Family Planning

Table of Contents

Family planning empowers individuals and couples to make informed decisions about:

  • Number of Children: How many children they want to have.

  • Timing of Births: When they want to have children.

  • Spacing of Births: How much time they want between pregnancies.

This ensures that each child is wanted and can be adequately provided for, including basic needs like health, education, and shelter. Family planning is about making choices based on desires rather than chance.

Benefits of Birth Spacing:

  • Mother’s Health: Allows for physical and mental recovery after pregnancy.

  • Child’s Health: Improves the well-being of children.

  • Father’s Well-being: Contributes to the overall health of the family.

Consent for Family Planning Services:

  • General Rule: No verbal or written consent is required from a parent, guardian, or spouse for an individual to receive family planning services.

  • Exception: Consent is required for individuals with incapacitation (intellectual disability).

  • Permanent Methods: Clients must provide written consent for permanent family planning methods.

Where to Access Family Planning Services:

  • Facility-Based Outlets:

    • Hospitals

    • Health Centers

    • Dispensaries

  • Outreach Services:

    • Mobile Clinics

    • Workplaces

  • Community-Based Outlets:

    • Community-Based Distribution points

    • Drug Shops

    • Dispensing Machines

  • **Social Marketing Initiatives

  • Private Sector Facilities:

    • Clinics

    • Maternity and Nursing Homes

    • Pharmacies

    • Drug Retail Shops

  • **Social Mobilization Events for Health Services

  • **Youth Clubs and Schools (through family life education)

  • Women’s and Men’s Organized Clubs/Groups

Counseling for Informed Choice:

  • Right to Information: All individuals seeking contraceptives have the right to accurate and adequate information about available family planning methods.

  • Purpose of Counseling: To enable informed decisions about starting and continuing family planning practices.

  • Individualized and Respectful Approach: Discussions between service providers and clients should be private, confidential, and conducted with dignity.

  • No Coercion or Incentives: The selection of a method should be free from pressure or rewards.

Initial Counseling Should Include:

  • Reproductive Goals: Discussing the client’s desires and plans for having children.

  • Prior Knowledge/Experience: Understanding the client’s existing knowledge and experiences with family planning methods.

  • Available Methods: Presenting the range of family planning options.

  • Mechanism of Action: Explaining how each method prevents pregnancy.

  • Effectiveness: Discussing the reliability of each method and factors that influence its effectiveness.

  • Method Failure: Explaining the possibility of the method not working.

  • Common Side Effects: Informing the client about potential side effects.

  • Follow-up: Explaining the necessary follow-up procedures for each method.

  • Accessibility: Providing information on where to obtain the chosen method.

  • Physical Examination: Explaining the importance of physical and pelvic examinations.

  • STI/HIV Awareness: Providing information on HIV/AIDS/STIs in relation to family planning.

  • HIV Testing and STI Screening: Offering information and services for these.

  • Cancer Screening: Discussing symptoms of breast and cervical cancer and available screening services.

  • Addressing Misconceptions: Clarifying any rumors or incorrect beliefs the client may have.

Subsequent Counseling Should Focus On:

  • Satisfaction and Problems: Reviewing the client’s experience with the chosen method.

  • Understanding of Instructions: Ensuring the client understands how to use the method correctly.

  • Addressing Rumors and Misconceptions: Correcting any ongoing misinformation.

  • Changes in Reproductive Goals: Discussing if the client’s family planning needs have changed.

  • STI/HIV/AIDS Counseling: Continued education and support.

  • Possible Method Failure: Reinforcing information about potential failures.

  • Cancer Screening Information: Reminding clients about symptoms and available services.

Other Important Counseling Situations:

  • Contraceptive Method Failure

  • Regret After Permanent Method

  • Cases of Rape or Defilement

  • Need for Referral for Appropriate Care

Screening for Contraceptive Use:

  • Timing: After thorough counseling, when the client is ready to choose a method.

  • Hormonal Methods: Clients choosing hormonal methods should have their health and social history taken and a physical assessment performed.

  • Purpose of Assessment: To rule out contraindications for method use.

  • Simplified Screening: For oral contraceptives and Depo Provera, a qualified staff member can use a standard checklist for initiation or resupply when a full physical assessment isn’t necessary or possible.

  • Communication: Important findings should be communicated to the client for clarification.

  • Documentation: Findings should be recorded according to guidelines.

  • Routine Physicals: While not mandatory for oral contraceptives and Depo Provera initiation/resupply, they are valuable for reproductive health and ruling out contraindications or infections/cancer.

