in Pakistan - Nursing - Tutor's - Final

Birth Spacing and Family Planning in Pakistan
Nursing Tutors Guide
BIRTH SPACING AND FAMILY PLANNING IN PAKISTAN

Nursing Tutors Guide
ACKNOWLEDGEMENT
Pakistan Nursing Council would like to acknowledge Jhpiego, an affiliate of The John Hopkins University, and FALAH for managing this valuable work. Pakistan Nursing Council also wishes to thank all of the members of the working group on preservice education, including Controllers of the four Boards of Nursing Examination, faculty members from nursing and allied institutions from DG Khan and Jhelum, and all of the experts for their valuable contributions made during consultative workshops and meetings. Pakistan Nursing Council would also especially like to acknowledge the services of Ms. Julia Bluestone, Training and PQI Advisor, Jhpiego, and Dr. Fauzia Assad, Technical Advisor FP, Jhpiego, for putting their utmost efforts into creating this book. We are also thankful to the Baltimore Publications staff of Jhpiego, especially Ms. Renata Kepner, Desktop Publishing Specialist, for formatting and designing the document and making it user-friendly. The technical supplement provided in these materials on birth spacing and family planning has been adapted with the permission of the Pakistan Nursing Council from the Community Midwifery Manual, 2007.* The following members of the working group and experts contributed to the development of this book: 1. Ms. Nighat DurraniRegistrar, Pakistan Nursing Council 2. Ms. Julia BluestoneTraining and PQI Advisor, Jhpiego 3. Dr. Jeffery SmithRegional Director Technical for Asia, Jhpiego 4. Dr. Fauzia AssadTechnical Advisor FP, Jhpiego 5. Dr. Syed Hasan ShoaibProgram Advisor, Training and Quality Improvement, Jhpiego 6. Dr. Waqar SaleemManager, Quality Assurance, Jhpiego 7. Ms. Amina IjazSenior Instructor, School of Nursing, Aga Khan University Hospital, Karachi 8. Ms. Shakila BegumController, Nursing Board of Examination, Peshawar 9. Ms. Mehboob SultanaController, Nursing Board of Examination, Karachi
* Noor A., Ibrahim, H., Izhar, H. and Norman, J. Community Midwifery Manual, October 31, 2007. Pakistan Nursing Council and UNFPA, Pakistan.
ii
Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide
10. Ms. Rashida AyubController, Nursing Board of Examination, Lahore 11. Ms. Fatima NasreenController, Nursing Board of Examination, Quetta 12. Ms. Hameeda BegumPrincipal, School of Nursing Jhelum 13. Ms. Farzana BibiSenior Tutor, School of Nursing Jhelum 14. Dr. Nudrat AlmasPrincipal, School of Midwifery and Public Health, DG Khan 15. Ms. Salma SikandarSenior Instructor, School of Midwifery and Public Health, DG Khan 16. Ms. SaminaTutor, School of Midwifery and Public Health, DG Khan 17. Ms. Nasreen AkhtarInstructor, School of Nursing, Jehlum 18. Dr. Zaira TahirIncharge RHS-A, Jhelum 19. Ms. Shahida ShaheenPrincipal, Lady Dufferin Hospital, Quetta 20. Ms. Farzana AkramTutor, School of Nursing, Jhelum 21. Ms. Farhana AzimPrincipal, Postgraduate College of Nursing, Peshawar 22. Ms. Aqsa JaleelSenior Instructor, School of Nursing, Ayub Teaching Hospital, Abbottabad 23. Mr. Tabassum ParvezPrincipal, School of Nursing, Mission Hospital, Quetta 24. Mr. SarwarNursing Instructor, Sindh Govt. Qatar Hospital, Karachi
iii
iv
TABLE OF CONTENTS
OVERVIEW ...................................................................................................................................... 1
Before Starting the Module ....................................................................................................... 1 Overview of This Learning Package ....................................................................................... 1 Course Syllabus .......................................................................................................................... 2
SECTION 1: COMMUNICATION SKILLS AND BEHAVIOUR CHANGE

TECHNICAL CONTENTS
Behaviour Change and Communications....................................................................... 1 Ensuring Quality Materials Job Aid ................................................................................ 5
CASE STUDIES AND ROLE PLAYS

Case Studies ................................................................................................................... 51 Role Plays........................................................................................................................ 65
SKILL DEVELOPMENT TOOLS

Checklist for Community Interventions......................................................................... 14 Checklist for Effective Communication......................................................................... 16 Checklist for Group Health Education .......................................................................... 17 Checklist for Conducting Semi-Structured Interview.................................................... 18 Checklist for Transect Walk ......................................................................................... 19 Checklist for Mapping................................................................................................... 20 Checklist for Community Entry..................................................................................... 21 Checklist for Community Profile ................................................................................... 22 Checklist for Community Mobilization .......................................................................... 23 Checklist for Planning a Health Talk with the Community............................................ 24
KNOWLEDGE ASSESSMENT TOOLS PRESENTATION GRAPHICS
SECTION 2: BIRTH SPACING AND FAMILY PLANNING

TECHNICAL SUPPLEMENT
Government of Pakistan Policy on Family Planning ..................................................... 1 Family Planning and Islam............................................................................................... 4 Healthy Timing and Spacing of Pregnancy .................................................................... 7 Method Provision and Support...................................................................................... 10 Contraceptive Methods .................................................................................................. 14 Contraception in Special Circumstances ..................................................................... 35
TEACHING AIDS
Job Aids........................................................................................................................... 41
EXERCISES, CASE STUDIES AND ROLE PLAYS

Exercises ......................................................................................................................... 65 Case Studies ................................................................................................................... 79 Role Plays........................................................................................................................ 94

Checklist for Breast Examinations ............................................................................. 105 Checklist for Pelvic Examinations .............................................................................. 107 Checklist for Family Planning Counselling ................................................................. 110 Checklist for Family Planning CounsellingSAHR Approach................................. 113 Checklist for Postpartum Family Planning Counselling on the Ward ......................... 115 Checklist for LAM Counselling for Birth Spacing........................................................ 116 Checklist for Injectables Clinical Skills ....................................................................... 118 Checklist for IUCD Counselling Skills ........................................................................ 119
ASSESSMENT TOOLS
Logbook Sample ........................................................................................................... 125
PRESENTATION GRAPHICS
vi
ABBREVIATIONS AND ACRONYMS

BBT BBC BTL CIC COC CPR CRC DVT EC ECP ENG FP HLD HTSP IEC IPC IUCD LAM LHV LMP MCH MDG M&E MEC MIS MoH NFP NGO NSAID NSV OCP OPD PID POP PPE PPFP RH Basal body temperature Behaviour Change Communication Bilateral tubal ligation Combined injectable contraceptive Combined oral contraceptive Contraceptive prevalence rate Client clinical record card Deep venous thrombosis Emergency contraception Emergency contraceptive pill Etonorgestrel Family planning High-level disinfection Healthy Timing and Spacing of Pregnancy Information, education and communication Interpersonal communication Intrauterine contraceptive device Lactational amenorrhoea method Lady Health Visitor Last menstrual period Maternal and child health Millennium Development Goal Monitoring and evaluation Medical Eligibility Criteria Management information system Ministry of Health Natural family planning Non-governmental organization Non-steroidal anti-inflammatory drug No-scalpel vasectomy Oral contraceptive pill Outpatient department Pelvic inflammatory disease Progestin-only pill Personal protective equipment Postpartum family planning Reproductive health
vii
RTI SDM STI TL VSC WHO
Reproductive tract infection Standard Days Method Sexually transmitted infection Tubal ligation Voluntary surgical contraception World Health Organization
viii
PREFACE
Education in Pakistan has tried to keep abreast of the latest developments in different fields. Nursing, midwifery and LHV education programmes are no exception, and have tried to incorporate internationally accepted competencies in their curricula. One of the areas that need to be emphasized is the promotion of optimal birth spacing, as the failure to do so contributes to infant and maternal morbidity and mortality. Health care providers are the key to meeting the populations health needs, so optimal birth spacing must be adequately addressed in preservice health professional education. With the help of Jhpiego and faculty from Nursing Council, the related curriculum for birth spacing and contraception is being strengthened for nursing, midwifery and LHV cadres. The new curriculum follows best practices in education, with a focus on: 1. Improved links between theory and practice. Effective education provides consistent practice opportunities for students to apply theories learned. This is reflected in the increased attention to links between classroom and clinical training. 2. Increased emphasis on clinical decision-making. Often in theory or didactic teaching, the emphasis is on rote learning. The curriculum includes exercises and case studies to shift the focus from rote learning to clinical decision-making and problem solving. 3. Increased focus on skills practice in simulation and with clients. Effective education ensures that students have adequate skills practice so they are competent upon graduation to provide safe, beginning level services. This has been addressed by including tools for skills development and assessment. 4. Adequate attention to provider ethics, attitudes and beliefs. Provider bias and beliefs can be a barrier to the provision of quality services. The curriculum addresses these issues through exercises and built-in activities. These materials can be used by nurses, midwives, and LHV faculty, preceptors, and students to prepare graduates who are able to successfully counsel families about birth spacing and provide desired contraception based on clients situations. An informed and capable workforce will help ensure that families receive the services they need for healthy spacing. I would like to place on record our gratitude to Jhpiego, an affiliate of The Johns Hopkins University, for providing technical support in
ix
updating and strengthening the document. I would also like to thank the faculty of nursing, midwifery, and public health schools for contributing to the development of this module. The untiring work and secretariat support provided by the staff are gratefully acknowledged. Ms. Nighat Durrani Registrar, Pakistan Nursing Council
OVERVIEW
BEFORE STARTING THE MODULE The module and its technical supplement contents and activities are intended to promote learning, and the student is expected to be actively involved in all aspects of that learning. The tutor will create a comfortable environment and promote those activities that assist the learner in acquiring new knowledge, attitudes, and skills. The tutor and the students are provided with a similar set of educational materials. The tutor, by virtue of previous training and experiences, works with the students as a facilitator on the topic and facilitates or guides the learning activities. OVERVIEW OF THIS LEARNING PACKAGE This learning resource package (LRP) is composed of two main components: the tutors materials and students materials. The tutors materials include everything needed to teach, as described below: Graphics Presentations, which cover all of the basic knowledge update Content supplement, which provides consolidated information on birth spacing and recent changes to the Pakistan family planning policy Tools for teaching, which includes job aids, exercises, case studies, and role plays for practice. In addition, a quick review of how to develop lesson plans and a sample are included. Tools for assessment, which includes sample logbook forms, checklists, and a question bank organized by topic area that may be used for formative and summative assessment The students materials, presented as a Student Notebook, include the content supplement, exercises, case studies and role plays (without the answers), job aids, checklists, and sample logbook forms. There is also a thumbnails handout1 of the Graphics Presentation. An essential reference for both is Family Planning Handbook for Service Providers, as well as Family Planning: A Global Handbook for Providers (available at: http://www.infoforhealth.org/globalhandbook/).
This handout will be distributed at the end of the course; this ensures that participants will have key content for future reference (without having to take extensive notes).
In addition, Leadership and Management for Nursing and Community Medicine are also used. COURSE SYLLABUS Learning Objectives During the nursing programme, birth spacing is addressed in community health nursing. CHN 1 Describe various strategies that can be used to deliver health education. Develop a teaching plan and conduct mock health session on a selected topic. CHN II Describe family planning in Pakistan. Identify the benefits of healthy birth spacing. Identify social, economic, political and religious aspects of FP in Pakistan. Discuss the responsibilities of a nurse with regard to family planning. Describe family planning services available in Pakistan. Describe the advantages, disadvantages and side effects of different contraceptive methods. Discuss the importance and steps of counselling skills. Training/Learning Methods Illustrated lectures and group discussions Individual and group exercises, including case studies, role plays, brainstorming, and small group discussions Demonstration and practice activities in simulation Clinical Placement/Practical Experience The tutor should make the arrangements for placement of students in the family planning clinics, antenatal clinic, and postnatal ward under supervision of a qualified provider or doctor. In addition, the students will visit the community with the LHV. Each student must counsel minimum of 5 women for birth spacing, during the whole of this unit; however she is encouraged to do more.
During clinical placement, it is expected that students will: Plan and give health talks according to their needs at home Motivate families to use healthy birth spacing Demonstrate birth spacing counselling skills Always make sure the staff supervising students are aware who will be visiting, and the times and the purpose of the visit(s) (learning objectives). It is essential that staff supervising students (clinical preceptors) are demonstrating skills correctly. Always provide the staff supervising students and the students with checklist to assist them. Provide sufficient time for debriefing and discussion after their time spent in the labour ward. All of the activities should be recorded in the students logbook. Methods of Evaluation Written examinations Checklists for skill assessment
TEACHING PLAN Use this table to help you teach the related objectives, no matter which course they belong to.
LEARNING OBJECTIVES CHN I Describe various strategies that can be used to deliver health education. Difference between education and counselling List education methods Develop a teaching plan and conduct mock health session on a selected topic. Apply the effective counselling skill in both the classroom and clinical setting Apply various methods of health education CHN II Describe family planning (FP) in Pakistan. Identify the benefits of healthy birth spacing. Identify FP services available in Pakistan. Identify social, economic, political and religious aspects of FP in Pakistan. Discuss the responsibilities of a nurse for FP. Government of Pakistan FP policy Healthy timing and spacing benefits Sources of contraception FP and Islam Provider bias and attitudes Provider ethics Role of the nurse in FP Interactive Lecture Discussion Interactive Lecture Discussion Interactive Lecture Discussion Interactive Lecture Discussion Antenatal clinic Postnatal ward Family planning clinics Interactive lecture Case studies and role plays Group Work Demonstration Role play Field test Interactive Lecture Discussion CONTENTS TIME TEACHING METHODOLOGY EVALUATION
Describe the indications, contraindications, advantages and side effects of different contraceptive methods. Discuss the importance and steps of counselling skills.
Natural methods Barrier methods Hormonal methods IUCD Permanent methods Observation Counselling: Antepartum FP Clinic Ward
Practice in simulation Practice with clients
SECTION 1
COMMUNICATION SKILLS AND BEHAVIOUR CHANGE
TECHNICAL CONTENTS
BEHAVIOUR CHANGE AND COMMUNICATION2 Many health and development programmes use behaviour change communication (BCC) to improve peoples health and well-being, including family planning and reproductive health, maternal and child health, and prevention of infectious diseases. BCC is a process that motivates people to adopt and sustain healthy behaviours and lifestyles. Sustaining healthy behaviour usually requires a continuing investment in BCC as part of an overall health programme. The BCC process can be broken down into five steps: Analysis, Design, Development and Testing, Implementation and Monitoring, and Evaluation. Heres a summary of key tasks to accomplish for each step. Analysis Understand the health issue: Determine severity and causes of the health issue, noting differences by audience characteristics such as gender and ethnicity. Identify possible health-related behaviours that could be encouraged or discouraged. Identify social, economic, and political factors blocking or facilitating desired behaviour changes. Develop problem statement that summarizes the above points to help identify what aspects of the health issue can be addressed through communication. Understand audience and other potential participants in the programme: Identify primary audience (people who are at risk of or are suffering from the health problem) and secondary audiences (people who influence health behaviours of primary audience). Collect in-depth information about the audience: What are their knowledge, attitudes, and beliefs about health? What factors affect their health behaviours? What are their media habits? What access do they have to information, services, and other resources? Where do they currently stand in the stages of behaviour change? Are there different groups of people who have similar needs, preferences, and characteristics (audience segments)? Will the BCC programme need customized messages and materials to suit audience segments?
Involve audience members and other key stakeholders in the analysis of their own concerns. Participatory techniques include scoring and preference ranking (community members weigh different problems or programme options as to how well they meet various criteria) and community mapping and modelling. In this process, community members draw a map of their community to identify what programs are available and where they may be needed most.
2 This section was adapted and used with permission from Salem, R.M, Bernstein, J. and Sullivan, T.M. Tools for Behaviour Change Communication, INFO Reports, No 16, Baltimore, INFO Project, Johns Hopkins Bloomberg School of Public Health, January, 2008.
Develop a profile, or description, of each audience segment to help the creative team develop effective messages and materials later (see page 5 for a tool). Conduct participant analysis. Which other people or groups can participate in the BCC programme (partners, stakeholders, allies, and gatekeepers)? These may include nongovernmental organizations, professional associations, schools, faith-based groups, and the media. What skills or resources can they offer? What would motivate their participation? Conduct channel analysis. What channel or means, can be used to reach the audience? What communication channels are available? Radio? TV? Print? What are the strengths and weaknesses of each channel? For example, how effective are the channels in reaching the audience? How many people can they reach? Design Define communication, behaviour change, and programme objectives. Communication objectives describe desired changes in indirect influences on behaviour, such as knowledge, attitudes, and social norms. Behaviour change objectives refer to intended changes in the audiences actual behaviour. Together, communication and behaviour change objectives contribute to the overall programme objective, which refers to anticipated results of the overarching health programme. Select monitoring and evaluation indicators (how will you measure success?) Are indicators validthat is, do they measure the topic or issue that they are meant to reflect? Are indicators reliablethat is, do they produce consistent results when repeated over time? Are they specific (measure a single topic or issue), sensitive (responsive to change), and operational (measurable)? Prioritize communication channels. Use findings from analysis to guide the choice of channels. To help maximize effect, can the programme use a mix of the three major types of channelsmass media, interpersonal, and/or community channels? Develop a creative brief to share with people and organizations involved in developing messages and materials. Does the brief include a profile of the intended audience, behaviour change objectives, resulting benefits that the audience will appreciate, channels that will carry the messages, and the key message points?
2 Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide
During design, involve those most directly affected by the health issue; ensure fair representation of women and marginalized groups.
Draw up an implementation plan, including activities, partners roles and responsibilities, timeline, budget, and management plan. Develop a monitoring and evaluation plan. Development and Testing Develop messages and materials. Use findings from analysis and the strategic plan to guide development. The creative brief and audience profiles developed in Step 2 summarize this information. Tailor messages to the audiences needs. Choose type of appeal, such as empowering or entertaining, and tone, such as humorous or authoritative. Pretest messages and materials with audience members. Revise messages and materials based on pretesters reactions. Implementation and Monitoring
Form an advisory group made up of key stakeholders close to or representing the audience. Advisory groups can provide useful advice about developing appropriate messages and materials and can help with revisions after pretesting.
Develop and implement a dissemination plan. Manage and monitor programme progressactivities, staffing, budget, and responses of the audience and other stakeholders. Make midcourse adjustments to the programme based on monitoring results. Mobilize a large number of stakeholders to help implement activities and develop a broad sense of ownership. Offer different means and levels of participation during implementation. For example, for a radio programme, audience members can participate in listening groups, suggest questions for the programme, or even start a community radio programme. Include audience members and other stakeholders in steering committees to oversee programme implementation, make recommendations, and ensure action to improve activities. EVALUATION Measure outcomes, assess impact: Involve audience members in evaluating the programme. Ask what they want to know and why, how they can help conduct the evaluation, and how they will use the results. Share key findings of the experimental evaluation with audience members and findings of the participatory evaluation with other
stakeholders. Encourage participants from the audience to share evaluation findings with their communities, advocate further activities, and spread activities to other communities. Disseminate results to partners, key stakeholders, the news media, and funding agencies. Record lessons learned and archive research findings for use in future programmes. Revise or redesign programme based on evaluation findings.
ENSURING QUALITY MATERIALS JOB AID3 Use this job aid to help you review communication materials or messages developed.
Are messages accurate and clear? Experts reviewed programme messages to ensure they are scientifically accurate. Messages are simple and contain as few scientific and technical terms as possible. Messages state explicitly the action that audiences should take. Visual aids such as photographs reinforce messages to help the audience understand and remember the messages. Are messages and materials relevant for the audience? Messages state benefits of the recommended behaviour that the audience will value. For example, psychological benefit (you will feel more in control), altruistic (spacing pregnancies is healthier for your wife and children), economic (have just a few children, and you can educate them all), or social (condom users are cool). Presentation style of messages is appropriate to the audiences preferences. For example, rational versus emotional approach, serious versus light tone. Messages keep in mind regional differences, ranging from the language and dress of people portrayed in materials to the organization of health care delivery. Messages and materials speak to the experience of the audience. New and unfamiliar information is related to something familiar to help the audience learn the new information more easily. Messages suit the readiness of the audience to make a change. Are communication channels credible? The source of information is credible with the audiencefor example, doctors or opinion leaders. Celebrity spokespeople are carefully selected. Celebrities should be directly associated with the message and practice the desired health habitfor example, an athlete promotes exercise. Are messages and materials appealing? Messages stand out and draw the audiences attention. Materials are of high quality by local standards. Mass media programming is both accurate and interesting. Are messages and materials sensitive to gender issues? Messages do not reinforce inequitable gender roles or stereotypes. Messages and materials include positive role models. Messages, materials, and activities are appropriate for the needs and circumstances of both women and men. In particular, they consider differences in workload, access to information and services, and mobility.
This job aid was created from Salem, R.M, Bernstein, J. and Sullivan, T.M. Tools for Behaviour Change Communication, INFO Reports, No 16, Baltimore, INFO Project, Johns Hopkins Bloomberg School of Public Health, January, 2008.
CASE STUDIES AND ROLE PLAYS
CASE STUDY
CASE STUDY: COMMUNICATION FOR BEHAVIOUR CHANGE Background During a Mohallah Meeting in the Orangi community, Ms. Munana, the nurse, spoke to the community members about the need to keep their environment clean to avoid being ill. Feedback received indicated that all had accepted the need to keep their environment clean. On one of her visits 2 months after this Mohallah Meeting, Ms. Munana realized that some community members had started dumping refuse in a pit not too far away from the market, which is in the centre of town. She was surprised and disappointed. She concluded that the community was difficult. Questions 1. Why is there the need to hold Mohallah Meetings once a while in the communities? 2. How is feedback received or given during Mohallah Meetings? 3. Was the Mohallah Meeting sufficient to effect the needed behaviour change? 4. What can Ms. Munana do now to improve the situation?
ROLE PLAY
TITLE: COMMUNICATION FOR BEHAVIOUR CHANGE Background A nurse in the community has noticed that the spacing after births is usually within a year. She believes that this situation is contributing to low birth weights and increased maternal morbidity. She has therefore decided to focus on this situation for her next quarterly meeting with the community. Instructions Discuss with participants the process of holding a meeting to sensitize them the need for behavioural change After the discussion, participants should carry out a role play of the scenario. In the role play, participants should play the following: A nurse 1 opinion leader 3 community members Questions 1. How would you use the communication skills covered in this unit to prepare to discuss this issue at the meeting? 2. Which skills would be the most important and why?
10
TOPIC: COMMUNITY PARTICIPATION Background Ms. Nargis, a nurse at health centre, Pabbi, holds a review meeting with community members to assess the half-year health status of the people. The nurse maintains a cordial relationship with the people by asking about their health, giving everybody the chance to talk about their concerns. She listens to them attentively, ensuring active participation. She is interested in increasing the communitys use of contraception for better spacing in between children and improved maternal and newborn outcomes. In the role play, participants should play the following roles: Nurse Village community members Village Chief Midwife Questions Students are to observe the following attitudes: Patience Tolerance Respect for other peoples views Good listening attitude Humility 1. During the role play, what did you observe about the attitude of the nurse? 2. What other communication skills did you observe? 3. What positive relationship did you observe between the nurse and the community members? 4. What important lessons have you learned from the role play?
11
12
SKILL DEVELOPMENT
CHECKLISTS Checklist for Community Interventions Name: Dates:
Place a in case box if step/task is performed satisfactorily, an 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, task or skill not performed by participant during evaluation by trainer CHECKLIST FOR COMMUNITY INTERVENTIONS STEP/TASK PLANNING MONTHLY COMMUNITY ACTIVITIES 1. Identifies health issues and problems: Home visiting Immunization Common ailment Nutrition-related issues Family planning Health education School health 2. Reviews disease profile of the community 3. Sets criteria for prioritizing health activities: Epidemiological criteria Technical criteria Community criteria Political criteria Logistic/economic criteria Consensus 4. Sets targets for programmes and activities; Objectives for setting the targets should be: Specific Measurable Achievable Realistic Time bound SKILL/ACTIVITY PERFORMED SATISFACTORILY PROCURING/MOBILIZING RESOURCES 1. Sources of resources will include: Teachers, midwives Nazim, naib nazim, patwari of the area Community members District assemblies Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide CASES
15
CHECKLIST FOR COMMUNITY INTERVENTIONS STEP/TASK NGOs involved health activities SKILL/ACTIVITY PERFORMED SATISFACTORILY IMPLEMENTING PLANNED ACTIVITIES 1. Things to note in field notebook: Activity Purpose Time/date Others SKILL/ACTIVITY PERFORMED SATISFACTORILY MONITORING AND EVALUATING ACTIVITIES CARRIED OUT 1. Things to note when monitoring: Scheduled activities Objectives/targets Resources and cost as against what was estimated Achievements Constraints Conclusions Subsequent actions to be taken
SKILL/ACTIVITY PERFORMED SATISFACTORILY
CASES
16
Checklist for Effective Communication

Place a in case box if step/task is performed satisfactorily, an 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, task or skill not performed by participant during evaluation by trainer CHECKLIST FOR EFFECTIVE COMMUNICATION STEP/TASK PREPARATION General 1. Maintains eye contact. 2. Uses appropriate tone of voice. 3. Uses appropriate body language. 4. Listens attentively. 5. Uses language that is easily understood. 6. Asks open-ended questions. 7. Demonstrates respect for socio-cultural differences. 8. Demonstrates a respectful attitude. ACTIVE LISTENING 1. Paraphrases as appropriate by restating what was said. 2. Summarizes as appropriate by reviewing and summarizing what was said or discussed. 3. Probes as appropriate by asking further questions to get more information. SKILL/ACTIVITY PERFORMED SATISFACTORILY PROVISION OF FEEDBACK 1. Gives immediate feedback. 2. Gives appropriate feedback on the situation in the right cultural context. 3. Gives polite feedback. 4. Gives constructive and non-judgemental feedback. 5. Gives feedback that provides clear suggestions as appropriate. SKILL/ACTIVITY PERFORMED SATISFACTORILY RECEIVE FEEDBACK 1. Listens attentively. 2. Avoids arguments. 3. Shows appreciation for feedback offered. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
17
Checklist for Group Health Education

Place a in case box if step/task is performed satisfactorily, an 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, task or skill not performed by participant during evaluation by trainer CHECKLIST FOR GROUP HEALTH EDUCATION STEP/TASK 1. Greets and introduces self to clients. 2. Establishes rapport. 3. Projects voice for all to hear. 4. Exhibits enthusiasm about the subject. 5. Maintains eye contact. 6. Encourages group participation. 7. Discusses the various aspects of the topic chosen. Presents information clearly and in an organized manner. 8. Gives opportunity for clients to ask questions. If unable to answer a question, tells the group you will find out the answer and let them know later. 9. Provides positive feedback. 10. Uses audio-visuals effectively. SKILL/ACTIVITY PERFORMED SATISFACTORILY CLOSING THE SESSION 1. Summarizes the major points of the session. 2. Reminds clients about next visits. 3. Records health education done in notebook. 4. Thanks clients for their participation. 5. Distributes flyers, etc. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
18
Checklist for Conducting Semi-Structured Interview

Place a in case box if step/task is performed satisfactorily, an 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, task, or skill not performed by participant during evaluation by trainer CHECKLIST FOR CONDUCTING SEMI-STRUCTURED INTERVIEW STEP/TASK 1. Prepares interview guide based on the issue at stake: Discusses the context in relation to time, place, seating arrangement, etc. Demonstrates active listening, by being attentive, open-minded and avoids being judgemental. Addresses sensitive questions, by asking open ended and probing questions. Judges and cross-checks responses for accuracy. Records interviewAsks permission and records. SKILL/ACTIVITY PERFORMED SATISFACTORILY ACTIVE PHASE 1. Greets in a traditional/culturally appropriate manner and states that the team is there to learn. 2. Establishes rapport. 3. Assigns one recorder or note taker to record everything. 4. Asks group the key questions to start discussion, taking the following tips into consideration: Carefully leads up to sensitive questions Is open minded and objective Mixes questions with discussion Lets each team member finish their line of questioning Is aware of non-verbal signs Avoids leading questions and judging responses Avoids questions that can be answered with Yes or No 5. Finishes interview in less that 2 hours. 6. Thanks them for their cooperation and asks for permission to leave. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
19
Checklist for Transect Walk

Place a in case box if step/task is performed satisfactorily, an 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, task, or skill not performed by participant during evaluation by trainer CHECKLIST FOR TRANSECT WALK STEP/TASK 1. Draws a community map. 2. Draws transect line through the map. 3. Develops observation guide for transect walk. 4. Finds community members who are knowledgeable and willing to walk through their community and its surrounding areas. 5. Discusses with them the different factors to be drawn on the transect walk, such as sanitary conditions, availability of public health facilities. 6. Does the transect walk. 7. Observes, asks, listens (does not lecture). 8. Discusses problems and opportunities. 9. Identifies the main natural and agricultural zones and sketches the important features e.g., health facility, sanitation condition, etc. 10. Draws the transect map. 11. Cross-checks the transect with key informants. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
20
Checklist for Mapping

Place a in case box if step/task is performed satisfactorily, an 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, task, or skill not performed by participant during evaluation by trainer CHECKLIST FOR MAPPING STEP/TASK PREPARATION 1. Decides on the type of map and its objectives. 2. Provides the borders for the map. 3. Helps community to choose appropriate place for the mapping activity. 4. Guides community to draw their own map using appropriate symbols. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
21
Checklist for Community Entry

Place a in case box if step/task is performed satisfactorily, an 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, task or skill not performed by participant during evaluation by trainer CHECKLIST FOR COMMUNITY ENTRY STEP/TASK 1. Collects information on the community. 2. Identifies the community leaders. 3. Identifies the contact persons and opinion leaders. 4. Conducts meetings with the community leaders. 5. Briefs leaders of the purpose of visit. 6. Seeks approval and support for the programme. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
22
Checklist for Community Profile

