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FAMILY PLANNING By, Lutfi Abdallah

Laso - Family planning

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Page 1: Laso - Family planning

FAMILY PLANNING

By,Lutfi Abdallah

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Definition..• FP Refers to voluntary decision and action taken

by a couple or individual to delay, space or limit child bearing

• Family planning means deciding how many children to have and when to have them. Birth control is a cornerstone of the concept.

• FP services are provided to all adults who voluntarily seek the services regardless of the parity or marital status.

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..• The family planning services offered by the

National Family Planning Program include; Education and counseling.The provision of contraceptives. Education about sex and parenthood. Management of infertility

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Why Family Planning?• The population size of TZ has almost tripled from

12.3mil in 1967 to 34.4mil in 2002 while the national economy did not grow significantly.

• With an annual growth rate of 2.9%, Tanzania’s population has been projected at 65 million by 2025. Based on the fact that all of the girls who will enter childbearing age over the next decade have already been born, and the fact that almost 50% of the country’s population are under 15 years, Tanzania’s population growth is set to remain at 2.8% by 2025, according to the National Bureau of Statistics (NBS) national projections.

• Therefore it became evident that improvement in the quality and expansion of services such as health and education is unlikely to happen without controlling rapid population growth

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Why family planning cont..• High fertility levels are partly attributable to early

initiation of childbearing coupled with socio-cultural practices that place emphasis on big families, hence contributing to rapid population growth. 26% of mothers are teenage (15-19) in Tanzania.

• High Maternal Mortality Rate due to illegal abortion, frequent pregnancies, high parity, and women having children at ages recognized as high risk.

• High infant and child mortality rate

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• Achievement: The total fertility rate (TFR) has slightly decreased from an average of 5.6 children per woman of reproductive age (15-49) in 2007/08 to an average of 5.4 children per woman of reproductive age in 2009/10

• Challenge:Factors contributing to high fertility still pertain and continued advocacy efforts are needed to sustain an enabling environment necessary for reduction in TFR. The impact is especially significant in the peripheral areas where health facilities are poorly equipped.

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• Achievement: There is a drop in the high rate of maternal deaths of 578 per every 100,000 live births in 2004-5 to 454 per every 100,000 live births 2010.

• Challenge:According to a United Nations Report released in September 2010, Tanzania is among countries in the world that still have high rates of maternal death despite falling rates of maternal mortality at the global level.

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• Achievement:Good progress has been made in reducing the infant and under-five mortality rate from 58 and 91 deaths of infants per 1,000 live births in 2007/08 to 51 and 81 deaths per 1,000 live births, respectively, according to the 2010 TDHS.

• Challenge:UN Report placed Tanzania as the third country with the largest number of death of children in Africa after Nigeria and Democratic Republic of Congo.

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• AchievementAccording to the DHS, 34% of married women are currently using a method of contraception (traditional and modern) compared to 26% of married women that were using any method in 2004/05. The survey showed that the number of married women that were using modern methods of contraception (i.e., oral contraceptive pills, contraceptive injectables, IUDs, implants, sterilization and condoms) has continued to increase from only 20% of the married women in 2004/05 to 27.4% in 2009/10.

Challenge:About 22% of married women in Tanzania who want to prevent or delay a pregnancy and use contraception do not have access to a method because of weak infrastructure, electricity and space of storage

Socio-cultural barrier: gender inequalities, low women empowerment and misconceptions of various health related issues exist.

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Other challenges and obstacles hindering smooth delivery of FP services

1. Some service providers’ attitudes towards FP are poor and they lack motivation to reach out to clients with accurate information.

2. Low public awareness of reproductive health matters such as management of pregnancy, newborn care, childcare and related complications. For example, some clients associate condom use with extra-marital sex and vasectomy as castration.

