WHO Decision-making Tool for Family Planning Clients and Providers

Publication date: 2005

WHO Library Cataloguing-in-Publication Data Decision-making tool for family planning clients and providers. 1.Family planning services 2.Contraception- methods 3.Counseling 4.Decision making 5.Teaching materials I.World Health Organization II.Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs. Suggested citation: World Health Organization (WHO). and Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs. Information and Knowledge for Optimal Health (INFO). Decision-making tool for family planning clients and providers. Baltimore, Maryland, INFO and Geneva, WHO, 2005. (WHO Family Planning Cornerstone) ISBN 92 4 159322 9 (NLM Classification: WA 550) © 2005 World Health Organization and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs All rights reserved. The publishers welcome requests to translate, adapt or reproduce the material in this document for the purpose of informing health care providers, their clients, and the general public, as well as improving the quality of reproductive health care. Enquiries should be addressed to WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (fax: +41 22 791 4806; email: permissions@who.int). Authorized translations, adaptations and reprints may bear the emblem of the World Health Organization and the logo of the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Translations, adaptations and reproductions may be made without authorization so long as they are not used in conjunction with any commercial or promotional purposes, and so long as they do not use the emblems of the World Health Organization and/or the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs or the INFO Project, and so long as they acknowledge the original source in line with the suggested citation below. Neither the World Health Organization nor the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs accepts responsibility for any translations, adaptations and reproductions published by others. The publishers request print and electronic copies of all translations, adaptations and reproductions of this publication. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the publishers to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation for unofficial translations or adaptations of this tool: Translated/adapted from "Decision-Making Tool for Family Planning Clients and Providers" prepared by the World Health Organization and the INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Geneva, World Health Organization, and Baltimore, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, 2005. More copies of this tool and information on adaptation, training and translations can be obtained from: The INFO Project Johns Hopkins Bloomberg School of Public Health Center for Communication Programs 111 Market Place, Suite 310 Baltimore, Maryland 21202, USA Fax: +1 410 659 6266. Email: orders@jhuccp.org Documentation Centre Department of Reproductive Health and Research World Health Organization 1211 Geneva 27 Switzerland Fax +41 22 791 4189. Phone +41 22 791 4447. Email: rhrpublications@who.int CD-ROMs and limited numbers of printed copies are available free of charge. The document is also available online at: • WHO’s Department of Reproductive Health and Research website http://www.who.int/reproductive-health/ • The INFO Project’s website http://www.infoforhealth.org/pubs/dmt Decision-Making Tool for Family Planning Clients and Providers Acknowledgements: This tool is a collaborative effort of the World Health Organization’s Department of Reproductive Health and Research and the INFO Project at Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. The tool has been developed by Sarah Johnson, Ward Rinehart and Kathryn Church. Sharon Rudy also helped develop the concept and initial drafts. Special thanks go to Kathryn Curtis, Carlos Huezo, Herbert Peterson, Annie Portela, James Shelton, Jennifer Smith and Paul Van Look for their support and contribution to this work. We would like to thank Young Mi Kim of the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs for her work in fieldtesting the tool, along with the following individuals and organizations: Ilka Maria Rondinelli of the International Planned Parenthood Federation/Western Hemisphere Region, and its Member Association of Trinidad and Tobago; Antonietta Martin of the Population Council and Frontiers in Reproductive Health, Mexico; Jenni Smit of the Reproductive Health Research Unit of the University of Witwatersrand, South Africa; Dian Rosdiana of the Johns Hopkins University STARH Programme, Indonesia; and Michelle Heerey and Adrienne Kols of Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. We would also like to thank the family planning providers in Indonesia, Mexico, Nicaragua, South Africa and Trinidad and Tobago who participated in the fieldtesting. We also gratefully acknowledge Rafael Avila and Stephen Goldstein of the INFO Project for their help in production of this tool. We would like to thank the following experts at WHO for their review and comments: Nathalie Broutet, Catherine d'Arcangues, Timothy Farley, Catherine Hamill, Rita Kabra, Svetlin Kolev, Ornella Lincetto, Justin Mandala, Adriane Martin-Hilber, Francis Ndowa, and Jelka Zupan (Department of Reproductive Health and Research); Adepeju Olukoya and Claudia Garcia-Moreno (Department of Gender, Women and Health); Tin-Tin Sint (Department of HIV/AIDS); Peter Weis (Family and Community Health Cluster); Yvan Hutin and Dina Pfeifer (Department of Immunizations, Vaccines and Biologicals). The tool is also based on expert advice from many international organizations in the field of family planning. We would like to thank the following interagency groups for their expert reviews and guidance: the Client-Provider Interaction Subcommittee of the USAID MAQ Initiative, and the Expert Working Group to develop Selected Practice Recommendations for Contraceptive Use. In addition, we would like to thank the following individuals for their crucial early input: Marcos Arevalo, Jeannette Cachan, Moshira El-Shafei, Pape Gaye, Mihai Horga, Federico Leon, Shalini Shah, and Theresa Velasco. Illustrations by Rita Meyer at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Additional illustrations by Greg Dayman of Prographics, Inc.; by the Reproductive Health Research Unit, Johannesburg, South Africa (images from page AP5 adapted from the Reproductive Health Flipchart); and by the Institute of Reproductive Health, Georgetown University (pages FA3 and FA4). Support for this project was provided by the United States Agency for International Development (USAID) (through the INFO Project from Global, GH/PRH/PEC, under the terms of Grant No. GPH-A-00-02-00003-00), and by the governments of Japan, the Netherlands, Norway and Sweden. This tool constitutes one of the Four Cornerstones of WHO's evidence-based guidance in family planning. The technical content of this tool was developed using international evidence-based family planning guidance, including Medical Eligibility Criteria for Contraceptive Use (WHO, Third Edition, 2004), Selected Practice Recommendations for Contraceptive Use (WHO, Second Edition, 2005), and The Essentials of Contraceptive Technology (JHU/CCP 2003). Introduction for the Provider Using the Decision-Making Tool for Family Planning Clients and Providers Introduction for the Provider About this Tool • The front section, covered by the tabs on the side, helps new clients make decisions about a family planning method and helps meet returning clients’ various needs. Counselling usually starts with one of the side tabs. • The methods section, with the tabs at the bottom, provides information for you and your client on each family planning method. This information can help confirm a client’s choice and help the client use a method correctly. Each method section includes information on who can and cannot use each method, side-effects, how to use the method, when to start, and what to remember. • The Appendices section, the last side tab, offers more counselling aids that you can use as needed and reference pages on sexual and reproductive health topics. This flip-chart is a tool for you and your client to use during family planning counselling. It can: • help clients choose and use the method of family planning that suits them best; • give you the essential information you need to offer high-quality family planning care to your clients; • help you counsel clients more effectively. i Principles of this “Decision-Making Tool” 1. The client makes the decisions. 2. The provider helps the client consider and make decisions that best suit that client. 