Pathfinder International CHBC Handbook

ADVANCED UNIT 16: FAMILY PLANNING

The CHW can help clients and others in the community by: Remember:
• Explaining how women get pregnant (conception). Family planning is very important for
• Giving them:
PLWHA so that they can prevent
spreading HIV from mother to baby
h Family Planning (FP) information.
(PMTCT) and make choices about
h FP counseling. having babies that are right for them.
h FP methods (like condoms and pills) that do not need a
visit to the clinic or health facility.
h All of the information about FP and HIV/AIDS so they can
choose to get pregnant or not get pregnant.
• Helping clients get good health care and VCT.

• Making sure clients are happy with the FP method they are using.

• Helping clients with any FP side effects and giving referrals to a

health facility.

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Conception and Family Planning

Conception
Conception means getting pregnant. It happens when a woman and a man have sex, and his sperm joins
with her egg. Getting pregnant happens through these steps:

1. Ovulation and Production of Sperm

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2. Sex during the fertile period 3. Sperm and egg join together

4. Pregnancy

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Monthly Bleeding: If the woman’s egg is not joined with a man’s sperm, the egg will pass out of her
body about 2 weeks later with her monthly bleeding. There is no monthly bleeding during pregnancy
because the woman’s body needs that blood to feed the baby in the womb.

Family Planning (FP) is having the number of children you want, when you want them, when the
mother is not too young and not too old, by using a method such as condoms or pills.

Birth spacing: For the health of the mother and the baby it is best to wait 2 years between the last birth
and trying to get pregnant again.

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Choosing to Have a Baby

PLWHA, like all other people, have the right to decide whether to have children or not. It is very
important not to judge a person living with HIV/AIDS who wants to have children. If you judge someone,
s/he may not listen to you when you tell them how to have a healthy pregnancy.
To help the client decide if s/he wants to have a child, the CHW should talk with the client about how:
• A baby needs healthy parents to give it food, clothes, love, and a safe place to live.

• If an HIV+ woman has a baby, her baby may be born with

HIV. HIV+ babies need more care from the family and more
health services.
• A baby born to HIV+ parents is more likely to get sick, die
young, or be orphaned (even if the baby is not HIV+).
• If a client wants to have a baby, she should protect the baby
from getting HIV. (There is more information in Unit 17:
Preventing Mother-to-Child Transmission (PMTCT) of HIV.)
• If a client does not want to have a baby, she can use FP
methods to prevent pregnancy.

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Family Planning Methods

There are different kinds of FP methods:
• Methods that have to be used every day (like the pill ) or every
time you have sex (like condoms).
• Methods that last for a short time (like injectables). These have to be
put in a woman’s body by a health worker at a clinic or hospital.
• Methods that last for a long time (like implants or IUDs). These
have to be put in a woman’s body by a health worker at a clinic
or hospital.
• Natural methods that work just with a woman’s body, and do
not need anything else (like only breastfeeding for 6 months
after giving birth, or the standard days method and mucus method for knowing when your body is
fertile). Sometimes, the methods that help you know when you are fertile are hard to follow, and do
not work as well as other methods.
• Permanent methods, that last forever (like getting your tubes tied). These must be done by a health
worker at a clinic or hospital.

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Side Effects of FP Methods

Sometimes, FP methods may have side effects. This is when a FP method causes a person some
discomfort or a problem. Many people will not have any side effects. But, there are some side effects that
are more common with certain methods.

Remember:
CHWs can and should give
condoms, pills, and Emergency
Contraceptive Pills (ECP) to anyone
in the community who needs them.

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FP Referrals and Follow-Up

CHWs should:
• Know what health clinics in their community can give these methods.

• Refer clients to the right clinic.

• Follow-up to find out if the client is happy with her FP method

or if the client is having side effects.
• Remind the client that most side effects are normal.

• Know FP warning signs and refer to the clinic if they are having
bad side effects or warning signs.

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Condoms
For more information on how to use male and female condoms, see Unit 4:
Our Bodies and Safer Sex..

