1. Method-specific Counseling 27. 12. 2012

2. Specific counseling Choosing a contraceptive: efficacy, safety and personal considerations Common side effects. Counseling in Follow up visits

3. Revision Clients should make their own decision. The counselor should help clients to match their FP needs and preferences to a safe and appropriate method. If the client is visiting the clinic to start using a method of contraception, ask the client if s/he has a particular method of contraception in mind.

4. If the client is considering a method: Review client’s medical and social history for appropriateness Review client’s medical and social history for appropriateness - If the method is appropriate What? - If the method is not appropriate. What? If the client chooses the inappropriate method. If the client chooses the inappropriate method.MECIV MEC III MEC II

5. If the client has no method in mind Ask the client which methods of family planning s/he knows Briefly describe each method to the client. If still unable, suggest a method and explain why If the client does not agree, recommend another method If there is still some hesitation, give her more time Never try to impose a method on the client.

6. Special situations If the client chooses a method which you do not have in stock or do not offer If the client chooses a method which you do not have in stock or do not offer If the client chooses female or male sterilization If the client chooses female or male sterilization

7. Explanation of how to use the method - How to use the method. - Possible side-effects. - Management of side-effects. - Warning signs that indicate need for medical follow-up, and where to obtain this follow-up. - Re-supply information, if applicable. - When the next follow-up visit should take place. Provide each client with printed information on the chosen method Provide each client with printed information on the chosen method Explain when the client should return for routine follow-up and re-supply. Explain when the client should return for routine follow-up and re-supply. Explain the importance of a return visit if the client: - Is experiencing any side-effects. - Has any questions. - Wishes to switch to a different method. - Wants to stop using the method.

8. Return for follow-up Follow-up visits are an important opportunity to: Follow-up visits are an important opportunity to: Reinforce the decision clients have made to plan their family. Reinforce the decision clients have made to plan their family. Discuss any problems and Answer any questions they may have. Discuss any problems and Answer any questions they may have. Explore changes in their current health status or life situation. Explore changes in their current health status or life situation. During a follow-up visit: Briefly review the chart for the main details of the reproductive health history. Briefly review the chart for the main details of the reproductive health history. Ask the client how s/he feels with the method and if there are any questions. Ask the client how s/he feels with the method and if there are any questions. If s/he is having any problem with the method, assess and discuss possible solutions. If s/he is having any problem with the method, assess and discuss possible solutions. If the problem is a side-effect, assess how severe it is and offer suggestions for managing it or refer the client for treatment. If the problem is a side-effect, assess how severe it is and offer suggestions for managing it or refer the client for treatment. If the client is not using the method any more, ask why not (it may be due to problems related to misunderstanding, side-effects or supply). If the client is not using the method any more, ask why not (it may be due to problems related to misunderstanding, side-effects or supply). If the client still wishes to continue using a contraceptive answer her questions and provide information If the client still wishes to continue using a contraceptive answer her questions and provide information

9. Choosing a contraceptive: efficacy, safety and personal considerations

10. A (Ask her about her needs) Types of clients Newly married Breast-feederSpacerLimiter Others (postabortion, medical disorders)

11. IS SHE ELIGIBLE

16. Tell her about the methods EfficacySafety Convenience (Side effects, ease of use, reversibility, cost …...etc)

17. Failure RateContraceptive As Commonly UsedUsed Correctly 6-8%0.1%COC 1%0.5%POP 0.3% DMPA Less than 1% Once-a-month Combined Injectables Almost 0% Implanon 0.8%0.6%Cu T 380-IUD Less than 1%IUS 14%3%Condoms 20%6%Diaphragm with Spermicide 26%6%Spermicide 2%0.5%LAM (first 6 months) 2%0.5%Tubal Ligation N/A Abstinence N/A Coitus Interruptus 20%1-9%Fertility Awareness Methods 0.15%0.1%Vasectomy

19. Counseling for Side Effects Counseling for Side Effects When counseling clients for side effects: Prepare clients for what might occur while using a method. Prepare clients for what might occur while using a method. Tell the client about symptoms/side effects which probably or may diminish over time Tell the client about symptoms/side effects which probably or may diminish over time (e.g., lack of menses with DMPA). Do not dismiss, but take seriously, any client's concern about side effects. Do not dismiss, but take seriously, any client's concern about side effects. Provide reassurance and practical suggestions for coping with side effects. Provide reassurance and practical suggestions for coping with side effects. Assist the client to switch to or choose another method if the client wishes Assist the client to switch to or choose another method if the client wishes Common Side Effects by Method Weight Gain: COCs, Injectables Spotting: COCs, POPs, Injectables, Implants, IUDs Amenorrhea: POPs, Injectables, Implants Nausea: COCs Cramping: IUDs Heavier Menses: IUDs, POPs, Injectables, Implants

