Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 13: Family Planning (introduction...) Benefits of Family Planning Is Family Planning Safe? Choosing to Use Family Planning Choosing a Family Planning Method (introduction...) How well each method works Barrier Methods of Family Planning (introduction...) The condom Condoms for women (female condoms) The diaphragm Spermicide (contraceptive foam, tablets, jelly, or cream) Hormonal Methods of Family Planning hormones (introduction...) The pill Implants Birth control injections Intra-Uterine Devices (Devices that go into the womb) THE IUD (IUCD, Copper-T, The Loop) Natural Methods of Family Planning (introduction...) Breastfeeding for the first 6 months (Lactational Amenorrhea Method, LAM) The mucus method and the rhythm method Traditional and Home Methods to Prevent Pregnancy Permanent Methods of Family Planning Emergency Methods of Family Planning Choosing the Best Method Working for Change

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 13: Family Planning

Figure

Having the number of children you want, when you want them, is called family planning. If you decide to wait to have children, you can choose one of several methods to prevent pregnancy. These methods are called family planning methods, child spacing methods, or contraception.

¨ Family planning saves lives.

Benefits of Family Planning

¨ In poor countries about half of all deaths in women of child-bearing age are caused by problems of pregnancy and childbirth. Family planning prevents these pregnancies and deaths.

Every year, half a million women die of problems from pregnancy, childbirth, and unsafe abortion. Most of these deaths could be prevented by family planning. For example, family planning can prevent dangers from pregnancies that are:

· too soon. Women under the age of 17 are more likely to die in childbirth because their bodies are not fully grown. Their babies have a greater chance of dying in the first year.

· too late. Older women face more danger in child bearing, especially if they have other health problems or have had many children.

· too close. A woman’s body needs time to recover between pregnancies.

· too many. A woman with more than 4 children has a greater risk of death after childbirth from bleeding and other causes.

As well as saving lives, family planning has other benefits Mothers and babies will be healthier, because risky pregnancies are avoided. Figure Fewer children means more food for each child. Figure Waiting to have children can allow young women and men time to complete their education. Figure Fewer children can mean more time for yourselves and your children. Figure Family planning can also help you and your partner enjoy sex more, because you are not afraid of unwanted pregnancy. And some methods have other health benefits. For example, condoms and spermicides can help protect against the spread of sexually transmitted diseases (STDs), including HIV/AIDs. Hormonal methods can help with irregular bleeding and pain during a woman’s monthly bleeding.

Is Family Planning Safe?

All of the family planning methods found in this chapter are used safely by millions of women. In fact, these methods are much safer than pregnancy and childbirth:

Of 15,000 women who become pregnant, 500 are likely to die from problems of pregnancy or childbirth.

Figure

Of 15,000 women who use family planning methods, only one is likely to die from using these methods.

Figure

Choosing to Use Family Planning

Figure

You have a right to make your own decisions about family planning.

Some women want a lot of children - especially in communities where poor people are denied a fair share of land, resources, and social benefits. This is because children help with work and provide care for their parents in old age. In these places, having just a few children may be a privilege only wealthier people can afford.

Other women may want to limit the number of children they have. This often happens where women have opportunities to study and earn income, and where they can negotiate with men in a more equal way.

No matter where a woman lives, she will be healthier if she has control over how many children she has, and when she will have them. Still, deciding to use - or not to use - family planning should always be a woman’s choice.

Talking with your husband or partner about family planning It is best if you can talk together with your husband or partner about choosing to use family planning and what method you will use. Some men do not want their wives to use family planning, often because they do not know very much about how different methods work. A man may worry about his wife’s health, because he has heard stories about the dangers of family planning. He may fear that if a woman uses family planning, she will have sex with another man. Or he may also think it is ‘manly’ to have lots of children. Try sharing the information in this chapter with your partner. It may help him understand that: · family planning will allow him to take better care of you and your children. · child spacing is safer for you and your children. · family planning can make sex with him more pleasant, because neither of you will have to worry about an unplanned pregnancy. Being protected against unwanted pregnancy will not make you want to have sex with other men. If your husband still does not want you to use family planning even after learning about its benefits, you must decide whether you will use family planning anyway. If you do, you may need to choose a method that can be used without your partner knowing about it.

Choosing a Family Planning Method

Once you have decided to use family planning, you must choose a method. To make a good decision you must first learn about the different methods, and their advantages and disadvantages.

There are 5 main types of family planning methods:

· Barrier methods, which prevent pregnancy by keeping the sperm from reaching the egg.

· Hormonal methods, which prevent the woman’s ovary from releasing an egg, make it harder for the sperm to reach the egg, and keep the lining of the womb from supporting a pregnancy.

· IUDs, which prevent the man’s sperm from fertilizing the woman’s egg.

· Natural methods, which help a woman know when she is fertile, so that she can avoid having sex at that time.

· Permanent methods. These are operations which make it impossible for a man or a woman to have any children.

These methods of family planning are described on the following pages. As you read about each method, here are some questions you may want to consider: · How well does it prevent pregnancy (its effectiveness)? · How well does it protect against STDs, if at all? · How safe is it? If you have any of the health problems mentioned in this chapter, you may need to avoid some types of family planning methods. · How easy is it to use? · Is your partner willing to use family planning? · What are your personal needs and concerns? For example, do you have all the children you want, or are you breastfeeding your baby? · How much does the method cost? · Is it easy to get? Will you need to visit a health center often? · Will the side effects (the problems the method may cause) create difficulties for you? After reading about these methods, you can get more help with choosing one on Choosing the Best Method. It may also help to talk with your partner, other women, or a health worker about different methods. Only you can decide which family planning method is right for you. Figure

How well each method works

Here is some basic information about the effectiveness of the different methods, their usefulness in protecting against STDs as well as pregnancy, and whether you can use them while breastfeeding.

