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You are here » Home » Our Work » Health » Family Planning » News/Info » Pearls » Family Planning Pearls »

Family Planning Pearls

I think the Family Planning Global Handbook for Providers is an excellent tool, but is there an even more condensed tool with the “essentials” that providers can use expeditiously?

Yes, the INFO Project has developed one for hormonal methods (OCs, injectables and implants). Entitled “Key Reminders” [PDF, 502KB], it’s configured as a simple sheet that can be hung on a wall or placed on a desk for the provider to refer to easily.

Key sections are: When to start, Who can use, Comparing effectiveness, Correcting mistakes, and Managing common side effects.

What is new and different about the new Family Planning: A Global Handbook for Providers compared to the old Essentials of Contraceptive Technology?

Much is the same in the new family planning handbook, including the familiar organization of chapters by method and the commitment to practical "essential" information. However, in addition to updated technical information on the 13 major family planning methods, you will find:

  • A new section with tools for providers such as the pregnancy "checklist" and new guidance on what to do if a client misses oral contraceptive pills
  • New contraceptive effectiveness chart on the back cover
  • Brief looks at up and coming methods and others not widely available
  • New sections on related health needs such as sexually transmitted infections (STIs) and clients with special needs such as youth
  • More key programmatic points for family planning provision

Additionally, the family planning handbook is expected to ship with an updated version of the methods wall chart, "Do you know your family planning choices?"

We really value Essentials of Contraceptive Technology in our program, but I heard there will be a new family planning clinical handbook to take its place. Is that true?

Yes. The new and markedly improved handbook, Family Planning: A Global Handbook for Providers, reflects an unprecedented global collaborative effort. Partners include the World Health Organization (WHO), USAID, and the INFO Project at Johns Hopkins along with numerous others - including Family Health International (FHI); JHPIEGO; EngenderHealth; Population Council; Institute for Reproductive Health (IRH); Management Sciences for Health (MSH); International Planned Parenthood Federation (IPPF); IntraHealth; International Federation of Gynecology and Obstetrics (FIGO); United Nations Population Fund (UNFPA); and American College of Obstetricians and Gynecologists (ACOG). The book incorporates all the current WHO guidance on contraceptive methods as well as new guidance developed especially for the book—“evidence-based guidance developed through global collaboration.” It is due for release in May 2007.

Many organizations are backing the book, are adopting it as their own, and will be helping with dissemination. Organizations interested in lending their support can contact Jeff Bernson at the INFO Project (jbernson@jhuccp.org) within the next two weeks to receive acknowledgement in the book. INFO is particularly looking for help with printing, translation, and local distribution of this valuable resource.

Order or download Family Planning: A Global Handbook for Providers:

In 1995 an estimated 12 million married women worldwide used injectable contraceptives.  In 2005, what number were using them? (According to the new Population Report “Expanding Services for Injectables.”)

  1. 12 million
  2. 18 million
  3. 24 million
  4. 32 million
  5. 40 million

Correct answer: d - 32 million.

Reference:
Lande R, Richy C. Expanding services for injectables. Population Reports, Series K, No 6. Baltimore, INFO Project, JHU, December 2006.

Since the maker of Norplant contraceptive implants is phasing out manufacture, can you give me an update on USAID support for implants?

Yes. The winning bid in a recent competitive procurement was from the Schering Oy company for Jadelle implants. Jadelle is the 2-rod successor to Norplant which releases the same progestin levonorgestrel at very similar low levels, and is labeled as lasting five years. The base price under the contract is $21 per set. Shipments are scheduled to begin in January 2007.

Has the Implanon™ contraceptive implant received approval in United States?

Yes. See the press release from Organon.

I can see that it can be difficult for clients to understand measures of contraceptive effectiveness. I have to admit, I sometimes have some difficulty with it myself. Are there any innovative ways to describe effectiveness to clients?