Place a in case box if step/task is performed satisfactorily, an 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, task or skill not performed by participant during evaluation by trainer CHECKLIST FOR COMMUNITY PROFILE TASK/ACTIVITY 1. Identifies the community (location). 2. Informs community on objectives so that the community understands the purpose of the survey and participate. 3. Mobilizes resources. 4. Makes a plan for the activities. 5. Collects data. 6. Conducts periodic evaluations. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
23
Checklist for Community Mobilization

Place a in case box if step/task is performed satisfactorily, an 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, task, or skill not performed by participant during evaluation by trainer CHECKLIST FOR COMMUNITY MOBILIZATION STEP/TASK 1. Identifies the community (location). 2. Finds out if community is ready: Does the community perceive a problem and a need for change? Is there an event and or persons that spark the desire for change? Catalysts Does the existing system support the desired change? Environmental support Are community members willing to take up responsibilities? 3. Identifies resources: Human resources Natural resources Man-made resources Organizational resources 4. Selects committee members. 5. Assigns responsibilities to committee. 6. Conducts periodic evaluations. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
24
Checklist for Planning a Health Talk with the Community

Place a in case box if step/task is performed satisfactorily, an 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, task, or skill not performed by participant during evaluation by trainer CHECKLIST FOR PLANNING A HEALTH TALK WITH THE COMMUNITY STEP/TASK 1. Conducts community entry. 2. Conducts community study (profile). 3. Conducts needs assessment of community. 4. Contacts leaders of community. 5. Briefs leaders on objectives of Mohallah Meeting. 6. Fixes a date for the Mohallah Meeting in consultation with community. 7. Organizes the Mohallah Meeting. 8. Evaluates effectiveness of Mohallah Meeting. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
25
26
ASSESSMENT TOOLS
QUESTION BANK
BEHAVIOUR CHANGE AND COMMUNICATION 1. Define communication: Communication is a process of conveying thoughts and ideas from a person to others with the sole aim of getting some action taken. The only way you can determine whether the purpose of communication has been understood is to obtain feedback. 2. List the components of communication process: a) Source b) Message c) Channel d) Receive e) Feedback 3. Describe tools and techniques used for Participatory Learning and Action. Information-Gathering Tools: Mapping (geographical and physical) Transect walks Observation Timelines/time trends Seasonal calendars Daily schedule Analytical Tools: Preference ranking Pair-wise ranking Matrices 4. The following tools are used under the Participatory Learning and Action to gather information EXCEPT: a) Mapping and diagramming b) Sorting and ranking c) Structured interviews d) Transect walk
29
5. What are semi-structured interviews? Semi-structured interviews are informal conversations for gathering information. 6. Define mapping. Mapping is a process of creating a visual representation of a geographical area, (a district, sub-district, a community, or part of a community) with a specific theme in mind. This theme could be health, education, agriculture, etc. 7. Which of these is NOT a step in the community entry process? a) Conduct meetings with the community leaders b) Deal with identified groups only c) Identify the contact person d) Know the community involved 8. Why is it necessary to do community entry? Doing a community entry helps the person doing it to: Know the community involved Identify the community leaders Identify the contact persons Conduct meetings with the community leaders Let the community leaders and people know him/her and his/her mission Brief leaders of the purpose of his/her visit Seek approval and support for his/her programme 9. Describe the importance of women in the community entry process. Women are key players in the promotion of CHPS in communities. During the community entry process, women get more chance to exhibit confidence to communicate meaningfully during meetings. They therefore contribute meaningfully towards the progress of the community. 10. Community mobilization does NOT include: a) Bringing people together b) Directing people to undertake community activity c) Identifying the relevant resources for mobilization d) Simulating community members to undertake an activity
30
11. What is the nurses role in community mobilization for health? Being a facilitator in the community health delivery system Bringing people together to perform a task or activity Playing the role of a preceptor in the community Settling conflicts when they occur 12. What is advocacy? Advocacy is speaking up, drawing a communitys attention to an important issue, and directing decision-makers towards a solution. Advocacy is working with other people and organizations to make a differencee.g., Social Services Group of the District Assembly; National Commission on Children. 13. What is community participation in health? Community participation in health is the process by which individuals, families, groups, and in fact the entire community assume responsibility for their health and well-being and resolve to and get involved in developing the capacity to contribute to solving their own and the communitys health problems. 14. List five (5) benefits of community participation. Promotion of community knowledge and skills Increase in community self reliance Lowering of expenditures Increase in utilization of services Facilitation of behavioural change 15. Community mobilization faces the following challenges EXCEPT: a) Constraint in investment of time b) Creation of more culturally appropriate service c) Maintaining momentum and enthusiasm of community members d) The need to keep programme objectives and outputs on target 16. What is needs assessment? Needs assessment is a process of finding out and prioritizing the local problems of a community, identifying the environment and socio-cultural factors influencing such problems, and structuring the resources available in the community to solve the problems.
31
17. Mention at least three (3) types of needs assessment. Felt needs Expressed needs Organizational determined needs 18. Why is it important to carry out needs assessment? It enables health workers and their partners to gather and disseminate information on the health and well-being of the community. It promotes the collection of appropriate information for effective programme planning. It helps to raise awareness of the key issues confronting the people in the community and among the partners in community-based health services delivery. It creates the foundations for the peoples active participation in the implementation of future health programmes.
32
34
Objectives
Describe the purpose of social mobilisation Outline the role of advocacy in social mobilisation Describe the steps involved in behaviour change Describe the seven principles of community participation
SOCIAL MOBILISATION
Social Mobilisation
To reach, influence and involve all relevant segment of society Across all sectors To create an enabling environment and effect positive behaviour & social change
Social Mobilisation
Embraces behaviour change strategies and skills including:
Advocacy Community Mobilisation Behaviour Change Communication Social Marketing
Advocacy
The purpose of advocacy is to achieve
Specific policy change Programme change, or Allocation of resources
Community Mobilisation
Uses participatory processes Involve local institutions, local leaders, community groups & members of the community Organize for collective action towards a common purpose Characterized by respect for the community and its needs
Benefitting the population involved in the process
35
Behaviour Change Communication

Reaches and involves specific audiences Positions health practices persuasively as a benefit in the minds of the intended audience Recognizes that people move through several steps before they change their behaviour.
Steps to Behaviour Change

Social Support Create Confidence to speak out Build skills Reduce barriers Convey concrete benefit Peer support for action Cater to heart and head Create trust Clarify information Personalize benefits & risks
Advocacy Practice Intention Approval Knowledge
Social Marketing
Promotes and sells products, ideas or services that are considered to have social value Using a variety of outlets and marketing approaches SM is not always a component of social mobilisation
Social Mobilisation
SM should ultimately link the hands of those having
Less power Less voice and Less resources
with those who have more
Catalysts
Catalysts are those agencies or individuals, typically a few charismatic leaders, who hasten the process of change by
Taking the first step, Lighting the flame, and Reaching out to people at all levels, e.g.,
anyone with vision
Mobilizers
Mobilizers are key people and agencies who can effect the change through
What they do, What they decide, or What they say, e.g.,
Minister of health sports star NGO Directors
36
Mobilized
Moblized (anticipated) are groups that the catalysts wish to engage in the process to change behaviour, e.g.
Young men and women Health professionals School teachers parents
Community Participation
The involvement of community members and resources as an integral component of programs. A process in which people, in partnership with those able to assist them, identify problems and needs and increasingly assume responsibility themselves to plan, manage, control and assess the collective actions needed
Seven Principles of Community Participation

It is educational because a dialogue a twoway exchange of knowledge takes place in the interactions between communities and agencies. It is empowering because experience of how to influence, implement and control activities which improve the quality of life is gained by the people. It is a process. Progress can only be made gradually if the changes are to be permanent.
Seven Principles of Community Participation Continued

It is a partnership between community and agency because in most services there will always be resources which must be provided from outside the community. Problems and needs must be identified by the community. Only when problems and needs are recognized by the community will participation in programs be feasible. The community must bear responsibility for planning, managing, and assessing their actions if they are to control them. Collective action is necessary to address collective problems.
37
Objectives
At the end of the session, the students will be able to:
Describe questioning skills Describe how to use different PLA tools and techniques
HEALTH EDUCATION
Participatory learning and action (PLA), tools and methodologies
Tips
Foundations: behaviour, attitudes, participatory learning tools Always separate groups with unequal power, men, women, adolescents
Questioning Skills
Use open-ended questions instead of closed ones Avoid leading questions, such as Dont you think that immunization is unnecessary?
Triangulation
Use a variety of methods Cross-check information gathered from other sources Draw a map, do a community walk, use semistructured interview (SSI) as you walk. At the end, compare the information from all 3 sources
Mapping It is solely for the community Be patient, allow discussions Use it to learn from the community
38
Steps for Mapping

Let a community member draw Put borders around the map Put in cardinal points, east, west, etc. Represent yourself with a dot in the centre of the map Allow the community to use their preferred symbols Ask questions; let them explain Use actions to plan activities like home visiting areas
Semi-Structured Interview (SSI)

Use a written informal guide to focus on questions or information you wish to gather Perform the interview in a conversational and informal manner Gather information as you discuss Ask general questions and narrow to focus on prepared questions
Uses of Semi-Structured Interview Individual Interview Group interviews Focus Group Discussion (FGD)
Types of Diagramming
Venn diagrams Chapati diagrams Timelines: Indicate what occurred when in the community Flowchart: Useful to help communities understand disease spread, cause and effect Seasonal calendar Daily activity schedules
10
Pair-Wise Ranking
Used for prioritising community needs Used in the form of a matrix (place choices across the top and along left side) Cross out the boxes where the choices are the same Compare what is listed on the left to what is listed at the top, whichever is selected as most preferred need, place that letter in the box Ask why each is more important and note it down Go through each and count the highest choice
Schedules/Activities
Daily schedule Seasonal schedule USES Used in getting an idea of the lifestyles of community members Used in finding out the seasonal illnesses or problems in the community
11
12
39
Transect and Community Walk

Transect walk: conduct to learn about the land. Walk with a guide who can give you information. Community walk: conduct to learn about the community by walking through it and noting the important landmarks.
Summary
Bear in mind that it is very important to enter the community ready to learn Different methods can be used to gather information about communities PLA tools can help in learning about health and other issues and in the community
13
14
40
What is Community? COMMUNITY MOBILISATION FOR BIRTH SPACING

It builds confidence and when communities start believing in themselves, they become inspired to act
Group of people
Whenever the individual live together, in such a way that they share they basic condition of common life, we call them common community Life of people in a community is near about the same, i.e., their dressing style, language, and eating pattern found to be the similar, since they live in a geographical are, they develop similar emotional & cultural uniformity
What is a Community Organization?

A community organization is a body of people representing all or at-least 75% the of the households in a certain locality with the following characteristics:
Must have common interest Must be socially viable Must reside in a specific geographical-like area
What is Community Mobilisation?

Community Mobilisation is a capacity building process through which community individuals, groups or organizations plan, carry out and evaluate activities on a participatory and sustained basis to improve their health & other needs, either on their own initiative or stimulated by others
Key Elements of CM for Birth Spacing

Collective will of the community Mobilisation on internally defined rhythm Capacity building of the community by external organization Timing of the external support Committees/groups for addressing the problem
Community Action CycleA Path to Individual and Social Change

Explore the health issue Prepare to mobilize Organize the Community for action
Plan Together
Prepare To Scale-Up
Evaluate Together
Act Together
41
Guidelines
Select a health issue and define the community Put together a community mobilisation team Gather information about the health issue Identify resources & constraints Develop a community mobilisation plan & team
Select a Health Issue and Define the Community Assess how the community perceive the issue of birth spacing Articulate the issue Define the community
With poor health indicators Strong or weak identification among Community members How and whether minority voices will be heard
Sharing Magnitude of the Issue with the CommunityThe Unmet Need

Globally,120 million couples do not want pregnancy but are not using any form of FP method. These women are considered to have an unmet need for FP Each year, 75 million women around the world experience unwanted pregnancies Out of these 75 million, about 50 million will opt for abortion
How we can contribute to solving this issue? Any ideas?
Common Reasons for Unmet Need

Difficult access to modern contraceptive methods Low-quality health care services Little perceived risk of becoming pregnantthe stated reason for one- to two-thirds of women with unmet need Opposition from husbands, families and communities Fears about contraceptive side effects
Community Perspective: Getting to the Door
Community Perspective: Inside the Door
42
Community Mobilisation Team

Community Mobilisation team must include members who have
Expertise in the health issues Understanding of the environment Basic communication skills Personal attributes such as openness, patience, good listening & belief in peoples potential
Gather InformationWhat is Healthy Timing and Spacing of Pregnancy (HTSP) Delaying pregnancy until age 18 Healthy pregnancy spacing (after live birth/miscarriage/induced abortion) Interventions to help women and families:
Make informed decisions about delay/spacing Achieve healthiest maternal/newborn outcomes
Demand for HTSP

Large generation of adolescents Main FP demand for <29 age group is for spacing methods High percentages of births occur after too short intervals Even higher percentages of young women with short birth intervals also desire longer birth intervals Only 35% of postpartum women want another child within two years Significant service delivery gaps
Prenatal Outcomes
Birth to pregnancy (BTP) interval of <18 months is associated with increased risk of:
Pre-term birth Small size for gestational age Low-birth weight
BTP interval of >59 months is associated with increased risk of:

Pre-eclampsia
Sources: Conde-Agudelo, A et al. Effect of birth spacing on maternal health: A systematic review, American Journal of Obstetrics and Gynecology, 2006, DaVanzo, J, Hale L, Razzaque A, Rahman M, Effects of interpregnancy interval and outcome of the preceding pregnancy on pregnancy outcomes in Matlab, Bangladesh, BJOG: An International Journal of Obstetrics and Gynaecology, 2007.
Perinatal Outcomes (contd)

Abortion/miscarriage Pregnancy intervals of less than six months are associated with increased risk of:
Premature rupture of membranes, maternal anaemia Pre-term birth, low-birth weight, small for gestational age
Outcome for Child

Children born at least 3 years apart are at low-risk of illness & death in the first year of life Better chances of survival beyond 5 years Birth spacing allows more time for younger children during their developmentally critical first years Lower risk of stunting Lower risk of being underweight
43
Maternal Outcomes
Mother will have more energy and less stressed out Mother will have more time to bond with the baby Future babies will be healthier Mother will be able to give more attention to children Less maternal mortality rate Mother will get protection against unintended pregnancies & complications
Outcomes for Family

Family Will have more time to spend with each child Will have more time for each other Will have less financial stress Will enjoy better social class in society Parents will have more time for each other
Outcome for the Country

Developed, economically stable with force of educated, mentally sound & physically fit people
Birth Interval Recommendations

Recommendation for spacing after a live birth:
Recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, perinatal and infant outcomes.
Recommendation for spacing after miscarriage or induced abortion:

Recommended minimum interval to next pregnancy should be at least six months in order to reduce risks of adverse maternal and perinatal outcomes
Orient the Community

Group meetings: have the added advantage that participants can have their questions addressed quickly and personal relationships can be established, includes:
Introductions Purpose A discussion about birth spacing Reinforcing the main messages
Build Trust, Credibility and a Sense of Ownership with the Community Identify an activity that community enjoy such as community fair or sporting event Establish meeting timings and places based on community members availability, taking planting and harvesting into account Help to create safe spaces in which participants can express themselves
44
Build Trust, Credibility and a Sense of Ownership with the Community Be honest and transparent Ensure that all members of the team communicate consistently with community members Apologize and accept responsibility when mistakes are made Be an active listener Be empathetic
Invite Community Participation
Communicate Counselling
Counselling helps clients choose and learn to use a family planning method that suits them has a positive impact on method adoption, continuation, compliance with regimens, and resulting health outcomes.
What Community Mobiliser Can Do?

Be sensitive to power imbalances between them and their community members. Build rapport, put clients at ease. Encourage the client to ask questions and express concerns. Listen actively; don't dominate the interaction. Assess the client's needs and tailor the interaction to the individual. Don't overload the client with unnecessary information. Provide essential information clearly in terms the client can understand. Respect and support the clients' decisions. Provide their preferred family planning method Discuss potential sides effects proactively and take clients concerns about side effects seriously Refer the client for services
Meeting Counselling Challenges

The client is silent.
If the client is silent at the start of the meeting, gently call attention to the silence. You could say, I can see that it is difficult to talk. Its often that way for new clients. I wonder if you are feeling a little anxious. Look at the client and use body language that shows empathy and interest. Wait for the client to answer. During discussion, silence can be okay. Sometimes the client is thinking or deciding how to express feelings or thoughts. Give the client time to think.

The counsellor cannot see a solution to the clients problem.
Counsellors may feel anxious if they are not sure what to advise. The counsellor knows the health issue but does not have to solve every problem for the client. Express understanding. Sometimes this is what the client really wants. Also, suggest others who could help or refer.
The counsellor does not know the answer to a clients question. Say honestly and openly that you do not know the answer but together you can find out. Check with a supervisor or reference materials, and give the client the accurate answer or refer.
45

The counsellor makes a mistake.
Correct the mistake and say you are sorry. It is important to be accurate. It is not important to look perfect. Admitting a mistake shows respect for the client. Be honest. The more honestly you express your own feelings when appropriate (without revealing your personal life), the easier for the client to do the same.

The client asks a personal question.
In general, try not to talk about yourself. It takes attention away from the client. You do not have to answer personal questions. The relationship between client and counsellor is a professional one, not a social one. It can help to talk about your own family planning experience if you wish. Or you can describe what happened to someone else, without using names or identifying them as other clients. Sometimes the client asks if the counsellor has the same problem. It is best not to say yes or no. Instead, you can say something such as, Im familiar with that kind of situation. Please tell me more.
Counsellor and client already know each other.

Emphasize confidentiality and ensure privacy. If the client wishes, arrange for another counsellor.

The client wants the counsellor to make the decision.
This client may actually be asking for help. You can ask questions such as these: You seem to be having trouble reaching a decision. Perhaps you are not quite ready?
Act Together
There is a solution, but it is in their terms-not yours
Would you like to discuss this further? Do you need more information? More time to think? Would you like to talk this over with someone elseperhaps your spouse or your parents?
You can say, I can answer your questions and help you think about your choices, but you know your own life best. The best decisions will be the decisions you make yourself.
Define Your Role in Accompanying the Community In the community mobilization process, you can play many possible roles in relation to community where you work
Mobiliser Organizer Capacity Builder Liaison Advisor
Strengthen the Community

Establish support groups, women groups and health committees Provide information about nearby health facility where they can take FP services Establish linkage with the facility Distribute IEC material Health Education
46
Monitor Community Progress and Do Problem-Solving

Follow up visits to individuals and families Inquire about their experience with the health provider & health facility In case of couple counselling, ask support of the colleague providing support in the same area Refer an individual or couple to nearby health facility for further counselling and services
Evaluate Together
Identify the purpose of evaluation Establish an evaluation team Determine evaluation indicators Analyze results Generate recommendations and lesson learned Document the results
47
48
SECTION 2
BIRTH SPACING AND FAMILY PLANNING
TECHNICAL SUPPLEMENT
GOVERNMENT OF PAKISTAN POLICY ON FAMILY PLANNING

The Government of Pakistans Policy on Family Planning is based on the following parameters: Prohibition on targets or quotas for service providers or referral agents Prohibition on payment of incentives and financial rewards to clients or programme personnel Prohibition on denial of rights or benefits to persons who choose not to use FP Requirement to provide comprehensible information on the method chosen Informed voluntary decision in case of voluntary surgical contraception No promotion of abortions
Targets or Quotas Service providers or referral agents shall not implement or be subject to quotas, or other numerical targets, of total number of births, number of FP acceptors, or acceptors of particular FP method (this provision shall not be construed to include the use of quantitative estimates or indicators for budgeting and planning purposes).
Service providers and referral agents are defined as people who implement a service delivery and who deal directly to the client. This may include doctors, midwives, nurses, lady health visitors, as well as community level workers.
Incentives and Financial Rewards Government of Pakistan will not allow payment of incentives or financial rewards to: a) an individual in exchange for becoming FP acceptor; or b) staff for achieving a numerical target or quota for total number of births, number of family planning acceptors, or acceptors of particular method of FP.
Government of Pakistan does not prohibit: Fee for the service/per case payment to FP providers Non-financial, small value items provided across the board to acknowledge general good performance (e.g., caps, work aprons, backpacks, etc.) Providing special training opportunities or promotions to personnel who are considered good performers
Denial of Rights The provider will not deny any right or benefit, including the right of access to health care, as a consequence of any individuals decision not to accept family planning services.
For example: Denying access to supplemental food programmes for indigents who do not use FP Denying free maternal health services after more than certain number of live births Requiring community health workers to use modern contraceptives or to have small families
Comprehensible Information The provider will provide FP acceptors comprehensible information on the health benefits and risks of the method chosen, including those conditions that might render the use of the method inadvisable and those adverse side effects known to be consequent to the use of the method.
The comprehensible information applies to the method chosen. This means when the decision has been made about a method, the provider should then discuss more detailed information about that method, including: Health benefits of using the method Conditions that would make using the method inadvisable Known side effects The provider can use two track approaches that incorporate: Promotion of informed choice and good client-provider interaction (through training, supervision, counselling, mass media campaign, etc.). Ideally the communication is interactive, the provider offers information, listens to the client, answers specific questions, and tries not to burden the client with more information than is useful. Specific, tangible interventions at each service delivery point of contact (e.g., wall charts, counselling flip charts, client pamphlets, and package inserts).
Informed Consent in Case of VSC Informed consent is defined as Voluntary, knowing assent from the individual after being advised of the surgical procedures to be followed, the attendant discomforts and risks, expected benefits, the availability of alternative FP options, the purpose of the operation and its reversibility, and the option to withdraw a consent at any time prior to operation.
An individuals consent is considered voluntary if it is based upon the exercise of free choice and is not obtained by any special inducements or element of force, fraud, deceit, duress, or other forms of coercion or misrepresentation. The health facility is required to document specifically the clients informed consent. The document should meet the following criteria: Cover the risks, benefits and other FP options Be written in a language that a client understands and speaks Be signed by the individual and the attending service provider When the client is unable to read a written certification adequately, the basic elements of informed consent must be presented orally and this must be acknowledged with the clients mark, as well as that of a witness. The witness should be of the same sex and speak the same language as the client. Copies of the consent forms for each procedure must be retained for 3 years. No Promotion of Abortion Government of Pakistan strictly prohibits abortion as a method of contraception. This may include: Providing advice and information regarding the benefits and availability of abortion as a method of FP Providing advice that abortion is an available option in the event other methods of FP are not used or are not successful, or encouraging women to consider abortion Lobbying to make abortion legal Conducting a public information campaign regarding the benefits and/or availability of abortion as a method of FP Abortion is not considered as a method of FP when it is performed in the following circumstances: The life of the mother would be endangered if the foetus were carried to term Following rape or incest Postabortion carethe treatment of injuries or illnesses caused by legal or illegal abortionsis permitted under the policy.
FAMILY PLANNING AND ISLAM

These are certain dialogues, providing an Islamic perspective to questions agitating the minds of people today. CAN A COUPLE LIMIT THEIR CHILDREN? Question: Is it appropriate for a married couple not to have more than two children because of their limited economic resources? Is it acceptable that they take measures to prevent pregnancy after having had two children? Answer: During the time of the Prophet, some of his companions tried to reduce the chances of conception and pregnancy, because they did not want any more children. The Prophet was aware of that. Some referred to him while some relied on the fact that no edict was given concerning the question of preventing pregnancy. The general rule is that "everything is permissible unless pronounced otherwise." Thus, we have statements by some of the Prophet's companions such as: "We resorted to contraception at the time when the Qur'an was being revealed", and "We resorted to contraception and the Prophet was aware of that but he did not stop us." These statements are clear in their import. If the Prophet's companions had been doing something unacceptable to Islam, God would have either revealed a prohibition in the Qur'an or the Prophet would have given an order in a Hadith. The fact is that the Prophet did not give such an order. Instead, when he learned from one of his companions that he resorted to contraception, the Prophet said clearly that no method of contraception would stop the creation of a child, should God will that the child be born. As such, no method of contraception can stop God's will being fulfilled. COITUS INTERRUPTUS Question: You advised a young man to get married and delay having children until he has finished his studies. This obviously means that he has to resort to methods of birth control. In our community, most scholars say that birth control is not acceptable from the Islamic point of view. Please comment. Answer: In ancient times, before the new methods of birth control were invented, people resorted to coitus interruptus in order to restrict the number of children. This is a safe method, because it does not involve the use of any substance or chemical compound. It is a simple method, which involves withdrawal before discharge. It is not highly effective, because some of the sperms may be released before the actual discharge. These
could easily fertilize the female egg. This method was practiced in Arabia, as well in many other places. The companions of the Prophet mentioned it to him and asked him whether it was wrong. The Prophet did not forbid them that, but he told them that it could not stop Allah's work. If He wants us to create something, or in this case, if He wants a child to be born, the resort to contraception would not prevent the mother from getting pregnant. We have reports from companions of the Prophet mentioning that he was aware of their resort to contraception, but he did not forbid them that. In the light of the foregoing, we can say that using a safe and effective method of birth control is permissible, if it does not involve the use of a harmful substance. The couple must check with their doctor if a particular method is safe for them to use. If so, then they decide whether to use it or not. WHY IS BIRTH SPACING IMPORTANT? Question: Is it necessary to keep an interval of 24 months after live birth? Answer: The demands on a womans body during pregnancy, childbirth, and breastfeeding are great. She needs adequate rest and nutrition during these challenging times. Taking care of children the mother already has is also taxing on her physically. Properly spacing the births of children can help give the woman time to recover and become strong again, and will enable her to properly care for an infant before she faces the demands of another pregnancy. Health care professionals recommend spacing pregnancies at least 2 years apart. In order to space pregnancies properly, a woman and her husband will need to use appropriate contraceptive methods. In your role as a religious leader, you can encourage them to seek advice on birth spacing from a health care professional. The carrying of the (child) to his weaning is (a period of) thirty months. (Quran 46:15) And We have enjoined on man (to be dutiful and good) to his parents. His mother bore him in weakness and hardship upon weakness and hardship, and his weaning is in two years, give thanks to Me and to your parents, unto Me is the final destination. (Quran 31:14) For Muslim men and women for believing men and women for devout men and women for true men and women for men and women who are patient and constant for men and women who humble themselves for men and women who give in charity for men and women who fast (and deny themselves) for men and women who guard their chastity and for men and
women who engage much in Allahs praise for them has Allah prepared forgiveness and great reward. (Quran 33:35)
HEALTHY TIMING AND SPACING OF PREGNANCY

HTSP is an intervention to help women and families delay or space their pregnancies to achieve the healthiest outcomes for women, newborns, infants, and children, within the context of free and informed choice.
INTRODUCTION Recent research from developing countries shows that unhealthy timing or spacing of pregnancies is linked to increased risk of multiple adverse health outcomes. Following a pregnancy that occurred quickly after a previous birth, the risk of a child dying is at least twice as high as that for longer intervals. An infant born after a short interval has increased chances of: Being born pre-term Having below normal weight at birth Being small for gestational age A woman, who becomes pregnant too quickly following a previous birth, or induced abortion or miscarriage, faces higher risks of: Anaemia Premature rupture of membranes Abortion Miscarriage Death IN PAKISTAN Among married women of reproductive age (MWRA) approximately 1 out of 3 of births are spaced <2 years apart. International data show that there is a 170300% increased risk of a neonatal, post-neonatal, or infant death associated with birth-to-birth intervals of less than 18 months. Short birth intervals have returned to the same high level seen in the early 1990s. Birth-to-birth pregnancy intervals have become shorter over the last 6 years. The portion of births occurring less than 24 months after a previous birth, and associated with very high health risks, decreased by 40% between 1991 and 2001, only to rebound to
relatively high levels (33.7% or 1 in 3 births) in the 2006/07 survey. The shortest birth interval is born to women age 1519 (21 months). The desire to space pregnancies is low (<20%) among married women), but increasing. Need for birth spacing remains. Pakistans high maternal mortality ratiocurrently estimated at 533/100,000 (200001 PRHFPS), with unsafe abortion being a significant contributing factoris an issue of great concern for the government of Pakistan. At the root of this problem is one of the highest levels of unmet need for family planning services in the world. About 60% of Pakistani couples want contraception, but less than half of them have access to services. According to the 2006/07 Pakistan Demographic and Health Survey, about 30% of all married women of reproductive age in Pakistan currently use any contraceptive method. Use of modern methods is about 22%. Among 15- to 19-year-old married women, less than 1 in 10 (6.7%) uses any contraception. Use of contraception among zero-parity women is virtually nil, at 0.6%. Data from a 2000/01 survey show that, although unmet need for spacing among the total population of married women of reproductive age remains low (around 12%), the unmet need for spacing in the younger age cohorts (1529) is about two-thirds higher, running around 21%. Consider these findings in relation to the overall risks to mothers and newborns in Pakistan, outlined in Table 1.
Table 1.4 Annual number of births Annual number of neonatal deaths Neonatal mortality rate Annual number of infant deaths (includes neonatal) Infant mortality rate Annual number of <5 deaths (includes both infant and neonatal deaths) Child mortality rate Annual number of low birth weight Maternal mortality ratio (UNICEF adjusted #) Lifetime risk of maternal death when a woman becomes pregnant 4,773,000 272,330 57 377,440 79 473,000 99 19 500 1 in 31
Source: UNICEF, 2007 State of the Worlds Children.
WORLD HEALTH ORGANIZATION (WHO) RECOMMENDATIONS5 Based on a review of six USAID-supported studies, WHO produced a policy brief in 2006 on birth spacing, which included the following preamble and recommendations: Preamble Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing support, social and economic circumstances, and personal preferences in making choices for the timing of the next pregnancy. Recommendation for spacing after a live birth After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of adverse maternal, perinatal, and infant outcomes. Recommendation for spacing after an abortion After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy is at least 6 months in order to reduce risks of adverse maternal, and perinatal outcomes. SUMMARY Key research findings regarding the risks of closely spaced pregnancies: Recent USAID-sponsored research found that unhealthy pregnancy spacing is associated with multiple adverse outcomes for mothers and newborns. Becoming pregnant too soon after a previous birth, miscarriage, or abortion places mothers and newborns at a higher risk of health complicationsor even death. With early pregnancy (when the mother is younger than 18), the mothers and their newborns face increased risks of health complications compared to women 2024 years old.
Source: World Health Organization, 2006 Report of a WHO Technical Consultation on Birth Spacing.
METHOD PROVISION AND SUPPORT

