بسم هللا الرحمن الرحيم الحمد هلل رب العالمين والصالة والسالم على نبينا محمد خاتم األنبياء وسيد المرسلين وعلى آله وصحبه أجمعين وبعد

Transcription

1 بسم هللا الرحمن الرحيم الحمد هلل رب العالمين والصالة والسالم على نبينا محمد خاتم األنبياء وسيد المرسلين وعلى آله وصحبه أجمعين وبعد

2 Family Planning Services Dr. Samar Sharif MD. MPH. Community and Family Medicine Department. Medical School University of Jordan

3 What is family planning? Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved. [1] WHO website US Dept. of Health, Administration for children and families(2012).1

4 Goals of Family Planning services 1- Enable women and men to limit family size 2- It safeguards individual health and rights 3- Preserves our planet s resources 4- Improves the quality of life for individual women, their partners, and their children 11/11/2018 4

5 5- Prevent unwanted or risky pregnancies 6- Decreases incidence of congenital abnormalities 7- Decreases Maternal and infant mortality rates 8- Control the world population size 9- Improves all aspects of life standers economical, educational, and health psychological 11/11/2018 5

6 Counseling GREAT a) Great b) Reassure c) Explain d) Answer e) Therapy/Rx. 11/11/2018 6

7 Counseling Choosing a birth control method is an important decision. Some of the things you might want to consider when choosing a method are : 1- Personal consideration 2- Effectiveness 3- Safety 4- Cost 11/11/2018 7

8 Counseling on Family Planning: methods 1) A detailed history 2) Information on all available 3) All practical points related to the use of the selected method must be discussed in detail 11/11/2018

9 Contraceptive efficiency: It is the measurement of unplanned pregnancies even after the use of contraceptive measures.

10 Contraceptive Methods: 1-Traditional or Natural Methods a-abstinence : not having sexual intercourse b-withdrawal ( Coitus interrupts ): pulling out c-fertility Awareness Method (FAM) : basal body temperature (BBT) 11/11/

11 Traditional Methods d) Breast Feeding LAM (Lactation Amenorrhea Method). - Risk of pregnancy is 1.8% at the end of 6 months after delivery in women who exclusively breast-feed & who have not yet started to menstruate. - Cheap method - No side effects - Many other advantages of breast feeding. 11/11/

12 Lactational Amenorrhea Method Algorithm 11/11/

13 Abstinence : Safe Period Drawbacks: Irregular cycle so difficult to predict Only for educated and responsible couples Programmed Sex High Failure rate Complication: Embryonic Abnormalities, Ectopic Pregnancy 11/11/

14 2-Hormonal methods 11/11/

15 Classification of hormonal contraceptives Combined pills Oral Pills Progesterone only pills (POP) Once a month (long acting) pills Hormonal contraceptives Male pill Injectables Depot Preparations Subdermal Implants Vaginal Rings 11/11/

16 Oral Contraceptives 11/11/

17 Combined pills Composition: In early 1960s Oestrogen µg and Progesterone - 10mg Greater side effects Nowadays Oestrogen µg and Progesterone mg. Taken from 5 th to 25 th day of menstrual cycle, followed by a break of 7 days (withdrawal bleeding). Failure rate: /11/

18 Mechanism of action: A)Prevents ovulation B)Prevents implantation C)Makes cervical secretions thick Effectiveness 100% effective if taken correctly. 11/11/

19 Beneficial Effects with Combination Oral Contraceptives 100% effective in correct users. Beneficial effects on menorrhagia (anemia), dysmenorrhea, ovulatory pain, acne and hirsutism Lower the risk of endometrial, ovarian- (30-50%) and possibly colon cancer Preserves bone mineral density May reduce the risk of ovarian cysts, rheumatoid arthritis, benign breast disease & Ectopic preg. May have protective effect against atherosclerosis

20 Untoward Effects with Combination Oral Contraceptives Cardiovascular effects hypertension in 5% users myocardial infarction Stroke ; ischemic or haemorrhagic DVT s especially smokers >35, overweight and sedentary Cancers (increase risk of) breast hepatocellular cervical Endocrine and metabolic effect, impaires glucose tolerance and responses to glucose challenge Breast tenderness, Weight gain, Headache and migraine

21 Contraindications to OCP Use Absolute Contraindications Cancer of breast and Genitals H/O venous thromboembolism Vascular disease- CAD or CVD Liver disease ( i.e. Viral hepatitis, cirrhosis) Pregnancy Congenital hyperlipidaemia 11/11/2018 Relative Contraindications Age above 40 yrs. Smoking and age above 35 yrs HTN with SBP>160, DBP>99 Chronic renal diseases Epilepsy, Migraine Hyperlipidemia LDL>160 DM with secondary complications Infrequent bleeding, Amenorrhoea. 21

22 Progesterone only pills Minipill or Micropill. Composition: Low dosage of progesterone, mainly Norgestrel 0.075mg Dosage: One tab daily throughout the menstrual cycle It is mainly given in older women in whom combined pills are C/I as in CVDs Efficacy 96-98% Failure rate:0.5/hwy 11/11/

