DOW UNIVERSITY OF HEALTH SCIENCES

INSTITUTE OF NURSING & MIDWIFERY

UNIT : VI

FAMILY PLANNING
Year 3 ,Semester V

Modified by: Farhana Nisar

Acknowledge: Misbah Khan
( Lecturer, DION&M)

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 Objectives
At the end of this unit, learners will be able to:

1. Describe the consequences of population growth in Pakistan.

2. Identify Family Planning (FP) services available in Pakistan.

3. Identify social, economic, political and religious aspects of FP in Pakistan.

4. Discuss the responsibilities / role of a nurse for Family Planning.

5. Describe the indications, contraindications, advantages and side effects of

different contraceptive methods.

6. Discuss the importance and steps of counseling skills

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Family Planning
• Family planning is a way of thinking and living that it is adopted voluntarily,
upon the basis of knowledge, attitude and responsible decision by
individuals and couples in order to promote the health and welfare of
family group and thus contribute effectively to social development of a
country”( WHO, 1971)

• Family planning allows people to attain their desired number of children, if

any, and to determine the spacing of their pregnancies.

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Objectives of Family Planning
• Family planning refers to practice that help individuals or couples to attain
certain objectives( WHO 1971) given below:

i. To avoid unwanted births.

ii. To bring about wanted births.
iii. To regulate the intervals between pregnancies.
iv. To control the time at which birth occur in relation to the age of the
parents.
v. To determine the number of children in the family.

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 Consequences of Population
Growth In Pakistan
• Pakistan’s total population is 177.1 million, up from 173.5 million the
previous year, according to the Pakistan Economic Survey 2010-11.
Pakistan ranks sixth among the world’s most populous countries, with a
population growth rate of 2.1 percent.

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 Consequences of Population
Growth In Pakistan
The major effects and explosion of population in Pakistan are:
– Low standard of living, in spite of five year plans.

– Shortage of food is one of the cause of malnutrition.

– Old persons have a work beyond the age of retirement.

– Young person work at the cost of education.

– Unemployment, housing and law and order problems.

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 Family Planning (FP) Services Available
In Pakistan
• Family planning services address public health challenges by providing

education, counseling, and medical services . Family planning services

include the following:

– The proper spacing and limitation of birth.

– Education for parenthood.

– Screening for pathological condition related to the reproductive system.

– Genetic counseling.

– Premarital consultation and examination.

– Carrying out pregnancy test.

– The preparation of couples for arrival of first child. 7

 Role of Nurse in Family Planning
• The community health nurse can educate the family and the eligible couples
on advantages of a planned family.
• The role of nurses in family welfare program will include in:
 Administrative Role: nurses participate in the organization of family welfare
program at national, regional or community level and in development of
nursing activities within the framework of these programs.
 Supervisory Role :Community health nurse should encourage their staff to
watch carefully for indication that mother or couples would accept advice on
how to space their children and so on.

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Role of Nurse in Family Planning
 Functional Role: finding eligible couples and making referral to adopt
suitable family planning method, and also help the client to choose one of
the simple and suitable method of contraception.
 Educational Role : All nurse have an education role to fulfill with their
patient and the community.
 Role of Research: Nurse are essential members of multidisciplinary
research team and then nursing as a science or practice provides valuable
data upon which research may be based.
 Role of Evaluation : Evaluation is an important part of planning of nursing
services including those related to regulation of fertility and should be
build into the plan as it is being formulated.
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 Contraceptive Method
• Contraception is defined as the intentional prevention of conception
through the use of various devices, sexual practices, chemicals, drugs, or
surgical procedures.
• The contraceptive method can be divided as :

– Temporary method(spacing )

– Permanent method (terminal)

Note: No single method of birth control is the “best” one. Each has its
own advantages and disadvantages. Abstinence is the only 100%
effective way to prevent pregnancy and STD’s

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 Methods of Family Planning

Natural Methods Modern Methods

LAM Terminal method

Abstinence Spacing method
SDM

Tubal Ligation Vasectomy

Hormonal
Non-Hormonal

Pills Implants Barrier IUCD

Injectable

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 Methods of Contraception
There are two types of contraception.