OVERVIEW OF THE WHO MEDICAL ELIGIBILITY CRITERIA The WHO MEC for contraceptive use (first issued: 1996; revised: 2000, 2003, 2004) help providers assist clients in weighing the risks and advantages of different contraceptive methods relative to specific conditions. A condition is either a biologic characteristic (e.g., age, reproductive history) or a known medical condition (e.g., HIV, diabetes, anaemia) that may have an impact on the effectiveness or safety of a given contraceptive. In the WHO system, a womans eligibility for using a specific method falls into one of four categories, depending on the presence/absence of various condition(s). These categories are summarized in Table 2.
Table 2. Categories Based on the WHO MEC for Contraceptive Use6 CATEGORY 1 DESCRIPTION A condition for which there is no restriction for the use of the contraceptive method. A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. A condition that represents an unacceptable health risk if the contraceptive method is used. WITH CLINICAL JUDGEMENTa Use method in any circumstances. Generally use the method. WITH LIMITED CLINICAL JUDGEMENT Yes (Use the method.)
Use of method not usually recommended unless other more appropriate methods are not available or acceptable. Method not to be used.
No (Do not use the method.)
a In care situations where resources for clinical judgment are in place (e.g., availability of skilled care, access to a wide range of services), the four-category framework corresponds to four possible determinations of whether a woman can use an IUCD. b In care situations where resources for clinical judgment are limited (e.g., community-based services), the fourcategory framework is simplified into two possible determinations of whether a woman can use an IUCD.
Sometimes a given condition is considered one category for initiating use (i.e., insertion) and another for continuing use. For example, a woman with PID should not have an IUCD inserted (Category 4), but can continue to use an IUCD already in place while receiving appropriate treatment (Category 2), if she so desires.
Any risk posed by a method should be weighed against the risk posed by unintended pregnancy on a case-by-case basis.
Adapted from: WHO 2004a. (Footnotes a and b added per the present publication.)
Note: WHOs four-category system is intended to be used in the context of clinical judgement. This means that the provider has the knowledge, skills, and resources necessary to determine whether the benefits of using an IUCD outweigh the risks for a particular woman. This capacity is especially important when there may be some question about whether the IUCD is an appropriate choice for a particular woman. For example, a provider mayafter considering all of the factors involved determine that one woman who is anaemic is a good candidate for IUCD use, but advise another woman with anaemia (e.g., if it is severe) to consider other, more appropriate methods. In making this determination, the provider may consider and weigh factors such as: Risks posed by the method versus those posed by an unintended pregnancy Severity of the womans condition, and whether she is undergoing adequate treatment Presence of other conditions The womans understanding of any special risks involved Access to additional services and follow-up care, as needed Availability/acceptability of other contraceptive methods Any other circumstances or factors that may be relevant In situations in which the provider does not have the knowledge, skills, or resources necessary to make such determinations, the four categories can be simplified into two, as shown in the far right column of Table 2. In the context of this simplified system, women with Category 1 and 2 conditions can use the IUCD, and women with Category 3 and 4 conditions cannot. Or, the provider may refer a woman to a higher level facility if there is some question about whether she can use the IUCD.
COUNSELLING AND EDUCATION Six Principles of Good Counselling Treat each client well. All clients deserve respect, regardless of their age, marital status, ethnic group, sex, or sexual and reproductive health (RH) behaviour. (See Greet.) Interact. Each client is a different person. Ask questions, listen, and respond to each client's own needs, concerns, and situation. (See Ask.) Give the right amount of information. Provide enough for the client to make informed choices but not so much that the client is overloaded. (See Tell.) Tailor and personalize information. Give clients the specific information that they need and want, and help clients see what the information means to them. (See Tell.) Provide the FP method that the client wants. Provide the method unless a valid medical reason prevents it. (See Help.) Help clients remember instructions. (See Explain.)
10
The Counselling Process FP counselling has six elements, which can be remembered by the word GATHER. G = GREET the client in a friendly and polite manner. A = ASK and assess the clients knowledge, needs, and feelings. Remove any doubts/concerns the client has and listen actively. T = TELL the client about all available FP methods with the help of samples, flip charts, leaflets, and brochures. H = HELP the client choose a method. A particular method may not be suitable for a particular client. Explain this clearly and help the client choose another method. If this method is not available, help by referring the person to a relevant facility. E = EXPLAIN the use of the chosen method. This would include how it should be used, its effectiveness, advantages and limitations, possible side effects, warning signs, and follow-up regime. To ensure that the client has understood, ask the client to repeat the information given. The client must also be informed of the warning signs for which return to the facility is important. R = RETURN for follow-up. At the follow-up visit, inquire if the client is still using the method. If the answer is yes, ask if there are any problems or side effects; also confirm that the method is being correctly used. Give appropriate advice about any minor side effects, and refer for treatment if side effects are severe. In discussing contraceptive options with clients, the counsellor should briefly review all available methods, even if a client has a preference for a specific method. The counsellor should be aware of a number of factors about each client that may be important, depending on the method in question. These are: Reproductive goals of the client or couple (spacing or timing births) Personal factors including the time, travel costs, pain, or discomfort likely to be experienced Accessibility and availability of other methods at referral facilities The need for protection against STIs (e.g., hepatitis B and C, HIV/AIDS) Counselling can be divided into three phases: Initial counselling: all methods are described and the client is helped to choose the most appropriate methods. Method-specific counselling prior to and immediately following service provision: the client is given instructions on how to use the method, and common side effects, warning signs, and follow-up regime are discussed.
11
Follow-up counselling: during the return visit, use of the method, satisfaction with it, and any problem that may have occurred are discussed. These important elements should be followed during counselling for every contraceptive method. SAHR Approach: Another approach to counselling is SAHR. It is a client-centred approach and assures two-way exchange of information between the health care provider and the client in an environment of equality. In this approach, the provider and the client mutually negotiate a solution that helps in meeting the clients need. This approach has been developed and tested by the Population Council in Pakistan. The acronym SAHR stands for: S = Salutation (Treat the client with dignity) A = Assess the client's RH needs H = Help negotiate a solution to the client's RH needs R = Reassure the client Dispelling Myths The provider has a great responsibility in dispelling myths in the community and in increasing awareness and use of contraceptive methods. There are some misconceptions about different contraceptive methods, and the provider should give the correct information and counsel the couples. Oral Contraceptive Pills Do not cause birth defects, infertility, or build up in a womens body Women do not need to take a rest from using oral contraceptive pills Generally, pills do not decrease female sex drive IUCDs Are not abortifacients Are not too large for small women Do not cause infertility, discomfort for the male partner, or travel to distant parts of the body Vasectomy Is not castration
Community Visit The class will be taken to the community with a provider to observe the counselling about dispelling myths.
12
No loss of sexual desire, male physical traits, or strength No effect on urination, quantity of ejaculation Sperm does not build up in body Tubal Ligation No loss of femininity or sexual desire Does not cause weight gain, heart disease Menstruation occurs but no longer signals fertility Eggs do not build up in body
CONTRACEPTIVE METHODS*
It is the providers responsibility to help the couple choose and continue to use correctly the best method for them, and provide the method or refer them to a family planning centre. The best method is the most effective one (has best chance of always preventing pregnancy) that is safe for them and that they want to use.
Table 3. Summary of Contraceptive Methods Natural Methods Fertility awareness method (FAM) Natural family planning (NFP) (abstinence) Billings or ovulation method (cervical secretions) Basal body (waking) temperature Lactational Amenorrhoea (LAM) Standard Days Method (SDM) Withdrawal Barrier Methods Male condoms Female condoms Spermicides Diaphragms and cervical cap Hormonal Methods Combined oral contraceptive pills Combined injectable contraceptives Progestin-only contraceptives Norplant implants Progestin-only injectable contraceptives Progestin-only pills Intrauterine Devices Intrauterine devicesBasic Voluntary Sterilization Female: Tubal ligation Male: Vasectomy
NATURAL METHODS Fertility Awareness Methods (FAM) Natural Family Planning (NFP) or safe period Not having sex at all (abstinence) during the fertile time. It is the surest way to prevent pregnancy. However, it is impractical for married couples, so they have to use alternate methods to prevent pregnancy. The provider
* Adapted from Noor A., Ibrahim, H., Izhar, H. and Norman, J. Community Midwifery Manual, October 31, 2007. Pakistan Nursing Council and UNFPA, Pakistan.
13
should explain to the woman that this method depends upon the physiological changes in the body during menstruation. Physiological Principle The teacher should remind the students that ovulation in a regular normal menstrual cycle (28 + 2 days) takes place around 14 + 2 (1216) days before the onset of the next menstruation. Once the egg (ovum) is shed from the follicle, it is viable for 23 days. The fertilization of the ovum must takes place within this period. If fertilization fails to occur soon after ovulation, it does not take place during the menstrual cycle. The sperm can survive for 23 days, so if coitus takes place 23 days before the ovulation, there is a possibility of fertilization. Women are able to get pregnant for about 8 days in a month. These 8 days start from the 10th day from the beginning of the menstrual cycle (if the periods cycle is of 28 days). The rest of the days she usually cannot get pregnant even if she has sex. Billings or ovulation method (cervical secretions) To determine the fertile period, both to avoid getting pregnant or in case one wants to have a baby, a woman can know when she has had ovulation. The provider should explain to the woman that to find out this period, the woman has to take out a little mucus from the vagina every day with a clean finger (after washing her hand thoroughly with soap and clean water). She then checks the stickiness of the mucus between her finger and thumb. Normally the mucus does not stretch between a finger and thumb. If it gets slippery, then the woman is approaching her fertile period If the mucus can be stretched to form a thread, then the woman is most likely in her fertile period This method may not work in the following conditions: If the woman has heavy vaginal discharge If she has an STI Basal body (waking) temperature The provider should ask the woman to take her temperature immediately on waking every day. After ovulation, the temperature rises by about 0.2C and remains at the higher level until the next menstruation. Therefore the infertile phase of the menstrual cycle begins on the third day after the temperature shift has been observed. Lactational Amenorrhoea Method (LAM)
Clinical Visit The teacher will take the class to a family planning clinic to see the different methods available and their 14 use.
Many women do not have menstruation due to increased level of prolactin hormones during breastfeeding (lactation). Absence of menstruation is called amenorrhoea. Therefore, exclusive breastfeeding can delay the next pregnancy for a while, if all of the following are present: Baby is less than 6 months old and mother is giving only breast milk (exclusive breastfeeding during day and night) The baby does not take pacifiers or dummies The mother breastfeeds the baby frequently, a minimum 812 times during day and night Under the effect of prolactin, ovaries do not release an egg, so ovulation does not take place. The provider should explain to the woman that in exclusive breastfeeding, ovulation starts after 6 months as other foods are also introduced into the babys diet, and baby feeds less frequently at the breast. At this time, another birth spacing method is needed. If a woman starts having menstruation during exclusive breastfeeding of a baby under 6 months, then the provider should tell the woman that it means that ovulation has returned, maybe because the mother was not feeding her baby frequently enough during day and night. Therefore she should use another birth spacing method. Advantages of LAM When practiced correctly, LAM is very effective. It is reliable to use immediately after childbirth without having to seek medical attention. It gives time to the mother to decide on another method for birth spacing after 6 months of exclusive breastfeeding (as long as she has not begun to menstruate). Standard Days Method A woman can use the Standard Days Method if most of her menstrual cycles are 2632 days long. If she has more than two longer or shorter cycles within a year, the Standard Days Method will be less effective and she may want to choose another method. Risk of pregnancy is greater when couples have sex on the fertile days without using another method; with consistent and correct use, 5 pregnancies occur per 100 women over the first year of use. How to use? A woman keeps track of the days of her menstrual cycle, counting the first day of monthly bleeding as Day 1. Days 8 through 19 of every cycle are considered fertile days for all users of the Standard Days Method.
Group Work The class will be divided into 3 groups. One group will prepare a presentation on the physiological principle of the safe period, another will prepare a presentation on lactational amenorrhoea, and a third group will prepare the presentation on barrier methods and how to use d tl
15
The couple avoids vaginal sex or uses condoms during days 8 through 19. They can also use withdrawal, but this is less effective. The couple can have unprotected sex on all the other days of the cycledays 1 through 7 at the beginning of the cycle and from day 20 until her next monthly bleeding begins. Developed by the Institute for Reproductive Health, the SDM is based on the fertile window during a womans menstrual cycle, and involves a simple set of colour-differentiated counting beads (Cycle BeadsTM) that couples can use to help them avoid intercourse during that period.7 If a couple wishes to prevent a pregnancy, the woman and her partner avoid unprotected intercourse on days 8 through 19 of every menstrual cycle (see Figure 1 below).
Figure 1. The Fertile Window FERTILE WINDOW 32-Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Cycle FERTILE WINDOW 26-Day Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
The SDM can be taught by a trained provider or community health/outreach worker to women, men, or couples in either individual or group sessions.
Figure 2. Cycle Beads
The Standard Days Method and CycleBeadsTM are trademarks of the Institute for Reproductive Health at Georgetown University. CycleBeads are a U.S. patent-pending technology.
16
Although the SDM does not protect against HIV/AIDS, counselling for the method can afford the counsellor an opportunity to provide information about HIV/AIDS and the importance of dual protection. Withdrawal (Coitus Interruptus) In this method the man withdraws his penis from inside the woman before ejaculation. The provider should tell the couple that this is a natural method that can be practiced without any medical check-up or visit to a medical clinic. This method is well accepted by clients. However, it has a higher failure rate, and a woman can get pregnant. Sometimes a man is not able to pull out before he ejaculates and even a very little amount of fluid containing sperm leaked into the vagina can cause pregnancy. BARRIER METHODS Barrier methods prevent sperm from coming into contact with the ovum. They comprise male and female condoms, cups, and diaphragms, which are usually used with spermicides (chemical substance which kills the sperm).
Ensure that anyone choosing a barrier method is made aware of emergency contraception and how to access it if required.
Condoms Male condom A condom is a balloon-like sheath that a man wears over his penis during intercourse. This balloon traps the sperm and does not let it enter the vagina. Condoms also prevent the Male Condom transmission of sexually transmitted infections (STIs). Condoms are easily available in the market. A male of any age can use it. The provider should teach the clients/couple the correct use of condoms. How to Use a Condom The provider should tell the couple that: Condoms are usually rolled up into a ring. A new condom is in an unopened, thin plastic foil. Open the packet carefully. Do not use the condom if it is stiff, sticky, or torn.
Correct use of the Male Condom
17
Put on the condom when the penis is hard (erect), but before it touches the vagina. Make sure the rim of the condom is on the outside, away from the penis. It is easier to roll down. Place the condom over the end of the hard penis with a space for the sperm to collect. Squeeze the air out of this space by pinching between your finger and thumb. This will prevent tearing of the condom. Then slowly unroll the condom over the penis, until it is covered. Right after the man has ejaculated, he should pull out the penis from the vagina before it gets soft. Female Condom Check the condom for tears before disposing of it. If it is torn, apply spermicidal foam in the vagina. Tie a condom in a knot and dispose of it. Use a condom only once. Side Effects The condoms have no side effects except for people who are allergic to latex; they may use plastic male condoms instead. It is not as effective as LAM. It interrupts sex (it has to be put on the penis before going into vagina). It may become weak if kept in a warm, humid place and can rupture during use.
Diaphragms
Female condom The female condom is a reversible barrier method of birth control. These are not available in Pakistan. Spermicidal Creams, Foams, Jelly, or Suppositories A spermicide is a chemical that kills sperms. It must be inserted in the vagina prior to intercourse. Diaphragms and Cervical Caps The diaphragm or cervical cap is worn over the cervix during intercourse. It must be worn prior to the intercourse and used with some spermicidal jelly or foam. These are not common in Pakistan.
Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide Technique of Inserting the Female Condom
18
Contraceptive Sponges Sometimes contraceptive sponges are available. They also work like the cervical cap soaked with spermicidal chemicals. HORMONAL METHODS A hormonal method contains hormones either oestrogen and progesterone or only progesterone. This method prevents the ovary from releasing an egg. The hormones also make the mucus at the opening of the uterus (cervical os) thick so that the sperm can not penetrate it and enter the uterus. Contraceptive Oral Pills (PILLS) There are two type available, in a packet of 21 or 28 tablets. The packet of 28 tablets contains 21 white contraceptive tablets and 7 brown tablets of iron.
Role Play Two students will take part in the role play. One will act as a provider and the other as a woman who wants to know the pros and cons of the use of oral contraceptive pills. After the role play, the class will discuss the points missed by the provider and her communication skills. Ten minutes will be given to prepare the role play.
Low-dose combined oral contraceptives (COCs), Lofeminol 0.3 mg norgestrel with 0.03 mg ethinyl estradiol and 75 mg ferrous fumarate Combined oral pills are not recommended for lactating mothers because they may interface with milk production or have side effects in the child (weight gain, etc.) Progestin-only contraceptives: Exlution (Lynestrenol 0.5 mg) Postinor (Levonorgestrel 0.75 mg) These pills can be used during breastfeeding. Oral contraceptive pills act by inhibiting ovulation, causing thickening of cervical mucus and making the endometrium less suitable for implantation of the fertilized ovum. Indications The provider should know that this method can be used by the woman who: Needs short-term birth spacing, Has completed her family but does not want sterilization. Contraindications It is important for the provider to know the conditions in which this method cannot be used so that she can refer the woman to a family planning clinic for counselling on other methods. The conditions are:
19
Pregnancy/suspected pregnancy Fully breastfeeding a baby under 6 months old (COCs only) Breastfeeding a baby under 6 weeks old (POCs only) Active liver disease like hepatitis Has breast cancer Abnormal uterine bleeding (POCs only) Woman taking anti-tuberculosis or anti-epileptic drugs Heavy smoking and over 35 Has cardiovascular diseases Diabetes with vascular complications History of disseminated venous thrombosis (DVT), blood clotting, stroke, heart attack, migraine, and epilepsy High blood pressure Diabetes mellitus for more than 20 years or with system damage Advantages The provider should be able to explain to the woman the advantages as mentioned below: A newly married woman who has not conceived and does not want to become pregnant (nulliparous) can use combined oral contraceptive (COC), as fertility return is immediate on discontinuation of pills. COCs helps to regulate the menstrual cycle. Women can switch to any other method or quit any time but the provider should recommend that she finish the pill pack and, if necessary, use a backup until the new method becomes effective Disadvantages The provider should be able to explain to the woman that: Menstrual irregularities can occur the first few months and then settle.. A pill has to be taken every day. A pill has to be obtained from the clinic or chemist. Some woman may have side effects. Side effects The provider should inform the woman that she may experience:
20
Pregnancy-like symptoms Menstrual irregularities Weight gain (POCs) Rise in BP Acne, pigmentation of skin, generalize loss of hair, depression, irritability, loss of libido Initiating COCs Oral contraceptives can be given at any time but the provider should make sure that the woman is not pregnant. The provider should explain to the woman that she should have a complete physical examination in the hospital, especially: Weight: to compare the weight before and after the initiation of tablets Breast: for any swelling, lump or nodule B.P.: should be in the normal range Urine Test: there should be no sugar or proteins in the urine Vaginal Examination: to assess the condition of the uterus She should start taking white pills on the first day of menstruation. On finishing the white pills, start brown pills on the very next day, and on finishing the brown pills, start taking the second packet without any delay. The provider should know that during postpartum, if the woman is not breastfeeding, delay the use of COCs for 3 weeks, and if the woman is breastfeeding, delay the use of COCs for 6 months or till breastfeeding is discontinued. The provider should inform the woman that the COC schedule is as follows: Take one pill each day 21-day packs, with a 7-day break 28-day packs, no break If the packet has arrows, follow the order of the arrows. Missed pill Key message: Take a missed hormonal pill as soon as possible. The provider should advise the woman that if she forgets to take the tablet, she should follow the guidance given below:
21
Missed One Active Pill Take missed pill as soon as remembered, even if she takes two pills at the same time; keep taking other pills on schedule and no backup is needed. Missed Two Active Pills Take hormonal pill as soon as possible, as soon as remembered, and keep taking other pills on schedule. Little or no risk of pregnancy. Missed Three or More Pills First or second week: Take hormonal pill as soon as possible. Use a backup method for 7 days, and consider emergency contraception. In third week: Take hormonal pill as soon as possible. Finish all the hormonal pills in the pack. Throw away the non-hormonal pills in the 28-day pack, and start a new pack the next day. Use a backup method for the next 7 days, and consider emergency contraception. If She Forgets to Take Brown Tablet These are iron tablets, so missed tablets do not affect contraception. Throw away the missed pill and start the new pack on schedule.
CAUTION NOTE The provider should tell the women to stop taking the pills and seek medical advice if she develops: Sudden, severe chest pain and shortness of breath Sudden breathlessness Severe, one-sided calf pain Weakness and numbness in arms and legs Severe abdominal pain (warning sign for progesterone-only pills) Unusual, severe, prolonged headache with blurred vision
Injections The provider should know that the injections work for 1 or 3 months, depending upon the brand and dose. Progestin-only Depo-Provera (DMPA) 150 mg of Depomedoroxy, progesterone acetate effective for 12 weeks. The provider should inform the woman that the lactating woman can safely use it. It is safe to start them as early as 6 weeks after delivery. Noristerat (Net-N) 200 mg of norethindrone enanthate effective for 8 weeks. Lactating woman can safely use it. It is safe to start them as early as 6 weeks after delivery. Combined injectables
22
Mesigyna (50 mg NET-EN) 5 mg estradiol valerate effective for 4 weeks The high dose of progesterone inhibits ovulation. Bleeding changes are common, but not harmfulusually irregular bleeding for several months and then no bleeding. This is seen as an advantage for many women. Menstrual bleeding changes are a common reason for discontinuation, but proper counselling regarding expected side effects can decrease discontinuation rates. Delay in return of fertility on discontinuation is a disadvantage. A woman must visit the clinic to receive the injection. Indications The provider should know that the woman who wants long-term birth spacing: Has completed her family but does not want sterilization Is breastfeeding Is having side effects with oestrogen Contraindication Same as for oral contraceptive pills. Side effects The provider should inform the woman that she may experience: Menstrual irregularity like abnormal vaginal bleeding, usually no menstruation after the first year Breast discomfort Nausea and/or vomiting Depression or mood swings Weight gain
Group Work The class will be divided into 3 groups. One group will prepare a presentation on indications, contraindications, and advantages of oral contraceptives, another will prepare a presentation on indications, contraindications and side effects of injections, and the third group will prepare a presentation on intrauterine contraceptive devices (IUCDs).
REMEMBER Preconception Consideration: Return of fertility is slow once the injection is stopped. It may take 5 to 7 months. Therefore, it is not recommended for women who plan to conceive soon after its use. Postpartum Consideration: Early postpartum use increases the possibility of heavy, prolonged bleeding. Immediately refer to the hospital if a woman starts having: Continuous heavy vaginal bleeding Excessive weight gain Anxiety and stress
23
Using injectable progesterone The initial injection is given within the first 7 days of the menstrual period. If given on Day 1, the contraceptive effect is immediate; however, if given at any other time, additional contraception should be used for the next 7 days. Implants Implants are an extremely effective method. They are small, flexible capsules placed under the skin, usually in the arm. They are slow-release hormone devices. The indications, contraindications, and side effects are similar to those for injectables. They can be removed whenever needed. There are several types: Jadelle: 2 rods, effective for 5 years Sinoplant: 2 rods, effective for 5 years Implanon: 1 rod, effective for 3 years Norplant: 6 capsules, labelled for 5 years, effective for 7 They require a provider trained in insertion and removal. Once they are in place, the client doesnt have to do anything. Bleeding changes are common, but not harmful. Usually these changes involve prolonged, irregular bleeding over the first year, followed by lighter, more regular and less frequent bleeding. There is no delay in the return to fertility. INTRAUTERINE CONTRACEPTIVE DEVICES (IUCDS) IUCDs are the small devices that are inserted Copper-T into the uterus. Evidence shows that IUCDs work primarily by causing chemical changes to the sperm that prevent fertilization, and also by thickening cervical mucus. They work by preventing fertilization, not by preventing implantation. There are various shapes like copper T. A trained person has to insert it in the clinic, hospital, or family planning centre. The provider should refer those women who opt for this method for examination and counselling. The provider should advise the woman who has an IUCD in her uterus that she can check the strings the first few months but does not need to continually do so. Medicated IUCDs Copper-releasing: Copper T380 A, labelled effective for 10 years, but studies show effective for 12, at which time it should be replaced
24
Multiload 375, effective for 5 years Progestin-releasing: Mirena, effective for 5 years Nova T Progestasert The provider should know that the IUCDs act by preventing the: Sperm transportation through womens reproductive tract Fertilization of ovum by reducing the mobility of sperm (Uterine washings have not recovered fertilized ova from IUCD-wearing womenthere is no evidence to support the prevention of implantation) Indications The woman of any reproductive age and parity who is suitable for this contraceptive method should be referred to a family planning clinic. The women who: Want highly effective, long-term contraception Are breastfeeding Are postpartum and not breastfeeding Are postabortion Are at low individual risk of having an active STIs Cannot remember to take a pill every day Prefer not to use hormonal methods or should not use them Are in need of emergency contraception Are HIV-positive or have AIDS but are well and on ARV therapy Contraindications It is important for the provider that she knows the conditions in which this method cannot be used so that she can refer the woman to a family planning clinic for counselling on other methods. The IUCD should not be used if the woman: Is pregnant (known or suspected) Has unexplained vaginal bleeding, until the cause is determined and any serious problem is detected Has current pelvic inflammatory disease (PID)
25
Has current very high individual risk of having gonorrhoea or chlamydia Has acute purulent (pus-like) vaginal discharge Has a distorted uterine cavity Has malignant trophoblast disease Has known pelvic TB Has genital tract cancer Has an active genital tract infection e.g., cervicitis, vaginitis Has AIDS and is not clinically well Advantages The provider should be able to explain to the woman the advantages of this method as mentioned below: IUCDs are highly effective, they help to prevent ectopic pregnancies and have no interactions with any medicines. IUCDs provide longterm protection, up to 12 years with the copper T380 A. There is immediate return to fertility after its removal. IUCDs do not affect breastfeeding. An IUCD can be taken out whenever a woman wants to get pregnant, or whenever she wants it out. Disadvantages The disadvantages are: The woman may have increased menstrual bleeding and cramping during the first few months (copper-releasing only). Side effects The provider should inform the woman that she may experience some side effects with copper-releasing IUCDs, for example: Changes in bleeding patterns (for the first 36 months): Prolonged and heavier menstrual bleeding Irregular or heavy vaginal bleeding Increased menstrual cramping or pain Progestin-releasing IUCDs may cause amenorrhoea or very slight menstrual bleeding/spotting.
26
Insertion of an IUCD The provider should explain to the woman that a skilled person will insert the IUCD after her full examination in a clinic. IUCD can be inserted any time during the menstrual cycle, preferably days 1 to 7 of the menstrual cycle, when the health care provider is reasonably sure that the client is not pregnant. During postpartum, it can be inserted immediately following delivery, during the first 48 hours or after 46 weeks, or after 6 months if using LAM. The IUCD can be inserted postabortion immediately or within the first 7 days, provided there is no evidence of pelvic infection. How to check the string If the woman wants, she can check her strings, especially the first few months. The provider should teach the woman that to check the string of the IUCD, she should follow these steps: Wash her hands with soap. Sit in a squatting position or stand with one foot up on a step. Gently insert a finger into the vagina. Feel for the cervix. It feels firm like the tip of a nose. Feel for the string but do not pull it (pulling the string might move the IUCD or cause it to come out). New Evidence about IUCD Safety and Effectiveness Based on studies, there is new information on IUCD safety. Randomized controlled trials and literature reviews have led to changes in WHO eligibility criteria about IUCD use. Although product insert literature does not always reflect these changes, the IUCD is safer and presents fewer risks than once thought. Following is a summary of key new facts about the IUCD: Infertility is not caused by IUCD use. A case control study in Mexico found that tubal problems or blockages that may cause infertility are not associated with previous IUCD use, but with chlamydia (current infection oras indicated by the presence of antibodiespast infection) (Hubacher et al. 2001). The IUCD itself is not associated with pelvic infections. The risk of pelvic infection related to IUCD use is a transient risk presented by IUCD insertion (due to lack of proper infection prevention practices), and is not related to the IUCD itself. A continued risk of PID is associated with risk of sexually transmitted infections (STIs), not IUCD use (ARHP 2004).
27
IUCDs are suitable for use in nulliparous women. The only precaution (which may be defined as a condition that exposes women to increased risk) is because of the increased risk of IUCD expulsion. The smaller size of a nulligravid uterus may create mechanical problems in using the IUCD, but there is no association between using the IUCD and infertility (Hatcher et al. 2004). There are very few precautions related to IUCD insertion. Gonorrhoea, chlamydia, current purulent cervicitis, current PID (not history), and pregnancy are the main ones. Other STIs or pelvic infections (such as herpes, bacterial vaginosis, or candida) are not contraindications to IUCD insertion. The Copper T 380A has been shown to be effective for at least 10 and up to 12 years (Hatcher et al. 2004, Shelton and Rivera 2004). The IUCD does not act as an abortifacient. Studies suggest that the IUCD prevents pregnancy primarily by preventing fertilization rather than inhibiting implantation of the fertilized egg (Rivera et al. 1999; Alvarez et al. 1988; Segal et al. 1985). This is particularly true of the copper-bearing IUCDs. The IUCD does not increase a womans risk of ectopic pregnancy. The IUCD reduces the risk of ectopic pregnancy by preventing pregnancy. Because IUCDs are so effective at preventing pregnancy, they also offer excellent protection against ectopic pregnancy. Women who use copper-bearing IUCDs are 91% less likely than women using no contraception to have an ectopic pregnancy (Sivin 1991).
The absolute number of ectopic pregnancies among IUCD users is much lower than that among the general population.
The IUCD does not cause PID, nor does the IUCD need to be removed to treat PID. Strict randomized controlled trials and literature reviews reveal that PID among IUCD users is rare (ARHP 2004; Grimes 2000). Early studies that reported a link between PID and IUCD use were flawed and poorly designed. Inappropriate groups were used for comparison, infection in IUCD users was over-diagnosed, and there was a lack of control for confounding factors (Buchan et al. 1990; Vessey et al. 1981). Here are some important points about PID and the IUCD based on more recent research: During the first 34 weeks after IUCD insertion, there is a slight increase in the risk of PID among IUCD users compared to nonIUCD users, but it is still rare (less than 7/1,000 cases). After that, an IUCD user appears to be no more likely to develop PID than a non-IUCD user (Farley et al. 1992).
28
PID in IUCD users is caused by the STIs gonorrhoea and chlamydia, not the IUCD itself (Darney 2001; Grimes 2000). However, the risk is still very low, with an estimated three cases per 1,000 insertions in settings with a high prevalence (10%) of these STIs (Shelton 2001). If PID occurs, the infection can be treated while the IUCD is kept in place, if the woman so desires. Studies have shown that removing the IUCD does not have an impact on the clinical course of the infection. If the infection responds to treatment within 72 hours, the IUCD does not need to be removed (WHO 2004b). Randomized controlled trials and cohort studies reveal that the monofilament string does not increase the risk of PID (Grimes 2000). Women who have a history of PID can generally use the IUCD (the advantages generally outweigh the risks), provided their current risk for STIs is low. The IUCD does not cause infertility. Infertility caused by tubal damage is associated not with IUCD use, but with chlamydia (current infection or as indicated by the presence of antibodiespast infection) (Hubacher et al. 2001). Moreover, there is an immediate return to fertility after an IUCD has been removed (Belhadj et al. 1986). In one study, 100% of women who desired pregnancy (97 of 97) conceived within 39 months of IUCD removal (Skjeldestad and Bratt 1988). The IUCD is suitable for use in nulliparous women. Nulliparous women can generally use the IUCD (the advantages generally outweigh the risks). In theory, the smaller size of a nulligravid uterus may increase the risk of expulsion, whereas uterine enlargement, even if due to an abortion, may promote successful IUCD use (Hatcher et al. 2004). Expulsion rates tend to be slightly higher in nulliparous women compared to parous women (Grimes 2004). The IUCD can be safely used by HIV-infected women who are clinically well. HIV-infected women who are clinically well can generally use the IUCD (the advantages generally outweigh the risks). A large study in Nairobi showed that HIV-infected women had no significant increase in the risk of complications, including infection in early months, than HIV-negative women (Sinei et al. 2001). In another study of HIV-infected and HIVnegative IUCD users with a low risk of STI, no differences were found in overall or infection-related complications between the two groups (Sinei et al. 1998).
29
The IUCD does not increase the risk of HIV transmission. There is no current evidence that use of the IUCD in HIV-infected women leads to increased risk of HIV transmission. Studies have shown that among HIV-infected women using the IUCD, there is no increase in viral shedding and no statistically significant increase in HIV transmission to male partners (ARHP 2004; Richardson et al. 1999). The IUCD does not interfere with ARV therapy. Women who have AIDS, are on ARV therapy, and are clinically well can generally use the IUCD (advantages generally outweigh the risks). Because it is a non-hormonal contraceptive method, the IUCD is not affected by liver enzymes and will not interfere with or be affected by ARV therapy (ARHP 2004; Hatcher et al. 2004). STERILIZATION (SURGICAL CONTRACEPTION) Sterilization is a permanent surgical procedure in which the fallopian tubes in a woman or the vas deferens in a man are cut and tied. They lead to permanent inability to conceive. Couples need thorough and careful counselling to ensure that they accept the permanence of the procedure. The provider should refer the couple to the clinic for counselling and safe procedure. Vasectomy It is safe, simple, painless and quick surgical procedure that ties the mens tubes (vas deferens) and prevents the sperm joining the semen. The man still ejaculates but the semen does not have sperm. It does not affect the sexual activity of the man in any way, except that he cannot impregnate a woman. A proper informed and written consent is essential. Vasectomy is an easier and less complicated procedure than tubal ligation in a woman. Precautions Although the couple receive counselling before and after the procedure in the clinic, the role of the provider in counselling in the community is very important. The provider should counsel the couple and tell them the precautions they have to take: Some sperm are usually left in the semen. It takes about 1520 ejaculations to clear them. This is why even after the vasectomy, the man is able to impregnate the woman. Therefore it is advisable for a man to use condoms for 3 months after the surgery to prevent pregnancy. The operation takes 15 minutes and the man can leave the hospital in 12 hours. He should take rest at home for 2 days and not do hard work for a week.
Clinical Visit The class will be taken to the family planning clinic to observe the counselling on contraceptive methods and will do the counselling, under supervision.
30
In case of any bleeding from the cut, fever, or swelling of scrotum, he should consult the doctor. The provider should make clear to the man or couple that this procedure does not affect the general health of the man or diminish sexual desire and does not result in sexual impotency. Indications The provider should refer the married healthy man who has two or more children and willingly decides for vasectomy. Contraindications It is important for the provider that she know the conditions in which this method cannot be used so that she can refer the male partner to a family planning clinic for counselling on other methods. Absolute Contraindications STIs Scrotal infection Bulge in the groin or scrotum when part of an organ (usually the intestines) protrudes through a weak point or tear in the thin muscular wall that holds the abdominal organs in place (inguinal hernia) Swelling in the scrotum when the veins at the top of the scrotum get bigger (varicocele) Accumulation of fluid around the testis (hydrocele) T.B. of genital tract Relative Contraindication Bleeding disorders, psychoneurotic problems, drug addictions, diabetes, hypertension, liver disease Side effects/complications The provider should inform the couple that there are no side effects and complications are rare. Rare complications include: Uncommon to rare: severe scrotal or testicular pain for months or years Very rare: infection at incision site Tubal Ligation
31
It is a procedure that consists of tying or cutting the ovarian (fallopian) tubes. This stops the sperm and eggs from meeting, thus preventing pregnancy. The procedure can be done by minilaparotomy or through an operating laparoscope. Consent of the client is voluntary and informed. The woman should be counselled about risks and failure of the procedure and alternatives available. She should be asked about her reason for requesting sterilization over and above other long-term, reversible methods of contraception. She should be asked about possibility of wanting more children. Previous methods of contraception used, and current method of contraception she is using should be enquired about. The provider should specifically ask about any problems with previous and current contraceptive methods. The provider should ascertain that the client is sure that her family is complete and the request for sterilization is not under any coercion or in reaction to a sudden loss (death of partner, dissolution of relationship). Alternative forms of long-term contraception should be discussed, including advantages and disadvantages. The provider will explain that the recommended method is laparoscop, with the application of clips or rings. Sterilization can be done via a minilaparotomy, but the laparoscopic approach has a shorter operating time and quicker recovery. This is done under general anaesthesia (GA) usually, and is a day case procedure. The client should be advised to continue her current method of contraception or offered a short-term, reliable form of contraception until the operation date. Sterilization can be done at any time in the menstrual cycle, provided the client has been on a reliable form of contraception. Otherwise it should be avoided in the luteal phase. A pre-operative urine pregnancy test should be done and, even if it is negative, it should be explained to the woman that a luteal phase pregnancy may be present (if patient is not on any contraception) and the procedure deferred. The provider should refer the woman to the family planning clinic. Indications The provider should know that she can refer the woman for tubal ligation in the following conditions. The decision is in the best interest of the client, and becoming pregnant would cause a health risk for the woman or baby When the couple agrees that they do not want more children The woman has three or more children
Role Play Two students will take part in the role play. One will act as a provider and the other will act as a woman who has five children and is afraid of becoming pregnant again. She wants to have the method most suitable for her. After the role play, the class will discuss the points missed by the provider and her communication skills. Ten minutes will be given to prepare the role play.
32
Contraindications It is important for the provider that she know the conditions in which this method cannot be used so that she can refer the woman to a family planning clinic for counselling on other methods. Delay: pregnancy Use caution: past PID since LAST pregnancy, breast cancer, uterine fibroids, previous abdominal or pelvic surgery Use caution: respiratory disease, T.B. chest infection, hypertension, diabetes, renal impairment, severe nutritional deficiencies, severe anaemias, psychiatric disorders, umbilical hernia, obesity, recent injuries (to eliminate tetanus) Advantages The provider should be able to explain to the woman that it is a very effective, permanent, life-long method. There is no need for repeated hospitals visits. It has no interference with sex, no long-term side effects or health risks, and minilaparotomy can be performed just after a woman gives birth. Disadvantages The provider should be able to explain to the woman that it is usually painful, and requires trained providers. The reversal is difficult, expensive, and not available in most areas. It is more risky as compared to vasectomy. Rarely, bleeding or infection during or soon after the procedure can occur. Side effects: none Very rarely there may be complications of surgery: such as infection, bleeding, abscess, or death. In case the tubal ligation fails, there is a risk of ectopic pregnancy. The woman should be told to seek medical advice in case there is abnormal abdominal pain or vaginal bleeding. The provider should remove the womans doubts about this procedure. She should assure the woman that it does not interfere with a womans sexual pleasure. There is no risk or fear of a new pregnancy, so the couple can relax and their sexual relationship may be more satisfying. The sterilization does not affect menstruation. Recovery period The provider should tell the woman that she should rest for 2 days after the procedure. She should not have sex or hard work for 1 week, and if
33
she has severe pain or fever within a month after the procedure, she should consult her doctor. EMERGENCY OR POSTCOITAL CONTRACEPTION (PCC) PCC is reserved for use when contraception was not used, used incorrectly, or failed. It can prevent pregnancy in about three-fourths of cases; the sooner it is used, the better it is. It should not be used in place of contraceptive methods. The provider should inform the couple that Role Play emergency contraception will not cause an abortion. PCC does not continue to prevent pregnancy during the rest of the cycle; other methods Two students will of birth control must be used. It is provided in two ways: take part in the
role play. One will act as a provider and the other will act as a woman who complains that the condom leaked inside her and she does not want to become pregnant. She wants to know what could be done to prevent pregnancy. The provider will tell her about ECP and counsel her. After the role play, the class will discuss the points missed by the provider and her communication skills. Ten minutes will be given to prepare the role play.
Emergency Contraception Pills (ECPs) COC4 tablets within 120 hours and 4 after 12 hours Postinar1 tablet within 120 hours and 1 after 12 hours The Copper Intrauterine Device If it is inserted within 5 days of the unprotected intercourse. Almost any woman can safely use emergency contraceptive pills, which give her a second chance to prevent pregnancy after sex. This option is especially important given that there is a high percentage of women who get pregnant each year when they are not trying to have a baby (unintended pregnancy). Side Effects Emergency contraceptive pills have no long-term or serious side effects, and emergency contraception is safe for almost every woman to use. In general, progestin-only emergency contraceptive pills have fewer side effects than combined emergency contraceptive pills. The provider should explain to the woman that she might find herself feeling queasy and some women throw up after taking emergency contraceptive pills. She might also get a headache, feel tired or dizzy, have some lower abdominal pain, or find that her breasts are more tender than usual. The provider should advise her that if she feels this way, it should stop within a day or two. Some women also find that the female hormones in the pills (either progestin alone or a combination of progestin and oestrogen) cause unexpected bleeding; this is not dangerous and should clear up by the time she has her next period. The pills might also cause her next period to come early or late.
34
Emergency contraceptive pills (morning after pills) have no long-term or serious side effects. Contraindications The only time emergency contraception is contraindicated, meaning it should not be used, is confirmed pregnancy. Emergency contraceptive pills wont work then, and using an IUCD as emergency contraception could increase the risk of infection during pregnancy. The Risk of Pregnancy Progestin-only pills reduce the risk of pregnancy by 89% and, if used within the first 24 hours after sex, reduce the risk of pregnancy by up to 95%. Emergency contraceptive pills containing both progestin and oestrogen (known as combined pills) reduce the risk of pregnancy by 75%. In other words, if 100 women use this type of pill after having unprotected sex, only two of them will get pregnant. Emergency insertion of a copper-T IUCD reduces the risk of pregnancy by more than 99%. Counselling The provider should counsel the lactating woman that using emergency contraceptive pills once will probably not affect either the quantity or quality of the milk her breasts are producing. Although some hormones may be passed on through a mothers breast milk, the child is not likely to experience any adverse effects from it. Emergency contraceptive pills do not appear to cause any birth defects. There is no evidence to suggest that emergency contraceptive pills increase the risk of having an ectopic pregnancy. Because emergency contraceptive pills reduce the risk of pregnancy, they also reduce the risk of having an ectopic pregnancy. Making emergency contraception available and informing women about it can help them prevent an unintended pregnancy and reduce the need for abortion.
CONTRACEPTION IN SPECIAL CIRCUMSTANCES

