Family Planning

FAMILY
PLANNING
For: Midwifery 3rd year students By: Fikadu T (MSc)
Learning objectives
 Discuss the rationale for family planning

 Identify different types of contraceptives
 Describe the benefits and side effects of each method
 Demonstrate administer of methods based on procedure
eligibility criteria

Population policy of Ethiopia
Goal
Harmonization of the rate of population growth and the
capacity of the country for the development and
Rational utilization of natural resources to the end that
the level of welfare of the population is maximized over
time
General objectives
Closing the gap between high population growth and
low economic productivity through planned reduction of
population growth and increasing economic returns.
Reducing the rate of rural to urban migration.
Maintaining/improving the carrying capacity of the
environment by taking appropriate environmental
protection
General objectives cont…
 Raising the economic and social status of women by

freeing them from the restrictions and drudgeries of
traditional life and making it possible for them to
participate productively in the larger community
 Significantly improving the social and economic status of
vulnerable groups (women, youth, children and elderly)
Specific objectives
• Reducing the total fertility rate to 4% by 2015
• Increasing contraceptive prevalence rate use to 44%
by 2015
• Reducing maternal, infant and child morbidity and
mortality rates
Specific objectives cont…
• Significantly increasing female participation at all

levels of education
• Removing all legal and customary practices
militating against the full enjoyment of economic
and social rights by women
Family Planning (FP)
• Family planning: the ability of individuals and couples to anticipate
and attain their desired number of children and the spacing and
timing of their births
• Contraceptive methods: refers to methods or ways by which
unwanted pregnancy is prevented
• Not all these methods are equally effective, safe or equally
acceptable
• Therefore, individualization of contraceptive choice is important for
successful prevention of unwanted pregnancy

Prevalence of FP in Ethiopia
• According to EDHS, 2016
-Currently married women
36%
-Sexually active unmarried
women – 58%
(For detail see figure)
For: Midwifery 3rd year students

Fig2:Trends of family planning Fig3:Trends of family planning
according to EDHS 2016. based on EDHS 2019 min report
For: Midwifery 3rd year students
TYPES OF FP method
 There are several types of contraceptive methods
 Two broad categories
1. Traditional/Natural contraceptive methods
2. Modern contraceptive methods

TYPES OF FP METHODS....
A. Natural methods
Traditional methods
Abstinence
Lactational amenorrhea method(LAM)
Coitus interrupts (withdrawal)
Fertility awareness method
The rhythm or calendar method
The basal body temperature(BBT)
The cervical mucus method(Billings ovulation)
Sympto-thermal(combination of BBT & Billings)

Types of FP methods cont…
B. Modern methods
Barrier methods
Male or female condom
Spermicidal tablets, foams, jells
Diaphragms/cervical caps
Hormonal methods
• Contraceptive pills
• Implants
• Injectables

Types of FP methods cont…
 Intrauterine contraceptive devices(IUCD)

 Surgical methods(permanent)
a. Tubal-ligation (TL)
b. Vasectomy (VSC)

Classification of modern methods
 Hormonal methods Emergency contraceptives
– Oral contraceptives ✔ ECPs
– Injectables ✔ ECPser releasing IUDs
– Implants
o d is
 Non hormonal methods m eth non
de rn l a nd
– IUDs l m o on a
e r a l hor m
Ge n d a s
– Barriers s ifi e
cl a s l.
o n a
– VSC, TL ho r m

Checklist to reasonably rule out
woman is not pregnant
1. Did your last menstrual cycle within the past 7 days
2. Have baby less than 6 months and are fully or nearly fully breast
feeding have you had menstrual cycle since then
3. Abstained from sex since your last menstrual period or delivery
4. Have you had a baby in the last 4 weeks
5. Have you had a miscarriage or abortion in the last 7 days
6. Have you been using a reliable contraceptive method consistently
and correctly

Modern Methods of FP
Barrier methods and hormonal methods. Barrier
includes:-
1. Male condom
2. Female condom
3. Diaphragm
4. Cervical cap
5. Spermicide
For: Midwifery 3rd year students By: Fikadu T (MSc) 18

