Reproductive Health For 1 Years Level Nurse

Reproductive health for 1 st
years level nurse
30/01/2010 1
Chapter 1
Introduction to
Reproductive Health
06/08/2023 2
Reproductive Health
Outlines
1. Introduction to Reproductive Health
2. Maternal Health
3. Abortion
4. Family Planning
5. Sexually Transmitted Infections
6. HIV/AIDS and Reproductive Health
7. Harmful Traditional Practices
8. Adolescent Reproductive Health
9. Infertility Prevention and Treatment
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Learning objectives:
 To define reproductive health
 Describe magnitude of RH problems
 Identify RH indicators and criteria for
selection of indicators
 To show the relationship of reproductive
health and gender
 Identify the targets of reproductive health
06/08/2023 4
Definitions
• RH: A state of complete physical, mental, and

social well being and not merely the absence of
disease or infirmity, in all matters related to the
reproductive system and to its functions and
process”.
• RH care: the group of related methods,
techniques and services that contribute to
reproductive health and wellbeing by preventing
and solving reproductive health problems.
06/08/2023 5
Cont…
RH implies
• People are able to have a satisfying and safe sex
life
• People have the capability to reproduce and the
freedom to decide when and how often to do so
• People have the right to be informed of and to
have access to safe, effective, affordable and
acceptable methods of FP of their choice
06/08/2023 6
Cont…
• Sexuality: it is a broad term covering
what we physically are, what we feel and
do in relation to the sex we have as well as
social rules and guidelines existing for
each gender.
• Sexual health is the enhancement of life
and personal relations, and not merely
counseling and care related to
reproduction and STDs.
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Objectives of RH Care
• To ensure that comprehensive and factual

information and a full range of RH services
• To enable and support responsible voluntary
decisions about child bearing and methods of
family planning of their choice
• To meet the changing reproductive health needs
over the life cycle
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Quality of care
• Good-quality RH care is comprehensive,
accessible and inclusive, addressing the RH
needs of all persons without discrimination.
7/01/2010 9
Cont…
Quality of RH care means:-
Care should be personalized
Clients should be treated with dignity
Privacy should be maintained
Clients should not have to wait a long time
before being served
Health workers should inform about the
available services
Facilities where services are provided should be
clean
06/08/2023 10
Cont…
Why is quality of care important?
Good-quality services help fulfill human
rights.
Good-quality services are effective:
Clients are more likely to use services and
maintain good health practices
Providers are professionally satisfied and
motivated
06/08/2023 11
Magnitude of RH Problem
• Women in developing countries and
economically disadvantaged women suffer the
highest rates of complications from pregnancy,
sexually transmitted diseases, and reproductive
cancers
• 529,000 women die each year- 1 every min -
from pregnancy related causes.
• 99% of these deaths occur in developing
countries.
06/08/2023 12
Cont…
• More than 340 million new cases of sexually
transmitted diseases occur every year.
• 20 million unsafe abortions occur every year —>
55,000 each day
• resulting in 80 000 maternal deaths and
hundreds of thousands of disabilities.
06/08/2023 13
Components of Reproductive
Health
Women’s health component
Child health component
Youth component
Men’s health component
06/08/2023 14
Components of Reproductive
Health
The priorities
1. Safe motherhood:
2. FP information and services.
3. Prevention and treatment of infertility and
sexual dysfunction in men and women.
4. Prevention and treatment of abortion
complications.
5. Provision of safe termination of pregnancy
6. Prevention and treatment of genital infections
06/08/2023 15
Cont…
7. Promotion of healthy sexual development from

pre-adolescence; safe and responsible sex, and
sexual equality.
8. Eradication of harmful practices like FGM
9. The treatment of non-infectious genital
disorders, such as genital fistula
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Enabling conditions for RH
Empowering Women and Promoting
Gender Equality
Eliminating Discrimination against the
Girl Child
Ensuring Male Responsibility and
Participation
Achieving Universal Education
06/08/2023 17
Reproductive health indicators
•A health indicator is usually a numerical

measure which provides information about a
complex situation or event.
•Maternal health care quality, availability and
accessibility can be measured using maternal
mortality.
•Indicators are expressed in terms of rates,
proportions, averages, categorical variables or
absolute numbers.
12/02/2007 18
1. Total fertility rate

2. Contraceptive prevalence
3. Maternal mortality ratio
4. Antenatal care coverage
5. Births attended by skilled health personnel
6. Availability of basic essential obstetric care
7. Availability of comprehensive essential obst.
care
8. Perinatal mortality rate
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9. Low birth weight prevalence

10. Positive syphilis serology prevalence in
pregnant women
11. Prevalence of anemia in women
12. Percentage of obstetric and gynecological
admissions owing to abortion
13. Reported prevalence of women with FGM
14. Prevalence of infertility in women
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15. Reported incidence of urethritis in men

16. HIV prevalence in pregnant women
17. Knowledge of HIV-related prevention practices
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Gender and RH
• Sex: biological and physiological attributes that
identify a person as male or female
• Gender: to the economic, social and cultural
attributes and opportunities associated with
being male or female in a particular social setting
at a particular point in time.
• Gender is learned and changes over time.
06/08/2023 22
Cont…
• Gender equality: equal treatment of women
and men in laws and policies, and equal access to
resources and services
• Gender equity: fairness and justice in the
distribution of benefits and responsibilities
between women and men.
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Cont…
• Gender discrimination refers to any
exclusion or restriction made on the basis
of socially constructed gender roles and
norms which prevents a person from
enjoying full human rights.
06/08/2023 24
Cont…
• Gender stereotypes: beliefs that are so
ingrained in our consciousness that many of us
think gender roles are natural and we don’t
question them.
• Gender bias: gender based prejudice;
assumptions expressed without a reason and are
generally unfavorable.
06/08/2023 25
Cont…
• Gender mainstreaming: the
incorporation of gender issues into the
analysis, formulation, implementation,
monitoring of strategies, programs,
projects, policies and activities
06/08/2023 26
RH and defining target population
Rationale for Defining Target

Population
 To set priority and deliver appropriate services to high
risk groups.
 To utilize resources efficiently,
 To determine the number of eligible for the services,
 To measure / evaluate changes,
 To address equity in delivery of the health services
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 Women of child-bearing age (15-49

years old)
are at risk of complications from pregnancy and
childbirth
face high risks in preventing unwanted
pregnancy
suffer from the consequences of unsafe abortion
Deaths and illnesses from reproductive causes
are highest among poor women
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 Adolescents (Both sexes)
Adolescents lack reliable reproductive health
information
Parents are reluctant to provide education on
sexuality
Many adolescents are already sexually active
The RH status of young people lays the
foundation for the country’s demographic feature
Adolescents are at high risk to acquire infertility
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#4
 Under Five Children
Children’s health is a base for healthy
adolescence and childbearing ages
The health of children and women is
inseparable
The morbidity and mortality of children in
Ethiopia is one of the highest in the world
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Chapter 2
Maternal Health
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Learning objectives
• Discuss rational of maternal health
• Describe the safe motherhood initiative and
services included under safe motherhood
• Understand important causes of maternal
mortality and morbidity
• Describe maternal health services
• Explain elements of focused ANC
• Discuss delivery care
• Explain post natal care
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Introduction
• Motherhood should be a time of expectation and
joy for a woman, her family, and her community
• Worldwide 529,000 women die yearly from
complications of pregnancy and childbirth
• 60-80% of maternal deaths are due to obstetric
hemorrhage, obstructed labor, obstetric sepsis,
hypertensive disorders of pregnancy, and
complications of unsafe abortion
06/08/2023 33
Why maternal health? / rational of
maternal health
1. Women as a mother
– Complications of pregnancy and delivery can lead to
a broad range of acute or long-term disabilities,
• chronic pelvic pain,
• damage to reproductive organs,
• kidney failure,
• uterine rupture, and
• infertility.
– 10 to 20 million women suffer from physical or
mental disabilities each year as a result of such
complications of birth or their management
06/08/2023 34
Cont…
2. Women as an individual
– Poor maternal health is not just a problem of
women’s health but also a problem of poverty
and gender inequality
– Maternal mortality is an indicator of disparity
and inequity between men and women
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Cont…
• Where women have power in the household, and
access to resources such as education and
economic opportunity, they are better able to
access and use services during pregnancy and
childbirth
06/08/2023 36
cont…
3.Women as Family member

–Effects of maternal health on children
and families, maternal health and
mortality are of fundamental importance
to the survival and wellbeing of children.
–Children whose mothers die are:-

– more likely to be stunted and
– Less likely to attend school and health Service
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Cont…
• 75 % of perinatal deaths could be avoided
with improved maternal health, adequate
nutrition, health care during pregnancy
and appropriate care during childbirth
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Cont…
4. Women as Citizen
 The economic cost the cumulative effect
of maternal mortality and morbidity
affects national and global development.
 Good maternal health services can
strengthen the entire health system
 So, investing in women’s health yields
significant savings.
06/08/2023 39
The safe motherhood initiative
• The SMI is launched during the conference at
Kenya in 1987 which issued an international call
to action to reduce maternal mortality and
morbidity
• The SMI's target has subsequently been adopted
by most developing countries.
• countries have developed programs to reduce
maternal mortality and morbidity.
06/08/2023 40
Cont…
• The strategies adopted to make motherhood
safe vary among countries and include
Providing family planning services.
Providing post abortion care.
Promoting antenatal care.
Ensuring skilled assistance during childbirth
Improving essential obstetric care.
Addressing the reproductive health needs of
adolescents.
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Four pillars of safe motherhood
1. Family planning
2. Antenatal care
3. Clean/ safe delivery
4. Essential obstetric care
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Essential Services for Safe
Motherhood
• Safe motherhood can be achieved by providing
high quality maternal health services to all
women.
• These services for safe motherhood should be
readily available through a network of linked
community health care providers, clinics and
hospitals.
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cont…
These essential Services include:

1. Community education on safe motherhood
2. Prenatal care and counseling
3. Skilled assistance during childbirth
4. Care for obstetric complications, including
emergencies
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Cont…
5. Postpartum care
6. Post-abortion care and safe services for the
termination of px
7. FP counseling, information and services
8. RH education and services for adolescents
06/08/2023 45
Causes of maternal mortality and
morbidity
• Maternal death: the death of a woman while
pregnant or within 42 days of termination of
pregnancy
• Maternal morbidity: Any deviation,
subjective or objective, from a state of
physiological or psychological well being of
women.
06/08/2023 46
Epidemiology Maternal Mortality
• In 2005 more than 636,000 women died each

year worldwide.
• From that, 99% was accounted by developing
countries.
• Of those, around 270,000 women died each year
in Africa.
• 46,000 women died each year in Ethiopia.
06/08/2023 47
Cont…
I. Direct obstetric deaths: result from obstetric
complications of the pregnancy state, labor and
purperium
– The commonest causes:
• Hemorrhage
• Unsafe Abortion
• Hypertensive disorders of pregnancy
• Obstructed Labor and uterine rupture
• Infection
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Cont….
II. Indirect Obstetric Death:
• Resulting from previous existing diseases or
diseases that developed during pregnancy, which
are aggravated by the pregnancy
• This includes
– Anemia: the commonest
– Other indirect causes
• CV ds, DM, HIV/AIDS, TB, Malnutrition…
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Cont…
III. Incidental/Coincidental/ causes:
• are neither due to direct nor indirect
obstetric causes:
E.g. - Car accident

