Pre-service Education on FP and AYSRH Session I Topic 1 Concepts of Family Planning

Defining Contraception and Family Planning What is the definition of contraception? Contraception is the intentional prevention of pregnancy by artificial or natural means. What is the definition of 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. – World Health Organization, Department of Reproductive Health and Research Instructions for facilitator: Show the questions to the participants without showing the definition. Ask participants to construct a definition of contraception and then family planning. Record participant suggestions on a flip chart—each response can build on previous responses until participants have cited the primary features of family planning and the group collectively arrives at comprehensive definition. Ask the group- What is the difference between contraception and family planning? After the group has crafted their definition, show the definition from WHO as an example. Ask the participants to compare the features included in their definition with the WHO definition.

Women with an Increased Risk of Having Problems During Pregnancy and Delivery Women who: Are under the age of 18, or over age 35 Become pregnant less than 2 years after a previous live birth Become pregnant less than six months post-abortion or post-miscarriage Have too many children (high parity) Have certain existing health problems Do not have access to skilled health care Suggested script: Explain that one of most important benefits of family planning is the potential to save lives. Each minute of every day, a woman dies from pregnancy or childbirth-related causes. Provide copies of Handout #1 “Family Planning Saves Lives” and ask students to read the handout in the evening. Explain that in many developing countries, the high-risk factors referred to as "Too Young, Too Old, Too Many, Too Close" are major culprits of maternal and infant mortality. Research shows that women in these categories are at greater risk for problems during pregnancy and delivery, making access to family planning even more critical. <pause to allow participants to review the list > In the next several slides, we’ll examine these risks in more detail. Compare your experiences and observations with the issues described on the slides, and raise any issues that you would like to discuss in further detail. Ask students which of these characteristics and conditions are common among women in their community who have problems during pregnancy and delivery. Problems are more likely in those with multiple risk factors.

Pregnancy Is Greater Risk for Adolescents Over 70,000 maternal deaths occur among adolescents aged 15–19 each year Girls below the age of 15 are five times more likely to die in childbirth than women in their twenties Adolescents are more likely to: Have pregnancy related complications Deliver prematurely Have babies that die before their first birthday About 3 million young women aged 15-19 have an unsafe abortion in the developing world each year Suggested script: Maternal deaths related to pregnancy and childbirth are a significant cause of mortality for adolescents. Over 70,000 maternal deaths occur among 15-19 year olds annually. Adolescents this age are twice as likely to die as women in their twenties. The younger a girl is when she becomes pregnant, the greater the health risks. Girls who become pregnant before the age of 15 are five times more likely to die in childbirth than women in their twenties. Adolescents are more likely to have pregnancy related complications such as preeclampsia and vaginal fistula, to deliver prematurely, and to have babies that die before their first birthday. Adolescents aged 15–19 are estimated to have 3 million of the approximately 21.6 million unsafe abortions that occur annually in the developing world. Sources: Advocates for Youth, 2007; UNICEF, 2008; Guttmacher, 2009, WHO 2014

Pregnancy Is Greater Risk for Women with Pregnancies Spaced Too Closely Women who become pregnant less than 2 years after a previous live birth are more likely to: Become sick or die from pregnancy and delivery complications Have babies at risk of prematurity, low birth weight, small size for gestational age, fetal and neonatal death Women who become pregnant less than 6 months postabortion or miscarriage may be at increased risk of complications for mother and child Suggested script: Research has shown that women who become pregnant less than two years after the birth of their last child are more likely to experience adverse maternal, perinatal, newborn, and infant outcomes. For example, 35 percent of deaths among children younger than age five in developing countries could have been avoided if births had been spaced at least 36 months apart. Thirty-six months approximates the recommended two-year delay following a birth combined with the nine-month gestation period of the next pregnancy. Women who do not wait six months after an abortion or miscarriage and become pregnant again may experience adverse maternal and perinatal outcomes such as elevated risks of premature rupturing of membranes, anemia and bleeding, pre-term birth, and low birth weight, compared with longer intervals. Source: WHO, 2006; Conde-Agudelo, 2006; Rutstein , 2005; Conde-Agudelo, 2005.

