Family Planning - Dr Sienna Tran Australian South Asian Healthcare Association (ASHA) Maternal Health Education Program

What is Family Planning Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy. Reduces the need for unsafe abortions (the cause of 13% of maternal mortality worldwide) Some methods of contraception reduce the transmission of sexually transmitted infections (including HIV) (WHO, 2015)

The Menstrual Cycle Fertile window 5 days before ovulation and on the day of ovulation.

Contraception

Natural Methods of Birth Control Fertility awareness methods – 76% effective Avoidance of intercourse during the fertile phase of the menstrual cycle Methods: Calendar/cycle method Cycle length is recorded for at least 6 cycles and then fertile days are calculated Temperature method Ovulation causes your basal body temperature to increase by 0.2-0.4˚C, intercourse should be avoided from the onset of menstruation until the third day on which the higher level temperature has been recorded Cervical mucous method (Billing’s method) “fertile mucous” looks like raw egg white – clear, slippery and stretchy Ovulation most likely to happen on the final day of “fertile mucous” Sympto-thermal method A combination of above methods

Natural Methods of Birth Control Lactational Amenorrhoea method - 98% effective The use of breastfeeding as a contraceptive. Effective only if meets all criteria of: Exclusive breastfeeding, including >1 overnight <6 months post-birth Menstrual periods have not returned post-birth Coitus interruptus (withdrawal method) – 78% Effective Where the male withdraws from the woman’s vagina before ejaculation

Does not interfere with the menstrual cycle Advantages Disadvantages No cost Natural Does not interfere with the menstrual cycle It can be difficult to predict ovulation especially in women with irregular periods requires a lot of commitment and daily awareness of changes requires varying periods of abstinence if it is the only method used Sperm can be found in pre-ejaculatory fluid.

Barrier Methods Provide a physical barrier which stopes the sperm from getting into the vagina or the upper genital tract Male condoms - 82% effective Female condoms – 79% effective Caps – used in combination with spermicides Female Diaphragm – 88% effective Cervical and vault caps Vaginal sponge Use with spermicide inserted into vagina to cover cervix Spermicides

Advantages Disadvantages Male condoms protect against STIs Low cost Only need to be used during intercourse Cost Can be a problem if sensitive to latex, spermicide or lubricant Condoms can break or slip off Female condoms can be difficult to place Diaphragms can cause local irritation

Progestogen Only Pill (POP) 91% effective Contains low dose progestogen Thickens cervical mucous so that sperm cannot enter the uterus Changes lining of uterus making it unsuitable for pregnancy May prevent ovulation Must be taken at the same time every day (3 hour window)

Advantages Disadvantages Can be used if breastfeeding Rapid return to fertility Can be used by women who cannot use the COCP / oestrogen Cost Affects menstrual bleeding Does not protect against STIs Must be taken at the same time every day

Combined Oral Contraceptive Pill (COCP) 91% effective Contraceptive pill containing 2 hormones – oestrogen and progestogen Prevents ovulation Thickens cervical mucous Thins lining of uterus Taken daily Additional contraception needed if pills are missed Monthly bleed occurs during the ‘inactive’ pills Contraindications: Undiagnosed vaginal bleeding, cardiovascular disease, liver disease, some cancers, etc.

Advantages Disadvantages Highly effective Rapid return to fertility Can control when you have your period Cost A rare but serious risk of thrombosis (blood clots) Does not protect against STIs Must be taken daily Side effects: nausea, headache, breast tenderness

Contraceptive Vaginal Ring 91% effective Soft plastic ring inserted into the vagina, releases low doses of oestrogen and progestogen Prevents ovulation Thickens cervical mucous Changes lining of uterus Insert ring on day 1-5 of cycle (day 1 is the day your period starts), ring is left in place for 3 weeks, then removed and a new ring inserted a week later. A monthly bleed occurs in the week when there is no ring in place

Contraceptive Injection 94% effective A hormonal contraceptive given by injection every 3 months Contains progestogen Prevent ovulation Thickens cervical mucous

Contraceptive Implant (Implanon) 99% Effective A small rod that is placed under the skin and releases the hormone progestogen into the blood stream Lasts up to 3 years

Intrauterine Devices Mirena Copper intrauterine device 99% effective Plastic, T-shaped device that sits in the uterus and releases progestrogen Lasts up to 5 years Not suitable for use in some circumstances e.g. recent pelvic infection, recent breast cancer Copper intrauterine device Prevent fertilisation Can last up to 5-10 years

Advantages Disadvantages Highly effective Long-acting Fast return to fertility Needs to be inserted by trained professional May have irregular spotting Does not protect against STIs May fall out Risks with insertion – perforation, infection

Sterilisation Female sterilisation Male Sterilisation (vasectomy) 99% effective Surgical procedure that involved blocking or cutting the Fallopian tubes (where eggs travel from the ovaries to the uterus) to prevent the ova (eggs) from coming in contact with sperm Permanent Male Sterilisation (vasectomy) Surgical procedure that involves blocking the path of sperm by cutting or tying the tube that transports it

Emergency Contraception Copper Intrauterine device Can be inserted up to 5 days after unprotected sex Not if there is any possibility of a sexually transmitted infection Progestogen only emergency pill Used up to 72 hours after unprotected sex Works mainly through inhibiting ovulation Can be used more than once in a cycle Ulipristal acetate (selective progesterone receptor modulator) Used up to 120 hours after unprotected sex Inhibit or delay ovulation Use only once per cycle

References World Health Organisation, Family Planning/Contraception, 2015, http://www.who.int/mediacentre/factsheets/fs351/en/ Family planning Australia Luesly & Kilby, Obstetrics & Gynaecology: An evidence based text for the MRCOG, 3rd Ed, 2016