- fire burn
- bullet injury
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Cont…
Others Haemorrhage
15% 10%
Sepsis
12%
Hypertention
Abortion 9%
32%
Obstructed
labor
22%
06/08/2023 51
Maternal Mortality in Context
• The Three D’s (Delays)
Delay in deciding to seek care
Delay in reaching care
Delay in receiving appropriate care
06/08/2023 52
Causes of Maternal Morbidity
1. Infection
2. Fistula
3. Incontinence
4. Infertility
5. Uterine prolaps
6. Nerve Damage
7. Psychosocial problems
8. Others (pain during intercourse, anemia ….)
06/08/2023 53
Maternal health services
1. Antenatal Care
2. Delivery Care
3. Postnatal Care
4. Essential Newborn Care
06/08/2023 54
1. Antenatal Care
• Care given to pregnant women so that they have
safe pregnancy and healthy baby
• ANC strategies target pregnant women in order
to screen and detect early signs of or risk factors
for disease, followed by timely intervention
• However, the contribution of ANC specifically to
maternal mortality reduction has been
challenged
06/08/2023 55
Criticisms of traditional ANC
• Ritualistic rather than rational
• Emphasis of visits on frequency and numbers of
visits
• Communication is minimal, and focused on
findings
• Preparation/planning is not stressed
• Risk assesst based on predetermined parameters
06/08/2023 56
Focused antenatal care
(New ANC approach)
• Traditional ANC uses risk approach to classify
which women are more likely to develop
complication and assumes that more visits
means better outcome for the mother and the
baby.
• Focused ANC recognizes that every Px woman is
at risk for complications, and therefore all
women should receive the same basic care and
monitoring for complications.
06/08/2023 57
Focused antenatal care
• The new approach to ANC emphasizes the
quality of care rather than the quantity.
• For normal pregnancies, WHO recommends a
minimum of 4 antenatal visits.
(<16, 24-28, 30-32 & 36-40 wks)
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Cont…
• The major goal of focused antenatal care is to help
women maintain normal pregnancies through:
Identification of pre-existing health conditions
Early detection and management of
complications arising during the pregnancy
Health promotion and disease prevention
Birth preparedness and complication readiness
planning.
06/08/2023 59
Cont…
Health Promotion and Disease
Prevention:
 How to recognize danger signs, what to do,
and where to get help
 Good nutrition and its importance to the
health of the mother and baby; and the
importance of rest
 Hygiene and infection prevention practices
06/08/2023 60
Cont…
Health Promotion and Disease

Prevention:
Risks of using tobacco, alcohol, local drugs,
and traditional remedies
Benefits of child spacing to mother and child;
options for family planning services following
the baby’s birth
Breastfeeding importance of early and
exclusive breastfeeding
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Cont…
• All pregnant women should receive the
following preventive interventions:
Immunization against tetanus
Iron and folate supplementation
06/08/2023 62
2. Delivery Care
• Delivering women should be observed at least for
24 hours after delivery as most of the deaths post
partum occur at this time.
Aims of delivery care are to achieve:

A healthy mother and child with the least
possible level of intervention
Early detection and management of
complications
Timely referral of obstetric emergencies
06/08/2023 63
Cont…
• More than three-quarters of all maternal deaths
in developing countries take place during or
soon after childbirth.
• Adequate equipment, drugs and supplies are also
essential to enable skilled attendants to provide
good quality care.
• When delivery is taking place at home or in a
local health facility, an emergency transport
system must be available to take women to
facilities that can be provide more advanced
care.
06/08/2023 64
3. Postnatal Care
• Care provided to the woman and her baby during
the 6 weeks period following delivery in order to
promote healthy behavior and early
identification and management of complications.
• The main life threatening complications of the
postnatal period include hemorrhage, anemia,
genital trauma, hypertension, sepsis, UTI &
mastitis.
• The postnatal period is the period when most
maternal deaths occur compared to the
antepartum and intrapartum periods.
06/08/2023 65
4. Essential Newborn Care
• Any intervention to prevent fetal deaths must
focus on the mother, since direct causes of
neonatal deaths such as asphyxia, respiratory
distress syndrome and sepsis are related to the
health or care of the mother.
• The majority of neonatal deaths (around 66%)
occur in the first week of life.
06/08/2023 66
Chapter 3
Harmful Traditional
Practices
06/08/2023 67
Chapter objectives
 Identify different types of HTP to reproductive health
 To understand the concept, magnitude and effect of

violence on women’s reproductive health
 Recognize different type of female genital mutilation
 Identify reasons for different HTP
 Explain consequences of common HTP
 Recognize strategies to solve HTP
06/08/2023 68
Introduction
• HTPs are known to affect adversely the health of
people and the process of economic development
• Common HTP in Ethiopia include:
– Violence against women
– Female Genital Mutilation
– Uvelectomy
– Milk Teeth Extraction
– Early Marriage
– Marriage by Abduction and
– Food Prohibition
06/08/2023 69
A. Violence against women (VAW)
• Any act of gender-based violence that results
in, or is likely to result in, physical, sexual or
psychological harm or suffering to women
including threats of such acts, coercion or
arbitrary deprivations of liberty, whether
occurring in public or private life.
• In addition to causing injury, violence increases
women's long-term risk of a number of other
health problems
06/08/2023 70
Cont…
• Females of all ages are victims of violence, in part
because of their limited social and economic
power compared with men
• VAW encompasses, but it is not limited to:
 Spousal battering/hitting
 Sexual abuse of female children
 Dowry-related violence(widow's inheritance)
 Rape including marital rape
06/08/2023 71
Cont…
• VAW encompasses, but it is not limited to
Traditional practices harmful to women
Non-spousal violence
Sexual harassment and intimidation at work
and in school
Trafficking in women/ the business of
transporting women
Forced prostitution
06/08/2023 72
Magnitude of the Problem
• Around the world, at least 1 woman in
every 3 has been beaten, coerced into sex
or otherwise abused in her lifetime
• 2 of the most common forms of violence
against women are:
abuse by intimate partner violence (IPV)
and
coerced sex(persuade unwilling women to
engage in sex).
06/08/2023 73
Cont…
Intimate Partner Violence (IPV)
Occurs in all countries
life-time prevalence of physical or sexual
partner violence or both is 15 % to 71 %,
4 % to 54 % of these are reported violence in
one year.
In Ethiopia, the life-time prevalence of
physical and sexual violence were reported to
be 48.7% and 58.6%
06/08/2023 74
Cont…
Sexual Coercion
• Exists along a continuum, from forcible rape, to
non-physical forms of pressure that compel girls
and women to engage in sex against their will.
• A woman lacks choice and faces severe physical
and social consequences if she resists the sexual
advances.
06/08/2023 75
Cont…
Sexual violence includes:
Rape within marriage or dating relationships
Rape by strangers
Systematic rape during armed conflict
Sexual harassment/threatening
Sexual abuse of children
Forced first sex
FGM
Forced marriage
Denial of the right to use contraception
06/08/2023 76
Impact on Health
• Physical
injuries, bruises, chronic pain syndromes,
disability, fractures, GI disorders, irritable
bowel syndrome, reduced physical functioning
• Sexual and reproductive health
gynecological disorders, infertility, PID,
pregnancy complications/miscarriage, sexual
dysfunction, STIs including HIV/AIDS, unsafe
abortion and unwanted pregnancy
06/08/2023 77
Cont…
• Psychological and behavioral
alcohol and drug abuse, depression and
anxiety, poor self esteem, psychosomatic
disorders, unsafe sexual behavior, phobias
and panic disorder
• Fatal health consequences
AIDS-related mortality, maternal
mortality, homicide, and suicide
06/08/2023 78
Cont…
• Women have a difficult time protecting

themselves from unwanted pregnancy or disease
• Can lead directly to unwanted pregnancy or
STIsillegal abortions
• Associated with miscarriage, late entry into
prenatal care, stillbirth, premature labor, fetal
injury, and LBW
• Mental health Death of the woman
06/08/2023 79
What can be done against gender based
violence (GBV)?
• Initiatives against gender-based violence take
many forms, including
police and judicial reforms,
legislative initiatives,
community mobilization to encourage behavior
change, and
the reorientation of health services.
06/08/2023 80
Cont…
• The most effective approach is integrated and
multi-level:
in the short term it provides services for
victims and punishes perpetrators,
while in the long term it addresses the
social and economic determinants of
violence.
06/08/2023 81
Cont…
• Prevention strategies
 Empowering women and raising their status
 Combating norms of violence, and
 Reducing poverty and alcohol consumption
•Leaders of Reproductive Health Programs Can:
 Establish policies and procedures to ask women
clients about abuse
 Establish protocols that clearly indicate appropriate
care and referral for victims of violence
06/08/2023 82
B. Female Genital Mutilation
 Is the removal of the whole of or some parts of
the external female genital organs.
 The practice is not unique to Ethiopia
 The operation is performed for cultural or other
non-therapeutic reasons”
06/08/2023 83
Reasons for FGM
1. Maintaining of virginity
2. Enhancement of fertility
3. Increase matrimonial opportunities
4. Prevention of promiscuity
5. Maintenance of cleanliness
6. Aesthetics
7. Prevention of stillbirths in Primigravidae
8. Societal privileges and positions
9. Improvement of male sexual performance
10. Maintenance of good health
06/08/2023 84
Cont…
1. Maintenance of virginity
To be virgin is very important in most African cultures.
Since it is very painful to have intercourse after FGM,
it is believed that young girls will not indulge
themselves in premarital sex and thus stay pure for
their husbands.
In addition in Somalia, Djibouti, parts of Ethiopia,
Sudan, Egypt, and parts of Mali girls are not only
severely cut but the remaining part is closed or
stitched to maintain the virginity of the girl until the
night of her marriage.
06/08/2023 85
Cont…
2. Enhancement of fertility –
Certain societies believe that circumcised girls become
pregnant very easily.
3. Increase matrimonial/marrital opportunities –
In societies where marriages are arranged by relatives,
they make sure that the bride is circumcised.
In some areas the bride price goes up with the tightness
of the vagina.
4. Prevention of promiscuity –
In some African societies, it is believed that
uncircumcised women have too much sexual desire that
they might indulge in sex, both outside and inside the
wedlock.
06/08/2023 86
Cont…
5. Maintenance of cleanliness –
Some communities believe that the female
external genitalia produce secretions that
make the woman wet and produce bad
odor.
6. Aesthetics –
For some ethnic groups the female
genitalia are ugly to look at and thus should
be removed.
06/08/2023 87
Cont…
7. Prevention of stillbirths in Primigravida
Some communities such as those found in Burkina
Faso and Nigeria believe that the clitoris has the
power to kill the first born, if during delivery, the
baby’s head touches it.
8. Societal privileges and positions –
People who fail to accept traditions of a group may
not get the privileges and benefits available to the rest
of the community and thus are ostracized/excluded.
Heads of households in which daughters and wives
are not circumcised may lose the benefits.
06/08/2023 88
Cont…
9. Improvement of male sexual performance –
 It is believed that when the penis comes in
contact with the clitoris, the man gets excited
very fast, and leading to an early ejaculation
which may lead to matrimonial disharmony.
10. Maintenance of good health –
Circumcision is said to keep the women healthy
and cure her from diseases such as epilepsy,
hysteria/instable, insanity/foolish, depression,
and melancholia/sever depression.
06/08/2023 89
Types of Female Genital
Mutilation
1. Sunna :-
 the prepuce of the clitoris is incised
2. Clitoridoectomy:-
 is the removal of the prepuce and the clitoris
3. Excision: –
 is the removal of the prepuce, clitoris and the labia
minora.
 The wound is left to heal naturally, by keeping the legs close
together.
 The healing takes place by scaring which is tough, making
sexual intercourse painful.
06/08/2023 90
Cont…
4. Infibulation or Pharonic circumcision –
 The prepuce, clitoris, labia minora,
labia majora and the lower part of the
vagina are removed.
 The edges are stitched together with thorn or
thread leaving a small opening for the
passage of urine and menstrual blood.
06/08/2023 91
Cont…
 After excision the legs are tied together. The
wound is left to heal taking about two to three
weeks.
 In societies where infibulation is practiced,
the economic value of a girl depends on her
virginity.
 There is support for infibulations from an
economic point of view. The concept of
preserving family honour further strengthens
this practice.
06/08/2023 92
Complications of FGM
Immediate Complications
 Haemorrhage
 Fall in blood pressure, Shock
 Urinary Tract Infection
 Renal failure
 Septicaemia
 Tetanus
06/08/2023 93
Cont…
Delayed and Long Term
Complications
 Dysmenorrhoea
 Pelvic abscess
 Dysparenuia(painful intercourse)
 Recurrent Urinary Tract Infections
 Infertility
 Calculus/stone
06/08/2023 94
Cont…
Delayed and Long Term Complications