Protection against pregnancy: VERY GOOD

ÌÌÌ
Protection against STIs/HIV:
Sometimes condoms do not cover sores or ulcers on the outside body parts, which means that
STIs can be spread to a partner. People who have sores or ulcers on their reproductive body parts
that are not covered by a male or female condom should not have sex until they have healed.
Possible side effects:
Usually none. A few people may be allergic to latex (male condoms only) and have bad
itching, skin bumps, or difficult breathing.

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Things to know about condoms:

• Condoms should only be used one time.

• Male latex condoms are the most common kind of condom. If a person is allergic to
latex, they can use condoms made of polyurethane. (Condoms made of lamb’s skin
will NOT protect against STIs and HIV!)
• Lubricants (spit, KY Jelly, or glycerin) can be used with condoms. DO NOT use oils,
petroleum jelly (Vaseline), skin lotions, or butter because they can make the condom break.
• A new female condom should be used every time you have sex. But if there are no other condoms are
available, a female condom can be washed carefully with soap and water and re-used.
• To wash a female condom:

h Wash off all the old lubricant on the outside of the

condom with soap and water. Remember:
h Turn the condom inside out and wash the other side. Even if someone is using another
method to prevent pregnancy,
h Let both sides dry all the way.
CONDOMS SHOULD BE USED EVERY
h Soap and water does not always get rid of all the virus, TIME DURING SEX to prevent STI/HIV
so you should only re-use a female condom (with new infection or HIV re-infection.
lubrication) when there are no other condoms available.

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Oral Contraceptive Pills (OCPs)

Protection against pregnancy: BEST

ÌÌÌÌ

Protection against STIs/HIV:

Possible side effects:

None at all, or nausea, headaches, weight gain, swelling of the breasts, and changes in
monthly bleeding (usually less than usual). Combined Oral Contraceptive (COC) pills may
cause more side effects for some women than for others.

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Things to know about the pill:

• Women must take their pill every day at about the same time. Women who are forgetful should not use the pill.

• When a woman is on TB medicine she should not use the pill to prevent pregnancy. She should choose
another method. Some ARVs and other medicines (like anti-seizure medicine) also make the pill not
work as well. CHWs and clients should talk to a doctor at the health facility before any woman who is
taking medicine to treat AIDS or seizures starts taking OCPs.
• Other antibiotic medicines are OK to take along with the pill, unless the woman is having a hard time taking
the pill because of vomiting.
• Most pills CANNOT be used during breastfeeding because they stop a woman from making enough milk for
her baby. (If a woman is breastfeeding and wants the pill, she should go to the clinic to get the type of pills
that can be used when breastfeeding.)
• If a woman stops taking the pill, she can get pregnant very soon (even after a few days).

• It is NOT safe for PLWHA to use pills if they have:

h Breast cancer. h Very bad headaches with eye/sight problems.

h Liver problems. h TB, and take TB medicine.

h Heart problems or high blood pressure. h Seizures and take medicine for their seizures

• It is important to ask women some questions to find out if they can take the pill safely. CHWs
should use the checklist at the end of this Handbook in the Useful Forms and Checklists section to
know if a client can take OCPs.
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How to take the pill:

1. Take the first pill on: Remember:
The pill does not protect against STIs
h The first day of the monthly bleeding, or
and HIV, so condoms should always
h Any of the next 5 days, or be used along with pills.
h Any other time the woman is pretty sure she is not pregnant.

2. Take one pill every day, at the same time of day.

3. For 28-day pill packets: When the woman finishes one packet, she should take the first pill in the
next packet on the next day.
For 21-day pill packets: When the woman finishes one packet, she should wait 7 days. Then take the
first pill in the next packet on the next day. (Usually, a woman will start her monthly bleeding during
the 7 days when she is not taking pills. But, if she does not get her monthly bleeding, she should still
th
start a new pill packet on the 8 day.)
4. If a client forgets to take a pill, she can get pregnant.
h If she misses any pills, she should take 2 pills as soon as she remembers, and keep taking 1 pill each day at
the regular time.
h If she misses 3 or more pills, she should use another FP method (like condoms) or not have sex for the
next 7 days.
rd
h If she misses 3 pills in the 3 week of her cycle, she should throw away the rest of her pills and start a new
packet right away.
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Warning Signs for the Pill

The CHW should refer the client to the health facility if she has any of these side effects after starting the pill:
• Abdominal pain—pain in the belly that goes on a long time without stopping.