3. Advocacy to improve public knowledge on FP towards overcoming the negative perceptions in some of the FP methods is greatly needed. There are numerous reasons that are attributable to the situation of reproductive health commodities being insufficient. One is that of funding.  Donor support in the commodities dropped from $560 million in 1995 to $460 million in 2003.The Global Programme to Enhance Reproductive Health Commodity Security reveals the same trend between 2007 and 2013, the amount needed was $750,000,000 only $208,528,277 was receives while $170,041,267 was pledged and still $371,430,456 was needed.

4. Inconsistent and ineffective FP messages, limited support by indigenous organizations to advocate for FP, and inadequate skilled personnel especially for Intra-Uterine Device (IUD) and implants.

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Benefits..• Family planning helps women to stay healthy and

improves the outcomes of their pregnancies.

• Family planning can improve the economic position of families and communities and preserve natural resources.

• Prevent too-close spacing of pregnancy which increases the risk of miscarriage and premature births

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• The government’s dedication to promote FP over the past several decades dates back to the 1970s.

• In 1974, the government acknowledged the role of the Family Planning Association of Tanzania (UMATI) established in 1959, and allowed it to expand FP services to public sector maternal and child health (MCH) clinics throughout the country.

• Several national policy documents have been developed targeting improvement of reproductive and child health services, which include maternal and newborn health.

• Apart from ensuring that FP was integrated into maternal and child health services in the 1980s and 90s, the government put in place a number of policies, guidelines and frameworks to ensure that FP become integral to socio-economic development.

• Government had to revise the National Population Policy in order to accommodate those new developments, in 2006 the Revised National Population Policy was published.

• The main goal was to Coordinate and Influence other policies, strategies and programs that ensure sustainable development of the people and promoting gender equality and the empowerment of women.

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These policies include:• The National Health Policy (2007);• National Road Map Strategic Plan to Accelerate

Reduction of Maternal and Newborn & child deaths in Tanzania (2008-15);

• Health Sector Strategic Plan III (2009-2015);• Primary Health Services Development Programme

(2007-2017);• National FP Costed Implementation Plan (2010-

2015);• National Strategy for Growth and Poverty Reduction

(NSGPR).

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..• With specific reference to FP, the goals of the

policy were:• To strengthen family planning services to promote

the health and welfare of the family, community and the nation and eventually to reduce pop growth rate.

• Making FP services available to all who want them.

• Encourage every family to space births at least two years apart.

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• The above situation calls for intensified efforts to promote family planning as part of comprehensive health strategy in TZ in order to:Avoid pregnancies before 18yrs and above 35yrs.Promote women health and family health at large by

promoting child spacing.Reduce unwanted pregnancies and hence abortions.Finally reduce the Maternal Mortality and Morbidity.

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Methods of Family PlanningA. Reversible Method

- Natural Method.- Barrier Methods.- Intrauterine contraceptive devices.- Hormonal Methods.

B. Non Reversible Methods- Bilateral Tubal Ligation.- Vasectomy.

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Natural family planning• Natural family planning involves trying to

determine when ovulation will occur and timing sexual intercourse to either achieve or avoid pregnancy.

• Couples keep a chart to monitor changes in the woman's body(rising body temperature or thickening of the cervical mucous, both of which suggest ovulation).

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Natural Method

• This is an extremely important method of contraception worldwide and may be the only one acceptable to some couples because of cultural and religious reasons.

• As birth control, natural family planning can be 90 to 98 percent effective.

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• Coitus interruptus-Also called withdrawal, involves removal of the penis from the vagina immediately before ejaculation takes place.

- It is not reliable as pre-ejaculatory secretions may contain millions of sperm and also it is hard to judge timing of withdrawal.

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• The failure rates of natural methods are quite high, largely because couples find it difficult to abstain from intercourse when required or unable to withdraw the penis before seminal discharge.

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Barrier Method• Male Condoms

•Have been heavily promoted in the Safe Sex campaign to prevent spread of STD particularly HIV/AIDS.•They are cheap and widely available to purchase or are even free from many clinics

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•When used properly they can be 95%-100% effective against unwanted pregnancies.•Some men and women may be allergic to latex condoms but these days plastic condoms are available.