20. Side effects/ complications COC Nausea (most common in first 3 months). Nausea (most common in first 3 months). Spotting Spotting Mild headaches. Mild headaches. Breast tenderness. Breast tenderness. Slight weight gain. Slight weight gain. Stroke Stroke blood clots in deep veins of the legs blood clots in deep veins of the legs Amenorrhoea Amenorrhoea may cause mood changes may cause mood changes heart attack heart attack

21. POP „„ Changes in bleeding patterns lengthened postpartum amenorrhoea Irregular menstrual bleeding Amenorrhoea „„ Headaches „„ Dizziness „„ Mood changes „„ Breast tenderness „„ Abdominal pain „„ Nausea „„ For women not breastfeeding, enlarged ovarian follicles

22. IUCD Changes in bleeding pattern, especially in the first 3–6 months, but likely to lessen after 3 months of use: Changes in bleeding pattern, especially in the first 3–6 months, but likely to lessen after 3 months of use: Longer and heavier menstrual periods Longer and heavier menstrual periods Irregular bleeding or spotting between periods Irregular bleeding or spotting between periods More cramps or pain during periods More cramps or pain during periods Cramping pain may occur for the first 24 to 48 hours after insertion. Vaginal discharge may occur during the first few weeks May contribute to anemia May contribute to anemia Perforation of the wall of the uterus (very rare) Perforation of the wall of the uterus (very rare) Expulsion Expulsion PID PID

23. Implanon Discomfort for several hours to 1 day after insertion Removal is sometimes painful and more difficult than insertion. One in every six pregnancies is ectopic. Menstrual irregularity Headache. nervousness, Nausea Dizziness weight gain skin side-effects such as acne

24. Tubal sterilization Complications of Minilaparotomy Drug reaction Bleeding from the wound Uterine perforation Bladder or intestinal injury Anesthesia problems Tears/transaction of the tubes Wound infection Haematoma or abscess formation Menstrual disorders Ectopic pregnancy Failure Complications of Laparoscopy Bleeding Visceral injuries Infection gas embolism subcutaneous emphysema respiratory or cardiac arrest Injured blood vessel or viscera Injured blood vessel or viscera

25. Most effective and nothing to remember. Effective but must be carefully used. Fewer side-effects: Very effective but must be carefully used. More side-effects: Pills Injectables Fertility awareness- based methods Vaginal methods Male and female condom IMPORTANT! Only condoms protect against both pregnancy and STIs/HIV/AIDS Fewer side-effects, permanent: More side-effects: Implants IUD Fewer side-effects: LAM Female sterilization Vasectomy Comparing methods

26. counseling in Follow up visits

27. COC ask the client: „„ If she has any questions or anything to discuss. „„ whether she is satisfied whether she has any problems. whether she has any problems. „„ If she has had any health problems since her last visit Assess the following: Check blood pressure once a year if possible. Ask if she has developed any contraindication If appropriate, help her choose another method. Plan for Her Next Visit

28. COC Warning signs A= Abdominal pain (severe) C= Chest pain (severe) with cough and shortness of breath H= Headache (severe) with dizziness and shortness of breath E= Eye problems (vision loss, blurring, or flashes of light) S= Severe leg pain (calf or thigh)

29. POP Ask if the client has any questions or anything to discuss. Ask whether she is satisfied Whether she has any problems. Plan for Next Visit Encourage her to come back for more pills before she uses up her supply of pills.

30. DMPA Ask the following questions at any return visit: „„ if she has any questions or anything to discuss. „„ whether she is satisfied, whether she has any problems. „„ Ask about her bleeding patterns. „„ Ask if she has had any health problems since her last visit:

31. Warning symptoms A= Abnormal heavy bleeding S= Stroke and heart disease (chest pain and dyspnea) H= Headache (severe) Y= Yellow color of eyes (jaundice)

32. warning symptoms PAINS P= Period late or heavy A= Abdominal pain I= Infection N= Not feeling well (pyrexia and chills) S= String changes or problems.

33. IUCD return visit The client can come after her first menses, but not later than 3 months, for her first check-up. If no complaints, she can come whenever a problem arises. During the first follow-up visit: „„ Ask the client if she has any complaints, whether she is satisfied or has anything to discuss „„ Check for anemia if excessive or prolonged bleeding. „„ Do a pelvic examination to check if: IUCD threads are visible. There are any signs of infection.