1. Reversible/ Temporary methods

• Natural Family Planning methods
• Barrier Methods
• Hormonal Family Planning methods

2. Permanent/ surgical methods

• Tubal Ligation & Vasectomy

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 Natural
Family Planning
Methods

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 Natural Method
• No introduction of chemical of foreign material into the body.
• Effectiveness varies greatly, depends on couples ability to refrain from
having intercourse on fertile days.
Natural Method includes:
 Lactation Amenorrhea
 Rhythm (Calendar) method/SDM
 Basal Body Temperature (BBT)
 Ovulation or Cervical Mucus Method
 Symptothermal method
 Coitus Interruptus

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 Lactational Amenorrhea Method
(LAM)
• For breastfeeding mothers
• Works primarily by preventing the release of eggs from the ovaries (ovulation).
• During breast feeding Prolactin increase & FSH and LH not release.
• During breast feeding periods not come called lactating amenorrhea.
• No FSH and LH no ovulation so no pregnancy.
• During exclusive breast feeding 90% no chance of having pregnancy.
• After exclusive feeding 50% reliable.

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Advantages & Disadvantages Of Breast Feeding
Advantages Disadvantages
High immunity power of baby. 90% reliable for starting 6 month.

Good health & high IQ Level of baby.
Require no medical supervision.
No cost is involved.
Good for areas where f/p services are
not available.
Baby may be malnourish because the
woman want family planning.
Woman may be pregnant and know
after 4 to 5 month that she is pregnant
when she feel quickening.

An acceptance method for those

couple who can not use any
contraceptive due to the religious
believe.

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 Standard Days Method
• Also known as Rhythm method/ Fertility awareness method.
• Natural method with no side- effects
• Keep track of the days of the menstrual cycle
• Day 8–19 of the cycle is considered to be the fertile days
• This method may be used by women whose cycles are always regular and
between 26 and 32 days in length.

Disadvantage:

• Not reliable method for women with irregular cycles.

• sperm live for 3–5 days in the female reproductive system, for example, means
you could have sex several days before your partner ovulates and still result in a
pregnancy.

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18
 Safe Period
 There are certain days in the monthly cycle of a woman when there is
no free female egg in the woman body.
 This mean it has either not been release from the ovary or it was
release but died.
 During this eggless days a woman can not be pregnant.

 Not suitable for the woman who does not have regular periods.

 Require self control during the highly unsafe period.

 Life of sperm = 72 hours

 Life of ovum =48 hours.

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There are total 3 methods to find out the safe period.
 Calendar method.
 BBT (Basal Body Temperature).
 CMM (Cervical Mucous Method).

 From these use any two.

 If female is educated use calendar and BBT.
 If female is not educated use calendar and CMM.
 Require 3 month to find out safe period.

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 Calendar Rhythm Method
• Also known as Rhythm method/ Fertility awareness method/Standard Days
Method.
• Require next 6 month calendar.
• A woman keeps a record of the monthly period for 6 months, then subtract 18
days from the shortest cycle & 11 days from the longest cycle.
Shortest cycle 26 – 18 = 8
Longest cycle 30 – 8 = 19
This means that from the 8th to the 19th day of each cycle is the “Unsafe period” or
“Fertile Period”.

Remember: she should abstain from sexual intercourse on her “Fertile Days”

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 Basal Body Temperature Method
 Take a body temperature once a daily continue 3 month and note it down.

 Identify fertile and infertile period of a woman’s cycle by daily taking and
recording of the rise in body temperature during and after ovulation.
 Just before ovulation, a woman’s BBT falls about 0.5°F

 At time of ovulation, her BBT rises a full degree (influence of progesterone).

 Disadvantage:

 Not reliable method for women with irregular cycles.

 Other factors may cause a woman’s temperature to vary.