23 Pop (contd...) Mechanism of action: Makes cervical mucosa thick action starts in 2-4 hrs last for 24hrs. Decreases the motility of Fallopian tubes. Prevent pregnancy without preventing ovulation, as ovulation occurs in 20-30% women. Suitable for Lactating women Smokers above 35 yrs old Estrogen sensitive women Disadvantages: Higher risk of neoplasia in women taking POP than in women on Combined Pills Poor control of cycle. 11/11/

24 Post coital pills Morning after pills types. Levonorgestrel only, combined form,mifepristone. Dosage: 1 st tab within 72hrs of intercourse 2 nd tab after 12 hrs of 1 st tab In WHO multicentric randomized trial- within 120 hours of exposure to unprotected sex, a single dose of LNG 1.5 mg is as effective as 2 doses given 12 hours apart. Indications: Contraceptive failure Rape Unprotected intercourse. Failure Rate: 2/HWY 11/11/

25 Depot preparations 11/11/

26 Injectable Depot preparati ons Subdermal implants Vaginal rings 11/11/

27 Classification Injectable contraceptives Injectable contraceptives. Progesterone only injectables Combined injectables DMPA (depot- medroxy progesterone acetate) NET-EN ( Norethandrone Enanthate) 11/11/

28 Side effects: Disruption of normal menses Amenorrhoea Contraindications: Breast cancer Genital cancer Undiagnosed uterine bleeding Suspected malignancy Lactating women Failure rate: 0.3/HWY 11/11/

29 Norplant For long term contraception. Has 6 capsules containing 35mg each of norgestrel. Norplant R2 contains rods of norgestrel. Contraception is achieved in 24hrs & lasts for 5-6 yrs Disadvantage: Surgical procedure Failure Rate: 0.1/HWY Subdermal implant 11/11/

30 Terminal methods Terminal methods Male sterlisation Vasectomy No scalpel vas occlusion Tubectomy Female sterlisation Laparoscopic occlusion Tubal inserts (no incision) 11/11/

31 Failure Rate: 0.15/HWY (due to mistaken identification of vas) COMPLICATIONS: Operative Sperm granules Spontaneous recanalisation Autoimmune response Psychological response 11/11/

32 Mechanical Methods Intrauterine Device: Plastic T shaped piece, covered with copper, inserted in the uterus Efficacy rate: 1/100 women/year ADVANTAGES OF IUDs: Safe, Effective, Reversible Inexpensive High continuation rate DISADVANTAGES OF IUDs: Heavy bleeding and pain Pelvic Inflammatory diseases Ectopic pregnancy May come out accidently if not properly inserted 11/11/

33 IDEAL IUD CANDIDATE: Who has borne at least 1 child Has no history of PID Has normal menstrual periods Is willing to check IUD tail Has an access to follow up and treatment of potential problems Is in monogamous relationship

34 Condoms: Rubber pouches which prevent the ejaculation from reaching the vagina No side effects whatsoever Effective in prevention of STD transmission Does not affect lactation Contraindicated in cases of sensitivity to latex DISADVANTAGE: Chances of slip off and tear off Failure rate: 2-3% 11/11/

35 What Do Religions Say About Birth Control and Family Planning? The knowledge of contraception has been accounted for since early times. Family planning is embraced by religions across the spectrum as a moral good, a responsible choice, and a basic human right. The world s religions recognize that family planning helps build strong families, protect the health of women and children. According to survey research, 83 percent of the Islamic religious leaders in Jordan believe that family planning is permitted under Islam

36 Why Family planning is needed In Jordan? Before the start of family planning services in the late of 1970 s, Jordan was considered one of the world s fastest growing young population.in addition, Jordan suffers from a severely limited financial, energy, water, and other natural resources, the Government of Jordan (GOJ) recognizes that population increase hinders further socioeconomic progress.

37 Therefore the GOJ has set the goal of reducing the 2009 fertility rate of 3.8 children per woman to less than 3 children per woman in 2020 by promoting Family planning in Jordan.

38 Family Planning in Jordan At current fertility levels JPFHS (Jordan Population and Family Health Survey) 2012, a woman in Jordan will have an average of 3.5 children a total fertility rate that is 50 percent lower than the rate recorded in 1976 ( 7.4 children per woman) 11/11/

39 Effective family planning is increasingly seen as an important part of Jordan's overall development strategy. In contrast to several years ago, such programs are openly discussed and rarely encounter public opposition. 11/11/

40 Fertility Rates in Jordan: The figure shows the overall fertility rates in Jordan from 1990(5.6)-2012(3.5) 2017(2.7)

41 Decrease of infant and child mortality/1000 live birth with decrease of fertility rate

42 Its obvious how the rapid the fertility rate decreased from 5.6 in 1990 to 3.7 in and then the fertility rate is fluctuating between 3.5 and 3.8 between 2002 and Family Planning had a great role in controlling and decreasing fertility rates during this period.

43 Family planning in Jordan: Jordan is one of the most modern countries of the Middle East with a population that has grown from 2.1 million to reach 6.3 million in Fertility declines in Jordan have contributed to a slowing down in the population growth rate from 3.2 % in the second half of 1990, to 2.3 % 2007, to 2.2 in 2012 and 2.4 in 2017.

