Nursing –Level III

Based on January, 2022, Curriculum Version I

Module Title: Comprehensive Family Planning Service

Module Code: HLT NUR3 09 0122
Nominal duration: 105 hours
Prepared By: Ministry of Lobar and Skill
August, 2022
Addis Ababa, Ethiopia

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Acknowledgement
Ministry of Labor and Skills and Ministry of Health wish to extend thanks and appreciation
to the many representatives of TVET instructors and respective industry experts who donated
their time and expertise to the development of this Teaching, Training and Learning Materials
(TTLM).

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Table of Contents
Acknowledgement ..................................................................................................................... II

Table of Contents ........................................................................ Error! Bookmark not defined.

Introduction Comprehensive Family Planning Services ........................................................ - 1 -

Module units .......................................................................................................................... - 1 -

Learning objectives of the Module ......................................................................................... - 1 -

Module Learning Instructions: ............................................................................................... - 2 -

Unit one: Describing and Plan family planning services ......................................................... - 3 -

1.1. Definition of family planning ...................................................................................... - 4 -

1.2. Basic component of comprehensive family planning ................................................... - 4 -

Modern and traditional family planning methods.................................................................... - 4 -

1.1.1. Natural Contraceptives ...................................................................................... - 4 -

1.1.2. Artificial contraceptive Methods ....................................................................... - 5 -

1.4. Resource mapping ....................................................................................................... - 7 -

1.5. Eligibility ................................................................................................................ - 8 -

1.6. Calculating number of expected target group for family planning Practice ................... - 8 -

1.7. Developing a plan of action to reach eligible ............................................................... - 8 -

Self Check 1 ..................................................................................................................... - 10 -

Unit Two: Promoting family planning services..................................................................... - 11 -

2.1. Communicating with influential community representatives and voluntaries .......... - 11 -

2.2. Undertaking community mobilization .................................................................... - 12 -

2.3. Implementing and sustaining family planning practice promotion and education. ... - 12 -

Unit Three: Providing family planning services .................................................................... - 13 -

3.1. Family planning counseling ....................................................................................... - 14 -

3.1.1. Informed and Voluntary Decision Making and Informed Consent ....................... - 14 -

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3.1.2. Counseling Steps in Family Planning ...................................................................... - 16 -

3.2. Providing Short Acting Family Planning Methods ..................................................... - 17 -

3.2.1. Natural Family Planning Methods ....................................................................... - 17 -

3.2.2. Barrier Methods .................................................................................................. - 31 -

3.2.3. Providing Combined Oral Contraceptives ........................................................... - 48 -

3.2.3. Providing Progestin-Only Injectable ....................................................................... - 62 -

3.2.4. Providing Implants.............................................................................................. - 69 -

Self-Check 3 .................................................................................................................... - 75 -

Unit Four: Monitoring family planning services ................................................................... - 76 -

4.1. Collecting, sustaining and updating family planning services data .......................... - 78 -

4.1.2. Individual FP recording tools at Health Facilities ............................................... - 78 -

4.2. Utilize HMIIS standards for registration of FP related activities ............................. - 79 -

4.3. Report family planning activities to the concerned higher bodies ........................... - 80 -

4.4. Monitor family planning practice ........................................................................... - 80 -

Self-check-4 ..................................................................................................................... - 81 -

Reference ............................................................................................................................. - 83 -

Developers Profile..................................................................................................................... 84

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Acronyms
AIDS Acquired Immune Deficiency Syndrome
BBT Basal Body Temperature
BCC Behavioral Change Communication
BTL Bilateral Tubal Ligation
CAC Comprehensive Abortion Care
CEDAW Convention on Elimination of all forms of Discrimination against Women
COC Combined Oral Contraceptives
DEVAW Declaration for Elimination of Violence against Women
DHS Demographic and Health Survey
DMPA Deoxy Medroxy Progesteron Acetate
EC Emergency Contraception
EMDHS Mini-Demographic and Health Survey
FP Family Planning
GBV Gender Based Violence
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HSDP Health Sector Development Program
HSTP Health Sector Transformation Plan
ICPD International Conference on Population and Development
IEC Information, Education and Communication
IUCD Intrauterine Contraceptive Device
LAM Lactational Amenorrhea Method
LARC Long Acting Revisable Contraceptive
LMIS Logistic Management Information System
LNG-IUS Levonergestrol Intrauterine system
MOH Ministry of Health
PAC Post Abortion Care
PFSA P Pharmaceuticals Fund & Supply Agency
PID Pelvic Inflammatory Disease
PLWHA People Living With HIV/AIDS

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POP Progestin Only Pill

RH Reproductive Health
SDM Standard Days Method
SDGs Sustainable Development Goals
STD Sexually Transmitted Disease
STIs Sexually Transmitted Infections
TT Tetanus Toxoid
VDRL Venereal Disease Research Laboratory
WHO World Health Organization

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Introduction Comprehensive Family Planning Services
The Government of Ethiopia committed itself to the achievement of Sustainable Development
Goals (SDGs), and strongly believed FP is one of the key strategies to improving maternal health
and bringing about development.
Family planning is the voluntary use of natural or modern methods of contraceptives by
individuals or couples. This approach helps the users to have the number of children they want
and when they want them and also assures the well-being of the children and the parents. Family
planning service was introduced in Ethiopia in 1948. Although at the beginning the services were
limited to only major cities, gradually the services expanded to the rural areas and are being used
now by the rural communities
The provision of inadequate family planning services in Ethiopia has contributed and is still
contributing to the high morbidity and mortality of mothers and children; unwanted and
unplanned pregnancies; high risk abortion; HIV/AIDS and other sexually transmitted diseases; in
adequate information and education about family planning. The Ethiopian population is rapidly
increasing and causing incompatibility with the country’s available natural resources. This
situation, surely, is creating the inadequacy of farm land; deforestation; drought accompanied
with famine and displacement; soil degradation and erosion; crowding of households; in
compatible social service (health, education etc.) infrastructures and adverse impact on house
hold income.
Module units
• Describing and Planning family planning services
• Promoting family planning services
• Providing family planning services
• Monitoring family planning services
Learning objectives of the Module
At the end of this session, the students will able to:
• Describe and Plan family planning services
• Promote family planning services

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• Provide family planning services

• Monitor family planning services
Module Learning Instructions:
1. Read the specific objectives of this Learning Guide.
2. Follow the instructions described below.
3. Read the information written in the information Sheets
4. Accomplish the Self-checks

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Unit one: Describing and Plan family planning services

This learning unit is developed to provide the trainees the necessary information regarding the
following content coverage and topics:
• Definition of family planning
• Basic component of comprehensive family planning
• Modern and traditional family planning methods
• Resource mapping
• Eligibility
• Calculating number of expected target group for family planning Practice
• Developing a plan of action to reach eligible
This unit will also assist you to attain the learning outcomes stated in the cover page.
Specifically, upon completion of this learning guide, you will be able to:
• Describe basic component of comprehensive family planning
• Describe modern and traditional family planning methods
• Conduct resource mapping
• Identify the eligible target group for family planning
• Calculate number of expected target group for family planning practice
• Develop a plan of action to reach eligible

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1.1. Definition
Family planning is defined as the ability of individuals or 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.
Family planning is a means of promoting the health of women and families and part of a strategy
to reduce high maternal, infant and child mortality. People should be offered the opportunity to
determine the number and spacing of their own children. Information about FP should be made
available, and should actively promote access to FP services for all individuals desiring them.

1.2. Basic component of comprehensive family planning

The following services and activities offered at different levels of the national health care
delivery system
• EC/BCC
• Counseling
• Provision of contraceptives
• Testing and counseling for HIV
• Screening and treatment of STIs
• Prevention and management of infertility
• Screening for reproductive tract cancers
Modern and traditional family planning methods
Currently the different family planning methods used are categorized in to the following
categorizations. Each type of contraceptive has its own effectiveness, advantage and
disadvantage, mechanism of action, medical eligibility criteria, time of initiation and way of use.
1.1.1. Natural Contraceptives
Natural family planning refers to methods used to prevent or postpone pregnancy by giving
attention to natural reproductive events related to fertility. All natural methods except for LAM
require partners’ cooperation. Couple must be committed to abstaining or using another method
on fertile days. Couple/client must stay aware of body changes or keep track of days, according
to rules of the specific method. Natural contraceptives methods do not have side effects or health
risks. These methods include:
• Withdrawal method
• Fertility awareness method

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✓ Calendar-based methods
➢ Standard day method
➢ Calendar/rhythm method
✓ Symptoms-based methods
➢ Two day method
➢ Basal body temperature method
➢ ovulation method (also known as Billings method or cervical mucus method), and
symptothermal method
➢ Lactational amenorrhea method (LAM)
1.1.2. Artificial contraceptive Methods

These methods include:

I. Barrier methods

Barrier methods prevent pregnancy by blocking the sperm from reaching the egg. They cause
very few side effects. Barrier methods are safe if a woman is breastfeeding. Most of these
methods also protect against Sexually Transmitted Infections (STIs), including HIV. When a
woman wants to become pregnant, she simply stops using the barrier method. The most
common barrier methods are:
• Male and female condoms
• Spermicide
• Diaphragm
• Cervical cup
II. Oral Contraceptives (OCPs)
Oral contraceptive pills are contraceptives that are taken orally once daily to prevent pregnancy.
Oral contraceptives contain either two or one female sex hormones. The hormones are synthetic
estrogens and synthetic progesterone. These include:
• Combined oral contraceptive pills (COCs): contain both synthetic estrogrn and
progesterone like the natural female sex hormones.
• Progestin only pills (POPs): contain progestin only like the natural female sex hormone.
III. Injectables

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The contraceptive injection, also known as ‘the shot’, contains progestogen or a combination of
estrogen and progestogen. The injectables contraceptives depot medroxyprogesterone acetate
(DMPA) and norethisterone enanthate (NET-EN) each contain a progestin like the natural
hormone progesterone in a woman’s body. In contrast, monthly injectables contain both estrogen
and progestin. DMPA, the most widely used progestin-only Injectable, is also known as Depo or
Depo-Provera. In this learning you will learn progestin only injectables.

IV. Implants

Small plastic rods, each about the size of a matchstick, that release a progestin like the natural
hormone progesterone in a woman’s body. A specifically trained provider performs a minor
surgical procedure to place one or 2 rods under the skin on the inside of a woman’s upper arm.
Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot
use methods with estrogen. The Types of implants incude:
• Jadelle: 2 rods containing levonorgestrel, highly effective for 5 years
• Implanon NXT (Nexplanon): 1 rod containing etonogestrel, labeled for up to 3 years of
use (a recent study shows it may be highly effective for 5 years). Replaces Implanon;
Implanon NXT can be seen on X-ray and has an improved insertion device.
• Levoplant (Sino-Implant (II)), 2 rods containing levonorgestrel. Labeled for up to 4
years of use.
• Norplant, which consisted of 6 capsules and was effective for 5−7 years, was
discontinued in 2008 and is no longer available for insertion. A small number of women,
however, may still need Norplant capsules removed.
V. Intra Uterine Contraceptive Device (IUCD)

A specifically trained health care provider inserts it into a woman’s uterus through her vagina
and cervix. IUCD provides a long-term pregnancy protection and it is immediately reversible.
The types of IUCD include:
• Copper- bearing Intra uterine device: is a small, flexible plastic frame with copper
sleeves or wire around it. Shown to be very effective for up to 12 years
• Levonorgestrel Intrauterine Device: The Levonorgestrel intrauterine device (LNG-
IUD) is a T-shaped plastic device that steadily releases a small amount of Levonorgestrel
each day. (Levonorgestrel is a progestin hormone also used in some contraceptive

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implants and oral contraceptive pills.) Also called the Levonorgestrel-releasing

intrauterine system, LNG-IUS, or hormonal IUD. Very effective for 5 year5. Works by
preventing sperm from fertilizing an egg also cause the thickening of cervical mucus,
which stops the sperm from entering the uterus. IUCDs’ contraceptive effect is not
abortificient. In this learning guide you will learn about Copper-Bearing Intrauterine
Device.
VI. Permanent family planning methods

Permanent FP methods, also called voluntary surgical contraception are among the most
effective, popular and well-established contraceptive method options available for men and
women who desire no more children. For individuals and couples desiring no more children, it
provides the most effective protection against pregnancy. It offers the advantage over other
contraceptive methods that it is a once-only procedure. The need for continued contraceptive
supplies is eliminated. Globally, the permanent method of contraception is the most popular and
commonly used method of contraception, but is one of the least utilized in Ethiopia. Following
effective counseling and improving the availability and quality of service in permanent methods
of contraception, it is possible to improve the acceptability of the methods in the community.
The methods of permanent family planning are:
• Bilateral Tubal Ligation: is a permanent contraception method for female.
• Vasectomy: Is a permanent contraception method for male

1.4. Resource Mapping

• Resource mapping is a method of showing information regarding the occurrence,
distribution, access to and use of resources; topography; human settlements; and
activities of a community from the perspective of community members.
• Resource mapping is used to:
✓ Identifying and examining relationships between a community’s resources,
topography, settlements, and activities
✓ Enabling people to picture resources and features and to show graphically the
significance
attached to them
✓ Identifying problems, possibilities, and opportunities

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• Resource mapping tell you:

✓ How people within a community view their environment
✓ Community members' analysis of the natural resources found in their community and
how they are used
• Key elements of resource mapping are local perceptions of resources and territories.
• To make resource mapping it takes 1.5 to 2 hours and no need supporting software
• A community resource map is usually spatially limited to the social, cultural, and
economic domains of the local analysts who produce it so for larger geographical areas
(such as a protected area or national park) and areas with several different
administrations, producing a sufficient number of community specific sketch maps might
be politically unrealistic.
1.5. Eligibility
Any person, male or female, who is sexually active and married, is eligible for FP services,
including information, education, and counseling. Eligibility for specific choice of family
planning is clearly stated under unit three of this module.
1.6. Calculating number of expected target group for family planning Practice
When you are planning family planning services in your community, the first step is to calculate
the number eligible mothers for by using the base line data under the catchment of your facility
or the conversion factors established by MOH family planning services. According to the
findings of the surveys the percentage of women eligible for family planning services are
18.63% of the total population of Ethiopia.
1.7. Developing a plan of action to reach eligible
A work plan is a document developed by the manager and staff, which lists all planned activities,
the date on which they will occur or by which they will be accomplished, the resources they will
require, and the person who is responsible for carrying them out. Such a document is a valuable
tool for efficient and effective programme implementation, and should be used regularly and
consistently as a monitoring tool at all levels. Basically, there are two types of plans:
(a) The strategic (long-term) plan
(b) The annual (work) plan.