3. The client’s wishes are respected whenever possible. 4. The provider responds to the client’s statements, questions, and needs. 5. The provider listens to what the client says in order to know what to do next. Principles of this “Decision-Making Tool” 1. The client makes the decisions. 2. The provider helps the client consider and make decisions that best suit that client. 3. The client’s wishes are respected whenever possible. 4. The provider responds to the client’s statements, questions, and needs. 5. The provider listens to what the client says in order to know what to do next. • Choosing Method tab: New clients may need help to choose a method that best suits their needs. This tab will help you discuss these needs and help the client make a healthy choice. • Dual Protection tab: All clients need to consider dual protection—protection from both sexually transmitted infections (STIs), including HIV/AIDS, and pregnancy. STIs and HIV/AIDS are a growing problem, and all clients should understand the risk and decide how to protect themselves. At first, STI risk may seem difficult to discuss, but actually, most clients welcome such discussion. Consider how to introduce the topic without expressing disapproval. • Special Needs tab: Clients with special needs include younger clients, older clients, pregnant/postpartum clients, post-abortion clients, clients living with HIV/AIDS, and clients who want to become pregnant. These clients may have particular family planning needs or need special advice or counselling. • Returning Clients tab: Clients returning to the clinic may be having problems with their method, may have questions, or may simply want more supplies. This tab can help you address their needs. Helping clients with different needs In the front section there are different tabs for clients with differing needs (also see flow-chart below): Using the Tool with different types of clients This is a summary of the key steps you usually follow with the various types of family planning clients. Start here: Introduction for the Provider ii Method Tabs Tab Overview & information for choice Medical eligibility criteria Possible side-effects How to use When to start What to remember Emergency Contraception (method tab) Client had unprotected sex, needs emergency contraception. Tab TabTabTab Welcome client Clients with Special Needs Find out reason for visit Go to correct tab Ask client: Do you have a method in mind? Choosing Method (for new clients) Discuss options for dual protection. Go to correct page in section: • Younger client • Older client • Postpartum/ pregnant client • Post-abortion client • Client living with HIV/AIDS • Client who wants to become pregnant Tab Returning Client Switch method Go to Choosing Method tab (side) or Method tab (bottom) Ask what method client is using: Go to method page in Returning Client section Check for new health conditions. Check about need for STI protection. Problems using method. Help manage side-effects. Provide method No problems with method. Note: Some method sections do not have all these pages. If method in mind: Check if method suits needs and situation. Check dual protection needs. If no method in mind: Discuss needs and situation and review method options. Check dual protection needs. Dual Protection (for clients who need STI protection) If needed, help client consider risk. Check if chosen option is suitable. Counselling icons Many pages have small icons (symbols) on them. These icons will remind you of good counselling behaviour that is especially important at that moment. Here are the icons: Introduction for the Provider How to use this Tool with clients • The Tool stands up so both you and the client can see the pages on each side. Your page shows the same words that the client sees but not the pictures. Instead, your page has more information and suggestions for you. • Place the Tool where the client can easily see it. Try not to place the flipchart directly between you and the client. You can place it to the side or where both of you look at the client’s side. • Tell the client about the Tool. Explain that it will help meet her or his needs. • For every client, start with the Welcome page, which follows this introduction. After you welcome the client, you turn to the next page. Here you ask the client how you can help. The client’s answer usually will lead you to one of the side tabs. These pages may then lead you to a contraceptive method tab at the bottom. • To use the tabs, place your fingertip against the tab and slide it under the page in front of the tab. Then flip over all the pages. Do not lift the page with the tab on it. • Each page shows the client an important question or topic. To use this tool correctly, you usually need the client’s answers or information before you can go to the next page. You can tell the client this. Then the client will know that her or his participation is important. The diagram below (page iv) shows how to use the provider's pages. iii Preparing to use this Tool • Studying this tool will help you become familiar with how it works and with the information in it. Using the flip-chart will become easier with practice. • If this is your own personal copy, you may wish to write in it, adding things to say or other reminders. • This guide covers only the main points. When you talk with clients, you can add information and discuss matters further, responding to the client’s needs and concerns. • Some words and pictures on the client’s pages may not apply in your programme. You can cover them or cross them out. For example, you may not have every family planning method that is pictured. • You can and should use your own words. In general, the text is not meant to be read to the client. Once the guide becomes familiar, a glance will remind you of key information and your next steps. Do not try to read the small type while counselling. • However, you may want to read aloud and discuss some key points on the client’s pages. If the client cannot read well, you may need to read more. Point to pictures if that is helpful. Listen carefully Offer support Ask if client has questions Check understanding • “It can take time for the body to adjust.” • Different people have different reactions to methods. • About half of all users never have any side-effects. • Side-effects often go away or lessen within 3 months. Possible side-effects Does client understand side-effects? Is she ready to choose method? • But many women do not have any • Often go away after a few months Next Move: Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. • "Please come back any time you want help or have questions." • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. • Tell client: skipping pills may make bleeding side- effects worse and risks pregnancy. P3 Most common: • Nausea (upset stomach) • Spotting or bleeding between periods • Mild headaches • Tender breasts • Slight weight gain or loss The Pill If she has decided to use method, go to next page. If not, discuss further or consider other methods. If you choose this method, you may have some side-effects. They are not usually signs of illness. How to use the provider's pages The other side of this page is the client’s first page. Please flip to next page for Welcome Icon: Reminder of good counselling practice. Provider’s information (blue boxes): Suggested questions, phrases, actions, information for reference and study ahead. “Suggested words you might use.” p Look here for your next move based on client’s statements. n Glance here for reminder of main point to address now. o Glance here. Discuss these points with client as needed. The blue boxes on the right have more information and suggestions. Picture of decision-making client: This picture reminds you that the client needs to make a decision or say what she/he prefers before moving on. Page numbering: All tabbed sections are numbered separately, with a letter or letters to indicate the section. For example P3 is Pill section, page 3. iv Shows which method section you are in. ↓ Welcome Using this flipchart, we can help you: • Choose and use a method • Solve any problems • Get accurate information Please tell me about: • Yourself • Your needs • Your questions We promise you privacy and confidentiality Welcome • Greet client with warmth and respect. • Thank client for coming. • Point to this flipchart. Explain that it will help both you and the client. • Invite client to talk and ask questions. • Make clear that you want to listen. • Explain that you need the client to speak openly so you can help. When client is comfortable and ready to talk, go to next page. Next Move: Using this flipchart, we can