Bleeding due to forceful intercourse or use of
instruments to cut the scar tissue open
Rectovaginal or vesicovaginal fistula
Prolonged labour leading to uterine inertia,
haemorrhage, ruptured uterus, shock and death
Still births, foetal distress
Sub – normal children
06/08/2023 95
What should be done?
 Education of women
 Creating awareness
 Assistance to women on whom FGM has been
conducted
 Training of educators and health workers on the
hazards of FGM
 Support to programs that aim at abolishing FGM
06/08/2023 96
C. Early Marriage (EM)
• Marriage before the age of 18 is a reality for
many young women
• In actuality, child marriage is a violation of
human rights
• It is a common practice particularly in rural
Ethiopia
• The young adolescent girl is not ready for
intercourse, px, child bearing and child rearing.
06/08/2023 97
Reasons for early marriage
 Parents desire to see the marriage of their
daughters and their grandchild before they die
 Strengthen the family or business ties between
the two parties to be married
 Conformity - conform to tradition.
 Avoid the possibility of a daughter not getting
married or becoming not eligible for marriage
 Avoid premarital sex or loss of virginity and its
consequences
06/08/2023 98
Harmful effects of early marriage
 Psychological effect
 The small genitalia are traumatized
 Preclampsia, prolonged and obstructed labour
leading to fistula formation
 Haemorrhage and shock at delivery
 Still born babies
 Loveless marriage often ending in divorce
 Difficulty in managing a household
 Deprivation of the girl of her education
06/08/2023 99
D. Marriage by abduction
 Unlawful kidnapping or carrying away a girl for
marriage
 In almost all case rape follows it
 It has been common in some parts of Ethiopia
06/08/2023 100
Reasons for Marriage by Abduction
 Refusal or anticipated refusal of consent

 Avoid excessive wedding ceremony expenses
 Ease the economic burdens of the conventional
bride price
 Outsmart rivals/compition when the girl has
many suitors and/or the inclinations of the girl or
her parents are not predictable
 Difference of ethnic origins or economic status of
partners may also be reasons for possible
abduction
06/08/2023 101
Harmful effects of marriage by abduction
 Battering, inflicting bodily harm, suffocation,
and severe disabilities and death may result.
 Conflict created between families may lead to
feuding/long violent dispute lasting for
generations.
 Unhappy, unstable and loveless marriage
 Psychological stress on the girl. Might end up in
suicide
06/08/2023 102
Cont…
 Large expenses related to conflict
resettlements as compensation to the
family or for court cases
 Discontinuation of schooling and other
opportunities for the girl
06/08/2023 103
Other harmful traditional practices
• Other HTPs that are prevalent in Ethiopia

include:
uvulectomy,
milk teeth extraction,
food prohibitions for mothers,
eye brow incision, and
soiling the umbilicus of the new born
with cow dung
06/08/2023 104
Cont…
• Each of these traditional practices has
mistakenly perceived advantages.
• These HTPs & beliefs might result in
serious health outcomes including:
serious bleeding,
acquiring infection and
malnutrition
06/08/2023 105
Strategies to minimize and
eliminate HTPs
 Communication methodologies
 Provide legal support against the negative
aspects of traditional practices and
formulate legislative measures to eliminate
them
 Endeavour to educate practitioners of
harmful traditional practices about the
dangers of such practices
06/08/2023 106
Cont…
 Imposing punishment on such
practitioners if they persist with the
practice
 Alternative employment opportunities e.g.
for the circumciser
06/08/2023 107
Chapter 4
Adolescent Reproductive
Health
06/08/2023 108
Learning objectives
 Understand why RH focuses on adolescents
 Recognize the RH risks and consequences
among adolescents
 Discuss the challenges of adolescent RH
 Identify factors affecting adolescent RH
 Recognize characteristics of adolescent RH
service
06/08/2023 109
Introduction
 Adolescents are a large and growing segment of
the population
 More than half of the world's population is below
the age of 25
 Young people develop their adult identity, move
toward physical and psychological maturity, and
become economically independent
06/08/2023 110
Cont…
 They are often less informed, less
experienced, and less comfortable
accessing FP and RH services  Risk
 Encounter health risks and often exhibit
risk-taking and experimental behavior
06/08/2023 111
Adolescent sexual and reproductive
health
• The physical, mental, and emotional well being
of adolescents
• Includes freedom from:
– unwanted pregnancy
– unsafe abortion
– STIs, including HIV/AIDS
– All forms of sexual violence and coercion
06/08/2023 112
Why Focus On Young People?
• Young people constitute a large and growing
segment of the population
• Certain health problems (like STIs and HIV) are
more prevalent in this age group
• Young people can bring tremendous dividends
and can play vital role in their family and to the
society as a whole
06/08/2023 113
Cont…
• Future economic development depends on
having increasing proportion of well
educated, healthy and economically
productive population
06/08/2023 114
Characteristics of The Adolescence Period
 individual progresses from the point of initial

appearance of secondary sex characteristics to
sexual maturity.
 Psychological processes and patterns of
identification to those of an adult.
 Transition from the state of total socio-economic
dependence to relative independence.
06/08/2023 115
Cont…
 Period of rapid physiological changes and
vulnerability to physical, psychological
and environmental influences.
 Period of physical, biological,
psychological and social maturity from
childhood to adulthood.
06/08/2023 116
Global Youth Today
1. Education
– 121 million children worldwide are out of school,
with 9 million more girls than boys
– The net enrollment ratio in primary education
was 86 % for developing countries and 64 % for
sub- Saharan Africa.
– Ethiopia 42.3 %
– In Ethiopia, the ratio of girls to boys is 0.91 in
primary education and 0.65 in secondary
education.
06/08/2023 117
Cont…
2. Sexuality
– Most people become sexually active during
adolescence
– Premarital sexual activity is common and is on the
rise
– Millions of adolescents are bearing children, in sub-
Saharan Africa, more than half of women give birth
before age 20
– In AA: 8 % of unmarried boys and 9 % of unmarried
girls (10-19 years old) were sexually experienced
06/08/2023 118
Cont…
• Driving forces for an early sexual activity
Early sexual maturation
Decline in religious and cultural influences
Changing trends for marriage values
Urbanization and mass media influence
Lack of proper knowledge about sex and
reproductive health
06/08/2023 119
Cont…
Causes for early unprotected sexual intercourse
– Early marriage
– Sexual violence and coercion
– Peer influence
06/08/2023 120
Cont…
3. Childbearing
– In developing countries: 1 in 6 births is to women age
15-19
– Among SSA girls, 55 % have had a child by age 20
– EDHS 2005: 46.1 % of 20-24 old women had given
birth by age 20
– Pregnancy-related health risks are much higher
among women under age 18
– MM in developing countries is 2-5 times higher
among girls <18 years old than those 18-25 years old.
06/08/2023 121
Cont…
4. Unwanted Pregnancy
• Contributors
– Limited knowledge of sexual physiology
– early marriage
– limited use of contraceptives
– limited access to RH information and education
– girls’ limited agency over their sex lives
• One of the major RH challenges faced by
adolescents in Ethiopia
06/08/2023 122
Cont….
5. Abortion
– One in 10 abortions worldwide occurs among
women age 15-19
– Young women in SSA suffer 1/4 to 1/2 of all
reported complications from abortions
– Up to 10% of all abortions occur among girls
aged 15-19;
– Adolescents are more likely to seek abortions at
a late gestational stage when clinical risks are
higher
06/08/2023 123
Cont…
6. Early Marriage
– The prevalence of early marriage varies
throughout SSA
– from 10 to 54 % of 20-24 year olds entered
their first marriage before they reached age
18.
06/08/2023 124
Cont…
7. STIs and HIV/AIDS
– The HIV problem in Ethiopia has become a “feminine
epidemic”
– Girls’ ages 15-19 years are 7 times more likely to be
HIV +ve than boys the same age
– The highest rates of infection for STIs, including HIV,
are found among young people age 20 to 24
– the next highest rate occurs among adolescents age 15
to 19
– At least 1/3 of all new STDs each year occur in persons
under 25 years.
06/08/2023 125
Cont…
8. Contraceptive use
– married adolescents report very limited use of
contraception methods (EDHS)
– Fewer than 10% of currently married girls’
ages 15-19 report using any modern method;
– 15% of women ages 20-24 reported using any
modern method.
– Generally contraceptive uses amongst
adolescent of both sexes are poor.
06/08/2023 126
Cont…
9. Challenges
– Often lack basic reproductive health
information, skills
– Lack strong stable relationships with parents
or other adults whom they can talk to about
their reproductive health
– Programmes that meet the information and
service needs of adolescents can make a real
difference
06/08/2023 127
Factors that influence youth reproductive
health
 Individual Factors
 Peers and Partners
 Family and Household
 Institutions
 Communities
06/08/2023 128
Health Needs of Adolescents
– Motivation and skills to help them postpone
sex and other risks
– Information, skills and technologies for
protection against infections and unplanned
pregnancies
– Counseling for change of risky behaviors
– Information for helping delay and space
pregnancies
06/08/2023 129
Cont…
– Information and support during
pregnancy, labor/delivery, childcare,
nutrition and healthy lifestyles
– Protection from violence, forced sex or
sexual coercion
– Avoidance of non-healthy traditional
“health” practices
06/08/2023 130
Strategies to Improve ARH
 Create a supportive environment for youth
 Improve the reproductive health
knowledge, attitude, skills, and behaviors
of youth
 Increase youth’s use of reproductive health
services and programs
06/08/2023 131
Chapter 5
Infertility Prevention and