F P
s o f
h o d
e t
er m
r ri
B a
Objectives
• Describe male and female condoms
• Explain the implication of dual use
• Demonstrate proper use of male & female condoms
• Describe spermicides, diaphragm and cervical caps

Male Condoms
• Sheaths, or coverings, that fit over a man’s erect penis
• ASK– Hiwot Trust, Sensation, French Feelings, etc.
• Most are made of thin latex rubber
• 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.
• Lubricants (glycerine, silicone, water and saliva) should be applied
on the outside of the condom, in the vagina, or in the anus. ✔
condom is 3rd choice (1. Abstinence 2. Be faithful 3.
Condom) = ABC
Male Condoms …
• Provides dual protection against STIs and unwanted pregnancy
• Have no hormonal side effects
• Can be used as a temporary or backup method
• Can be used without seeing a health care provider
• Available in health facilities, over the counter and in shops,
kiosk, supermarkets, etc.
• Use a new condom for each act of sex
• May help protect cervical cancer and infertility

Male Condoms …
• As commonly used, about 15 pregnancies per 100 women
whose partners use male condoms over the first year.
• When used correctly with every act of sex, about 2
pregnancies per 100 women whose partners use male
condoms over the first year.

Proper use of male Condom
 Before any physical contact, place the condom on the tip of the
erect penis with the rolled side out
 Unroll the condom all the way to the base of the erect penis
 Immediately after ejaculation, hold the rim of the condom in place
and withdraw the penis while it is still erect
 Dispose of the used condom safely

Female condom/Reality
• Poly urathane
• Has 2 flexible rings at the end
• 15 cm in length and 7 cm in width
• It enables a woman to control its use to prevent pregnancy
and STIs including HIV.

Female condom …
using female condoms over the first year.
pregnancies per 100 women using female condoms over the
first year.

Proper use of female condom
• Use a new female condom for each act of sex
• Before any physical contact, insert the condom into the vagina
• Ensure that the penis enters the condom and stays inside the
condom
• After the man withdraws his penis, hold the outer ring of the
condom, twist to seal in fluids, and gently pull it out of the
vagina
• Dispose of the used condom safely

Proper use of female condom ..

28
Can a female condom and a male
condom be used at the same time?
No.
male and female condoms should not be used together.
this can cause friction that may lead to slipping or

tearing of the condoms

Diaphragm
• Circular, rubber dome with flexible outer rim covers the vaginal
fornices & the cervix and keep diaphragm in place
• Used with spermicidal cream, jelly, or foam to improve
effectiveness
• Works by blocking sperm from entering the cervix;
spermicide kills or disables sperm (both keep sperm from
meeting an egg)
• Shouldn't be removed for 6 hrs

Diaphragm …
using the diaphragm with spermicide over the first year
pregnancies per 100 women using the diaphragm with
spermicide over the first year

Diaphragm…

32
Diaphragm …
• The diaphragm should not be fitted until 6 weeks after
childbirth or second-trimester abortion, when the uterus and
cervix have returned to normal size. Give her a backup
method to use until then
• Allergic to latex rubber she should not use a latex
diaphragm but possible to use diaphragm made of plastic
• HIV infection do not provide help to use dual methods

Diaphragm …
Known Health Benefits
• Help protect against: Risks of pregnancy & may help protect against:
Certain STIs (chlamydia, gonorrhea, PID, trichomoniasis) Cervical
precancer and cancer
Known Health Risks
• Common: Urinary tract infection
• Uncommon: Bacterial vaginosis & Candidiasis
• Rare: Frequent use of nonoxynol-9 may increase risk of HIV
infection
• Extremely rare: Toxic shock syndrome

Diaphragm …
Urinary tract infection
• Treat with cotrimoxazole 240 mg orally once a day for 3 days, or trimethoprim
100 mg orally once a day for 3 days, or nitrofurantoin 50 mg orally twice a day
for 3 days
Bacterial vaginosis
• Treat with metronidazole 2 g orally in a single dose or metronidazole 400–500
mg orally twice daily for 7 days
Candidiasis
• Treat with fluconazole 150 mg orally in a single dose, miconazole 200 mg
vaginal suppository, once a day for 3 days, or clotrimazole 100 mg vaginal
tablets, twice a day for 3 days