help you: • Choose and use a method • Solve any problems • Get accurate information Please tell me about: • Yourself • Your needs • Your questions • Is meeting space private? • Explain that the meeting will be confidential: “What you say will not be told to others.” We promise you privacy and confidentiality W1 How can I help you today? • Are you using a family planning method now? • Choosing a method? • Question or problem about a method? • Concern about sexually transmitted infections (STIs) or HIV/AIDS? • Worried you might be pregnant? • Other needs? • Are you using a family planning method now? Go to purple Returning Client tab (page RC1). Choose next move based on client’s purpose: • New client choosing a method? Go to green Choosing Method tab (page CM1). How can I help you today? • Concern about sexually transmitted infections (STIs) or HIV/AIDS? Go to pink Dual Protection tab (page DP1). • Question or problem about a method? Go to purple Returning Client tab (page RC1) or specific method tab below. • Clients with special needs. Some clients may need special advice or have special concerns. Go to light blue tab (page SN1) for: - Younger clients - Older clients - Pregnant/postpartum clients - Post-abortion clients - Clients living with HIV/AIDS - Clients who want to become pregnant • Worried you might be pregnant? Offer advice and support, perform pregnancy test if needed, and discuss her options. For emergency contraception, go to EC method tab. Respond first to the client’s needs. Once client tells reason for coming, go to a tab. • Other needs? Offer advice and support. Refer if needed. Appendices may help with some other needs.Next Move: W2 Do you have a method in mind? If you do, let’s talk about how it suits you • What do you like about it? • What have you heard about it? If not, we can find a method that is right for you Important for choosing a method: Do you need protection from sexually transmitted infections (STIs) or HIV/AIDS? Do you have a method in mind?Choosing method:Method in mind Next Move: If you do, let’s talk about how it suits you Check if client understands method: • Check what the client knows about the method and whether she/he needs more information. • If the client’s answers suggest misunderstanding or incorrect information, discuss and make it clear. Ask questions to see if method suits client. For example: • “Are you confident that you could remember to take a pill every day?” • “Would you be able to come back for injections?” • Explain that everyone needs to consider protection from both pregnancy and STIs such as HIV/AIDS. • Encourage client to speak openly about her/his situation, her/his relationship(s) and sexual behaviour. If client needs protection or is unsure, go to Dual Protection tab. Check if client would like to know about other methods. For STI/HIV/AIDS protection go to Dual Protection tab. Important for choosing a method: Do you need protection from sexually transmitted infections (STIs) or HIV/AIDS? If no method in mind or if method in mind doesn’t suit client, go to next page. To discuss method in more detail, go to method tab. • What do you like about it? • What have you heard about it? If not, we can find a method that is right for you (Go to next page) Use this page for client who has a method in mind, to check if it suits her/his needs and situation. CM 1 No method in mind? We can discuss: • Your experiences with family planning • What you have heard about family planning methods • Your plans for having children • Protection from sexually transmitted infections (STIs) or HIV/AIDS • Your partner’s or family’s attitudes • Other needs and concerns You can find a method right for you Now let’s discuss how a method can meet your needs You can find a method right for you No method in mind? We can discuss: • Your experiences with family planning • What you have heard about family planning methods • Your plans for having children • Protection from sexually transmitted infections (STIs) or HIV/AIDS • Your partner’s or family’s attitudes • Other needs and concerns Next Move: Go to next page to discuss what methods could suit the client’s needs. Helping client with no method in mind to make a decision: • Use this page to help client think about her/his situation and life and what seems most important about a method. • Discussing some of the topics at left can help the client consider different methods. You can say: “Here are some things to consider when choosing a family planning method.” “What is most important to you?” “The choice is yours. I want you to be happy with your choice.” Choosing method: NO method in mind • Explain that everyone needs to consider protection from both pregnancy and STIs such as HIV/AIDS. • Encourage client to speak openly about her/his situation, her/his relationship(s) and sexual behaviour. If client needs protection or is unsure, go to Dual Protection tab. • The Special Needs tab or Appendices may help. CM 2 Most effective and nothing to remember. Effective but must be carefully used. Fewer side-effects: Very effective but must be carefully used. More side-effects: Pills Injectables Fertility awareness- based methods Vaginal methods Male and female condom IMPORTANT! Only condoms protect against both pregnancy and STIs/HIV/AIDS Fewer side-effects, permanent: More side-effects: Implants IUD Fewer side-effects: LAM Female sterilization Vasectomy Comparing methods Comparing methodsChoosing method Next Move: • Use this page to help client compare methods and narrow down choices. If client finds it hard to choose: • Find out what the client needs: To talk with partner? More information? Talk with a user? Think about it more? • Explain to clients that they can try a method for a few weeks or months to see how they like it (except sterilization, vasectomy and implants). To discuss a method in more detail, go to method tab. For more information on comparing methods, see Appendices 2 and 3. Important considerations: • Effectiveness: Depends on how much the client has to do or remember. The most effective methods require no repeated action. You can ask: “How important is it to you that you don’t get pregnant now?” “Do you think you can use a method that requires repeated action (such as taking a pill or getting an injection)?” • Side-effects: Side-effects of hormonal methods (pills, injectables and implants) are common at first, but may go away after a few months. The IUD may also bother some women. Discuss how client would feel, for example: “How would you feel if this method changed your monthly bleeding?” • Permanent, long- or short-term: Sterilization and vasectomy are permanent. IUD and implants can be left in place for many years. • Protection from HIV/AIDS and other STIs: Condom is the only method that protects against STIs. To help client consider options and risk, go to next page. For STI/HIV/AIDS protection, go to next page. CM 3 Most effective and nothing to remember. Effective but must be carefully used. Fewer side-effects: Very effective but must be carefully used. More side-effects: Pills Injectables Fertility awareness- based methods Vaginal methods Male and female condom IMPORTANT! Only condoms protect against both pregnancy and STIs/HIV/AIDS Fewer side-effects, permanent: More side-effects: Implants IUD Fewer side-effects: LAM Female sterilization Vasectomy Other safe forms of intimacy Any family planning method WITH Uninfected partner Condoms AND Another family planning method AND For example: Condoms Male condoms Female condomsOR Some other options: Options using family planning: AND for added protection from STIs/HIV/AIDS. Reduce your number of sexual partners: one uninfected partner is safest n po rq Delay or avoid having sex Ways to avoid both pregnancy & STIs/HIV/AIDS You can decide Other safe forms of intimacy Any family planning method WITH Uninfected partner Condoms AND Another family planning method AND For example: Condoms Male condoms Female condomsOR Some other options: Options using family planning: AND for added protection from STIs/HIV/AIDS. Reduce your number of sexual partners: one uninfected partner is safest n po rq Delay or avoid having sex ∗ What is an uninfected partner? Clients must consider if their partner could have an STI or HIV. Go to next page. Which option would the client like to discuss further? Ways to avoid both pregnancy & STIs/HIV/AIDS Introduce the topic of STIs & HIV/AIDS gently but honestly: • “Because STIs and HIV/AIDS are a growing problem, we all need to choose ways to protect ourselves and our families.” • Explain HIV/AIDS and STIs if needed (see Appendix 8), including possible consequences (such as pain, infertility, life-threatening illness). • “Whether