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• Female Condom

•Made of plastic, they are also available.•They offer particularly good protection against infection.•Many couples find them unaesthetic and they have not achieved widespread popularity

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• Diaphragm•Are inserted into the vagina and cover the cervix.•Should be inserted prior to intercourse and should be removed no earlier than six hrs later.•Effective use of diaphragm involves careful fitting and teaching.•Can be used with a spermicidal gel or cream.

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• Combined Oral Contraceptive Pills (COC)• Contains a combination of two hormones, synthetic

oestrogen and progesterone.• They inhibit ovulation.• Easy to use and offers a very high degree of protection

against pregnancy with many other beneficial effects.• It is used mainly by young, healthy women.• They are absolutely Contra Indicated to pts with

Circulatory diseases, acute or severe liver diseases, oestrogen-dependent neoplasm e.g.breast cancer.• Side effects include irregular bleeding, vaginal discharge,

breast pain, weight gain, nausea and vomiting, headaches, depression

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• Progestogen only pills (POP)• Ideal for women who like the convenience of the pill but

cannot take COC.• Particular indications for POP include breastfeeding, older

women, presence of cardiovascular risk factors and diabetes

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• Injectable progestogen• Also known as Depo Provera, each injection lasts around

12-13 weeks.• It is highly effective and it is given by deep IM injection.• Its particularly good for those with difficulty in

remembering to take a pill.• Side effects include weight gain, delay in return of fertility,

persistent menstrual irregularity

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• Sub-dermal implants• Norplant consist of 6 silastic rods which contain levonogestrel. They are inserted subdermally in the upper arm.• Release levonogestrel slowly and lasts for five years.• They are very effective. • Insertion and removal of Norplant must be done by a trained healthcare professional i.e client cannot start or stop use on her own.• Common SE include changes in menstrual bleeding, headaches, dizziness,nausea, nervousness, acne or skin rash, weight gain.• Implanon, single silastic rod, 3yrs.

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Intrauterine Devices• They are highly effective but not widely used in

our setup.• Fitting of an IUD should be carried out by trained

healthcare personnel only.• Ideal for women who want a long-term method of

contraception independent of intercourse and where regular compliance is not required.

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• Types:

•Plastic IUD e.g. LIppes loop•Copper-bearing IUD e.g. copper T•Hormonal releasing IUD e.g. progestogen releasing IUD.

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• They are long-lasting, 5-10yrs.• Common side effects include menstrual changes

in the first 3 months.• Others, like PID is more likely to follow STD

infection, or the IUD may come out of uterus without the woman’s awareness.

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INDICATORS TO MEASURE CONTRACEPTIVE PRACTICE.The following indicators summarizes themost useful pieces of information availablefrom large scale survey for measuringcontraceptive practice.

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• Contraceptive Prevalence Rate (CPR)• Proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at particular point in time.• The CPR provides a measure of pop coverage of contraceptive use, taking into account all sources of supply and all contraceptive methods.• It is the most widely reported measure of outcome for family planning program at a population level.• Currently in TZ the contraceptive prevalence is 25%.

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• Number of Current Users• The number of women (or their partners) of reproductive age who are estimated to be using a contraceptive method at a given point in time.• Number of current users provide a summary measure of total program service volume.• But counting number of current users from program has proven to be labour intensive and time consuming.• Also most researchers and evaluators are more interested in CPR

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• Level of Past Use.• The proportion of women of reproductive age who have ever used a contraceptive method, include those who currently use one.• Provides a crude measure of the extent to which a given population has experimented with methods of contraception i.e that they have first hand knowledge by having tried it at some point in time.• In TZ 41% of women aged 15-49 and 48% of all men have used a contraceptive method at some point in their lives (1999).