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 Cervical Mucous Method

• Cervical mucus is a fluid produced by small glands near the cervix

• This fluid changes throughout her cycle, from scant and sticky, to cloudy
and thick, to slick and stringy.
• After menstrual period normally watery discharge occur, that is normal.
 After this watery discharge change into sticky mucous, note this period
mean when sticky discharge come.
 This gum like discharge show the ovulation period.

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 Advantages & Disadvantages Of Safe
Period
Advantages Disadvantages

Better than nothing. Not highly reliable.

No medical supervision. Not suitable for the woman who

does not have regular periods.
No any cost required.
Require self control during the highly
Acceptable for religious person. unsafe period.

Any personal tension could change

the body mechanism and cycle disturb
in this condition this method can be
fail.

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 Abstinence
• Abstinence is when partners do not engage in sexual intercourse

• Continuous Abstinence is the only 100% effective in preventing

pregnancy.
• There are no side effects.

Advantages Disadvantages
Better than nothing Not highly reliable.

No medical supervision. Complete abstinence for 12 month.

No any cost required A whole year control or avoid can

become useless by one sexual
Acceptable for religious person. intercourse during the unsafe period.

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 Withdrawal Method
Removal of penis from the vagina before ejaculation occurs.
Advantages Disadvantages
Require no medical supervision. Not very reliable because if the man
does not separate in time and even one
No cost is involved. drop of semen is deposit inside, it has
enough sperms to make the woman
It is better than not using anything. pregnant.

Good for areas where f/p services are The man need a high degree of self
not available. control.

An acceptance method for those
couple who can not use any
contraceptive due to the religious
believe.
Since it is directly related to the sex
act the couple can not relax and enjoy
the intercourse.
There some time it is not a very
acceptable.

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 Barriers
Family Planning
Methods

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 Barrier Contraceptives
• Methods that physically or chemically block sperm from reaching an egg and
provide a BARRIER
• Barrier methods have higher failure rates than hormonal methods due to
design and human error.
 PHYSICAL
• Condoms (male and female)
• Diaphragm
• Cervical cap

 CHEMICAL
• Spermicidal, creams,
• Vaginal tablets

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 Physical Methods
• The condom, diaphragm, cervical cap are called physical barrier because they
are thing or object have no medicine, chemical or hormones.

1. Condom
• Most common and effective barrier method of F/P.
• A flexible sheath, usually made of thin rubber or latex, designed to cover the
penis or vagina during sexual intercourse for contraceptive purposes or as a
means of preventing sexually transmitted diseases.
• There are two type of condom male and female.

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 Male Condoms
• Male condoms are 82 to 98 percent effective at preventing pregnancy
• Condoms can only be used once

Female Condoms
• Female condoms are 79 to 95 percent effective

• Worn by the woman, this method keeps sperm from getting into her body

• It can be inserted up to eight hours before sexual intercourse (though not

necessary)

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 Advantages & Disadvantages Of Condom
Advantages
Inexpensive & Easily available.
Usually no side effect.
Need no medical supervision.
Provide a lot of protection for the
couple who can not get other
contraceptives because there are no
F/P services available.
Prevent from HIV, AIDS, STDs, Hep B
&C
Disadvantages
Not highly reliable it can be rupture
and cause pregnancy.
It is directly connected with sexual
act and interrupts the sexual mood.
It decrease sensation and thus
decrease pleasure hence not
acceptable to some couple.
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 2. Diaphragm
• The diaphragm is a form of female contraception
• It prevents pregnancy by creating a barrier between a woman’s uterus and a
man’s sperm.
• A diaphragm is a reusable dome-shaped cup. It fits over the opening of the
cervix. It is common to use a diaphragm with spermicidal. This is a gel, cream,
or foam that kills sperm.
• It should be inserted immediately prior to intercourse and should be remove
no earlier than 6 hours later.

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 3. Cervical Cap

 The cervical cap is a birth control (contraceptive) device that prevents

sperm from entering the uterus.
 The cervical cap is a reusable, deep silicone cup that is inserted into the
vagina and fits tightly over the cervix.