Yes. I really like the approach being taken by WHO, FHI, JHU and other collaborating organizations in the development of the new contraceptive clinical handbook. Since the effectiveness numbers are hard for many to deal with, the idea is to arrange the methods in order of effectiveness [PDF, 145KB]. I also like the column on the right that describes what is needed to improve effectiveness with each method.

I'm curious to know, what is the most important reason women give in choosing a method of contraception?

Of course there are many different attributes that can go into contraceptive choice, clients’ needs and desires vary greatly. Thus it is crucial to provide as many contraceptive options as is practicable, to try to best satisfy individual needs and desires.

Interestingly, in a recent Family Health International (FHI) study, contraceptive effectiveness was found to be far and away the most important factor. In this convenience sample of 450 women in India and 450 in Jamaica in response to an open-ended question, 54 percent overall cited how well a method prevents pregnancy as the most important reason for choice. Second most common overall was how few side effects it has at 17 percent.

A previous study from the US also found effectiveness was the most important factor.

References:

Steiner MJ, Trussell J, Mehta N, Condon S, Subramaniam S, Bourne D. Communicating contraceptive effectiveness: A randomized controlled trial to inform a World Health Organization family planning handbook. A J Ob Gyn 2006; Available online.

Steiner MJ, Dalebout S, Condon S, Dominik R, Trussell J. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstetrics & Gynecology 2003;102:709-17.

We are very interested in improving our ability to provide IUDs in our program. Can you please point me to a source of authoritative information on IUDs including programmatic considerations?

Definitely. Experts from various organizations that collaborate with USAID under its Maximizing Access and Quality (MAQ) initiative, have developed an online IUD “Toolkit” of programmatic information and other tools to help with IUD service delivery.

Some of the tools were already existing and just included, and some were created specifically for the toolkit.

Major categories (tabs) in the tool kit are:

  • Overview Documents
  • Essential Knowledge
  • Policies and Guidelines
  • Service Delivery
  • Training
  • Logistics
  • Marketing and Communication
  • Country Experiences
  • Tools

Since Norplant is being phased out, is there any developing-country experience in the transition to either Jadelle or Implanon?

Yes. The transition at the Profamilia clinic in the Dominican Republic has been recently described and (at least in the context of this high-quality, high-volume clinic) the transition from Norplant to Jadelle went smoothly.  The very experienced staff needed little training.

In a study of 249 women, 53% preferred Jadelle, primarily because of: the reduced number of implants, easier insertion and removal, and less visibility in the arm. Those who preferred Norplant did so mainly because of greater familiarity with it.  A few preferred it because of the potential for longer use.  

Reference: Brache V et al. Transition from Norplant to Jadelle in a clinic with extensive experience providing contraceptive implants. Contraception 2006; 73:364-7.

A while back you noted the successful programming in Malawi, where modern method contraceptive prevalence increased from 7.4 percent in 1992 to 26.1 percent in 2000, despite a predominantly rural population and desperately high poverty. Can you please provide some insights to explain this success?

Yes. The “Repositioning Family Planning” initiative has conducted some intensive country “look back” analyses on selected programs in Africa. Here are the key factors for success that I see from the Malawi report:

  1. State-of-the art service guidelines and clinical practices based on international consensus to improve quality and decrease medical barriers to access
  2. A positive policy and leadership environment from the government
  3. The strong presence of nongovernmental organizations, which provided not only significant services but technical leadership as well
  4. An active community-based distribution program that provided services and – probably more importantly – helped legitimatize and broadly disseminate information on family planning
  5. A vigorous communication component that used multiple channels, with key messages developed in consultation with communities
  6. Delegation of service provision duties to a variety of properly trained front-line service provider cadres
  7. An effective commodity logistics system that included support for long-term and permanent methods

For more insights here is the URL:
http://www.acquireproject.org/fileadmin/user_upload/ACQUIRE/Malawi_case_study.pdf [PDF, 767KB]

Also see the “Tech Brief” on the first three Repositioning case studies: http://www.maqweb.org/techbriefs/tb21reposition.shtml

Reference: Solo J, Jacobstein R, Malema D. 2005. Repositioning family planning – Malawi case study: Choice, not chance. New York: The ACQUIRE Project/Engender Health.

