Family Planning and Contraception

Family Planning is the conscious process by which a couple decides on the number and spacing of children and the timing of births.

Specific Objectives of Family Planning:

1. Avoiding unwanted pregnancies through contraception
2. Regulating intervals between pregnancies
3. Deciding on the number of children that will be in the family
4. Controlling the time at which births occur
5. Preventing pregnancy for women with serious illness in whom pregnancy would pose a health risk
6. Providing the option of avoiding pregnancy to women who are carrier of genetic disease

The overall goal of nursing intervention in family planning is to improve general maternal, neonatal and family health.

Preconception Planning – an ideal that is not always realized – offers couple an opportunity to enhance the probability of having a healthy newborn. It involves examining the health history and physical health of both partners and providing appropriate instruction relative to physical, psychological an financial preparation for pregnancy and childbirth.

Contraception – is the voluntary prevention of pregnancy. The decision to practice contraception has individual and social implications.

Factors to consider when choosing the appropriate contraceptive method:

1. Religious orientation
2. Social and cultural values
3. Medical contraindications
4. Psychological contraindications
5. Individual sexual expression
6. Cost
7. Availability of bathroom facilities and privacy
8. Partner’s support and willingness to cooperate
9. Personal lifestyle

Abstinence – the most effective way to protect against conception. This has 0% failure rate. Also, this is the most effective way to prevent STDs.

I. Natural Family Planning Method – this involve no chemical or foreign material being introduced into the body. The effectiveness of these methods varies greatly, depending mainly on the couple’s ability to retain from having sex on fertile days. Failure rates usually range from 10% to 20%, although theoretical failure rate is as low as 1% or 2%. If pregnancy should occur, the continued use of these methods poses no risk to the fetus.

A. Calendar (Rhythm) Method – This requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most likely to conceive (3 or 4 days before until 3 or 4 days after ovulation).

B. Basal Body Temperature Method (BBT) – The basis of this method is that just before the day of ovulation, a woman’s BBT falls about half a degree. At the time of ovulation, her BBT rises a full degree because of the influence of progesterone. This higher level is then maintained for the rest of the menstrual cycle.

C. Cervical Mucus (Billings) Method –Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger (known as spinnbarkeit). Just before ovulation, mucus secretion increases. With ovulation (the peak day), cervical mucus becomes copious, thin, watery and transparent. It feels slippery and stretches at least 1 inch before the strand beaks. In addition, breast tenderness and an anterior tilt to the cervix occur. All the days the mucus is copious and the 3 days after the peak day are considered to be fertile days, or days the woman should abstain from sex to avoid conception.

D. Symptothermal Method – The symptothermal method of birth control combines the cervical mucus and BBT methods. The woman takes her temperature daily, watching for the rise is temperature that marks ovulation. She also analyzes her cervical mucus daily. The couple must abstain from intercourse until 3 days after the rise in temperature or the fourth day after the peak of mucus change because these are the woman’s fertile days. The symptothermal method is more effective than either the BBT or cervical mucus method alone.

E. Ovulation Awareness – This is another method to predict ovulation with the use of over-the-counter ovulation detection kit. These kits detect the midcycle surge of luteinizing hormone that can be detected in urine 12 to 24 hours before ovulation. Such kits are about 98% to 100% accurate in predicting ovulation. Although fairly expensive, using such kit in place of cervical mucus testing makes this form of natural family planning more attractive to many women.

F. Lactation Amenorrhea Method (LAM) – As long as a woman is breast-feeding an infant, there is some natural suppression of ovulation. However, the use of lactation as a birth control method is not dependable. Because women may ovulate but not menstruate while breastfeeding, the woman may still be fertile even if she has not had a period since childbirth. After 6 months of breast feeding, the woman should be advised to choose another method of contraception.

G. Coitus Interruptus – It is one of the oldest known methods of contraception. The couple proceeds with coitus until the moment of ejaculation. The man withdraws and spermatozoa are emitted outside the vagina. Unfortunately, ejaculation may occur before withdrawal is complete and, despite the care used, some spermatozoa may be deposited in the vagina. Because there maybe a few spermatozoa in pre-ejaculation fluid, even though withdrawal seems controlled, fertilization may occur. For these reason, coitus interruptus offers little protection against conception.

II. Barrier Methods – are forms of birth control that works by the placement of a chemical or another barrier between the cervix and advancing sperm so sperm cannot enter the uterus or fallopian tubes and fertilize the ovum.

A. Spermicides – Spermicidal agents cause the death of spermatozoa before they can enter the cervix. Vaginal jelly, cream, suppository, or foam preparations interfere with sperm viability and prevent sperm from entering the cervix. Nonoxynol-9, the active chemical ingredient, destroys the sperm cell membrane. Pregnancy rates among typical users range from 5% to 50%. Advantages are that they are available without prescription, are useful when other methods are inappropriate or contraindicated, and have few or no side effects. They also may provide moderate protection (up to 25%) against some STDs, including gonorrhea and Chlamydia. Disadvantages are that they have a lower effectiveness than other methods, may irritate tissues (most products contain alum), and are esthetically unpleasant. One dose of most spermicides is effective for 1 hour. If a longer time has passed, a new application of spermicide is required.