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Short term plans/Plan of action should be developed and used at all levels of a programme or
organization. They are particularly useful for nurses to deliver family planning services. The
activities in work plans are based on the annual plan, which has been developed at your health
facility.

Steps in organizing Family Planning services

Step 1: Conducting a needs assessment of existing services at facility

• It will help you identify existing problems and the people and materials available to
provide
Step 2: Assess whether the health workers are trained to provide FP services and find out what
materials are available in the health facility.
Step 3: Identifying problems related to FP

Steps 4: Developing a proposal

• Now you should develop a proposal to show how you are going to solve the problems
you identified in your assessment.
• You may not be able to respond to all of the problems you have identified.
• Therefore you should prioritize the problems based on the importance of the problem and
the resources you have or you could acquire.
• The proposal should have the problems identified.
• The proposal should also have what you want to achieve by addressing the identified
problem. This is called Objective.
• The proposal should also have the different methods you use to tackle the problems. This
is called Strategy.
• The following table will help you in how to write a proposal.
Step – 5: - Prepare Action Plan
Table1: Table shows how to prepare action plan

Problem Action required Responsible Time bound

person
Collecting health education
Lack of health Health care January 2023

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education Materials request both orally and professional (E.C.)

materials on through formal letter that
contraceptives at (i) the woreda health office Or
the health facility (ii) the NGO working in the
kebele (if any Or

(iii) the health centre provides you with

health education materials on
contraceptives

Self Check 1
Part I say “True” if the statement is correct or “False” if the statement is incorrect
1. Family planning is a means of promoting the health of women and families and part of a
strategy to reduce high maternal, infant and child mortality.
2. Family planning is not a strategy to decrease the occurrence of unwanted pregnancy and
abortions.
3. Family planning prevents the depletion of maternal nutritional reserves and reduces the
risk of anemia from repeated pregnancies and birth.
4. Using a family planning can aggravate poverty.

Part II. choose the correct answer for the following alternatives
1. ____________is about making available family planning methods at an affordable price
using private retailers.
A. Community-based distribution
B. Social marketing
C. Work-based services
D. Outreach family planning services.
2. Which contraceptive option is categorized under natural family planning method?
A. Male and Female Condoms
B. Injectable contraceptives
C. Lactational Amenorrhea Method (LAM)

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D. Intra-Uterine Contraceptive Devices

Unit Two: Promoting family planning services

This learning unit is developed to provide the trainees the necessary information regarding the
following content coverage and topics:
• Communicating with influential community representatives and voluntaries

• Undertaking community mobilization

• Implementing and sustaining family planning practice promotion and education

This unit will also assist you to attain the learning outcomes stated in the cover page.
Specifically, upon completion of this learning guide, you will be able to:
• Conduct communication with influential community representatives and voluntaries

• Undertake community mobilization

• Implement and sustain family planning practice promotion and education

2.1. Communicating with influential community representatives and voluntaries

Information Education Communication (IEC) combines strategies, approaches, and methods that
enable individuals, families, groups, organizations, and communities to play an active role in
achieving, protecting, and sustaining their own health. Embodied in IEC is the process of
learning that empowers people to make decisions, modify behaviors, and change social
conditions.
The Government of Ethiopia has initiated an innovative strategy; the health Development army
(HDA), which aims to foster community ownership. The health development army
provides the platform to promote family planning (FP) and reproductive health (RH) in the
community. Partners working on FP and RH should work with HEW’s and the primary health
care unit staff to improve the knowledge of health development team leaders. Furthermore, FP

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and RH issues should be recognized as priorities and be discussed on regular basis during
community dialogues at the health development teams.
2.2. Undertaking community mobilization
Community mobilization a capacity-building process through which individuals, groups,or
organizations plan, carry out, and evaluate activities on a participatory and sustained basis to
improve their health and other needs, either on their own initiative or stimulated by others
Community mobilization is the process of engaging communities to identify community
priorities, resources, needs and solutions in such a way as to promote representative
participation, good governance, accountability and peaceful change.
The community should be made aware of the overall benefits and availability of FP services. FP
programs and services, including IEC/BCC activities, should respect the customs and traditions
of the community. Community involvement is key to dispelling rumors and misconceptions, and
thereby developing ownership of FP programs by the community for successful and sustainable
outcome.
Challenges of Community Participation

• Less control
• Time and cost
• Differing priorities
• Stakeholders disagree
• Community skills and capacity
• Selection of community participants may be biased
• Contraceptive insecurity
• Need to plan for sustainability from beginning

2.3. Implementing and sustaining family planning practice promotion and

education.

2.3.1. Social and Behavioral Change (SBC) for FP

Social and Behavioral change combines strategies, approaches, and methods that enable
individuals, families, groups, organizations, and communities to play an active role in achieving,

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protecting, and sustaining their own health. Accordingly, individual, community, organizational
and socio economic level strategies are recommended to increase awareness and demand for
family planning services.

Self-Check 2
Part I Give short answer for the following question
1. Define community mobilization
2. List challenges in community participation in planning family survice practice
Implementation

Unit Three: Providing family planning services

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This learning unit is developed to provide the trainees the necessary information regarding the
following content coverage and topics:
• Family Planning counseling
• Provide short acting contraceptive methods and manage side effects
• Assist long acting Family Planning methods.
• Follow-up and Referral
This unit will also assist you to attain the learning outcomes stated in the cover page.
Specifically, upon completion of this learning guide, you will be able to:
• Family Planning counseling
• Provide short acting contraceptive methods and managed side effects
• Assist long acting Family Planning Methods.
• Follow-up and Referral

3.1. Family planning counseling

Counseling is a type of client-provider interaction that involves two-way communication

between a health care staff member and a client for the purpose of confirming or facilitating a
decision by the client or helping the client address problems or concerns..

Family planning counseling is defined as a continuous process that you as the counselor
provide to help clients and people in your village make and arrive at informed choices about the
size of their family (i.e. the number of children they wish to have). Counseling can be conducted
with:

✓ Individual levels

✓ Couples and

✓ family

3.1.1. Informed and Voluntary Decision Making and Informed Consent

The concept of informed and voluntary decision making applies broadly to any health care
decision and assumes that individuals have both the right and the ability to make their own health

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care decisions without pressure or coercion and with full information and understanding of the
consequences of each option.
Informed consent is a medical, legal, and rights-based construct whereby clients agree to
receive medical treatment, such as surgery (for an FP method or for another purpose) or to take
part in a study. Informed consent is ideally given as a result of the client’s informed choice.
Unfortunately, there are many instances in which a client signs an informed consent form
without adequate information and without feeling that he or she has had any choice in the matter.
General principles of counseling and counselor characteristics
These are the important principles and conditions necessary for effective counseling:
• Privacy — finds a quiet place to talk.

• Take sufficient time.

• Maintain confidentiality.

• Conduct the discussion in a helpful atmosphere.

• Keep it simple — use words people in your village will understand.

• First things first — do not cause confusion by giving too much information.

• Say it again — repeat the most important instructions again and again.

• Use available visual aids like posters and flip charts, etc.

Skills and characteristics of a counselor

The most important characteristics are:
• Respect the dignity of others.

• Respect the client’s concerns and ideas.

• Be non-judgmental and open.

• Show that you are being an active listener.

• Be empathetic and caring.

• Be honest and sensitive.

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3.1.2. Counseling Steps in Family Planning

The REDI framework:

• Emphasizes the client’s right and responsibility for making decisions and carrying them
out
• Provides guidelines to help the counselor and client consider the client’s circumstances
and social context
• Identifies the challenges a client may face in carrying out their decision
• Helps clients build skills to address those challenges

Step 1: Rapport Building

1. Greet client with respect

2. Make introductions (identify category of the client i.e., new, satisfied return, or dissatisfied
return)

3. Assure confidentiality and privacy

4. Explain the need to discuss sensitive and personal issues

Step 2: Exploration

1. Explore in depth the client’s reason for the visit (This information will help determine the
client’s counseling needs and the focus of the counseling Handout.)\

2. Explore client’s future RH-related plans, current situation, and past experience

✓ Explore client’s reproductive history and goals, while explaining healthy timing and
spacing of pregnancy (HTSP)
✓ Explore client’s social context, circumstances, and relationships
✓ Explore issues related to sexuality
✓ Explore client’s history of STIs, including HIV
✓ Explain STI risk and dual protection, and help the client perceive his or her risk for
contracting and transmitting STIs

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3. Focus your discussion on the method(s) of interest to client: discuss the client’s preferred
method, if any, or relevant FP options if no method is preferred, give information as needed, and
correct misconceptions

4. Rule out pregnancy and explore factors related to monthly bleeding, any recent pregnancy and
medical conditions

Step 3: Decision Making

1. Identify the decisions the client needs to confirm or make (for satisfied clients, check if client
needs other services; if not, go to Phase 4, Step 5)

2. Explore relevant options for each decision

3. Help the client weigh the benefits, disadvantages, and consequences of each option (Provide
information to fill any remaining knowledge gaps)

4. Encourage the client to make his or her own decision

Step 4: Implementing the Decision

1. Assist the client in making a concrete and specific plan for carrying out the decision(s)
(obtaining and using the FP method chosen, risk reduction for STIs, dual protection, and so on)
2. Have the client develop skills to use his or her chosen method and condoms

3. Identify barriers that the client might face in implementing his or her decision

4. Develop strategies to overcome the barriers

5. Make a plan for follow-up and/or provide referrals as needed

3.2. Providing Short Acting Family Planning Methods
3.2.1. Natural Family Planning Methods
A. Withdrawal (Coitus interrupts) method
What Is Withdrawal?

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Just before ejaculation, the man withdraws his penis from his partner’s vagina and ejaculates
outside the vagina, keeping his semen away from her external genitalia. Also known as coitus
interrupts and “pulling out.” Works by keeping sperm out of the woman’s body.
How Effective?
Effectiveness depends on the user: Risk of pregnancy is greatest when the man does not
withdraw his penis from the vagina before he ejaculates with every act of sex.
• One of the least effective methods, as commonly used.
• As commonly used, about 20 pregnancies per 100 women whose partners use withdrawal
over the first year. This means that 80 of every 100 women whose partners use
withdrawal will not become pregnant.
• When used correctly with every act of sex, about 4 pregnancies per 100 women whose
partners use withdrawal over the first year.
Return of fertility after use of withdrawal is stopped: No delay
Protection against sexually transmitted infections: None
Advantage
• Always available
• Does not cost anything
• Requires no supplies and
• Has no side effects
Disadvantage
• It requires motivation, cooperation and self-control.
• It is least effective
• There is no protection against sexually transmitted infections.
Who can and can’t use withdrawal method?
• All men can use withdrawal. No medical conditions prevent its use.
• Remember that there are some men who cannot consistently sense when ejaculation is about
to occur and there are men who ejaculate prematurely.
• Always suggest that an additional or alternative family planning method is available. Explain
ECP use in case a man ejaculates before withdrawing his penis from the vagina.
When can withdrawal method be initiated?
• The method can be initiated at any time.

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Table 2: Table showing how to use withdrawal method

When the man feels He should withdraw his penis from the woman’s vagina and
close to ejaculating ejaculate outside the vagina, keeping his semen away from her
external genitalia.
If the man has ejaculated Before sex he should urinate and wipe the tip of his penis to remove
recently any semen remaining.

B. Fertility Awareness Method

What Are Fertility Awareness Methods?
• “Fertility awareness” means that a woman knows how to tell when the fertile time of her
menstrual cycle starts and ends. (The fertile time is when she can become pregnant.)
• Sometimes called periodic abstinence or natural family planning.
• A woman can use several ways, alone or in combination, to tell when her fertile time begins
and ends.
• Calendar-based methods involve keeping track of days of the menstrual cycle to identify the
start and end of the fertile time. Examples: Standard Days Method, which avoids unprotected
vaginal sex on days 8 through 19 of the menstrual cycle, and calendar rhythm method.
• Symptoms-based methods depend on observing signs of fertility.
✓ Cervical secretions: When a woman sees or feels cervical secretions, she may be fertile.
She may feel just a little vaginal wetness.
✓ Basal body temperature (BBT): A woman’s resting body temperature goes up slightly
after the release of an egg (ovulation). She is not likely to become pregnant from 3 days
after this temperature rise through the start of her next monthly bleeding. Her temperature
stays higher until the beginning of her next monthly bleeding. Examples: Two Day
Method, BBT method, ovulation method (also known as Billings method or cervical
mucus method), and symptothermal method.
• Work primarily by helping a woman know when she could become pregnant. The couple
prevents pregnancy by avoiding unprotected vaginal sex during these fertile days—
usually by abstaining or by using condoms or a diaphragm. Some couples use
spermicides or withdrawal, but these are among the least effective methods.
How Effective?

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Effectiveness depends on the user: Risk of pregnancy is greatest when couples have sex on the
fertile days without using another method.
• As commonly used, in the first year about 15 pregnancies per 100 women using periodic
abstinence. This means that 85 of every 100 women relying on periodic abstinence will not
become pregnant.
• Pregnancy rates with consistent and correct use vary for different types of fertility awareness
methods (see table below).
• In general, abstaining during fertile times is more effective than using another method during
fertile times.