What African country has shown excellent recent progress in family planning, with modern method contraceptive prevalence increasing from six percent in 2000 to 14 percent in 2005?

Answer: Ethiopia

Reference: Ethiopia Demographic and Health Survey 2005, Preliminary Report, Ethiopia Central Statistical Agency and ORC Macro, Calverton 2005.

While there is no ideal contraceptive method mix, it is a concern that in many countries contraceptive use is dominated by one or two methods. However, one country has a method mix that is remarkably balanced in that the five leading methods (as of 2004) are quite close, as follows below. Can you name this country? (Overall modern method prevalence is 60.5% and total prevalence is 72.8%.) Hint: It is in South America.

  • Oral contraceptive – 15.0%
  • Condom – 11.9%
  • Intrauterine device (IUD) – 11.5%
  • Female sterilization – 11.5%
  • Injection – 10.4%

Answer: Paraguay.

Reference: Centro Paraguayo de estudios de población CEPEP. Paraguay. Encuesta nacional de demografia Y salud sexual Y reproductiva 2004. Informe final. July 2005. Asunción, Paraguay.

We have had good experience with the Standard Days Method of natural family planning and are interested in obtaining additional CycleBeads so we can expand our efforts. Is there a central source we can order from?

Yes. Cycle Technologies has agreed to make them available at $0.99 per set plus shipping in increments of 500 if your program is affiliated with USAID. The CycleBeads are made in Hong Kong, but USAID has obtained an applicable source origin waiver. In addition to the beads you get (1) an extra “O” ring, (2) an instructional insert and multiyear calendar insert in English, French, or Spanish, and 3) a clear plastic bag that holds all of the items.

Alternatively, you can order the beads alone at a unit cost of $0.87. Should you choose this option, you will receive an extra ring and a plastic bag, but it will be your program’s responsibility to develop locally appropriate instructional inserts and calendars using an electronic file of the instructions that will be provided to you.

Programs not affiliated with USAID may also be eligible to obtain favorable bulk prices and can contact Cycle Technologies for further information.

An additional option is producing CycleBeads locally, but this option is rarely cost-effective and experience has found that significant management time is required to ensure a satisfactory product is made available on a timely basis and in accordance with intellectual property laws. A CycleBeads procurement and production guide is available from irhinfo@georgetown.edu.

Cycle Technologies can be reached at:

Email: info@cyclebeads.com
Telephone number: +1 (202) 237-0662
Address: Cycle Technologies Inc.
5505 Connecticut Avenue NW, #237
Washington DC, 20015, USA
Website: www.CycleBeads.com

Additional resources:

Thanks for the information about bone density and injectable progestin-only contraceptives such as DMPA. But what about other progestin-only contraceptives such as progestin-only pills and implants like Norplant?

They do not appear to have an effect on bone density, though the data are somewhat limited. Presumably this is because these methods do not completely suppress the ovary and allow for considerable natural ovarian estrogen production.

Thus the recent World Health Organization (WHO) expert meeting recommended:

"There should be no restriction on the use of other progestogen-only contraceptive methods among women who are otherwise eligible to use these methods, including no restrictions on duration of use."

I understand that the World Health Organization (WHO) recently convened a scientific review of injectable progestin contraceptives (such as DMPA) and reduced bone density. Can you tell me the result?

Yes. Clearly there is a legitimate concern because such progestin-only injectables do reduce bone density over time, in all likelihood because they largely suppress the ovaries' natural estrogen production (without replacement with another estrogen as combined oral contraceptives do). These effects are relatively modest and appear to be largely if not completely reversible. Still there is specific concern about very young women who may not have achieved peak bone mass and older women nearing menopause.