  • Referral: If necessary tests can’t be done at the clinic, clients should be referred to an equipped facility.

Importance of Family Planning:

  • To the Mother:

    1. Physical and mental recovery after pregnancy.

    2. Time for productive activities (e.g., work, business).

    3. Strengthened bond with the baby.

    4. Reduced maternal mortality and morbidity.

    5. Promotes happy marital life without fear of unwanted pregnancy.

  • To the Child:

    1. Adequate emotional and social support.

    2. Proper nutrition during pregnancy leading to a healthy newborn.

    3. Reduced risk of malnutrition due to appropriate weaning and sufficient food.

    4. Fewer infections due to stronger immunity.

  • To the Father:

    1. Reduced domestic violence.

    2. Increased ability to meet basic needs.

    3. Reduced cost of living, allowing for investment.

  • To the Community:

    1. Healthy and productive citizens, leading to stability and harmony.

    2. Reduced overcrowding, allowing for better land use.

    3. Increased socio-economic development.

    4. Fewer social problems like street children.

  • To the Nation:

    1. Reduced rapid population growth.

    2. Decreased dependence on foreign aid.

    3. Improved ability of the government to provide social services and infrastructure.

    4. Easier resource budgeting.

Available Family Planning Methods in Uganda:

  • Natural/Traditional Methods:

    • Calendar/Rhythm Method

    • Basal Body Temperature

    • Cervical Mucus Method

    • Lactation Amenorrhea Method (LAM)

    • Abstinence

    • Withdrawal/Coitus Interruptus

  • Artificial Methods:

    • Barrier Methods:

      • Spermicides

      • Condoms (Male and Female)

      • Intrauterine Contraceptive Devices (IUCDs)

      • Diaphragm

    • Hormonal Methods:

      • Oral Pills:

        • Combined Oral Contraceptives

        • Progesterone-Only Pills

        • Emergency Contraceptive Pills

      • Implants:

        • Implanon (1 rod)

        • Jadelle (2 rods)

        • Norplant (6 rods – less common now)

      • Injectable Contraceptives:

        • Depo Provera

        • Injector plan

        • Sayana Press

        • Noristerat

    • Permanent Methods:

      • Tubal Ligation (Tubectomy) for women

      • Vasectomy for men

Natural Methods of Family Planning (Fertility Awareness Methods):


  • Basis: Understanding the fertile window based on sperm (24-hour lifespan) and egg (48-hour lifespan) viability, and the timing of ovulation.

  • General Advantages:

    1. Safe, with no side effects.

    2. Inexpensive.

    3. Acceptable to some religious and cultural groups.

    4. Educates women about their menstrual cycle and fertility.

    5. Gives couples control.

    6. Can help in planning pregnancy.

  • General Disadvantages:

    1. Requires substantial education and practice.

    2. Difficult to use with irregular periods.

    3. Requires adjustments to sexual behavior.

    4. Requires cooperation between partners.

    5. Does not protect against STIs/HIV/AIDS.

  • Specific Fertility Awareness Methods:

    • Basal Body Temperature (BBT)

    • Cervical Mucus Method

    • Symptom-Thermal Method (combining BBT and cervical mucus)

    • Calendar (Rhythm) or Standard Days Method

  • Requirement: Special training from a trained counselor is needed.

  • Indications (When these methods might be suitable):

    • Motivated individuals/couples willing to track fertility signs daily.

    • Those with religious or other objections to modern methods.

    • Individuals unable to use other methods due to health reasons.

    • Couples willing to abstain or use barrier methods during fertile periods.

  • Contraindications (When these methods might be difficult):

    • No medical conditions are worsened by these methods.

    • However, conditions that make tracking difficult require special counseling:

      • Breastfeeding (especially before menses return).

      • Less than three postpartum menstrual cycles.

      • Irregular vaginal bleeding.

      • Abnormal vaginal discharge.

      • Illnesses that elevate body temperature.

Calendar/Rhythm Method

This method is the only one approved by the Roman Catholic Church.

To effectively use the calendar/rhythm method, a woman needs to maintain an accurate record of her menstrual cycles for approximately 6 to 8 months prior to starting.

The typical failure rate for this method ranges between 20% and 30%.

The calendar/rhythm method is based on identifying “safe days,” which are the days in a woman’s cycle when the chance of conception is lowest.

To utilize this method, the woman must provide a record of her menstrual cycles to a healthcare worker, who will then assist with the necessary calculations outlined below.