Cervical cap
• A bell-shaped rubber device that fits over the cervix
For: Midwifery 3rd year students By: Fikadu T (MSc) 36 36

Cervical cap....
• If treated or going to be treated for cervical
precancer (cervical intraepithelial neoplasia
[cIN]) or cervical cancer, do not provide the
cervical cap

Inserting Cervical Cap
• Fill one-third of the cap with spermicidal cream, jelly, or
foam.
• Press the rim of the cap around the cervix until it is
completely covered, pressing gently on the dome to apply
suction and seal the cap.
• Insert the cervical cap any time up to 42 hours before having
sex

Removing
• Leave the cervical cap in for at least 6 hours after her partner’s
last ejaculation, but not more than 48 hours from the time it was
put in.
• Leaving the cap in place for more than 48 hours may increase
the risk of toxic shock syndrome and can cause a bad odor
and vaginal discharge.
• Tip the cap rim sideways to break the seal against the cervix,
then gently pull the cap down and out of the vagina

Spermicides -Nonoxynol-9
• Sperm-killing substances inserted deep in the vagina, near the cervix,
before sex.
Nonoxynol-9 is most widely used.
Others include benzalkonium chloride, chlorhexidine, menfegol,
octoxynol-9, and sodium docusate.
• Available in foaming tablets, melting or foaming suppositories, cans
of pressurized foam, melting film, jelly, and cream.
• Work by causing the membrane of sperm cells to break, killing them
or slowing their movement (keeps sperm from meeting an egg)

Spermicides -Nonoxynol-9.......
• Jellies, creams, foams or suppositories
• As commonly used, about 29 pregnancies per 100 women using
spermicides over the first year
pregnancies per 100 women using spermicides over the first year
• Not recommended for clients who
– Are at high risk for HIV infection
– Have HIV infection
– Have AIDS

Natural Methods of family planning
1. Fertility Awareness Methods

2. Withdrawal.
3. Lactation Amenorrhea Method.

Fertility Awareness Methods
• Sometimes called periodic abstinence
• A woman knows how to tell when the fertile time of her
menstrual cycle starts and ends.
It require partners’ cooperation.
No side effects or health risks.

A. Calendar -Based Methods
1. Standard Days Method
• A woman can use if most of her menstrual cycles are 26 to 32
days long.
• If she has more than 2 longer or shorter cycles within a year
less effective.
• Counting the first day of monthly bleeding as day 1, then day
(8-19) of every cycle are considered as fertile days
• Avoid unprotected sex on days 8–19 or use barrier method.

Cont…
• If the client’s menstrual cycle is regular and comes every 28
days or close to it, ovulation should occur about 14 days
before the next period.
• For this reason, the woman should count backwards 14
days from her next period to calculate the day she will
ovulate.
• Consequently, she should avoid sex from about 7 days
before that day, and about 2 days after ovulation is
expected. (-7, +2 from estimated ovulation day)

Fig: standard day method

2. Calender written methode ➡If
menstruation irregular
Estimate the fertile time for clanedar rhythm methods, record
length of menstruation consicative months
• The woman subtracts 18 from the length of her shortest
recorded cycle.
– This tells her the estimated first day of her fertile time.
• Then she subtracts 11 days from the length of her longest
recorded cycle.
– This tells her the estimated last day of her fertile time.

Cont…
Example1:
• A client comes to you and asks about using the calendar
method to prevent pregnancy.
• When you ask her about the history of her menstrual cycle
over the last six months, she tells you it comes regularly
every 30 days.
• Calculate the fertile period of your client and advise her
when to avoid sex in order to prevent pregnancy.

Cont…
• Answer
-Regular cycle
30 - 14 = 16
-First day of fertile phase
16 - 7 = 9
-Last day of fertile phase
16 + 2 = 18
• Therefore, her fertile period is between the 9th and 18th days, and she
should avoid sex between these days of the cycle.

Cont…
• Example 1:
A woman’s last six menstrual cycles were 28, 26, 29, 27, 31
and 27 days. Using this information, calculate and instruct
her about how to use the calendar method to prevent
pregnancy.