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Diaphragm

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43
 Hormonal
Methods
of
Family Planning
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 Hormonal Methods
• NO hormonal methods reduce chances of STD’s!
• Methods that prevent the release of an egg (ovulation)
• Prevents a fertilized egg from implanting in the uterus (prevents
pregnancy).

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Hormonal Methods

Mode of Action: Make the endometrium less

suitable for implantation.

Inhibit
Thicken cervical ovulation
mucus 46
 Hormonal Methods of Family Planning
These methods contain hormones, called estrogen and progestin, that are similar
to the estrogen and progesterone a woman makes in her own body.

It Includes:
 Oral Pills (takes every day)
 Progestin-only pill
 Combine oral pill
 ECP (Emergency contraceptive pills).

 Injectable contraceptives (given every few months)

 Progestin injectable contraceptives (CICs)
 Combine injectable contraceptives (CICs)

 Sub Dermal Implant (Norplant and implanon)

Put into a woman’s arm and last for several years.
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Combined Hormonal Contraception(CHC)
• CHC contains a combination of two hormones: a synthetic estrogen and
progesterone.
• CHC come in differently forms:
– Pills
– Transdermal patch
– Vaginal ring

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Combined Oral Contraceptives pills
(COCP)
• Some contain estrogen, progestin, or mix of other hormones depending

on pill.

• The pill is 91 to 99 percent effective at preventing pregnancy.

• Prescribed by doctor

• COCPs should be taken on 1st day of the cycle, at roughly the same time

each day.

• A pill is taken at the same time each day (once a day for three weeks, no

pill fourth week -will get menstrual period)

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Combined Oral Contraceptives pills
(COCP)

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 The Emergency Contraceptive Pill
(ECP)
• Also known as the “morning after pill”and “postcoital contraception”

• It is used after intercourse has taken place and before implantation has
occurred.
• The ECP is taken after unprotected sex within 72 hours (three days) to prevent
pregnancy.
• Effectiveness decreases after 24 hours

• Emergency contraception should only be used after no birth control was used
during sex, or if the birth control method failed, such as if a condom broke

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Contraindication of Contraceptive Pills
The pills are not suitable for women who have history of/ or suffering from
any of the following disease:

 Migrain Headache
 High Blood Pressure
 Pregnancy
 Breast Lumps/ Cancer
 Abnormal/ Unexplained vaginal bleeding
 DVT
 IHD & Valvular heart disease
 Epilepsy or Cerebral stroke
 Fibroid (Tumor)
 Blood disorders

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Advantages & Disadvantages Of Contraceptive Pills
Advantages Disadvantages

 If taken regularly and correctly it is an It needs daily efforts.

almost 100% reliable contraceptive.
 The pill is contraindicated in certain
 Easily Reversible. health conditions.

 Regulates Periods.  for a very small number it is risky

to take the pills.
 Reduce or eliminates Period pain.
 it Does not protect against STDs &
 Periods are shorter and less heavy. AIDs.

 Sometimes the facial skin become

clearer & acne is improved.

Easy to use.

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 Combined Hormone Transdermal
Patch
• The regimen is same as for COCP i.e.21 days of application followed by 7 day

hormone free interval.

• The patch is 91 to 99 percent effective at preventing pregnancy

• It releases hormones progestin and estrogen into the bloodstream

• You put on a new patch once a week for three weeks. During the fourth

week, you do not wear a patch, so you can have a menstrual period

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 Combined Hormone Transdermal
Patch
• Patch application sites:
– Any skin area- lower abdomen, buttocks, arms
• Site contraindication: Breast

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Combined Hormonal Vaginal Ring
• The birth control ring releases the hormones progestin and estrogen
• It is worn in vagina for 21 days followed by 7 day hormone free interval.
• It is 91 to 99 percent effective at preventing pregnancy
• Ring goes inside vagina up around your cervix
• You wear the ring for three weeks, take it out for the week you have your
period, and then put in a new ring
• This method does not protect you from HIV or other STDs.