Table 3: Compare the pregnancies that can occur if used consistently and correctly versus if
used as commonly of different fertility awareness methods.
Pregnancies per 100 Women
Over the First Year of Use
Method Consistent and correct use As commonly used
Calendar-based method
Standard day method 5 12
Symptoms based method
Two day method 4 14
Ovulation method 3 23
Symtothermal method <1 2

Return of fertility after fertility awareness methods are stopped: No delay

Protection against sexually transmitted infections (STIs): None
Side Effects, Health Benefits, and Health Risks
Side Effects
None
Known Health Benefits
Help protect against:

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• Risks of pregnancy
Known Health Risks
None
Advantage
• Have no side effects
• Do not require procedures and usually do not require supplies
• Help women learn about their bodies and fertility
• Allow some couples to adhere to their religious or cultural norms about contraception
• Can be used to identify fertile days by both women who want to
• become pregnant and women who want to avoid pregnancy
Disadvantage
• It has a high failure rate because it needs several days of abstinence and a lot of experience in
using the method to be effective.
• Fewer "safe" days to have intercourse each month
• Training is essential
• No protection from STIs
• It is also difficult to use Two Day Method and Ovulation method in the case of vaginal
infections, secretions may be misleading.
• If periods are not regular, calendar-based method may not be as effective
• False interpretation or indications in the case of fever, as this may mislead the result of BBT
• A special thermometer may be required to use BBT effectively
Correcting Misunderstandings
Fertility awareness methods:
• Can be effective if used consistently and correctly.
• Do not require literacy or advanced education.
• Do not harm men who abstain from sex.
• Do not work when a couple is mistaken about when the fertile time occurs, such as
thinking it occurs during monthly bleeding.
Fertility awareness methods for women with HIVHIV
• Women who are living with HIV or are on antiretroviral (ARV) therapy can safely use
fertility awareness methods.

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• Urge these women to use condoms along with fertility awareness methods. Used consistently
and correctly, condoms help prevent transmission of HIV and other STIs.
Who can use calendar-based methods?
All women can use calendar-based methods. No medical conditions prevent the use of these
methods, but some conditions can make them harder to use effectively and necessitate using
caution or delaying their use.
• Caution means that additional or special counseling may be needed to ensure correct use of
the method. E.g., menstrual cycles have just started or have become less frequent or stopped
due to older age.
• Delay means that use of a particular fertility awareness method should be delayed until the
condition is evaluated or corrected. Other temporary methods of contraception should be
offered. E.g., recently gave birth or is breastfeeding, recently had an abortion or miscarriage,
irregular vaginal bleeding, use of drugs that may delay ovulation (for example, certain
antidepressants, thyroid medications, long-term use of certain antibiotics, or long-term use of
any non steroidal anti-inflammatory drug, such as aspirin or ibuprofen)..
Who can use symptoms-based methods?
All women can use calendar-based methods. No medical conditions prevent the use of these
methods, but some conditions can make them harder to use effectively and necessitate using
caution or delaying their use.
• Caution is necessary in the following situations. E.g., recently had an abortion or
miscarriage, menstrual cycles have just started or have become less frequent or stopped due
to older age, a chronic condition that raises her body temperature (for BBT and
symptothermal methods)
• Delay is necessary in the following situations. E.g., recently gave birth or is breastfeeding, an
acute condition that raises her body temperature (for BBT and symptothermal methods),
irregular vaginal bleeding, abnormal vaginal discharge, use of drugs that may affect cervical
secretions (antihistamines), raise body temperature or delay ovulation (antibiotics).
Table 4: Depicts when to start using fertility awareness methods.
Women’s Calendar-Based Methods Symptoms- Based Methods
situation
Having Any time of the month Any time of the month

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regular • No need to wait until the start of next • No need to wait until the
menstrual monthly bleeding. start of next monthly
cycles bleeding.
No monthly • Delay calendar-based methods until • Delay symptoms-based
bleeding monthly bleeding returns. methods until monthly
bleeding returns.
After • Delay the Standard Days Method until • She can start symptoms-
childbirth she has had 4 menstrual cycles and the based methods once
(whether or not last one was 26–32 days long. normal secretions have
breastfeeding) returned.
After • Delay the Standard Days Method until • She can start symptoms
miscarriage the start of her next monthly bleeding. based methods
or abortion immediately with special
counseling and support, if
she has no infection-related
secretions or bleeding due
to injury to the genital
tract.
Switching • Delay starting the Standard Days • She can start symptoms
from Method until the start of her next based methods in the next
a hormonal monthly bleeding. menstrual cycle after
method • If she is switching from injectables, stopping a hormonal
delay the Standard Days Method at method.
least until her repeat injection would
have been given, and then start it at
the beginning of her next monthly
bleeding.
After taking • Delay the Standard Days Method until She can start symptoms based
emergency the start of her next monthly bleeding. methods once normal
contraceptive secretions have returned.
pills

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How are calendar-based methods used?

Standard Days Method (SDM): It can be used if most of the cycles in a year are between 26 to
32 days long.
• A woman keeps track of the days of her menstrual cycle, counting the first day of monthly
bleeding as day 1.
• Avoids unprotected sex or uses condoms or a diaphragm on days 8 – 19 that are considered
fertile days for all users of the SDM.
• The couple can have unprotected sex on all the other days of the cycle—days 1 through 7 at
the beginning of the cycle and from day 20 until her next monthly bleeding begin.
• The couple can use Cycle Beads, a color-coded string of beads that indicates fertile and non-
fertile days of a cycle (see diagram below), or they can mark a calendar or use some other
memory aid.

Figure 1: Displays different strategies for usage of standard days method.

Calendar Rhythm Method:
Before relying on this method, a woman records the number of days in each menstrual cycle for
at least 6 months. The first day of monthly bleeding is always counted as day 1

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• The woman estimates the fertile time by subtracting 18 from the length of her shortest
recorded cycle. This tells her the estimated first day of her fertile time. Then she subtracts 11
days from the length of her longest recorded cycle. This tells her the estimated last day of her
fertile time.
• The couple avoids unprotected sex or uses condoms or a diaphragm during the fertile time.
• She updates these calculations each month, always using the 6 most recent cycles.
• Example: a women has a length of menstrual cycle for 6 months as follows; 28,31,29,30,28
and 27
• The shortest of her last 6 cycles is 27 days, 27 – 18 = 9. She starts avoiding unprotected sex
on day 9.
• The longest of her last 6 cycles was 31 days, 31 – 11 = 20. She can have unprotected sex
again on day 21. Thus, she must avoid unprotected sex from day 9 through day 20 of her
cycle.

Figure 2: Way of identifying of fertility periods in calendar rhythm method.

How are symptoms-based methods used?
Two Day Method:
If the woman has a vaginal infection or another condition that changes cervical mucus, Two Day
method will be difficult to use.

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• The woman checks for cervical secretions every afternoon and/or evening, on fingers,
underwear, or tissue paper or by sensation in or around the vagina.
• As soon as she notices any secretions of any type, color, or consistency, she considers herself
fertile that day and the following day.

Figure 3: Identifying the nature of survical secretions to use two day method
• The couple avoids unprotected sex or uses condoms or a diaphragm on each day that she
considers herself fertile and the following day.
• The couple can have unprotected sex again after the woman has had 2 dry days (days without
secretions of any
Basal Body Temperature (BBT) Method:
If a woman has fever or other changes in body temperature, the BBT method will be difficult to
use.
• The woman takes her body temperature at the same time each morning before she gets out of
bed and before she eats anything. She records her temperature on a special graph.
• She watches for her temperature to rise slightly—0.2° to 0.5°C (0.4° to 1.0°F)—around the
time of ovulation (usually about midway through the menstrual cycle).
• The couple avoids vaginal sex, or uses condoms or a diaphragm from the first day of monthly
bleeding until 3 days after the woman’s temperature has risen above her regular temperature.
• When the woman’s temperature has risen above her regular temperature and stayed higher
for 3 full days, ovulation has occurred and the fertile period has passed.
• The couple can have unprotected sex on the 4th day and until her next monthly bleeding.

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Figure 4: Basal Body Temperature (BBT) Method

Ovulation method (also known as Billings method or cervical mucus method):
If a woman has a vaginal infection or another condition that changes cervical mucus, this method
may be difficult to use.
• The woman checks every day for any cervical secretions on her finger, underwear, or tissue
paper or by sensation in the vagina.
• Ovulation might occur early in the cycle, during the last days of monthly bleeding. Heavy
bleeding could make mucus difficult to observe.
• Avoids unprotected sex on days of heavy bleeding that makes mucus difficult to observe
• Between the end of monthly bleeding and the start of secretions, the couple can have
unprotected sex, but not on 2 days in a row. (Avoiding intercourse on the second day allows
time for semen to disappear and for cervical mucus to be observed.)
• As soon as she notices any secretions, she considers herself fertile and avoids unprotected
sex.
• She continues to check her cervical secretions each day. The secretions have a “peak day”—
the last day that they are clear, slippery, stretchy, and wet. She will know this has passed
when, on the next day, her secretions are sticky or dry, or she has no secretions at all. She
continues to consider herself fertile for 3 days after that peak day and avoids unprotected sex.
The couple can have unprotected sex on the 4th day after her peak day and until her next
monthly bleeding begins.

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Figure 5:different types of cervical methods

Symptothermal Method (basal body temperature + cervical secretions + other fertility signs):
• Users identify fertile and non-fertile days by combining BBT and ovulation method
instructions.
• Women may also identify the fertile time by other signs such as breast tenderness and
ovulatory pain (lower abdominal pain or cramping around the time of ovulation).
• The couple avoids unprotected sex between the first day of monthly bleeding and either the
fourth day after peak cervical secretions or the third full day after the rise in temperature
(BBT), whichever happens later.
• Some women who use this method have unprotected sex between the end of monthly
bleeding and the beginning of secretions, but not on 2 days in a row.

C. Lactational Amenorrhea Method (LAM)

What Is the Lactational Amenorrhea Method?

• A temporary family planning method based on the natural effect of breastfeeding on fertility.
(“Lactational” means related to breastfeeding. “Amenorrhea” means not having monthly
bleeding.)

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• The Lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met:
1. The mother’s monthly bleeding has not returned.
2. The baby is fully or nearly fully breastfed and is fed often, day and night.
3. The baby is less than 6 months old.
• “Fully breastfeeding” includes both exclusive breastfeeding (the infant receives no other
liquid or food, not even water, in addition to breast milk) and almost-exclusive breastfeeding
(the infant receives vitamins, water, juice, or other nutrients once in a while in addition to
breast milk).
• “Nearly fully breastfeeding” means that the infant receives some liquid or food in addition to
breast milk, but the majority of feedings (more than three-fourths of all feeds) are breast
milk.
• Works primarily by preventing the release of eggs from the ovaries (ovulation). Frequent
breastfeeding temporarily prevents the release of the natural hormones that cause ovulation.
Suckling causes increased prolactin, which inhibits estrogen production and ovulation
How Effective?
Effectiveness depends on the user: Risk of pregnancy is greatest when a woman cannot fully or
nearly fully breastfeed her infant.
• As commonly used, about 2 pregnancies per 100 women using LAM in the first 6 months
after childbirth. This means that 98 of every 100 women relying on LAM will not become
pregnant.
• When used correctly, less than 1 pregnancy per 100 women using LAM in the first 6 months
after childbirth.
Return of fertility after LAM is stopped: Depends on how much the woman continues to
breastfeed
Protection against sexually transmitted infections: None
Side Effects, Health Benefits, and Health Risks
Side Effects
None
Known Health Benefits
Helps protect against risks of pregnancy
Encourages the best breastfeeding patterns, with health benefits for both mother and baby

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Known Health Risks

None
Advantages
• It is a natural family planning method
• It supports optimal breastfeeding, providing health benefits for the baby and the mother
• It has no direct cost for family planning or for feeding the baby
• Effectively prevents pregnancy for at least 6 months
Disadvantage
• Not a suitable method if the mother is working outside the home
• If the mother have HIV small chance to transmitter
• No protection against STIs including HIV
• Not effective after 6months
Correcting Misunderstandings
The Lactational amenorrhea method:
• Is highly effective when a woman meets all 3 LAM criteria.
• Is just as effective among fat or thin women.
• Can be used by women with normal nutrition. No special foods are required.
• Can be used for a full 6 months without the need for supplementary foods. Mother’s milk
alone can fully nourish a baby for the first 6 months of life. In fact, it is the ideal food for
this time in a baby’s life.
• Can be used for 6 months without worry that the woman will run out of milk. Milk will
continue to be produced through 6 months and longer in response to the baby’s suckling
or the mother’s expression of her milk.
Who can and cannot use LAM?
All breastfeeding women can safely use LAM, but a woman in the following circumstances may
want to consider other contraceptive methods:
• Has HIV infection including AIDS.
• Is using certain medications during breastfeeding (including mood altering drugs, reserpine,
ergotamine, anti-metabolites, cyclosporine, and high doses of corticosteroids, bromocriptine,
radioactive drugs, lithium, and certain anticoagulants).

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• The newborn has a condition that makes it difficult to breastfeed (including being small-for-
date or premature and needing intensive neonatal care, unable to digest food normally, or
having deformities of the mouth, jaw, or palate).
LAM for Women with HIV
• Women who are infected with HIV or who have AIDS can use LAM. Breastfeeding will not
make their condition worse. There is a chance, however, that mothers with HIV will transmit
HIV to their infants through breastfeeding. As breastfeeding is generally practiced, 10 to 20
of every 100 infants breastfed by mothers with HIV will become infected with HIV through
breast milk.
• Women taking antiretroviral (ARV) medications can use LAM. In fact, ARV therapy during
the first weeks of breastfeeding may reduce the risk of HIV transmission through breast milk.
• Replacement feeding poses no risk of HIV transmission. If—and only if— replacement
feeding is acceptable, feasible, affordable, sustainable, and safe, it is recommended for the
first 6 months after childbirth. If available replacement feeding cannot meet these 5 criteria,
exclusive breastfeeding for the first 6 months is the safest way to feed the baby, and it is
compatible with LAM.
When can LAM be initiated?
If the woman is within 6 months after childbirth:
• Start breastfeeding immediately (within one hour) or as soon as possible after the baby is
born. In the first few days after childbirth, the yellowish fluid produced by the mother’s
breasts (colostrum) contains substances very important to the baby’s health.
• Any time if she has been fully or nearly fully breastfeeding her baby since birth and her
monthly bleeding has not returned.
Remember: A breastfeeding woman can use LAM to space her next birth and as a transition to
another contraceptive method. She may start LAM at any time if she meets all the 3 above
mentioned criteria required for using the method.
3.2.2. Barrier Methods
Condoms

➢ Male condoms

What are male condoms?