• Chest pain—pain in the chest that goes on a long time without stopping and is very bad.

• Headaches—pain in the head that goes on a long time without stopping, are very
bad, and make it hard to speak or move an arm or leg.
• Eye problems—seeing things that are blurry, seeing more than 1 of the same thing,
or seeing flashing lights or zigzag lines.
• Severe leg pain—pain in the leg that goes on a long time without stopping or does not go away
(usually in the lower leg).
Also refer the client if:
• She is very sad for a long time or her mood changes quickly,

• She has yellow skin or eyes,

Remember:
Tell the client to come and see
• She misses 2 periods (monthly bleeds), or
you if she has a problem, or if
• She has signs of pregnancy. she needs more pills.

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Emergency Contraceptive Pills (ECP)

Women can take ECPs to prevent pregnancy AFTER having unprotected sex (for example, if a
condom breaks, or if sex is forced or not planned).
CHWs should:
• Get ECPs and learn how to get them from their supervisor or CHBC program.

• Give ECPs to anyone who needs it.

• Tell clients how to take ECP the right way.

• Refer clients to a health facility right away if the CHW does not have any ECPs left.

Protection against pregnancy: GOOD

ÌÌ
• If taken within 120 hours (5 days) after unprotected sex.

• ECPs should not be used as a regular FP method because they do not work as well as other methods.

Protection against STIs/HIV:

Possible side effects: Remember:
ECP should be taken as soon after
None at all, or nausea, vomiting, monthly bleeding may be unprotected sex as possible!
off by a few days after taking ECP.

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How to take ECP:

1. Only use ECP within 120 hours (or 5 days) after unprotected sex.
2. Take the pills:
h If using a special product for ECP (like Postinor), take both pills together as soon after unprotected
sex as possible.
h If using pills that have been prepared by a nurse or doctor, take the first dose (usually 4 pills) as
soon after sex as possible. Take the second dose 12 hours later.
h Take the pills with food.

h If the woman vomits within the first 2 hours, take another dose right away with some food, and take
the second dose 12 hours later.
3. There will not be any signs that show if the ECP worked. The monthly bleeding should come on time.
4. If monthly bleeding is more than 1 week late, or there is any problems, go to the clinic.
Make sure to talk to the client about other FP methods, and help her choose a method. This way she
will not have any more unplanned pregnancies or have to use ECP again.

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Spermicides

Protection against pregnancy: SOME

Ì
Protection against STIs/HIV :
• Spermicides can irritate the woman’s vagina and make it easier for a woman to get infected or re-infected
with HIV.

Possible side effects:

Skin allergy. Remember:
Spermicides work best to prevent
pregnancy if they are used with
condoms.

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Intrauterine Device (IUD)

Protection against pregnancy: BEST

ÌÌÌÌ
Protection against STIs/HIV:

Possible side effects: Heavy and painful monthly bleeding in the first 6 months.

Things to know about the IUD:

• The woman must have an IUD put in by a health worker.

• Once in the womb, an IUD can stay for at least 10 years. Different kinds of IUDs can be left in for different
amounts of time.
• The woman and the man cannot feel the IUD during sex.

• The IUD will not move from the womb to other parts of the woman’s body.

• The woman does not have to do anything before having sex and no one can tell she is using a FP method.

• An HIV+ woman can get an IUD if: she does not have STIs, she is not likely to get STIs, and if she is on ART.

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Warning Signs for IUDs:

The client should go to the clinic if she has:
• Late or missed monthly bleeding.

• Spotting (light bleeding) that is not normal between her monthly bleeding.