For every 100 women who use this method for one year...	This many women will become pregnant:	Protection against STDs
Condom	12	good
Condom for Women	20	good
Diaphragm	18	some
Spermicide	20	some
Pill (the combined pill)	3	none
Progestin Only Pill	5	none
Implants	Less than 1	none
Injections	Less than 1	none
IUD	1	none
Breastfeeding (1st 6 mo.)	2	none
Natural Family Planning	20	none
Sterilization	Less than 1	none
No Method	85	none
All of these methods can be used safely while breastfeeding except the combined pill, and injections that have estrogen.

Barrier Methods of Family Planning

Barrier methods prevent pregnancy by blocking the sperm from reaching the egg. They do not change the way the woman’s or man’s body works, and they cause very few side effects. Barrier methods are safe if a woman is breastfeeding. Most of these methods also protect against STDs, including HIV/AIDs. When a woman wants to become pregnant, she simply stops using the barrier method.

The most common barrier methods are the condom, condoms for women, the diaphragm, and spermicides.

The condom

The condom is a narrow bag of thin rubber that the man wears on his penis during sex. Because the man’s semen stays in the bag, the sperm cannot enter the woman’s body.

Condoms work best when they are used with spermicide. Condoms made of latex are the best protection against STDs and HIV/AIDS, and can be used alone or along with any other family planning method.

Condoms can be bought at many pharmacies and markets, and are also available at health posts and through AIDS prevention programs. They can help some men last longer during sex.

¨ Condoms can help some men last longer during sex.

Be careful not to tear the condom as you open the package. Do not use a new condom if the package is torn or dried out, or if the condom is stiff or sticky. The condom will not work. Do not unroll the condom before putting it on.

How to use a condom: 1. If the man is not circumcised, pull the foreskin back. Squeeze the tip of the condom and put it on the end of the hard penis. Figure 2. Keep squeezing the tip while unrolling the condom, until it covers all of the penis. The loose part at the end will hold the man’s sperm. If you do not leave space for the sperm when it comes out, the condom is more likely to break. Figure 3. After the man ejaculates, he should hold on to the rim of the condom and withdraw from the vagina while his penis is still hard. Figure 4. Take off the condom. Do not let sperm spill or leak. Figure 5. Tie the condom shut and dispose by burning or burying it away from children and animals. Figure

¨ If the condom tears or slips off, the woman should immediately put spermicide into her vagina. If possible, use an emergency method of family planning.

The condom must be put on the man’s penis when it is hard, but before it touches the woman’s genitals. If his penis touches the woman’s genitals or goes into her vagina, he can make the woman pregnant or can give her an STD, even if he does not spill his sperm (ejaculate).

Remember:

· Use a condom every time you have sex.

· If possible, always use condoms made of latex. They give the best protection against HIV. Condoms made of sheepskin will not protect against HIV.

· Keep condoms in a cool, dry place away from sunlight. Condoms that are from old or torn packages are more likely to break.

· Use a condom only once. A condom that has been used before is more likely to break.

¨ Since condoms are the best protection against STDs and HIV/AIDS, they should be used with other family planning methods when a woman needs protection from both pregnancy and STDs.

Use lubricants to keep condoms from breaking. Lubricants should be water based, such as spit (saliva), spermicide, or K-Y Jelly. Rub the lubricant on the sides of the condom after it is on the hard penis. Do not use cooking oils, baby oil, mineral oil, petroleum gel, skin lotion, or butter. They can make the condom break.

Figure

A man may not want to use a condom at first, but often a woman can convince her partner to use condoms by explaining the advantages of family planning and the importance of protection against HIV/AIDs and STDs.

Condoms for women (female condoms)

Figure

A female condom, which fits into the vagina and covers the outer lips of the vulva, can be put in the vagina any time before sex. It should be used only once, because it may break if it is washed and reused. But reusing a female condom is better than no condom.

¨ Female condoms are larger than condoms made for men and are less likely to break.

The female condom is the most effective of the methods controlled by women in protecting against both pregnancy and STDs, including HIV/AIDS. It is available only in a few places now. But if enough people demand this method, more programs will make them available.

The female condom should not be used with a male condom.

How to use the female condom: 1. Carefully open the packet Figure 2. Find the inner ring, which is at the dosed end of the condom. Figure 3. Squeeze the inner ring together. Figure 4. Put the inner ring in the vagina. Figure 5. Push the inner ring up into your vagina with your finger. The outer ring stays outside the vagina. Figure 6. When you have sex, guide the penis through the outer ring. Figure 7. Remove the female condom immediately after sex, before you stand up. Squeeze and twist the outer ring to keep the man’s sperm inside the pouch. Pull the pouch out gently, and then burn or bury it. Do not flush it down the toilet.

The diaphragm

The diaphragm is a shallow cup made of soft rubber that a woman wears in her vagina during sex. The diaphragm works by covering the opening to the womb (cervix), preventing the sperm from entering it. The spermicide jelly used with the diaphragm helps kill the sperm, and also protects against gonorrhea and chlamydia (2 common STDs).

¨ New research shows that using a diaphragm without spermicide can also help prevent pregnancy. You can leave the diaphragm in all the time, except during monthly bleeding. Remove it once a day for cleaning.

Diaphragms come in different sizes, and are available at some health posts and family planning clinics. A health worker who has been trained to do pelvic exams can examine you and find the right size diaphragm.

Diaphragms can get holes, particularly after being used for more than a year. It is a good idea to check your diaphragm often. Replace it when the rubber gets dry or hard, or when there is a hole in it.

When you use a diaphragm with spermicide, it can be put in just before you have sex, or up to 6 hours before.

