18) National Family Planning Program

National Family Planning Program
Unmet need for family planning:

What is Unmet need for FP ?
Currently married women who are not using any method of
contraception but who do not want any more children or want to wait
two or more years before having another child, are defined as having an
unmet need for family planning
• The NFHS–4 reports total unmet need of 12.9% currently married
women(12.1% Urban and 13.2% Rural)
• For spacing methods 5.7%(5.1% Urban and 5.9 % Rural)
Transforming Comprehensive Healthcare in India

FP Methods
For delaying the first child For healthy spacing For limiting future
between two childbirths pregnancies
• Condoms • Condoms • Female
• Combined Oral • COCs, POPs, sterilization
Contraceptives (COCs) Centchroman • Male sterilization/
• Progestin-only-pills • IUCD Vasectomy
(POPs) • Inj. MPA • IUCD (to be
• Centchroman (Chhaya) • LAM (Needs to be replaced every 5 or
• IUCD (Copper-T) followed up by any other 10 years depending
• Inj. MPA (Antara Program) method, before on type
• EC Pills (Not to be used as completing 6 months)
a regular method)
2

Comparing Effectiveness of FP Methods

Safe Time for Initiation of Various FP Methods

1. IUCD
Two Types:
• Copper 380 A (For use up to 10 years)
• Copper 375 (For use up to 5 years)
Can be inserted in a woman immediately after childbirth up to 48 hours of delivery or after

6 weeks of childbirth
How it prevents Prevents fertilization of ovum by sperms

pregnancy
Advantages • Very effective method (like limiting methods)
• No activity needed by woman after insertion
• Effective immediately after insertion and immediate return of
fertility after removal (reversible)
• No effect on breastfeeding
• Used as both long term and short term
5

1. IUCD (Contd)
Limitations & • Possibility of minor side effects which decrease after
Side effects initial few months and are not harmful:
- Longer and heavier menstrual periods
- Bleeding or spotting between periods
- More cramps or pain during periods
• Does not protect against STIs and HIV
• Requires a trained health care provider to insert and
remove the IUCD
• May be expelled spontaneously, in a few cases

1. IUCD (Contd)
Who can use • Have just had a delivery or an abortion (if no evidence
the method of infection)
• Are breastfeeding
• Have or had breast cancer
• Have headaches
• Have high blood pressure (>140/90 mm hg), diabetes,
liver or gall bladder disease, epilepsy, non-pelvic
tuberculosis
• Are HIV positive and/or have AIDS who are clinically
well

1. IUCD (Contd)
Who cannot use the method
• Pregnant women • Pelvic infections
• Current or high risk for infections • 48 hours to less than 6 weeks
in genital organs postpartum
• Women with AIDS who are not • Malignant trophoblastic disease
clinically well • For PPIUCD:
• Immediately after a septic • Puerperal sepsis
abortion
• Prolonged rupture of membranes for
• Pelvic tuberculosis more than 18 hours
• Distorted uterine cavity • Unresolved postpartum haemorrhage
• Unexplained vaginal bleeding • Substantial genital trauma
• Genital tract cancer
1. IUCD (Contd)
Warning signs Needs to come back to the facility soon if any of the following
in IUCD signs develop:
clients P: Period related problems or absence of periods and/or
pregnancy symptoms
A: Abdominal pain or pain during intercourse
I: Foul smelling/unusual vaginal discharge
N: Not feeling well, fever, chills
S: String problems or expulsion of IUCD
Time for first Routine follow up for interval IUCD – after 1 month/after next
follow-up menses
Routine follow up for PPIUCD – after 6 weeks of childbirth
9

2. Inj MPA (Medroxy Progesterone Acetate)
Two Types:
• Intramuscular Inj MPA (One dose = one vial of 150 mg/1 ml)
• Subcutaneous Inj MPA (One dose =104 mg/0.65 ml)
Injection is given once in 3 months or 13 weeks (Can also be given up to 4 weeks
late or 2 weeks early from the scheduled date)
How it acts Prevents release of eggs from ovary
Advantages • Highly effective and reversible method (fertility returns 7-10
months after last injection)
• Suitable for breast feeding women (after 6 weeks postpartum)
• Protects against cancer of lining of uterus (endometrial cancer),
uterine fibroids, and iron deficiency anaemia
10

2. Inj MPA (Contd)
Limitations & • Does not protect against STI/RTI and HIV infection
Side effects • Once taken its action cannot be stopped immediately
• Causes changes in the menstrual cycle and bleeding
• Has to be repeated every three months to achieve desired
contraceptive effectiveness
• Return of fertility takes 7-10 months from date of last
injection (Average 4-6 months after 3 month effectivity of
last injection is over)
• Decreases bone density, but users are not likely to have
fractures. After stopping Inj MPA, bone density increases
again
11