Treatment
06/08/2023 132
Learning Objectives
 Define infertility
 Identify factors contributing for male &
female infertility
 List steps of assessing infertility
 Discuss management of infertility
06/08/2023 133
Definition
• Infertility: when a pregnancy has not
occurred after at least 1 year of engaging in
unprotected sex
– Primary infertility
– Secondary infertility
• Sterility: the inability to conceive because
of a known condition, such as the absence of
a uterus.
• Subfertility is a lessened ability to conceive
06/08/2023 134
Male Infertility Factors
A. Disturbance in spermatogenesis
Inadequate Sperm Count
The minimum sperm count considered
normal is 20 mil/ml of seminal fluid, or
50 mil/ejaculation.
At least 50% of sperm should be motile,
and 30% should be normal in shape and
form.
06/08/2023 135
Cont…
Factors that reduce sperm count
Condition that significantly increases body T0
Actions that increase scrotal heat
Frequent use of hot tubs or saunas
Congenital abnormalities
Varicocele
06/08/2023 136
Cont…
Factors that reduce sperm count
Trauma to the testes
Surgery on or near the testicles
Endocrine imbalances
Drug use or excessive alcohol use
Environmental factors
06/08/2023 137
Cont…
B. Obstruction
 Orchitis
 Epididymitis
 Tubal infections such as gonorrhea
 Congenital stricture of a spermatic duct
 Hypertrophy of the prostate gland
 Infection of the prostate
 Anomalies of the penis
06/08/2023 138
Cont…
C. Development of autoimmunity that immobilizes
sperm
D. Problems in ejaculation or deposition
preventing spermatozoa from being placed close
enough to the woman's cervix to allow ready
penetration and fertilization
Erectile dysfunction
Premature ejaculation
06/08/2023 139
Female Infertility Factors
A. Faulty or inadequate production of ova
• Anovulation: most common cause
– may occur from a genetic abnormality,
hormonal imbalance (hyopothyroidism),
ovarian tumors
• Chronic or excessive exposure to x-rays or
radioactive substances, general ill health, poor
diet, and stress
06/08/2023 140
Cont…
B. Problems of ova transport through the
fallopian tubes to the uterus
– Scarring in the fallopian tubes
• chronic salpingitis
06/08/2023 141
Cont…
C. Uterine factors (tumors or poor
endometrial devt)
block the entrance of the fallopian tubes
limit the space available
Affect implantation
Poor secretion of estrogen or progesterone
06/08/2023 142
Cont…
D. Endometriosis
Implantation of uterine endometrium, or
nodules, that have spread from the interior of
the uterus to locations outside the uterus
Proliferate and grow at the new sites
Impeding fertility
06/08/2023 143
Cont…
E. Cervical and vaginal factors that
immobilize sperm
– Infection or inflammation of the cervix
– A stenotic cervical os or obstruction of the os
– Infection of the vagina
F. Unexplained Infertility
06/08/2023 144
Fertility Assessment
1. Health History
– General health
– Nutrition
– Alcohol, drug, or tobacco use
– Congenital health problems
– Operations
– Past and current occupation and work habits
– Sexual practices
– Past contraceptive measures
– Menstrual history
06/08/2023 145
Cont….
2. Physical Assessment
Man
– Inspect secondary sexual characteristics and
genital abnormalities
Woman
– Secondary sex characteristics
– Breast and thyroid examination
– Pelvic examination
06/08/2023 146
Cont….
3. Fertility Testing
– Semen Analysis
• The man ejaculates by masturbation
• Spermatozoa are examined under a
microscope
• An average ejaculation should produce 2.5-
5.0 mL of semen
• Should contain a minimum of 20 million
spermatozoa per milliliter of fluid
06/08/2023 147
Cont….
Ovulation Monitoring
– Record BBT for at least 1 month
– The woman takes her temp. each morning
– Plot this daily temp. on a monthly graph
– At the time of ovulation, the basal temp
can be seen to dip slightly
– It then rises to a level no higher than
normal body temp.
06/08/2023 148
Cont…
– stays at that level until 3/4 days before
the next menstrual flow
– A temp rise should last approximately
10 days
– If not, a luteal phase defect is
suggested
06/08/2023 149
Cont…
Hysterosalpingography
Radiologic examination of the fallopian tubes
using a radiopaque medium
The most frequently used method of assessing
tubal patency
Scheduled immediately after the menstrual flow
The radiopaque material outlines the uterus
and both tubes, provided that the tubes are
patent.
06/08/2023 150
Infertility Management
• Focuses on correction of any underlying
problem that was discovered on
assessment
06/08/2023 151
Cont…
• Practical information on how to increase
the chance of achieving conception
Planning sexual relations for every other day
around the time of ovulation is ideal.
The male-superior position
The male should try for deep penetration
The woman should remain on her back with
knees drawn up for at least 20 minutes after
ejaculation
06/08/2023 152
Cont…
 Correction of the Underlying Problem
 Increasing Sperm Count and Motility
 Reducing the Presence of Infection
 Hormone Therapy*
 Surgery
 Assisted Reproductive Techniques
 Artificial Insemination, IVF-ET, Surrogate Embryo
Transfer
06/08/2023 153
Chapter 6
Sexually Transmitted
Infections
06/08/2023 154
Learning Objectives
 Describe the Classification of STIs
 Outline the public health significance of STIS
 Discuss STI Control strategies and obstacles
 Explain advantages and limitations of syndromic
approach
 Treat STI based on syndromic approach
06/08/2023 155
Introduction
• Reproductive tract infections (RTIs) are
infections of the genital tract of women and men.
There are 3 types of RTIs:

1. Sexually transmitted infections (STIs)
Infections caused by organisms that are passed
through sexual activity with an infected partner.
More than 40 have been identified, including
Chlamydia, gonorrhea, hepatitis B and C, herpes,
HPV, syphilis and trichomoniasis and HIV.
06/08/2023 156
Cont…
2. Endogenous infections
Infections that result from an overgrowth of
organisms normally present in the vagina.
These infections are not usually sexually
transmitted, and include bacterial vaginosis
and candidiasis
06/08/2023 157
Cont…
3. Iatrogenic infections
– Infections introduced into the reproductive
tract by a medical procedure such as
induced abortion,
IUD insertion, or
childbirth.
06/08/2023 158
Cont…
• This can happen if
surgical instruments used in the
procedure are not properly sterilized, or
an infection already present in the lower
reproductive tract is pushed through the
cervix into the upper reproductive tract
06/08/2023 159
Cont…
• These 3 types of RTIs overlap and should be
considered together.
• Eg.
– some STIs, like gonorrhea or Chlamydia, can
be spread in the reproductive tract if not
treated prior to a procedure.
– some non-sexual infections, such as
candidiasis, can be passed on through sexual
activity.
06/08/2023 160
Cont…
• Not all STIs are RTIs; and not all RTIs are
sexually transmitted; STI refers to the way of
transmission whereas RTI refers to the site
where the infections develop.
06/08/2023 161
Cont…
Main STI Pathogens
• More than 30 pathogens are transmissible
through sexual intercourse-oral, anal, or
vaginal.
• The main sexually transmitted bacteria are:
Neisseria gonorrhoeae (causes gonorrhoea)
Chlamydia trachomatis (chlamydial infections)
Treponema pallidum (causes syphilis)
Haemophilus ducreyi (causes chancroid)
06/08/2023 162
Cont…
• The main sexually transmitted viruses are:
Human immunodeficiency virus (causes AIDS)
Herpes simplex virus (causes genital herpes)
Human papilloma virus (causes genital warts)
Hepatitis B virus
Cytomegalovirus
• The main parasitic organisms are:
Trichomonas vaginalis (causes vaginal
trichomoniasis)
06/08/2023 163
Public Health Significance of STIs
 Over 340 million STIs occur each year

 In developing countries, STIs and their
complications rank in the top 5 disease
categories for which adults seek health care
 Self reported prevalence of STIs in Ethiopia is 2
% in women and 1.5 % in men.
 In women (15-49 years), STIs, even excluding
HIV, are 2nd to maternal factors as causes of
disease, death and healthy life lost
06/08/2023 164
Cont…
• Reasons that force the world to give
attention to STIs:
The links between STIs and HIV
STIs can lead to the development of serious
complications
STIs constitute a huge health and economic
burden
06/08/2023 165
Distribution of STIs
 Prevalence higher in urban than rural
 Higher in unmarried & young adults
 More frequent among females than males b/n
the ages of 14-19
 After the age of 19, there is slight male
preponderance
06/08/2023 166
STI statistics are underestimated
for these reasons
– People with asymptomatic STIs do not
seek treatment
– Poor access
– Missed opportunity
– Stigma
– Non-reporting facilities
– Cost of services etc…
06/08/2023 167
Classification of STIs
1. Genital ulcer:
 Chancroid, Genital herpes simplex virus, Granuloma
inguinale, Lymphogranuloma Venarum, Syphilis
2. Urethritis and cervicitis:
 Chlamydial infection, Gonorrhea
3. Vaginal discharge:
 Bacterial vaginosis, Trichomoniasis, Vulvovaginal
candidiasis
4. Pelvic Inflammatory Disease (PID)
06/08/2023 168
Cont…
5. Epididymitis
6. Human papiloma virus infection (Genital wart)
7. Vaccine preventable STDs: Hepatitis A, Hepatitis
B
8. Proctitis, Proctocolitis and enteritis
9. Ectoparasitic Infections: Pediculosis Pubis,
Scabies
06/08/2023 169
Syndromic Approach to STI Mgt
• Many different agents cause STIs, however,

some of these agents give rise to similar or
overlapping clinical manifestations
•Aim of Syndromic management of STIs:
Prompt and effective detection and treatment
of STIs
Decrease STI incidence and prevalence by
reducing period of infectiousness
06/08/2023 170
Principles in the Syndromic Mgt
 Many STIs can be identified and treated on the

basis symptoms and signs.
 Treatment covers several possible infections
responsible for the syndrome
 Syndromic mgt will reduce the cost of laboratory
work up and extra visits to the clinic and
treatment delay.
06/08/2023 171
Advantages & Limitations of
Syndromic Mgt
Advantages Limitations
 Immediate  In diagnosing vaginal
Rx discharge
 Effectivene  Potential for over treatment
ss  Ineffectiveness against
 Ease of use asymptomatic infections
 Need for data
 Low costs
06/08/2023 172
Cont…
1. Prevention by promoting safer sexual
behaviors;
Safer sex: any sexual activity that reduces
the risk of passing STI and HIV from one
person to another.
06/08/2023 173
Cont…
•Some safer sex practices:
– Consistent use of condom
– Reducing the number of sex partners
– Massaging, rubbing, touching, dry kissing,
instead of intercourse
– Not to have intercourse with partner having
genital sore or discharge
06/08/2023 174
Cont….
2. General access to quality condoms at affordable prices;
3. Promotion of early recourse to health services by
people suffering from STIs and by their partners;
4. Inclusion of STI treatment in basic health services;
5. Specific services for populations with frequent or
unplanned high-risk sexual behaviors
6. Proper treatment of STIs, i.e. use of correct and
effective medicines; treatment of sexual partners;
education and advice; reliable supply of condoms;
06/08/2023 175
Cont…
7. Screening of clinically asymptomatic patients;
8. Provision of counseling and voluntary testing for
HIV infection;
9. Prevention and care of congenital syphilis and
neonatal conjunctivitis;
10. Involvement of all relevant stakeholders,
including the private sector and the
community, in prevention of STIs and prompt
contact with health services for those requiring
care.
06/08/2023 176
The main STI syndromes are:
Urethral discharge
Genital ulcer
Inguinal bubo
Scrotal swelling
Vaginal discharge
Lower abdominal pain
Neonatal conjunctivitis
06/08/2023 177
Specific STI syndromes
06/08/2023 178
1. Urethral Discharge
Agents:
 N. gonnorhea, C. trachomitis, T. vaginalis
Clinical presentation
 Burning sensation on urination, dysuria, Urethral
discharge
Treatment
Cipro 500mg PO stat or Spect 2gm IM stat
Plus
 Doxy 100mg bid, 7d or TTC 500mg qid, 7d or
Erythro 500 qid,7d
06/08/2023 179
2. Genital Ulcers
Agents:
•Vesicular: HSV2(herps simplex v) (Genital
Herps)
• Non-Vesicualr:
– T. pallidum (Syphilis), H. ducreyi (Chancroid),
– C. trachomatis serovars L1-L3 (LGV)
– Calymmatobacterium Granulomatis
(Granuloma ingunale)
06/08/2023 180
Cont…
Recommended treatment
Benz. Penic 2.4m U. IM stat or Doxy 100mg bid/14 d
Plus
 Cipro 500mg PO bid /3 d or Erythr 500 mg
qid/7days Plus
 Acyclovir 400mg PO tid/10 d (or 200mg 5 times per
day of 10 day)
• If only vesicular, recurrent & multiple ulcers:

Acyclovir
06/08/2023 181
3. Common causes of vaginal
discharge
Sexually transmitted: Neisseria
gonorrhoeae, Chlamydia trachomatis,
Trichomonas vaginalis
Endogenous infection: Gardnerella
vaginalis (for Bacterial Vaginosis), Candida
albicans
06/08/2023 182
Cont…
Initial evaluation of patients with vaginal discharge
– Risk assessment
 Age less than 25 years
 Having multiple sexual partner in the last three
months
 Having new partner in the last three months
 Having ever traded for sex
– Clinical speculum exam to determine site of infection
06/08/2023 183
Cont…
Risk assesment Risk assesment negative
positive
Cipro 500 mg PO stat Metron 500 mg bid/7d

or Plus
Spect 2 gm IM stat Clotri vaginal tabs 200 mg at bed
Plus time/3d
Doxy 100 mg PO bid/7d

Plus
Metron 500 mg PO bid/7d
06/08/2023 184
4. Lower Abdominal Pain
Syndrome (PID)
 Infection of pelvis not related to pregnancy or
surgery
Ascending infection of the Ux, FT, ovaries and
or adjacent structures
 Sexually transmitted: N.gonorrhea,
C.trachomatis
• May or may not be sexual: Anaerobes i.e. (poly
microbial): Bacteroids, Streptococcus, E. Coli, H.
Influenza
06/08/2023 185
Cont…
•Diagnosis
– Often difficult & inconsistent clinical presentations are
common.
– Bilateral or unilateral lower abdominal pain & vaginal
discharge support diagnosis
•History
– Erratic bleeding
– Missed period
– Recent delivery
– Miscarriage
06/08/2023 186
Cont…
• Pelvic Exam: Temperature, Palpate abdomen

for tenderness, guarding & mass vaginal
bleeding & abnormal discharge
•Indications for hospitalizations in PID
Uncertain diagnosis
Acute abdomen cannot be excluded
Pelvic abscess is suspected
06/08/2023 187
Cont…
• Indications for hospitalizations in PID

Severe illness precludes mgt on an outpatient
basis
Pregnancy
The patient is unable to follow or tolerate an
outpatient regimen
The patient has failed to respond to outpatient
therapy
06/08/2023 188
Cont…
• Recommended treatment
Out patient In patent
Cipro 500 mg PO stat OR Spect2 gm Ceftr 250 mg IV/IM OR

IM stat Spectinomycin 2 gm IM bid
Plus Plus
Doxy 100 mg PO bid for 14 days Doxycycline 100 mg bid for 14
Plus days
Metronidazole 500 mg bid for 14 days Plus
Metron 500 mg bid/14d OR

Admit if there is no improvement CAF 500 mg IV qid.
within 72 hours
06/08/2023 189
5. Scrotal Swelling Syndrome
•Main causes
 < 35 years - N. Gonorrhoea & C.Trachomatis
 >35 years - other organisms, TB possible (Other:
brucellosis, mumps, onchocerciasis or W.
babcrofti)
 In pre-pubertal children - coliform,
pseudomonas or mumps virus
• Other causes of scrotal swelling: Trauma,
Tumor, incarcerated inguinal hernia
06/08/2023 190
Cont…
Recommended treatment
 Cipro 500 mg po stat Or Spect 2 gm im stat
Plus
 Doxy 100 mg PO bid/7d Or TTC 500 mg PO
bid/7d
06/08/2023 191
6. Inguinal Bubo
• It is a painful, often fluctuant, swelling of
the lymph nodes in the inguinal region
(groin).
• The common pathogens are
C. trachomatis (serovar L1, L2 and L3): LGV
H. ducreyi: Chancroid
C.Granulomatis (Calmitobacterium
granulomatis): Granuloma ingunale
06/08/2023 192
Cont…
•Complications:
 Abscess formation and PID
 Lymphatic obstruction
 Stenosis and Infertility
•Recommended treatment
Ciprofloxacin 500 mg po bid for 3 days
Plus
Doxy 100mg po bid/14d Or Eryth 500 mg po qid/14d
06/08/2023 193
7. Neonatal Conjunctivitis
 Purulent conjuctivitis occurring in a baby less
than one month of age
 Common presentation are Redness, swelling of
the eye lid & discharge from the eye (sticky eye).
 The most causes are gonorrhoea & chlamydia
 If caused by gonorrhoea, blindness often follows
 For babies older than 1 month, the cause is
unlikely to be an STI.
06/08/2023 194
Cont…
•Prevention
As soon as the baby is born, carefully wipe
both eyes with dry, clean cotton wool
Then apply 1% silver nitrate solution or 1%
tetracycline eye ointment into the infant’s
eyes;
Other options: 0.5% Erythromycin ointment
06/08/2023 195
Cont…
Treatment
Ceftr 125mg IM stat or Spect 25mg/kg IM stat
Plus
Erythr 50 mg/kg PO in four divided doses/14d
06/08/2023 196
Chapter 7
Abortion
197
Learning Objectives
At the end of this chapter students will able to:-
 Define abortion
 Describe causes, s/sx and management of abortion
 Understand the magnitude of abortion
 Identify reasons behind unplanned pregnancy
 Define unsafe abortion and know contributing factors
 Recognize different components of post abortion care
 Recognize the revised Penal Code of Ethiopia on Safe
abortion
06/08/2023 198
Definitions
• Abortion is the termination of pregnancy/
expulsion of the products of conception, either
spontaneously or intentionally, before the fetus
develops sufficiently to survive.
06/08/2023 199
Cont…
Definition varies
• In developing countries including Ethiopia
“the termination of pregnancy before fetal
viability, less than 28 weeks from the
LNMP or < 1000gram
• In developed countries
pregnancy termination prior to 20 weeks'
gestation or less than 500-g birth weight
06/08/2023 200
Classification of abortion
Abortion can be classified based on :
Cause/etiology :induced Vs spontaneous
Gestational age: Early Vs Late
Clinical feature: threatened, inevitable,
incomplete, complete, missed, habitual
06/08/2023 201
Based on Cause/etiology
1. Spontaneous Abortion (miscarriage):

It is the loss of a fetus during pregnancy due
to natural causes
It occurs without medical or mechanical
means to empty the uterus
About 15 % of all clinically recognizable
pregnancies end in spontaneous abortions
06/08/2023 202
Cont…
30 to 50 million induced abortions are
performed annually in the world
In Ethiopia approximately 500,000 pxs end in
either spontaneous or unsafely induced
abortion.
06/08/2023 203
Cont…
Pathology in spontaneous abortion
Hemorrhage into the decidua basalis often
occurs.
 Necrosis and inflammation appear in the area of
implantation.
 The pregnancy becomes partially or entirely
detached.
Uterine contractions and dilatation of the cervix
result in expulsion of most or all of the products
of conception.
06/08/2023 204
cont…
2. Induced abortion
it is the loss of products of conception
intentionally or deliberately
It occurs due to medical or mechanical
means to empty the uterus
It can be classified as
therapeutic (legal)
criminal (illegal) or
 safe
unsafe
06/08/2023 205
Cont…
• Septic abortion:-when any of the stage of
abortion complicated by pelvic infection
• Recurrent abortion:-three or more
consecutive spontaneous termination of
pregnancies
• Therapeutic abortion :-termination of
pregnancy before the time of fetal viability for
the purpose of saving the life of the mother
06/08/2023 206
Unsafe abortion
• It is a procedure for terminating an unintended
px either by
individuals without the necessary skills or
 in an environment that lacks minimum
medical standards, or both. (WHO,1992)
06/08/2023 207
Cont….
• It mainly endangers women in countries
where abortion is highly restricted by law
and countries where, although legally
permitted, safe abortion is not easily
accessible.
• It is the commonest cause of maternal
mortality in Ethiopia. (32% of all maternal
deaths)
06/08/2023 208
Based on Clinical features
A. Threatened abortion
Slight intermittent bleeding with or without
cramping
The cervix remains closed and no cervical
effacement
At least 20–30% of pregnant women have some
first-trimester bleeding.
In most cases, this is thought to represent an
implantation bleed.
More than 50-80% go to term.
06/08/2023 209
Cont…
B. Inevitable abortion
The cervix has dilated, but the products of
conception have not been expelled
Abdominal or back pain and mild to severe
vaginal bleeding
Cervical effacement, cervical dilatation,
and/or rupture of the membranes is noted.
It is Irreversible
06/08/2023 210
Cont…
C. Incomplete abortion
• Some, but not all, of the products of
conception have been passed; retained
products may be part of the fetus, placenta, or
membranes
• In gestations of less than 10 weeks' duration,

the fetus and placenta are usually passed
together. After 10 weeks, they may be passed
separately, with a portion of the products
retained in the uterine cavity.
06/08/2023 211
Cont…
Sign and symptoms
 Cramps are usually present
 Profuse persistent bleeding
 HX of passing concepts tissue
 Some times visible or palpable concepts
tissue through the opening cervix
Complications
– Anemia, hemorrhage and infection
06/08/2023 212
Cont…
D. Missed abortion
Def. a pregnancy in which there is a fetal
demise (usually for a number of weeks) but no
uterine activity to expel the products of
conception
Sign and symptoms
Regress sx/s of pregnancy , Uterine size
decreased, cervix closed, Brownish vaginal
discharge
Complications
 Infection, DIC, AF embolism
06/08/2023 213
Cont…
E. Complete abortion
All products of conception have been
passed without need for surgical or
medical intervention.
 Slight bleeding may continue for a short
time
Pain usually ceases after products has
traversed/passed the cervix.
06/08/2023 214
Differential diagnosis
 Idiopathic bleeding in unviable pregnancy
 Ectopic pregnancy
 Molar pregnancy
 Infection of the vagina or cervix
 Cervical abnormalities
 Vaginal trauma
06/08/2023 215
Diagnosis
Laboratory
-HCG
-Progesterone levels
Ultrasound
-Status of the pregnancy
- Intrauterine? Ectopic?
Vaginal Exam:
 dilated cervix ~> inevitable
abortion
06/08/2023 216
Diagnosis#2- S/SX
06/08/2023 217
Laboratory investigations
Blood type and RH factor
Complete blood count
HCG to confirm pregnancy
WBC and differential to rule out infection
06/08/2023 218
General management
First-trimester loss
 MVA ,E&C or D&C
After the first trimester