The provider has to look after all women of reproductive age and be able to take appropriate action in special circumstances; therefore, she should know how to handle special situations for family planning.
Role Play Two students will assume roles. One will be the midwife, the other a client. The students taking part in the role play should spend a few minutes reading the background
ADOLESCENT Young married girls less 20 years of age or young couples can use fertility awareness methods, combined oral contraceptive, injections, or barrier methods. POSTABORTION CONTRACEPTION
35
information and preparing for the exercise. The observers in the class should also read the background information so that they can participate in the discussion following the role play. The provider is an experienced family planning service provider. She does not, however, believe that adolescents should use any family planning method other than condoms.
Combined oral contraceptive pills (COCs), progestin-only pills (POPs), and progestin-only injectables contraceptives (PICs) can be started immediately. The provider should tell the couple that they should use any method suitable for them for at least 6 months after abortion. First Trimester Abortion IUCDs can be inserted immediately if risk or presence of infection can be ruled out. Second Trimester Abortion Delay for 46 weeks. There is some concern about the risk of expulsion and perforation; if infection is suspected, delay insertion until the infection has been resolved for 3 months.
POSTPARTUM CONTRACEPTION For Lactating Mothers Client: The client is an 18-year-old girl. Lactational Amenorrhoea Method (LAM) can be used from delivery of She got married the baby up to 6 months. IUCDs can be inserted just after delivery or recently. They have after 6 weeks. Progestin-only contraceptives, combined oral tried to use condoms, but the contraceptives (COCs), combined injectable contraceptives (CICs), and husband doesnt natural methods can be used after 6 weeks. Sterilization can be performed like them and they just after delivery or after 6 weeks. really dont know
how to use them. The provider will provide counselling based on the clients method of interest.
For Non-Lactating Mothers IUCDs can be inserted just after delivery or after 6 weeks. Progestin-only contraceptives can be used just after delivery, and combined oral contraceptives (COCs) should be used after 6 weeks. Sterilization can be performed just after delivery or after 6 weeks. For Woman > 35 years old IUCD are safely used by older women if not at risk for STIs; possibly it is a preferred method because it is long-term and effective. Condoms can be used best with predictable intimacy acts, and they protect against STIs.
36
37
TEACHING AIDS
38
Birth Spacing and Family Planning in Pakistan Midwifery Student Notebook
JOB AIDS
These job aids include tools to help you plan for teaching, and to help in counselling and screening clients. Use these to help in teaching, in practice in simulation, and encourage students to use them in the clinical setting as well. PLAN FOR TEACHING Lesson Planning There are many variations of lesson plan formats that may be used, but in general, most lesson plans include these components: Identify the desired learning objectives Identify appropriate content to cover Identify appropriate teaching methods or activities required Identify how to measure if the objective has been met A practical way to identify the essential content and activities to meet the learning objectives is to ask these questions: What do I want learners to be able to DO after this session? What practice activities will help them practice the behaviour or skill? What is the MINIMUM information they need in order to do this skill or demonstrate this behaviour? This practice helps focus on practice and essential knowledge only to make efficient use of time. Here are several sample lesson plans that may be adapted and used as needed: Example 1 8 Topic: Venue: Seating Arrangement: Equipment Require:
S.# OBJECTIVE CONTENT TIME TEACHING STRATEGY EVALUATION
8 Adapted with permission from the Higher Education Commission, Islamabad and Pakistan Nursing Council, Islamabad. 2006 (revised). Curriculum of Nursing Education, BSCN.
40
Example 2
41
INSTRUMENT PROCESSING GUIDELINES

WASTE DISPOSAL After completing either an IUCD insertion or removal, and while still wearing gloves, dispose of contaminated objects (gauze, cotton, and other waste items) in a properly marked, leakproof container (with a tight-fitting lid) or plastic bag. DECONTAMINATION Fully immerse all metal instruments in a plastic container filled with 0.5% chlorine solution or other locally available disinfectant for 10 minutes before allowing staff and cleaning personnel to handle or clean them. (This step is necessary to help prevent transmission of HBV and HIV to clinic staff.) If the instruments cannot be cleaned immediately, rinse the objects with water and towel dry to minimize possible corrosion. Decontaminate all large surfaces (e.g., the procedure table or instrument stand) that could have been contaminated by blood or mucus by wiping them down with 0.5% chlorine solution. Briefly immerse both gloved hands in the bucket containing the 0.5% chlorine solution and then carefully remove by turning them inside out. If disposing of gloves, place in the leakproof waste container. However, if the gloves are reusable, deposit the gloves in the chlorine solution and soak for 10 minutes. CLEANING AND RINSING After decontaminating instruments, thoroughly scrub them under the surface of the water with a soft brush and liquid soap or detergent, taking care to brush all teeth, joints, and s screws. Rinse well after cleaning to remove all soap or detergent (some detergents can interfere with the action of some chemical disinfectants). Dry instruments by air or with a clean towel before further processing. Proceed with sterilization (if available) or high-level disinfection of instruments. Wash large surfaces (procedure table or instrument stand) with soap and water if organic material remains on them after decontamination. HIGH-LEVEL DISINFECTION High-level disinfection by boiling, steaming, or the use of chemicals is the recommended practice. Surgical (metal) instruments should be boiled or steamed for 20 minutes and allowed to dry. Alternatively, instruments can be soaked for 20 minutes in a glutaraldehyde/8% formaldehyde solution or a 0.1% chlorine solution prepared with boiled water, thoroughly rinsed with boiled water, and air dried. Use immediately or store for up to 1 week in a clean, dry, high-level disinfected container with a tight-fitting lid or cover. Surgical gloves can be boiled or steamed for 20 minutes and allowed to dry. STERILIZATION Alternatively, instruments and reusable gloves used for IUCD insertion and removal can be sterilized by autoclaving (121C [250F] and 106 kPa [15 lb/in2] for 20 minutes if unwrapped and 30 minutes if wrapped). Note: Dry-heat sterilization (170C [340F] for 60 minutes) can be used only for metal or glass instruments. STORAGE Unwrapped instruments must be used immediately or stored in dry, sterile containers (1 week only). Wrapped instruments and gloves can be stored for up to 1 week if the package remains dry and intact; 1 month if sealed in a plastic bag. If high-level disinfected instruments and other items are not used immediately, they should be stored in a high-level disinfected container with a tight-fitting cover. Sterilized instruments not used immediately should be stored in a dry, sterile container with a tight-fitting cover. High-level disinfected gloves should be stored in a dry, high-level disinfected container with a tightfitting cover or in the stacked and covered steamer pans as long as a bottom pan without holes is used. Sterilized gloves should be stored in a cool, dry place.
42
STANDARD PRECAUTIONS JOB AID

HANDWASHING (OR USING AN ANTISEPTIC HANDRUB) After touching blood, body fluids, secretions, excretions, and contaminated items Immediately after removing gloves Between patient contacts GLOVES For contact with blood, body fluids, secretions, and contaminated items For contact with mucous membranes and non-intact skin MASKS, GOGGLES, FACE MASKS Protect mucous membranes of eyes, nose, and mouth when contact with blood and body fluids is likely GOWNS Protect skin from blood or body fluid contact Prevent soiling of clothing during procedures that may involve contact with blood or body fluids LINEN Handle soiled linen to prevent touching skin or mucous membranes Do not pre-rinse soiled linens in patient care areas PATIENT CARE EQUIPMENT Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to prevent contamination of clothing or the environment Clean reusable equipment prior to reuse ENVIRONMENTAL CLEANING Routinely care, clean, and disinfect equipment and furnishings in patient care areas SHARPS Avoid recapping used needles Avoid removing used needles from disposable syringes Avoid bending, breaking or manipulating used needles by hand Place used sharps in puncture-resistant containers PATIENT RESUSCITATION Use mouthpieces, resuscitation bags, or other ventilation devices to avoid mouth-to-mouth resuscitation PATIENT PLACEMENT Place patients who contaminate the environment or cannot maintain appropriate hygiene in private rooms
43
CLIENTS RIGHTS
FAMILY PLANNING INFORMATION THAT IS Unbiased Includes education, counselling, and a range of options DECISION ON Choice among available and appropriate methods Starting, stopping, or switching a method TREATED WITH Kindness and respect for clients concerns SAFE AND COMFORTABLE ENVIRONMENT Physically safe and comfortable with regard to the chosen contraceptive option Reasonable with regards to the time spent for receiving the service (e.g., ventilation, lighting, seating, and toilet facilities) CONFIDENTIALITY IN Discussion with service provider Medical records PRIVACY DURING Physical examinations REFUSAL TO ANY Examinations Procedures Treatments APPROPRIATE REFERRAL AND FOLLOW-UP FOR Advanced level of care required CONTINUITY OF SERVICES FOR Contraceptives Non-contraceptive options EXPRESSION OF VIEWS ABOUT Quality of services received Suggestions for improvement in services
44
COUNSELLING AND SCREENING CLIENTS The following quick reference chart provides a quick summary of whether the method is recommended or not with the listed conditions. Green means it usually can be used, red indicates caution. Again, the availability of additional testing or diagnostics will help decide if a method is appropriate or not. It is followed by some method-specific screening tools and counselling job aids.
Source: Family Health International (FHI). Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use. Research Triangle Park, NC: FHI, 2008. Birth Spacing and Family Planning in Pakistan Curriculum Supplement
45
46
Source: Family Health International (FHI). How to Be Reasonably Sure a Client is Not Pregnant. Research Triangle Park, NC: FHI, 2008.
47
48
49
Source: Family Health International (FHI). Checklist for Screening Clients Who Want to Initiate Use of the Copper IUCD. Research Triangle Park, NC: FHI, 2008.
50
51
POSTPARTUM CONTRACEPTIVE OPTIONS
Adapted from: The MAQ Exchange. Contraceptive Technology Update. At: http://www.maqweb.org/maqslides/powerpoint/Theme1/CTU/CTU.pdf.
52
JOB AIDPOSTPARTUM EDUCATION TOOL
53
54
55
56
LAM CLIENT CARD9
Source: LAM Client Card. 2008. FAM Project and LAM Inter-Agency Working Group. At: www.irh.org/LAM.
57
58
LAM PROVIDER CARD10
10 Source: LAM Provider Card. 2008. FAM Project and LAM Inter-Agency Working Group. At: www.irh.org/LAM.
59
60
61
EXERCISES, CASE STUDIES, AND ROLE PLAYS
EXERCISES
This section is organized in three areas: exercises, case studies, and role plays. The checklists needed for practicing related skills are included in the Skill Development Tools section. Within each area, content is generally organized in this way: infection prevention and counselling, short-term methods, long-term methods, permanent methods, postpartum, or special situations. INSTRUCTIONS Use exercises as homework or activities to reinforce key points. Use case studies and role plays for practice sessions in the classroom or in simulation. Decide whether it will be an individual or group-based effort. In all cases, the national standards will be used as a reference source. When the case study is used in the classroom alone, include the following information in the instructions: Individual or group activity Learning objectives Time for completing the task How the case study results will be discussed Prepare for the case study or role play. This will include: Deciding on the instructions to be given to students Reviewing the case study and the answers beforehand
64
FEMALE ANATOMY AND PHYSIOLOGY REVIEW Questions 1. Label the various parts of the internal female reproductive organs shown below:
2. Label the various parts of the external female reproductive organs shown below:
3. What two hormones are produced by the ovary?
4. Give one function of each hormone in female reproduction
5. What are the three phases of menstrual cycle?