Cont…
Answer: The shortest of her last 6 cycles was 26 days, 26 – 18 =

8.
– She starts avoiding unprotected sex on day 8.
• The longest of her last 6 cycles was 31 days, 31 – 11 = 20.
• Therefore, the fertile period of this client is between the 8th –20th
days, so she should avoid sex during this period to prevent
pregnancy.
➡ Subtract 11 day from shorter day and subtract 18 from

longer day if menstrual cycle is irregular by recording 6 months

B. Symptoms-Based Methods
1. Two Day Method OR Cx mucus method
 The woman checks for cervical secretions every
afternoon and/or evening
 As soon as she notices any secretions considers herself
fertile in the day and the following day.
 Avoid unprotected sex or use barrier method from day of
secretion to 2 dry cervical secretion days (days without
secretions of any type)
 Resume unprotected sex after 2 dry days.
Cont…
2. Basal Body Temperature (BBT) Method:
Take body temperature daily
 At the same time each morning before she eats anything.
 Her temperature will rise slightly 0.2° to 0.5°C just after
ovulation to the next menstrual cycle.
 Avoid sex or use another method from first day T° rise to 3
days after the temperature rise.
NB. If a woman has a fever or other changes in body
temperature, the BBT method will be difficult to use.

How Effective?

Side Effects, Health Risks and Medical
Eligibility
• Side Effects
-None
• Known Health Risks
-None
• Medical Eligibility
-No medical conditions prevent the use of these
methods.

Woman’s situation When to start
• Having regular menstrual cycles
Any time of the month
• No monthly bleeding
Delay until monthly bleeding returns.
 After childbirth (whether or not breastfeeding)
Delay until 4 menstrual cycles and the last one was
26–32 days long

Cont..
• After miscarriage or abortion

Delay until the start of her next monthly bleeding.
• Switching from a hormonal method
Delay her next monthly bleeding
• After taking emergency contraceptive pills
Delay until next monthly bleeding

Managing Any Problems
• Cycles are outside the 26–32 day and Very
irregular menstrual cycles.
-Suggest use of a symptoms-based method instead.
( BBT, Cx mucus or 2-day method or ovulation
method, symptotermal)

Withdrawal
• Just before ejaculation, the man withdraws his penis
from his partner’s vagina and ejaculates outside the
vagina, keeping his semen away from her external
genitalia.
• One of the least effective contraceptive methods

Lactational Amenorrhea Method
• It based on breastfeeding: Provides contraception for
the mother and best feeding for the baby.
• Can be effective for up to 6 months after childbirth
• Requires 3 conditions; All 3 must be met:
1. The mother’s monthly bleeding has not returned.
2. The baby is fully or nearly fully BF & is fed often,
day & night.
3. The baby is less than 6 months old.

Cont…

LAMs for Woman with HIV
• If they are not taking antiretroviral therapy (ART), will
transmit HIV to their infants through breastfeeding.
• Women taking ART can use LAM.
• 14% of baby have chance to get HIV during BF among
women who are not taking ART.
• Among women taking ART, less than 1% of their
babies will be infected.