 Hospitalization should be considered
 Oxytocins are helpful in contracting the uterus,
limiting blood loss, and aiding in expulsion of clots
and tissue.
06/08/2023 219
Cont…
• Anti D for RH negative
• Surgical evacuation
-Patient is unstable:-Heavy bleeding
-Septic abortion
-Patient choice
• Medical therapy
 Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion??
06/08/2023 220
Cont…
For threatened abortion
Bed rest and pelvic rest
Avoid coitus, douching and strenuous
exercise
• Prognosis is good when bleeding and/or
cramping resolve.
06/08/2023 221
Cont…
For inevitable abortion
• According to gestational age
<12 weeks MVA
>12weeks oxytocin infusion and
E/C with pethidine or sedative
06/08/2023 222
Cont…
For incomplete abortion
Evacuation based on gestational age
Uterotonic agents
Blood and fluid replacement
Antibiotic
The prognosis for the mother is excellent if the
retained tissue is promptly and completely
evacuated.
06/08/2023 223
Cont…
For complete abortion
Observed for further bleeding.
 The products of conception should be
examined.
Prognosis for the mother is excellent
06/08/2023 224
Cont…
For missed abortion
• Expectant management
-3-4 weeks follow up
-Clotting profile
>12weeks
-Prostaglandin or balloon catheter to dilate
cervix
-Pitocin
<12 weeks :-MVA or D/c
06/08/2023 225
Complications of Abortion
 Severe or persistent hemorrhage(life
threatening).
 Sepsis develops most frequently after
self-induced abortion.
 Intra abdominal injury
- Perforation of the uterine wall
- injury to the bowel and bladder
06/08/2023 226
Cont…
• Other complications of abortion
-Anemia
- Renal failure
-Infertility(if hysterectomy done
due to complication)
06/08/2023 227
Treatment of complication
Managed accordingly
Laparotomy are indicated to determine the
extent of laceration or bowel injury
Broad spectrum antibiotics for sepsis
Pre implantation diagnosis, or prenatal testing
on subsequent conceptions.
 Cervical cerclage
Appropriate antibiotics
06/08/2023 228
Medical abortion
Definition ;
 is termination of pregnancy using drugs with
out use of surgical evacuation.
Drugs used include
 Mifepristone
 Misoprostol
06/08/2023 229
How Mifepristone Works
It antagonize the effect of
Progesterone during pregnancy
Progestrone:
 Inhibits contractility of myometrium
 Inhibits secretion of prostaglandins in the
endometrium
 Maintains closed cervix
06/08/2023 230
Cont…
Mifepristone:
 Cause Detachment of the embryo, drop in
BHCG
 Increase in contractility of the myometrium
 Opening and softening of the cervix
Mifepristone alone: 80% abortion rate
06/08/2023 231
Misoprostol
Registered , brand name Cytotec for PUD
 Used to bring menses if delayed
 In 2OO6 WHO , added as essential drug for
induction of labor and abortion
Side effect
• High dose in late pregnancy is associated with
uterine rupture and fetal death
06/08/2023 232
Cont…
Mechanism of action
Acts on prostaglandin receptors and cause
Uterine contraction
Cervical ripening (opening)
Route of administration
Oral and sublingual ; fast onset
Vaginal ; longer to start
Dosage ; 200mcg (common) , 100mcg, 25mcg
06/08/2023 233
Common steps on its administration
• First, give mifepristone tablets by mouth.

It causes the placenta to separate from the
endometrium.
 It also softens the cervix and
It increases uterine contractions to allow
the uterine contents to pass.
• Second, you take tablets of misoprostol, usually
within 48 hours of mifepristone.
06/08/2023 234
Cont…
• Misoprostol causes uterine contractions so
that the uterus passes its contents. Some
clinics may allow the pt. to stay for 4
hours after misoprostol is given
06/08/2023 235
Contraindications: Miso and mefi
prostol
 Allergy
 Clinically unstable
 Ectopic pregnancy
 Severe anemia
 Hemorrhagic disorder or concurrent
anticoagulant therapy
06/08/2023 236
Protocol for Misoprostol Administration
• Day 1 is defined as the day mifepristone is taken.

Administer 200 mg mifepristone orally
Vaginal use:
56 days/8 weeks On Day 2, 3 or 4, insert four 200mcg tablets
(800mcg total) of misoprostol.
56–63 days/ 8–9 weeks On Day 2 or 3, insert four 200mcg tablets
(800mcg total) of misoprostol.
Oral use:
49 days/7 weeks On Day 2 or 3, take two 200mcg (400mcg
total) tablets of misoprostol.
49–63 days/ 7–9 weeks Not recommended due to lower efficacy—use
06/08/2023
vaginal misoprostol. 237
Incomplete abortion
• First trimester incomplete abortion
–single dose 600mcg oral ,91- 99 % success
no need of surgical evacuation
or
–Single dose 400mcg sublingual 95%
06/08/2023 238
Why Women Find Themselves with Unwanted
Pregnancy?
 Nearly 40% of the nearly 182 million
pregnancies each year in the developing world
are unwanted
 46 million unwanted pregnancies end in
abortion each year.
 Girls < 15 are 3x more likely to end their
pregnancies in abortion than those ages 20-
24yrs
06/08/2023 239
Causes of unwanted pregnancy
• Non-use of contraception
 This can be due to Lack of information,
limited access to services, financial
constraints, personal beliefs, family
objections, and/or health concerns.
The majority of unwanted pregnancies
occur in nonusers of contraceptive
methods.
06/08/2023 240
Cont…
• Contraceptive failure
Contraceptive failure results in 8-30
million pregnancies each year either from
inconsistent or incorrect use of family
planning methods or method-related
failure.
• Sexual coercion or rape
 Twenty to fifty percent of women and girls
report sexual abuse, rape or
06/08/2023 241
Cont…
Misinformation about reproduction
Others
Young age or single marital status/premarital
pregnancy;
Abandonment or unstable relationship;
Mental or physical health problems;
06/08/2023 242
Health consequences of unsafe abortion and
impact on health services
• When induced abortion is performed by
qualified persons using correct techniques and in
sanitary conditions, it is a safe surgical
procedure
06/08/2023 243
Cont…
• The mortality and morbidity risks associated
with unsafe induced abortion depend on
the facilities and the skill of the abortion
provider,
the method used,
the general health of the woman and
the stage of her pregnancy.
06/08/2023 244
Cont…
• Abortion attempts may involve
insertion of a solid object (root, twig or
catheter) into the uterus;
a dilatation and curettage procedure
performed improperly by an unskilled
provider;
ingestion of harmful substances;
exertion of external force; or
misuse of modern pharmaceuticals.
06/08/2023 245
Deaths from unsafe abortion
• Measurement of the worldwide prevalence of
abortion related mortality and morbidity is
difficult.
• Worldwide, an estimated 68,000 women die as a
result of complications from unsafe induced
abortions every year
06/08/2023 246
Morbidity from unsafe abortion
• Morbidity is a much more common consequence

of unsafe abortion than mortality
• Complications include
Haemorrhage
Sepsis
Peritonitis, and
Trauma to the cervix, vagina, uterus, and
abdominal organs
06/08/2023 247
Cont…
consequence of unsafe abortions (WHO estimates)
20–30% result in reproductive tract
infections (RTIs) and that about 20–40% of
these result in upper genital-tract infection and
infertility.
2% of women of reproductive age are infertile as
a result of unsafe abortion, and
5% have chronic infections.
It could increase the longterm risk of ectopic Px
06/08/2023 248
Abortion care services
There are two types of abortion services:-
1. Women Centered comprehensive
abortion Care (CAC)
2. Post abortion care (PAC)
06/08/2023 249
1. WOMEN - CENTERED ABORTION
CARE
 It is a comprehensive care service provision
that considers woman’s individual circumstances
 Woman-centered abortion services have three
key elements.
A. Choice
To have complete and accurate information.
The right to determine if and when to become
pregnant,
To continue or terminate a pregnancy,
To select between options
06/08/2023 250
CONT…
B. Access
Having access to termination of pregnancy
services
 provided by trained and competent providers
with up-to-date clinical technologies
 Are easy-to-reach, affordable, and non-
discriminatory.
C. Quality:
Refers to respectful, confidential services that
are tailored to each woman’s needs using
accepted standards and appropriate referral
procedures
06/08/2023 251
2. Post-Abortion Care (PAC)
• Is the strategy to reduce death and suffering from
the complications of unsafe and spontaneous
abortion.
The elements of PAC are:
Emergency management of incomplete abortion and
potentially life-threatening complications
Post-abortion family planning counseling and services
Making links between post-abortion emergency
services and other RH care services
06/08/2023 252
Cont…
The following steps should be taken to
manage post-abortion complications:
A. Conduct initial clinical assessment
B. Complete clinical assessment
C. Manage complications
Rest
Replacement of fluids
Laparotomy/ surgery
06/08/2023 253
Cont…
Uterine evacuation
Antibiotics
Management of pain
Prevention of tetanus
D. Post-Abortion Family Planning
E. Links to Other Reproductive Health
Services
06/08/2023 254
Ethiopian Abortion Law
The conditions under which the liberalized
abortion law allows legal abortion are:
When the pregnancy results from rape or
incest;
When continuity of the pregnancy endangers
the health or life of the woman or the fetus;
In cases of fetal abnormalities;
06/08/2023 255
Cont…
For women with physical or mental
disabilities
For minors who are physically or
psychologically unprepared to raise a child
06/08/2023 256
Chapter 8
Family Planning
06/08/2023 257
Learning objectives
Discuss the Rationale of Family planning
Recognize steps in counseling
Understand the reasons behind non-use of
contraceptive methods
Distinguish different family planning methods
06/08/2023 258
Introductions
• FP: the use of various methods of fertility
control that will help individuals or couples to
have the number of children they want and when
they want them in order to assure the well being
of children and the parents.
06/08/2023 259
Cont…
• Family planning simply means preventing
unwanted pregnancies by safe methods of
prevention.
• This is considered to be part of the basic
human rights of all individuals or couples as it
was endorsed by the International Conference
on Population and Development in Cairo in
1994.
06/08/2023 260
Objectives
 Limit family size
 Adequately space children
 Reduce maternal and child morbidity and
mortality
 Reduce the risk of sexually transmitted infection
06/08/2023 261
Rational to use of family planning
1. Demographic
Population growth as a threat to food supplies
and natural resources
2. Health*
Consequences of high fertility for maternal,
infant and child morbidity and mortality
06/08/2023 262
Cont…
3. Human rights
Individuals have a right to control
reproductive decisions, including family size
and the timing of births(ICPD, 1994 Cairo)
06/08/2023 263
Counseling in Family Planning
Goal of FP Counseling
to improve the quality of life and RH by
empowering individuals and couples to
exercise their right to safe sexuality, and
to decide whether and when to have children
and how many to have.
06/08/2023 264
Cont…
Goal of FP Counseling
a) Bridge Knowledge Gap
b) Help Clients Make Informed Choice
c) Provide Services
06/08/2023 265
Steps in FP Counseling
G Greet clients in an open, respectful manner. Assure
the client of confidentiality. Give as much time
listening as talking
A Ask clients about themselves. Help client talk about their

family planning practices, intentions, concerns, and wishes.
T Tell clients about choices. Depending on the clients need,

tell the client what reproductive health choices she/he
might take. Focus on methods that interest the client. Also
explain other services that the client may want.
H Help clients make an informed choice. Help the client think about the
options. Encourage the client to express opinions and ask questions.
Consider medical eligibility criteria for the family planning method that
interest the client. In the end, make sure that the client has made clear
decision.
06/08/2023 266
Cont…
E Explain fully how to use the chosen method: after
a client chooses a family planning method, give
her or him the supplies if appropriate.
Encourage questions, and answer them openly
and fully.
Give condoms to any one at risk for sexually
transmitted diseases (STD's) and encourage using
condoms along with any other family planning
method.
Check that the clients understand how to use their
method
R Return visits should be welcomed: Discuss and agree
when the client will return for follow-up or more supplies
if needed.
Always invite the client to return any time for any reason
06/08/2023 267
Family Planning methods
Natural methods Artificial methods
 Breast feeding  Barrier methods

