CONTRACEPTION Prof. Roshan Ara Qazi Chairperson Obstetrics & Gynaecology LUMHS, Jamshoro

LEARNING OBJECTIVES The student will be able to: Describe contraception, importance of family planning & concept of “healthy timing & spacing of pregnancy” (HTSP) Describe major family planning methods including mechanism of action, benefits & limitations

Definations Contraception: Intentional prevention of conception or impregnation through use of various devices, agents, drugs, sexual practices or surgical procedures. Family Planning: It allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through use of contraception

HEALTHY TIMING & SPACING OF PREGNANCY (HTSP) In June 2005, WHO brought together more than 30 technical experts to review the global scientific evidence regarding optional birth spacing & answer the following questions 1) Does pregnancy spacing affect the health of mothers and newborn? 2) How long should a woman wait to get pregnant after childbirth?

HEALTHY TIMING & SPACING OF PREGNANCY (HTSP) Cont.. 3) How long should a woman wait to get pregnant after miscarriage or induced abortion? The set of recommendation called healthy timing & spacing of pregnancy is based on the results of this technical consultation. Ref: WHO 2006; Report of a WHO technical consultation on birth spacing, Geneva, Switzerland, 13-15 June 2005, WHO Geneva

Key research finding Short birth intervals are associated with multiple adverse outcomes for mothers & newborns An infant born after short birth interval is at increased risk of Preterm birth Low birth weight Small for gestational age Death

Key research finding (cont..) A women who becomes pregnant too quickly following previous birth/miscarriage or induced abortion faces higher risks of Anemia Pre rupture of membranes Abortion Death

3 COMPONENTS OF HTSP AFTER LIVE BIRTH The recommended interval before attempting the next pregnancy is at least 24 months in order to reduce the risk of advise maternal perinatal & infant outcomes AFTER MISCARRIAGE OR INDUCED ABORTION The recommended minimum interval to next pregnancy should be at least 6months in order to reduce the risk of adverse maternal and perinatal outcomes DELAY ADOLESCENCE PREGNANCY Delay timing of the first pregnancy until age 18 to reduce risks of adverse maternal, perinatal & infant outcomes

Country Profile Pakistan 6th most populous country of Pakistan with high unmet need of family planning about 25% Approximately 1 in 3 births occurs less than 24 months after a previous birth The shortest birth intervals occurs in women ages 15 – 19 who are already at highest risk of pregnancy related complications

Country Policy The client will be given full information about optimal pregnancy spacing and the benefits of HTSP as a part of FP health education and counseling. The importance of timely initiation of an FP method after childbirth, miscarriage, or abortion will be emphasized The client’s right to make a free and informed choice regarding eventual family size and fertility will be respected.

Classification of Contraception Combined hormonal contraception The pill, patches, the vaginal ring Progestogen – only preparations Progestogen-only pills, injectables, subdermal implants Hormonal emergency contraception Intrauterine contraception Copper intrauterine device (IUD), hormone-releasing intrauterine system (IUS) Barrier Methods Condoms, female barriers, coitus interruptus, natural family planning Sterilization (Voluntary Surgical Contraception) Female sterilization, vasectomy

Effectiveness of contraceptive methods Method of contraception Failure rate per 100 woman years Combined oral contraceptive pill 0.1 – 1 Progestogen – only pill 1 – 3 Depo – Provera ® 0.1 – 2 Implanon 0.1 Copper IUD 1 – 2 Mirena 0.5 Male condom 2 – 5 Diaphragm 1 – 15 Natural family planning 2 – 3 Vasectomy 0.02 Female sterilization 0.13

Natural family planning method A) Lactational Amenorrhea Method (LAM or Breastfeeding) B) Fertility awareness-based method 1) Calendar Based Method Calendar based method Standard days method (SDM) 2) Symptoms Based Methods Ovulation method / cervical mucus method Basal Body Temperature (BBT) method 3) Withdrawal Method

Standard Days Method Helps a couple know which days they should not have unprotected intercourse For women with menstrual cycles between 26 and 32 days long Couples who can avoid unprotected intercourse from day 8-19

Calendar Rhythm Method Keeping a record of at least 6 menstrual cycles. Find the longest and shortest of the menstrual cycle Subtract 18 from the number of days in the shortest cycle to find the first fertile day of a current cycle. (e.g. 28-18=10days) Subtract 11 from the number of days in the longest cycle to find the last fertile day of a cycle. (e.g. 30-11=19days)

Lactational Amenorrhea Method (LAM) Preventing pregnancy by breast feeding Mechanism of action: ovulation prevention Very effective: 1-2 pregnancies / 100 women in firs 6 months No side effects or health risks Health benefits for the baby

Who Can Use LAM? Women who: Are fully or nearly fully breastfeeding Have not had return of menses Are less than 6 months postpartum

Symptom Based Method Presence or absence of cervical mucus Shift in BBT to identify post ovulatory infertile (safe) days Take temperature every morning before any activity Recorded daily on a graph paper Within twelve hours of ovulation , the BBT will rise (0.4 to 1 F) until start of next cycle Presence or absence of cervical mucus Dry (safe) days Wet (fertile) days Note mucus for: Color (yellow, white, clear, cloudy) Consistency (thick, sticky, stretchy) Feel (dry, wet, slippery, stretchy) Based Body Temperature Cervico Mucus

Barrier Methods: Male condoms Condoms are commonly made of thin sheaths of rubber (latex) or vinyl. They differ in, color, lubrication, thickness, texture and addition of spermicide. Prevent sperm from gaining access to female reproductive tract. Prevent microorganisms (STIs) passing from one partner to other.