How to use a diaphragm: 1. If you have spermicide, squeeze it into the center. Then spread a little bit around the edge with your finger. Figure 2. Squeeze the diaphragm in half. Figure 3. Open the lips of your vagina with your other hand. Push the diaphragm into your vagina. It works best if you push it toward your back. Figure 4. Check the position of your diaphragm by putting one of your fingers inside your vagina and feeling for your cervix through the rubber of the diaphragm. The cervix feels firm, like the end of your nose. The diaphragm must cover your cervix. Figure 5. If the diaphragm is in the right place, you will not be able to feel it inside you. 6. Leave the diaphragm in place for 6 hours after sex.

To remove the diaphragm: Put your finger inside your vagina. Reach behind the front rim of the diaphragm and pull it down and out. It sometimes helps to push your muscles down at the same time, as if you were passing stool. Wash your diaphragm with soap and water, and dry it. Check the diaphragm for holes by holding it up to the light. If there is even a tiny hole, get a new one. Store the diaphragm in a clean, dry place.

Spermicide (contraceptive foam, tablets, jelly, or cream)

Foam

Tablets

Cream or jelly

Spermicide comes in many forms - foam, tablets, and cream or jelly - and is put into the vagina just before having sex. Spermicide kills the man’s sperm before it can get into the womb. Spermicide made with nonoxynol-9 also provides some protection from gonorrhea and chlamydia, which are 2 common STDs.

If used alone, spermicide is less effective than some other methods. But it is helpful when used as extra protection along with another method, like the diaphragm or condom.

Spermicides can be bought in many pharmacies and markets. Some women find that some types of spermicides cause itching or irritation inside the vagina.

When to insert spermicide:

Tablets or suppositories should be put in the vagina 10 to 15 minutes before having sex. Foam, jelly, or cream work best if they are put in the vagina just before having sex.

If more than one hour passes before having sex, add more spermicide. Add a new tablet, suppository, or applicator of foam, jelly, or cream each time you have sex.

How to insert spermicide: 1. Wash your hands with soap and water 2. To use foam, shake the foam container rapidly, about 20 times. Then press the nozzle to fill the applicator. Figure To use jelly or cream, screw the spermicide tube onto the applicator. Fill the applicator by squeezing the spermicide tube. To use vaginal tablets, remove the wrapping and wet them with water or spit on them. (DO NOT put the tablet in your mouth.) Figure 3. Gently put the applicator or vaginal tablet into your vagina, as far back as it will go. 4. If you are using an applicator, press in the plunger all the way and then take out the empty applicator. 5. Rinse the applicator with clean water and soap. Leave the spermicide in place for at least 6 hours after sex. Do not douche or wash the spermicide out. If cream drips out of your vagina, wear a pad, cotton or clean cloth to protect your clothes.

Hormonal Methods of Family Planning hormones

These methods contain hormones, called estrogen and progestin, that are similar to the estrogen and progesterone a woman makes in her own body.

Hormonal methods include:

· birth control pills, which a woman takes every day.

· injections, which are given every few months.

· implants, which are put into a woman’s arm and last for several years.

Hormonal methods work by preventing the woman’s ovaries from releasing an egg. The hormones also make the mucus at the opening of the womb very thick, which helps stop the sperm from getting inside the womb.

IMPORTANT
Hormonal methods do not protect against STDs, or HIV/AIDS.

Most birth control pills and some injections contain both estrogen and progestin. These are called ‘combination’ pills or injections. The two hormones work together to give excellent protection against pregnancy. However, some women should not use pills or injections with estrogen for health reasons, or because they are breastfeeding.

¨ A woman controls hormonal methods and they can be used without a man knowing.

‘Progestin-only’ pills (also called mini-pills), implants, and some injections contain only one hormone - progestin. These methods are safer than combined pills or injections for women who should not use estrogen, or are breastfeeding.

These women should avoid ANY kind of hormonal method:

· Women who have breast cancer, or a hard lump in the breast. Hormonal methods do not cause cancer. But if a woman already has breast cancer, these methods can make it worse.

Figure

Figure

· Women who might be pregnant or whose monthly bleeding is late.

Figure

· Women who have abnormal bleeding from the vagina during the 3 months before starting hormonal methods. They should see a health worker to find out if there is a serious problem.

Figure

Some hormonal methods are harmful for women with other health problems. Be sure to check each method to see if it is safe for you. If you have any of the health problems mentioned and still wish to use a method, talk to a health worker who has been trained in hormonal methods of family planning.

¨ Some medicines for seizures (fits) or for tuberculosis (TB) make hormonal methods less effective. A woman taking these medicines should use other family planning methods.

Side effects of hormonal methods Because hormonal methods contain the same chemicals that a woman’s body makes when she is pregnant, these things may happen during the first few months: Nausea Headaches Swelling of the breasts Changes in monthly bleeding Side effects often get better after the first 2 or 3 months. If they do not, and they are annoying or worrying you, see a health worker. She may be able to help you change the amount of the hormones in your method or to change methods.

The pill

Birth control pills that contain estrogen and progestin

¨ Some women find that taking the pill helps their monthly bleeding to be more regular, with less bleeding and less pain.

If you take birth control pills every day, they will protect you from pregnancy for your entire monthly cycle. These pills are usually available at family planning clinics, health posts, pharmacies, and through health workers.

There are many different brands of pills. The pill you get should be what is called a ‘low-dose’ pill. This means it has 35 micrograms (mcg) or less of estrogen, and I milligram (mg) or less of progestin. (Mini-pills and low-dose pills are different - low-dose pills have both estrogen and progestin, while the mini pill has only progestin.) Never use a method with more than 50 mcg of estrogen.

Figure

Once you start taking pills, you should try to stick with one brand (and if you can, buy several packets at once). If you must change brands, try to get another with the same hormone names and strength. You will have fewer side effects and better protection.