Diaphragm ,Condom
 Abstinence
 Intra-uterine device (IUD)
 Withdrawal (Coitus
 Hormonal
interrupts) Pills, Implants, Injectable
 Calendar methods
 Surgical methods (Permanent)
 Cervical mucus (Billing’s Tubal ligation, Vasectomy
Method)  Emergency contraception

– IUD
 Sympathothermal – Levonorgestrel-only or combined
estrogenprogesterone
06/08/2023 268
Cont…
• Each method has its advantages and suits
special cases and not necessarily suits others
and the choice of contraception depends on
different needs of the patients like the period of
contraception and also doctor should decide
which method suits needs more.
• No method of contraception is completely
effective and failure rates for most reversible
methods are strongly influenced by
compliance.
06/08/2023 269
Cont…
Classifications:- two main classifications
1. Natural contraception
2. Artificial contraception
Artificial contraception again can be classified

as:-
A. Mechanical contraception
B. Hormonal contraception
C. Surgical contraception
06/08/2023 270
Conditions of family planning
Time specific situations/conditions which
prevents pregnancy include:-
Pregnancy
Lactation
Before puberty
After menopause
Abstinence
06/08/2023 271
Natural contraception
A. The Calendar or Rhythm Method
This method can be used for patients with
regular cycles only.
This is done depending on the exact knowledge
of ovulation day and avoiding intercourse
during the days before and after ovulation;
for example in a regular period that occurs
every 28 days the exact day of ovulation should
be the day 14 so intercourse should be avoided
4-5 days before and after this days.
06/08/2023 272
Cont…
There are many methods to detect
ovulation days;
1- Increase in body temperature by about
o.5 C.
2- Change in type cervical mucous
3- Ovulation kits nowadays are available for
ovulation day detection by measuring LH
surge
06/08/2023 273
Cont…
• It also involves numerical calculations based on
previous menstrual cycles to estimate the fertile
period(average cycle is every 28 days with
variation of 7, 21-35).
Procedure
• Record the no. of days in 6 consecutive
menstrual cycles.
• Calculate the 1st fertile day by subtracting 18
from the shortest cycle
06/08/2023 274
Cont…
• Calculate the last fertile day by subtracting
11 from the longest cycle
• E.g. for the average 28 day cycle, the
shortest and longest cycle is equal(i.e. 28).
So 28-18=10 and 28-11=17(this means the
woman should avoid coitus from 10-17).
This shows more precise estimation of
fertile periods(narrow gap)
06/08/2023 275
Cont…
• E.g.2 the menstrual cycle of w/ro Aster in the last
six months were recorded as 21, 25,32,24,28 and
34
• Based on the data, determine the days that she
should avoid sexual intercourse
Longest-11, 34-11=23
Shortest -18, 21-18=3
This is(3-23) wider gap,b/c the woman’s cycle is
irregular and the estimation of fertile period is
less precisely determined.
06/08/2023 276
Cont…
B. Withdrawal
When having sex, the man has to take his penis out of
the vagina before ejaculation.
This is intended to stop sperm from entering the
woman.
This method frequently fails as drops of sperm can
already escape from the penis into the vagina before
the man ejaculates.
Effectiveness: Failure rate can be as high as 15% (15
pregnancies per 100 women).
More reliable methods are advised.
06/08/2023 277
Cont…
C. Lactation amenorrheoa method (LAM)
• Women are less fertile when breastfeeding
• There is delay in ovulation during this time because
of hypophysial or hypothalamic stimuli from lactation
• But the duration of suppression of ovulation is quite
variable
• Complementary methods such as condoms or IUDs
are recommended.
06/08/2023 278
Cont…
• A woman who uses LAM should be given
specific instructions:
Breastfeed often
Breast feed properly
Supplemental foods should be started by
the 6th month
06/08/2023 279
Artificial FP methods
06/08/2023 280
1. Mechanical family planning
methods
These includes:
Male condoms
Female condoms
Diaphragms
Spermicidal
Intrauterine devices (IUD)
Sponge
06/08/2023 281
A. Male condom
• It's a thin latex or plastic sheath placed over a
man's erect penis during sex to trap sperm at
the point of ejaculation.
It must be put on the penis as soon as it
becomes erect and
before any contact takes place with the vagina.
Men should withdraw as soon as they have
ejaculated and take care not to spill any semen.
06/08/2023 282
Cont…
• Condoms must be used with care as they can
slip off or split.
• They should never be used with oil-based
products such as petroleum jelly or suntan oil
as these will damage the rubber.
06/08/2023 283
Cont…
• Advantages:
easily available;
offers protection against sexually
transmitted infections including
HIV/AIDS.
• Effectiveness: 94%-98% depending on correct use.
06/08/2023 284
B. Female condom (Femidom)
• It's a thin polyurethane sheath placed inside the
vagina (also covering the cervix and the area
outside) to stop sperm from entering.
It can be put in at any time before sex and
is
actually stronger than the male condom.
It need to be sure that the penis enters the
condom
and is not inserted between the condom
and the vaginal wall.
06/08/2023 285
Cont…
• Advantages: offers protection against sexually
transmitted infections, including HIV/AIDS.
• Effectiveness: 95% if used correctly.
06/08/2023 286
C. Diaphragms/cervical cap
• A diaphragm or cap is a dome of rubber which
is fitted by the woman over her cervix before
sex.
It acts as a barrier to stop sperm getting through
to the uterus.
It should be used with a spermicidal cream,
jelly or pessaries that contain a chemical that
kills sperm.
• The diaphragm must stay in place for six hours
after sex.
06/08/2023 287
Cont…
• Advantages: only needs to be used when the
couple has sex
• Spermicides may cause irritation or an allergic
reaction.
• Effectiveness: 92%-96% if used correctly.
06/08/2023 288
D. Spermicides
• These are creams, gels, sponges or
pessaries that contain a chemical that
kills sperm.
• They can increase the effectiveness of
certain barrier methods of contraception
such as a diaphragm.
• However, they don't provide reliable
contraception when used alone.
06/08/2023 289
E. The IUD
• An IUD - also known as a Coil - is a small plastic and
copper device, usually shaped like a 'T', which is
fitted into the woman's uterus by a doctor using a
simple procedure.
It works by preventing an egg from settling in
the womb.
An IUD can stay in place for five years -
sometimes for 12.
It can also be used as an emergency method of
contraception within five days of unprotected
intercourse.
06/08/2023 290
Cont…
• Advantages:
no need to think about it once it is in place and
it last for a long time.
• Considerations:
There is a higher risk of infection for women
with more than one partner.
It may cause heavier, more painful periods.
• Effectiveness: 98%-99%.
06/08/2023 291
Cont…
• Works primarily by causing a chemical
change that damages sperm and egg
• Gives Long-term pregnancy protection(for
12 years)
• Immediately reversible
• One of the most effective and long-lasting
methods
– 6 to 8 per 1,000 women
06/08/2023 292
Cont…
Side Effects
 Changes in bleeding patterns (especially
in the first 3 to 6 months)
Prolonged and heavy monthly bleeding
Irregular bleeding
More cramps and pain during monthly
bleeding
06/08/2023 293
F. VAGINAL SPONGE
• Vaginal contraceptive sponges are soft
synthetic sponges saturated with a spermicide.
Prior to intercourse, the sponge is
moistened, inserted into the vagina, and
placed over the cervix .
After intercourse, the sponge is left in
place for 6 to 8 hours.
• It is quite similar to the diaphragm as a barrier
mechanism.
06/08/2023 294
Cont…
• About 18 to 28 pregnancies occur over one
year for every 100 women using this method.
• The sponge may be more effective in women
who have not previously delivered a baby.
• This method was removed from the U.S.
market, but plans are underway to re-introduce
it in the near future.
06/08/2023 295
2. Hormonal family planning
methods
These includes:-
Skin patch
Vaginal ring
Pills ( Combined & Minipill )
Injection
Implant
06/08/2023 296
A. Contraceptive skin patch
• The Contraceptive Patch looks like a square
band-aid.
It is applied to the abdomen, buttocks,
upper arm, or upper torso(the upper part
of the human body, not including the head
and arms).
The Patch is changed each week for a
schedule of 3 weeks on and 1 week off.
06/08/2023 297
Cont…
• It works by slowly releasing a combination of
estrogen and progestin hormones through the
skin.
• These hormones prevent ovulation (release of
an egg from the ovary) and thicken the
cervical mucus, creating a barrier to prevent
sperm from entering the uterus.
06/08/2023 298
Cont…
• Effectiveness: When used correctly, it’s about
99% effective as birth control except for
women weighing 198 pounds(1 pound=0.37kg) or
more when it is only about 92% effective.
06/08/2023 299
B. Vaginal Ring
• A soft, flexible vaginal ring, which is about 2
inches in diameter, delivers low doses of
estrogen and progestin into the body.
This helps prevent pregnancy by
suppressing ovulation and thickening the
cervical mucus, which helps block sperm
from entering the uterus.
06/08/2023 300
Cont…
• The ring is inserted into the vagina and left
for 3 weeks. It is then removed for 1 week,
during which a woman menstruates, and a
new ring is inserted after the 1-week
"break."
• The vaginal ring is at least 98 percent
effective with perfect use, which refers to
always correct and consistent use.
06/08/2023 301
C. Combined Oral Contraceptives(COC)
This is the most common type.