they think about it or not, everyone either takes risks or protects themselves. I want to help you make a healthy choice.” If client needs help considering her/his risk, go to next page. Dual Protection Next Move: DP 1 Explain the dual protection choices: n Condoms can be very effective for family planning—when used consistently and correctly—and are the only method that also protects against STIs/HIV/AIDS. o Using condoms AND another family planning method offers more protection from pregnancy than condoms alone. p Any family planning method can be used if you and your partner are uninfected. q There are types of sexual intimacy that can be satisfying yet do not spread STIs or HIV. For best protection, no contact with partner’s semen or vaginal secretions. Avoid unprotected anal and oral sex. r Delaying or avoiding sexual activity (abstinence) can be a good choice for some adolescents or unmarried adults. If client chooses option 4 or 5, advise on the need for protection if she/he decides to have sex: “Always keep condoms at hand in case you need them.” To discuss condom use now, go to a condom tab. To discuss another method now, go to correct tab. ∗ • Some situations are more risky than others — such as having more than one sexual partner • Often, you may not know if you or your partner has an STI or HIV • A person with HIV can look and feel healthy • If you are unsure of infection, tests may be available For a MANFor a WOMAN Let’s consider your risk • Pain or burning when you urinate? • Sores in or around your vagina? • Open sores anywhere in your genital area?• Pus coming from your penis? Some STIs have signs and symptoms: • Pain in your lower belly? Do you want to be tested for HIV? Let’s consider your risk • You can tell clients which situations are risky. Then ask them to think about their sexual relationships to help assess risk. Offer to discuss. (See Appendix 12 for tips on talking about sex.) Risky situations include: • Sex with more than one partner without always using condoms. • Sex with a partner who may have sex with others. • Sex for money, food, or other payment. • Sex with a new partner who does not always use condoms. • Having a husband who travels for work and returns now and then. • Living in an area where HIV and other STIs are widespread. • Adolescents may be at higher risk. • Some situations are more risky than others — such as having more than one sexual partner Some STIs have signs and symptoms: For a WOMAN • Pain in your lower belly? • Sores in or around your vagina? For a MAN • Pus coming from your penis? • Pain or burning when you urinate? • Open sores anywhere in your genital area? Dual Protection • Often, you may not know if you or your partner has an STI Diagnosing STIs: • In women, many STIs do not cause obvious signs or symptoms (such as those listed at left). • Some obvious signs in the genital area may not be caused by STIs. Abnormal vaginal discharge and itching are often due to infections that are not sexually transmitted. • If a client suspects that she/he or partner has an STI: diagnose and treat, or refer. HIV testing and counselling: • Many people do not know if they are infected with HIV. A blood test is the only sure way to know. Rapid HIV tests are cheap, easy and reliable. Positive test results need confirmation before diagnosing or counselling the client. • If client wants an HIV test, give test or refer for testing and counselling. See Appendix 8 for more information on HIV testing and counselling. • A person with HIV can look and feel healthy • If you are unsure of infection, tests may be available If client wishes to be tested for HIV, offer counselling or refer. Once client understands STI risks and dual protection choices, go to next page. Next Move: DP 2 You can choose how to protect yourself Please consider: • What suits you best for family planning and STI/HIV/AIDS protection? • Will your partner agree? • What if you can't stick to your first choice? OR AND n po q r You can choose how to protect yourself Next Move: Dual Protection • For example, if client chooses condoms, could this couple abstain if they ran out of condoms? • Help client consider which of the 5 options will work best for her/him. • Explain that it is very important for clients to discuss dual protection and family planning decisions with their partner. “Can you talk to your partner about this?” “If your partner does not agree, what will you do?” Appendix 9 has tips on helping clients talk with partners. • Invite client to bring partner into clinic to discuss options and choices. • For client with family planning method in mind, discuss how to make her/his dual protection choice work with method: For example, “The IUD won’t protect you from STIs or HIV/AIDS. Will your partner be happy to use condoms? Or else will you and your partner stay faithful to each other?” • Will your partner agree? • What if you can't stick to your first choice? Please consider: • What suits you best for family planning and STI/HIV/AIDS protection? To discuss condom use now, go to a condom tab. To discuss another method now, go to correct tab. DP 3 Clients with special needs Next Move: • Pregnant/postpartum client…….go to page SN4 • Post-abortion client…………………………go to page SN5 • Older client….…………………….go to page SN3 These pages help clients who may need special counselling or advice. Special needs • Client living with HIV/AIDS…………….go to page SN6 Go to correct page in this section. • Younger client…………………….go to next page (page SN2) SN 1 • Client who wants to become pregnant….go to page SN7 How can I help? Anything you want to discuss? For example: • Will parents or partner find out? • Need contraception? • HIV/AIDS worries? • Partner problems? • Pregnancy? • About sex? • About the body? You are welcome here any time Anything you want to discuss? For example: • Will parents or partner find out? • Need contraception? • HIV/AIDS worries? • Partner problems? • Pregnancy? • About sex? • About the body? Younger clients may be at risk for STIs/HIV infection: • Explain AIDS, STIs, and risks, and urge consistent and correct CONDOM USE. • Discuss other ways to stay protected (see Dual Protection tab): - abstinence (including avoiding or delaying having sex until older or ready); - other safe forms of intimacy. How can I help? For Emergency Contraception go to EC method tab. For STI and HIV/AIDS protection go to Dual Protection tab. For family planning go to Choosing Method or Returning Client tab. Next Move: Special needs: Younger client SN 2 Family planning for younger clients: • A healthy adolescent can safely use any method. • Protection against pregnancy AND STIs/HIV may be important (see below). • Sterilization and vasectomy are usually not suitable as both are permanent. • Fertility awareness-based methods may be unsuitable if her periods are irregular. • Bone mineral density decreases slightly during DMPA use, but increases again after stopping. It is not known whether this leads to increased fracture risk. • Does client need emergency contraception? If likely, go to EC tab. Other topics to discuss: • Is client able to talk with partner? Use Appendix 9 to help advise them. • Could client be pregnant without knowing? Look for pregnancy signs or complications. • Younger clients may know little about their bodies, pregnancy, family planning and STIs/HIV/AIDS. Use Appendices to help counsel. Important points to remember when counselling adolescents: • All younger clients (married or unmarried, male or female) have a right to family planning information and services. • Assure privacy and confidentiality: “No one else will know that you came here unless you give permission.” • Tell client that you can discuss embarrassing or difficult topics, and encourage client to speak openly. Family planning for older women Important to consider: • Pregnancy is possible right up to menopause • Healthy older women can safely use any family planning method • When to stop using family planning methods • You must keep protecting yourself from STIs and HIV/AIDS Would you like to talk more about menopause? Family planning for older women Important to consider: • Pregnancy in older women carries greater risks for her and the baby. • IUDs can be left in place until after menopause. They should be removed at least 1 year after her last menstrual period. • Hormonal methods (pills, injectables, implants) affect bleeding. It may be difficult to know if the woman has reached menopause. After stopping a hormonal method, she can use condoms for 1 year. If she has no menstrual periods during that time, she no longer needs contraception. All methods are safe for healthy older women, but: • Older women