 

Calculating the Fertile Period

The fertile period represents the portion of a woman’s menstrual cycle when she has the highest likelihood of conceiving.

Procedure:

  1. Record Cycle Length: Document the duration of each menstrual cycle. The length of a cycle is calculated from the first day of one menstruation period to the first day of the following menstruation period.

  2. Identify Shortest and Longest Cycles: Determine the shortest cycle (the one with the fewest days) and the longest cycle (the one with the most days) from the recorded data.

  3. Calculate First Fertile Day (FFD): Subtract 18 from the number of days in the shortest cycle. The number 18 accounts for the estimated survival time of sperm (approximately 2 days).

  4. Calculate Last Fertile Day (LFD): Subtract 11 from the number of days in the longest cycle. The number 11 considers the estimated survival time of an ovum (egg) (approximately 1 day).

Examples:

Example 1:

A woman with a regular 28-day menstrual cycle visits a family planning clinic and chooses the calendar method. To initiate the method, the following calculation is performed:

  1. Record the length of each menstrual cycle: In this case, the cycle length is consistently 28 days.

  2. Identify the shortest and longest cycles: Since the cycle is regular, the shortest cycle is 28 days, and the longest cycle is also 28 days.

  3. Calculate the first fertile day (FFD): 28 days (shortest cycle) – 18 = 10th day.

  4. Calculate the last fertile day (LFD): 28 days (longest cycle) – 11 = 17th day.

Interpretation: This woman is most fertile between the 10th and 17th days of her menstrual cycle.

Comments/Remarks: It is recommended that this woman avoid sexual intercourse between the 10th and 17th days of her cycle to prevent pregnancy. Using condoms or another form of contraception as a backup method during this time is also advisable.

Example 2:

A woman with irregular cycles has a shortest cycle of 25 days and a longest cycle of 32 days. To calculate her fertile period:

Solution:

Given: Shortest cycle = 25 days; Longest cycle = 32 days.

Therefore:

  • First Fertile Day (FFD): Shortest cycle – 18 = 25 – 18 = 7th day.

  • Last Fertile Day (LFD): Longest cycle – 11 = 32 – 11 = 21st day.

Interpretation: This woman is most fertile between the 7th and 21st days of her menstrual cycle.

Recommendation: She should avoid sexual intercourse between the 7th and 21st days of her cycle to prevent pregnancy. Consistent use of condoms or another family planning method as a dual or backup method is highly recommended.

Self-Help Assessment:

Demonstrate your ability to calculate and interpret the fertile period for the following clients:

  • A client with a regular 29-day cycle.

  • A client with irregular cycles of 24 and 30 days respectively.

  • A client with a regular 27-day cycle.

Advantages of the Calendar/Rhythm Method:

  1. No Cost: There are no direct financial costs associated with this method.

  2. No Side Effects: This method does not involve any physical interventions or hormonal changes, thus having no direct physical side effects.

  3. Refer to general advantages of natural methods of family planning.

Disadvantages of the Calendar/Rhythm Method:

  1. Difficult to Calculate Reliably: Accurately predicting the fertile period can be challenging, especially with irregular cycles, leading to a higher risk of unintended pregnancy.

  2. Requires Several Months of Training: Effective use requires careful tracking and understanding of menstrual cycles over several months.

  3. Compulsory Abstinence: Requires abstaining from sexual intercourse during the calculated fertile period, which can be demanding for some couples.

  4. Not Applicable During Lactation Amenorrhea: Irregular cycles common during breastfeeding make this method unreliable during lactation.

  5. Does Not Protect Against STIs: This method does not offer any protection against sexually transmitted infections, including HIV/AIDS.

Lactation Amenorrhea Method (LAM)

Immediately following childbirth, a period of naturally reduced fertility occurs, which can be extended through regular breastfeeding. Prolactin, the hormone responsible for milk production, also plays a key role in suppressing fertility during this time.

The impact of breastfeeding on reducing fertility is well-established. LAM serves as a temporary (short-term) method of contraception. It is highly effective (approximately 98%) for the first six months postpartum, provided the woman is fully breastfeeding and remains amenorrheic (without menstruation).

In mothers who are not breastfeeding, prolactin levels gradually decline within weeks after delivery, typically returning to normal levels around 4 weeks postpartum.

Regular nipple stimulation through frequent suckling is essential to maintain milk production and the effectiveness of the lactation amenorrhea method.

LAM’s effect can potentially last up to 24 months due to consistent prolactin release, which inhibits ovarian function.