65
Answers 1. Various parts of the internal female reproductive organs:
2. Various parts of the external female reproductive organs:
3. What two hormones are produced by the ovary? OestrogenFor repair of endometrium and maturation of the follicles ProgesteroneFor the growth of the endometrium and sustenance of corpus luteum
4. Give one function of each hormone in female reproduction OestrogenGrowth of endometrium ProgesteroneResponsible for change in the uterus
66
5. What are the three phases of menstrual cycle? Menstrual phase Proliferative phase Secretory phase MALE ANATOMY AND PHYSIOLOGY REVIEW Questions 1. Label the various parts of the male reproductive organs shown below:
1. 2. 3. 4. 5.
6. 7. 8. 9. 10.
2. State the main sex hormone produced by the testes.
3. Give one function of the identified hormone.
4. Trace the flow of sperm from its production to the exterior.
67
Answers 1.
2. State the main sex hormone produced by the testes. 3. The prostate gland is found below the urinary bladder and surrounds the urethra. While its physiologic function is not completely understood, it is known that it produces the major volume of the ejaculatory fluid. 4. Give one function of the identified hormone. 5. Testosterone 6. Trace the flow of sperms from its production to the exterior. 7. Produced in testes epididymis vas deferens urethra exterior
68
EXERCISE: INFECTION PREVENTION REVIEW 1. Which is the first step in instrument processing and what is its purpose? Answer: Decontamination, purpose is to make instruments safe to handle 2. Define the no-touch technique. Answer: Making sure that the uterine sound or loaded IUCD passes through the cervical canal without touching the vaginal wall.
3. When inserting an IUCD, the client should put on a clean gown, true or false? Answer: FALSE, if their clothes are clean 4. Standard precautions should be used with which type of clients? Answer: ALL clients 5. Which is the most important of the standard precaution procedures? Answer: Handwashing 6. What is the key difference between sterilization and high-level disinfection? Answer: Sterilization destroys endospores, and high-level disinfection does not 7. Why is it appropriate to use clean gloves rather than sterile when inserting an IUCD? Answer: Because using loading the IUCD in the sterile package and the no-touch technique prevent infection and make sterile gloves unnecessary. 8. List several types of contaminated waste: Answer: Answer can include any of the following: blood, pus, urine, stool and other body fluids, any equipment contaminated with any of these body fluids
69
EXERCISE: ATTITUDES ABOUT BIRTH SPACING: SELF-ASSESSMENT TOOL Please indicate your opinion and feelings about birth spacing using the following rating scale (write numbers in the appropriate column):
5-Strongly Agree
S. NO. 1 2 3 4 5 6 7 8 9
4-Agree
3-No Opinion
2-Disagree
1-Strongly Disagree
DESCRIPTION Contraception should be made available to married people only Hormonal contraception is not dangerous for womens health Lactational amenorrhea method is not effective contraception Emergency contraception should be available to women who ask for it, without limitations Men should be responsible for deciding how many children they have A woman should not question a mans decision Islam does not approve of birth spacing The more children a woman has, the higher her status Professional ethics are just as important as spiritual beliefs
RATING
70
EXERCISE: WORLD HEALTH ORGANIZATION (WHO) MEDICAL ELIGIBILITY CRITERIA 1. Mrs. N wants to start the shot. Her last menses started 5 days ago. She has a normal health and obstetrical history. Can she start injectables today? Answer: Yes 2. Mrs. A is breastfeeding her newborn baby who is only 5 weeks. Can she start a method of family planning? Answer: No, she cannot start a method today. Progestin-only methods can be started by nursing mothers after 6 weeks. Need to ask more about her breastfeeding, if she is using LAM, no other method is needed until she no longer is practicing LAM (exclusively or mostly breastfeeding, amenorrhoeic and baby is 6 months or less).
3. Mrs. L has 2 children. She is taking medications for TB. She and her husband want to avoid pregnancy while she is taking the medication. Her BP is 110/70. What methods could she use? Answer: Injectables, IUCD, or condoms 4. Mrs. M is 8 months pregnant and is HIV-positive. She does not want any more children for at least 6 or 7 years, maybe no more, but she is uncertain. She is very concerned about her own health and her ability to take care of her children. She wants a very effective method so that she can take care of her own health. What methods would be appropriate? Answer: Dual methods: condoms plus another method. An IUCD would be a good choice since she is requesting a very effective method, but also could use injectables or COCs. Tubal ligation is not an appropriate choice since she has voiced uncertainty about wanting more children. 5. Mrs. Z has a sister who has an IUCD to prevent pregnancy. Her sister likes it very much. Mrs. Z admits to you that she has lower pelvic pain, painful intercourse, and a bad-smelling, yellow vaginal discharge. She is also experiencing painful urination. She wants the IUCD to prevent another pregnancy. Is she a candidate? Why or why not? What other methods could she use? Answer: Mrs. Z has the symptoms of an STI, probably chlamydia, maybe PID. She needs an evaluation, medication, and advice that her husband needs to be evaluated. An IUCD is not a good choice for her today. However, she could use COCs or injectables. She should use condoms to prevent a re-exposure. 6. Mrs. T has a 6-month-old baby and has been using LAM. She has not had a menses since she delivered. She reports a normal medical and obstetrical history. Her BP is 110/76. She wants to start COCs. She took them before her last baby and had no problems. Can she start COCs today? Answer: Yes
71
7. Mrs. S has a 4-month-old baby. She only breastfeeds but her mother-in-law tells her that she needs to give her baby pap. She wants to use pills to prevent another pregnancy. Mrs. S has never taken any contraception. She thinks the shot is too strong for her. She has not yet started her menses. Her BP is 120/76 and she has another child who is 2. She denies any medical or obstetrical problems. What methods would be appropriate for Mrs. S? Answer: LAM no longer applies after she starts with supplemental feeding. POPs could be a good method although explore more her concerns with progestin-only injectables. Because her baby is less than 6 months, COCs are not as good a choice as progestin-only. She also could have an IUCD and/or condoms. 8. Mrs. C has 1 child who is 16 months old. During her pregnancy she had pre-eclampsia. In the hospital she received treatment so that it did not develop into eclampsia. The doctor in the hospital told her that she was very sick and should wait at least 2 years before she gets pregnant. She reports that she gets really bad headaches that make her head throb. She does not have any visual changes before or during the headache. She doesnt want the shot, because she heard that it makes you infertile. She thinks that she wants to start COCs. Her BP today is 110/72 and on physical exam, you notice that she has some superficial varicosities. Can she use COCs? Answer: Yes, normotensive today, headaches are not migraines with aura. Varicose veins are normal findings in women. Discuss with her that injectables do not cause infertility; she may have a delay in return to fertility, sometimes up to 1 year, but usually fertility returns 36 months after the next injection is due.
72
EXERCISE: LAM 1. What is the definition of LAM? Answer: The Lactational Amenorrhoea Method is a contraceptive method based on the natural infertility resulting from breastfeeding. 2. What are the three criteria of LAM? Answer: 1) The mothers menses has not resumed, 2) she is fully or nearly fully breastfeeding, and 3) the infant is 6 months or less. 3. What is the difference between breastfeeding and LAM? Answer: Breastfeeding is a method of infant feeding, NOT a contraceptive. LAM is a contraceptive method that uses a pattern of breastfeeding that can effectively suppress ovulation and prevent pregnancy up to 6 months postpartum. 4. When does LAM end? Answer: LAM ends when the womans menstrual periods have returned or when the pattern of breastfeeding changes to regularly include water, other liquids, or solid food, or when the infant is more than 6 months old. LAM ends when the woman wishes to change to another method of contraception. 5. What is the difference between LAM and amenorrhoea? Answer: Many women who breastfeed will have delay in return of menses. Only those women who breastfeed their babies frequently with no regular supplements and whose infants are 6 months or less can be more than 98% confident that they will not conceive. 6. What is fully breastfeeding? Answer: Full breastfeeding is both exclusive breastfeeding, when no other liquid or solid is given to the infant, and almost exclusive, that is, vitamins, medicines, water, juice, or ritualistic feeds are given infrequently in small amounts. The mother continues to frequently breastfeed. 7. How does LAM prevent pregnancy? Answer: Nipple stimulation from sucking leads to release of hormones that suppress ovulation. 8. What does the transition from LAM mean? Answer: Transition from LAM means the timely introduction of another modern method so that mothers can transition from LAM to another modern method to allow for healthy birth spacing.
73
9. What are three advantages of LAM? Answers: a. More than 98% effective b. Can be started immediately postpartum c. No side effects d. Motivates mothers to exclusively breastfeed e. Facilitates transition to another method f. Natural method 10. A LAM user has a 3-month-old baby. She wants to switch to another method and continue breastfeeding. Which methods could she use? Answer: Progestin-only injections or pills, IUCD, condoms, vasectomy, and bilateral tubal ligation. 11. A mother has a 4-month-old baby and has not had her menses. She does laundry for 3 hours and leaves the baby with her mother. She breastfeeds her baby exclusively. Is she practicing LAM? Answer: Yes 12. Another mother exclusively breastfeeds her 4-month-old baby. The mother had several consecutive days of vaginal bleeding and spotting about a month ago. She thinks that she is protected against another pregnancy because she is nearly fully breastfeeding. Is she? Answer: No, she had several consecutive days of bleeding and spotting during her 3rd postpartum month. She should be advised to start another modern method right away. 13. A mother has a 7-week-old baby. Even though she exclusively breastfed him for the last 7 weeks, she had spotting and brown discharge up to a week ago. Is she practicing LAM? Answer: Yes, because spotting and bleeding during the first 2 months is related to lochia and not menses. 14. A mother with a 4-month-old baby breastfeeds him and gives him sugar water 3 times a day. Her menses has not yet returned. Is she practicing LAM? Answer: No, because she is not fully or nearly fully breastfeeding her baby. 15. Miriam has a 5-month-old baby that she is fully breastfeeding. Her menses has not yet returned. She wants to avoid another pregnancy for at least 2 years and thinks the injectables injection is good. She wants to start today, but you know that the provider will only give injectables if the woman is on a very effective contraceptive method or the patient has her menstrual period. Do you think that she will receive her injection? Answer: Yes, because Miriam has satisfied the 3 criteria of LAM. LAM is 98+% effective so the provider knows that there is about the same risk of pregnancy in Miriam as it would be for a client taking combined oral contraception. Miriam is doing an excellent job of transitioning from one reliable method to another.
74
EXERCISE: BARRIER METHODS (CONDOMS) 1. What are the different types of barrier methods in use? Answer: There are different types of barrier methods in use all over the world, for example: male condoms, female condoms, diaphragms, and cervical caps. But male condoms are the most commonly used FP method among all of the barrier methods in Pakistan. 2. There are different types of male condoms (made of different materials), such as: Answer: a. Thin sheaths of rubber (latex) b. Vinyl c. Natural products Note: Condoms differ in such qualities as shape, colour, lubrication, thickness, texture, and whether a spermicidal has been added.
3. How do condoms protect against pregnancy? Do all types protect against STIs? Answer: The condoms prevent sperm from gaining access to the female reproductive tract. They also prevent microorganisms (STIs) passing from one partner to another (latex and vinyl condoms only). 4. What are the other benefits associated with the use of condoms? Answer: Condoms are used for the prevention of pregnancy and also for the prevention of STIs (only FP method that provides protection against STIs [latex rubber and vinyl condoms only]). Condoms can also be used as backup to other methods, do not have method-related health risks or systemic side effects, and are widely available (at pharmacies and community shops). No prescription or medical assessment is required for use of condoms; they are inexpensive (short-term), promote male involvement in family planning, and may also help prevent cervical cancer. 5. Allergic reaction to condoms is uncommon. In case of local irritation, what advice will you give to the client? Answer: Allergic reactionsalthough uncommoncan be uncomfortable. In case of any such event, ensure that the condom is not medicated. If the reaction persists with unmedicated condoms, consider natural condoms (lambskin or gut) or choose another method (help the client do this).
75
6. What are the limitations of condom use? Answer: The use of condoms does have some limitations, such as: They are moderately effective (two pregnancies per 100 women during the first year when correctly used), as their effectiveness as contraceptives depends on the couples willingness to follow instructions. They are user-dependent (require continued motivation and consistent use with each act of intercourse). They can reduce sensitivity of the penis, making maintenance of erection more difficult. 7. How can you avoid condom rupture during use? Answer: Condom rupture can be avoided by adhering to the following guidelines: Do not use teeth, knife, scissors, or other sharp utensils to open the condom package. If the condom does not have an enlarged end (reservoir tip), about 1 to 2 cm should be left at the tip for the ejaculate. Check the date on the condom package to ensure that it has not expired. Do not use mineral oil, cooking oils, baby oil, or petroleum jelly as lubricants for a condom. They damage condoms in seconds. If lubrication is required, use saliva or vaginal secretions. 8. What will you advise the client to do if the condom breaks or slips off during intercourse? Answer: Consider using a method of emergency contraception.
76
EXERCISE: PROGESTIN-ONLY PILLS (POPS) 1. Can a woman who is breastfeeding safely use POPs? Answer: Yes. This is a good choice for a breastfeeding mother who wants to use pills. POPs are safe for both the mother and the baby, starting as early as 6 weeks after giving birth. They do not affect milk production. 2. How long does it take to become pregnant after stopping POPs? Answer: A woman who stops using POPs can become pregnant as quickly as women who stop non-hormonal methods. POPs do not delay the return of a womans fertility after she stops taking them. The bleeding pattern that a woman had before she used POPs generally returns after she stops the method. 3. Is it important for a woman to take her POP at the same time each day? Answer: Yes, for two reasons. POPs contain very little hormone, and taking a pill more than 3 hours late could reduce their effectiveness for women who are not breastfeeding. (Breastfeeding women have the additional protection from pregnancy that breastfeeding provides, so taking pills late is not as risky.) Also, taking a pill at the same time each day can help women remember to take their pills more consistently. Linking intake of pills with a daily activity also helps women remember to take them. 4. Do POPs cause cancer? Answer: No. Few large studies exist on POPs and cancer, but smaller studies on the method are reassuring. Larger studies of implants have not shown any increased risk of cancer. Implants contain hormones similar to those used in POPs and at about twice the dosage during the first few years of implant use. 5. Can POPs be used as emergency contraceptive pills (ECPs) after unprotected sex? Answer: Yes. As soon as possible, but no more than 5 days after unprotected sex, a woman can take POPs as ECPs. Depending on the type of POP, she will have to take 40 to 50 pills. Although this is a lot of pills, it is safe because there is very little hormone in each pill.
77
CASE STUDIES
CASE STUDY: USING COCS 1 Scenario: Using COCs 1 Mrs. A. is a 31-year-old mother of five. While she is not certain that she has all the children she wants, she does know that she is not interested in having another child for at least several years. She is frightened of injections and her husband does not like to use condoms. She has heard that COCs are easy to use and effective; shed like to try them. You conduct some basic screening and obtain the following information: blood pressure is 140/90 mmHg; she was diagnosed with tuberculosis 8 months ago; she sometimes has headaches, about twice per month; and you observe mild varicosities on both lower legs. Questions: Using COCs 1 1. What other information do you need to obtain in order to assess whether COCs are the best choice for her? 2. The rest of the clients history and assessment do not reveal any precautions for COC use. Are COCs an appropriate choice for this client? Why or why not? 3. If she does use COCs, what counselling and information does she need? 4. If COCs are not an appropriate choice, what other method(s) might be? Why? Answers: Using COCs 1 1. When did she have her last birth? Was it less than 6 months? Is she breastfeeding? If so, how often is she breastfeeding and is the baby receiving any other sources of nutrition? If she is 6 months past birth and breastfeeding, COCs could be a consideration. Has she had problems with high blood pressure in the past? What medication is Mrs. A. taking for TB? If she is taking rifampicin, COCs will be less effective and therefore not the preferred method for her. How severe are her headaches and how often does she have them? Are the headaches migrainous? Does she have any visual disturbance before or during the headache (aura)? Visual signs with migraines are a reason not to give her COCs, regardless of her age. For migraines without auras, a patients risk of stroke increases with age, hypertension, and smoking. With mild or moderate headaches, you may give COCs. 2. High blood pressure (140/90) means COCs are not the best method. However, if this is the only blood pressure check she has had, a repeat may be appropriate at least 24 hours from the first reading. If her blood pressure is lower than 140/90 at the next exam, she may be given COCs (a single reading of 140/90 is not sufficient to diagnose high blood pressure). Varicose veins are not a precaution for using COCs. If she is taking a short course of rifampicin, she could be eligible for COCs when she finishes. Another highly effective method that she could use with her medical history is an IUCD. If her pelvic exam is within normal, she could get an IUCD today. Withdrawal is not very effective (failure rate is 2025%) but may be an acceptable contraceptive method to her husband, for the short term until she finishes her
78
rifampicin. If her pressure is still elevated, COCs are not an appropriate method, however progestin-only pill (POP) could be offered to her after her course of rifampicin. 3. Mrs. A. needs counselling on when to start, how to use, common side effects, and when to return for resupply. She should return to the provider if she has any problems. Counselling on correct and consistent use of the pill, ensuring she takes it every day, will be important for her to achieve several years spacing between births. 4. The IUCD may be a good choice for her. Mrs. A. has a few medical issues that, depending what her responses are, make COCs not a good choice; none of the medical issues prevent her from using an IUCD. An IUCD may be more effective in preventing another pregnancy for the next several years than COCs. Progestin-only pills (POPs) may be used with high blood pressure, but not with rifampicin. POPs can cause other side effects (break-through bleeding) and effectiveness is slightly lower than COCs. Also, exploring the reasons for fearing injections may be appropriate. If her fears could be addressed, injectables may be an option.
79
CASE STUDY: COCS 2 Scenario: COCs 2 Naseeb bi is a 30-year-old mother of three children. Her youngest child was delivered about 6 months earlier. Today, she has come to your clinic to get some family planning pills (specifically, combined oral contraceptives [COCs]). Naseeb bis menses have not yet returned because she has been exclusively breastfeeding her infant. Three days ago, she was at another health centre for some medical problems. She is taking antibiotics for a urinary tract infection and ferrous sulfate for anaemia. Questions: COCs 2 1. During the counselling, Naseeb bi wants to learn more about the pill and ask the following questions: What is the difference between low-dose and high-dose pills? Are high-dose pills better than the low-dose? What are some of the advantages and disadvantages of taking the pill? 2. During the screening, there are several considerations: Given her condition, how does breastfeeding affect her eligibility to use COCs? How about her medical problems? What antibiotics will affect the effectiveness of the COCs? How about anaemia and her intake of ferrous sulfate? What other pieces of information should you ask Naseeb bi to help her make a decision about whether to use COCs? How would this additional information help? 3. Towards the end of the counselling, she also asks about how to use the pill. Given her situation, 6 months postpartum and no menses, when can she start taking the pill? Aside from doing a pregnancy test, what can you do to be reasonably sure she is not pregnant? What questions should you ask? What should you tell her about what to do if she misses pills? 4. After all of Naseeb bis questions have been answered, you instruct her to return to the clinic for resupply or if there are problems related to using the pill. Three months later, Naseeb bi returns to the clinic to get more pills. During her consult, she says that in the first 2 months of using the pills, she had 12 days of spotting in the middle of her cycle. She was not too concerned but would like to know if this is going to happen every time she is on pills. Naseeb bi also mentions that she experienced nausea and some vomiting in the first month but presently has no nausea. Are her symptoms normal with pills? What other conditions may cause spotting? What would you advise Naseeb bi about the spotting?
80
Will this spotting continue while she is on pills? What should you advise Naseeb bi about the nausea and vomiting? When should this information have been provided and what advice would have been appropriate at that time? Answers: COCs 2 1. About COCs: Components of COCs: COCs contain oestrogen and progesterone hormones. Low-dose COCs contain 3035 mcg ethinyl estradiol (EE), while high-dose contain 50 or more mcg EE. In Pakistan, most of the available COCs are the low-dose types. Both are very effective in preventing pregnancy; however, the high-dose COCs often have the side effects associated with this method. Advantages and disadvantages of COCS: COCs have a high user-satisfaction rate. They are very effective, menstrual bleeding becomes lighter and more predictable, fertility returns rapidly. The disadvantages are side effects such as nausea or vomiting, breast tenderness or weight gain, or spotting or bleeding in between periods (most of these are minor and lessen after the first few cycles). 2. Screening for COCs: Breastfeeding: In the first 6 months postpartum, use of COCs during breastfeeding diminishes the quantity of breast milk, decreases the duration of lactation and may affect the growth of the infant. As her baby is 6-months old now, she can use COCs if this is her method of choice. Medical Problem: Griseofulvin (antifungal) and rifampicin (anti-TB) are two antibiotics that affect the effectiveness of COCs, especially the low-dose formulation of COC. In this case, it is important to ask the client which antibiotic she is taking. The use of COCs may help improve the anaemia because the monthly bleeding will be lessened by COC use. The one piece of advice that this client may find useful will be to separate the time of intake for COC and iron. Some clients are sensitive to the smell of iron. Iron also causes some gastric discomfort when taken on empty stomach. Other information that might affect Naseeb bis decision: Before it can be determined whether COCs are a suitable choice for Naseeb bi, more discussion of her medical history is neededsuch as whether she currently has or has a history of cardiovascular problems or hypertension. For women who are hypertensive presently, COCs are Category 3 or 4. For those who are not hypertensive presently but have a history of hypertension, COCs are Category 2.
81
3. Using COCs: Although Naseeb bi is amenorrhoeic, she can start COCs at any time as long as it is reasonably certain that she is not pregnant. If she starts COCs immediately, she will need to abstain from sex or use additional contraceptive protection for the next 7 days. If a woman is not amenorrhoeic, she can start COCs within 5 days after the start of her next menses. In that case, no additional contraceptive protection is needed. Use the How to be Reasonably Sure a Woman is Not Pregnant job aid to rule out pregnancy. You can be reasonably sure a client is not pregnant if she has no signs or symptoms of pregnancy and: Has not had intercourse since her last menses Has been correctly and consistently using another reliable contraceptive method Is within the first 7 days after the start of her menses Is within 4 weeks postpartum (for non-breastfeeding women) Is within the first 7 days postabortion Is fully breastfeeding, less than 6 months postpartum and has had no menstrual bleeding
Note: When a woman is more than 6 months postpartum, you can still be reasonably sure she is not pregnant if she: has kept her breastfeeding frequency high, still has no menstrual bleeding (amenorrhoeic), and has no clinical signs or symptoms of pregnancy.
A pregnancy test is needed only when it is difficult to confirm pregnancy and the results of the pelvic examination are not clear. Missing Pill Intake: If the woman misses one active (hormonal) pill, she must take the missed pill as soon as she remembers it, also take the other pill scheduled for that day (this means taking two pills in the same day), and complete the pack as usual. No backup method is necessary. When she misses two or more active pills (consecutively), she must take the missed pills as soon as she remembers, and continue with the remaining hormonal pills (as scheduled). The next day after the last hormonal pill has been taken, she should throw away the nonhormonal pills and begin a new pack. She needs to use a backup method for 7 days and should consider using EC if she has had sex within the last 5 days. 4. Continued Use: Breakthrough Bleeding or Spotting: Check for other causes of spotting including gynaecologic conditions (ectopic or intrauterine pregnancies, incomplete abortion and PID) and recent intake of new drugs. If neither is the case, advise the client that this is common during the first 3 months of COC use and decreases significantly in most women by the fourth month of use. If it persists and is bothersome, switch to another COC or help client choose another method. Nausea and Vomiting: Check for other causes such as early pregnancy and time of intake (morning or on empty stomach). If the client is not pregnant, advise her to take the pill with
82
her evening meal or before bedtime. Counsel that nausea and vomiting will probably decrease over the first 3 months.
83
CASE STUDY: PROGESTIN-ONLY PILLS Scenario: Progestin-Only Pills Mrs. B. comes to the health centre to immunize her baby against measles. She does not want another baby yet. Questions: Progestin-Only Pills 1. What would you do? Scenario Continued: Progestin-Only Pills She tells you that she has two children, ages 2 years and 9 months. The last baby was big and caused lots of bleeding. She is still tired and needs time to rest before she has another baby. She is not tasking any medicine and has no other medical complaints other than being tired. She understands about healthy timing after you explain to her that it can help prevent preterm and low birth weight babies. She will wait another 2 years before she tries to get pregnant. She is still mostly breastfeeding her 9-month old baby. He has started some pap but he feeds first from her breast then takes some pap. She has not yet started her menses. She has resumed sexual activity during the last 6 months. Her husband is using withdrawal. On exam, her conjunctiva are a bit pale, her BP is 140/90, and her breasts are full of milk. Questions Continued: Progestin-Only Pills 2. What methods of contraception would be a good choice for her, if any? She has no medical history. 3. She thinks that POPs are the best choice for her today. How would you counsel her on POPs? Answers: Progestin-Only Pills 1. Answers: Explain healthy timing and spacing of pregnancies Explain return to fertility Ask her when she would like another child-how much spacing does she want? 2. Answer: She could use progestin-only methods, also, since the baby is 9 months old, and she could also use COCs. Since her blood pressure is slightly elevated today, but she denies any previous history of elevated BP, progestin-only methods are a better choice for her. She should come back in 6 weeks to re-check her blood pressure. 3. Answers: POPs highly effective in preventing pregnancy (9299.7%). POPs will not interfere with milk production and not affect her nursing baby. She needs to take the pills every day at the same time regardless if she has sex that day or not. Some women who use POP as well as injectables may have some irregular vaginal bleeding. This is normal. Many
84
breastfeeding women may continue to be amenorrhoeic, and menses could further be delayed due to POPs. She should return to double-check her blood pressure in 6 weeks.
85
CASE STUDY: INJECTABLES Scenario: Injectables Husnia is 36 years old and has three children. She is using Famila, a low-dose COC, and has been since her last delivery 2 years ago. Husnia is having headaches and is concerned that they may be related to her use of Famila. She wants to shift to an injectable (progestin-only injectable contraception [PIC]). Husnia has come to the family planning clinic today to get an injection. She tells you she is not presently having her menses, and that she has been taking medications for epilepsy. Questions: Injectables 1. During the counselling, Husnia wants to learn more about injectable contraceptives: What are the injectables (Depot-Medroxyprogesterone Acetate, or Depo-Provera) and Net-en (Norethisterone enanthate)? What are their similarities and differences? What are some of the advantages and disadvantages of using injectables? What other information should you share with Husnia about PICs? 2. During screening, there are several considerations: Do you think Husnias fears about her headaches being related to her use of Famila are valid? Why? Given her age and headaches, do these factors affect her eligibility to use PICs? How about the medical problem of headaches? How would you further evaluate her complaint of headaches? How about epilepsy? Do medications for epilepsy affect the effectiveness of injectables? What other conditions should you check out to see if she is eligible? 3. Toward the end of the counselling, Husnia also asks about how she can get started on injectables: Given her condition (not presently having her menses), when can she start receiving Depo-Provera? If, for example, Husnia just had a delivery, can she receive an injection before discharge? What should you tell her about returning for reinjection? How about warning signs indicating that she should return to the clinic immediately? 4. Husnia has come back to the clinic for a reinjection. You check her records and note that she is 2 weeks late. Husnia reports that she experienced two episodes of 12 days of spotting in the past 2 months. Moreover, Husnia is complaining that she has gained about 1.5 kilograms since she started the PIC. What should you advise Husnia about spotting and weight gain?
86
Does her spotting need to be treated using other hormones? When is it appropriate to give additional hormones? What about the delay in returning for injection? Should you give her the injection? Will she need additional protection because of the delay? Answers: Injectables 1. Both injectables and Net-en are progestin derivatives, but they have different durations of effectiveness. Other similarities and differences are summarized in the table below:
INJECTABLES Similarities NET-EN
Mechanism of action: prevention of ovulation Pregnancy rate: 0.3% (perfect use), 3% (typical use) Effective immediately if given within 7 days of menses Window period: 2 weeks Active component: progestin only Eligibility, complications, side effects: same as POPs Type and amount of progestin: 150 mg of depotmedroxyprogesterone acetate Timing of injection: 3 months Type and amount of progestin: 200 mg of norethisterone enanthate Timing of injection: 2 months
Differences
Some of the advantages and disadvantages of PICs are: Advantages: They are a very effective and reversible method of family planning, and the client can use the method privately. They can be used by a breastfeeding woman as soon as after 6 weeks postpartum. A woman who is not breastfeeding can start PIC soon after delivery. There are no oestrogen-related side effects for PIC-users and they may help decrease menstrual cramps and bleeding (endometriosis). Disadvantages: Need a trained provider is needed to provide the injection, client must return every 2 or 3 months (depending on which type), and there is delayed return of fertility after discontinuation. 2. Other information regarding injectables: Husnia can be reassured that injectables are highly effective (3 pregnancies per 100 women during first year of typical use) and are rapidly effective (<24 hours) if started by Day 7 of the menstrual cycle. Husnia can shift to the injection at any time, provided she has been using oral contraceptives correctly (i.e., you can be reasonably sure she is not pregnant). 3. Screening considerations: Considering the clients complaint of headaches: Husnia is on Famila tablets, which are low-dose COCs. Famila tablets usually do not cause headaches for such a prolonged period time. Most women on Famila will not experience any headaches. Since Husnia has been using Famila for 2 years, it is unlikely that her headaches are due to COC use. However, clients having recurring severe headaches accompanied by neurological signs, as in migraine headaches, while on pills are advised to switch to another method. The
87
provider needs to ask Husnia about the nature of her headaches to be able to advise her on which methods might be best for her. Considering her age and headaches in terms of eligibility: PICs can be used by women of any age, including adolescents and women who are over 40. To further evaluate Husnias headaches, the provider needs to ask whether her headaches are accompanied by neurological signs (e.g., aura). Any woman with non-migrainous headaches or migraines with or without aura may start PICs, regardless of age. However, a woman who experiences new onset of migraines with aura while on PICs should stop using this method. Considering epilepsy: PICs can be used in clients who have epilepsy, including those who are receiving medications for epilepsy. Injectables has been found to decrease the frequency of seizure episodes among those with epilepsy. Considering other eligibility issues: Other eligibility issues that the provider needs to be aware of in the use of PICs include:

Breastfeeding: Breastfeeding women can start PICs 6 weeks after childbirth. Smoking: PICs may be used by women who smoke. Mild or controlled hypertension: PICs may be used by women with these conditions. Multiple cardiac risk factors, including history of heart attacks, ischemic heart diseases, stroke, blood clots, or severe hypertension, or diabetes of more than 20 years: PICs are not advisable for women with these conditions. Breast cancer, severe liver cirrhosis and liver tumour: PICs are not advisable in women with these conditions Unusual vaginal bleeding: This should be investigated first before starting PICs.
4. Starting PICs: Husnia can be shifted to injectables at any time. Although Husnia is not presently having her menses, she can start PICs at any time as long as it is reasonably certain that she is not pregnant. Return visits: Advise the injectables client to visit for reinjection every 3 months. To help her remember, provide her with a client reminder card and specifically mention the date of reinjection. The injection can be given on time (3 months after the last injection), or up to 4 weeks early or late. If more than 4 weeks late for next injection, use a backup method such as condoms or abstain from sex. Return even if more than 4 weeks late for injection. Warning signs indicating that she should return to the clinic immediately include: Significant/heavy vaginal bleeding, new onset of migraine headaches with neurologic signs, yellowing of skin and eyes 5. Continued PIC use: Spotting and weight gain advice: Reassure client that light, intermenstrual bleeding/spotting occurs in many women using PICs (5080%) during the first few cycles of use. It is not serious and usually does not require treatment. Weight gain:
88 Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide
Counsel the client that fluctuations of 12 kg may occur especially with PICs. Review diet if weight change is excessive. If weight gain is unacceptable even after counselling, assist the client in choosing another method. Delay in returning for injection: Current guidelines allow for up to 4 weeks delay in injectables reinjection without checking for pregnancy or requiring use of a backup method. For greater delays, pregnancy must be ruled out before giving the injection. In such cases, the WHO recommends also providing a backup method such as condoms to be used for a length of time equal to the delay past 14 weeks. For example, if it has been 15 weeks since the last injection, the client should use the backup method for 1 week.
89
CASE STUDY: IUCD Scenario: IUCD Mrs. D. is a 35-year-old woman with six children. She had a normal birth of her last child 8 weeks ago. She and her husband do not want more children, and she heard that the IUCD is highly effective for a long time. She is fully breastfeeding and has not had a menstrual period since the birth. She had sexual intercourse in the last month. She has no other conditions that constitute a precaution for using an IUCD. You find her pelvic exam to be normal with the uterus anterior, small, firm, and non-tender. The cervix is parous, non-tender, and normal discharge and ectropian are present. Questions: IUCD 1. Is it appropriate to insert an IUCD in this client today? Discuss the pros and cons. 2. How would your considerations make use of the criteria for breastfeeding as a reliable method of family planning? 3. If you provide Mrs. D. with an IUCD today, what information will you give her? 4. Under what circumstances is it appropriate to proceed with IUCD insertion in a woman who is not currently having, or just completed, her menstrual period? Answers: IUCD 1. It is important that the provider be reasonably certain that the woman is not pregnant. In this example the woman had her baby 8 weeks ago and is fully breastfeeding. She is using LAM that is 98.5% effective. Her pelvic exam is normal. Ectropian is a normal cervical finding. If possible, a pregnancy test could rule out pregnancy. However, if no pregnancy test is available, this woman should be provided with an IUCD because she is using a very effective form of family planning and there are no other precautions. 2. Breastfeeding is a reliable form of contraception if the woman meets three conditions: 1) fully breastfeeding, 2) amenorrhoeic, and 3) less than 6 months since childbirth. 3. Mrs. D. needs to be informed that the copper T 380A IUCD is highly effective and can remain in place for 12 years (recent evidence from WHO shows it to be effective for 12 years). She also needs to know the most common side effects of the IUCD: some cramping and pain for a short time after insertion; heavier, longer menstrual bleeding, and more cramping with the IUCD, which is normal, and usually becomes less in the first and second years. She should be shown how to check the string, and be encouraged to return to the clinic if she has any problem such as: she cannot feel the strings, she experiences severe abdominal pain, she misses her menses, she or her husband feel the tip of the IUCD or she has foul-smelling vaginal discharge or her husband experiences painful urination or penile discharge.
90
4. It is appropriate to insert an IUCD (Copper T 380A) in a woman who is not currently menstruating or just after her menstrual period if you can be reasonably sure she is not pregnant.
91
CASE STUDY: EMERGENCY CONTRACEPTION Scenario: Emergency Contraception Warda is 24 years old. She is a student of medical science and was married about 6 months ago. She had unplanned sexual intercourse last night, and has come to you seeking advice about emergency contraception. Questions: Emergency Contraception 1. As part of SAHR, what technical information should be provided? 2. What side effects and limitations should be reviewed with the client? Nausea and vomiting are common with COCs and POPs, and cramping is common with IUCDs. 3. What information should be given during client education when providing EC? 4. When using the IUCD, what information should be provided? Answers: Emergency Contraception 1. Answer: There are different methods of emergency contraception available, for example: Combined oral contraceptives (COCs)low-dose (3035 g ethinyl estradiol and 150 g Levonorgestrel [LNG]) Progestin-only pills (POPs)750 g LNG (preferred) IUCDsCopper T 380A or Multiload 375 These methods have enormous potential for use as safe and effective post-coital contraceptives. Emergency contraception does not cause abortion. 2. Answer: EC pills do not provide future protection. EC pills will not cause menses to come immediately. Once the above information is given, the provider should counsel client to use regular contraceptive methods.
3. Answer: The provider should give the client the following information: COCs and POPs are effective as EC only if used within 120 hours of unprotected intercourse. They may cause nausea and vomiting, which are short-term side effects. They have a success rate of 98% when used correctly. Instructions to use the POP method of EC:
92
Step 1: Take 1 tablet (750 g of LNG) orally within 120 hours of unprotected intercourse. Step 2: Take 1 more tablet in 12 hours. (Total = 2 tablets). Step 3: If no menses within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.
The provider should give the client the following information: As the name emergency contraception suggests, these methods are to be used only in an emergency situation. They are not suitable for regular use and should not be a persons routine method of contraception. The client should be counselled to use a regular method of contraception on an ongoing basis.
4. Answer: The provider should give the client the following information: IUCDs are very effective, with a failure rate of less than 1%. They have no adverse foetal effects (although the IUCD should be removed if pregnancy is not prevented). They act by:

Preventing fertilization by interfering with sperm transport or function; or Preventing implantation by altering the tubal or endometrial environment.
Instructions to use the IUCD method of EC:

Step 1: Insert IUCD within 5 days of unprotected intercourse. Step 2: If no menses within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.
93
ROLE PLAYS
ROLE PLAY: COMMUNICATING ABOUT FAMILY PLANNING CHOICES Directions In the small groups, someone will play the role of a skilled provider and a client seeking a family planning method, and the others in the group will check on the counselling checklist. If a step is missed, then the checker will advise the participant playing the health worker about the missed step. If time allows, encourage the students to switch roles so that everyone has a turn to perform the various roles. Then ask two students to perform the role play in front of the all of the students. The purpose of the role play is to provide an opportunity for students to appreciate the importance of good interpersonal communication skills when providing counselling for a woman who is seeking a family planning method. Ask the questions after the role play to all of the students to see if the skilled provider counselled the client. Participant Roles Clinician: The provider is an experienced community provider at the basic health centre who has good communication skills. Client: Mrs. A. is a 24-year-old mother; she has 2 children, an 11-month-old and a 2-year-old. She is still breastfeeding. She would like to delay having another child for 2 or 3 years. Situation Mrs. A. has come to the health centre to get information about family planning methods. Some of her friends have had the shot. She is interested in learning more about the shot. Her husband has agreed to her trying a family planning method, but he does not want to use condoms. She is nervous about the safety of family planning; she has heard that it can make it impossible to have more children. Focus of the Role Play The focus of the role-play is the interaction between the provider and Mrs. A. The provider should target counselling and education based on the clients method of interest and assess if she is a good candidate for the method. The provider should demonstrate good communication skills and efficient counselling. Discussion Questions 1. Did the provider target the education and counselling based on the clients method of interest? 2. Did the provider give Mrs. A. all of the information that she needed to make the best decision for herself? 3. How did Mrs. A. respond to the provider?
94
4. What did the provider do to demonstrate emotional support and reassurance during her interaction with Mrs. A? 5. What could the provider do to improve her interaction with a client?
95
ROLE PLAY: COUNSELLING THE POSTPARTUM WOMAN ON LAM BREASTFEEDING AND TRANSITION TO ANOTHER MODERN METHOD OF FAMILY PLANNINGANSWER KEY Participant Roles Clinician: The family planning health care provider is a doctor or provider who has good experience in counselling and communication. Client: Mrs. B. is a 25-year-old woman. She has two children and gave birth to her second child 3 months ago. During the delivery she had pre-eclampsia. She breastfeeds her baby and does not want to take any medication for family planning while her baby is small. She had to take medicine for a day or two after she had her baby and she was concerned about the medicine going to her milk. Situation Mrs. B. has come to clinic for family planning counselling. She and her husband do not want to use hormonal method while the baby is getting only breast milk. She and her husband want to have more children but they are undecided when to have their next. Focus of the Role Play The focus of this role-play is on the action and reaction of the health care provider and the woman. The woman should be supported in her desire to delay the next pregnancy, and it should be acknowledged that breastfeeding can be an effective method for a limited period. At the same time, the health provider should assess the knowledge of the client regarding other family planning methods and assure her of the safety of the advised methods during lactation, and the client should be knowledgeable about the use of various family planning methods. There should be discussion about the three criteria for effective use of breastfeeding for birth spacing and when she should begin another method of family planning in addition to breastfeeding. Note: Other answers may also be valid, as the interaction can include a wide range of discussion points. Breastfeeding for birth spacing is also called the Lactational Amenorrhoea Method (LAM) in the contraceptive literature. LAM can be difficult to understand and to translate. Discussion Questions 1. Did the health care provider give enough information on family planning? 2. Was the health care provider successful in assuring that Mrs. B. would be able to use breastfeeding and name the three criteria of LAM for birth spacing and when to start another method of family planning? 3. Was Mrs. B. able to gain the information completely? 4. In your opinion, what gaps were there in this counselling?
96
Answers 1. The health care provider should introduce her/himself and call her by her name, speak to her in a friendly environment and use simple and understandable words for her. The health care provider should give enough information about family planning methods and describe their advantages and disadvantages, particularly those methods that are compatible with breastfeeding. However, if the woman clearly wants to use breastfeeding, then most of the time should be spent on her chosen method. Too much information on other methods will detract from her ability to fully understand the method she chooses. 2. The health provider should mention the following information to the woman in her conversation: The three criteria for effective use of breastfeeding for birth spacing are: a) Fully breastfeeding (night and day feeds, no supplemental feeding), b) Infant is 6 months or less in age, and c) Amenorrhoea Before the period of lactational amenorrhoea is over, a woman needs to transition to another method such as one of the progestin-only methods (injectables or POPs) or an IUCD. The provider can be reasonably certain that the woman is not pregnant. During the period of LAM, the woman and her partner can decide what method of family planning best suits their needs and start that method before she stops LAM. It is possible to become pregnant before the first menses. The provider should discuss healthy timing and spacing of pregnancies since Mrs. B. is uncertain about when she should have another pregnancy. The provider should also discuss return to fertility, which may occur prior to the onset of menses, when she begins to offer her baby food other than breast milk or when her baby is 6 months. 3. and 4. The health care provider should listen carefully and respectfully and should consider the womans feelings and history. Whenever she asks about family planning methods, the health provider should answer with clear and concise information. A friendly interaction will help the woman to ask all the questions she has and to receive information that will help her be an effective user. In your discussion of this case, note the rapport between the woman and her health provider, if the proper information was presented by the health provider, and how responsive the health care provider is to the womans concerns.
97
ROLE PLAY: PRACTICING COUNSELLING (SAHR) TECHNIQUES Directions Two students in each group will assume (or be assigned) roles, as shown in Participant Roles. One will be the clinician, the other the client. Students taking part in the role play should spend a few minutes reading the background information (Participant Roles and Situation) and preparing for the exercise. The observers in the group also should read the background information so that they can participate in the small group discussion following the role play. Focus of the Role Play and Observer Discussion Questions can be used to guide or generate this discussion. Participant Roles (Young, married female seeking family planning) Provider: The provider should demonstrate effective counselling targeted to the clients method of interest. The provider should help the client make a voluntarily and informed decision. Client: Client C. is a 16-year-old girl. She was married at the age of 13 years and now has two sons. The youngest child is 6 months old. She and her husband have tried to use condoms, but the husband doesnt like them and they really dont know how to use them. Situation Client C. now comes to the clinic looking for another family planning method because she is afraid of getting pregnant. Several of her friends are using oral contraceptives and they havent gotten pregnant yet. She thinks pills would be good for her too, but she is nervous and ill at ease. Focus of the Role Play The focus of the role play is on the interaction between the provider and the client. The provider should demonstrate efficient counselling based on the clients method of interest. Observer Discussion Questions 1. How did the service provider approach the client? 2. How did the client respond to the service provider? 3. Did the service provider help the client to make the best decision for her? Did she provide the client with all of the information she needed? 4. How might the service provider improve her interaction with the client?
98
ROLE PLAY: COMBINED ORAL CONTRACEPTION (COCS) Participant Roles Provider: The clinician is an experienced family planning provider who is skilled in counselling. Client: Client A. is 31 years old and began taking COCs after the birth of her fifth child 2 years ago. At that time, she was screened for medical conditions that might be a precaution for COC use, but none were found. She has had no problems with COCs, once she got over the initial nausea and breast tenderness. She has had to take a job to contribute to the household income. Because of the job and work at home, she has never gotten more than 4 hours of sleep on any night for the last 4 months. Situation Client A. has now returned to the clinic complaining of headaches that she believes are caused by the COCs. She is very nervous. Her mother-in-law told her about someone who died after using COCs for years and suffering bad headaches, because the COCs caused something in her head to burst. Focus of the Role Play The focus of the role play is on the interaction between the clinician and the client. The clinician needs to assess the extent of the clients headaches and their possible relationship with COCs. She needs to counsel and reassure the client and recommend a plan of management. The client should remain adamant in her belief that the COCs are causing her headaches until the clinician provides her with the information and management plan that will calm her concerns. Observer Discussion Questions 1. How did the clinician approach the client? 2. How did the client respond to the clinician? Did the clinician change her approach based on this response? If so, was it appropriate? 3. Did the clinician accurately assess the relationship between the headaches and the COCs? Did she outline an appropriate management plan? 4. How might the clinician improve her interaction with the client?
99
ROLE PLAY: DEPO-PROVERA COUNSELLING: SIDE EFFECTS Participant Roles Provider: The clinician is an experienced family planning service provider. She/he is calm and knowledgeable when counselling clients. Client: Client E. is a 29-year-old woman with six children. She has been using Depo-Provera since 6 weeks after the birth of her youngest child, 2 years ago. She says that she had trouble breastfeeding her child because of the Depo-Provera. She kept taking the DepoProvera, however, because she was more concerned about another pregnancy than about her problems with breastfeeding. Situation Client E. has come to the clinic complaining of feeling very tired and unable to do her work for the past several months. She is sure it is because she has been taking Depo-Provera for such a long time. She thinks it would be a good idea to take a rest period from Depo-Provera. Focus of the Role Play The focus of the role play is on the interaction between the clinician and the client. The clinician needs to assess the relationship between the clients problems and her use of Depo-Provera. She/he also needs to counsel and reassure the client regarding her misconceptions about DepoProvera. The client should remain firm in her wish to take a rest from Depo-Provera until the clinician provides her with the information that will calm her fears and concerns. Observer Discussion Questions 1. What were strengths and weakness of the interaction? 2. How might the service provider improve her interaction with the client? 3. Are the clients past or present problems related to her use of Depo-Provera? Did the service provider explain this in an appropriate and convincing manner? 4. What might be better or alternative contraceptive choices for her? Why?
100
ROLE PLAY: VOLUNTARY SURGICAL CONTRACEPTION-TUBAL LIGATION Students Roles Provider: The provider has basic knowledge about family planning and counselling. Client: Client B. is 34 years old and has five living children. She has also had two abortions and one baby that died in infancy. Her last pregnancy, 3 years ago, was extremely difficult and both she and the baby almost died during delivery. The doctors have told her that it would be very dangerous for her to get pregnant again. Situation The client and her husband agree that sterilization is a good option for them, but are unsure which of them should be sterilized. They have come to the clinic today to get more information so that they can make a decision as soon as possible. The client is worried that if she is sterilized she will become fat and lazy and unable to care for all of her children. Her husband has heard that vasectomy will make him weak and unable to work in the fields or support his family. Focus of the Role Play The focus of the role play is on the interaction between the provider and the clients. The provider needs to provide information on tubal occlusion and vasectomy that will address the clients misconceptions and assist them in making a decision. The discussion should continue until a decision is reached. Observer Discussion Questions 1. How did the provider approach the clients? 2. How did he access the current situation? 3. How did the provider help the couple in reaching a decision?
101
ROLE PLAY: VOLUNTARY SURGICAL CONTRACEPTIONVASECTOMY Participant Roles Provider: The clinician is an experienced family planning service provider. He is calm and knowledgeable when counselling clients. Client: Client D. is a 38-year-old man with five children: three sons and two daughters. Because he and his wife have limited resources, he is certain that it would be very difficult for them to raise any more children. He plans to be sterilized. Situation Client D. has now come to the clinic to get more information on sterilization. He says that he does not want to have any more children, and repeatedly asks about the permanent nature of sterilization. Focus of the Role Play The focus of the role play is on the interaction between the clinician and the client. The clinician needs to assess the clients understanding of vasectomy. The clinician needs to give the client the information he needs in an impartial manner. He needs to pay particular attention about the permanence of vasectomy and what this implies. Observer Discussion Questions 1. How did the clinician approach the client? 2. How did the client respond to the clinician? 3. How might the clinician improve her interaction with the client? 4. Was the decision reached an appropriate one? If yes, why? If not, what would have been better?
102
SKILL DEVELOPMENT
CHECKLISTS Checklist for Breast Examinations
Place a in case box if step/task is performed satisfactorily, and 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 or skill not performed by participant during evaluation by clinical trainer CHECKLIST FOR BREAST EXAMINATIONS STEP/TASK GETTING READY 1. Greets the woman respectfully and with kindness. 2. Tells the woman you are going to examine her breasts. 3. Asks the woman to undress from her waist up. Has her sit on the examining table with her arms at her sides. 4. Washes hands thoroughly and dry them. If necessary, puts on new examination or high-level disinfected surgical gloves on both hands. SKILL/ACTIVITY PERFORMED SATISFACTORILY BREAST EXAMINATION 1. Looks at the breasts and note any differences in: Shape Size Nipple or skin puckering Dimpling Checks for swelling, increased warmth, or tenderness in either breast. 2. Looks at the nipples and note size, shape and direction in which they point. Checks for rashes or sores and nipple discharge. 3. Looks at breasts while woman has hands over her head and presses her hands on her hips. Checks to see if breasts hang evenly. 4. Has her lie down on the examining table. 5. Looks at the left breast and notes any differences from the right breast. 6. Places pillow under womans left shoulder and places her arm over her head. 7. Palpates the entire breast using the spiral technique. Notes any lumps or tenderness. 8. Squeezes the nipple gently and notes any discharge. 9. Repeats these steps for the right breast. If necessary, repeats this procedure with the woman sitting up and with her arms at her sides. 10. Has the woman sit up and raise her arm. Palpates the tail of the breast and checks for enlarged lymph nodes or tenderness. 11. Repeats this procedure for the right side. Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide CASES
105
CHECKLIST FOR BREAST EXAMINATIONS STEP/TASK 12. After completing the examination, has woman cover herself. Explains any abnormal findings and what needs to be done. If the examination is normal, tells the woman everything is normal and healthy and when she should return for a repeat examination. 13. Shows the woman how to perform a breast self-examination. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
106
Checklist for Pelvic Examinations

Place a in case box if step/task is performed satisfactorily, and 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 or skill not performed by participant during evaluation by clinical trainer CHECKLIST FOR PELVIC EXAMINATIONS STEP/TASK GETTING READY 1. Explains why the examination is being done and describes the steps in the examination. 2. Asks the woman to empty her bladder and wash and rinse her abdominal and genital area. 3. Checks that the instruments and supplies are available. 4. Asks the woman to undress and helps her onto the examining table. 5. Washes hands thoroughly with soap and water and dries them. SKILL/ACTIVITY PERFORMED SATISFACTORILY LOWER ABDOMINAL AND GROIN EXAMINATION 1. Asks the woman to lie down on the examining table. 2. Looks at the abdomen for abnormal colouring, scars, stretch marks, or rashes and lesions. 3. Palpates all areas of the abdomen using a light pressure. Then, palpates the abdomen using a deeper pressure. 4. Identifies any tender areas and checks for rebound tenderness. 5. Puts new examination or high-level disinfected surgical gloves on both hands if sores are present on groin. Palpates both groin areas for bumps, buboes, or swelling. SKILL/ACTIVITY PERFORMED SATISFACTORILY EXTERNAL GENITAL EXAMINATION 1. Positions and drapes woman. 2. Washes hands thoroughly and dries them. Puts new examination or high-level disinfected surgical gloves on both hands. 3. Inspects external labia, clitoris, and perineum. 4. Checks the labia minora, clitoris, urethral opening, and vaginal opening. 5. Checks the Skenes glands and urethra and takes smears, if discharge is present. 6. Checks the Bartholins glands and takes smears, if discharge is present. 7. Asks the woman to bear down while holding the labia open. Checks for any bulging of the anterior or posterior vaginal walls. 8. Looks at the perineum. SKILL/ACTIVITY PERFORMED SATISFACTORILY Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide CASES
107
CHECKLIST FOR PELVIC EXAMINATIONS STEP/TASK SPECULUM EXAMINATION 1. Inserts the speculum fully and opens the blades. Looks at the vaginal walls and notes any inflammation, ulcers, or sores. Checks for any discharge. 2. Looks at the cervix and os and notes the colour, position, smoothness, or discharge. If the cervix bleeds easily or there is mucopus, obtains a specimen for tests. 3. Removes the speculum and places in 0.5% chlorine solution for decontamination. SKILL/ACTIVITY PERFORMED SATISFACTORILY BIMANUAL EXAMINATION 1. Separates the labia with two fingers of the abdominal hand and inserts the tips of the index and middle fingers of the pelvic hand into the vagina. 2. Gradually inserts fingers fully or until the cervix is touched. 3. Palpates the uterus and checks for: Size Shape Location Consistency Mobility Tenderness 4. Locates ovaries and determines size and consistency. 5. Checks the size, shape consistency, mobility, and tenderness of any masses in the adnexa. SKILL/ACTIVITY PERFORMED SATISFACTORILY RECTOVAGINAL EXAMINATION 1. If changing gloves, immerses both hands in 0.5% chlorine solution, then removes them by turning them inside out. If disposing of gloves, places them in a leakproof container. If reusing the gloves, submerges them in 0.5% chlorine solution for decontamination. 2. Slowly inserts middle finger of the pelvic into the rectum and index finger into the vagina. 3. Checks for tenderness or masses between the uterus and rectum. 4. Immerses both gloved hands in 0.5% chlorine solution, removes gloves by turning them inside out and disposes of them in a leakproof container. SKILL/ACTIVITY PERFORMED SATISFACTORILY COMPLETING THE PELVIC EXAMINATION 1. If rectovaginal examination was not performed, immerses both gloved hands in 0.5% chlorine solution, then removes gloves by turning them inside out. If disposing of gloves, places them in a leakproof container. If reusing the gloves, submerges them in 0.5% chlorine solution for decontamination. 2. Washes hands thoroughly and dry them. 3. Helps the woman to sit up on the examining table and asks her to get dressed. Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide CASES
108
CHECKLIST FOR PELVIC EXAMINATIONS STEP/TASK 4. Discusses any abnormal findings and what, if anything, she needs to do. If the examination was normal, tells her that everything is normal and healthy. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
109
Checklist for Family Planning Counselling

Place a in case box if step/task is performed satisfactorily, an 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 teacher
Participant
Date observed CHECKLIST FOR FAMILY PLANNING COUNSELLING (Some of the following steps/tasks should be performed simultaneously) STEP/TASK CASES
PREPARATION FOR COUNSELLING 1. Ensures room is well lit and ventilated. 2. Ensures availability of chairs and table. 3. Prepares equipment and supplies. 4. Ensures availability of writing materials (e.g., client file, daily activity register, follow-up cards). 5. Ensures privacy. SKILL/ACTIVITY PERFORMED SATISFACTORILY GENERAL COUNSELLING SKILLS 1. Greets the woman with respect and kindness. Introduces self. 2. Confirms womans name, address, and other required information. 3. Offers the woman a place to sit. Ensures her comfort. 4. Reassures the woman that the information in the counselling session is confidential. 5. Tells the woman what is going to be done and encourages questions. Responds to the womans questions/concerns. 6. Gives a brief description of the family planning methods available, asks the woman if theres a specific method she is interested in. 7. Uses body language to show interest in and concern for the woman. 8. Asks questions appropriately and with respect. Elicits more than yes and no answers. 9. Uses language that the woman can understand. 10. Appropriately uses visual aids, such as posters, flipcharts, drawings, samples of methods, and anatomic models. 11. Asks the woman to repeat what she has learned to be sure that she has understood the information provided. SKILL/ACTIVITY PERFORMED SATISFACTORILY
110
CHECKLIST FOR FAMILY PLANNING COUNSELLING (Some of the following steps/tasks should be performed simultaneously) STEP/TASK SPECIFIC FAMILY PLANNING COUNSELLING 1. Asks the woman what she knows about family planning and if she has ever used a contraceptive method before; if yes: What methods did she use? Did she have any problems with that method or does she have any questions or concerns about that method? 2. Asks the woman about her reproductive goals. 3. Assesses the womans risk for STIs and HIV/AIDS, as appropriate. 4. Briefly provides general information about each contraceptive method available: How it prevents pregnancy How it is administered Effectiveness Advantages and disadvantages Side effects Need for protection against STIs including HIV/AIDS 5. Clarifies any misinformation the woman may have about family planning methods. 6. Asks which method interests the woman. Helps the woman chose a method. SKILL/ACTIVITY PERFORMED SATISFACTORILY METHOD-SPECIFIC COUNSELLINGONCE THE WOMAN HAS CHOSEN A METHOD OR HAS IDENTIFIED A METHOD OF INTEREST 1. Using the language the woman will understand, takes a reproductive and basic medical history. 2. Performs a physical assessment that is appropriate for the method chosen, and if indicated, refers the woman for evaluation. 3. Ensures there are no conditions that contraindicate the use of the chosen method. If necessary, helps the woman to find a more suitable method. 4. Briefly, giving only the most important information, tells the woman about the family planning method she has chosen: Type How it works Effectiveness Advantages and non-contraceptive benefits Disadvantages Contraindications Common side effects Protection against STIs, HIV/AIDS 5. Provides the method of choice if available or refers woman to the nearest health facility where it is available. 6. Gives the woman instructions about her chosen method of contraception: How to use the method of contraception. Side effects. Tell her to return to the clinic if she has any problems. Any other relevant information. CASES
111
CHECKLIST FOR FAMILY PLANNING COUNSELLING (Some of the following steps/tasks should be performed simultaneously) STEP/TASK 7. Educates the woman about prevention of STIs and HIV/AIDS if she is at risk. If necessary provides her with condoms, instructions on how to use them, and where to obtain them. 8. Encourages the woman to repeat the instructions to be sure she understands. 9. Asks if the woman has any questions or concerns. Listens attentively, addresses her questions and concerns. 10. Schedules the follow-up visit. Encourages the woman to return to the clinic at any time if necessary. 11. Records the relevant information in the womans chart. 12. Thanks the woman, politely says goodbye and encourages her to return to the clinic if she has any questions or concerns. SKILL/ACTIVITY PERFORMED SATISFACTORILY FOLLOW-UP COUNSELLING 1. Greets the woman with respect and kindness. Introduces self. 2. Confirms the womans name, address, and other required information. 3. Asks the woman the purpose of her visit. 4. Reviews her record/chart. 5. Checks whether the woman is satisfied with her family planning method and is still using it. Asks if she has any questions, concerns, or problems with the method. 6. Explores changes in the womans health status or lifestyle that may mean she needs a different family planning method. 7. Reassures the woman about side effects she is having and treats them if necessary. 8. Asks the woman if she has any questions. Listens to her attentively and responds to her questions or concerns. 9. Performs any necessary physical assessment. 10. If necessary, provides the woman with her contraceptive method (e.g., the pill, injectables, condoms, etc.). 11. Schedules return visit as necessary. 12. Records relevant information in the womans chart. 13. Thanks her, politely says goodbye and encourages her to return as needed. CASES
112
Checklist for Family Planning CounsellingSAHR Approach

Place a in the YES or NO observation box if the step is performed or not. OBSERVATIONS YES COMMUNICATION AND COUNSELLING SKILLS SALUTATION 1. Greets the client and introduces self. 2. Assures the client of confidentiality. ASSESS 1. Asks the client why she or he has come to the clinic. 2. Obtains medical history: Diabetes Jaundice Heart disease 3. Obtains obstetrical history: Number of pregnancies Date and type of last childbirth Last menstrual period (LMP) 4. Assesses the clients risk of contracting an STI and HIV infection by asking the following questions (if indicated): Spouses occupation Multiple partners (client or partner) Past STIs (client or partner) 5. Asks the client about her reproductive needs (short-term, longterm, or permanent). 6. Assesses what the client knows about family planning methods. 7. Asks client what method she or he is interested in. HELP 1. Correct rumours and misinformation. 2. Helps inform the client about the methods available, based on the clients previous knowledge of family planning, including: Mode of action Advantages Disadvantages Side effects Protection against STIs and HIV infection 3. Helps the client make a decision by focusing on the advantages and potential side effects of the method she/he is considering. 4. If the client is a return visit client, assesses for changes in her/his reproductive needs. 5. Explains to the client how to use the method. 6. Explains the warning signs. NO
STEP/TASK
113
STEP/TASK REASSURANCE 1. Reassures the client about any minor side effects she/he may have. 2. Ensures that the client understands instructions for use. 3. Discusses return visit(s) and follow-up with the client: Early identification of problems When to return to the health facility for follow-up 4. Encourages the client to return at any time if she/he has a question or problem. 5. Politely says goodbye to the client and invites her/him to return again.
OBSERVATIONS
114
Checklist for Postpartum Family Planning Counselling On the Ward

Place a in case box if step/task is performed satisfactorily, an 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 teacher
Participant
Date observed
CHECKLIST FOR POSTPARTUM FAMILY PLANNING COUNSELLING-ON THE WARD (Some of the following steps/tasks should be performed simultaneously) STEP/TASK GENERAL COUNSELLING SKILLS 1. Greets the woman with respect and kindness. Introduces self. SKILL/ACTIVITY PERFORMED SATISFACTORILY SPECIFIC FAMILY PLANNING COUNSELLING CONTENT 1. Asks the woman if she is breastfeeding and offers help to get her started. Discusses benefits for the baby once baby is attached to the breast. Discusses that exclusive breastfeeding also offers 98% protection against pregnancy. 2. Discusses the 3 criteria: Exclusive breastfeeding, no menses, and the baby is less than 6 months. 3. Asks the woman if she and her husband plan to have more children. 4. Asks the woman when she and her husband would like to have more children (if applicable). Tells the woman the benefit of healthy spacing of pregnancy (if applicable). 5. Tells the woman the risk of another pregnancy before the return of her menses if she is not fully breastfeeding her baby. 6. Tells her that there are methods of contraception that are available that will not affect the quantity or quality of her breast milk such as progestin-only pills, injectables, the IUCD, or condoms. 7. Reminds the client that withdrawal is not vey effective; 25 women in 100 will become pregnant! 8. Asks her of she would like any information about these methods. 9. Leaves the client information sheet and invites her to participate in the postpartum education session. 10. Thanks the woman and encourages her to see her obstetrician at 6 weeks to discuss contraception, or earlier if she is not breastfeeding. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
115
Checklist for LAM Counselling for Birth Spacing Introduction: Use these in order to get support and guidance to accomplish the learning objectives.
Instructions: Place a in the box beside each step/task that is accomplished. Place a NA in the box for each step/task that is not applicable/relevant to the specific client encounter. Leave box blank if task/step was appropriate but not completed. STEPS/TASKS 1. Greets the client respectfully and with kindness. Introduces herself. 2. Asks the client what services she is seeking. 3. Listens to the woman attentively, and responds to her questions and concerns. 4. Assures confidentiality and maintains privacy. 5. Respects the clients rights and allows her to make an informed decision. 6. Asks the client if and when she plans to have another baby. 7. Asks about previous contraceptive use. 8. Discusses return to fertility. If not lactating, first ovulation occurs on average 45 days postpartum. In breastfeeding women not using LAM, two-thirds ovulate before their first menses. 9. Discusses benefits of waiting at least 2 years to become pregnant again. 10. Asks woman if she is breastfeeding. If she is not, discusses contraceptive options other than LAM: Discusses advantages and limitations of each available method. Helps client decide which option is best for her. 11. Provides or refers for contraceptive method, along with instructions on management of possible side effects. 12. If woman is breastfeeding but does not choose to use LAM, advises the woman: That breastfeeding will not protect her from pregnancy. Regarding methods that are compatible with BF and the womans medical history. That breast milk gives her baby all the nutrition it needs for the first 6 months. 13. Counsels client concerning STI/HIV history, sexual behaviour and reduction of risks. 14. Ensures that woman/couple knows when and where to return if complication or other problem develops. 15. If woman is breastfeeding and is interested in using LAM, provides the related information. 16. Determines whether she meets all the three LAM criteria: Her menstrual bleeding has not returned since the birth of her baby. She only breastfeeds her baby. Her baby is less than 6 months old. 17. Explains that if she breastfeeds exclusively and her period have not returned, she is practicing contraception that is more than 98% effective until the baby turns 6 months old.
116
STEPS/TASKS 18. Gives the client advice on how to maintain exclusive breastfeeding: Breastfeed as often as your baby wants, day and night. Continue to breastfeed even when you or your baby is sick. Do not give your baby any foods, water or other liquids before 6 months of age. Breast milk gives your baby everything she/he needs to be healthy. Do not use bottles, pacifiers, or other artificial nipples. These discourage your baby from breastfeeding as frequently. 19. Discusses the importance of transitioning to another method immediately if any of the three criteria is not met. 20. Discusses the method of family planning she would like to use when no longer using LAM. 21. Discusses the importance of continuing to breastfeed after LAM criteria are not met and she is using another method of contraception. Includes discussion of appropriate methods for the breastfeeding mother. 22. Advises the woman to return to the clinic for a family planning method when LAM is no longer met. Gives client educational material.
117
Checklist for Injectables Clinical Skills

Place a in the YES or NO observation box if the step is performed or not. OBSERVATIONS YES GETTING READY 1. Checks expiration date on injectables single-dose vial. 2. Ensures arm or buttocks are clean for giving IM injection. PREPARING THE INJECTION SITE 1. Washes hands with soap and water and dries them with a clean, dry towel or air dries. 2. Checks that injection site is clean. 3. If a single-use cotton swab is used to prepare the skin, allows skin to dry before giving the injection. PREPARING THE INJECTION 1. Shakes the vial of injectables thoroughly before withdrawing the dose. 2. Attaches and tighten the needle to the syringe. 3. Inserts the needle through the rubber stopper. 4. Draws up complete contents of the injectables vial. 5. Removes the needle from the vial. 6. Expels any air bubbles by gently depressing the plunger. 7. Carefully pushes the plunger to the dose mark 1.0 mL. GIVING THE INJECTION 1. Inserts the needle deep into the muscle (deltoid in arm or upper outer quadrant of gluteal area). 2. Injects the full dose slowly and removes the needle. POST-INJECTION TASK 1. Applies pressure to injection site with cotton, but does not rub. 2. Discards needle and syringe in a puncture-proof container without recapping or breaking or bending the needle. 3. Washes hand with soap and water and dries them on a clean towel or air-dries. NO
STEP/TASK
118
Checklist for IUCD Counselling Skills