The WHO expert group examined the current evidence in depth, weighed the risks and benefits and issued the following recommendation:

  • There should be no restriction on the use of DMPA, including no restriction on duration of use, among women aged 18 to 45 who are otherwise eligible to use the method.
  • Among adolescents (menarche to <18) and women over 45, the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk. Since data is insufficient to determine if this is the case with long-term use among these age groups, the overall risks and benefits for continuing use of the method should be reconsidered over time with the individual user.
  • Recommendations regarding DMPA use also pertain to use of NET-EN.

Thus the WHO position is fairly reassuring and in essence consistent with current WHO eligibility recommendations of a Category 1 for women 18 to 45 (Use in any circumstances) and Category 2 for women less than 18 and over 45 (Generally use). Although for the latter group recommending some ongoing reconsideration with the client over time for long-term use.

Access the entire WHO statement at their website.

Since women are at risk of getting pregnant very soon after abortion, and many will want to begin contraception right away, which of these methods can be used immediately after abortion?

    1. Combined Oral Contraceptives
    2. Progestin-only OCs
    3. Contraceptive Patch
    4. Progestin-only injectables such as Depo-Provera
    5. Monthly Combined Injectables such as CycloFem
    6. Contraceptive Implants such as Norplant
    7. Condoms
    8. Vasectomy
    9. Intrauterine devices (IUDs) without restriction
    10. IUDs provided there is not evidence of uterine infection (e.g. septic abortion)
    11. Withdrawal
    12. All of the above
    13. All of the above except i
    14. All of the above except f and i

Correct answer: m. Any of these can be provided immediately following abortion, although not the IUD if there is evidence uterine infection.

Note 1) the list is not intended to be exhaustive. Other methods might also be used (e.g. ring or female sterilization.) And 2) free and informed choice is always important, but the postabortion situation calls for particular care.

Reference:
WHO Department of Reproductive Health and Research. Medical eligibility for contraceptive use. Third edition. Geneva 2004.

It seems to me that making contraception available after a woman has had an abortion (either induced or spontaneous) makes a lot of sense, since many may want to avoid pregnancy. But how soon after the abortion should a woman start contracepting?

Very soon. While there is probably some degree of disturbance of normal ovulation in some women in the first cycle, the majority of women have a rapid return to ovulation. So for all practical purposes, a women not wishing to get pregnant right away should begin contracepting as soon as possible after an abortion.

References:
Lahteenmaki P. Postabortal contraception. Ann Med 1993; 25:185-9.
Donnet ML et al. Return of ovarian function following spontaneous abortion. Clin Endocrin 1990; 3:13-20.

Oral Contraceptives as supplied by USAID alleviate anemia in three different ways. Can you name the three ways?

  1. Preventing pregnancy (since pregnancy and lactation take iron from the women's iron stores),
  2. By reducing blood loss during menstruation, and
  3. By providing a small amount of iron in the seven "placebo" pills (not all Oral Contraceptives have iron, but those USAID supplies do).

I understand a prototype E-Learning course on intrauterine devices (IUDs) may be available to take on the Internet. Is that true?

Yes. We are developing a USAID Global Health E-Learning Center envisioned to include dozens of one to one-and-a-half hour courses on the fundamentals of Global Health. The courses are still under development, but one on IUDs and one on tuberculosis can be viewed and actually taken by going to http://www.msh.org/usaidpilot/.

Major collaborators on the Learning Center thus far are Management Sciences for Health (MSH) and the INFO Project of Johns Hopkins University. We appreciate any feedback.

This new formulation of Depo-Provera for subcutaneous injection is really interesting. Does USAID have plans to provide it?

Image of a Uniject™ Prefilled Injection Device, with a line pointing to a circular middle area (about the diameter of a penny) labled as a Drug reservoir.