The Lactation Amenorrhea Method is considered about 98% effective when all three of the following criteria are met:

 

Indications (Criteria for Effective Use):

  1. Fully Breastfeeding: The woman is exclusively breastfeeding her baby.

  2. Amenorrheic: The woman has not experienced the return of her menstrual periods.

  3. Baby’s Age: The baby is less than six months old.

What Constitutes Fully Breastfeeding:

  • Breastfeeding the baby whenever the baby wants (on demand), with feeds occurring at least every four hours during the day.

  • Including nighttime feedings, with feeds occurring at least every six hours at night.

  • Not supplementing breast milk with other foods or drinks.

Who Cannot Use LAM/Contraindications:

  1. Women whose menstrual periods have returned.

  2. Women whose babies are six months old or older.

  3. Women who have started introducing supplementary feedings to their babies.

Note on HIV: Women with HIV should receive counseling about infant feeding options to minimize the risk of mother-to-child transmission and be supported in their chosen feeding method. Women who do not have reliable access to safe alternative feeding options should be encouraged to exclusively breastfeed for the first six months.

 

Standard Days Method (Moon Beads/Cycle Beads)

The Standard Days Method® is a fertility awareness-based family planning method designed for women with menstrual cycles that consistently fall between 26 and 32 days in length. This method identifies a fixed fertile window, which is days 8 through 19 of the cycle.

To use this method, a woman simply tracks the start date of her period and the current day of her cycle to determine if she is within the potentially fertile days.

 

What are Moon Beads?

Moon beads (also known as cycle beads) are a string of colored beads designed to help track the menstrual cycle.

The different colors of the moon beads provide a visual guide to help a woman identify the days when she is most likely to get pregnant and the days when pregnancy is less likely.

To prevent pregnancy using this method, a woman should avoid sexual intercourse or use a barrier method of contraception during the days indicated as fertile (white beads).

Note: When used correctly and consistently, the Standard Days Method is about 95% effective. This means that approximately 5 out of 100 women may become pregnant in a year despite using the method correctly.

 

Modes of Action:

If a woman wishes to prevent pregnancy using the Standard Days Method, she should abstain from intercourse or use a backup contraceptive method, such as condoms, during her fertile days (days 8-19). The patented CycleBeads® tool assists women in using this method by visually tracking their cycle, identifying fertile and non-fertile days based on the start date of their period, and confirming whether their cycle length falls within the effective range for this method.

 

Moon Beads and the Menstrual Cycle:

Moon beads visually represent a woman’s menstrual cycle. Each bead on the string corresponds to one day of the cycle.

Note: It’s important to distinguish between the menstrual cycle and a woman’s period (menstrual bleeding). The period refers specifically to the days of bleeding, while the menstrual cycle encompasses all the days from the start of one period to the day before the start of the next period.

 

Indications/Eligibility/Who Can Use It:

  1. Couples who have good communication and agree to avoid unprotected sex during the woman’s fertile window.

  2. Women who have found other modern contraceptive methods unsuitable.

  3. Women whose menstrual cycles are consistently between 26 and 32 days long.

Advantages of the Standard Days Method:

  • Refer to general advantages of natural methods.

  • More than 95% Effective: When used correctly and consistently for eligible women.

  • Side-Effect Free: As a natural method, it does not involve hormonal or physical interventions.

  • Easy to Use: The moon beads provide a simple visual aid for tracking.

  • Inexpensive: The cost of the moon beads is generally low.

  • Educational & Empowering: Helps women understand their menstrual cycles better.

How to Use Moon Beads:

  1. On the first day of your period (when menstrual bleeding begins), move the rubber ring on the moon beads to the RED bead.

  2. Also, mark this day on a calendar if desired.

  3. Move the ring one bead forward each day.

  4. Avoid unprotected sexual intercourse when the ring is on any of the WHITE beads, as these are your fertile days. Pregnancy is possible on these days.

  5. You can have unprotected sexual intercourse when the ring is on any of the BROWN beads, as you are less likely to get pregnant on those days.

  6. When your next period starts, move the ring back to the RED bead, skipping over any remaining beads.

When to contact the healthcare provider

1. Had unprotected sex on a WHITE bead If she thinks she might be pregnant because she has not gotten her period.
2. If she gets her period before she reaches the DARK BROWN beads, this means that her cycle is shorter than 26 days.
3. If her period does not start by the DAYAFTER she reaches the last brown bead, this mean that her cycle is longer than 3

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Diploma in Midwifery