who are at risk for heart disease (who have high blood pressure or diabetes or who smoke) should not use the pill or monthly injectables. Help her choose another method. • Users of fertility awareness-based methods should switch to another method as they approach menopause. Their irregular periods can make fertility awareness-based methods hard to use. • If an older woman is already having heavy bleeding problems, IUD use may increase them further. • Female sterilization or vasectomy may be a good choice for older couples who do not want any more children. • Bone mineral density decreases slightly during DMPA use, but increases again after stopping. It is not known whether this leads to increased fracture risk. • You must keep protecting yourself from STIs and HIV/AIDS • For tips about menopause, see Appendix 11. • Sexually active older women can still be at risk for STI or HIV infection, even if they no longer need contraception. See Dual Protection tab. • Pregnancy is possible right up to menopause • Healthy older women can safely use any family planning method • When to stop using family planning methods New client or switching: go to Choosing Method tab. Stopping family planning? Arrange for IUD or implant removal if needed. Continuing method? Go to Returning Client tab, or invite her to return any time she wants. Next Move: Special needs: Older client Would you like to talk more about menopause? SN 3 Family planning after childbirth • Let’s plan for the future • Pregnant now? You can think about family planning methods NOW • Recently gave birth? Are you breastfeeding? • Explain that if she is not fully (or nearly fully) breastfeeding, she can become pregnant again as soon as 4 weeks after childbirth. • Ask her about her plans for having more children. Go to page SN7 to discuss birth spacing. Encourage her to think about family planning during her pregnancy. • If she wants female sterilization immediately after childbirth, she should plan for delivery in a hospital or health centre. Immediate sterilization must be done within 7 days after delivery. Otherwise she must wait 6 weeks. • If she wants to have an IUD inserted immediately after childbirth, she should plan for delivery in a hospital or health centre. Immediate insertion must be done within 48 hours after delivery. Otherwise she must wait 4 weeks. • If she is at risk for STIs/HIV/AIDS, she should use condoms during pregnancy. Family planning after childbirth For information on LAM, go to method tab. For other family planning methods, go to Choosing Method or method tab. If breastfeeding: • Explain that if she is fully (or nearly fully) breastfeeding in the first 6 months after childbirth, this protects her against pregnancy (as long as she remains amenorrhoeic) (see LAM method tab). Exclusive breastfeeding is also best for the baby’s health. • Tell her about other methods in case she stops LAM or wants additional protection. • Other good methods while breastfeeding are nonhormonal methods such as condoms, IUD, vasectomy, sterilization. Progestogen-only methods can also be used while breastfeeding (the mini-pill, long-acting injectables, implants). See chart in Appendix 7 for when to start methods after childbirth. If not breastfeeding: • See chart in Appendix 7 for when to start methods after childbirth.Next Move: For antenatal clients, arrange a follow-up visit for after childbirth. Special needs: Pregnant/post- partum client • Let’s plan for the future • Pregnant now? You can think about family planning methods NOW • Recently gave birth? Are you breastfeeding? SN 4 Family planning after abortion Let’s discuss your needs: • You can get pregnant again quickly • I can help you choose and use a method • All family planning methods are safe now if you have no infection Offer support to women who have recently had an abortion. • They may need special counselling and advice. • Encourage her to speak openly. • If her story suggests other social or health concerns, such as sexual or other violence, offer help or refer for care. See Appendix 13. • Explain that she can become pregnant as soon as 2 weeks after an abortion. • If she has no post-abortion complications or infection, she can safely use any family planning method. She can start all methods immediately post-abortion, unless she has an infection or if using the diaphragm (see below). • Discuss her experiences with family planning. • For fertility awareness-based methods, give special counselling for correct use. She should abstain or use another method for 3 months before using Standard Days Method. • Explain emergency contraception (see EC method tab). Offer emergency contraceptive pills to take home in case she needs them in the future. Family planning after abortion If an infection is evident or suspected: • Treat infection or refer for treatment. • Advise her to avoid intercourse until the infection is ruled out or fully cured. • Delay female sterilization and IUD insertion until infection is ruled out or fully cured. Offer other methods to use in the meantime. Next Move: After second trimester abortion: • For female sterilization and IUD insertion, provider may need special training because of changed uterine size and position of the fallopian tubes. • Delay fitting diaphragm for 6 weeks. Offer other methods now. For STI and HIV/AIDS protection go to Dual Protection tab. For family planning go to Choosing Method or method tab. Special needs: Post-abortion client • You can get pregnant again quickly • All family planning methods are safe now if you have no infection • I can help you choose and use a method SN 5 Let’s discuss your needs: Clients living with HIV/AIDS • You need continued protection from STIs and HIV/AIDS • Pregnancy can be risky for you and your child • You can find a family planning method that is right for you Advise on effective family planning methods (see chart in Appendix 3), including condom use for dual protection (see above). Some methods are not appropriate for a woman living with HIV/AIDS: • A woman who has untreated AIDS cannot use the IUD. If she has HIV (but not AIDS) or successfully treated AIDS she can use the IUD, however. • Fertility awareness-based methods may be difficult to use if she has AIDS or is taking antiretroviral drugs, because of changes to the menstrual cycle and higher body temperatures. • Recently given birth? HIV can be passed to the baby in breast milk. To see if LAM can be used, go to LAM tab, page 2. • Taking rifampicin for tuberculosis? Usually cannot use pills, monthly injectables or implants. • Should not use spermicides, or diaphragm with spermicides. • Pregnancy may carry major health risks for HIV-positive women and their babies. See page SN7 to help counsel women who wish to have children. • Risks include: transmission of HIV to the baby (during pregnancy, delivery, or breastfeeding), miscarriage, anaemia, wasting, preterm labour, stillbirth, low birth weight and other complications. • Refer her to an HIV prevention and treatment programme, if available, for her and her child. Clients living with HIV/AIDS Next Move: • HIV-positive clients need continuing protection from other STIs and from HIV reinfection. • Correct and consistent condom use, alone or with another method, protects against both pregnancy and infection. See Dual Protection tab and Condom tab to advise on correct and consistent use of condoms. For family planning go to Choosing Method or method tab. Special needs: Client living with HIV/AIDS • Pregnancy can be risky for you and your child • You can find a family planning method that is right for you • You need continued protection from STIs and HIV/AIDS SN 6 For STI and HIV/AIDS protection go to Dual Protection tab. For HIV treatment refer for care, if possible. Do you want to become pregnant? • Spacing pregnancies 2 to 3 years apart is healthier for you and your child • If you are having problems getting pregnant, we can offer advice and support • For women living with HIV, we can offer advice and support • Like other women, some women with HIV want to have children. Offer her counselling and advice. Be supportive and respect her wish to have children, but explain that this carries risks for her and her baby (see page SN6). It may also be harder to become pregnant if she lives with HIV. • Also, discuss the need to plan treatment and care for herself and her family if she or other family members become ill. • The risk of HIV transmission to the baby can be reduced by: taking appropriate antiretroviral drugs to avoid mother-to-child transmission; choosing elective caesarian section (if appropriate); choosing a safe way to feed her baby (see LAM method tab, page L2); and by using condoms