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 The Injectable Hormonal Contraceptive
• In this family planning method, a woman is given injections of hormones every
1 to 3 months, usually at a health center or family planning clinic. The
protection lasts until you need a new injection.

Injection with one hormone:

• Progestin-only injections (PIC): contain only the hormone progestin. These are
especially good for women who should not use estrogen.
Example:
1. Depo Provera (DMPA): 150mg given IM every 12 weeks.
2. Norigest (NET-EN): 200mg given IM every 8 weeks.
Mechanism of action : inhibit ovulation
Injection frequency : 12- 14 weeks
Bleeding pattern : 50% amenorrhea rates at 1 year.

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Injection with Two Hormone:
• Combine injectable contraceptives (CICs): contain both estrogen and
progestin. This type of injection is good for women who want to have
regular monthly bleeding. Combined injections are given every month, are
more expensive than progestin-only injections, and are harder to find.
Example:
1. Mesigyna (Net-EN/ Estradiol Valerate): IM once a month.

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Advantages & Disadvantages Of Hormonal
Injections
Advantages
Very Effective
Highly reliable
8 to 12 weeks of protection with one
injection.
No daily effort is required.
It can be discontinued without a need
for a clinical procedure.
Disadvantages
The monthly periods become
irregular & sometimes don't come.
 After stopping the injection, it can
take between 6 to 18 months for the
women to become pregnant.
 it Does not protect against STDs &
AIDs.
Weight gain in first year
Decrease bone mineral density
(BMD)
Delayed in return of fertility of
around 6 months-1 year.
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 Sub Dermal Implants
• Implants are small, soft tubes that are placed under the skin on the inside of a
woman’s arm. These tubes contain the hormone progestin and work like
minipills.
There are 2 type of implants:
 Norplant (6 rods effective for 5 year)

 Implanon (1 rod effective for 3 year)

• They prevent pregnancy for 3 to 5 years, depending on the type of implant.

• A trained health worker makes a small cut in the skin to insert and remove the
implants. This is usually done at a clinic or family planning center.
• Implants can be used by women who are breastfeeding and others who have
problems with estrogen. 61
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63
 Advantages & Disadvantages Of
Contraceptive Pills
Advantages
 Almost 100% reliable.
Breast feeding mothers can also use it. months.
No daily effort is required.
Can prevent pregnancy for years.
No connected with sex act
Can be taken out any time when
couple decides to have a baby.
Return to fertility within 3 months.
Disadvantages
Some women experience irregular
or longer menstrual cycle in the first 6
Its insertion & removal have to be
done in a clinic by a trained health
care provider.
Slight bruising or pain of insertion
 It Does not protect against STDs &
AIDs.
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Side Effect Of Hormonal Contraception

 Weight gain.
 Acne
 Headaches and migraine.
 Nausea
 Irregular periods.
 Breast tenderness
 Mood changes.
 Missed periods.
 Decreased sexual desire.
 Changes in eyesight.
 Hirsutism.
 Increase in appetite.
 Increase in body temperature.

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 Intrauterine
Contraceptive
Device
(IUCDs)

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 Intrauterine Contraceptive Device
• Intrauterine contraceptive device (IUD) A device inserted into the uterus
(womb) to prevent conception (pregnancy).
• The IUD can be a coil, loop, triangle, or T-shape. It can be plastic or metal.
• An IUD is inserted into the uterus by a health-care professional.

• After fertilization IUCD prevent from implantation at the side of fundus the
upper part of uterus.
• IUDs have one of the lowest failure rates of any contraceptive method.

Two Types:
 Copper T (Last for 10 years)

 Multi Load (Last for 5 years)

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https://www.webmd.com/sex/birth-control/iud-intrauterine-device
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69
 Advantages & Disadvantages Of IUCD
Advantages
Highly effective 99%
No interference with intercourse.
Immediate return to fertility.
No hormonal side effects.
Safe in breast feeding
Disadvantages
Menstrual bleeding & cramping can
increase.
Spotting for few days after insertion.
Infection can occur if not doing good
practices. (Pelvic inflammatory disease)
May come out accidently if not
inserted properly.
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Permanent/ Surgical
Methods
of
Family Planning

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Sterilization/Voluntary Surgical
Contraceptive (VSC)
• It is permanent method of contraception that is highly effective .