• Pain in the belly that does not go away.

• Pain when she is having sex.

• Signs of infection (bad smell in the vagina, discharge, fever, chills, feeling ill).

• IUD strings get shorter or longer, or are missing.

• IUD comes out of her body.

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Injectables

Protection against pregnancy: BEST

ÌÌÌÌ
Protection against STIs/HIV:

Possible side effects:

None at all, or weight gain, sore breasts, nausea, and unusual monthly bleeding. Sometimes
there is no monthly bleeding at all, but this is not dangerous.

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Things to know about injectables:

• The woman does not have to do anything before sex and no one will know she is using a FP method.

• It is safe during breastfeeding.

• It might take up to 1 year for a woman to get pregnant once she stops getting the injections.

• One injection lasts 2-3 months.

• They do not cause babies to be born with bad health problems (birth defects).

• They do not stop a woman from getting pregnant once she stops getting the injections.

Warning Signs for Injectables

The woman should go to the clinic if she:
• Has headaches that happen often, and are very painful.

• Gets much more fat (more than 2 kilos in the first year).

• Has heavy monthly bleeding.

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Implants
BEST
Protection against pregnancy: ÌÌÌÌ

Protection against STIs/HIV:

Possible side effects:

None at all, or weight gain, sore breasts, nausea, and monthly bleeding that is not normal.
After the first year, there may be no monthly bleeding at all, but this is not dangerous.

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Things to know about implants:

• No one can tell the woman is using a FP method.

• Implants can be used during breastfeeding.

• A woman must get new implants at a clinic after 3 to 7 years.

• If a woman wants to get pregnant, she should go to the clinic to get the implants taken out.

• Implants will not break and move around in a woman’s body.

• Implants will not give a woman cancer.

• They do not cause babies to be born with bad health problems (birth defects).

Warning Signs for Implants:

The woman should go to the clinic if she has:
• Heavy bleeding from her vagina.

• Very bad headaches.

• Yellow skin or eyes.

• Bad pain in her belly.

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Diaphragm

• Women must get one from a trained health worker in the clinic that is the right fit for her body. But,
they are not available in most places.

Protection against Pregnancy: VERY GOOD

ÌÌÌ
Protection against STIs/HIV:

Possible side effects:

None.

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Sterilization
BEST
Protection against Pregnancy: ÌÌÌÌ

Protection against STIs/HIV:

Things to know about sterilization:

• Women and men can have the tubes in their bodies tied so that they can never have a baby.

• It is safe.

• It is permanent.

• It is an easy operation.

• It is done in a clinic or hospital.

• Women and men can take medicine for the operation so that they do not feel much pain.

• Women and men can still have sex and feel pleasure with sex after the operation.

• For men, it takes about 3 months after the operation for all of his sperm to be gone. He should use
condoms during that time.
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Natural FP Methods
Lactational Amenorrhea Method (LAM)
Women can prevent pregnancy by only breastfeeding for 6 months. The woman is
protected from getting pregnant if ALL of these things are true:
• She is giving the baby only breast milk whenever the baby is hungry and thirsty.

• She is breastfeeding at least every 4 hours during the day and every 6 hours
during the night.
• The baby is less than 6 months old.

• Her monthly bleeding has not returned since the baby was born.

If any one of these things is NOT true, the woman can get
pregnant and needs to use another kind of FP method.
Remember:
Protection against Pregnancy: BEST Women who are HIV+ should ALWAYS use
ÌÌÌÌ condoms if they are using LAM, so that
they will not get re-infected with HIV and
Protection against STIs/HIV: pass it to the baby through the breast

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Fertility Awareness
• A woman cannot get pregnant every day. She can only get pregnant during the days in her monthly
bleeding cycle that the egg is in the tube (ovulation).
• If a woman does not have sex in that time, she will not get pregnant.
• Women can use the mucus method or the standard days method to know what days they could
get pregnant.
• These methods can be very hard to follow.
• Counting days will not work if a woman’s monthly cycle is not the same every month.