during pregnancy to avoid reinfection with HIV and other STIs. Refer her to an HIV centre to asses treatment needs, as appropriate. • Some couples may have problems conceiving. Explain that this is common, especially among older couples. • If a client suspects that she/he or partner has an STI now: diagnose and treat, or refer. Many cases of infertility are caused by past STIs. • Advise the couple to keep trying to conceive for at least 1 year before offering infertility counselling or treatment. They should have sexual intercourse regularly to increase chances of conception. • See Appendix 11b for tips on infertility counselling. Do you want to become pregnant? Next Move: • Discuss appropriate method options for women who want to space their births. Go to Choosing Method tab. • Explain that she can become pregnant soon after stopping most contraceptive methods, except after stopping long-acting injectables, when there is usually a delay of several months (see method tab page LI1). For family planning go to Choosing Method or method tab. Special needs: Client who wants to become pregnant SN 7 For HIV treatment refer for care, if possible. • Spacing pregnancies 2 to 3 years apart is healthier for you and your child • If you are having problems getting pregnant, we can offer advice and support • For women living with HIV, we can offer advice and support For infertility treatment refer for care, if possible. • Vasectomy or Female Sterilization • Condoms (Male or Female) • Vaginal Methods • LAM • Fertility Awareness-Based Methods What method are you using? • IUD • The Pill • The Mini-Pill • Long-Acting Injectable • Monthly Injectable • Implants Go to the correct page to help returning client. What method are you using? Next Move: Returning Client The Pill………………….page RC 4 Long-Acting Injectable…………….page RC 8 The Mini-Pill………….page RC 6 IUD……………………….next page Implants……………….page RC 12 Vasectomy or Female Sterilization …………….…….page RC 14 Condoms (Male or Female)….………….page RC 15 Fertility Awareness- Based Methods……….page RC 21 Monthly Injectable………………page RC 10 RC 1 LAM………………………page RC 19 Vaginal Methods….….page RC 17 IUD return visit • Are you happy using the IUD? • We can check it for you • Any questions or problems? How can I help? Let’s check: • For any new health conditions • Need condoms too? Remember: IUD does not protect you against STIs or HIV/AIDS! Returning Client: the IUD • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Arrange IUD removal if client wishes. IUD return visit Copper IUD • Are you happy using the IUD? Switching? Discuss other methods. Go to Choosing Method tab. How can I help? Next Move: • Any questions or problems? A pelvic exam may be useful after first menstrual period or 3 to 6 weeks after insertion. • Check for partial or complete expulsion, pelvic infection. Check for any infections or other problems in the reproductive tract. • She can keep the IUD in the following circumstances: — while unexplained vaginal bleeding is being assessed, — receiving treatment for PID or STIs, — awaiting treatment of cervical, endometrial, or ovarian cancer, — if she returns with HIV (infection) or AIDS (illness): clients with AIDS should be closely monitored for pelvic infection. • If client returns with pelvic TB, she should have the IUD removed. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. • For any new health conditions • Need condoms too? Let’s check: Help with problems? Go to next page. Continuing? Invite her to return any time or when IUD needs removal. RC 2 IUD removal: If client is happy with the IUD, she can keep it until the end of its effectiveness (10 years after insertion for Copper T 380A). • We can check it for you Help using the IUD • Having bleeding problems? Happy to continue with the IUD, or want to switch methods? • Cramps or pain? • Think you might be pregnant? Any questions or problems? We can help. • IUD strings changed length or are missing? • Others? Does client want to keep using the IUD or switch methods? Irregular, prolonged, or heavy bleeding: • Heavier menstrual periods and spotting between periods are both common in first 3 to 6 months after insertion. • Ibuprofen or similar medication can reduce bleeding (NOT aspirin). • If bleeding problems continue, a pelvic exam may be necessary. Refer or treat any abnormal condition found. Check for anaemia. If clinical signs of anaemia, suggest IUD removal. • If she finds the bleeding unacceptable, suggest IUD removal. Lower abdominal pain can suggest PID or ectopic pregnancy: • Refer, or diagnose and treat as appropriate. Help using the IUD Next Move: Continuing? Reassure client. Check for new health conditions. (See previous page) Invite her to return any time or when IUD needs removal. Copper IUD • Having bleeding problems? • Cramps or pain? • Think you might be pregnant? Switching? Discuss other methods. Go to Choosing Method tab. Any questions or problems? We can help. • IUD strings changed length or are missing? If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. • IUD could be out of place (expulsion or partial expulsion). Perform pelvic exam. If out of place, IUD needs to be removed. She can use emergency contraception if she had unprotected sex in the past 5 days. See EC tab. • If she is pregnant, recommend IUD removal if strings are visible or can be retrieved safely from cervical canal. Explain small risk of miscarriage. If strings are NOT visible and IUD cannot be safely retrieved, arrange for doctor or nurse to monitor pregnancy closely. Returning Client: the IUD RC 3 • Others? The pill return visit • Are you happy using the pill? Want more supplies? • Any questions or problems? How can I help? Let’s check: • For any new health conditions • Need condoms too? Remember: The pill does not protect you against STIs or HIV/AIDS! Returning Client: the pill • Are you happy using the pill? Want more supplies? The pill return visit • Need condoms too? • If client is satisfied, check for any new health conditions before giving resupply. See below. • Can give up to a year’s supply of pills. • For any new health conditions How can I help? Let’s check: • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Can give up to a year’s supply of pills. Offer condoms. Check for new health conditions that may affect method use: • Check her blood pressure once a year, if possible. • Client should usually stop using the pill and choose another method if: - she has developed high blood pressure; - she has more frequent or more severe headaches (migraine); - she reports certain other new health conditions or problems (see list in Pill tab page P2). • If she has started taking rifampicin or medicine for seizures, provide condoms to use with the pill or, if she is on long-term treatment, help her choose another method. RC 4 • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. The Pill Help using the pill Any questions or problems? We can help. Happy to continue taking the pill, or want to switch methods? • Nausea or vomiting? • Bleeding changes? • Headaches? • Tender breasts? • Others? • Having trouble remembering to take your pills? Missed pills? Help using the pill • Vomiting within 2 hours after taking active pill: take another active pill from separate pack. Nausea may be reduced by taking pills after a meal. • Severe diarrhoea or vomiting for more than 2 days: Follow instructions for missed pills. • Mild headaches: Take pain relief pills if needed. • If headaches become more frequent or severe (migraine) while using the pill, she usually should switch to another method. Does client want to continue the pill or switch methods?Next Move: Continuing? Check for new health conditions. (See previous page.) Give up to another year’s supply of pills. Offer condoms. • For what to do if she missed pills, see Pill tab page P5. • “What would help you remember? What else do you do regularly every day?” • When is easiest time to take the pills? At a meal? At bedtime? • Check: “Would another method be better?” • Having trouble remembering to take your pills? Missed pills? • Nausea or vomiting? • Bleeding changes? • Headaches? • Tender breasts? • Spotting or bleeding between periods is common, especially in the first few months of pill-taking. Also caused by skipping pills, vomiting or diarrhoea, or by taking rifampicin or seizure medications. Switching? Discuss other methods. Go to Choosing Method tab. Any questions or problems? We can help. • Some women also report slight weight gain or loss, dizziness, amenorrhoea (no monthly bleeding), mood changes and less sex drive. • Others? The Pill Returning Client: the pill RC 5 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Reassure client that