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• Thin sheath usually made of rubber (latex) that is placed on an erect penis before intercourse.
It is the only method of contraception that also provides protection from STIs, including
HIV.
• Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. Also
keep infections in semen, on the penis, or in the vagina from infecting the other partner.
How effective are male condoms?
Effectiveness depends on the user: Risk of pregnancy or sexually transmitted infection (STI) is
greatest when condoms are not used with every act of sex. Very few pregnancies or infections
occur due to incorrect use, slips, or breaks.
Protection against pregnancy:
• As commonly used, about 13 pregnancies per 100 women whose partners use male condoms
over the first year. This means that 87 of every 100 women whose partners use male
condoms will not become pregnant.
• When used correctly with every act of sex, about 2 pregnancies per 100 women whose
partners use male condoms over the first year.
• Return of fertility after use of condoms is stopped: No delay
• Protection Against HIV and Other STIs:
Protection against HIV and other STIs:
• Male condoms significantly reduce the risk of becoming infected with HIV when used
correctly with every act of vaginal or anal sex.
• When used consistently and correctly, condom use prevents 80% to 95% of HIV
transmission that would have occurred without condoms
• Condoms reduce the risk of becoming infected with many STIs when used consistently and
correctly during vaginal or anal sex.
✓ Protect best against STIs spread by discharge, such as HIV, gonorrhea, and chlamydia.
✓ Also protect against STIs spread by skin-to-skin contact, such as herpes and human
papillomavirus.
Side Effects, Health Benefits, and Health Risks
Side Effects
None
Known Health Benefits

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Help protect against risks of pregnancy STIs, including HIV

May help protect against conditions caused by STIs:
✓ Recurring pelvic inflammatory disease and chronic pelvic pain
✓ Cervical cancer
✓ Infertility (male and female)
Known Health Risks
Extremely rare:
• Severe allergic reaction (among people with latex allergy)
Advantage
• Have no hormonal side effects
• Can be used as a regular, temporary or backup method
• Can be used without seeing a health care provider
• Are sold in many places and generally easy to obtain
• Help protect against both pregnancy and STIs, including HIV
• Can make sex last longer

Disadvantage
• Condom breaks, slips of the penis
• Difficulty putting on the condom
• Mild irritation in or around the vagina or penis or mild allergic reaction to condom (itching,
redness, rash, and/or swelling of genitals, groin)
• Some people connect condoms with immoral sex, sex outside marriage, or sex with
prostitutes, and do not want to use them.
• Some people are too embarrassed to buy condoms

Correcting Misunderstandings
Male condoms:
• Do not make men sterile, impotent, or weak.
• Do not decrease men’s sex drive.
• Cannot get lost in the woman’s body.
• Do not have holes that HIV can pass through.
• Are not laced with HIV.

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• Do not cause illness in a woman. Exposure to semen or sperm is not needed for a
woman’s good health.
• Do not cause illness in men by making sperm “back up”.
• Not only for use outside marriage. They are also used by married couples.
• Do not cause cancer and do not contain cancer-causing chemicals.
Who can use male condoms?
All men and women can safely use male condoms except those with severe allergy to latex
rubber. Also, condoms can be used by:
• Men and women needing a temporary method while waiting for a regular one
• Couples needing a backup method
• Men and women who have intercourse infrequently
• Couples who need contraception immediately
• Couples in which either partner has more than one sexual partner, even if using another
method
When to Start Using Male Condoms?
• Any time, whenever a man or a couple wants protection from pregnancy or STIs.
How to use a male condom
IMPORTANT: Whenever possible, show clients how to put on a condom. Use a model of a
penis, if available, or other item, like a banana, to demonstrate.
Table 5: The 5 basic steps of using a male condom
Basic steps Important details Picture
Use a new condom for • Check the condom package. Do not use if torn or
each act of sex damaged. Avoid using a condom past the
expiration date. Do so only if a newer condom is
not available.
• Tear open the package carefully. Do not use
fingernails, teeth, or anything that can damage the
condom

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Before any physical • For the most protection, put the condom on before
contact, place the the penis makes any genital, oral, or anal contact.
condom on the tip of the
erect penis with the
rolled side out
Unroll the condom all • The condom should unroll easily. Forcing it on
the way to the base of could cause it to break during use.
the erect penis • If the condom does not unroll easily, it may be on
backwards, damaged, or too old. Throw it away
and use a new condom.
• If the condom is on backwards and another one is
not available, turn it over and unroll it onto the
penis.
Immediately after • Withdraw the penis.
ejaculation, hold the rim • Slide the condom off, avoiding spilling semen.
of the condom in place • If having sex again or switching from one sex act
and withdraw the penis to another, use a new condom.
while it is still erect

Dispose of the used • Wrap the condom in its package and put it in the
condom safely rubbish bin or latrine. Do not put the condom into
a flush toilet, as it can cause problems with
plumbing.

➢ Female condoms

What Are Female Condoms?

• Sheaths, or linings, that fit loosely inside a woman’s vagina, made of thin, transparent, soft
film.
✓ Have flexible rings at both ends
✓ One ring at the closed end helps to insert the condom
✓ The ring at the open end holds part of the condom outside the vagina

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• Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. Also
helps to keep infections in semen, on the penis, or in the vagina from infecting the other
partner.

Figure 6: Female Condoms

How Effective?
Effectiveness depends on the user: Risk of pregnancy or sexually transmitted infection (STI) is
greatest when female condoms are not used with every act of sex. Few pregnancies or infections
occur due to incorrect use, slips, or breaks.
Protection against pregnancy:
• As commonly used, about 21 pregnancies per 100 women using female condoms over the
first year. This means that 79 of every 100 women using female condoms will not become
pregnant.
• When used correctly with every act of sex, about 5 pregnancies per 100 women using female
condoms over the first year.
Return of fertility after use of female condom is stopped: No delay
Protection against HIV and other STIs:
• Female condoms reduce the risk of infection with STIs, including HIV, when used correctly
with every act of sex.
Side Effects, Health Benefits, and Health Risks
Side Effects
None
Known Health Benefits
Help protect against: Risks of pregnancy and STIs, including HIV
Known Health Risks
None
Advantage

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• Women can initiate their use

• Have a soft, moist texture that feels more natural than male latex condoms during sex
• Help protect against both pregnancy and STIs, including HIV
• Outer ring provides added sexual stimulation for some women
• Can be used without seeing a health care provider
• Can be inserted ahead of time so do not interrupt sex
• Are not tight or constricting like male condoms
• Do not dull the sensation of sex like male condoms
• Do not have to be removed immediately after ejaculation
Disadvantage
• Condom slips of the vagina
• Difficulty insuring the female condom
• Inner ring uncomfortable or painful
• Makes squeaks or makes noise during sex
• Mild irritation in or around the vagina or penis (itching, redness or rash)

Correcting Misunderstandings
Female condoms:
• Cannot get lost in the woman’s body.
• Are not difficult to use, but correct use needs to be learned.
• Do not have holes that HIV can pass through.
• Are used by married couples. They are not only for use outside marriage.
• Do not cause illness in a woman because they prevent semen or sperm from entering her
body.

Who can use female condoms?

Any women can use female condoms. No medical conditions prevent the use of this method.
When to start female condoms?
Anytime the client wants.
How are female condoms used?
IMPORTANT: Whenever possible, show the client how to insert the female condom. Use a
model or picture, if available, or your hands to demonstrate. You can create an opening similar to

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a vagina with one hand and show how to insert the female condom with the other hand. Basic
steps and important details are of using a female condom are as follows.
1. Use a new female condom for each act of intercourse
• Check the condom package. Do not use if torn or damaged. Avoid using a condom past its
expiration date. Do so only if newer condoms are not available.
• If possible, wash your hands with mild soap and clean water before inserting the condom.
2. Before any physical contact, insert the condom into the vagina
• For the most protection, insert the condom before the penis comes in contact with the vagina.
Can be inserted up to 8 hours before sex.
• Choose a position that is comfortable for insertion—squat, raise one leg, sit, or lie down

Figure 7: Way of inserting of female condom

• Rub the sides of the female condom together to spread the lubricant evenly
• Grasp the ring at the closed end, and squeeze it so it becomes long and narrow

• With the other hand, separate the outer lips (labia) and locate the opening of the vagina.
• Gently push the inner ring into the vagina as far up as it will go. Insert a finger into the
condom to push it into place. About 2 to 3 centimeters of the condom and the outer ring
remain outside the vagina
3. Ensure that the penis enters the condom and stays inside the condom
• The man or woman should carefully guide the tip of his penis in to the condom. If his penis
goes outside the condom, withdraw and try again.
• If the condom is accidentally pulled out of the vagina or pushed into it during sex, put the
condom back in place (Figure 8)

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4. After the man withdraws his penis, hold the outer ring of the condom, twist to seal
in fluids, and gently pull it out of the vagina
• The female condom does not need to be removed immediately.
• Remove the condom before standing up, to avoid spilling semen.
• If the couple has sex again, they should use a new condom.
• Reuse of female condoms is not recommended

c
Figure 9: Removal of female condom after sex
5. Dispose of the used condom safely
• Wrap the condom in its package, and put it in the rubbish or latrine. Do not put the condom
into a flush toilet, as it can cause problems with plumbing.

Figure 10: Safe disposal of used female condom

Note: Male and female condoms should not be used together. This can cause friction that may
lead to slipping or tearing of the condoms.
3.1.2. Spermicides
What Are Spermicides?
• Sperm-killing substances inserted deep in the vagina, near the cervix, before sex.
✓ Nonoxynol-9 is most widely used.
✓ Others include benzalkonium chloride, chlorhexidine, menfegol, octoxynol-9, and
sodium docusate.

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• Available in foaming tablets, melting or foaming suppositories, cans of pressurized foam,

melting film, jelly, and cream.
✓ Jellies, creams, and foam from cans can be used alone, with a diaphragm, or with
condoms.
✓ Films, suppositories, foaming tablets, or foaming suppositories can be used alone or with
condoms.
• Work by causing the membrane of sperm cells to break, killing them or slowing their
movement. This keeps sperm from meeting an egg.

Figure 11: Spermicide

How Effective?
Effectiveness depends on the user: Risk of pregnancy is greatest when spermicides are not used
with every act of sex.
• One of the least effective family planning methods.
• As commonly used, about 21 pregnancies per 100 women using spermicides over the first
year. This means that 79 of every 100 women using spermicides will not become pregnant.
• When used correctly with every act of sex, about 16 pregnancies per 100 women using
spermicides over the first year.
Return of fertility after spermicides are stopped: No delay
Protection against sexually transmitted infections (STIs): None.
Frequent use of nonoxynol-9 may increase risk of HIV infection
Side Effects, Health Benefits, and Health Risks
Side Effects
Some users report the following:
• Irritation in or around the vagina or penis
Other possible physical changes:

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• Vaginal lesions
Known Health Benefits
Help protect against risks of pregnancy
Known Health Risks
Uncommon:
• Urinary tract infection, especially when using spermicides 2 or more times a day
Rare:
• Frequent use of nonoxynol-9 may increase risk of HIV infection.
Advantage
• Are controlled by the woman
• Have no hormonal side effects
• Increase vaginal lubrication
• Can be used without seeing a health care provider
• Can be inserted ahead of time and so do not interrupt sex

Disadvantage
• Irritation in or around the vagina or penis. (she or her partner has itching, rash, or irritation
that lasts for a day or more)
• Urinary tract infection (burning or pain with urination, frequent urination in small amounts,
blood in the urine, back pain)
• Bacterial vaginosis (abnormal white or gray vaginal discharge with unpleasant odor)
• Candidiasis (abnormal white vaginal discharge that can be watery or thick chunky)

Correcting Misunderstandings
Spermicides:
• Do not reduce vaginal secretions or make women bleed during sex.
• Do not cause cervical cancer or birth defects.
• Do not protect against STIs.
• Do not change men’s or women’s sex drive or reduce sexual pleasure for most men.
• Do not stop women’s monthly bleeding.

Who can use spermicides?

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spermicides safe and suitable for nearly all women.

Who cannot use spermicides?
All women can safely use spermicides except those who:
• Are at high risk for HIV infection
• Have HIV infection
• Have AIDS
When to start using spermicides?
Anytime the client wants.
How are spermicides used?
Spermicides should be inserted before sex.
• Foam or cream: Any time less than one hour before sex.
• Tablets, suppositories, jellies, film: Between 10 minutes and one hour before sex.
The client checks the expiration date and washes hands with mild soap and clean water, if
possible.
• Applying the spermicide:
✓ Foam or cream: Shake cans of foam hard. Squeezes spermicide from the can or tube
into a plastic applicator. Insert the applicator deep into the vagina, near the cervix, and
pushes the plunger.
✓ Tablets, suppositories, jellies: Inserts the spermicide deep into the vagina, near the
cervix, with an applicator or with fingers.
✓ Film: Folds film in half and inserts with dry fingers (or else the film will stick to the
fingers and not the cervix).
• Before each act of vaginal sex additional spermicide should be inserted.
• Douching is not recommended because it will wash away the spermicide and also increase
the risk of STIs. If the client must douche, she should wait for at least 6 hours after sex
before doing so.