We have a strong interest in it. In fact, we have been collaborating with Pfizer; PATH and Becton, Dickenson to develop and provide it in Uniject™ -- the onetime-use injection system that: is simple, foregoes vials and syringes and is virtually impossible to reuse. We hope this can occur in the relatively near future, but it will depend on working out some technical details and of course a favorable price. (See drawing of Uniject™ at right.)

I’m glad to see the new simplified guidance on missed 30-35 microgram pills that gives the main message of "Just keep going." But it seems to me that a woman would still have several options in terms of how to proceed and what to do with the missed pills. For example, if a woman misses two pills in the middle of the pack and remembers the next morning after that, should she:

  1. Discard the two pills and keep going with the next pill in sequence so that she stays on "schedule?"
  2. Not discard any pills, just keep taking them one a day, so that her cycle is extended by two days?
  3. Take a pill as soon as she remembers and then another one later at her "regular time" and discard the one extra pill so she stays on schedule?
  4. Take a pill as soon as she remembers and then another one later at her "regular time" and use the extra pill one day, so her cycle is extended by one day?

The beauty of the current guidance is that any of these is OK. The key point is “Just keep going.”

We advise our OC clients on what to do if they miss pills. But we find the guidance on missed pills rather complicated. I suspect many clients do not remember the recommendations. Is there any help?

Yes. WHO has new guidance for the standard low-dose pills that I think is easier to understand and remember.

The key concept is: "Just keep going." Whenever a woman realizes she has missed pills, regardless of how many she has missed, she should take one as soon as possible and then continue on with another pill the next day, etc. If a client just follows this advice, it will be a major advance.

There are two additional points that help round out the recommendation:

  • If it is 3 or more pills that are missed, she should use a back-up method (or abstain) for 7 days.
  • If the missed pills occur in the 3rd week of the cycle, she should skip the 7 placebo pills and just go on to a new pack.

(Part of the rationale of the guidance, is that even when women miss several pills in the middle of the pack, the probability of a viable ovulation is rather low. The risk increases if the missed pills are at the beginning or end of the 21 active pills, which in effect increases the vulnerable pill-free interval to more than 7 days.)

Reference WHO Department of Reproductive Health and Research: Selected Practice Recommendations for Contraceptive Use, Second Edition - 2004

How soon after a vasectomy procedure can a man rely on it for contraception?

  1. one month
  2. two months
  3. three months
  4. after 30 ejaculations
  5. after 100 ejaculations
  6. after three months or 30 ejaculations, whichever comes first?

The answer is c, three months - according to the latest Selected Practice Recommendations from WHO. (Previously some guidelines had recommended a certain number of ejaculations, but this is no longer the case.)

During the three-month period, men should continue sexual activity, but need to use additional contraceptive protection. In addition, semen analysis, where available, can confirm contraceptive protection after the three-month waiting period.

The URL for the WHO’s New Second Edition of the Selected Practice Recommendations for Contraceptive Use as of 11/10/04 is:

http://www.who.int/reproductive-health/publications/spr/index.htm

This new subcutaneous injection approach for Depo-Provera (DMPA) you described is interesting. But what are the potential advantages?

I can see three:

  1. The lower dose could provide even better safety and potentially fewer side effects (such as less weight gain.)
  2. A subcutaneous delivery system could make it easier to provide DMPA via a single-use injection system such as Uniject and thus enhance injection safety.
  3. Subcutaneous injections are somewhat easier for health providers to administer. In fact it is conceivable that there could ultimately even be a role for self-administration, perhaps along the lines of the way some people with diabetes inject their own insulin via subcutaneous injection.

We have recently heard of the Standard Days Method (SDM) of family planning - the method where the woman keeps track of her cycles with the "Cyclebeads" and avoids unprotected intercourse on days 8-19. We are impressed that the one-year pregnancy rate with correct use was only 4.8 percent and with "typical use" was 12 percent. For many women in our community, this is the only kind of method they will use.