Rate the performance of each step or task observed using the following rating scale: 1. Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted 2. Competently Performed: Step or task performed correctly in proper sequence (if necessary) but participant does not progress from step to step efficiently 3. Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary)
CHECKLIST FOR IUCD COUNSELLING SKILLS STEP/TASK COUNSELLING (INSERTION) GREET THE CLIENT 1. Greets client respectfully and with kindness. Assures necessary privacy. SKILL/ACTIVITY PERFORMED SATISFACTORILY ASK FOR INFORMATION 1. Asks for biographical information and documents it. 2. Asks the purpose of the visit and answers questions. Asks the woman which method she is interested in. 3. Asks the woman about her reproductive goals and obtains basic medical information. 4. Asks her about previous methods used and experiences. SKILL/ACTIVITY PERFORMED SATISFACTORILY TELL THE WOMAN ABOUT APPROPRIATE METHODS 1. Tells the woman about the contraceptives method she is interested in or methods that may be appropriate based on information gathered: Explains how the method works and its effectiveness. Explains advantages and most common side effects. Explains possible problems or risks. Tells her what to expect during the clinic visit. 2. Provides a sample method for her to handle. 3. Provides brochures or printed information for client. Help the Woman Select a Method 4. If not covered well earlier, helps the woman select a method by telling her the advantages and disadvantages, possible side effects, and problems. 5. Helps her choose a method based on her method of interest, reproductive goals, medical history, and other attitudes or wishes expressed. 6. Asks about her need for dual protection from sexually transmitted infections. CASES
119
CHECKLIST FOR IUCD COUNSELLING SKILLS STEP/TASK 7. Helps the client choose a method by screening her further when indicated. If IUCD selected, sees screening section in IUCD clinical skills checklist. CASES
120
CHECKLIST FOR IUCD COUNSELLING SKILLS STEP/TASK Explain How to Use the Method 8. Tells the client how to use the method, including warning signs. 9. Tells the client when to return to the clinic. 10. Encourages her to ask questions. Refer the Client 11. Tells client when to return to the clinic. 12. Tells the woman what to do if she has questions or problems. 13. Refers the woman to other clinics if you cannot provide follow up care. If the Client Chooses an IUCD 14. Screens the client carefully to make sure there is no medical condition that would be a problem. 15. Explains potential side effects and makes sure that each is fully understood. Stresses that most can be managed and makes sure she knows how to contact you if she has problems. Pre-insertion Counselling (Examination/Procedure Area) 16. Informs the client about required physical and pelvic examinations. 17. Describes the insertion procedure and what she should expect during the insertion and afterwards. Post-insertion Education 18. Reminds the client what type of IUCD she has and that it lasts 10 years. 19. Provides a client follow-up card and informs the client when to return for the follow-up visit. 20. Reminds the client of warning signs: PAINS (Period late or heavy, Abdominal pain, signs of Infection, Not feeling well, String changes or problems). 21. Reviews common side effects (menstrual changes) or problems and what to do if they occur. 22. Reminds client of need to use condoms in addition if she is at risk of sexually transmitted infections. 23. Assures the client she can return to the same clinic to receive advice or medical attention and, if desired, to have the IUCD removed. 24. Asks the client to repeat the instructions. 25. Answers the clients questions. 26. Observes the client for at least 15 to 20 minutes and asks how she feels before sending her home. SKILL/ACTIVITY PERFORMED SATISFACTORILY COUNSELLING (REMOVAL) 1. Greets the client respectfully and with kindness. 2. Establishes the purpose of visit and answer any questions. 3. Asks the client her reason for removal and answer any questions. CASES
121
CHECKLIST FOR IUCD COUNSELLING SKILLS STEP/TASK 4. Asks client about her reproductive goals (Does she want to continue spacing or limiting births?) and need for protection against GTIs and other STIs. 5. Describes the removal procedure and what she should expect during the removal and afterwards. 6. Discusses what to do if the client experiences any problems (e.g., prolonged bleeding or abdominal or pelvic pain). 7. Asks the client to repeat instructions. 8. Answers any questions. 9. If the client wants to continue spacing or limiting births using another method, reviews general and method-specific information about family planning methods that she is interested in. 10. Helps client obtain new contraceptive method or provides temporary (barrier) method until method of choice can be started. 11. Observes client for at least 15 to 20 minutes and ask how she feels before sending her home. SKILL/ACTIVITY PERFORMED SATISFACTORILY CASES
122
ASSESSMENT TOOLS
LOGBOOK SAMPLE
Skill Competency Tracking Sheet for Providers To be used by the clinical instructor (CI) in tracking skill development of each student in the course
D/O = Demonstration/Observer
S. NO 1 2 3 6 7 CLINICAL SKILL Birth spacing counselling Postpartum birth spacing counselling Perform breast examination Perform PV examination Universal Standard IP Practice
PS = Performed Under Supervision

D/O PS A PC D/O PS A PC D/O
A = Assistant
PS A PC
PC = Performed Competency
FINAL ASSESSMENT
125
QUESTION BANK
Instructions: Use questions to create additional exercises, create quizzes, or use to develop final examinations. Government of Pakistan Family Planning Policy 1. Incentives like financial benefits should be given to an individual for accepting family planning use. 2. The client of VSC should be provided transportation, food during the stay, medicines related to the procedure, and value of lost work. General Family Planning Services Questions 1. The health care provider should prescribe family planning method as per his/her best judgement. 2. Pregnancy before the age of 18 years has no adverse effects on the clients health. 3. Recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the health risks to mother and the child. 4. Vasectomy is effective immediately after the surgery. 5. It is preferable to lubricate condoms before use. 6. Condoms protect from sexually transmitted infections. 7. Family planning saves lives by reducing the risk of death related to a) Girls who are not fully mature and become pregnant b) Unsafe abortions c) Pregnancies that are spaced 2 years or less apart d) All of the above 8. Family planning improves the health of mothers and children because a) It helps young married girls attain full growth by delaying pregnancy until after 18 years of age b) It decreases the risk of having a low birth weight baby c) Spacing pregnancies allows more time for the mother to take care of the youngest baby and allows the mother to breastfeed her last infant for up to 2 years d) All of the above T T T T T T F F F F F F T F
126
9. Women should have access to family planning services because a) Family planning is a basic human right b) Family planning helps women control their fertility c) Controlling fertility widens opportunities for employment outside the home d) All of the above Counselling and Assessment 1. The best way to correct a family planning rumour is to ignore it. 2. If a woman is interested in a specific method, you target counselling to that specific method. 3. The womans spouse should always be present during family planning counselling. 4. It is not necessary to take the clients history before providing a contraceptive method. 5. During assessment of a family planning client, pregnancy can be ruled out only if a pregnancy test is done. 6. If a client asks me a question about family planning that I dont know, I will a) Go ask a colleague with whom I am working b) Tell her to use another method that is safe and natural c) I will look up the information in the Global Handbook on family planning and other up-to-date evidence-based resources and then inform the client d) Advise her to ask her physician whenever she decides to go back for her postpartum visit 7. During counselling using the GATHER or SAHR method, it is important to: a) Tell the woman about every contraceptive method available b) Find out which method the woman is interested in c) Tell the woman not to worry about side effects d) Choose a method for the woman based on information gathered 8. The most important part of counselling is: a) Providing brochures about contraceptive methods to the woman for review with her partner b) Identifying the womans concerns about using contraceptives and answering her questions c) Obtaining formal consent for the procedure from the client d) Describing adverse side effects to the client T T F F
127
9. Which of the following will make your education or client instructions most useful? a) Keep your messages simple b) Ask her to tell you what she has understood c) Focus education on what she is interested in d) All of the above 10. Counselling for family planning helps clients to a) Initiate use of appropriate contraception b) Use their contraceptive more effectively c) Continue with the current method or change to another method d) All of the above 11. Method-specific counselling involves a) Telling the client which method she should use b) Telling the client which methods are available c) Providing information about the method chosen by the client d) None of the above 12. Client assessment for family planning involves a) Taking a personal, social, and reproductive health history b) Taking a personal, social, reproductive health, and medical history c) Taking a personal, social, reproductive health, family, and contraceptive history, as well as history of STIs d) Taking a personal, social, reproductive health, family, and contraceptive history
13. A reproductive health history involves asking questions about a) Number of children ever born and desire for more children b) If last baby is less than 6 months old and whether breastfeeding fully or nearly fully c) Date of last menstrual period and regularity of bleeding d) All of the above 14. During assessment of a family planning client, pregnancy can be ruled out a) If the woman reports that she has no signs and symptoms of pregnancy b) If the woman reports that she has no signs and symptoms of pregnancy and she has been using a contraceptive correctly and consistently c) If the woman has given birth and is still amenorrhoeic d) Only if a pregnancy test is done
128
WHO Medical Eligibility Criteria 1. When a contraceptive method is safe to use for the client, it will be in the category number 1. 2. When the use of a particular contraceptive is absolutely contraindicated, it will fall in the category number 2. 3. Low-dose combined oral contraceptives can be given to a client with HIV/AIDS. 4. Nulliparous woman can use the IUCD as a method of contraception. 5. Using eligibility criteria following assessment of a family planning client a) Is the same as screening for a specific method b) Contributes to reducing the chances of side effects and complications c) Is necessary only if the client request an oral contraceptive d) All of the above 6. Pelvic examination is a necessary part of assessment a) For all family planning clients b) To determine eligibility for IUCDs c) To determine eligibility for IUCDs and oral contraceptives d) To determine eligibility for IUCDs and injectable contraceptives Oral Contraceptives 1. Combined oral contraceptives are the best method of contraception for a woman who is breastfeeding her infant age 3 months. 2. Oral contraceptive pills are also used as emergency contraception. 3. Combined oral contraceptive pills regularize the menstrual period. 4. Combined oral contraceptive pills have a protective effect on ovarian cancer. 5. COCs decrease menstrual cramps. 6. COCs are the combination of oestrogen and progesterone. 7. The mechanism of action of COCs is to prevent the release of the ovum (or egg). 8. COC pills can be started only during the menstrual period. 9. COCs benefit the breastfeeding mothers by increasing the quantity of milk. 10. Excessive bleeding is the most common side effect experienced by pill users. T T T T T T T T T T F F F F F F F F F F T F
129
11. Combined oral contraception a) Can be taken safely by women who are breastfeeding their newborn who is 3 weeks old b) Increases the risks to the mother, her pregnancy, or baby if she takes them inadvertently during early pregnancy c) Can be given to women only after the health worker takes a careful history, blood pressure, and physical exam inclusive of a pelvic exam and Pap smear d) Can be given to women after the health worker takes a careful history and blood pressure 12. Oral contraceptives are a) Very effective b) Moderately effective c) Not very effective d) More effective than any other contraceptive 13. A disadvantage of oral contraceptives is that they a) Interfere with sexual activity b) Must be taken every day c) Cause prolonged spotting/bleeding d) Cause cramps and increased bleeding during menstruation Postpartum Family Planning Questions 1. Contraception counselling includes: a) Introducing self, providing privacy, and making the client feel comfortable b) Asking the client what her intentions are about having children and benefits of pregnancy spacing c) Asking her if she has any previous experience with contraception, knows what method shed like to use, and any concerns about methods d) All of the above 2. Postabortion clients fertility returns: a) Right after the abortion b) At 6 weeks after the abortion c) After her next menses d) 1114 days after her abortion
130
3. When is an appropriate time or times to counsel clients on postpartum family planning? a) 6 weeks postpartum b) While in the postpartum ward c) Antenatal d) a) and c) e) All of the above 4. Although it is hard to know exactly when a postpartum womans fertility returns, on average, if she is not breastfeeding her fertility returns a) In 3 months b) In 45 days c) Immediately d) After her first menses 5. What is the best contraception for a woman who is 4 months postpartum, only breastfeeding, and her menses has not resumed? a) Condoms b) Combined oral contraception c) Lactational amenorrhoea method d) Withdrawal 6. Contraceptive counselling is important because a) The client will like you b) It increases the chances that she will take the method effectively and continuously c) The client doesnt know what she wants and you must tell her d) You must tell the client about the bad personal experience you had with oral contraception 7. For a woman who is not breastfeeding her baby, she can start a) Oral contraception in 3 weeks b) Injectables before she leaves the hospital c) Condoms as soon as she and her husband are sexually active d) All of the above 8. Postpartum family planning is important because: a) Women are not interested in family planning at that time b) The maternities have limited capacity and unable to accommodate more deliveries c) Can help prevent pregnancies that may occur in the next 24 months and promote healthy spacing of pregnancies d) All of the above
131
9. Healthy Spacing of Pregnancy means a) That couples need to work hard to provide for the next child b) That mothers need to eat well and space their meals to cover all the nutrients c) For the healthiest outcome to mother and baby, couples should wait until their last baby is at least 2 years old before they try to get pregnant again d) All of the above 10. Postpartum counselling involves: a) Discussing lactational amenorrhoea method for breastfeeding women b) Inquiring about what the couples plans are for more children and her return to fertility c) How effective different types of contraceptive methods are, common side effects, and how to use the method d) All of the above LAM and SDM Questions 1. One of the three criteria for effective lactational amenorrhoea method (LAM) is that the mothers menses have not returned. 2. SDM is only effective for women with menstrual cycles between 2632 days. 3. Breastfeeding can be used as an effective contraceptive method for the first year postpartum. 4. A postpartum woman isnt fertile until her menses returns. 5. Lactational amenorrhoea method is a) More than 98% effective b) Not a very good method of contraception and women should be advised to use something in addition to breastfeeding c) Only beneficial to the baby d) A temporary method good for the first 4 months of life 6. Lactational amenorrhoea is 98% effective a) If there is no menses and the baby is fully breastfeeding b) If the woman is less than 6 months postpartum, there is no menses, and the baby is fully breastfeeding c) If the woman is less than 6 months postpartum d) If the woman is less than 12 weeks postpartum T F
132
7. The criteria for LAM are a) Fully or nearly fully breastfeeding, less than 4 months postpartum, menses has not returned, and baby still feeds at least once during the night b) Fully or nearly fully breastfeeding, less than 6 months postpartum, and menses has not returned c) Fully or nearly fully breastfeeding, less than 4 months postpartum, and menses has not returned d) Fully breastfeeding infant who is 6 weeks or less 8. The advantages of lactational amenorrhoea are that a) It is ideal for the health of the infant b) It protects against pregnancy immediately c) There is no hormonal or mechanical intervention involved d) All of the above 9. For lactational amenorrhoea to be successful a) Breastfeeding must be on demand and the interval between feedings should not exceed 4 hours during the day and 6 hours during the night b) Breastfeeding should be at least every 4 hours during the day and at least once during the night c) Breastfeeding should be at least every 6 hours during the day and at least once during the night d) None of the above Emergency Contraception 1. Emergency contraceptive pills (ECPs) are effective if taken within 120 hours of unprotected intercourse. 2. Emergency contraceptive pills should be used if the client forgot to take the oral contraceptive (brown pills) on the 24th day of menstrual cycle. 3. After the use of ECP, the menstrual cycle gets 1 week late. T F
133
Injectables 1. If the client is on injectable contraceptive (3 months), and she comes 1 week later than the scheduled time, she should be given a second injection. 2. Since the women are familiar with injections, they do not need to have counselling. 3. If the patient develops bleeding P/V following contraceptive injection, the next injection should not be given. 4. Changes in bleeding pattern are the major reason for the discontinuation of injectables. 5. Injectable contraceptives prevent pregnancy for 1 year. 6. Inject able contraceptives prevent pregnancy for a) 3 weeks b) 3 months c) 3 years d) 6 months 7. Inject able contraceptives are effective a) Only if taken weekly b) Within 24 hours of having the injection if given in the first 7 days of the menstrual cycle c) Within 48 hours of having the injection d) Within 1 week of having the injection T F
134
IUCD Questions General 1. IUCDs are: a) Safe and effective long-acting method of contraception that can be used by postabortion and postpartum women b) Only appropriate for women who have their desired number of children c) Less effective than combined oral contraception d) Effective for 57 years 2. The IUCD is the best choice for a woman who: a) Has painful menstrual periods b) Has AIDS and is not on antiretroviral therapy c) Has heavy menstrual flow and anaemia d) Wants many years of contraceptive protection 3. Which of the following is TRUE about the IUCD? a) The IUCD itself does not increase the risk of pelvic infections b) An IUCD must be removed if a pelvic infection occurs c) The IUCD prevents pregnancy by causing abortion d) The IUCD may never be used in women who are HIV-positive
Supporting IUCD users 1. The Copper T 380A IUCD is effective for at least: a) 4 years b) 6 years c) 8 years d) 10 years 2. Following the insertion of the IUCD, the woman should return to the clinic: a) After her next period or at least within 3 months b) Every 6 months c) Only if she is having a problem or wants to have it removed d) In 10 years to have it removed or replaced
135
Infection Prevention 1. Decontamination of instruments makes the instruments safer to handle by staff who clean them. 2. Hands should be washed before examining a client. 3. To reduce the risk of infection or injury after giving an injection, the best practice is to remove the needle from the syringe and dispose of it in a puncture-proof sharps-disposal container. 4. Which is the first step in instrument processing and what is its purpose? Answer: Decontaminationto make instruments safe to handle for the person who processes the instruments. 5. Define the no-touch technique. Answer: Ensures that a uterine sound or loaded IUCD does not touch the vaginal wall or the speculum as it passes through the cervical canal. 6. When having an IUCD inserted, the client should put on a clean gowntrue or false? Answer: False. There is no need for a clean gown if the womans clothing is clean. 7. List the two antiseptics that may be used to prepare the cervix prior to IUCD insertion. Answer: An iodophor or chlorhexidine gluconate 8. A tarnished IUCD inside its intact, sterile package is contaminated and should not be used true or false? Answer: False. If a tarnished IUCD is inside its sterile package, and the expiration date has not passed, it can be used. 9. Which is the most important of the standard precaution procedures? Answer: Handwashing 10. What is the key difference between sterilization and high-level disinfection? Answer: Sterilization destroys endospores; high-level disinfection does not. 11. Why is it appropriate to use clean gloves rather than sterile when inserting an IUCD? Answer: Because loading the IUCD in the sterile package and using the no-touch technique prevent infection and make sterile gloves unnecessary. 12. Surgical (metal) instruments that have been decontaminated and thoroughly cleaned can be sterilized by: a) Heat (autoclave or dry heat sterilizer)
T T
F F
136
b) Soaking them for 30 minutes in fresh 1B3% iodine solution c) Boiling them for 20 minutes d) Exposure to ultraviolet light for 1 hour 13. Surgical (metal) instruments used for IUCD insertion, (i.e., the vaginal speculum, uterine sound, and tenaculum) can be safely used if, after thorough cleaning, they are: a) Dried and stored in a sterile container b) High-level disinfected c) Soaked in Savlon or Zephiran for 30 minutes d) Used immediately 14. To make items safer to handle during the cleaning process, instruments and gloves first should be: a) Rinsed in water and scrubbed with a brush before disinfecting by boiling b) Soaked in 0.5% chlorine solution for 10 minutes before cleaning c) Rinsed in water and scrubbed with a brush before sterilizing d) Soaked overnight in 8% formaldehyde 15. Which antiseptic can be safely used for cervical or vaginal preparation? a) Alcohols b) Dilute chlorine solution c) Iodine d) An iodophor
137
138
Objectives
Review the demographics of contraception and birth spacing in Pakistan Describe Healthy Timing and Spacing of Pregnancy (HTSP) Review available methods of contraception in Pakistan Describe global trends in contraceptive technology
Birth Spacing in Pakistan: An Overview
Data and Methodology

200607 Pakistan Demographic and Health Survey (DHS) Sample size (weighted)
Total number of women = 10,023 Number of postpartum women = 2,093
30% 25% 20% 15% 10% 5% 0%
Current Contraceptive Method Use
Traditional Modern
Extended postpartum period defined as:

Up to 12 months post-delivery
All women
N=10,023
Postpartum women
N=2,093
Ever Use and Current Use of Contraceptives Among Postpartum Women

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Ever use
N=2,093
Unmet Need Postpartum
Traditional Modern
Current use
N=2,093
141
Healthy Timing and Spacing of Pregnancy (HTSP)

After a live birth, the recommended minimum interval before attempting the next pregnancy is at least 24 months After a miscarriage or induced abortion, the recommended minimum interval before attempting the next pregnancy is at least six months Delay timing of the first pregnancy in adolescents until age 18 to reduce the risk of adverse maternal, perinatal and infant outcomes
Birth to Pregnancy Intervals and Neonatal and Early Neonatal Mortality

Birth-to-Pregnancy interval of < 24m is associated with higher neonatal and early neonatal mortality
Rutstein SO, 2008, Macro International
Birth to Pregnancy Intervals and Infant and Post Neonatal Mortality

Birth-to-Pregnancy interval of < 24m is associated with higher infant and post neonatal mortality
Benefits of Birth Spacing

For mothers: Women who space births by at least 2 years and three months are more likely to survive childbirth, avoid third-trimester bleeding, and anemia For fathers: Fathers benefit to see their wives healthy and with a greater chance of survival. Fathers also benefit financially as they avoid the unwanted burden of raising a child born from an unintended pregnancy
Rutstein SO, 2008, Macro International
Benefits of WHO Recommended Spacing Interval

For the unborn: Babies spaced at least two years after the birth of the youngest child are less likely to be premature, have low birth weights and more likely to survive than babies spaced by less than two years For the existing children: Chances of survival of the youngest existing child also improves through adequate birth spacing. For example, infant mortality in Pakistan could be reduced almost by halffrom 76 per 1,000 births to 50if all births were spaced by at least by three years.
Government of Pakistan FP Policy: Key Messages

1. Notargetsorquotasforserviceprovidersorreferralagents 2. Nopaymentofincentivesandfinancialrewardstoclientsor programpersonnel 3. Nodenialofrightsorbenefitstopersonswhochoosenotto useFP 4. Comprehensibleinformationonthemethodchosentobe providedtoeachclient 5. Informedvoluntarydecisiontobeensuredforsterilization 6. Nopromotionofabortionservices
12
142
Elements of Family Planning Service Provision

Education why is birth spacing is important and what contraceptive options are available Counseling what are the clients needs and how can they be met Assessment what contraceptive methods are safe for the client Provision of a contraceptive method at the clients re-quest
What are Medical Barriers?

Practices that:
Are derived (at least partly) from a medical rationale Result in impediment or denial of contraception that is not scientifically justifiable
These include eligibility restrictions, process barriers, contraindications and provider limitations/bias
14
Reduce Medical Barriers

Unnecessary barriers to initiation: menstruation Inappropriate contraindications Other client eligibility criteria: age, parity, marital status Inappropriate follow-up schedule: IUCD follow-up every six months Rest periods required: every 23 years for pills Unnecessary procedures required: pelvic examination, pregnancy test Provider bias: DMPA better for thin women
Checklists for Non-Menstruating Clients Can Improve Access

500
NewClientVolume*
400 300 200 7 Checklist Clinics 100 0 7 Control Clinics
15
16
Contraceptive Method Options

Oral contraceptive pills: combined, Progestin-only Injectables: combined, Progestin-only Implants: Progestin-only Intrauterine device (IUD): copper, progestin Female and male sterilization Lactational amenorrhea method (LAM) Fertility awareness-based methods Barrier methods
Woman and couples have a wide range of methods from which to choose.
143
Effectiveness: Perfect vs. Typical

Perfect use: when used perfectly, consistently, and exactly according to directions Typical, common or actual use: when used by an average person who does not always use the method consistently and correctly
Hormonal Methods
Highly effective Appropriate for use in most women Oral, injectables, implants, IUDs: Progestinonly vs Estrogen + Progestin Minor side effects generally abate after a few months Timing of initiation postpartum depends on breastfeeding status
COCs/CICs: Contraceptive Benefits

Highly effective (<1 pregnancy per 100 women during the first year of use if taken on time) Predictable return of fertility when discontinued Life threatening side effects are rare Can be provided by trained non-medical staff
COCs/CICs: Issues for Users

Mild side effects are common during the first few months of use: nausea, headaches, breast tenderness, irregular vaginal bleeding Do not protect against HIV and other STIs COC users must remember to take pill every day CIC users must come in for injection every month
21
22
Do CICs Function like COCs?

Similar function Similar side effects, health benefits and health risks Most of the findings about COCs also apply to CICs CICs do not pass through the liver first because they are not taken by mouth. Short term studies have shown that CICs have less effect than COCs on blood pressure, blood clotting, lipid metabolism and liver function.
How are CICs Different from DMPA or NET-EN injections?

CICs contain estrogen AND progestin, making it a combined method. DMPA and NET-EN contain progestin-only CICs are given as a monthly injection CICs contain less progestin than DMPA and NET-EN
144
How are COCs Different from POPs?

Combined oral contraceptives (COCs) contain estrogen and progesterone Progesterone only pills (POPs) contain progesterone only and therefore have different side effects, health benefits and health risks
POPs: Contraceptive Benefits

Contain no estrogen Predictable return of fertility when discontinued Life threatening side effects are rare Can be provided by trained non-medical staff
26
POPs: Effectiveness
Breastfeeding As commonly used About 1 pregnancy per 100 women over the first year Not breastfeeding About 3 to 10 pregnancies per 100 women over the first year Less than 1 pregnancy per 100 women over the first year if taken everyday at the same time
PICs: Progestin-only Injectables

DMPAdepot medroxyprogesterone acetate, 150 mgs deep IM injection every 12 weeks NET-ENnorethindrone enanthate, 200 mgs deep IM injection every 8 weeks Perfect use: <1 pregnancy/100 women Typical use: 3 pregnancies/100 women
When taken every day
Less than 1 pregnancy per 100 women over the first year
Implants
Norplant: 6 rods, levonorgestrel, lasts 7 years Jadelle: 2 rods, effective for 5 years Implanon: single rod, etonogestrel, lasts 3 years <1 pregnancy per 100 women over the first year
Types of Medicated IUDs

Copper-bearing: Work by causing chemical changes that damage sperm and egg before they meet Levonorgestrel-releasing: Works primarily by suppressing the growth of the lining of the uterus
Copper T 380A Multiload Cu375
LNG-IUS
145
IUCDs: Copper vs. LNG

Copper IUCD Effectiveness 68 pregnancies/1000 women over first year CuT 380 12 years ML-CU 375 5 years Good for 12 years Non-hormonal LNG-IUCD 2 pregnancies/1000 women over first year 5 years Cost
IUCDs: Copper vs. LNG

Copper IUCD + +++ LNG-IUS
Duration
Postpartum insertion: <48 hours after birth Bleeding pattern
Can insert in breastfeeding mothers Heavier periods more likely
If breastfeeding, delay insertion until 4 weeks postpartum Irregular light periods. May eventually become amenorrheic.
Advantages
More effective menorrhagia dysmenorrhea
Barrier Methods
Female Sterilization Effectiveness (pregnancies/1000 women over first year) Permanent Reversible Onset effectiveness 5 Vasectomy 2 If semen checked yes rarely 3 months
yes rarely immediate
Effectiveness depends on the user Not as effective as hormonal and LAPMs Few side effects Latex condoms protect against STIs Generally easy to obtain Can be used as a temporary or backup method
Postpartum Family Planning
Timing of Initiating FP Methods Postpartum

LAMwith breastfeeding Condomswhen intercourse resumes Progestin methods:
BF: when good milk supply and BF going well6 weeks Non-BF: right away
Combined Oral Pills (Estrogen + Progestin)

BF: when there is no risk if quantity of milk decreases6 months Non-BF: when risk of thrombosis is reduced3 weeks
IUCDwhen risk of infection and perforation low

First 48 hours or after 46 weeks
Tubectomywhen tubal inflammation and risk of infection low:

First 7 days or after 6 weeks
146
New Combined Hormonal Methods

Yasmin: pill contains newer progestin, drospirenone NuvaRing: a contraceptive vaginal ring OrthoEvra: a transdermal patch Seasonale: extended cycle pill (84 on/7 off)
A Question
What would be an ideal contraceptive for Pakistani women and why?
The crucial step in client-provider interaction
COUNSELING
40
Session Objectives
After this session, participants will be able to:
Understand the importance of effective counseling for healthy spacing Practice good counseling skills Be knowledgeable about two counseling approaches Provide clients comprehensible information for healthy spacing
Birth Spacing and Client-Provider Communication

MOTIVATION Creates demand Uses one-way communication Works through individual, group or mass communication EDUCATION Provides information on all available contraceptive methods Uses one- or two-way communication Dispels rumors and misconceptions COUNSELING Helps client make her/his own choice Encourages the client to ask questions Involves active listening Assures that client is fully informed
41
42
147
Counseling
A partnership of Experts. The provider knows about family planning and other reproductive health care. The client knows more than anyone else about her or his own life, wants, and feelings. For successful counseling, these experts must share their knowledge. This partnership has a purposeto help the client make decisions or solve problems about family planning and other reproductive health matters.
Family Planning Counseling

Providers Role
Share Facts
Give clear, accurate information that the client wants and needs Describe personal situation and health conditions
Client Role
Help the client apply this information that the client wants and needs
Ask questions and make sure of understanding
Share Feelings
Care for the client by showing understanding, respect, and honesty Express attitudes, preferences, concerns, expectations, and wishes about FP and RH
43
44
Key Terms
Counseling? The face-to-face, personal communication in which one person helps another to make decisions and then to act on them. A conversation between a service provider and a client about family planning.
Clients Who Receive Their Method of Choice are More Likely to Continue Using the Method
Family Planning Counseling? Informed Choice?
A client has the right to choose any family planning method s/he wishes A client has freely and voluntarily selected a method based on an appropriate and clear understanding of the facts
45
Informed Consent?
Source:Pariani,StudiesinFamilyPlanning,Nov/Dec1991
46
Family Planning Counseling: Benefits

Increases acceptance Promotes effective use Improves continuation Increases client satisfaction Dispels rumors and misconceptions
Family Planning Counseling: Rights of the Client

In serving clients, it is important to remember that they have:
The right to decide whether or not to practice family planning, The freedom to choose which method to use, The right to privacy and confidentiality, The right to complete and accurate information, The right to form/express their own opinions, and The right to refuse any type of examination.
47
48
148
Being a Good Counselor

A good counselor
Understands and respects the clients rights Earns the clients trust Understands the benefits and limitations of all contraceptive methods Understands the cultural and emotional factors Encourages the client to ask questions Uses a nonjudgmental approach Understands the effect of nonverbal communication Recognizes her/his limitations and refers the client when appropriate
Tips for Effective Education

Key points:
Be brief (most important information only) Cover first things first Use simple words and short sentences Repeat most important information Organize information Be specific
49
50
What We Sayand How We Say It

Think about the technical information you want to provide. Consider your own thoughts and biases in presenting that information. How do these statements differ?
The IUCD is more than 99% effective in preventing pregnancy. It is really just as good as sterilization, but not permanent. The IUCD is not perfect, it is 99% effective, which isnt 100%. So you really cant be as sure as with sterilization.
Family Planning Counseling: Framework

The GATHER Approach:
G A T H E R Greet respectfully Ask/assess needs Tell information Help choose Explain and demonstrate Return and reinforce/refer
The SAHR Approach:

S A H R Salutation Assess the clients RH needs Help negotiate a solution Reassure the client
52
General FP Counseling
New client with no method in mind
Ask the client about her reproductive needs (short term, long term, permanent) Help the client consider methods that might suit her. Help her reach a decision by providing information about available methods. Support the clients choice if medically eligible, give instructions on use, and discuss how to cope with any side effects.
Method-Specific FP Counseling
New client with a method in mind
Ensure that the client knows her options. Check that the clients understanding of her chosen method is accurate. Support the clients choice, if client is medically eligible. Discuss how to use the method and how to cope with any side effects.
149
Return Clients/Follow-up Counseling

Problems and side effects are discussed and managed Continuing use is encouraged unless major problems exist Instructions should be repeated Questions are answered and client concerns are addressed
Summary
Respect for clients rights should be demonstrated in every aspect of care Education and counseling should be integrated throughout the visit It is important to aid, not persuade, the client in choosing a contraceptive
55
56
Session Objectives
After this session, participants will be able to describe recent WHO guidelines on the use of selected contraceptive methods
Helping Clients Select a Method
Using the World Health Organization Medical Eligibility Criteria (MEC): An Overview
57 58
What are the Medical Eligibility Criteria (MEC)?