44 Population growth averaged 4.8 % during the period , 4.4 % between 1979 and 1994, 2.6 % between 1994 and 2004, and 2.2 % between 2004 and % in 2018 most probably due to immigrants and not due to higher fertility.

45 The high rates of growth have been due to the influx of immigrants to the east bank from the west bank, the inflow of large numbers of foreign workers, and the return of about 300,000 Jordanians from the gulf area as a result of the 1990 gulf war. The rapid increase in the population has created several problems for the country such as food shortage, water, housing and employment.

46 Birth Control and Current Use of Contraceptives: The level of current use of contraception is one of the indicators most frequently used to assess the success of family planning activities.

47 Overall, use of any method among currently married women has increased substantially in the last two decades Contraception Prevalence Rate: 40% of women in the 1990 JPFHS survey 53% in the 1997 JPFHS, 56% in the 2002 JPFHS, 57%in the 2007 JPFHS 59% in the 2009 JPFHS and 61% in the 2012 JPFHS *JPFHS : Jordan Population and Family Health Survey.

48 Results from the 2012 JPFHS indicate that 61% of currently married women are using a contraceptive method; 42% are using modern methods 19% are using traditional methods. Modern contraceptive use according to The latest 2017 JPFHS dropped to 37%.

49 The IUD is the most widely adopted modern method (21 %), followed by the pill and male condom (8% each), female sterilization (2%), and LAM and injectables (1% each). Less than 1 % of women rely on other modern methods. Withdrawal (14%) and rhythm (4%) are the most common traditional methods.

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54 Most commonly contraceptives use in Jordan JPFHS 2017 The IUD is the most popular method across all age groups except among year-olds. This method is used by 27%-29% of women age 35-44, and by almost one in five women age Withdrawal is the most commonly used method among the youngest married women age 15-19, followed by the pill, LAM, and the IUD. Among those age 20-24, withdrawal is the most common method, followed by the IUD and the pill. Use of female sterilization is positively associated with the woman s age; older women are more likely to use this method to terminate childbearing. Four percent of married women have been sterilized.

55 SOURCE OF SUPPLY FOR MODERN METHODS : Private sources serve almost three-fifths (56 %) of current users, compared with 58% in 2007 and 54% in Private hospitals or clinics, pharmacies, the Jordanian Association of Family Planning and Protection (JAFPP), and the United Nations Refugee Welfare Association (UNRWA) clinics are major private sources of supply for modern contraceptive methods. The share of the public sector decreased to 44% in 2012 from 46% in 2009.

56 The sources of contraceptive methods also vary by the method used: Pharmacies are the primary source for users of methods that require resupply, including the pill (35 %) and condoms (39 %). Private hospitals and clinics are the primary source for IUDs (22 %), followed by government health centers and JAFPP(Jordanian Association of Family Planning and Protection (19 % each).

57 Government hospitals are the primary source for most female sterilizations (54 %), followed by the Royal Medical Services (24 %) and private hospitals (20 %). Government health centers are the major source of injectables (63 %), followed by government maternal and child health (MCH) centers (18 %). [4] department of statistics (year book of 2012)

58 Comparison between Jordan and the other Regional Countries Country Jordan Egypt Lebanon Saudi Arabia India TFR Table 1 The fertility rare

59 Fig 1 shows fertility rate in ( Jordan, Egypt, India,Lebanon and Saudi Arabia from 1960 s till 2011

60 THANK YOU

61 References Contraceptive Updates, Reference Manual for Doctors 2009, by MOHFW & UNFPA,India. WHO - Medical eligibility criteria for contraceptive use 4th ed WHO, Family Planning A GLOBAL HANDBOOK FOR PROVIDERS Update 2011 Guidelines for administration of emergency contraceptive pills by medical officers, Research Studies and Standard Division, Department of Family Welfare, Government of India, June The essentials of Contraceptive Technology, a handbook for clinic staff, John Hopkins Population Information Program, 2010 Projestin Only Injectables: Fact Sheet. UNFPA India, 2004 Guidelines for IUDs for medical officers, research studies and standard division, Department of Family Welfare, Government of India - June /11/

62 References contd Westhoff C, Heartwell S, Edwards S. Initiation of Oral Contraceptives Using a Quick Start Compared With a Conventional Start: A Randomized Controlled TrialObstet Gynecol Jun;109(6): Jick SS et al. Risk of non fatal VTE in women using a contraceptive transdermal patch and oral contraceptives containing 35 mcg EE and norgestimate. Contraception 2006;73(3): Sheng J et al. The LNG-IUS study on adenomyosis: a 3 year followup study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception Mar;79(3): Grimes DA et al. Cochrane systematic reviews of IUD trials: lessons learned. Contraception Jun;75(6 Suppl):S55-9. Lethaby AE et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev Oct 19;(4) K.Park, Text book of preventive and social medicine,contraceptive methods pp ,21st edition,bhanot publication,jabalpur, India. Jordan Population and Family Health Survey /11/