One criterion for SDM is that women have regular periods between 26 and 32 days. But many of our clients don't keep track of their periods precisely. Is there a way to find out if such women are eligible?

Yes. In the clinical trial of SDM, in fact, the investigators faced the same issue. It turns out that if you ask simple questions like:

For regularity of cycles: "Do your periods come more or less once a month? and "Do your periods come more or less when you expect them?"

For duration of cycles: "When was the first day of your most recent period?" and "When do you expect your next period to come?"

Then you can easily assess if a woman is a good candidate. This was the kind of approach used in the study. Alternatively, one could require that women keep a menstrual history before using the method, but that would restrict access and add little to effectiveness.

OK, I see now how to make the initial screening for SDM practical. But once a woman starts SDM is it important for her to monitor her cycles on an ongoing basis to assess regularity and duration of her cycles?

Yes. The recommendation is that if a woman has two cycles out of the 26-32-day range within a year, she should not continue to use the method. This turns out to be about a quarter of women. The Cyclebeads are constructed to help women determine if a particular cycle falls outside the range.

A number of women in our clinic suffer from depression. Has WHO taken a position on depression and eligibility for various contraceptive methods?

Yes. In fact the addition of depressive disorders is one of the changes in the newly issued 3rd Edition of WHO's Medical Eligibility Criteria for Contraceptive Use. Depressive disorders are Category 1 (Use method in any circumstances) for all the hormonal methods and IUDs.

For more information, here is the current URL for the 3rd Edition of the Medical Eligibility Criteria:

3rd Edition Medical Eligibility Criteria

Norplant is effective for 7 years and Jadelle for 5, but does that really make much difference since many women discontinue before the maximum time anyway?

It clearly makes a difference for women on Norplant who want to continue after 5 years of use. Actually based on data from the comparative trials of Norplant versus Jadelle, when use-experience for Norplant is limited to 5 years, average use was 3.63 years. But for experience through 7 years the average use was 4.40. Thus the average increase in use was 0.77 years or 21%.

How does the Implanon contraceptive implant compare to Norplant?

See table below. The apparent advantages of Norplant are the longer duration and the cheaper price currently. The advantage of Implanon is the ease of insertion and removal because of the single implant and the special inserter. Norplant uses the traditional 2nd generation progestin levonorgestrel, while Implanon uses a 3rd generation progestin 3-ketodesogestrel at a level that is perhaps a bit higher in relative dosage. Effectiveness and side effects appear to be pretty similar.

 

Norplant

Implanon

Duration of Potential Use

7 years but still FDA labeled as 5 years

3 years

Number of Implants

6

1

Ease of Insertion and Removal

More difficult

Easier and faster (has special inserter)

Progestin

Levonorgestrel

3-ketodesorgestrel (etonorgestrel)

Cost

+Public sector price

Public sector price appears higher

In our clinic, clients sometimes complain about weight gain while taking oral contraceptives. Do OCs cause weight gain?

Probably not on average. If they do, it is very subtle. A recent Cochrane Review assessed 42 trials including 3 pertinent placebo-controlled randomized clinical trials (one of which was actually with the contraceptive patch). Notably, none of the randomized trials showed a statistically significant difference in weight gain for OC users compared to the placebo group. The report concludes: "Available evidence is insufficient to determine the effect of combination [oral] contraceptives on weight, but no large effect is evident."

In this country modern contraceptive prevalence increased from 14.6% in 1996 to 22.6% in 2000/2001. Also infant mortality declined from 109 to 95 and the percentage of men reporting 3 or more sex partners declined from 31 to 12 between 1996 and 2000. What country is it?

Zambia. Clearly someone has been doing some good public health work!

The increase in contraceptive prevalence in Mozambique is notable, but another African country has had an even more rapid and sustained increase. Modern method prevalence went from seven percent in 1992, to 17 percent in 1996 to 26 percent in 2000. What country is it?

Malawi

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