Who should not take combined pills:

Some women have health problems that make it dangerous for them to use the pill. NEVER take the pill if you have any of the conditions listed, or if you:

· have hepatitis, or yellow skin and eyes.
· have ever had signs of a stroke, paralysis, or heart disease.
· have ever had a blood clot in the veins of your legs or in your brain. Varicose veins are usually not a problem, unless the veins are red and sore.

¨ If you must change to a lower dose pill, use a barrier method of family planning or do not have sex during the first month.

If you have any of the following health problems, try to use a method other than combined birth control pills. But if you cannot, it is still better to take the combined pill than to become pregnant. Try not to take combined pills if you:

· smoke and are over 35 years old. You have a greater chance of having a stroke or heart attack if you take combined pills.

· have diabetes or epilepsy. If you are taking medicine for fits (seizures) you will need to take a stronger (50 mcg estrogen) birth control pill. Get medical advice from a health worker or doctor.

· have high blood pressure (more than 140/90). If you have ever been told you have high blood pressure or think you might have it, have your blood pressure checked by a health worker. If you weigh too much, have frequent headaches, get out of breath easily, feel weak or dizzy often, or feel pain in the left shoulder or chest, you should be tested for high blood pressure.

Figure

¨ If you are breastfeeding you should also try not to take the combined pills. The estrogen in combined pills will reduce your milk supply. This could affect your baby’s health.

Common side effects of combined pills:

· Irregular bleeding or spotting (bleeding at other times than your normal monthly bleeding). Combined pills often make your monthly bleeding shorter and lighter. It is also normal to sometimes skip your monthly bleeding. This is the most common side effect of combined birth control pills. To reduce spotting, be extra careful to take the pill at the same time every day. If the spotting continues, talk with a health worker to see if changing doses of progestin or estrogen will help.

· Nausea. Nausea, the feeling that you want to throw up, usually goes away after I or 2 months. If it bothers you, try taking the pills with food or at another time of day. Some women find that taking the pill just before going to sleep at night helps.

· Headaches. Mild headaches in the first few months are common. A mild pain medicine should help. If the headache is severe or comes with blurred eyesight, this could be a serious warning sign.

¨ If your monthly bleeding does not come at the normal time and you have missed some pills, continue to take your pills but see a health worker to find out if you are pregnant.

Warning signs for problems with combined pills:

STOP taking the pill and see a health worker if you:

· have severe headaches with blurred vision (migraines) that begin after you start taking the pill.

· feel weakness or numbness in your arms or legs.

· feel severe pain in your chest and shortness of breath.

· have severe pain in one leg.

If you have any of these problems, pregnancy can also be dangerous, so use another type of family planning such as condoms until you can see a health worker trained in hormonal family planning methods.

¨ If you are given a new medicine while on the pill, ask your health worker if you should use a barrier method or not have sex while taking the medicine. Antibiotics and some other medicines make the pill less effective.

How to take combined birth control pills: The pill comes in packets of 21 or 28 tablets. If you have a 28-day packet, take one pill every day of the month. As soon as you have finished one packet, begin taking pills from another packet. 28-Day Pill Packet If you have a 21 -day packet, take a pill every day for 21 days, then wait 7 days before beginning a new packet. Your monthly bleeding will usually happen during the days you are not taking pills. But begin a new packet even if your monthly bleeding has not come. 21-Day Pill Packet With both 21 -day and 28-day packets, take the first pill on the first day of your monthly bleeding. This way you will be protected right away. If it is after the first day, you can start taking a pill on any of the first 7 days of your monthly cycle. But you will not be protected right away, so for the first 2 weeks you are taking the pill you should also use another family planning method or not have sex. You must take one pill every day, even if you do not have sex. Try to take your pill at the same time every day. It may help to remember that you will always start a new packet on the same day of the week.

Forgetting to take pills:

If you miss pills you could get pregnant.

Figure

If you forget one pill, take it as soon as you remember. Then take the next pill at the regular time. This may mean that you take 2 pills in one day.

If you forget to take 2 pills in a row, start taking them again immediately. Take 2 pills for 2 days and then continue taking I pill each day until you finish the packet. Use condoms (or do not have sex) until you have taken a pill for 7 days in a row. If you forget to take 3 or more pills, stop taking the pills and wait for your next monthly bleeding. Use condoms (or do not have sex) for the rest of your cycle. Then start a new packet.

Late or missed pills will cause some bleeding, like a very light monthly bleeding.

If you have trouble remembering to take pills, try taking a pill when you do a daily task, like preparing the evening meal. Or take the pill when you see the sun go down or before you sleep. Keep the packet where you can see it every day. If you still forget to take your pills often (more than once a month), think about changing to a different method of birth control.

Figure

If you vomit within 3 hours after taking your pill or have severe diarrhea, your birth control pill will not stay in your body long enough to work well. Use condoms, or do not have sex, until you are well and have taken a pill each day for 7 days.

Stopping the pill:

If you want to change methods or get pregnant, stop taking the pills when you finish a packet. You can get pregnant right after you stop. Most women who stop taking pills because they want to get pregnant will get pregnant sometime within the first year.

The Mini Pill or Progestin-only Pills

Figure

Figure

Because this pill does not contain estrogen, it is safer for women who should avoid combined birth control pills and for women who have side effects from combined pills. But this pill is less effective than combined birth control pills.

The mini pill is also a better choice for women who are breastfeeding because it does not cause a decrease in the milk supply. The mini pill is very effective for most breastfeeding mothers. Like the combined pill, it is usually available at family planning clinics, health posts, pharmacies, and through health workers.

Women with any of the conditions and women who are taking medicine for seizures should not take the mini pill. The medicine makes the mini pill less effective.