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• Source of Supply (By Method)• The % distribution of the types of service delivery points

cited by users as the source of their contraceptive method.• Useful in family planning programme officials to show

where contraceptive users obtain their supply, for both evaluating program effectiveness and forecasting procurement needs• In Tanzania, current users (modern) are more likely to

obtain their supply from the public sector (67%) than the private medical sector (22%) or other private source (11%).• i.e. public sector is the source of modern contraceptives

to 7 of every 10 current users

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• Method Mix• Percentage distribution of contraceptive users by method.• It indicates the distribution of contraceptive use across different methods of contraception.• It can reflect provider bias, supply problems and client preferences.• Essential in forecasting of commodity and service needs in future.• In TZ, the most widely used methods are injectables (5%),the pill (5%), and male condom (4%) – 1999. From TDHS 2004-05, Injectables (8%), the pill (6%) and traditional method (6%).

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Trends in Contraceptive Use• Contraceptive use has substantially increased

over the past 15yrs. In 1991-92 only 10% of all women were using any contraceptive method; that proportion has more than doubled to 25%.

• On the other hand, in 1991-92, the use of any modern contraceptive method among all women was at 6%, and the % has almost tripled to 16% in 1999.

• On specific method most notable is the steady rise in use of injectables, from less than 1% in 1991-92 to 5% in 1999 to 8% in 2004/05.

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• In spite of the sizeable proportion of women who say that they do not want to have any more children, the proportion of women who have been sterilized has changed little.

• Current use of traditional methods has increased from about 4% in 1991-92 to 7% in 1999, despite the increased knowledge of modern contraceptive methods since 1991-92

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Factors Affecting Acceptance• Education• Is clearly related to the use of contraceptive method. Only

14% of women with no formal education are currently using any contraceptive, compared with 18% of women with incomplete primary school, 27% of women who have completed primary school and 43% of women with at least some secondary education

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• Parity• Current contraceptive use rises with the number of living

children. The % of women using any contraceptive method rises rapidly from 7% among women with no living children to 28% among those with one child and 30% among those with six or more children

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• Religion• Some religions believe in natural methods of contraception and not modern ones.

• Misconception about FP• A lot of individuals out there think that FP program is there to sterilize them.

• Worry over potential side effects •When expected side effects are not explained carefully to the client.

• Cultural beliefs• Some believe that more children will bring more wealth to their family.

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• Abortion is illegal in Tanzania (except to save the mother’s life or health), so women and girls turn to amateurs, who may dose them with herbs or other concoctions, pummel their bellies or insert objects vaginally.

• Infections, bleeding and punctures of the uterus or bowel can result, and can be fatal. Doctors treating women after these bungled attempts sometimes have no choice but to remove the uterus.

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..• Worldwide, there are 19 million unsafe abortions a

year, and they kill 70,000 women (accounting for 13 percent of maternal deaths), mostly in poor countries like Tanzania where abortion is illegal, according to the World Health Organization.

• More than two million women a year suffer serious complications. According to UNICEF, unsafe abortions cause 4 percent of deaths among pregnant women in Africa, 6 percent in Asia and 12 percent in Latin America and the Caribbean.

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• Keeping abortion outlawed does not actually reduce the number of abortions; rather, it reduces the safety of those performed.

• Legal restrictions on abortion do not affect its incidence. For example, the abortion rate is 29 [per 1,000 women aged 15–44] in Africa, where abortion is illegal in many circumstances in most countries, and it is 28 [per 1,000 women aged 15–44] in Europe, where abortion is generally permitted on broad grounds. The lowest rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions.

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• Where abortion is legal and permitted on broad grounds, it is generally safe, and where it is illegal in many circumstances, it is often unsafe. For example, in South Africa, the incidence of infection resulting from abortion decreased by 52% after the abortion law was liberalized in 1996.

• (ol by american humanist association)published 2012

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References• World Bank, World Development Indicators,

November 2010• National Family Planning Costed Implementation

Program (NFCIP 2010-2015), Ministry of Health and Social Welfare

• Tanzania Demographic and Health Survey 2010 (TDHS) Preliminary Report August 2010.

• TDHS 2004-05• Tanzania family planning landscape assessment,

October 2010