2. Inj MPA (Contd)
Who can use • Have or have not had children; Are not married; Are of any age
the method • Have just had an abortion or miscarriage
• Are breastfeeding (Inj can be started from 6 weeks after childbirth)
• Smokers
• Infected with HIV, whether or not on ARV therapy
Who cannot • Women breastfeeding infant • Migraine with aura at any age
use the less than 6 weeks • Current or past history of Breast
method • Unexplained vaginal bleeding Cancer
• High BP (160/100 or more) • Current or history of Ischemic
• Severe cirrhosis, liver tumors Heart Disease
(benign or malignant)
12

2. Inj MPA (Contd)
Who cannot • Diabetes with for more than 20 years or with complications
use the in arteries, vision, kidneys, nervous system
method • H/o stroke, blood clot in your legs or lungs, heart attack. Or
other serious heart problems
Common side • Lighter and fewer days of bleeding

effects • Weight gain, headache, dizziness, breast tenderness
• Side effects are not harmful
• Usually becomes less or stop within first few months of
injection
• Client can come back any time, if side effects bother her
13

3. Lactational Amenorrhea Method (LAM)
3 mandatory criteria for LAM:

1. Baby is being only breastfed
 The baby is not receiving any other solid food or liquids; only breast
milk
 Breastfeeding on demand - Gap between two consecutive feeds is not
more than 4 hours during day and 6 hours during night
2. Menstruation has not returned since the birth of the child
3. Baby is less than 6 months old
14

Oral Contraceptives
Hormonal Non-hormonal
Combined Oral Contraceptives Centchroman

(COC) (Ormeloxifene)
Progestin Only Pill (POP)
Levonorgestrel Emergency
Contraceptive Pill (ECP)
15
4. Combined Oral Contraceptives (COCs)-Mala-
N
• Available in public sector as free supply (Mala-N)
• Each of the white 21 hormonal tablets contain Levonorgestrel (0.15mg)
and Ethinyl Estradiol (.03 mg)
• There are 7 black tablets containing 60 mg of Ferrous Fumarate
• One pill to be taken daily
• Side effects like giddiness, nausea, breast tenderness
• Makes menstrual cycle regular and reduces bleeding/pain and improves
anemia
• Works primarily by preventing release of eggs from ovaries
• Can be started any time if it is reasonably certain that she is not pregnant
(Use pregnancy checklist)
• Should not be given to breastfeeding women till 6 months postpartum 16
4. COCs (Mala-N) contd..
Non • Protection against endometrial and ovarian cancer,
contraceptive • Protection against iron deficiency anemia, ovarian cysts
benefits
CoCs are not • Breastfeeding <6 months • With high BP

appropriate postpartum • With breast cancer
for women • With suspected pregnancy • With DVT
• Who smoke >15 • With heart disease
cigarettes/day and ≥ 35 • With recurrent migraine
years of age • On anticonvulsants
• With liver disease
17

4. Management of Missed Pills (COCs)
Missed pills How to manage
Missed 1 or 2 pills/
• Take one hormonal pill as soon as possible or two
started new pack 1 or
pills at scheduled time
2 days late?
• Take one hormonal pill as soon as possible and
Missed 3 or more pills in
continue the scheduled pills
the first or second week/
• Use a backup method for the next 7 days
started new pack 3 or
• Also can consider taking ECPs, if she had sex in the
more days late?
past 72 hours.
• Take one hormonal pill as soon as possible and finish
Missed 3 or more
all hormonal pills in the pack as scheduled. Throw
pills in the third
away the 7 non-hormonal pills in a 28-pill pack.
week?
• Start a new pack the next day 18

5. Progestin-only- Pills (POPs)
• Contain very low dose of a synthetic hormone

known as progestin (like natural hormone Progesterone)
• All 28 pills in a packet are hormone tablets
• These are safe for breastfeeding women and can be started earlier than
6 weeks postpartum
• More effective along with breast feeding than when taken after breast
feeding stops
• Decreases risk of ectopic pregnancy
• New pack to be started on the next day at the same time as starting a
pack late risks pregnancy
• No delay in return of fertility after POPs are stopped
19

5. POPs Contd.
5 How POPs work
• Thickening cervical mucus (this blocks sperm from meeting an egg)
• Preventing the release of eggs from the ovaries (ovulation)
How to Use POPs?
• One pill to be taken every day and at same time until packet is empty
• Linking pill intake to a daily activity may help her remember to take the
pill daily and reduce some side effects
• When she finishes one pack, first pill from the next pack should be
taken on the very next day at the same time
Conditions where POPs should be avoided
• Treatment with anticonvulsants or rifampicin
• History of breast cancer, Liver cirrhosis &Suspected pregnancy
• Deep vein thrombosis or Pulmonary embolism 20