Pregnancy Is Greater Risk for Women Over the Age of 35 Women over age 35 are: At least twice as likely to die in pregnancy or childbirth than women aged 20–24 More likely to have problems during pregnancy such as miscarriage, hypertension, or diabetes More likely to give birth to small babies, babies with disabilities, or stillborn babies Pregnancy for women over 35 is associated with certain risks that are less common with younger women. In many instances, older women are more likely to have more children and experience the additional risks associated with high parity. Older women are at least twice as likely to die in pregnancy and childbirth as younger women and in some data sets the risk rises to 4.5–8 times higher. Bleeding is the most common reason that women over age 35 die during childbirth. The chance of having twins increases with age. The risk of developing gestational diabetes or high blood pressure is greater in women over 35. Older mothers have a higher risk of pregnancy-related complications that might lead to a C-section delivery, such as placenta previa. The risk of miscarriage or giving birth to a low birth weight baby or a baby with a disability also increases in older women. Source: Stover, 2010; WHO, 1995.

Pregnancy Is Greater Risk for Women of High Parity Women with more than four children who have an additional pregnancy are more likely to: Die during pregnancy or childbirth Have anemia, experience blood loss (post partum hemorrhage), and need transfusions Develop complications such as uterine relaxation (during and after delivery) and uterine rupture Suggested script: If no other risk factors are involved, the risk of dying continues to increase with each additional pregnancy after the fourth pregnancy. The risk of dying is 1.5 to 3 times higher for women with five or more children than for women with two or three children. Pregnancy and delivery is riskier for these women because they are more likely to have anemia, require blood transfusions during delivery, or experience unexpected uterine relaxation which refers to the situation that the uterus does not contract as it should thus bleeding after delivery does not stop. They also are at high risk of uterine rupture. Both of these cause massive bleeding. In many instances, women with many children are older and experience the additional risks associated with births to women over 35. Long-acting and permanent family planning methods that limit childbearing—such as IUDs, implants, tubal ligation, or vasectomy for a partner—can help these women avoid a dangerous pregnancy. If a woman wishes to continue childbearing, she should be encouraged to wait at least two years after the birth of the last child before becoming pregnant, and use antenatal care. Source: WHO, 1995.

Pregnancy Is Greater Risk for Women with Certain Existing Health Problems Health risks associated with pregnancy make effective contraception especially important for women with these conditions: Reproductive tract cancers and some infections Serious cardiovascular problems Diabetes with vascular complications Sickle cell anemia Serious liver conditions Infections such as schistosomiasis, TB, and HIV Suggested script: Some medical conditions may make pregnancy riskier for women. The effectiveness of a contraceptive method has special importance if a woman has one of the following conditions: reproductive tract infections and disorders such as breast, endometrial, and ovarian cancer; some sexually transmitted infections including gonorrhea and chlamydia; some vaginal infections such as bacterial vaginosis; anomalies among women who have undergone female genital cutting cardiovascular disease such as high blood pressure, complicated valvular heart disease, ischemic heart disease, or stroke. insulin-dependent diabetes that damaged the arteries, kidneys, eyes, or nervous system or lasted more than 20 years. sickle cell anemia. severe cirrhosis of the liver, and cancerous liver tumors. other infections such as schistosomiasis with fibrosis of the liver, tuberculosis, and HIV AIDS; although HIV/AIDS is not made worse by pregnancy, HIV disease may increase some health risks of pregnancy and may also affect the health of the infant. Source: Global Handbook, updated 2011.