➢ Diaphragm
• A soft latex cup that covers the cervix. Plastic and silicone diaphragms may also be available.
• The rim contains a firm, flexible spring that keeps the diaphragm in place.
• Used with spermicidal cream, jelly, or foam to improve effectiveness.

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• Most diaphragms come in different sizes and require fitting by a specifically trained provider.
It does not require seeing a provider for fitting.
• Works by blocking sperm from entering the cervix; spermicide kills or disables sperm. Both
keep sperm from meeting an egg.

Figure 12: The diaphram

How Effective?
Effectiveness depends on the user: Risk of pregnancy is greatest when the diaphragm with
spermicide is not used with every act of sex.
• As commonly used, about 17 pregnancies per 100 women using the diaphragm with
spermicide over the first year. This means that 83 of every 100 women using the diaphragm
will not become pregnant.
• When used correctly with every act of sex, about 16 pregnancies per 100 women using the
diaphragm with spermicide over the first year.
Return of fertility after use of the diaphragm is stopped: No delay
Protection against STIs: May provide some protection against certain STIs but should not be
relied on for STI prevention.
Side Effects, Health Benefits, and Health Risks
Side Effects
Some users report the following:
• Irritation in or around the vagina or penis
Other possible physical changes:
• Vaginal lesions
Known Health Benefits
Help protect against:
• Risks of pregnancy

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May help protect against:

• Certain STIs (chlamydia, gonorrhea, pelvic inflammatory disease, trichomoniasis)
• Cervical pre cancer and cancer
Known Health Risks
Common to uncommon:
• Urinary tract infection
Uncommon:
• Bacterial vaginosis
• Candidiasis
Rare:
• Frequent use of nonoxynol-9 may increase risk of HIV infection
Extremely rare:
• Toxic shock syndrome

Advantage
• Is controlled by the woman
• Has no hormonal side effects
• Can be inserted ahead of time and so does not interrupt sex
Disadvantage
• Difficulty inserting or removing diaphragm
• Discomfort or pain with diaphragm use
• Irritation in or around the vagina or penis.

Correcting Misunderstandings
Diaphragms:
• Do not affect the feeling of sex. A few men report feeling the diaphragm during sex, but
most do not.
• Cannot pass through the cervix. They cannot go into the uterus or otherwise get lost in
the woman’s body.
• Do not cause cervical cancer.
Who can use the diaphragm?
• Nearly all women can use the diaphragm safely and effectively.

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Who cannot use the diaphragm?

Women who have the following conditions:
• Have had a baby or second-trimester abortion in the past 6 weeks
• Allergy to latex rubber
• Are at high risk for HIV infection
• Have HIV infection
• Have AIDS
When to start using the diaphragm?
Anytime the client wants, except within 6 weeks after full-term delivery or second-trimester
spontaneous or induced abortion.
How is diaphragm used?
• A pelvic examination is needed before starting use. The provider determines the correct
diaphragm size and checks that it fits properly and does not come out easily. With a properly
fitted diaphragm, the client should not be able to feel anything inside her vagina, even when
she walks or during sex.
IMPORTANT: Whenever possible, show the woman the location of the pubic bone and cervix
with a model or picture. Explain that the diaphragm is inserted behind the pubic bone and covers
cervix.
1. Squeeze a spoonful of spermicidal cream, jelly or foam into the diaphragm and around
the rim.
• Wash hands with soap and clean water if possible.
• Check the diaphragm for holes, cracks, or tears by holding it up to the light.
• Check the expiration date of the spermicide and avoid using any beyond its expiration date.
• Insert the diaphragm less than 6 hours before having sex.

2. Press the rim together; push into the vagina as far as it goes

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• Choose a position that is comfortable for insertion—squatting, raising one leg, sitting, or
lying down.
3. Feel the diaphragm to make sure it covers the cervix
• Through the dome of the diaphragm, the cervix feels like the tip of the nose.
• If the diaphragm feels uncomfortable, take it out and insert it again.
4. Keep in place for at least 6 hours after sex
• Keep the diaphragm in place at least 6 hours after having sex but no longer than 24 hours.
• Leaving the diaphragm in place for more than one day may increase the risk of toxic shock
syndrome. It can also cause a bad odor and vaginal discharge.
• For multiple sex acts, make sure that the diaphragm is in the correct position and also insert
additional spermicides in front of the diaphragm before each act.
5. To remove, slide a finger under the rim of the diaphragm to pull it down and out
• Wash hands with mild soap and clean water, if possible.
• Insert a finger into the vagina until the rim of the diaphragm is felt.
• Gently slide a finger under the rim and pull the diaphragm down and out. Use care not to tear
the diaphragm with a fingernail.
• Wash the diaphragm with soap and clean water and dry it after each use.

Tips for Users of Spermicides or the Diaphragm With

Spermicide
• Spermicides should be stored in a cool, dry place, if possible, out of the sun.
Suppositories may melt in hot weather. If kept dry, foaming tablets are not as likely to
melt in hot weather.
• The diaphragm should be stored in a cool, dry place, if possible.
• She needs a new diaphragm fitted if she has had a baby or a second trimester miscarriage
or abortion.
a) Cervical cap
What Is the Cervical Cap?
• A soft, deep, latex or plastic rubber cup that snugly covers the cervix.
• Comes in different sizes; requires fitting by a specifically trained provider.
How Effective?

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Effectiveness depends on the user: Risk of pregnancy is greatest when the cervical cap with
spermicide is not used with every act of sex.
Women who have given birth:
• One of the least effective methods, as commonly used.
• As commonly used, about 32 pregnancies per 100 women using the cervical cap with
spermicide over the first year. This means that 68 of every 100 women using the cervical cap
will not become pregnant.
• When used correctly with every act of sex, about 26 pregnancies per 100 women using the
cervical cap over the first year.
More effective among women who have not given birth:
• As commonly used, about 16 pregnancies per 100 women using the cervical cap with
spermicide over the first year. This means that 84 of every 100 women using the cervical cap
will not become pregnant.
• When used correctly with every act of sex, about 9 pregnancies per 100 women using the
cervical cap over the first year.
Return of fertility after use of cervical cap is stopped: No delay
Protection against sexually transmitted infections: None
Side Effects, Health Benefits, and Health Risks
• Same as for diaphragms
Who can use the cervical cup?
• Nearly all women can use the diaphragm safely and effectively.
Who cannot use the cervical cup?
• Treated or going to be treated for cervical pre cancer or cervical cancer.
• Have had a baby or second-trimester abortion in the past 6 weeks
• Allergy to latex rubber
• Are at high risk for HIV infection
• Have HIV infection
• Have AIDS
How to use cervical cup
Providing the cervical cap is similar to providing diaphragms and helping diaphragm users.
Differences include:

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Inserting
• Fill one-third of the cap with spermicidal cream, jelly, or foam.
• Press the rim of the cap around the cervix until it is completely covered, pressing gently on
the dome to apply suction and seal the cap.
• Insert the cervical cap any time up to 42 hours before having sex.
Removing
• Leave the cervical cap in for at least 6 hours after her partner’s last ejaculation, but not more
than 48 hours from the time it was put in.
• Leaving the cap in place for more than 48 hours may increase the risk of toxic shock
syndrome and can cause a bad odor and vaginal discharge.
• Tip the cap rim sideways to break the seal against the cervix, and then gently pull the cap
down and out of the vagina
3.2.3. Providing Combined Oral Contraceptives
Oral contraceptive pills are contraceptives that are taken orally once daily to prevent pregnancy.
Oral contraceptives contain either two or one female sex hormones. The hormones are synthetic
estrogens and synthetic progesterone. These include:
I. Combined oral contraceptive pills (COCs):
Contain both synthetic estrogen and progesterone like the natural female sex hormones.
Progestin only pills (POPs): contain progestin only like the natural female sex hormone.
When to start
Table 6: A woman can start using COCs any time she wants if it is reasonably certain she is not
pregnant.
Women’s When to start
situation
Having Any time of the month
menstrual • If she is starting within 5 days after the start of her monthly bleeding,
cycles or no need for a backup method.
switching from • If it is more than 5 days after the start of her monthly bleeding, she can
a non hormonal start COCs any time it is reasonably certain she is not pregnant. She
method will need a backup method for the first 7 days of taking pills.
• If she is switching from an IUD, she can start COCs immediately

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Switching from • Immediately, if she has been using the hormonal method consistently
a hormonal and correctly or if it is otherwise reasonably certain she is not pregnant.
method No need to wait for her next monthly bleeding. No need for a backup
method.
• If she is switching from injectables, she can begin taking COCs when
the repeat injection would have been given. No need for a backup
method.
Fully or nearly • Give her COCs and tell her to start taking them 6 months after giving
fully birth or when breast milk is no longer the baby’s main food—
breastfeeding whichever comes first.
Less than 6
months
after giving
birth
Fully or nearly • If her monthly bleeding has not returned, she can start COCs any time
fully it is reasonably certain she is not pregnant. She will need a backup
Breastfeeding method for the first 7 days of taking pills.
More than 6 • If her monthly bleeding has returned, she can start COCs as advised for
months women having menstrual cycles.
after giving
birth
Partially • Give her COCs and tell her to start taking them 6 weeks after giving
Breastfeeding birth.
Less than 6 • Also give her a backup method to use until 6 weeks since giving birth
weeks if her monthly bleeding returns before this time.
after giving
birth
Partially • If her monthly bleeding has not returned, she can start COCs any time
Breastfeeding it is reasonably certain she is not pregnant. She will need a backup
more than 6 method for the first 7 days of taking pills.
weeks • If her monthly bleeding has returned, she can start COCs as advised for

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after giving women having menstrual cycles.

birth
Not • She can start COCs at any time on days 21–28 after giving birth. Give
breastfeeding her pills any time to start during these 7 days. No need for a backup
Less than 4 method.
weeks
after giving
birth
Not • If her monthly bleeding has not returned, she can start COCs any time
breastfeeding it is reasonably certain she is not pregnant.† She will need a backup
More than 4 method for the first 7 days of taking pills.
weeks • If her monthly bleeding has returned, she can start COCs as advised for
after giving women having menstrual cycles.
birth
No monthly • She can start COCs any time it is reasonably certain she is not
bleeding (not pregnant. She will need a backup method for the first 7 days of taking
related to pills.
childbirth
or
breastfeeding)
After • Immediately. If she is starting within 7 days after first- or second-
miscarriage or trimester miscarriage or abortion, no need for a backup method.
abortion • If it is more than 7 days after first- or second trimester miscarriage or
abortion, she can start COCs any time it is reasonably certain she is not
pregnant. She will need a backup method for the first 7 days of taking
pills.
After taking • She can start COCs the day after she finishes taking the ECPs. There is
emergency no need to wait for her next monthly bleeding to start her pills.
contraceptive • A new COC user should begin a new pill pack.
pills (ECPs) • A continuing user who needed ECPs due to pill taking errors can
continue where she left off with her current pack.

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• All women will need to use a backup method for the first 7 days of
taking pills.

Figure13: Combined Oral Contraceptive

Giving Advice on Side Effects
IMPORTANT: Counseling about bleeding changes may be the most important help a woman
needs to keep using the method without concern.
Describe the most common side effects
• In the first few months, bleeding at unexpected times (irregular bleeding). Then lighter,
shorter, and more regular monthly bleeding.
• Headaches, breast tenderness, w eight change, and possibly other side effects.
Explain about these side effects
• Side effects are not signs of illness.
• Most side effects usually become less or stop within the first few months of using COCs.
• Common, but some women do not have them.
Explain what to do in case of side effects
• Keep taking COCs. Skipping pills risks pregnancy and can make some side effects worse.
• Take each pill at the same time every day to help reduce irregular bleeding and also help with
remembering.
• Take pills with food or at bedtime to help avoid nausea. The client can come back for help if
side effects bother her or if she has other concerns.

Explaining How to Use

1. Give pills
• Give up to 1 year’s supply (13 packs) depending on the woman’s preference and planned use.

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2. Explain pill pack

• Show which kind of pack—21 pills or 28 pills. With 28-pill packs, point out that the last 7
pills are a different color and do not contain hormones.
• Show how to take the first pill from the pack and then how to follow the directions or arrows
on the pack to take the rest of the pills.
3. Give key instruction
• Take one pill each day— until the pack is empty.
• Discuss cues for taking a pill every day. Linking pill-taking to a daily activity—such as
cleaning her teeth—may help her remember.
• Taking pills at the same time each day helps to remember them. It also may help reduce some
side effects.

4. Explain starting next pack

• 28-pill packs: When she finishes one pack, she should take the first pill from the next pack on
the very next day.
• 21-pill packs: After she takes the last pill from one pack, she should wait 7 days—no more—
and then take the first pill from the next pack.
• It is very important to start the next pack on time. Starting a pack late risks pregnancy.
5. Provide backup method and explain use
• Sometimes she may need to use a backup method, such as when she misses pills.
• Backup methods include abstinence, male or female condoms, spermicides, and withdrawal.
Tell her that spermicides and withdrawal are the least effective contraceptive methods. Give
her condoms, if possible.
• If she misses 3 or more hormonal pills, she can consider ECPs.

Managing Missed Pills

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Key message: Take a missed hormonal pill as soon as possible.

• Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the
same day.)
Missed 1 or 2 pills? Started new pack 1 or 2 days late?
• Take a hormonal pill as soon as possible.
• Little or no risk of pregnancy.
Missed pills 3 or more days in a row in the first or second week?
Started new pack 3 or more days late?
• Take a hormonal pill as soon as possible.
• Use a backup method for the next 7 days.
• Also, if she had sex in the past 5 days, she can consider ECPs.
Missed 3 or more pills in the third week?
• Take a hormonal pill as soon as possible.
• Finish all hormonal pills in the pack. Throw away the 7 non hormonal pills in a 28-pill pack.
• Start a new pack the next day.
• Use a backup method for the next 7 days.
• Also, if she had sex in the past 5 days, she can consider ECPs.
Missed any non hormonal pills? (Last 7 pills in 28-pill pack)
• Discard the missed non hormonal pill(s).
• Keep taking COCs, one each day. Start the new pack as usual.
Severe vomiting or diarrhea
• If she vomits within 2 hours after taking a pill, she should take another pill from her pack as
soon as possible, then keep taking pills as usual.
• If she has vomiting or diarrhea for more than 2 days, follow instructions for 3 or more missed
pills, above.