B. Female condom (vaginal pouch) – This is a long polyurethane sheath that inserts manually into the vagina with a flexible internal ring forming the cervical barrier and a wide outer ring extending to cover the perineum; it is lubricated with spermicide (nonoxynol-9). It can be inserted up to 8 hours before intercourse and is available over counter (OTC). It is about 80% effective. Advantages are that it protects against STDs and conception, allows the woman to control protection, is inexpensive for single use, and is disposable. Disadvantages are that it is esthetically unappealing, requires dexterity, is expensive for frequent use, may cause sensitivity to sheath material, and decreases spontaneity.

C. Male condom – This is a rubber sheath that fits over the erect penis and prevents sperm from entering the vagina. The condom is about 86% effective. Advantages are that it helps prevent conception and transmission of STDs (thereby preserving fertility), is available OTC, and has no side effects. In addition, the condom helps men maintain erections longer, prevents premature ejaculation, prevents sperm allergies, and is easily and discreetly carried by men and women. Disadvantages are that it may decrease spontaneity and sensation, and should be used with vaginal jelly if the condom or vagina is dry. Male condoms cannot be used in cases of latex allergy in the man or the woman. There are “natural” (animal skin) condoms available, but they are expensive and do not protect against most STDs.

D. Cervical cap – This is a small rubber or plastic dome that fits snugly over the cervix. Effectiveness depends on parity. In parous women, effectiveness is about 60%; in nulliparous women, effectiveness is about 80%. The advantage is that it provides continuous protection for 48 hours, no matter how many times intercourse occurs. Additional spermicide is not necessary for repeated acts of intercourse. Disadvantages are that it may dislodge, must be filled with spermicide, must be fitted individually by a health care provider, and may not be used if the woman has anatomic abnormalities or an allergy to plastic, rubber, or spermicide. Wear for longer than 48 hours is not recommended because of the risk of toxic shock syndrome. Side effects include trauma to the cervix or vagina, pelvic infection, cervicitis, and abnormal Pap test results. Odor problems may occur with prolonged use.

E. Diaphragm – This is a flexible ring covered with a dome-shaped rubber cap that inserts into the vagina and covers the cervix. The posterior rim rests on the posterior fornix and the anterior rims fits snugly behind the pubic bone. It is used with spermicide in the dome and around the rim, is applied no more than 2 hours before intercourse, and is left in place for 6 hours after coitus, but no longer than 12 ( and never more than 24). Additional spermicide must be applied for repeated intercourse. Effectiveness is about 80% with typical use. Advantages are that it is reusable and inexpensive with use over several years. Disadvantages are that it requires dexterity to insert, it must be fitted individually, it must be refitted after childbirth or after a weight loss of 15 lb or more. Wear for longer than 24 hours is not recommended because of the risk of toxic shock syndrome. Side effects include toxic shock syndrome, cystitis, cramps or rectal pressure, and allergy to spermicide or rubber.

F. Intrauterine device (IUD) – This is a flexible device inserted into the uterine cavity. It alters tubal and uterine transport of sperm so that fertilization does not occur. Estimates of effectiveness vary between 93% (typical effectiveness) and 97% (maximal effectiveness). Advantages are that it is inexpensive for long-term use, is reversible, has no systemic side effects, may be used in lactating women, and requires no attention other than checking that it is in place (by feeling for the attached string in the vaginal canal). An ideal candidate for an IUD is a parous woman in a mutually monogamous relationship. Disadvantages are that there are possibly serious side effects. The device is available only through a health care provider and cannot be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. It should not be used by women who have an increased risk of STDs and women with multiple sexual partners. Side effects include dysmenorrheal, increased menstrual flow, spotting between periods, uterine infection or perforation, and ectopic pregnancy. Danger signs to report to the health care provider include late or missed menstrual period, severe abdominal pain, fever and chills, foul vaginal discharge, and spotting, bleeding, or heavy menstrual periods. Spontaneous expulsions occur in 2% to 10% of users in the first year.

III. Pharmacologic methods – are reversible and contraceptive steroids are now formulated in pills, patches, intravaginal rings, subdermal implants and injections.