side-effects are normal: • Most are not harmful or signs of illness and often go away after 3 months or so. • Client may have more than one side-effect. • Switching to a different brand may help. How can I help? • Are you happy using the mini-pill? Want more supplies? • Any questions or problems? The mini-pill return visit Remember: The mini-pill does not protect you against STIs or HIV/AIDS! Let’s check: • For any new health conditions • Need condoms too? • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” When a mini-pill user stops breastfeeding, she may want to switch to the pill. • Wants to stop family planning? Discuss reasons, consequences, next steps. The mini-pill return visit • Are you happy using the mini-pill? Want more supplies? • Need condoms too? • For any new health conditions How can I help? Let’s check: • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Can give up to a year’s supply of pills. Offer condoms. Returning Client: the mini-pill RC 6 • If client is satisfied, check for any new health conditions before giving resupply. See below. • Can give up to a year’s supply of pills. Check for new health conditions that may affect method use: Client should usually stop using the mini-pill and choose another method if: • she has developed heart disease or had a stroke; • she sees a bright spot before bad headaches (migraine aura); • she reports certain other new health conditions or problems (see list in Mini-Pill tab page MP2). • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. The Mini-Pill Help using the mini-pill Any questions or problems? We can help. Happy to continue taking the mini-pill, or want to switch methods? • Nausea or vomiting? • Bleeding changes? • Headaches? • Tender breasts? • Others? • Having trouble remembering to take your pills? Missed pills? Help using the mini-pill • Vomiting within 2 hours after taking pill: take another pill from a separate packet. • Severe diarrhoea or vomiting for more than 2 days: keep taking pills if possible AND use condoms or avoid sex until she has taken a pill each day for 2 days in a row after the sickness has ended. • Mild headaches: Take pain relief pills if needed. • Some women also report dizziness. Does client want to continue the mini-pill or switch methods? Next Move: Continuing? Check for new health conditions. (See previous page). Give up to another year’s supply of pills. Offer condoms. The Mini-Pill • For what to do if she missed pills, see Mini-Pill tab page MP4. • “What would help you to remember? What else do you do regularly every day?” • When is the easiest time to take the pills? At a meal? At bedtime? • Check: “Would another method be better?” • Having trouble remembering to take your pills? Missed pills? • Nausea or vomiting? • Bleeding changes? • Headaches? • Tender breasts? Irregular periods, spotting or bleeding between periods, missed period: • Reassure her that this is common. Usually not harmful, not a sign of illness. • If she has stopped breastfeeding, and the continued bleeding changes bother her, she may want to switch to the pill or another method. • If not breastfeeding and periods have been regular but then stopped, check for pregnancy (see Appendix 1 or do pregnancy test). Switching? Discuss other methods. Go to Choosing Method tab. Any questions or problems? We can help. Returning Client: the mini-pill RC 7 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Reassure client that side-effects are normal: • Most are not harmful or signs of illness. • Client may have more than one side-effect. • Others? Long-acting injectable return visit How can I help? • Are you happy using the injectable? Need next injection? • Late for injection? • Any questions or problems? Remember: Injectables do not protect you against STIs or HIV/AIDS! Let’s check: • For any new health conditions • Need condoms too? • If client is satisfied, check for any new health conditions before giving repeat injection. See below. • Remember to use safe injection procedures! (see Long-acting Injectable tab page LI5). Client should usually stop long-acting injectables and choose another method if: • she has developed high blood pressure; • she sees a bright spot before bad headaches (migraine aura); • she reports certain other new health conditions or problems (see list in Long-acting Injectable tab page LI2). • Up to 2 weeks late: can have injection without need for extra protection. • More than 2 weeks late: she can have next injection if reasonably certain she is not pregnant (for example, she has not had sex since intended injection date). She should use condoms or avoid sex for 7 days after injection. Consider emergency contraception if she had sex after the 2 week “grace period.” • Discuss how she can remember next time. Long-acting injectable return visit • Are you happy using the injectable? Need next injection? • For any new health conditions How can I help? Let’s check: • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Give injection. Remind client of date to return for next injection. • Need condoms too? • Late for injection? Returning Client: long-acting injectable RC 8 • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. Long-acting Injectable Any questions or problems? We can help. Happy to continue with injections, or want to switch methods? • Bleeding changes? • Others? Help using long-acting injectable • Put on weight? • Headaches? • Put on weight? Does client want to continue the long-acting injectable or switch methods? • Spotting, bleeding between periods. Common with long-acting injectable. If spotting or bleeding persists and you suspect a problem, check for infections. If bleeding caused by STI or pelvic infection, she can continue using injectable during treatment. • No monthly bleeding (amenorrhoea). Common, especially after 1st year of use. Not harmful, not a sign of illness. • Very heavy bleeding. Rare. If bleeding continues, check for an abnormal condition and for anaemia (low iron). If the bleeding threatens her health, or she finds it unacceptable, help her choose another method. Help using long-acting injectable • Bleeding changes? • Weight gain is common, usually 1 to 2 kg each year. Changing diet may help. • Some women also report dizziness, moodiness, nausea, and/or less sex drive. • Others? Next Move: • Mild headaches: Take pain relief pills if needed.• Headaches? Continuing? Check for new health conditions. (See previous page). Give injection. Remind client of date to return for next injection. Switching? Discuss other methods. Go to Choosing Method tab. Any questions or problems? We can help. Long-acting Injectable Returning Client: long-acting injectable RC 9 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Reassure client that side-effects are normal: • Most are not harmful or signs of illness. • Client may have more than one side-effect. Monthly injectable return visit How can I help? • Are you happy using the injectable? Need next injection? • Late for injection? • Any questions or problems? Let’s check: • For any new health conditions • Need condoms too? Remember: Injectables do not protect you against STIs or HIV/AIDS! • If client is satisfied, check for any new health conditions before giving repeat injection. See below. • Remember to use safe injection procedures! (see Monthly Injectable tab page MI5). • Check her blood pressure once a year, if possible. • Client should usually stop monthly injectable and choose another method if: - she has developed high blood pressure; - she has more frequent or more severe headaches (migraine); - she reports certain other new health conditions or problems (see list on Monthly Injectable tab page MI2). Monthly injectable return visit • Are you happy using the injectable? Need next injection? • For any new health conditions? How can I help? Let’s check: • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Give injection. Remind client of date to return for next injection. • Need condoms too? Returning Client: monthly injectable RC 10 • Late for injection? • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. • Up to 7 days late: can have injection without need for extra protection. • More than 7 days late: she can have next injection if reasonably certain she is not pregnant (use Appendix 1 or do pregnancy test). She should use condoms or avoid sex for 7 days after injection. Consider emergency contraception if she had sex after the 7-day “grace period.” • Discuss how she can remember next time. Monthly Injectable Any questions or problems? We can help. Happy to continue with injections, or want to switch methods? • Bleeding changes? • Others? Help using monthly injectable • Headaches? • Tender breasts? Does client want to continue the monthly injectable or switch methods? • Spotting, bleeding between periods. Common with monthly injectable. But, if caused by STI or pelvic infection, she can continue using injectable during treatment. • Some women report amenorrhoea (no monthly bleeding). Help using monthly injectable • Bleeding changes? • Some women also report slight weight gain, dizziness.