Planning the Next Visit

1. Encourage her to come back for more pills before she uses up her supply of pills.
2. An annual visit is recommended.
3. Some women can benefit from contact after 3 months of COC use. This offers an
opportunity to answer any questions, help with any problems, and check on correct use.

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Managing Side Effects of Combined Oral Contraceptives

May or may not be due to the method.
• Problems with side effects affect women’s satisfaction and use of COCs. They deserve the
provider’s attention. If the client reports side effects or problems, listen to her concerns, give
her advice, and support, and, if appropriate, treat. Make sure she understands the advice and
agrees.
• Encourage her to keep taking a pill every day even if she has side effects. Missing pills can
risk pregnancy and may make some side effects worse.
• Many side effects will subside after a few months of use. For a woman whose side effects
persist, give her a different COC formulation, if available, for at least 3 months.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be
overcome.
Irregular bleeding (bleeding at unexpected times that bothers the client)
• Reassure her that many women using COCs experience irregular bleeding. It is not harmful
and usually becomes less or stops after the first few months of use.
• Other possible causes of irregular bleeding include:
✓ Missed pills
✓ Taking pills at different times each day
✓ Vomiting or diarrhea
✓ Taking anticonvulsants, rifampicin, or rifabutin
• To reduce irregular bleeding:
✓ Urge her to take a pill each day and at the same time each day.
✓ Teach her to make up for missed pills properly.
✓ For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5
days or other no steroidal anti-inflammatory drug (NSAID), beginning when irregular
bleeding starts.
✓ If she has been taking the pills for more than a few months and NSAIDs do not help, give
her a different COC formulation, if available. Ask her to try the new pills for at least 3
months.

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• If irregular bleeding continues or starts after several months of normal or no monthly

bleeding, or you suspect that something may be wrong for other reasons, consider underlying
conditions unrelated to method use.
No monthly bleeding
• Reassure her that some women using COCs stop having monthly bleeding, and this is not
harmful. There is no need to lose blood every month. It is similar to not having monthly
bleeding during pregnancy. She is not pregnant or infertile. Blood is not building up inside
her. (Some women are happy to be free from monthly bleeding, and for some women this
may help prevent anemia.)
Ordinary headaches (nonmigrainous)
• Try the following (one at a time):
✓ Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or
other pain reliever.
• Any headaches that get worse or occur more often during COC use should be evaluated.
Nausea or dizziness
• For nausea, suggest taking COCs at bedtime or with food. If symptoms continue:
• Consider locally available remedies.
Breast tenderness
• Recommend that she wear a supportive bra (including during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or
other pain reliever.
• Consider locally available remedies.
Weight change
• Review diet and counsel as needed.
Mood changes or changes in sex drive
• Some women have changes in mood during the hormone-free week (the 7 days when a
woman does not take hormonal pills).
• Ask about changes in her life that could affect her mood or sex drive, including changes in
her relationship with her partner. Give her support as appropriate.
• Clients who have serious mood changes such as major depression should be referred for care.

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Acne
• Acne usually improves with COC use. It may worsen for a few women.
• If she has been taking pills for more than a few months and acne persists, give her a different
COC formulation, if available. Ask her to try the new pills for at least 3 months.
• Consider locally available remedies.
II. Providing Progestin-Only Pills
Progestin only pills (POPs): contain progestin only like the natural female sex hormone.
IMPORTANT: A woman can start using POPs any time she wants if it is reasonably certain she
is not pregnant.
Table 7: Time to start POP
Fully or nearly fully -If her monthly bleeding has not returned, she can start POPs any time between
breastfeeding giving birth and 6 months. No need for a backup method.
Less than 6 months -If her monthly bleeding has returned, she can start POPs as advised for
after giving birth women having menstrual cycles.
Fully or nearly fully • If her monthly bleeding has not returned, she can start POPs any time it is
breastfeeding reasonably certain she is not pregnant. She will need a backup method for
More than 6 months the first 2 days of taking pills.
after giving birth • If her monthly bleeding has returned, she can start POPs as advised for
women having menstrual cycles.
Partially breastfeeding • She can start POPs any time it is reasonably certain she is not pregnant.
If her monthly She will need a backup method for the first 2 days of taking pills.
bleeding has
not returned
Partially breastfeeding • She can start POPs as advised for women having menstrual cycles.
If her monthly
bleeding has returned
Not breastfeeding • She can start POPs at any time. No need for a backup method.
Less than 4 weeks
after giving birth
Not breastfeeding • If her monthly bleeding has not returned, she can start POPs any time it is
More than 4 weeks reasonably certain she is not pregnant. She will need a backup method for

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after giving birth the first 2 days of taking pills.

• If her monthly bleeding has returned, she can start POPs as advised for
women having menstrual cycles.
Switching from • Immediately, if she has been using the hormonal method consistently and
a hormonal correctly or if it is otherwise reasonably certain she is not pregnant. No
method need to wait for her next monthly bleeding. No need for a backup method.
• If she is switching from injectables, she can begin taking POPs when the
repeat injection would have been given. No need for a backup method.
Having menstrual Any time of the month
cycles or • If she is starting within 5 days after the start of her monthly bleeding, no
switching from need for a backup method.
a non hormonal • If it is more than 5 days after the start of her monthly bleeding, she can
method start POPs any time it is reasonably certain she is not pregnant. She will
need a backup method for the first 2 days of taking pills.
• If she is switching from an IUD, she can start POPs immediately.
No monthly • She can start POPs any time it is reasonably certain she is not pregnant.
bleeding (not She will need a backup method for the first 2 days of taking pills.
related to childbirth
or breastfeeding)
After • Immediately. If she is starting within 7 days after first- or second-trimester
miscarriage or miscarriage or abortion, no need for a backup method. If it is more than 7
abortion days after first- or second trimester miscarriage or abortion, she can start
POPs any time it is reasonably certain she is not pregnant. She will need a
backup method for the first 2 days of taking pills.
After taking • She can start POPs the day after she finishes taking the ECPs. There is no
emergency need to wait for her next monthly bleeding to start her pills.
contraceptive ✓ A new POP user should begin a new pill pack.
pills (ECPs) ✓ A continuing user who needed ECPs due to pill-taking errors can
continue where she left off with her current pack.
• All women will need to use a backup method for the first 2 days of taking
pills.

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Giving Advice on Side Effects

Describe the most common side effects

• Breastfeeding women normally do not have monthly bleeding for several months after giving
birth. POPs lengthen this period of time.
• Women who are not breastfeeding may have frequent or irregular bleeding for the first
several months, followed by regular bleeding or continued irregular bleeding.
• Headaches, dizziness, breast tenderness, and possibly other side effects.

Explain about these side effects

• Side effects are not signs of illness. Lack of bleeding does not mean pregnancy.
• Usually become less or stop within the first few months of using POPs. Bleeding changes,
however, usually persist.
• Common, but some women do not have them.

Explain what to do in case of side effects

• Keep taking POPs. Skipping pills risks pregnancy.
• Try taking pills with food or at bedtime to help avoid nausea.
• The client can come back for help if side effects bother her or if she has other concerns.

Explaining How to Use

1. Give pills
• Give as many packs as possible—even as much as a year’s supply (11 packs of 35 pills each
or 13 packs of 28 pills each).
2. Explain pill pack
• Show which kind of pack—28 pills or 35 pills.
• Explain that all pills in POP packs are the same color and all are active pills, containing a
hormone that prevents pregnancy.
• Show how to take the first pill from the pack and then how to follow the directions or arrows
on the pack to take the rest of the pills.
3. Give key instruction
• Take one pill each day— until the pack is empty.

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• Women who are not breastfeeding should take a pill at the same time each day. Taking a pill
more than 3 hours late makes it less effective.
• Discuss cues for taking a pill every day. Linking pill-taking to a daily activity—such as
cleaning her teeth— may help her remember.
4. Explain starting next pack
• When she finishes one pack, she should take the first pill from the next pack on the very next
day.
• It is very important to start the next pack on time. Starting a pack late risks pregnancy.
5. Provide backup method and explain use
• Sometimes she may need to use a backup method, such as when she misses pills or is late
taking a pill.
6. Explain that effectiveness decreases when breastfeeding stops
• Without the additional protection of breastfeeding itself, POPs are not as effective as most
other hormonal methods.
• When she stops breastfeeding, she can continue taking POPs if she is satisfied with the
method, or she is welcome to come back for another method.

Managing Missed Pills

• Key message: Take a missed pill as soon as possible.
• Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the
same day.)
Do you have monthly bleeding regularly?
• If yes, she also should use a backup method for the next 2 days.
• Also, if she had sex in the past 5 days, she can consider taking ECPs.
Severe vomiting or diarrhea
• If she vomits within 2 hours after taking a pill, she should take another pill from her pack as
soon as possible, then keep taking pills as usual.
• If she has vomiting or diarrhea for more than 2 days, follow instructions for 3 or more missed
pills, above.
Planning the Next Visit
1. Encourage her to come back for more pills before she uses up her supply of pills.

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2. Contacting women after the first 3 months of POP use is recommended. This offers an
opportunity to answer any questions, help with any problems, and check on correct use.

Managing Side Effects of Progestin Only Pills

Side Effects May or may not be due to the method.

• Problems with side effects affect women’s satisfaction and use of POPs. They deserve the
provider’s attention. If the client reports side effects or problems, listen to her concerns, give
her advice and support, and, if appropriate, treat. Make sure she understands the advice and
agrees.
• Encourage her to keep taking a pill every day even if she has side effects. Missing pills can
risk pregnancy.
• Many side effects will subside after a few months of use. For a woman whose side effects
persist, give her a different POP formulation, if available, for at least 3 months.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be
overcome.

No monthly bleeding
• Breastfeeding women:
✓ Reassure her that this is normal during breastfeeding. It is not harmful.
• Women not breastfeeding:
✓ Reassure her that some women using POPs stop having monthly bleeding, and this is not
harmful. There is no need to lose blood every month. It is similar to not having monthly
bleeding during pregnancy. She is not pregnant or infertile. Blood is not building up
inside her. (Some women are happy to be free from monthly bleeding.)
Irregular bleeding (bleeding at unexpected times that bothers the client)
• Reassure her that many women using POPs experience irregular bleeding—whether
breastfeeding or not. (Breastfeeding itself also can cause irregular bleeding.) It is not harmful
and sometimes becomes less or stops after the first several months of use. Some women have
irregular bleeding the entire time they are taking POPs.
• Other possible causes of irregular bleeding include:
✓ Vomiting or diarrhea

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✓ Taking anticonvulsants or rifampicin

• To reduce irregular bleeding:
✓ Teach her to make up for missed pills properly.
✓ For modest short-term relief she can try 800 mg ibuprofen 3 times daily after meals for 5
days, or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular
bleeding starts.
✓ If she has been taking the pills for more than a few months and NSAIDs do not help, give
her a different POP formulation, if available. Ask her to try the new pills for at least 3
months.
• If irregular bleeding continues or starts after several months of normal or no monthly
bleeding, or you suspect that something may be wrong for other reasons, consider underlying
conditions unrelated to method use.
Heavy or prolonged bleeding (twice as much as usual as or longer than 8 days)
• Reassure her that some women using POPs experience heavy or prolonged bleeding. It is
generally not harmful and usually becomes less or stops after a few months.
• For modest short-term relief she can try NSAIDs, beginning when heavy bleeding starts.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods
containing iron, such as meat and poultry (especially beef and chicken liver), fish, green
leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no
monthly bleeding, or you suspect that something may be wrong for other reasons, consider
underlying conditions unrelated to method use.
Ordinary headaches (nonmigrainous)
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or
other pain reliever.
• Any headaches that get worse or occur more often during POP use should be evaluated.
Mood changes or changes in sex drive
• Ask about changes in her life that could affect her mood or sex drive, including changes in
her relationship with her partner. Give her support as appropriate.

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• Some women experience depression in the year after giving birth. This is not related to
POPs. Clients who have serious mood changes such as major depression should be referred
for care.
• Consider locally available remedies.
Breast tenderness
• Breastfeeding women:
✓ It may due to cracked nipples, sore breast or infection give appropriate treatment
• Women not breastfeeding:
✓ Recommend that she wear a supportive bra (including during strenuous activity and
sleep).
✓ Try hot or cold compresses.
✓ Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or
other pain reliever.
✓ Consider locally available remedies.
Nausea or dizziness
• For nausea, suggest taking POPs at bedtime or with food.
• If symptoms continue, consider locally available remedies.
i. Emergency contraceptives

Emergency contraceptive are methods of contraception that can be used to prevent pregnancy
following an unprotected act of sexual intercourse. The methods include:
Emergency contraceptive pills (ECPs): can be used up to five days following unprotected
intercourse (120 hours).
A cupper- bearing IUD: can also be used within seven days of unprotected intercourse as an
emergency contraceptive.

3.2.3. Providing Progestin-Only Injectable

The contraceptive injection, also known as ‘the shot’, contains progestogen or a combination of
estrogen and progestrogen. The Injectable contraceptives depot medroxyprogesterone acetate
(DMPA) and norethisterone enanthate (NET-EN) each contain a progestin like the natural
hormone progesterone in a woman’s body. In contrast, monthly injectables contain both estrogen
and progestin. DMPA, the most widely used progestin-only Injectable, is also known as Depo or
Depo-Provera. In this learning you will learn progestin only injectables.

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When to Start
IMPORTANT: A woman can start injectables any time she wants if it is reasonably certain she
is not pregnant.