Common side effects of the mini pill:

· irregular bleeding or spotting. This is the most common side effect. If it becomes a problem, taking ibuprofen may help stop spotting.

· no monthly bleeding. This is fairly common, but if you go more than 45 days without bleeding you may be pregnant. Keep taking your pills until you can see a health worker to find out if you are pregnant.

· occasional headaches.

¨ If you forget a pill, use a barrier method (or do not have sex) for 7 days, AND keep taking your pills.

How to take the mini pill: · Take your first pill on the first day of your monthly bleeding. · Take one pill at the same time each day, even if you do not have sex. If you take a pill even a few hours late or forget only one day’s pill, you can become pregnant. · When you finish a packet, start your new packet the next day, even if you have not had any bleeding. Do not skip a day. If you are breastfeeding and have not started your monthly bleeding, you can start taking the pills any day. You may not begin bleeding. This is normal. What to do if you miss a mini pill: Take it as soon as you remember. Take the next pill at the regular time, even if it means taking 2 pills in one day. You may have bleeding if you take your pill at a later time than usual. Stopping the mini pill: You can stop taking the pill any time. You can get pregnant the day after you stop, so be sure to use another family planning method right away if you do not want to become pregnant.

Implants

Figure

Implants are 6 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 mini pills. They prevent pregnancy for 5 years. The only brand available when this book was written is called Norplant.

How to use implants: 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. Figure

IMPORTANT
Before trying implants, be sure a health worker near you is trained and willing to remove the implants, in case you want them removed. It is harder to take implants out than it is to put them in.

Implants can be used by women who are breastfeeding and others who have problems with estrogen. Women should not use implants if they have any of the conditions described, if they have heart disease, or if they want to become pregnant in the next few years. If you are taking medicines for seizures, you will need to use a backup method, like a condom or a diaphragm, as well as the implants.

Figure

Common side effects of implants:

During the first months, the implants may cause irregular bleeding (in the middle of your monthly cycle) or more days of monthly bleeding. Or you may have no bleeding at all. This does not mean that you are pregnant or that something is wrong. These changes will go away as your body becomes used to having more progestin. If this irregular bleeding causes problems for you, a health worker may have you take low-dose combined birth control pills along with the implants for a few months.

You may also have occasional headaches and the same side effects common with progestin-only injections.

¨ Ibuprofen or aspirin will also help control irregular bleeding.

To stop using implants:

Although Norplant implants last for 5 years, they can be removed at any time - though it can be hard to find a health worker who knows how to remove them. After removal, you can get pregnant right away, so use another family planning method if you do not want to become pregnant.

¨ Many women want their implants removed early because they do not like the side effects. The most common concern is irregular bleeding.

Birth control injections

Figure

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, by someone who knows how. The protection lasts until you need a new injection, and can be used without others knowing.

Progestin-only injections

Progestin-only injections, such as Depo Provera and Noristerat, contain only the hormone progestin. These are especially good for women who are breastfeeding and women who should not use estrogen. They are given every 2 to 3 months.

Women should not begin progestin-only injections if they have any of the conditions listed, if they are unable to get regular injections, or if they want to become pregnant within the next year.

Common side effects of progestin-only injections:

Because of the large doses of progestin given with each injection, women experience more changes in their monthly bleeding during the first few months than with other hormonal methods.

Other common side effects are:

· irregular bleeding or heavy spotting. If this is a problem, a health worker can give 2 cycles of a combined low-dose birth control pill to take along with the injections to stop the spotting. Most irregular bleeding will stop after a few months.

· no monthly bleeding.

· weight gain.

¨ Progestin-only injections almost always cause changes in the monthly bleeding. You may have light bleeding every day or every once in a while. You will probably stop having monthly bleeding by the end of the first year. These changes are normal.

Combined injections

Other injections, such as Cyclofem and Mesigyna, 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.

Women who should not take combined birth control pills or progestin-only injections should not take combined injections either. Do not begin combined injections while breastfeeding.

Common side effects of combined injections:

Because the injection contains the same hormones as combined birth control pills, the same side effects are common.

How to use birth control injections: It is best to get your first injection during your monthly bleeding. This way you know that you are not pregnant. You can start the injections any time if you are breastfeeding and have not started your monthly bleeding. The injection protects you against pregnancy immediately if it is given within 5 days after your monthly bleeding begins. If the injection was given 6 or more days after the beginning of your monthly bleeding, you should use condoms or not have sex for the next 2 weeks. You must have an injection every 1, 2, or 3 months, depending on the kind of injection: · Depo Provera: every 3 months · Noristerat: every 2 months · Cyclofem and Mesigyna: every month Try not to be late getting injections. The injection becomes less effective the longer you wait. Figure

To stop using injections:

You can stop having birth control injections any time you want. But after you stop, it can take a year or more to become pregnant and for your monthly bleeding to return to normal. But it also may come back sooner. So if you do not want to become pregnant right away, you must use another family planning method during this time.

Figure

Intra-Uterine Devices (Devices that go into the womb)

THE IUD (IUCD, Copper-T, The Loop)

The IUD is a small object or device that is inserted into the womb by a specially trained health worker or midwife. Once in the womb, the IUD prevents the man’s sperm from fertilizing the woman’s egg. The IUD can stay in the womb for up to 10 years (depending on the kind of IUD it is) before it must be removed and replaced. An IUD can be used without the man knowing you are using it (although sometimes a man can feel the strings).

Figure

The most common IUDs are made of plastic, or plastic and copper.

Figure

Progestin IUD This kind of IUD also contains the hormone progestin and is available in some countries. Progestin decreases the pain and bleeding that some women have with the IUD. It protects against pregnancy for 5 years.