Male Condoms: Contraceptive & Health Benefits and limitations No systemic side effects Widely available No prescription or medical assessment necessary Only FP method that provides protection against STIs LIMITATIONS Effectiveness depends on willingness to follow instructions User-dependent (require continued motivation and use with each act of intercourse)

Brief Introduction of COCs Containing both estrogen and progestin (COCs) Prevents the release of the ovum or egg from ovaries

COCs: Contraceptive & Health Benifits Highly effective when taken daily (0.1 to 1) pregnancies per 100 women during the first year of use) Client can stop use Fertility returns soon after stopping Decrease menstrual flow (lighter, shorter periods) Decrease menstrual cramps Protect against ovarian and endometrial cancer

COCs: Limitations Some nausea, dizziness, mild breast tenderness, headaches or spotting may occur Effectiveness may be lowered when certain drugs are taken barbiturates, carbamazetine, phenytoin and rifampicin Rare serious side effects possible Resupply must be readily and easily available Do not protect against STIs (e.g., HBV, HIV/AIDS)

Who Can Use COCs Women: Of any reproductive age or parity who want highly effective protection against pregnancy (within first 5 days of the menstrual cycle or any time if the client is not pregnant) Who are breastfeeding (6 months or more postpartum) Who are postpartum and are not breastfeeding (begin after third week) Who are post abortion (start immediately or within 7 days) With severe menstrual cramping or with irregular menses In need of emergency contraception

Progestin only Pills (POPs) – Minipills – General Information Contains only progestin (single hormone) Mechanism of action Inhabits ovulation Thickness cervical mucous Used less often in Pakistan than COCs

Injectable Contraceptives Contains both estrogen and progesterone Mechanism of action: preventing ovulation Given every 1 month Very effective at < 1 pregnancy / 100 women Health benefits and risk similar to COC Only progestin: DMPA NET-EN Mechanism of action: preventing ovulation / thickness cervical mucous Given DMPA – every 3 months mNet-EN - every 2 months Very effective at < 1 pregnancy/100 women Combined injectable contraceptive Progestin injectable contraceptive

PICs: Advantages Very effective Reversible Do not affect breastfeeding Few side effects Protect against endometrial cancer and fibroids

PICs: Limitations Return to health clinic for an injection every 3 months (DMPA) or every 2 months (NET-EN) Changes in menstrual bleeding patterns are common If using DMPA, return of fertility is temporarily delayed, but does not decrease fertility in the long term If using DMPA, 50% of women will stop having any bleeding by end of first year of use PICs do not provide protection against STIs, (e.g., HBV, HIV/AIDS).

Emergency Contraception EC should be considered if unprotected intercourse has occurred, if there has been failure of a barrier method for example a burst condom or if hormonal contraception has been forgotten. Hormonal emergency contraception: single dose levonorgestrel 1.5mg within 72hours of unprotected intercourse IUD for emergency contraception: upto 5days of unprotected intercourse.

Intra Uterine Contraceptive Device Copper containing IUCD Hormone releasing intra uterine system (Levonorgestrel) Copper T 380 A Mirena Multiload Cu 375 LNG - IUCD Intrauterine Contraceptive Devices (IUCDs) Types of IUCDs

Mode of Action (IUCD) Prevents Fertilization by: Changing endometrial lining Interfering with ability of sperm to pass through uterine cavity

Characteristics of Copper IUCD Highly effective and economical Does not interfere with intercourse Long lasting (Multiload up to 5 years and CuT up to 12 years) Quick return of fertility after removal no systemic effects

Voluntary Surgical Contraception (VSC): Definition Minor voluntary surgical procedure for permanently terminating fertility in men (vasectomy) and women (mini-laparotomy and laparoscopy)

VSC: Mechanism of Action Vasectomy (no-scalpel or incisional): By blocking the vas deferens, sperm are no longer present in the ejaculate Minilaparotomy or laparoscopy: By blocking the fallopian tube (tying the cutting, rings, clips or electrocautery) ovum is prevented from meeting with sperm

VSC BENEFITS LIMITATIONS Highly effective, Permanent Simple surgery usually performed under local anesthesia No change in sexual functin LIMITATIONS Must be considered permanent (not reversible) Client may regret later Short-term discomfort/pain following procedure

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