Table 8: Shows When to Start injectables

Women’s situation When to start
Having menstrual Any time of the month
cycles or switching • If she is starting within 7 days after the start of her monthly bleeding, no
from a need for a backup method.
nonhormonal • If it is more than 7 days after the start of her monthly bleeding, she can
method start injectables any time it is reasonably certain she is not pregnant. She
will need a backup method* for the first 7 days after the injection.
• If she is switching from an IUD, she can start injectables immediately.
Switching from a • Immediately, if she has been using the hormonal method consistently and
hormonal method correctly or if it is otherwise reasonably certain she is not pregnant. No
need to wait for her next monthly bleeding. No need for a backup method.
Fully or nearly • If she gave birth less than 6 weeks ago, delay her first injection until at
fully least 6 weeks after giving birth.
breastfeeding • If her monthly bleeding has not returned, she can start injectables any time
Less than 6 months between 6 weeks and 6 months. No need for a backup method.
after giving birth • If her monthly bleeding has returned, she can start injectables as advised
for women having menstrual cycles.
Fully or nearly • If her monthly bleeding has not returned, she can start injectables any time
fully if it is reasonably certain she is not pregnant. She will need a backup
breastfeeding method for the first 7 days after the injection.
More than 6 months • If her monthly bleeding has returned, she can start injectables as advised
after giving birth for women having menstrual cycles.
Partially • Delay her first injection until at least 6 weeks after giving birth.
breastfeeding Less
than 6 weeks after
giving birth

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Partially • If her monthly bleeding has not returned, she can start injectables any time
breastfeeding More if it is reasonably certain she is not pregnant. She will need a Backup
than 6 weeks after method for the first 7 days after the injection.
giving birth • If her monthly bleeding has returned, she can start injectables as advised
for women having menstrual cycles.
Not breastfeeding • She can start injectables at any time. No need for a backup method.
Less than 4 weeks
after giving birth
Not breastfeeding • If her monthly bleeding has not returned, she can start injectables any time
More than 4 weeks if it is reasonably certain she is not pregnant. She will need a backup
after giving birth method for the first 7 days after the injection.
• If her monthly bleeding has returned, she can start injectables as advised
for women having menstrual cycles.
No monthly • She can start injectables any time if it is reasonably certain she is not
bleeding (not related pregnant. She will need a backup method for the first 7 days after the
to childbirth or injection.
breastfeeding)
After miscarriage • Immediately. If she is starting within 7 days after first- or second-trimester
or abortion miscarriage or abortion, no need for a backup method.
• If it is more than 7 days after first- or second trimester miscarriage or
abortion, she can start injectables any time if it is reasonably certain she is
not pregnant. She will need a backup method for the first 7 days after the
injection.
After taking • She can start or restart injectables on the same day as taking the ECPs. No
emergency need to wait for her next monthly bleeding to have the injection.
contraceptive pills ✓ She will need to use a backup method for the first 7 days after the
(ECPs) injection.
✓ If she does not start immediately but returns for injectables, she can
start at any time if it is reasonably certain she is not pregnant.

Giving Advice on Side Effects

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IMPORTANT: Counseling about bleeding changes may be the most important help a woman
needs to keep using the method without concern.
Describe the most common side effects
• For the first several months, irregular bleeding, prolonged bleeding, frequent bleeding. Later,
no monthly bleeding.
• Weight gain (about 1–2 kg per year), headaches, dizziness, and possibly other side effects.
Explain about these side effects
• Side effects are not signs of illness.
• Common, but some women do not have them.
• The client can come back for help if side effects bother her.

Giving Intramuscular Injection with a Conventional Syringe

1. Obtain one dose of Injectable, needle, and syringe
• DMPA: 150 mg for injections into the muscle (intramuscular injection). NET-EN: 200 mg
for injections into the muscle.
• For each injection use a prefilled single-use syringe and needle from a new, sealed package
(within expiration date and not damaged), if available.
• If a single-dose prefilled syringe is not available, use single-dose vials. Check expiration
date. If using an open multi dose vial, check that the vial is not leaking.
✓ DMPA: A 2 ml syringe and a 21–23 gauge intramuscular needle.
✓ NET-EN: A 2 or 5 ml syringe and a 19-gauge intramuscular needle. A narrower needle
(21–23 gauge) also can be used.

2. Wash
• Wash hands with soap and water, if possible. Let your hands dry in the air.
• If injection site is dirty, wash it with soap and water.
• No need to wipe site with antiseptic.

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If using a prefilled syringe, skip to step 5.

3. Prepare vial
• DMPA: Gently shake the vial.
• NET-EN: Shaking the vial is not necessary.
• No need to wipe top of vial with antiseptic.
• If vial is cold, warm to skin temperature before giving the injection.
4. Fill syringe
• Pierce top of vial with sterile needle and fill syringe with proper dose.
5. Inject formula
• Insert sterile needle deep into the hip (ventrogluteal muscle), the upper arm (deltoid muscle),
or the buttocks (gluteal muscle, upper outer portion), whichever the woman prefers. Inject the
contents of the syringe. Do not massage injection site.

6. Dispose of disposable syringes and needles safely

• Do not recap, bend, or break needles before disposal.
• Place in a puncture-proof sharps container.
• Do not reuse disposable syringes and needles.

Supporting the User Give specific instructions

• Tell her not to massage the injection site.
• Tell the client the name of the injection.
• Agree on a date for her next injection and give her a paper with the date written on it.

Planning the Next Injection

1. Agree on a date for her next injection in 3 months (13 weeks) for DMPA, or in 2 months (8
weeks) for NET-EN. Discuss how to remember the date, perhaps tying it to a holiday or other
event or circling a date on a calendar.

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2. Ask her to try to come on time. With DMPA she may come up to 4 weeks after the scheduled
injection date and still get an injection. With NET-EN she may come up to 2 weeks after the
scheduled injection date and still get an injection. No need for tests, evaluation, or a backup
method. With either DMPA or NET-EN, she can come up to 2 weeks before the scheduled
injection date.
She should come back no matter how late she is for her next injection. If more than 4 weeks late
for DMPA or 2 weeks late for NET-EN, she should abstain from sex or use condoms,
spermicides, or withdrawal until she can get an injection. Also, if she has had sex in the past 5
days without using another contraceptive method, she can consider emergency contraceptive
pills.

Managing Side Effects of Progestin only Injectable

May or may not be due to the method.

• Problems with side effects affect women’s satisfaction and use of injectables. They deserve
the provider’s attention. If the client reports side effects, listen to her concerns, give her
advice and support, and, if appropriate, treat. Make sure she understands the advice and
agrees.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be
overcome.

No monthly bleeding
• Reassure her that most women using progestin-only injectables stop having monthly bleeding
over time, and this is not harmful. There is no need to lose blood every month. It is similar to
not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up
inside her. (Some women are happy to be free from monthly bleeding.)

Irregular bleeding (bleeding at unexpected times that bothers the client)

• Reassure her that many women using progestin-only injectables experience irregular
bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
• For modest short-term relief, she can take 500 mg mefenamic acid 2 times daily after meals
for 5 days or 40 mg of valdecoxib daily for 5 days, beginning when irregular bleeding starts.

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• If irregular bleeding continues or starts after several months of normal or no monthly

bleeding, or you suspect that something may be wrong for other reasons, consider underlying
conditions unrelated to method use.

Weight gain
• Review diet and counsel as needed.

Abdominal bloating and discomfort

• Consider locally available remedies.

Heavy or prolonged bleeding (twice as much as usual as or longer than 8 days)

• Reassure her that some women using progestin-only injectables experience heavy or
prolonged bleeding. It is not harmful and usually becomes less or stops after a few months.
• For modest short-term relief she can try (one at a time), beginning when heavy bleeding
starts:
✓ 500 mg of mefenamic acid twice daily after meals for 5 days
✓ 40 mg of valdecoxib daily for 5 days
✓ 50 μg of ethinyl estradiol daily for 21 days
• If bleeding becomes a health threat or if the woman wants, help her choose another method.
In the meantime, she can use one of the treatments listed above to help reduce bleeding.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods
containing iron, such as meat and poultry (especially beef and chicken liver), fish, green
leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no
monthly bleeding, or you suspect that something may be wrong for other reasons, consider
underlying conditions unrelated to method use.

Ordinary headaches (nonmigrainous)

• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or
other pain reliever.
• Any headaches that get worse or occur more often during use of injectables should be
evaluated.

Mood changes or changes in sex drive

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• Ask about changes in her life that could affect her mood or sex drive, including changes in
her relationship with her partner. Give support as appropriate.
• Clients who have serious mood changes such as major depression should be referred for care.
Consider locally available remedies.

Dizziness
Consider locally available remedies.
a. Long acting contraceptive method
At this level you are expected to assist the provision of long acting contraceptive methods
available in our country.
3.2.4. Providing Implants
When to Start
IMPORTANT: A woman can start using implants any time she wants if it is reasonably certain
she is not pregnant. No tests or examinations are necessary before starting implants, although
blood pressure measurement is desirable.
Table 9 appropriate time to start implants
Woman’s When to start
situation
Having Any time of the month
menstrual • If she is starting within 7 days after the start of her monthly bleeding, no
cycles or need for a backup method.
switching • If it is more than 7 days after the start of her monthly bleeding, she can
from a have implants inserted any time if it is reasonably certain she is not
nonhormonal pregnant. She will need a backup method for the first 7 days after
method insertion.
• If she is switching from an IUD, immediately
Switching • Immediately, if she has been using the hormonal method consistently and
from another correctly or if it is otherwise reasonably certain she is not pregnant. No
hormonal need to wait for her next monthly bleeding. No need for a backup method.
method • If she is switching from a progestin-only or monthly injectable, she can
have implants inserted when the repeat injection would have been given.

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No need for a backup method.

Fully or • If her monthly bleeding has not returned, she can have implants inserted
nearly fully any time between giving birth and 6 months. No need for a backup
breastfeeding method.
Less than 6 • If her monthly bleeding has returned, she can have implants inserted as
months after advised for women having menstrual cycles.
giving birth
Fully or • If her monthly bleeding has not returned, she can have implants inserted
nearly fully any time if it is reasonably certain she is not pregnant. She will need a
breastfeeding backup method for the first 7 days after insertion.
More than 6 • If her monthly bleeding has returned, she can have implants inserted as
months after advised for women having menstrual cycles.
giving birth
Partially • She can have implants inserted any time if it is reasonably certain she is
breastfeeding not pregnant. She will need a backup method for the first 7 days after
If her monthly insertion.
bleeding has
not returned
Partially • If her monthly bleeding has returned, she can have implants inserted as
breastfeeding advised for women having menstrual cycles.
If her monthly
bleeding has
returned
Not • She can have implants inserted at any time. No need for a backup method.
breastfeeding
Less than 4
weeks after
giving birth
Not • If her monthly bleeding has not returned, she can have implants inserted
breastfeeding any time if it is reasonably certain she is not pregnant. She will need a
More than 4 backup method for the first 7 days after insertion.

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weeks after • If her monthly bleeding has returned, she can have implants inserted as
giving birth advised for women having menstrual cycles.
No monthly • She can have implants inserted any time if it is reasonably certain she is
bleeding (not not pregnant. She will need a backup method for the first 7 days after
related insertion.
to childbirth or
breastfeeding)
After • Immediately. If implants are inserted within 7 days after first- or second-
miscarriage trimester miscarriage or abortion, no need for a backup method.
or abortion • If it is more than 7 days after first- or second trimester miscarriage or
abortion, she can have implants inserted any time if it is reasonably certain
she is not pregnant. She will need a backup method for the first 7 days
after insertion.
After taking • Implants can be inserted on the same day as she takes the ECPs.
emergency ✓ She will need to use a backup method for the first 7 days.
Contraceptive • If she does not start immediately, but returns for an implant, she can start
pills (ECPs) at any time if it is reasonably certain she is not pregnant.

Giving Advice on Side Effects

IMPORTANT: Thorough counseling about bleeding changes and other side effects must come
before inserting implants. Counseling about bleeding changes may be the most important help a
woman needs to keep using the method without concern.
Describe the most common side effects
• Changes in her bleeding pattern:
✓ Irregular bleeding that lasts more than 8 days at a time over the first year.
✓ Later, regular, infrequent, or no bleeding at all.
• Headaches, abdominal pain, breast tenderness, and possibly other side effects.
Explain about these side effects
• Side effects are not signs of illness. Lack of bleeding does not mean pregnancy.
• Most side effects usually become less or stop within the first year.
• Common, but some women do not have them.

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• Client can come back for help if side effects bother her or if she has other concerns.
3.1.3. Providing the Intrauterine Device
When to Start
IMPORTANT: In many cases a woman can start the IUD any time if it is reasonably certain she
is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy Checklist.
Table 10: Shows time to start IUCD.
Woman’s situation When to start
Having menstrual Any time of the month
cycles • If she is starting within 12 days after the start of her monthly
bleeding, no need for a backup method.
• If it is more than 12 days after the start of her monthly bleeding,
she can have the IUD inserted any time if it is reasonably certain
she is not pregnant. No need for a backup method.
Switching from • Immediately, if she has been using the method consistently and
another method correctly or if it is otherwise reasonably certain she is not pregnant.
No need to wait for her next monthly bleeding. No need for a
backup method.
• If she is switching from an injectable, she can have the IUD
inserted when the next injection would have been given. No need
for a backup method.
Soon after • Any time within 48 hours after giving birth, including by caesarean
childbirth delivery. (Provider needs specific training in postpartum insertion
(regardless of by hand or using a ring forceps.)
breastfeeding status) • If it is more than 48 hours after giving birth, delay until 4 weeks or
more after giving birth.
Fully or nearly • If the IUD is not inserted within the first 48 hours and her monthly
fully breastfeeding bleeding has not returned, she can have the IUD inserted any time
Less than 6 months between 4 weeks and 6 months after giving birth. No need for a
after giving birth backup method.
• If her monthly bleeding has returned, she can have the IUD inserted
as advised for women having menstrual cycles.

