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

2. 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

3. 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

4. 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?

5. 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, June 2005, WHO Geneva

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

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

14. 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

15. 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 =10days)
Subtract 11 from the number of days in the longest cycle to find the last fertile day of a cycle. (e.g =19days)

16. 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

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

18. 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

19. 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.

20. 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)

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

22. 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

23. 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)

24. 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

25. 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

26. 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

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

28. 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).

29. 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.

30. 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

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

32. 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

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

34. 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

35. 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

36. Thank You