Benefits of FP for All Women Lower risk of maternal death Lower risk of anemia, poor pregnancy outcomes and complications, and complications related to miscarriage or unsafe abortion Non-contraceptive benefits from some methods such as protection from: Disease transmission/acquisition Certain cancers and other gynecological problems Improved educational and economic opportunities • Divide the students into small groups. • Ask them to identify the benefits of FP for each of the following groups; 1) women 2) adolescents, 3) newborns, infants and children, 4) families and communities 5) people with HIV. • Ask the group to record on flip chart and be ready to present. • Give 20 minutes for the group work. • After the students, have identified the potential FP benefits for all the subsets, ask each group to present. Women who use family planning experience many benefits, including: A lower risk of maternal death. A lower risk of anemia; poor pregnancy outcomes including stillbirth, low-birth weight, preterm birth, miscarriage, and complications such as hemorrhage, infection, vaginal fistula, pre-eclampsia, and eclampsia; and a lower risk of complications related to miscarriage or unsafe abortion. Additional benefits provided by some contraceptive methods. For example, barrier methods such as male and female condoms provide protection from STI/HIV transmission between partners. Hormonal contraceptives may protect from acquiring symptomatic pelvic inflammatory disease (PID). In addition, various hormonal methods offer protection from endometrial and ovarian cancer and other gynecological problems such as symptoms of endometriosis and dysmenorrhea. When given control over their fertility, girls are more likely to stay in school and women to be employed. It is important to educate all women about the benefits of family planning. Targeted messages should be tailored to certain groups. For example, for nulliparous adolescents the message about delaying first pregnancy until at least age 18 should be emphasized to achieve greater benefits. For women who are pregnant, have just given birth, or experienced an abortion, messages about the benefits of healthy timing and spacing of pregnancies are key. For women with several children, messages about limiting are relevant and for people with mulitple partners….condoms! It may be important to involve a woman’s husband or partner, her mother-in-law, or other key family members in counseling and education about the benefits of family planning. Tailor messages to best serve needs of clients. Source: Lloyd, 2008; Wilcher, 2008.

Benefits of FP for Children Longer breastfeeding: Provides nutrition Protects from childhood diseases Improves mother/child bonding Reduces child illness and death Allows more time and resources for parents to meet the needs of each child Suggested script: When women and couples use family planning to space, time, and limit their pregnancies, their children also benefit. Better spaced pregnancies allow for longer periods of breastfeeding which give infants and young children the chance to derive the maximum benefits from the practice of breastfeeding including better nutrition, protection from childhood diseases, and opportunities for mother and child bonding. Children who are exclusively breastfed are at lower risk of disease, especially diarrhea and respiratory infections. Children born to women who use family planning to space, time, and limit births are more likely to survive and less likely to be sick. Research has shown that babies born less than two years after the next oldest sibling are more than twice as likely to die in the first year as those born after an interval of three years. Spacing births could save the lives of more than two million infants and children each year. Family planning gives parents the option to have the number of children they want when they want them which allows them to meet the varied needs of each individual child. Note to facilitator: Present and discuss country-specific or district/local data regarding infant and child deaths. Source: Rutstein, 2005; Demographic and Health Surveys, various years.

Benefits of FP for Families and Communities Families can devote more resources to providing for each child Reduced maternal and child illness reduces economic strain on family Reduced maternal deaths strengthen families and communities Relieves economic, social, and environmental pressures Enhances women’s status and promotes equality between men and women Suggested script: Family planning allows families to devote more resources to providing their children with food, clothing, housing, and education. The reduced risk of death and illnesses among mothers, newborns, infants, and children achieved by healthy timing, spacing, and limiting of pregnancies contributes to reducing the economic strain on a family and helps to ensure family health. Reductions in maternal mortality mean that more women are able to care for their children and families thus improving the quality of life for the entire community. When entire communities carefully plan their families, better space their pregnancies and limit the number of overall births, family planning may relieve the economic, social and environmental pressures from rapidly growing populations.1 Healthier families and communities may enhance opportunities for better planning and development and facilitate preservation of natural resources like forests, water, and land. Family planning has the potential to enhance women’s status in the community and promote equality between men and women.

Benefits of FP for People Living with HIV Experience same benefits as others Additional benefits include: Reduction in number of children born HIV-positive (by reducing number of unintended pregnancies) Reduction in number of children born who could become orphans _ Couples can use family planning until they are ready to get pregnant Suggested script: Integrated reproductive health services, that include family planning counselling and access to contraception, along with HIV testing, care and treatment, can improve the lives of women and couples with HIV and the lives of their families. When FP services are easy to access, clients with HIV experience the same health benefits as others in their communities. Couples can limit the size of their families to the number of children they desire and are able to care for. Women can better space their children and reduce the risks associated with too many pregnancies or pregnancies spaced too closely. What are some additional benefits that FP affords people with HIV? <accept suggestions from several participants without addressing whether the responses are correct, then click the mouse to reveal the first bullet> The impact of antiretroviral therapy may encourage clients with HIV to reconsider decisions about sex, relationships, and childbearing as ARVs improve their health and longevity and reduce mother-to-child HIV transmission. For clients with HIV: Family planning can also reduce HIV infections among children by helping women with HIV who do not want to have children avoid pregnancy. Parents with HIV who are concerned that they may eventually die of AIDS may decide to use contraception to avoid having children who may some day become orphans. Knowing about family planning means that couples can use family planning until they are ready to get pregnant.