A. Oral contraceptives – Combined estrogen and progesterone preparation in tablet form inhibits the release of FSH, LH, and an ovum. The tablets are taken daily and are available in numerous hormone combinations (and as a progesterone-only preparation. Biphasic and triphasic contraceptives closely mirror normal hormonal fluctuations of the menstrual cycle. They are about 97% effective. Advantages are that they are among the most reliable contraceptive methods and are convenient to use. In addition, they are protective against ovarian and endometrial cancer, benign breast disease, ovarian cysts, ectopic pregnancy, pelvic inflammatory disease (PID), and anemia. Oral contraceptives also tend to decrease menstrual cramps and pain. Disadvantages are that they should not be used by women who smoke; women with a history of thrombophlebitis, circulatory disease, varicosities, diabetes, estrogen-dependent carcinomas, and liver disease; or by women who are older than 35 years of age. Reassessment and reevaluation are essential every 6 months. No protection is conferred against STDs. Side effects include breakthrough bleeding, nausea, vomiting, susceptibility to vaginal infections, thrombus formation, edema, weight gain, irritability, and missed periods. Danger signs indicating complications include abdominal pain, chest pain or shortness of breath, headaches, blurred or loss of vision, or leg pain in the calf or thigh.

B. Minipills – These contraceptive pills contain progestin but no estrogen. A pill must be taken each day and preferably at the same time each day to achieve maximal effectiveness. The use of minipills results in a thin atrophic endometrium and a thick cervical mucous, which inhibits permeability of sperm. Minipills do not suppress ovulation consistently; 40% of women will ovulate normally. Typical user failure rate is 3%. Advantages are that it may be used immediately postpartum if the client is not breast feeding and 6 weeks postpartum if she exclusively breastfeeding; it is highly effective when combined with breast feeding; it has no estrogen side effects; there is an immediate return to fertility when discontinued; and there is a decreased risk of PID and iron-deficiency anemia. Disadvantages include irregular bleeding, increased risk of functional ovarian cysts, increased risk of ectopic pregnancy (if pregnancy does occur), and it must be taken at the same time each day. There is no data to suggest that minipills increase the risk of cardiovascular disease or malignancy.

C. Subdermal implants – Six, soft, Silastic rods filled with synthetic progesterone are implanted into the woman’s arm. The progesterone leaks into the bloodstream, inhibiting ovulation, making cervical mucus hostile to sperm and inhibiting implantation in the endometrium. The implants are known as Norplant. Estimates of effectiveness vary from 0.04% failure to 99% effective within 24 hours (dropping to 96% effective after 5 years). Advantages are that they are long acting (effective for up to 5 years), not coitus dependent, reversible, inexpensive over the life of the drug, and require little attention other than health care visits for problems or scheduled health maintenance. Production of thick cervical mucous confers a protective effect against PID. Disadvantages are that they require surgical insertion through a half-inch incision on the inside surface of the nondominant arm. They may be difficult to remove and should not be used by a woman who has active thrombophlebitis, unexplained bleeding, active liver disease or tumor, or known or suspected breast cancer. Side effects include tenderness and bruising at the insertion site, irregular bleeding, headaches, acne, weight change, and breast tenderness. Signs of reportable complications include infection, bleeding, or pain at the insertion site; subdermal rod breaking through the skin; heavy vaginal bleeding; severe abdominal pain; and sudden menstrual irregularity after a regular cycle has been established. Any pregnancy that does occur is likely to be ectopic.

D. Subcutaneous injections – Medroxyprogesterone (DMPA or Depo-Provera) is an intramuscular injection given every 3 months that works like subdermal implants. Effectiveness is similar to subdermal implants. Advantages are that it is highly effective and requires little attention except for returning to the health care provider for injection every 3 months. Also, it may be used by breast-feeding women. Disadvantages are similar to those for subdermal implants. In addition, the risk for breast cancer and osteoporosis may be increased, and there may be a delayed return to fertility (up to 18 months) and a decrease in bone density (reversible). Side effects are similar to those for subdermal implants, primarily spotting, headache, and weight gain. DMPA is likely cause amenorrhea, particularly after the first year.

IV. Sterilization – is considered a permanent method of contraception. In certain cases, sterilization can be reversed, but this is not guaranteed. For this reason, sterilization is meant for men and women who do not intend to have children in the future.

A. Vasectomy – Surgical ligation of the vas deferens terminates sperm passage through the vas completely after residual sperm clear the male reproductive tract. It is almost 100% effective (nurses should point out the finality of the procedure). Advantages are that it is highly effective and usually permanent. Disadvantages are that it requires surgery and may be irreversible. Reversal success rates vary; anatomic success is 40% to 90%; clinical success is 18% to 60%. There is no protection against STDs.

B. Tubal ligation – The fallopian tubes are surgically ligated or cauterized either through minilaparotomy or laparoscopy. It is almost 100% effective (nurses should stress the finality of the procedure). Advantages are that it is highly effective and usually permanent. May be performed immediately postpartum. Disadvantages are that it is an invasive procedure and may be irreversible. Tubal reconstruction has a 50% to 70% successful reversal rate; however, there is a high risk of ectopic pregnancy after reversal. In addition, no protection is conferred against STDs.

CONTRACEPTIVE FAILURE RATES:

Resources:

Maternal and Child Health Nursing by Adele Pillitteri

Lippincott Review Series

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