Protection against Pregnancy: VERY GOOD

ÌÌÌ
Remember:
Protection against STIs/HIV: A woman’s sex partner must agree to
not have sex on the days when the
woman can get pregnant.

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Mucus Method
A woman can know which days she could get pregnant by watching the mucus (the wet fluid) inside her
vagina every day. She should:
• Look at the mucus on her fingers,

• Touch the mucus to see if it is stretchy and slippery, and

• Feel how wet she is in her vagina.

CAN get CANNOT get

She should: pregnant pregnant
1. Start checking the mucus the day after her monthly bleeding ends.
2. Check her mucus at the same time every day (making sure that she
checks before having sex).
3. Not have sex (or use a condom) if the mucus is clear, slippery, and stringy. Remember:
The mucus method
4. Not have sex (or use a condom) until 4 days after the last day she has works best if it is used
clear, stringy, slippery mucus. with condoms or other
5. Not douche, or wash the vagina out, because the mucus will be washed away. FP methods.

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Standard Days Method (SDM)

A woman can know what days she will get pregnant by counting the days of
her cycle. Women can use “CycleBeads” (a string of 32 different colored
beads) to help count the days of their cycle when using this method.
1. Using the cycle beads, the woman should count the first day of her monthly
bleeding as day 1 and move the small black ring to the red bead.
2. She should then move the ring forward (toward the white beads)—one
bead each day.
3. On days 1 through 7 (the brown beads), unprotected sex is OK.
4. On days 8 to 19 (the white beads), unprotected sex is NOT ok. The woman should either not have sex at all,
or use a condom.
5. Between day 20 to the end of her cycle (until the first day of the next monthly bleeding), unprotected sex is
OK. These days will be marked with brown beads.
6. If a woman’s monthly bleeding starts before the dark brown bead is reached by
the little ring, her cycle is less than 26 days and she should use a different FP Remember:
method. SDM works best if it is
7. On the first day of the next monthly bleeding, she should move the small ring to used with condoms or
the red bead and start again. other FP methods.

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Other Ways to Prevent Pregnancy during Sex:

• Oral Sex (low risk for passing HIV)

• Sexual touching (low risk for passing HIV)

• Anal sex (low risk for passing HIV if a condom is used, high risk for passing HIV/STIs if a condom is
not used)
• Pulling out the penis from the vagina before the man
cums (ejaculates). This is very hard to do, because a
small bit of semen will come out of the man’s penis
before he cums. This should only be used for FP if
there is NO OTHER WAY to protect from pregnancy.
Things that DO NOT prevent pregnancy:
• Wearing charms, saying prayers, and/or doing spells.
Remember:
• Peeing (passing urine) after sex. It is hard for many people to
• Washing out the vagina after sex (douching). This can harm the
not have penis-vagina sex, so
vagina. it is important to use other FP
methods (like condoms).
• Other local traditional methods.

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Dual Protection
• Dual protection means protecting against TWO things at the same time:
h STIs/HIV

h Pregnancy

• For dual protection, people should ALWAYS USE CONDOMS.

• Condoms can be used alone, or with another FP method.
• The best protection is when condoms are used at the same time as another FP method.

Remember:
CHWs should teach all of their
clients about how condoms
can help them prevent
pregnancy, STIs, and HIV!

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Counseling Clients about FP

CHWs should:
• Help clients learn about all the FP methods that they can choose from.

• Let the client (and their partner) choose the method that they want to use.

• Give all the information about every FP method to the client before they make their choice (this is
called “informed choice”).
Privacy is very important when talking about FP. CHWs should not talk about a client and her/his FP
choices with anyone. (Sometimes it is OK to talk to a doctor or nurse at the health facility if they are
caring for the client.)
When talking about a FP method, the CHW should tell their client:
• What the FP method is.

• How to use the FP method. Remember:

• How well it protects from pregnancy. When counseling, KEEP IT
• How well it protects from STIs/HIV. SIMPLE, CLEAR, AND
PRIVATE!
• About possible side effects.

• When to go to the clinic for follow-up.

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