Key Timing, Spacing, and Limiting Messages to Share with Clients Women and infants may get sick or die if a pregnancy happens: Too early among adolescents  delay first pregnancy until 18 years Too soon after giving birth  wait at least 24 months before trying to become pregnant Too soon after an abortion or miscarriage  delay trying to become pregnant at least 6 months Too late in a woman’s life  plan prior to age 35 After having four children  risks increase with each pregnancy Suggested script: As we have discussed, family planning allows clients to time, space, and limit births in healthy ways, and thereby avoid the risks of illness or death that are associated with pregnancies that occur too often, too early or late in life, or too soon after a previous pregnancy, miscarriage, or abortion. For clients to make an informed choice about family planning, they should understand the health benefits for themselves and their children. Providers should explain risks that are related to maternal age, high parity, and certain spacing practices. Providers should target messages for specific groups of clients.1, 2 For adolescents, the key messages are: For the health of the mother and baby, women should wait until they are at least 18 years of age before trying to become pregnant. If and when adolescents become sexually active, they should consider using a family planning method of their choice until they are 18 years old, or older if they don't want to get pregnant. For couples who desire another pregnancy after a live birth, the messages are: For the health of the mother and the baby, after a birth wait at least 24 months, before trying to become pregnant again. Women should consider using a family planning method of their choice during that time. For couples who decide to have a child after a miscarriage or abortion, the messages are: For the health of the mother and the baby, wait at least six months before trying to become pregnant again. Women should consider using a family planning method of their choice during that time. For women over 35 years of age, the messages are: For the health of the mother and the baby, consider avoiding additional pregnancies. Women over the age of 35 should consider using a family planning method of their choice―particularly long-acting or permanent methods―if they want to avoid additional pregnancies. If women over the age of 35 want to become pregnant, they should space their pregnancies and be sure to use antenatal care and skilled birth attendants at delivery. For couples who have four or more children, the messages are: There are health risks for the mother and the baby when women have more than four children. Women should consider using a family planning method of their choice―particularly long-acting or permanent methods―if they want to avoid additional pregnancies. In addition to communicating these messages to clients, providers should screen all women for existing health conditions that would put them at risk for health complications associated with pregnancy and childbirth. Source: WHO 1995; ESD, 2008.

Family Planning and Human Rights All individuals and couples have the right: “…to decide freely and responsibly the number, spacing and timing of their children and to have the information, education, and means to do so, and the right to attain the highest standard of sexual and reproductive health...” – ICPD Programme of Action Suggested script: • Explain that the 1994 International Conference on Population and Development (ICPD) in Cairo was a milestone in the history of population and development, as well as in the history of women's rights. At the conference the world agreed that population is not just about counting people, but about making sure that every person counts. • Ask participants to explain what the quotation means. Note their responses on a flip chart. • Ask participants to generate ideas about how they can help ensure the ICPD Program of Action. Answers should include basic principles such as providing full access to information on contraceptive choices and to counseling, services, and supplies that allow a client to choose freely and allowing clients to make decisions independently, without the influence of any special incentives or forms of coercion. Explain that: • Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for. • When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family. • Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld. • FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size. Source: United Nations, 1995.

Benefits of Providing FP Services Improves well-being of families and communities Helps achieve the healthiest outcomes for women and their children Allow women and couples to delay, space, and limit pregnancies Suggested script: Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for. When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family. Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld. FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size. Note to facilitator: For participants who desire more information about the Benefits of FP and healthy timing and spacing of pregnancy, distribute copies of the optional handout Family Planning Saves Lives Backgrounder, Population Reference Bureau, 2009 Ask students to mention one thing they learnt from this session. Acknowledge responses are include: How FP saves lives Reinforcement of human rights etc. Thank students and adjourn the session. FP services are most effective when clients are free to make informed choices.