• It is ideal for relatively older couples who are sure that they have
completed their families.
• It is of two types:

– Male sterilization : Vasectomy

– Female sterilization : Tubal ligation

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Sterilization
1. Vasectomy:
• Vasectomy is a surgical procedure for male
sterilization or permanent contraception.
• During the procedure, the male vas deferens are cut
and tied or sealed so as to prevent sperm from
entering into the urethra and thereby prevent
fertilization.
• This operation is done to keep a man’s sperm from
going to his penis, so his ejaculate never has any
sperm in it that can fertilize an egg.
• Operation is more simple than tying a woman’s tubes
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Sterilization
2. Tubectomy/Tubal Ligation “Tying Tubes.”
• It is a surgical procedure for sterilization in female.

• Permanent method for women and couples who do

not want more children
• A woman can have her fallopian tubes tied (or closed)
to stop eggs from being fertilized .

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 Qualities Of A Good Contraceptive
 Reliable.

 Acceptable.

 Easily available.

 In expansive.

 Easy to use.

 Reversible.

 Safe.

 Does not interfere with sex life.

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Family Planning Counseling
• Counseling is one of the most important components of family planning (FP).

• It is the responsibility of service providers at all levels to offer effective

counseling on FP methods
• FP counseling is the process of helping clients to make informed and
voluntary decisions about the choice of contraceptives.
• The role of family planning counseling is to support a woman and her
partner in choosing the method of family planning that best suits them and
to support them in solving any problems that may arise with the selected
method
• Counseling focuses on the client's/patient's situation and needs.

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Counseling Skills
• GATHER is an acronym that will help you remember the 6 basic steps for

family planning counseling.

 Greet the client respectfully.

 Ask them about their family planning needs.

 Tell them about different contraceptive options and methods.

 Help them to make decisions about choices of methods.

 Explain and demonstrate how to use the methods.

 Return/refer; schedule and carry out a return visit and follow up.

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 1. Greet
• Welcome client.

• Register client

• Determine purpose of visit.

• Give clients full attention.

• Assure the client that all information discussed will be confidential.

2. Ask
• Ask client about her/his needs.

• Assess what the client knows about family planning methods.

• Ask the client if there is a particular method s/he is interested in.

• Discuss any client concerns about risks vs. benefits of

modern methods 78
 3. Tell
• Tell the client about the available methods.

• Focus on methods that most interest the client, but briefly mention other
available methods.

• Describe how each method works, the advantages, benefits, possible

side effects, and disadvantages.

• Answer client concerns and questions.

4. Help
• Help the client to choose a method.

• Repeat information if necessary..

• If there is any reason found on examination or while taking a more detailed

history that there are precautions for the method, help the client choose
another method. 79
 6. Return
• Explain how to use the method (how, when, where).
• Explain to the client how and when s/he can/should get resupplies of the
method, if necessary.

5. Explain
• At the follow-up or return visit ask the client if s/he is still using the method.

• If the answer is yes, ask her/him if s/he is experiencing any problems or side
effects and answer her/his questions, solve any problems, if possible.

• If the answer is no, ask why s/he stopped using the method and counsel
her/him to see if s/he would like to try another method or re-try the same
method again.

• Make sure s/he is using the method correctly (ask her/him how s/he is using
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it).
References
• Ansari. I. M. et al .(2016) Community Medicine and Public Health 8 th edition.

• Basavanthappa, B. (2008). Community health nursing. 2nd ed. New Delhi: Jaypee
Brothers Medical.

• Gavin.L.,Moskosky.S.,(2014). Providing Quality Family Planning Services. Center Of

Disease Control.

Retrieved From Websites:

• https://www.familyplanning.org.nz/advice/contraception/contraception-methods

• https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

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Thank
You
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