• It contains two hormones - estrogen and
Progesterone
These hormons prevent an egg from being
released from a woman's ovary each
month(0vulation).
06/08/2023 302
cont….
Advantages:
the pill does not interfere with the spontaneity
of sex.
There is No delay for fertility to return
COCs are safe and Suitable for Nearly All
Women
With some exceptions
can reduce pre-menstrual syndrome (PMS)
and period pain.
it also offers some protection against cancer of
the uterus and ovaries
06/08/2023 303
Cont…
• A full medical history is essential as
this pill is not suitable for women who
have certain conditions such as
high blood pressure,
circulatory disease or
diabetes.
06/08/2023 304
Cont…
• Women over 35 who smoke or are very
overweight may be advised to choose
another method of contraception.
• There are several different types of pill so
if one does not suit then another might
06/08/2023 305
Cont…
• The combined pill is not reliable
if taken over 12 hours late or
if have vomiting and diarrhea, extra
protection is required.
• Some drugs like antibiotics can also affect its
reliability.
06/08/2023 306
Cont…
• Effectiveness:
99% if taken correctly.
• Bleeding changes are common but not harmful
• COCs are also called “the Pill,” low-dose
combined pills, OCPs, and OCs.
06/08/2023 307
D. Progestin-Only Pills
• Pills that contain very low doses of a progestin.
• Do not contain estrogen, and so can be used
throughout breastfeeding and by women who
cannot use methods with estrogen
• Progestin-only pills (POPs) are also called
“minipills” and progestin-only oral
contraceptives.
06/08/2023 308
Cont…
• Mechanism of action
 Work primarily by thickening cervical mucus
disrupting the menstrual cycle, including
preventing the release of eggs from the ovaries
It also makes the lining of the womb thinner,
to prevent it accepting a fertilised egg
06/08/2023 309
Cont…
Advantages:
 It does not interfere with the spontaneity of sex
It is good for women who are breast-feeding,
older women, smokers and others who cannot
use the combined pill.
It can also help with pre-menstrual syndrome
(PMS) and painful periods
06/08/2023 310
Cont…
Effectiveness:
98% if taken correctly
It must be taken at the same time each day or
at most within three hours of that time.
It will not work if taken over three hours late,
or if have vomiting and diarrhea, in these
cases extra protection is needed.
06/08/2023 311
Cont…
Side Effects: Some users report the following:
 Changes in bleeding patterns including:
– Frequent bleeding, Irregular bleeding, Infrequent
bleeding, Prolonged bleeding and No monthly bleeding
 Breastfeeding also affects a woman’s bleeding
patterns.
 Headaches, Dizziness, Mood changes, Breast
tenderness, Abdominal pain, and Nausea
06/08/2023 312
E. Progestin-Only Injectable
• The injectable contraceptives depot
medroxyprogesterone acetate (DMPA) and
norethisterone enanthate (NET-EN) each
contain a progestin
• Do not contain estrogen
• DMPA, the most widely used progestin-only
injectable, is also known as “the shot,” “the jab,”
the injection, Depo, Depo-Provera, Megestron,
and Petogen.
• Given intramuscularly
06/08/2023 313
Cont…
• Work primarily by preventing the release of eggs
from the ovaries (ovulation).
• Effectiveness depends on getting injections
regularly
• As commonly used, about 3 pregnancies per 100
women using progestin-only injectables over the
first year might occur.
06/08/2023 314
Cont…
• Bleeding changes are common but not
harmful.
• Typically, irregular bleeding for the first
several months and then no monthly
bleeding
06/08/2023 315
Cont…
Advantages:
unlike the pill don’t need to remember to
take a tablet every day.
Injections may reduce heavy or painful
periods and may give some protection
against cancer of the uterus.
06/08/2023 316
Cont…
• Disadvantages
Periods can become irregular or stop
altogether.
It can take over a year for fertility to return
to normal after stopping contraceptive
injections, so if patient is planning to start a
family in the near future, it may not be
suitable.
Gradual weight gain is common
06/08/2023 317
Cont…
• Effectiveness: 99%.
• Each injection lasts for 8-12 weeks.
•Some users report the following:
 Changes in bleeding patterns including:
– First 3 months: Irregular bleeding &
Prolonged bleeding
– At one year: No monthly bleeding,
Infrequent bleeding, Irregular bleeding
06/08/2023 318
Cont…
Weight gain
Headaches
Dizziness
Abdominal bloating and discomfort
Mood change
Less sex drive
06/08/2023 319
F. Implants
• Small plastic rods or capsules, each about the
size of a matchstick, those release a progestin
• Minor surgical procedure to place the implants
under the skin on the inside of a woman’s upper
arm
• Do not contain estrogen
• They are very effective for 3 to 7 years and
Immediately reversible
06/08/2023 320
Cont…
 Advantages:
 implants are a good method for women
who want a long-term contraceptive, as
each implant lasts for three years.
 Periods can become irregular or stop altogether.
 Effectiveness: 99%.
06/08/2023 321
Cont…
Mechanism of action:
•The hormone is slowly released into the body&
causes
– Thickening cervical mucus(prevent sperm from
reaching an egg )
– Disrupting the menstrual cycle(prevent
ovulation)
• Most effective and long-lasting methods
– 5 per 10,000 women
06/08/2023 322
Cont…
•Types of implants:
Jadelle: 2 rods, effective for 5 years
Implanon: 1 rod, effective for 3 years
Norplant: 6 capsules, labeled for 5 years of
use
06/08/2023 323
Cont…
• Side Effects
Changes in bleeding patterns
Headaches,
Abdominal pain,
Acne (can improve or worsen),
Weight change,
Breast tenderness,
Dizziness,
Mood changes and Nausea
06/08/2023 324
Side effects of Hormonal family
planning methods
 Nausea
 Weight gain
 Headache
 Breast tenderness
 Breakthrough bleeding/injectables
 Vaginal infections
 Mild hypertension
 Depression
06/08/2023 325
Absolute Contraindications of Hormonal
family planning methods
 Breast feeding
 Family history of CAD(Coronary artery disease)
 History of thromboembolic disease
 History of liver disease
 Undiagnosed vaginal bleeding
06/08/2023 326
Possible Contraindications of
Hormonal family planning methods
 Age > 40 years
 Breast or reproductive tract malignancy
 DM
 Elevated cholesterol and triglyceride
 High blood pressure
 Mental depression
 Migraine and other types of vascular headache
06/08/2023 327
Cont…
 Obesity
 Pregnancy
 Seizure disorders
 Sickle cell and or other
hemoglobinopathies
 Smoking
 Use of medication or drug with drug
interaction effect
06/08/2023 328
Emergency Contraceptive Pills
• Pills that contain a progestin alone, or a
progestin and estrogen together hormones and
copper T IUD
• Emergency contraceptive pills (ECPs) are
sometimes called “morning after” pills or
postcoital contraceptives
• Work primarily by preventing or delaying the
release of eggs from the ovaries (ovulation)
06/08/2023 329
Cont…
• Emergency contraceptive pills help to
prevent pregnancy when taken up to 5
days after unprotected sex.
• The sooner they are taken, the better
• Many options can be used as emergency
contraceptive pills.
06/08/2023 330
Cont…
• Progestin only pills and combined oral
contraceptives all can act as emergency
contraceptives
• No delay for return of fertility after taking
ECPs
06/08/2023 331
Emergency Contraceptive Pills
Some users report the following:
 Changes in bleeding patterns including:
– Slight irregular bleeding for 1–2 days after taking
ECPs
– Monthly bleeding that starts earlier or later than
expected
 In the week after taking ECPs: Nausea, Abdominal
pain, Fatigue, Headaches, Breast tenderness,
Dizziness, and Vomiting
06/08/2023 332
Surgical Methods (Surgical Sterilization)
• A permanent method of contraception

done both for men and women
– Vasectomy
– Tubal Sterilization
06/08/2023 333
Male sterilization
Vasectomy:-division or occlusion of the
vas deference prevents the passage of
sperms.
Methods:-
- Clips
- Diathermy
- Percutaneous injection of sclerosing agents or
occlusive substances.
06/08/2023 334
Cont…
• The success of the procedure is verified by the
absence of sperms from two consecutive samples
of ejaculate collected at least 4 weeks apart.
• Contraception must be continued until
confirmation of two negative semen results
has been achieved and this is achieved after 16-
18 weeks of performing the vasectomy.
06/08/2023 335
Female sterilization
• Female sterilization is done surgically by
blocking both fallopian tubes by three
ways:
Laparotomy minilaparatomy laparoscopy
• Laparotomy: Bilateral salpingectomy or
hysterectomy may be preferable when
there is a coexistent pathology while the
other two ways are more preferable, safe
and effective
06/08/2023 336
Cont…
• A number of chemical agents have been
tested for their ability to occlude the
fallopian tube when installed into the tube
either directly or transcervically via the
uterus. Inflammation and fibrosis result
and occlude the tubes.
• However, safety of sterilization has not yet
been determined so surgical method is
safer
06/08/2023 337
Cont…
• Methods of tubal occlusions:-
– Ligation by absorbable or non-absorbable
sutures the ends left free or buried in the
broad ligament or uterine cornue.
– Electrocautery:-Bipolar diathermy allows
only the tissue held between the jaws of the
forceps to be cauterized.
06/08/2023 338
Cont…
– Falope ring:- ring of silicone or rubber is
placed over a loop of the tube with a specially
designed applicator. This destroys 2-3 cm of
tube.
– Clips: - a variety of clips are available tlulka-
clemens clip (stainless steel and polycarbonal
and filshie clip) (titanium lined with silicon
rubber). Smaller length of the tube is
destroyed via this method.
06/08/2023 339
Cont….
• Laser; CO2 laser divides tube very cleanly but
may allow a high incidence of recanalization.
06/08/2023 340
TH
A NK
U!
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Reproductive health for 1 st

years level nurse

• RH: A state of complete physical, mental, and

• To ensure that comprehensive and factual

7. Promotion of healthy sexual development from

•A health indicator is usually a numerical

1. Total fertility rate

9. Low birth weight prevalence

15. Reported incidence of urethritis in men

Rationale for Defining Target

 Women of child-bearing age (15-49

3.Women as Family member

–Children whose mothers die are:-

These essential Services include:

• In 2005 more than 636,000 women died each

E.g. - Car accident

Health Promotion and Disease

Aims of delivery care are to achieve:

 To understand the concept, magnitude and effect of

• Women have a difficult time protecting

Delayed and Long Term Complications

 Refusal or anticipated refusal of consent

• Other HTPs that are prevalent in Ethiopia

 individual progresses from the point of initial

Infertility Prevention and

There are 3 types of RTIs:

 Over 340 million STIs occur each year

• Many different agents cause STIs, however,

 Many STIs can be identified and treated on the

• If only vesicular, recurrent & multiple ulcers:

Cipro 500 mg PO stat Metron 500 mg bid/7d

Doxy 100 mg PO bid/7d

• Pelvic Exam: Temperature, Palpate abdomen

• Indications for hospitalizations in PID

Cipro 500 mg PO stat OR Spect2 gm Ceftr 250 mg IV/IM OR

Metronidazole 500 mg bid for 14 days Plus

Metron 500 mg bid/14d OR

1. Spontaneous Abortion (miscarriage):

• In gestations of less than 10 weeks' duration,

After the first trimester

Mifepristone alone: 80% abortion rate

• First, give mifepristone tablets by mouth.

• Day 1 is defined as the day mifepristone is taken.

• Morbidity is a much more common consequence

A Ask clients about themselves. Help client talk about their

T Tell clients about choices. Depending on the clients need,

 Breast feeding  Barrier methods

Method)  Emergency contraception

Artificial contraception again can be classified

This is the most common type.

• A permanent method of contraception

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