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Fully or nearly • If her monthly bleeding has not returned, she can have the IUD
fully breastfeeding inserted any time it is reasonably certain she is not pregnant. No
More than 6 months need for a backup method.
after giving birth • If her monthly bleeding has returned, she can have the IUD inserted
as advised for women having menstrual cycles.
Partially • If her monthly bleeding has not returned, she can have the IUD
breastfeeding or inserted if it can be determined that she is not pregnant. No need
not breastfeeding for a backup method.
More than 4 weeks • If her monthly bleeding has returned, she can have the IUD inserted
after giving birth as advised for women having menstrual cycles.
No monthly • Any time if it can be determined that she is not pregnant. No need
bleeding (not related for a backup method.
to childbirth or
breastfeeding)
After miscarriage • Immediately, if the IUD is inserted within 12 days after first- or
or abortion second-trimester abortion or miscarriage and if no infection is
present. No need for a backup method.
• If it is more than 12 days after first- or second trimester miscarriage
or abortion and no infection is present, she can have the IUD
inserted any time if it is reasonably certain she is not pregnant. No
need for a backup method.
• If infection is present, treat or refer, and help the client choose
another method. If she still wants the IUD, it can be inserted after
the infection has completely cleared.
• IUD insertion after second-trimester abortion or miscarriage
requires specific training. If not specifically trained, delay insertion
until at least weeks after miscarriage or abortion.
For emergency • Within 5 days after unprotected sex.
contraception • When the time of ovulation can be estimated, she can have an IUD
inserted up to 5 days after ovulation. Sometimes this may be more
than 5 days after unprotected sex.

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After taking • The IUD can be inserted on the same day that she takes the ECPs
emergency (progestin-only, combined, or ulipristal acetate ECPs). No need for
contraceptive pills a backup method.
(ECPs) • If she does not have it inserted immediately, but returns for an IUD,
she can have it inserted any time if it can be determined that she is
not pregnant.

Giving Advice on Side Effects

IMPORTANT: Thorough counseling about bleeding changes must come before IUD insertion.
Counseling about bleeding changes may be the most important help a woman needs to keep
using the method without concern.
Describe the most common side effects
• Changes in her bleeding pattern:
✓ Prolonged and heavy monthly bleeding
✓ Irregular bleeding
✓ More cramps and pain during monthly bleeding
Explain about these side effects
• Bleeding changes are not signs of illness.
• Usually become less after the first several months after insertion.
• Client can come back for help if problems bother her or if she has other concerns.

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Self-Check 3

Directions: Answer all the questions listed below.

Part II say “True” if the statement is correct or “False” if the statement is incorrect
1. A woman who takes COCs of 21-pill packs, she takes the last pill from one pack, should
not wait for 7 days and then take the first pill from the next pack.
2. Pills in POP packs are the same color and all are active pills, containing a hormone that
prevents pregnancy.
3. POPs are as effective as most other hormonal methods, without the additional protection
of breastfeeding itself.
4. Women who are not breastfeeding if taking a pill more than 3 hours late makes it less
effective.
5. When we prepare for NET-EN injection shaking the vial is not necessary.

Part II. Choose the correct answer for the following alternatives

1. Suggest taking COCs at bedtime or with food is used to manage which side effect of
COC?
a. Ordinary headaches (nonmigrainous)
b. Nausea or dizziness
c. Breast tenderness
d. Mood changes or changes in sex drive
2. A women using progestin only pills complaining about breast tenderness. Which is NOT
the appropriate intervention to manage her complains?
a. Recommend that she wear a supportive bra
b. Suggest taking COCs at bedtime or with food
c. Try hot or cold compresses.
d. Suggest aspirin, ibuprofen, paracetamol , or other pain reliever.
3. What results if a women using COCs starting treatment with anticonvulsants, rifampicin,
or rifabutin for long term
a. Migraine headache
b. Less effect
c. Heart attack

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d. Liver disease
4. A woman who has migraine headaches with or without aura can safely start ___.
a. Combined oral contraceptives
b. Progestin only pills
c. Progestin only pills
d. All
5. After child birth which contraceptive method should not give immediately? Progestin
only injectables
A. Lactational amenorrhea
B. Progestin only pills implants
C. Male or female condoms Spermicides
6. To reduce the chances of low birth weight, premature birth, and maternal anemia after
abortion if she wants to become pregnant again soon, encourage her to wait at least
_____
A. 3 month
B. 6 months
C. 1 year
D. 2 year

7. After treatment of abortion which method can be started once infection is ruled out or
resolved?
A. Intra uterine device
B. Combined oral contraceptives
C. Progestin-only injectables
D. Male condoms, female condoms

Unit Four: Monitoring family planning services

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This learning unit is developed to provide the trainees the necessary information regarding the
following content coverage and topics:
• Collecting family planning services data
• Collecting, sustaining and updating RH events data
• Utilizing HMIIS standards for registration of FP related activities
• Reporting family planning activities to the concerned higher bodies
• Monitoring family planning practice
• Revising plan FP health services for the catchments
This unit will also assist you to attain the learning outcomes stated in the cover page.
Specifically, upon completion of this learning guide, you will be able to:
• Collect family planning services data
• Collect, sustain and update RH events data
• Utilize HMIIS standards for registration of FP related activities
• Report family planning activities to the concerned higher bodies
• Monitor family planning practice
• Revising plan FP health services for the catchments

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4.1. Collecting, sustaining and updating family planning services data

The family planning service provision is one of the services, which need to be captured through
the DHIS system. In this guideline, the major data that need to be captured in the DHIS and the
tools used to collect clients information are described to help health care workers and health
managers to follow FP services are well recorded and used for decision making. The major
records are categorized as individual client’s records, registers, and tally sheets.
4.1.2. Individual FP recording tools at Health Facilities
I. Integrated individual Folder
Any client who came to health facilities to receive FP service should visit medical record room
and issued integrated individual folder that captures the basic demographic information of the
client. The inside part of the folder contains a summary sheet to summarize summary of service
provided for client at each visit and should be filled by service providers immediately after the
service is provided.

II. Women’s Card

All clients seeking FP services need to have a Women card. The card records their socio-
demographic and health history including screening for family planning, past and current FP
methods, the physical examination findings, and the client’s current FP method. The follow-up
section of the card records the history and physical examination findings at the time of the visit.
III. Appointment Card
It is a small card, which is used to remind clients who have next appointment. The card contains
the client demographic information, appointment date and reason for appointment.
IV. Referral form
Referral form is used to transfer basic information from referring health facilities to accepting
health facilities. The referral form is attached in which is based on the community-based health
information system (CHIS) from HP to HC.
V. Family health Card [at health post level]
Any clients that visit health post should be issued a family health card. The card helps the HEW
to capture all demographic information, FP provision and long-term FP removal. The HEW
should keep all family health cards with appointments in a tickler box. Otherwise it should be put
on the back on family folder.

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VI. Registers
A. Family Planning Register
Family Planning Register is a longitudinal register that is used to capture HMIS data related to
family planning services. The information required to complete the FP register is obtained from
woman’s card. The register should be kept in the Family Planning service room. The service
provider will obtain complete information on individual clients from a woman’s card and copy
all the required information to the family planning register. This will help to compile and
generate monthly family planning service statistics reports.
B. Long Acting Removal Register
The Long Acting Removal Register is used to record data for clients who have had long acting
family planning methods and who have returned for removal. The family planning methods that
are included for removal are implants (different types) and IUCD. Data is abstracted from
women card and entered to the LAFP removal register by service providers.

Figure 14: Family planning register

4.2. Utilize HMIIS standards for registration of FP related activities

The HMIS captures much of its service and disease surveillance data from client/patient records
that health professionals maintain for care and follow up. HMIS simply exploits this routinely
established procedure and builds on its potential without itself imposing a totally separate
requirement. Obviously there is a need for close integration between client/patient recording and
HMIS reporting.
The recording instruments and processes to be reformed fall into four major areas:
1. Client/patient encounter formats record interactions between clients or patients and care
providers and other technical or administrative health staff. The information recorded may

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include medical history, clinical observations, diagnosis, treatment, laboratory, pharmacy, and
financial data. The formats proposed here are based on current Federal Ministry of Health
(FMOH) guidelines and regional practices.
2. Intrafacility data flow describes the way patient/client encounter formats follow an
individual through the facility and how the medical information recorded by one
practitioner can be consolidated so that it becomes available for other practitioners.
3. HMIS reporting formats contain the data required for the indicators used in
performance improvement.
4. HMIS data flow moves data from facilities and administrative offices through the reporting
chain from facility to regional and nation offices.
4.3. Report family planning activities to the concerned higher bodies
Report family planning activities is moving the data from facilities and administrative offices
through the reporting chain from facility to regional and nation offices. HMIS reporting
formats contain the data required for the indicators used in performance improvement. FP Tally,
FP registers and other data tools serves as a reference o report the FP activities.
4.4. Monitor family planning practice
Monitoring
Monitoring is a process by which priority data and/or information is routinely collected,
analyzed, used and disseminated to see progress towards the achievement of planned targets.
This helps the managers take timely corrective actions in order to improve performance. It
includes monitoring of inputs, outputs, outcomes and impacts of health programmes, including
family planning.
At all levels, performance monitoring will be conducted regularly on a weekly, monthly,
quarterly and annual basis, supplemented by semi-annual and annual review meetings. With
regard to family planning, you need to know what has to be monitored and how — you can refer
to national HMIS technical guidelines.
Common performance indicators for a family planning programme
Inputs (resources, activities)
▪ Total commodities (supplies, equipment, contraceptives) received.
▪ Training and technical assistance received by the staff.
▪ Supplies and contraceptives expended (subtract inventory from amount received).

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▪ Number of educational materials received, by type.

Outputs (services, training, information, education and communication)
▪ Number of new clients, given by choice of contraceptive method.
▪ Number of providers trained.
▪ Number of households covered.
▪ Number of community meetings and number of people informed at meetings.
▪ Number of referrals for clinical methods.
▪ Number of contraceptives distributed, by contraceptive method.
Indicators of quality of care (Some of these indicators can only be measured through evaluation
research, depending on the programmes Management Information System.)
▪ Providers’ level of adherence to informed choice protocols.
▪ Method mix offered.
▪ Percentage of clients referred by other clients (an indicator of client satisfaction).
▪ Continuation rates in programme.
▪ Percentage of clients expressing satisfaction with the service.
Indicators of effectiveness:
▪ Indicators of knowledge of, attitudes towards, and practice of family planning in
programme area.
▪ Indicators of impact
▪ Contraceptive prevalence rate (CPR) in area.
▪ Crude birth rate in area.
▪ Induced abortion rates in area (if available).
▪ Total Fertility Rates (TFR) in area.
▪ Infant mortality rate.
▪ Maternal mortality rate.
▪ Rate of high-risk births (women over 35 years with 5+ births).
Self-check-4
Choose the correct answer
1. The process by which priority data and/or information is routinely collected, analyzed, used
and disseminated is called:
A. Evaluation B. monitoring C. Supervision D. Meeting

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2. Which tool is important to capture FP data?

A. registers B appointment Card C. Tally Sheet D. all except B
3. One of the following is input variable Under FP service procedure
A. Training B. commodities. C. Educational materials D all
Test II: Short answer question

1. Discuss components of monitoring

2. List at least five family planning program indicators of effectiveness

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Reference

1. World Health Organization; Medical Eligibility Criteria for Contraceptive Use, 5th
Edition. Geneva: 2015.
2. Central Statistical Agency [Ethiopia] and ORC Macro. 2001. Ethiopia Demographic and
Health Survey 2000. Addis Ababa and Calverton, MD, USA.
3. Central Statistical Agency [Ethiopia] and ORC Macro. 2006. Ethiopia Demographic and
Health Survey 2005. Addis Ababa and Calverton, MD, USA.
4. Federal Democratic Republic of Ethiopia. 1995. The Constitution of the Federal
Democratic Republic of Ethiopia. Addis Ababa.
5. Federal Democratic Republic of Ethiopia. 1998. Policy on HIV/AIDS of the Federal
Democratic Republic of Ethiopia. Addis Ababa.
6. Federal Ministry of Health (MOH). 2005. Health Sector Development Plan (HSDP-III)
2005/6-2009/10. Addis Ababa: Planning and Programming Department.
7. Federal Ministry of Health. 1996. Guidelines for FP services in Ethiopia. Addis Ababa.
8. Federal Democratic Republic of Ethiopia, Ministry of Health: National Guideline for
Family Planning Services in Ethiopia, November 2011, Ethiopia
9. United Nations. Report of the International Conference in Population and Development.
1995. New York, NY.
10. World Health Organization. Family Planning, A Global Hand Book For Providers 2011
update): 2011.
11. World Health Organization. The Medical Eligibility Criteria for contraceptive use: 5 th
Edition, 2015. 7. World Health Organization. The Selected Practice Recommendations
for Contraceptive Use. (2015 update). Geneva WHO, 2008.

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 Developers Profile
S.N Name Educational Qualification( Field of Study Organization/ Mobile E-mail
o back ground Level) Institution number

1 FikreBojola BSc Nursing Master in Public Health ACHS 924744202 [email protected]

public health

2 S/ r DinkieTadele BSc Nursing MSC in nursing Clinical nurse in DHSC 914736645 [email protected]
medical

3 Tesgera Begize BSc Nursing MSC (A) Medical Nursing PHSC 945747265 [email protected]

4 Habtamu Teshome Bsc nursing Master of MPH epidemiology MACOHS 921897815 [email protected]
Public health

5 KitesaBiresa Health Officer MPH MPH in ShHSC 902774004 [email protected]

Epidemiology

6 Admasu Belay Nursing Assistant Adult Health ENA & JU 925270512 [email protected]
Professor of Nursing
Adult Health
Nursing

Page 84 of 92 Author/Copyright Module title : Comprehensive family planning service Training module
Ministry of Labor and Skills Version -1
August , 2022
Page 85 of 92 Author/Copyright Module title : Comprehensive family planning service Training module
Ministry of Labor and Skills Version -1
August , 2022