34. Implanon „„ Ask the client to come for a check-up after 1 month and for removal of the implants at the end of their effective lifespan. „„ Reassure her that removal is available whenever she wants it. „„ Ensure that she understands that the implants must be removed after the effective period is over. „„ Check the insertion site to see whether it has healed. „„ Check that the implants are in place. On the visit for removal of implants, do the following: „„ Remove the implants. „„ Insert a new set of implants if the client desires.

35. Warning Signs D= Delay in monthly periods I= Infection at insertion site S= Severe abdominal pain C= Capsule of the implant comes out of the skin U= Unusually heavy vaginal bleeding S= Soreness of the arm S= Severe headache or blurred vision

36. أسئلة

37. طيب أسأل أنا 1. For most clients, the best family planning method is: a. the one that the health provider thinks is best for a particular client. b. the one that is most effective. c. the one that is most convenient for the provider. d. the one that the client chooses after learning about all the available methods. e. The one that the husband chooses. 2. Informed choice means that a family planning client: a. has been informed about all methods and agrees to use the contraceptive method the provider recommends. b. has been informed about the side effects of the method she has chosen. c. has informed you of the method she wants. d. has the right to choose any method she wants based on full information

38. An informed consent form signed by the client is required for: a. COCs b. IUD c. DMPA d. Tubal Ligation e. all of the above Which is the best way to correct a rumor about a FP method? a. Laugh at the client for believing such a silly rumor. b. Politely tell the client the rumor is not true, and try to change the subject. c. Politely explain that the rumor is not true and why it is not true. d. Ignore the comment. e. None of the above.

39. Which of the following are characteristics of active listening? T/F a. Occasionally paraphrasing or summarizing what the client has said b. Looking at the client while s/he is talking c. Thinking about what you will say next to the client d. Writing or reading notes while the client is speaking e. Asking specific questions related to what the client has told you f. Interrupting the client g. Nodding your head and making encouraging sounds while client is speaking h. Filing papers Which of the following are characteristics of effective questioning? T/F a. Asking more than one question at a time b. Asking one question and waiting for an answer c. Asking questions that begin with why d. Phrasing questions to avoid yes or no answers e. Using a tone of voice that indicates interest and concern f. Using words to encourage client to keep talking, such as "oh?" and "then?" g. Asking leading questions

40. The word GATHER is a memory aid to help us remember the steps of the counseling. What does each letter stand for? G = ___________________________________________________ A = ___________________________________________________ T = ___________________________________________________ H = ___________________________________________________ E = ___________________________________________________ R = ____________________________________________________

41. A client will better understand and remember the correct use of a method if: a. she is given general counseling and a detailed pamphlet to read at home. b. the instructions are given to her mother-in-law or husband. c. she is able to handle and/or look at the method chosen d. technical medical language is used. e. she is encouraged to ask questions. A client has had an IUD in for three months and now wants to have it removed. What would be the best counseling response? a. try to persuade her to keep it for another three months. b. remove it without questions and help her choose another method. c. Ask her why she wants it removed and act accordingly d. Remove and tell her that she will not have another inserted e. Counsel about consequences of unintended pregnancy

42. Indicate whether the statement is true or false. a. A good counseling session is one in which the service provider leads and controls the discussion. b. A spouse or mother-in-law should be encouraged to participate in FP counseling sessions, even if the client does not seem eager to involve them. c. It is acceptable for a provider to persuade a client to use a method that the provider genuinely thinks is better for the client. d. Counseling is more important when the client is illiterate than when the client is highly educated. e. Brief, simple, specific messages which are repeated often are a good way to provide instructions for method use. f. The decision to use a particular method must be made by the client.

43. Detailed information about a particular method is usually discussed with a client during: a. general FP counseling. b. method-specific counseling. c. follow-up counseling. d. all of the above. If a client is unsure about choice of a FP method, a service provider should: a. tell the client which method the provider thinks is best. b. not mention a method that involves action on part of client. c. counsel the client on all the methods available and suggest she think about it and return when she has made a decision. d. explore with the client what method would best fit her and guide her in her final decision.

44. Which of the following is an open-ended question? a. Do you want to use the Pill? b. How would you feel about using the Pill? c. What have you heard about the IUD? d. Have you heard of the IUD? e. Do you remember what to do if you miss one pill? f. Tell me what you will do if you miss one pill. g. How would you feel about not having any more children? h. You realize that female sterilization is permanent?