IMPORTANT
IUDs do not protect against STDs, including HIV/AIDS. Not only that, but if a woman has an STD, the IUD can lead to more serious complications, such as pelvic inflammatory disease (PID). PID can lead to infertility.

Figure

Who should not use an IUD:

¨ IUDs can be used safely by women who are breastfeeding.

Do not use an IUD if you:

· are pregnant or might be pregnant.

· are in danger of getting an STD. (This includes any woman who has more than one partner, or whose partner may have other sex partners.)

· have ever had an infection in your tubes or womb, or an infection after giving birth or after having an abortion.

· have had a pregnancy in your tubes.

· have a lot of bleeding and pain during your monthly bleeding.

· are very anemic.

· have never been pregnant.

¨Do not use an IUD if you are unable to get to a health center or clinic where you can have the IUD removed if necessary.

Common side effects:

You may have some light bleeding during the first week after getting an IUD. Some women also have longer, heavier, and more painful monthly bleeding, but this usually stops after the first 3 months.

How to use the IUD: An IUD must be inserted by a specially trained health worker after doing a pelvic exam. The best time to have the IUD put in is during your monthly bleeding. After childbirth, it is best to wait 6 weeks for the womb to return to its normal size and shape before getting an IUD. Occasionally an IUD will slip out of place. If this happens, it will not be effective in preventing pregnancy, so it is important to learn to check your IUD to make sure it is still in place. Most lUDs have 2 thread-like strings attached which hang down into the vagina. You should check the strings after each monthly bleeding to make sure the IUD is in place. Figure How to check the IUD strings: 1. Wash your hands. 2. Squat down and reach as far as you can into your vagina with your 2 fingers. Feel for the IUD strings, but do not pull them. 3. Take out your fingers and wash your hands again.

Warning signs for problems with an IUD:

Pelvic inflammatory disease is the most serious problem that can result from having an IUD. Most infections happen in the first 3 months, usually because the woman already had an infection when the IUD was put in. Or it may happen because the health worker did not put in the IUD under clean conditions.

If you have any of the following signs, you should see a health worker trained to insert lUDs and to treat complications, or go to a hospital immediately:

· Your monthly bleeding is late.
· You have pain in your lower belly or pain during sex.
· You have a heavy or bad-smelling discharge from the vagina.
· You do not feel well, or have fever or chills.
· Your IUD string is missing, or is shorter or longer than usual.
· Your partner can feel the IUD (not just the strings) during sex.

To stop using an IUD:

When you want to stop using an IUD, it must be removed by a trained health worker. Never try to remove an IUD yourself.

You can become pregnant as soon as it has been removed.

Natural Methods of Family Planning

There are also 3 methods to avoid pregnancy that do not require any devices or chemicals (as with barrier methods) or medicines (as with hormonal methods). The methods are:

· breastfeeding for the first 6 months
· the mucus method
· the rhythm method

IMPORTANT
Natural methods of family planning do not protect against STDs, including HIV/AIDS. If you use any of the natural methods listed in these pages, you still need to think about ways to protect yourself from these diseases.

Breastfeeding for the first 6 months (Lactational Amenorrhea Method, LAM)

Breastfeeding under certain conditions can prevent the ovaries from releasing an egg. This method does not cost anything, but it is most effective for only the first 6 months after childbirth.

How to use breastfeeding to prevent pregnancy: Breastfeeding is not an effective method of family planning unless these 3 conditions are true: 1. Your baby is less than 6 months old. Figure 2. You have not had your monthly bleeding since giving birth. Figure 3. You are giving your baby only breast milk, and feeding it whenever it is hungry - with no more than 6 hours between feedings - day and night. Your baby does not sleep through the night without feeding. Figure Use another method of family planning that is safe with breastfeeding as soon as any of the following things happen: · Your baby is more than 6 months old, or · Your monthly bleeding starts, or · Your baby starts taking other kinds of milk or other foods, or starts sleeping for more than 6 hours during the night, or · You must be away from the baby for more than 6 hours and cannot remove milk from your breasts during that time.

The mucus method and the rhythm method

To use either of these methods, you must understand when you are fertile during your monthly cycle. This is sometimes called ‘fertility awareness’. Then, to avoid pregnancy, you and your partner must not have sex, or must use a barrier method of family planning, during your fertile days.

¨ All these methods require the man’s cooperation or they will not be effective.

Figure

Because there are no costs or side effects, these methods can be used by women who cannot or do not want to use other methods, or when other methods are not available.

To practice fertility awareness more effectively, both you and your partner should visit a specially trained health worker to learn about your bodies and about fertility. It usually takes about 3 to 6 months of practice to learn how to use these methods.

Natural family planning methods do not work as well if:

· you have little control over when you will have sex. During your fertile times, your partner must be willing to wait and not have sex or to use condoms or some other barrier method.

· your fertility signs change from month to month. You will not be able to know when you are fertile.

· you have just had a baby or miscarriage. It is hard to know when you are fertile at these times.

Figure

What you should know about a woman’s cycle of fertility:

· A woman produces one egg each month.

· The egg is released from the ovary about 14 days before the next monthly bleeding.

· The egg lives for about 24 hours (1 day and 1 night) after it has been released from the ovary.

· The man’s sperm (seed) can live up to 2 days inside the woman’s body.

Figure

To make all natural family planning methods more effective: · Have sex only on the days between the end of the fertile time and your next monthly bleeding. · Use both the mucus method and the rhythm method at the same time. · Use condoms whenever you are not sure if you are fertile, or do not have sex.

Mucus Method

To use the mucus method, you must pay careful attention to the mucus (wetness) in your vagina. Your body produces wet mucus during your fertile time to help the sperm get into the womb. So if you check your mucus every day, you will know when you are becoming fertile. Then you can avoid sex during this time.