5. POPs (Contd)…..
Common side effects of POPs:
• Irregular bleeding/amenorrhea
• Nausea, headache, dizziness
• Breast tenderness
• Occasional ovarian follicular enlargement
Limitations
• Effectiveness decreases when breastfeeding stops
• Do not protect against STIs/HIVs
21

5. Management of Missed Pills (POPs)
1. Three or more hours late taking a pill or misses one completely

1. Take a pill as soon as possible.
2. Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on
the same day)
2. If she has monthly bleeding
1. A backup method should be used for the next 2 days
2. Also, can consider taking ECPs, if she had sex in the past 72 hours
3. If she has vomiting or diarrhoea
1. If she vomits within 2 hours after taking a pill, she should take another pill from the
pack as soon as possible and continue with the schedule pill as usual.
2. If her vomiting or diarrhoea continues, follow the instructions for missed pills above
22

6. Centchroman (Ormeloxifene)
• Non steroidal, non-hormonal and once-a week pill, available in public
sector as Chhaya
• It has weak estrogenic action on bones but strong anti-estrogenic action
on uterus, breasts
• Safe for breast feeding mothers, even soon after childbirth
• Prolongation of menstruation cycle is the only side effect. It occurs in
8% cases usually in first 3 months
• It makes the periods lighter and can help anemic women
• Can be used safely in conditions where hormonal contraceptives are not
advised
• Decreases risk of ectopic pregnancy and return of fertility on stopping
the drug is prompt 23

6. When to Start and How to Use
Centchroman
• One pill (30 mg)is taken twice a week for first three months, followed by
once a week thereafter
• Starting from fourth month, the pill is to be taken once a week on the first
pill day and should be continued on the weekly schedule regardless of her
menstrual cycle
• For initiation: 1 pill is

st If 1st day of pill First 3 months After 3
is months
to be taken on 1st day of
period (1st day of Sunday Sun, Wed Sun
bleeding) and the 2nd pill Monday Mon, Thu Mon
3 days later Tuesday Tue, Fri Tue
Wednesday Wed, Sat Wed
24

6. Centchroman (Contd)….
• Major advantages of Centchroman include that they:
 Are highly effective if taken correctly
 Can be given after childbirth. Safe in breastfeeding women
 Decreases the risk of ectopic pregnancy
Centchroman are not appropriate for the following women:

 Polycystic ovarian disease  Severe allergic state
 Cervical hyperplasia  Chronic illness, like tuberculosis or
 Recent history of jaundice or liver renal disease
disease
25

Managing Missed Pills
• Take a pill as soon as possible after it is missed
• If pill is missed by lesser than 7 days, take the missed pill ASAP and
normal schedule to be continued; and a back-up method (condom) to be
used till the next period starts
• If pill is missed by more than 7 days, client needs to start taking it all
over again like a new user i.e. twice a week for 3 months and then once a
week
• if periods are delayed by more than 15 days, pregnancy needs to be ruled
out

7. Emergency Contraceptive Pill (ECP)
• To be used within 72 hours of unprotected sex
• Sooner it is taken, more effective
• Safe for all women even for those who cannot use regular
hormonal contraceptives, no known health risks
• Not appropriate as a regular contraceptive method due to less
effective than other contraceptives, chances of menstrual
irregularities
• In national program, EC pill contains only progestin -
Levonorgestrel (1.5 mg per tab) and available as free and ASHA
supply (ezy-pill)
• Do not disrupt an existing pregnancy
27

7. Emergency Contraceptive Pill (ECP)
How to Use ECP?

• To be taken immediately after unprotected/accidental intercourse or
as soon as possible within next 3 days (72 hours)
How ECP Works?
• Works primarily by preventing or delaying release of eggs from
ovaries (ovulation). Does not work if woman is already pregnant
ECP: Side Effects
 Side effects like nausea, vomiting and bleeding irregularity
28

8. Condom (Male)
• Available as free and ASHA supply
• New condom required for each act of sexual intercourse
• Correct use reduces chances of failure. If condom slips/ruptures, ECP
can be taken
• Only contraceptive providing protection against STIs and HIV
• Cooperation of male partner required
• No effect on breast milk
• No hormonal side effects
• Easy to keep stock handy, can be used by men of any age
29

Permanent Methods
(Female and Male Sterilization)
• Female Sterilization (Minilap and Laparoscopic operation)
• Male Sterilization (NSV and Conventional Vasectomy)
Limiting Methods of Family Planning
Limiting methods are for those women/couples, who do not want any more
pregnancy, as they have completed the family.
What methods can be used as limiting method ?
• Female sterilization
• Male sterilization/ Vasectomy
• Long acting reversible method, like IUCD, can act as a limiting method (after
completing the total duration of the method, the old IUCD should be replaced by
a new one) 30