Recommendations on the specific conditions (medical and non-medical) to safely use contraceptive methods:
Initiation Continuation
Classification Categories
CLASSIFICATION WITH CLINICAL JUDGMENT 1 2 Use method in any circumstances Generally use method Use of method not usually recommended unless other more appropriate methods are not available or not acceptable Method not to be used WITH LIMITED CLINICAL JUDGMENT YES (Use method)
Evidenced-based:
Direct studies on users with and without the conditions Theoretical considerations Expert opinions
NO (Dont use method)
Source:WHOMEC,2004edition.
59
60
150
Medical Eligibility Criteria: Breastfeeding and Contraceptive Use

Breastfeeding Less than 6 weeks postpartum 6 weeks6 months postpartum 6 months or more postpartum
Source:WHOMEC,2004edition.
Summary
Many factors affect contraceptive access and quality Medical barriers are one factor that clinical providers can influence directly Using MEC helps remove medical barriers WHO eligibility criteria:
Category 1 and 2 = USE THE METHOD Category 3* and 4 = DO NOT USE
* Generally do not use unless there are no other appropriate FP methods.
COC
DMPA NET-EN DONT USE USE USE
Copper T IUCD USE (within 48 hrs) USE USE
DONT USE DONT USE USE
61
62
Session Objectives
Offer various natural family planning methods Understand how these methods are used and how to counsel clients
Expansion of FP Choices
NATURAL BIRTH SPACING METHODS: An Overview
63
64
Methods of NBSM
METHOD
Standard Days Method (SDM) Calendar Method (Rhythm) Symptom-Based Method Basal Body Temperature (BBT) Cervical Mucus Method (Billings) Other Methods Lactational Amenorrhea Method (LAM) Withdrawal or Coitus Interruptus
1
NBSM: Benefits
Can be used to prevent or achieve pregnancy No method-related health risks No systemic side effects Inexpensive Improved knowledge of reproductive system Possible closer relationship between couple Increased male involvement in FP
EFFECTIVENESS1
Calendar-Based Method 5 9 1 3 12 4 (27)2
Pregnancies/100 women first year with consistent and correct use 2 Pregnancies/100 women first year with correct use/common use
65
66
151
NBSM: Limitations
Not very effective: Moderate to least effectiveness (1 to 27 pregnancies per 100 women during the first year of use) Effectiveness depends on willingness to follow instructions Requires abstinence during fertile phase to avoid conception Does not protect against STIs (e.g., HBV, HIV/AIDS)
LAM: Mechanisms of Action

Frequent intense suckling disrupts secretion of gonadotrophin-releasing hormone (GnRH) Irregular secretion of GnRH interferes with release of follicle-stimulating hormone (FSH) and leutinizing hormone (LH) Decreased FSH and LH disrupts follicular development in the ovary to suppress ovulation
67
68
Using LAM
Who can use LAM? Women who:
Are fully or nearly fully breastfeeding Have not had return of menses Are less than 6 months postpartum1
Client Instructions Feeding on demand:

1012/day initially 810/day subsequently
Add other food at six months Plan for next visit Provide backup method (condom or POP)
Promotes male involvement
BARRIER METHOD
WHOrecommendssupplementationatsixmonths.Ifbegunearlier,LAMisnotaseffective.
69
70
Session Objectives
Describe mechanism of action, benefits and limitations of the condom Manage minor side effects Communicate importance of using barrier method to promote healthy spacing and also against STIs
Barrier Methods
Condoms
Male condoms (commonly used) Female condoms
Diaphragms Cervical caps
71
72
152
Male Condoms: Definition

Condoms are made of thin sheaths of rubber (latex), vinyl or natural products. They differ in such qualities as shape, color, lubrication, thickness, texture and addition of spermicide.
Male Condoms: Mechanisms of Action

Prevent sperm from gaining access to female reproductive tract. Prevent microorganisms (STIs) from passing from one partner to another (latex and vinyl condoms only).
73
74
Male Condoms: Contraceptive Benefits

Effective immediately Do not affect breastfeeding Can be used as backup to other methods No method-related health risks No systemic side effects Widely available (pharmacies and community shops) No prescription or medical assessment necessary Inexpensive (short-term)
Male Condoms: Non-Contraceptive Benefits

Promote male involvement in FP Only FP method that provides protection against STIs (latex rubber and vinyl condoms only) May help prevent cervical cancer
75
76
Male Condoms: Limitations

Moderately effective (2 pregnancies per 100 women during the first year when correctly used) Effectiveness as contraceptive depends on willingness to follow instructions User-dependent (require continued motivation and use with each act of intercourse) May reduce sensitivity of penis, making maintenance of erection more difficult
Hormonal contraceptive
COMBINED ORAL CONTRACEPTIVES
77
78
153
Session Objectives
Discuss the mechanism of action of COCs List advantages and disadvantages Respond to client concerns and problems, as well as to commonly asked questions about COCs
Brief Introduction to COCs

Contain both estrogen and progestin (COCs) Commonly used in Pakistan Available in Pakistan since 1970s Come in two types of packets:
Packets contain 28 pills, with 21 active pills of hormones and 7 Placebo (iron or lactic sugar) Others packets only have 21 active pills with no iron pills
79
80
COCs: Mechanisms of Action

Suppress ovulation Reduce sperm transport in upper genital tract (fallopian tubes) Change endometrium, making implantation less likely Thicken cervical mucus, preventing sperm penetration
COCs: Contraceptive Benefits

Are highly effective when taken daily (0.1 to 51 pregnancies per 100 women during the first year of use) Are effective immediately if started by Day 5 of menstrual cycle Do not require pelvic examination to initiate use Do not interfere with intercourse Have few side effects Are convenient and easy to use Can be stopped by client Allow fertility to return soon after stopping
1 FamilyPlanning:AGlobalHandbookforProviders.2008WorldHealthOrganizationandJohnsHopkinsBloombergSchoolof PublicHealth/CenterforCommunicationPrograms.
81
82
COCs: Non-Contraceptive Benefits

Decrease menstrual flow (lighter, shorter periods) Decrease menstrual cramps May improve anemia Protect against ovarian and endometrial cancer Decrease benign breast disease and ovarian cysts Prevent ectopic pregnancy
COCs: Limitations
User-dependent (require continued motivation and daily use) Some nausea, dizziness, mild breast tenderness, headaches or spotting may occur Effectiveness may be lowered when certain drugs are taken Rare serious side effects possible Resupply must be readily and easily available Do not protect against STIs (e.g., HBV, HIV/AIDS)
83
84
154
COCs: Common Side Effects

Amenorrhea Nausea/dizziness/vomiting Bleeding/spotting Headache Breast fullness or tenderness (mastalgia)
Management of Amenorrhea
Evaluate for pregnancy, especially if amenorrhea occurs after a period of regular menstrual cycles If not pregnant, counsel and reassure client; if client is still uncomfortable, help her choose another method
85
86
COCs: Management of Bleeding or Spotting

Advise to take:
Ponstan Forte (Mefanamic acid), 1 tablet 3x daily for 5 days OR Brufen (Ibuprofen), maximum of 800 mg 3x daily for 5 days
COCs: Management of Nausea and Vomiting

Make sure she is taking pill at bedtime with meals Check for pregnancy; if no cause found, reassure her If she vomits within 2 hours of taking a pill, ask her to take an extra pill from another packet
Refer if not settled
87
88
COCs: Management of Weight Gain

Less than 2 kg in 3 months: Ask if her appetite has increased, if so suggest dietary restrictions More than 2 kg in 3 months: Stop pills, provide her with another method of contraception
COCs: Other Common Side Effects

Some nausea, dizziness, mild breast tenderness and headaches, as well as spotting or light bleeding are common during menstrual cycle (usually disappear within 2 or 3 cycles) Clients can be provided symptomatic treatment if required
89
90
155
COCs: Warning Signs

Tell the woman to return to the clinic if she develops any of the following problems:
Severe chest pain or shortness of breath Severe headaches or blurred vision Severe leg pain
Dispelling Myths Regarding COCs

Contraceptive pills DO NOT:
Cause birth defects Cause infertility Require a rest period Generally decrease sex drive Collect in a womans body
Absence of any bleeding or spotting while taking the 7 inactive pills (28-day pack)may be a sign of pregnancy
Source:FHIProviderChecklist,2002.
91
92
POPs: General Information

Contain only progestin (single hormone) Mechanism of action is almost the same as COCs Used less often in Pakistan than COCs
Minipills
PROGESTIN-ONLY PILLS
93
94
POPs: Contraceptive Benefits

Are effective when taken at the same time every day (0.055 pregnancies per 100 women during the first year of use) Are immediately effective (<24 hours) Do not require a pelvic examination prior to use Contain no estrogen Do not affect breastfeeding Allow for immediate return of fertility when stopped Protect against endometrial cancer Decrease ectopic pregnancy
POPs: Limitations
Cause changes in menstrual bleeding pattern Some weight gain or loss may occur Must be taken at the same time every day Resupply must be available Effectiveness may be lowered when certain drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampin) are taken
95
96
156
Who Can Use POPs

Women who:
Are of any reproductive age Are breastfeeding (6 weeks or more postpartum) and need contraception Are postpartum or postabortion Have blood pressure <160/100 Have moderate to severe menstrual cramping Smoke (any age, any amount) Prefer not to or should not use estrogen
POPs: General Information

Changes in menstrual bleeding patterns are common, especially during first two or three cycles. They are often temporary and rarely a risk to health. Other minor side effects may include weight gain, mild headaches and breast tenderness. These symptoms are not dangerous and gradually disappear. Certain drugs (rifampin and most anti-epilepsy drugs) may reduce effectiveness of POPs. Tell your provider if you start any new drugs.
97
98
POPs: Warning Signs

Return to clinic if any of the following occur:
Delayed menstrual period after several months of regular cycles (may be sign of pregnancy) Severe lower abdominal pain Heavy or prolonged bleeding Migraine headaches
Side Effects of POPs

Nausea or dizziness Breast tenderness Amenorrhea Irregular bleeding Heavy or prolonged bleeding Depression Loss of sexual desire Severe pain in lower abdomen
99
100
Management of Amenorrhea
Breastfeeding women:
Reassure her that this is normal during breastfeeding and that it is not harmful
Management of Irregular Bleeding

Women who experience irregular bleeding:
Reassure her that many women using POPs experience irregular bleedingwhether they are breastfeeding or not
Women not breastfeeding:

Reassure her that some women using POPs stop having monthly bleeding and that this not harmful
Other possible causes include:

Vomiting or diarrhea Taking anticonvulsants or rifampicin
101
102
157
Management of Irregular Bleeding (contd)

To reduce irregular bleeding:
Tell her to make up for the missed pills properly, including after vomiting or diarrhea
Management of Heavy or Prolonged Bleeding

Provide reassurance For temporary relief:
Tab. Ibuprofen 800 mg TDS, after meals for 5 days OR Tab. Ponstan 2 TDS, beginning when bleeding starts Tab. Iron 1 TDS and foods containing iron
For temporary relief:

Tab. Ibuprofen 800 mg TDS, after meals for 5 days OR Tab. Ponstan 2 TDS, beginning when irregular bleeding starts
Counsel client about another suitable method if needed
103
104
Emergency Contraception
Also known as:
Morning-after pills Postcoital contraception
ThesetermsdonotconveythecorrecttimingofECuse,northe factthesemethodsshouldbeusedonlyforemergencies.
Prevention against Unplanned Pregnancy
EMERGENCY CONTRACEPTION
105
106
Emergency Contraception: Methods

Combined oral contraceptives (COCs):
Low-dose (3035 g EE and 150 g LNG)
Emergency Contraception: Counseling

Ensure that client does not want to become pregnant Explain the following:
Correct way to use EC EC is not suitable for regular use Nausea and vomiting are common with COCs and POPs; cramping is common with IUCDs EC pills do not provide future protection following treatment EC pills will not cause menses to come immediately
Progestin-only pills (POPs):

750 g LNG (preferred)
Intrauterine contraceptive devices (IUCDs):

Copper T 380A (or TCu 380A), Multiload Cu 375
Offer client regular contraceptive methods
107
108
158
Emergency Contraception: Limitations

COCs and POPs are effective only if used within 120 hours of unprotected intercourse. May cause nausea and vomiting. IUCDs are effective only if inserted within 5 days of unprotected intercourse.
Emergency Contraception: COCs

Both the COCs and POPs have the same mechanism of action. They may:
Block ovulation May alter tubal motility May alter endometrium
Effectiveness: 2% failure rate when used correctly (Early use of ECPs lowers the failure rate) Safety:
No long-term problems in nearly all women Nausea and vomiting most common short-term side effect
109
110
Combined Injectable Contraceptive (CIC) vs. Progestin-Only Injectable Contraceptive (PIC)
CICs
Contain both estrogen and progesterone Mechanism of action: preventing ovulation
CIC & PIC Given every 1 month Very effective at <1 pregnancy/100 women Health benefits and risks similar to COC
PICs
Contain only progestins:
DMPA NET-EN
Mechanism of action: preventing ovulation Given:

DMPAevery 3 months NET-ENevery 2 months
INJECTABLE CONTRACEPTIVES
Very effective at <1 pregnancy/100 women

112
111
PICs: Timing of Injection

Days 1 to 7 of the menstrual cycle Anytime during the menstrual cycle when you can be reasonably sure the client is not pregnant Postpartum:
Immediately if not breastfeeding After 6 months if using LAM
PICs: Advantages
Very effective Reversible Do not affect breastfeeding Few side effects Protect against endometrial cancer and fibroids Decrease endometriosis symptoms
Postabortion: immediately or within first 7 days
113
114
159
Who Can Use PICs

Women of any reproductive age or parity who:
Want an effective, reversible method Are postpartum and not breastfeeding Are breastfeeding (6 weeks or more postpartum) Are postabortion Are smokers (any age, any amount) Are infected with HIV and on ARVs
Who Can Use PIC (contd)

Women of any reproductive age or parity who:
Have moderate to severe menstrual cramping Take drugs for epilepsy or tuberculosis Have high blood pressure or blood clotting problems Prefer not to or should not use estrogen Cannot remember to take a pill every day Prefer a method not related to intercourse Note: Women who cannot tolerate any changes in their menstrual bleeding pattern may require additional counseling
115
116
PICs: Common Side Effects

Irregular or heavy bleeding Headache Nausea/dizziness/vomiting Amenorrhea (absence of vaginal bleeding or spotting) Weight gain or loss (change in appetite)
PICs: Common Side Effects (contd)

Most of the side effects, like nausea, headache and dizziness, will settle in 23 months. Women taking regular injections can have amenorrhea, which is normal. For a client who has irregular bleeding advise:
Ponstan Forte 1 tablet 3x daily for 5 days OR Brufen maximum of 800 mg 3x daily for 5 days
Refer if the problem persists.
117
118
PICs: Warning Signs

Severe lower abdominal pain Heavy bleeding Migraine (vascular) headaches, repeated headaches that are very painful or blurred vision
PICs: Management of Amenorrhea

Give reassurance that this is a common, but not serious side effect Evaluate for pregnancy, especially if amenorrhea occurs after period of regular menstrual cycles If no problem is found, do not attempt to induce bleeding with COCs
119
120
160
PICs: Management of Irregular Bleeding

For prolonged spotting (>8 days) or moderate bleeding:
Provide reassurance Check for gynecologic problem (e.g., cervicitis) Give short-term treatment:
COCs (3050 g EE) for one cycle
PICs: Management of Prolonged or Heavy Bleeding

If client is bleeding twice as long or twice as much as normal:
Carefully review history and check hemoglobin (if available) Check for gynecological problem Give short-term treatment:
COCs (3050 g EE) for one cycle
OR
Ibuprofen (up to 800 mg 3x daily for 5 days)
OR
Ibuprofen (up to 800 mg 3x daily for 5 days)
121
122
PICs: Management of Irregular Return for Reinjection

PIC
DMPA
PICs: Dispelling Myths

Injectables DO NOT:
EARLY
>4 WEEKS YES >2 WEEKS YES <4 WEEKS YES <2 WEEKS YES
LATE
>4 WEEKS YES
(-) Pregnancy Test
Cause birth defects Cause permanent infertility Cause abortion
Net-En
>2 WEEKS YES

(-) Pregnancy Test
123
124
Types of IUCDs
COPPER Copper T 380A Multiload Cu 375
Long term protection against pregnancy
LEVONORGESTREL Mirena
Yuangong 200, 300 & 365
INTRAUTERINE CONTRACEPTIVE DEVICE
125
126
161
IUCD Safety
Research has proven IUCDs to be safe and effective Elements of high-quality IUCD services:
Appropriate screening Effective counseling Adequate infection prevention measures and careful insertion Proper follow-up care
Copper IUCDs: Mechanisms of Action
Interfere with ability of sperm to pass through uterine cavity Thicken cervical mucus
Interfere with reproductive process before ova reach uterine cavity Change endometrial lining
127
128
Characteristics of Copper IUCD

Highly effective and economical Does not interfere with intercourse Easy to use Long lasting Reversible Quick return of fertility No systemic effects
Characteristics of Copper IUCD (contd)

Possible side effects:
Pain and cramping Heavier menstrual bleeding
Possible complications include:

Perforation Pelvic inflammatory diseases
129
130
Who Can Use Copper IUCDs

Can be used safely by women who:
Are of any age and parity Are young and nulliparous, although they should be counseled on expulsion risk Are postpartum, postabortion or breastfeeding Have a chronic condition, including hypertension, cardiovascular disease, diabetes, liver or gall bladder disease
Who Should Not Have an IUCD Inserted

The copper IUCD should not be inserted in women with:
Known or suspected pregnancy Cervical or endometrial cancer or unexplained vaginal bleeding Pelvic tuberculosis Uterine distortion that impedes correct IUCD placement Infection following childbirth or following incomplete abortion
131
132
162
Dispelling Myths
IUCDs:
Are not abortifacient Do not cause infertility Do not travel to distant parts of the body Are not too large for small women
Summary
IUCDs are:
Safe, effective, convenient, reversible, long lasting, cost effective
Providers can ensure safety by:

Careful screening Effective counseling Good infection prevention Proper follow-up
133
134
Voluntary Surgical Contraception (VSC): Definition

Minor voluntary surgical procedures for permanently terminating fertility in:
Men vasectomy Women minilaparotomy and laparoscopy
Overview
VOLUNTARY SURGICAL CONTRACEPTION (VSC)
135
136
VSC: Most Common Methods

Vasectomy (male):
No-scalpel technique (preferred) Incisional
VSC: Mechanism of Action

Vasectomy (no-scalpel or incisional):
By blocking the vas deferens, sperm are no longer present in the ejaculate
Tubal occlusion (female):

Minilaparotomy Laparoscopy
Minilaparotomy or laparoscopy:
By blocking the fallopian tubes (tying and cutting, rings, clips or electrocautery), sperm are prevented from reaching the ovum
137
138
163
VSC: Benefits
Highly effective Permanent Does not interfere with intercourse Simple surgery usually performed under local anesthesia No long-term side effects No change in sexual function Good for couples if pregnancy would pose serious health risk to woman
VSC: Limitations
Must be considered permanent (not reversible) Client may regret later Risk of complications, especially if general anesthesia used Short-term discomfort/pain following procedure Requires trained physician Does not protect against STIs (e.g., HBV, HIV/AIDS)
139
140
VSC: Client Issues

The client should make the decision for sterilization voluntarily. The client has the right to change her/his mind at anytime prior to the procedure. The client should understand that VS is a permanent (not easily reversible) method. No incentives should be given to clients to accept VS. A standard consent form must be signed by the client before the procedure.
When to Perform Tubal Ligation (TL) Procedure

Anytime during the menstrual cycle you can be reasonably sure the client is not pregnant Postpartum: Within 48 hours or after 6 weeks Postabortion: Immediately or within 7 days, provided no evidence of pelvic infection
141
142
Vasectomy: General Information

Vasectomy does not provide protection from pregnancy until 3 months after it is performed, when no sperm are seen in a microscopically examined semen specimen. Vasectomy will not affect sexual performance because the testes still function normally. Vasectomy does not provide protection against STIs (e.g., HBV, HIVAIDS). If either partner is at risk, the couple should use condoms even after vasectomy.
Simple, Effective and Inexpensive
INFECTION PREVENTION
143
144
164
Purpose of Infection Prevention

To reduce the risk of disease transmission to health care providers, clients, patients and communities. To protect health care providers at all levels from physician and nurses to cleaning, housekeeping and laboratory staff.
Standard Precautions
Guidelines designed to create a physical, mechanical or chemical barrier between microorganisms and a person to prevent the spread of infection.
145
146
Standard Precautions (contd)

Examples of barriers:
Physical:
High-level disinfect (HLD) by boiling, steaming Sterilization
Standard Precautions (contd)

Examples of barriers (contd):
Chemical:
Antiseptics High-level disinfectants
Mechanical:
Gloves Face masks, goggles Aprons Drapes
147
148
Components of Standard Precautions

Consider every person potentially infectious. Wash hands for preventing cross-contamination. Wear gloves (both hands) before touching anything wet and before performing invasive procedures. Use antiseptics for cleansing skin or doing hand scrubs.
Components of Standard Precautions (contd)

Safely dispose of infectious waste materials. Process instruments, gloves and other items. Use safe work practices.
149
150
165
Handwashing
Purpose:
To mechanically remove soil and debris from the skin
Handwashing (contd)
Steps:
Thoroughly wet hands. Apply plain soap. Vigorously rub all areas of hands and fingers together for at least 1015 seconds. Rinse hands thoroughly with clean water. Dry hands with clean individual towel or air dry.
Required:
Before
Examining patient Putting on HLD/sterile gloves
After
Any condition in which hands may become contaminated Removing gloves
151
152
Safe Injection Practices

Use disposable syringe. Do not disassemble the needle and syringe after use. Do not recap needle. Decontaminate the needle and syringe prior to disposal. Dispose of the needle and syringe in puncture proof container.
Sharps:
Waste Disposal
Encapsulation Used needles can be buried Destruclip to destroy the needle
Liquids:
Pour into drain Dispose of in a deep covered hole
Solids:
Place in plastic bags Bury it Use incinerator
153
154
Contraceptive Options for Teens and Young Women

METHOD OCs REMARKS Precautions in teens are rare Most popular among teens Lifestyle may increase missed intake Used for EC also Side effects (spotting, acne and weight gain) are potential issues In place even when teen is not sexually active
Implants
Teenagers, Women over 35 Post-Pregnancy and Postabortion
CONTRACEPTION FOR SPECIAL SITUATIONS
Source: Pocketguide forFPServiceProviders,19961998;GlobalFPHandbook,2007
155
156
166
Contraceptive Options for Teens and Young Women (contd)

METHOD PICs REMARKS Side effects (spotting, acne and weight gain) are potential issues Highly recommended for teens requiring intermediateduration contraception Not recommended for teens with multiple sex partners Provide immediate protection Protects against STIs
Additional Points to Tell Teens and Young Women Caution that OCs do not prevent STIs Discuss condom use: How are you protecting yourself from AIDS? Ask how he/she plans to discuss condom use with her partner Discuss EC
IUDs Condoms
Source: Pocketguide forFPServiceProviders,19961998;GlobalFPHandbook2007
157
158
Women over 35: Do They Still Need Contraception?

% Distribution of Pregnancies
100 80 60 40 20 0 1519 2024 2529 3034 3539 40+
Women over 35: Contraceptive Options

METHOD COCs and CICs REMARKS Women over 35 who smoke > 15 cigarettes/day (Class 4) Low-dose COCs source of estrogen for perimenopause ECPs can be used POCs can be used in perimenopausal years (40s50s) Safely used by older women who smokes (Class 1)
Unintended births
Abortions
Intended births
POCs (implants, PIC and POPs)
*Doesnotincludemiscarriages. Source: Lynch,C,Contraceptionforwomen35andolder,2001
159
160
Women over 35: Contraceptive Options (contd)

METHOD IUDs REMARKS Safely used by older women if not at risk for STIs Possibly preferred method because it is longterm and effective Best used by women with predictable intimacy acts Only method protecting against STIs Appropriate for clients/couples who are certain about limiting pregnancies
Post-Pregnancy Contraception: Postpartum and Postabortion Periods

Why needed? Women in the first year postpartum have higher unmet need for FP than the general population of women Demographic and Health Survey data show that:
Very few women (38%) want another child within 2 years after giving birth Of women in the first year postpartum, 40% intend to use a FP method but are not doing so (MAQ*)
*DatafromMaximizingAccessandQualityGlobalHealthTechnicalBriefsUSAID
Condoms
Surgical Contraception
161
162
167
Postpartum FP Goals
Reduce unmet need for FP Improve contraceptive choice Promote optimum health through breastfeeding Counsel on return to fertility Promote healthy pregnancy spacing Integrate with maternal, newborn and infant services
Stephenson&MacDonald,FPforPostpartumWomen:SeizingaMissedOpportunity 2005
FP Opportunities for Postpartum Woman

ANCinitiate postpartum FP idea Dischargecounsel
BreastfeedingLAM Non-breastfeeding
6-week postpartum visit Immunization visits Sick and well-child visits
163
164
Postpartum Contraception Options
Need for Postabortion FP Services

Unsafe abortion is a prime indicator of unmet need for FP Failure to provide FP is a major contributor to the problem of unsafe abortion Emergency treatment is not linked to FP counseling or services
165
166
Risk Factors for Repeat Unsafe Abortion

Lack of understanding of patients reproductive health needs (provider) Lack of FP services for some groups of women (e.g., adolescents, single women) Separation of emergency services from FP services Misinformation about which FP methods are appropriate postabortion (provider and patient) Lack of recognition of problem of unsafe abortion and patient FP needs (provider)
Why Start Postabortion FP Immediately?

Increased risk of repeat pregnancy because:
Ovulation may occur by Day 11 postabortion Within 6 weeks postabortion, 75% of women will have ovulated
Source: L@hteenm@ki 1993;L@hteenm@ki etal1980.
167
168
168
Postabortion Contraception
METHOD Hormonal Contraception (COCs, DMPA) IUCDs: First trimester Second trimester Tubal Ligation/ Vasectomy WHEN TO START Immediate Immediate or delayed 4 to 6 weeks postabortion Immediate Delayed REMARKS Effective immediately Can be used even if infection present No infection present Similar to postpartum Clean procedure Allow infection/injury to resolve
169
169
170

Birthspacing and Family Planning in Pakistan - Nursing - Tutor's - Final

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Birthspacing and Family Planning in Pakistan - Nursing - Tutor's - Final

Uploaded by

Copyright:

Available Formats

Birth Spacing and Family Planning in Pakistan

Nursing Tutors Guide

BIRTH SPACING AND FAMILY PLANNING IN PAKISTAN

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

SECTION 1: COMMUNICATION SKILLS AND BEHAVIOUR CHANGE

CASE STUDIES AND ROLE PLAYS

SKILL DEVELOPMENT TOOLS

KNOWLEDGE ASSESSMENT TOOLS PRESENTATION GRAPHICS

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

SECTION 2: BIRTH SPACING AND FAMILY PLANNING

EXERCISES, CASE STUDIES AND ROLE PLAYS

SKILL DEVELOPMENT TOOLS

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

ABBREVIATIONS AND ACRONYMS

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

RTI SDM STI TL VSC WHO

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Practice in simulation Practice with clients

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

COMMUNICATION SKILLS AND BEHAVIOUR CHANGE

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

CASE STUDIES AND ROLE PLAYS

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

SKILL DEVELOPMENT TOOLS

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Effective Communication

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Group Health Education

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Conducting Semi-Structured Interview

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Transect Walk

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Mapping

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Community Entry

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Community Profile

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Community Mobilization

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Checklist for Planning a Health Talk with the Community

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide

Birth Spacing and Family Planning in Pakistan Nursing Tutors Guide