o d s
e t h
a l m
o n
o r m
H
Oral Contraceptive
 There are two types of oral contraceptives
o Combined oral contraceptives(COC)- pills which
combine synthetic estrogen and progestin hormones
– Estrogens: mestranol and ethinyl estradiol
– Progesterone: eg Norgestrel, esogestrel, norgestimate
o Progestin only pills (POP)- pills which contain only
progesterone not estrogen
Progesterone only pills (POP)
• Also know as mini pills, 28 tab, taken with out dlay after
completing 1st 28 pill, start the next month immediatly
with out rest time
• Candidates for use include women who are breastfeeding and
women with contraindications to estrogen use.
• Not efficacious as COC. (but in ECP POP (85%) us more
effective than COC(75%). Also COC is more Side effect than
POP)
Mechanisms of action
 Suppression of ovulation (not uniformly in all cycles)
 A variable dampening effect on the midcycle peaks of LH and
FSH
 Increase in cervical mucus viscosity by a reduction in its volume
and an alteration of its structure;
 A reduction in the number and size of endometrial glands, leading
to an atrophic endometrium not suitable for ovum implantation;
and
 A reduction in cilia motility in the fallopian tube, thus slowing the
rate of ovum transport.
Efficacy
• Serum progestin levels peak approximately 2 hours
after administration
• Can be used as emergency or as monthly pills but the
dose is different)
• Greater efficacy is achieved with consistent
administration.
• Failure rates with typical use are estimated to be 7% in
the first year of use.
Advantage
• Due to the lack of estrogen, evidence of serious
complications to which estrogen can contribute (i.e,
thromboembolism) is minimal
• Can be given for breast feeding women
• Non contraceptive benefits include:
– Decreased dysmenorrhea, decreased menstrual blood
loss, and decreased premenstrual syndrome symptoms
Side effects
 For breastfeeding women, longer delay in return of monthly bleeding
after childbirth (lengthened postpartum amenorrhea)
 Frequent bleeding, irregular bleeding, infrequent bleeding, prolonged
bleeding, an no monthly bleeding
 Headaches
 Dizzines
 Mood changes
 Breast tenderness
 Abdominal pain
 Nausea
 For women not breastfeeding, enlarged ovarian follicles
POPs cont….
• A pill is considered late if ingestion occurs 3 hours
after the established time of administration.
• If a pill is missed, it should be taken as soon as
possible; the next pill should be taken at the
scheduled time.
• Backup contraception(e.g. ECP) should be used for
the next 48 hours.
Combined oral contraceptives(COCs)
• It contains both estrogens and progesterone derivatives in a
single tablet. COC 21 & have 7 hormone free pills(21/7)
• Estrogen or progesterone alone is capable of inhibiting both
FSH & LH sufficiently to prevent ovulation.
• The combination of the two steroids creates a synergistic
effect that greatly increases their antigonadotropic and
ovulation-inhibitory effects.
Due to this COC is more effective than POP
Formulations
• Monophasic: have a constant dose of both estrogen
and progestin in each of the hormonally active pills,
which is taken for 21 days followed by 7 days ‘hormone
free’ pills.
• Depending on the amount of estrogen, monophasic pills
are subdivided in to low dose and high dose.
– Low dose- ethinyl estradiol < 0.05 mg eg. Microgenon
– High dose- ethinyl estradiol > 0.05 mg
Formulations cont….
 Biphasic
– For biphasic pills, the first 10 pills have one dosage,
and then the next 11 pills have another level of
estrogen and progestin.
 Triphasic:
– The first 7 or so pills have one dosage, the next 7 pills
have another dosage, and the last 7 hormonal pills
have yet another dosage.
Mechanisms of action
• Making cervical mucus thick

• Inhibits ovulation by suppression of FSH by estrogen
& LH by progesterone
• Alter tubal transport.
• Prevents implantation by altering uterine wall
Efficacy
• Failure rates are correlated to individual compliance.

• Rates range from 0.1% with perfect use to 5% with
typical use (for POP it is 7%)
• No delay in return of fertility after COCs are
stopped
Advantages
• Prevents unwanted pregnancy & its sequel
• Highly effective
• Can used by the untrained person
• Don't interfere with intercourse
• Can be used as emergency contraceptive after
unprotected sex
Advantage cont…
 Non-contraceptive use
o Oral contraceptives prevent benign conditions, such as
benign breast disease, PID and functional cysts.
o Ectopic pregnancies are prevented
 If women who is precautions for COC, consider