Female Sterilization
• Permanent method: A procedure for permanently stopping future pregnancy
by occluding fallopian tubes. Reversal is difficult and may not be successful
• Effectiveness: One of the most effective method. Failure occurs sometimes (5
per 1000 women)
• Informed choice and written informed consent of client before the procedure
are mandatory
• Can be done within 7 days and after 6 weeks of delivery
• Renewed focus on post-partum sterilization (PPS – within 7 days of delivery)
due to increasing institutional deliveries
31

Female sterilization Contd..
How it prevents pregnancy?
• Both fallopian tubes are blocked by ligating and cutting, so that the egg cannot
travel beyond the blocked area and thus cannot be fertilized by sperm
Two types: Minilap operation and Laparoscopic operation
• Minilap – Tubes are cut or blocked after bringing them to the incision made
in the abdomen:
o PPS within 7 days of vaginal delivery or during cesarean section
o Interval period (Anytime after 6 weeks of delivery)
o Post-abortion (both after 1st and 2nd trimester abortions)
• Laparoscopic – Tubal occlusion is done by a laparoscope introduced
through a small incision in the abdomen:
o Anytime after 6 weeks of delivery after ruling out pregnancy
o Post-abortion (after1st trimester) 32

Female sterilization Contd..
Advantages Limitations
• Highly effective method • Requires a physical examination and surgical
• Has no lasting side effects procedure
• No need to think about • Does not provide protection from sexually
contraception again transmitted infections (STIs), including HIV
• Does not affect sexual • Complications of surgery: Uncommon to
activity, menstruation or extremely rare, but include:
breastfeeding - Adverse reactions to anesthesia
• Nothing to do or to remember - Infection of the incision site
by woman - Bleeding in abdomen (from the cut
fallopian tubes)
33

Routine Follow-up after Female
Sterilization
3 follow-ups:
• 1st follow-up: With in 48 hours of surgery
• 2nd follow-up: On 7th day of surgery
• 3rd follow-up (At facility):
One month after surgery or after the next menstrual period (Certificate to
be issued)
Client to be told to return to the facility if there is any missed
period/suspected pregnancy, within two weeks to rule out pregnancy
34

Male Sterilization/Vasectomy
• Permanent method and reversal difficult
• Involves cutting or blocking the vas deferens, the tubes that carry sperms to penis
• Types:
o Conventional
o No scalpel vasectomy (NSV)- No cut on the skin nor any skin stitch, after the
procedure is completed
• Can be done on men anytime under local anesthesia (Simpler operation than
female sterilization)
How it prevents pregnancy?
• Tubes those carry the sperms (the vas deferens) will be cut so that sperms cannot
pass through semen. So there will be no sperms during the ejaculation, which
occurs after 3 months of operation
35

Male sterilization/Vasectomy Contd..
Advantages Limitations
• Very effective method • Not effective immediately after
• Simpler operation than female the procedure. Client has to use
sterilization condom or wife to use another FP
• Usually takes 10-15 minutes method for 3 months
• Acceptor can walk back home • Does not protect against STIs
within 30 minutes including HIV
• Failure rate less than female
sterilization
• No major complication usually
36

Follow-up after Vasectomy
Routine:
• After 48 hours for check-up
• On the 7th day for stitch removal (for conventional vasectomy)
• After 3 months- return to the facility for semen examination. If no sperm-
certificate is issued (If semen still shows sperm, return to facility every month
till 6 months).
Emergency:
• excessive pain, fainting, fever, bleeding, increase in scrotal size, or pus
discharge from the operated site.
• As and when required
37

18) National Family Planning Program

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18) National Family Planning Program

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National Family Planning Program

Unmet need for family planning:

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Can be inserted in a woman immediately after childbirth up to 48 hours of delivery or after

How it prevents Prevents fertilization of ovum by sperms

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Common side • Lighter and fewer days of bleeding

Transforming Comprehensive Healthcare in India

3 mandatory criteria for LAM:

Transforming Comprehensive Healthcare in India

Combined Oral Contraceptives Centchroman

Progestin Only Pill (POP)

CoCs are not • Breastfeeding <6 months • With high BP

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

• Contain very low dose of a synthetic hormone

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

1. Three or more hours late taking a pill or misses one completely

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

• For initiation: 1 pill is

Transforming Comprehensive Healthcare in India

Centchroman are not appropriate for the following women:

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

How to Use ECP?

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

Transforming Comprehensive Healthcare in India

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