How to tell when you are fertile: 1. Wipe the outside of your vagina with your finger or a piece of paper or cloth. 2. If there is mucus there, take some between your fingers. How does it feel? Wet and slippery? Dry and sticky? clear, wet, slippery mucus = fertile white, dry, sticky mucus = not fertile Figure How to use the mucus method: · Do not have sex on any day you see or feel wetness or mucus. Or, if you want to have sex on those days, use a condom or a diaphragm without spermicide (these are the only methods that do not change the mucus). · Do not have sex until 4 days after the last day of clear, slippery mucus. · Do not have sex during your monthly bleeding. There is a small possibility you could be fertile and not be able to tell. · Do not douche or wash out your vagina at any time. · If you are having trouble knowing when you are fertile, or if you have a vaginal infection, you should use another method.

Rhythm Method

The rhythm method teaches you to find your fertile time by counting the days in your monthly cycle. You CANNOT rely on the rhythm method if:

· you are breastfeeding and your monthly bleeding has not returned.

· you have recently been pregnant and your monthly bleeding is not yet regular.

How to use the rhythm method: · Count the number of days in each of your monthly cycles for 6 months, from the first day of one monthly bleeding until the first day of the next. · Pick out the longest and the shortest cycles. · Take away or subtract 20 days from your shortest cycle and 10 days from your longest cycle. The time between these 2 days is your fertile time. · Although you can have sex any time before or after your fertile time, the safest time is between the end of your fertile time and the beginning of your next monthly bleeding. For example: Julia kept track of her monthly bleeding for 6 months. Her shortest cycle was 26 days and her longest cycle was 34 days: To avoid pregnancy, Julia should not have sex, or she should use another family planning method, from day 6 after her monthly bleeding starts until day 24. You must use another method of family planning while you are counting your 6 monthly cycles. But you should not use the pill, implants, or injections during the time you are counting, because these methods change the time when your monthly bleeding starts.

Traditional and Home Methods to Prevent Pregnancy

Every community has traditional methods to prevent or stop pregnancy. Many of these can be very useful in limiting the number of children a couple has, although they are usually not as effective as modern methods. But some traditional methods are not effective at all, and some can even be very harmful.

TRADITIONAL METHODS THAT WORK

Withdrawal or pulling out (coitus interruptus). With this method, a man pulls his penis out of the woman and away from her genitals before he ejaculates. This method is better than no method, but it does not always work. Sometimes a man is not able to pull out before he ejaculates. Even if the man pulls out in time, some liquid that contains sperm can leak out of his penis before ejaculation and cause pregnancy.

Figure

Separating partners after childbirth. In many communities, couples do not have sex for months or years after the birth of a baby. This allows the mother to give more time to the care of the new baby and to regain her strength without fear of pregnancy.

TRADITIONAL METHODS THAT DO NOT WORK OR THAT CAN BE HARMFUL

· Omens and magic do not prevent pregnancy.

· Putting grasses, leaves, pods, and dung in the vagina can cause infection and irritation.

· Washing out the vagina (douching) with herbs or powders does not prevent pregnancy. Sperm move very fast and some will reach the inside of the womb before they can be washed out.

· Urinating after sex does not prevent pregnancy. (But it can help to prevent infections of the urine system.)

Permanent Methods of Family Planning

STERILIZATION (the operation for no more children)

There are operations that make it almost impossible for a man or a woman to have any children. Since these operations are permanent, they are only good for those women or men who are certain that they do not want any more children.

To have one of these operations, you must go to a health center or hospital. The surgery is fast and safe, and does not cause side effects.

The operation for the man (Vasectomy)

A vasectomy is a simple operation in which the tubes that carry the sperm from the testicles to the penis are cut. The man’s testicles are not cut. This operation can be done in any health center where there is a trained health worker. It takes only a few minutes to do.

Figure

Figure

The operation does not change a man’s ability to have sex or to feel sexual pleasure. He still ejaculates semen but there are no sperm in the semen. He must ejaculate 20 times after the operation before all the sperm are gone. During this time, keep using your regular method of family planning.

The operation for the woman (Tubal Ligation)

Figure

A tubal ligation is a slightly more difficult operation than a vasectomy, but it is still very safe. It takes about 30 minutes.

A trained health worker makes I or 2 small cuts in the woman’s belly, and then cuts or ties the tubes that carry the eggs to the womb. It does not change a woman’s ability to have sex or to have sexual pleasure.

IMPORTANT
Sterilization does not protect against STDs, including HIV/AIDS. So you will still need to think about ways to protect yourself from these diseases.

Emergency Methods of Family Planning

Emergency methods are ways for women to avoid pregnancy after having unprotected sex. These methods prevent a fertilized egg from attaching to the womb wall. They are only effective if used soon after having sex.

Emergency methods are safe and effective. But they are not as effective as consistent use of the other family planning methods discussed in this chapter and they can cause unpleasant side effects.

EMERGENCY PILLS

The pills used for emergency family planning are the same combined birth control pills that some women take each day. But in emergencies, you take a much higher dose for a short time. You must take the pills within 3 days (72 hours) of having unprotected sex. The pills will not work if you are pregnant from having sex more than 3 days earlier.

Figure

¨ Emergency family planning methods should not be used instead of other methods.

How to take Emergency Pills: Low dose pills. Take 4 low-dose birth control pills, which contain 35 mcg of the estrogen called ethinyl estradiol. Then take 4 more tablets 12 hours after the first dose. Some common brands are Brevicon 1 + 35, Lo-Femenal, Lo-Ovral, Microgynon 30, Microvlar, Neocon, Nordette, Ortho-Novum 1/35, 1/50. OR High dose pills. Take 2 high-dose birth control pills, which contain 50 mcg of the estrogen called ethinyl estradiol. Then take 2 more tablets 12 hours after the first dose. Some common brands are Ovral, Femenal, Primovlar, Norlestrin, Ovcon 50, Nordiol, Eugynon, and Neogynon. Emergency pills can make you have headaches or feel nauseous. Try eating something at the same time you take the pills and, if possible, take a medicine that will keep you from vomiting. If you vomit within 3 hours of taking the pills, you should take them again.