IUCD
 If women who is precautions for IMPLANTS due
to excessive bleeding, change to COC is best.
Non-contraceptive use cont…
• Prevent epithelial ovarian and endometrial carcinoma.
• Decrease acne (excess Androgen)
• Decrease hirsutism
• Decrease menstrual flow, (COC is one treatment for
excess bleeding caused by Implants)
• Cancer of the lining of the uterus (endometrial cancer)
• Cancer of the ovary
• Protect against iron deficiency anemia
Disadvantages
o Nausea
o Breast tenderness
o Breakthrough bleeding
o Amenorrhea
o Headache- migraine headache
o Mood change including depression
o Missed period or very scanty bleeding
o Daily administration is necessary, and inconsistent use may
increase the failure rate.
o No protection against sexually transmitted infections
How to use the pill
 28 pill packet- when she finishes
one packet she should take the first
from the next packet on the very
next day.
 21- pill packet- after she takes the
last pill from one packet she should
wait 7 days & then take the first
pill from the next packet.
Missed pill advice
• If 1 or 2 pills missed, she should take 1 tablet as soon as
she remembers, continue taking the remaining pill at
usual time, she does not need to take backup
contraception. (but for POP if 1 pill is missed continue
as soon as remember & need 48 hrs backup, ECP)
• If 3 or more pills missed advice as above, but she
should be advised to use a backup method of
contraception until pills have been taken for 7 days in a
row.
Missed pill advice cont…
• If pill is missed in week 1(days 1-7) & unprotected
sexual intercourse has taken place in pill week or week
1 then emergency contraception is needed.
• If pills missed in week 3 (days 15-21), advise to finish
pill in pack and start new pack the next day, omitting
pill free interval and needs backup for 7 day
• If one has missed > 7 consecutive days then consider as
stopped COC
Who Cannot Use COCs Category 4
 Cerebrovascular disease or coronary artery disease
 A history of deep vein thrombosis
 Pulmonary embolism, or CHF
 Untreated hypertension
 Migraine with aura
 Diabetes with vascular complications
 Breast feeding & less than 6 months postpartum
 Suspected pregnancy
 Age older than 35 years and > 30 cigarette smoking per day
Who Cannot Use cont…. Category 4
• Deep vein thrombosis (DVT)

• Major surgery with prolonged immobilization
• Complicated valvular disease
• Breast cancer within the past 5 years
• Active viral hepatitis
• Benign or malignant liver tumor, b/c metabolism of
estrogen and progesterone is at liver.
Who Cannot Use cont… Category 3
• Severe headache
• Hypertension
• Gall bladder disease
• Diabetes mellitus, gestational diabetes
• Epilepsy
• Sickle cell disease
• Known hyper lipidemia
• Drug treatment affecting liver enzymes: rifampicin & certain
anticonvulsants (phenytoin, carbamazepine, barbiturates,
primidone)
When to start
• Having menstrual cycle
with in 5 days --- no need of backup
delayed > 5 days ---- 2 days backup
• Switching from IUD ---start immediately, no backup
• From hormonal method --- if use was consistent & correct
start at the next schedule & no backup
• Fully breast feeding
start at 6 months or when supplementation started
>6 mo & no menses--- R/O pregnancy + backup
• Partial breast feeding
<6wk---start at 6wk
>6wk & no menses ---R/O pregnancy + backup
• Non breastfeeding
<4wks---start anytime b/n 21-28days
>4wk & no menses---R/O pregnancy + backup
• After miscarriage
<7days ---no backup
>7days----backup
• After ECPs----the day ECPs finished + backup
• No monthly bleeding ----R/O pregnancy + backup

Family Planning

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FAMILY

 Discuss the rationale for family planning

For: Midwifery 3rd year students By: Fikadu T (MSc)

 Raising the economic and social status of women by

• Significantly increasing female participation at all

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

 Intrauterine contraceptive devices(IUCD)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc) 18

For: Midwifery 3rd year students By: Fikadu T (MSc) 20

For: Midwifery 3rd year students By: Fikadu T (MSc) 22

For: Midwifery 3rd year students By: Fikadu T (MSc) 23

For: Midwifery 3rd year students By: Fikadu T (MSc) 24

For: Midwifery 3rd year students By: Fikadu T (MSc) 25

For: Midwifery 3rd year students By: Fikadu T (MSc) 26

For: Midwifery 3rd year students By: Fikadu T (MSc) 27

For: Midwifery 3rd year students By: Fikadu T (MSc) 28

this can cause friction that may lead to slipping or

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc) 31

For: Midwifery 3rd year students By: Fikadu T (MSc) 32

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc) 36 36

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc) 41

1. Fertility Awareness Methods

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

Answer: The shortest of her last 6 cycles was 26 days, 26 – 18 =

➡ Subtract 11 day from shorter day and subtract 18 from

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

• After miscarriage or abortion

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

• One of the least effective contraceptive methods

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)

For: Midwifery 3rd year students By: Fikadu T (MSc)