Until your next monthly bleeding, you should use a barrier method of family planning, like condoms, or not have sex. After your monthly bleeding, you can use any family planning method you choose.

Your next monthly bleeding should begin in about 2 weeks. If it does not, you may have become pregnant despite the emergency family planning. You should continue to use a barrier method of family planning until you know for sure.

OTHER EMERGENCY METHODS

Mini pills (progestin only pills). These pills contain no estrogen, so they cause less nausea than combined birth control pills. They only work if taken within 2 days (48 hours) of having unprotected sex.

· Take 20 mini pills followed by 20 more pills 12 hours after the first dose.

Figure

Mifepristone, also known as RU 486 or the ‘French Pill’, causes less nausea and vomiting than the other emergency pills.

· Take 600 mg within 3 days of having unprotected sex. Take this amount only once.

Figure

IUD (Intra-Uterine Device): An IUD can also keep the egg from attaching to the womb wall.

Figure

· The IUD must be inserted by a specially trained health worker within 5 days after having unprotected sex. The IUD can be kept in and continue to protect you from pregnancy for up to 10 years. Do not have an IUD inserted if you are at risk of having an STD.

Figure

New methods of family planning The following new methods of family planning are available or are being developed. They may only be available in some places and may be expensive. We include them here because the more women know about new methods and ask for them, the more likely it is that the methods will become available for everyone and perhaps be less costly. The more methods there are, the more likely it is that every woman who wants to prevent pregnancy will be able to find a method that suits her needs. 1. Plastic condoms are made from very fine polyurethane. They are thinner than latex condoms and allow for more feeling. They are less likely to be damaged by heat or oils. 2. Once-a-week birth control pills work by changing a woman’s natural balance of estrogen, which prevents a fertilized egg from attaching to the womb wall. The once-a-week pill is less effective than regular daily birth control pills at preventing pregnancy. Little is known about its side effects. 3. Vaginal rings slowly release progestin into a woman’s vagina. Vaginal rings come in only one size and a woman can put one in herself. They last from 3 months to a year. After taking the ring out, fertility returns within 24 hours. If you are offered a new method of family planning, be sure to discuss any concerns you have before choosing that method. Make sure you have all the information you need to make a good choice, and that you are not being pressured into using a method that is not right for you.

Choosing the Best Method

After reading this chapter, if you still have questions about which family planning method is best for you, the chart below may help. It is important to choose a method that meets your needs, because then you will be likely to use it regularly and it will be more effective.

Personal Needs	You Might Prefer	You Should Probably Avoid
Your partner is not willing to take an active role in family planning.	Hormonal methods, diaphragm, female condom, IUD	Male condoms, natural methods
Other bleeding, besides your normal monthly bleeding, worries you or creates difficulties for you.	Barrier methods, IUD	Hormonal methods
You do not want any more children.	Sterilization, implants, IUD, injections	Natural methods, barrier methods
No matter what you say, your partner does not want you to use family planning.	Injections, inserts, lUDs	Barrier methods, pills, natural methods
You feel embarrassed to touch your vagina.	Hormonal methods, male condoms	Diaphragm, female condoms
You do not feel comfortable asking your partner to avoid or to interrupt sex.	IUD, hormonal methods	Barrier methods, natural methods
Your are concerned that your partner has had sex with others and may infect you with STDs	Male or female condom, or other methods combined with condoms	IUD, hormonal methods
You have more than one sex partner or have had STDs.	Male or female condom	IUD
You think you will want to have a child within a year	Male or female condom, diaphragm, natural methods, combined or progestin-only pills	IUD, injections, implants
You are breastfeeding.	IUD, male or female condoms, diaphragm with spermicide, mini pill, progestin-only injections	Combined birth control pills, injections with estrogen
You have not had a child.	Hormonal methods, barrier methods	IUD
You do not want to have to remember to do anything.	IUD, implants, injections	Birth control pills, natural methods

After you choose a new method

Figure

Working for Change

Sometimes a woman would like to space her children or limit the number she has, but cannot use family planning. This can happen because:

· she cannot get the information about different methods.

· some family planning methods are not easily available or cost too much for the family to afford.

· there are no women’s health or family planning services nearby, or the local health worker is not trained to provide family planning services.

· religious beliefs forbid the use of family planning.

· a woman’s husband does not agree to use family planning.

Here are some things that groups of people can do to make family planning services more available to all women in the community, and to encourage the use of family planning: · Provide education. Make information about family planning available to everyone - boys and girls as well as women and men. Education programs can show the benefits of family planning and help couples choose the best methods for them. Perhaps you can lead discussions with women or couples about their concerns and experiences related to family planning. Include information about preventing STDs and HIV/AIDS when you talk about family planning. · Make family planning methods accessible at a low cost. Have a local health worker trained to provide family planning services start a women’s health center or include family planning services at your local clinic. · Train male outreach workers to educate men about the importance and benefits of family planning. Help men understand their role in reproduction so they can see that they should share the responsibility for family planning. Try to change attitudes about what is ‘manly’ so that men will support and participate in family planning with their partners. · Address local religious concerns about family planning. If a family planning method can be explained in a way that respects religious beliefs, it will help create more acceptance of it. Figure As you talk about family planning in your community, it helps to remember and remind others that family planning is important to improve not just women’s health and well being, but the health and quality of life of everyone in your community.