• Others? Next Move: • Mild headaches: Take pain relief pills if needed. • If headaches become more frequent or severe (migraine) while using a monthly injectable, she should usually switch to another method (but not the pill). • Headaches? • Tender breasts? Any questions or problems? We can help. Monthly Injectable Returning Client: monthly injectable RC 11 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Reassure client that side-effects are normal: • Most are not harmful or signs of illness. • Client may have more than one side-effect. Continuing? Check for new health conditions. (See previous page). Give injection. Remind client of date to return for next injection. Switching? Discuss other methods. Go to Choosing Method tab. Norplant implants return visit How can I help? • Are you happy using implants? • Any questions or problems? • Time to have implants removed or replaced? Let’s check: • Your weight • For any new health conditions • Need condoms too? Remember: Implants do not protect you against STIs or HIV/AIDS ! • Are you happy using implants? Norplant implants return visit • Need condoms too? • If client is satisfied, check for any new health conditions. See below. • For any new health conditions How can I help? Let’s check: • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? See Implants tab (page IM4) for removal procedure. Discuss other methods. Go to Choosing Method tab. Continuing? Remind client to return when implants need removing. Implants Client should usually stop using implants if: • she has developed heart disease or had a stroke; • she sees a bright spot before bad headaches (migraine aura); • she reports certain other new health conditions or problems (see list in Implants tab page IM2). Returning Client: implants RC 12 • To help manage side-effects and other problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” “You can have the capsules taken out any time you want.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. • Your weight When to remove or replace implants? • Norplant implants need to be removed or replaced 4 to 7 years after insertion, depending on client's weight. Check when her implants were inserted. • If possible, check her weight: – Still weighs less than 70 kg: Should replace or remove implants after 7 years. – Weighs 70 to 79 kg: Should replace or remove implants after 5 years. – Weighs 80 kg or more: Should replace or remove implants after 4 years. • See Implants tab (page IM4) for removal procedure. • Time to have implants removed or replaced? Help using implants Any questions or problems? We can help. Happy to continue with implants, or want to switch methods? • Bleeding changes? • Headaches? • Others?• Infection in the insertion site? Other side-effects usually go away within 1 year of use. • Mild headaches: Take pain relief pills if needed. • Some women also report tender breasts, lower abdominal pain, dizziness, nervousness, nausea, acne, weight gain or loss, hair loss, and/or hair growth on face. • Spotting or light bleeding between periods. Common, especially during the first year of use. If spotting or bleeding persists and you suspect a problem, check for infections. If bleeding caused by STI or pelvic infection, she can keep implants during treatment. • No monthly bleeding (amenorrhoea). Reassure that bleeding changes are normal and not harmful, not a sign of illness. • Very heavy bleeding. Rare, but requires care. Check for abnormal condition. If none found, treat as follows: — ibuprofen or mefenamic acid; not aspirin; or — 1 cycle of low-dose combined pills (if client can use estrogen). • Clean site with soap and water or antiseptic, if available. No need to remove implants. • If abscess, incise and drain abscess. Remove implants. Offer another method. • Perform wound care. Give oral antibiotics for 7 days. Help using implants Any questions or problems? We can help. Does client want to continue using implants or switch methods? Next Move: Continuing? Check for new health conditions. (See previous page). Remind client to come back at the right time to have implants replaced. • Bleeding changes? • Headaches? Implants • Others? Switching? See Implants tab (page IM4) for removal procedure. Discuss other methods. Go to Choosing Method tab. • Infection in the insertion site? Returning Client: implants RC 13 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Reassure client that side-effects are normal: • Most are not harmful or signs of illness. • Client may have more than one side-effect. Vasectomy or female sterilization return visit • Any questions or problems? • Need condoms too? For women with sterilization: • Remember to come back if you think you might be pregnant Remember: Vasectomy and female sterilization do not protect you against STIs or HIV/AIDS! How else can I help? We will need to examine the incision site Vasectomy or female sterilization return visit If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Wound painful, hot, swollen, with pus (infection or abscess): • Clean site with soap and water, or antiseptic if available. • If abscess, incise and drain it. • Perform wound care. Give oral antibiotics for 7 to 10 days. Ongoing pain after vasectomy: • A very small number of men report chronic ongoing pain in their testicles or scrotum after vasectomy. This pain can last for 1 to 5 years or more. Refer for diagnosis and treatment if possible. • He can take ibuprofen or similar drugs to relieve the pain. • Examine the incision site and check for infection or abscess. • Remove stitches, if necessary. • Any questions or problems? Invite client to return any time she/he wishes, or if she/he wants other available reproductive health care. After vasectomy: Provide condoms or another method (go to Choosing Method tab). • Need condoms too? Vasectomy and Female Sterilization After vasectomy: • Remind client to use condoms or another effective method for 3 months after vasectomy. Provide condoms if needed. Check how client is preventing STIs/HIV/AIDS. • If not protected, go to Dual Protection tab. Give condoms if needed. For women with sterilization: • Remember to come back if you think you might be pregnant Next Move: • Pregnancy after sterilization is rare but can occur. • If she may be pregnant, rule out ectopic pregnancy. Refer if needed. How else can I help? Returning Client: vasectomy or female sterilization RC 14 We will need to examine the incision site • Are you happy using condoms? Want more supplies? Condoms return visit How can I help? Let's check: • Are you able to use condoms every time? Does your partner agree to use condoms? • Any questions or problems? Condoms return visit • Are you happy using condoms? Want more supplies? How can I help? • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Give supply of condoms. • Explain risks of not using a condom every time. Suggest also using another family planning method. • Discuss ways to make condom use more comfortable: — woman can help man put on male condom — man or woman can practice putting on a condom by him/herself — man can help insert female condom — try a different brand. • Practice with client how to talk with partner. Use Appendix 9. Condoms Returning Client: condoms RC 15 • To help manage problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • If client is satisfied, provide more condoms. Let's check: • Are you able to use condoms every time? Does your partner agree to use condoms? Help using condoms Any questions or problems? Happy to continue using condoms, or want to switch methods? Remember: Condoms are the only method that protect you against STIs or HIV/AIDS! • Condom causes itching? • Need more lubrication? • Broken or slipped condom? Does client want to continue using condoms or switch methods? • Broken or slipped condom? • Need more lubrication? Help using condoms Any questions or problems? • If condom breaks or slips off, may need to use emergency contraception (see Emergency Contraception tab). • Clients at high risk of STI or HIV may also need post-exposure prophylaxis treatment. • If male condoms break often, try using lubricant. Also, make sure they are not damaged or old. Inspect the condom package and check the expiry or manufacturing date. Review instructions for use (see Male Condom tab page MC2 or Female Condom tab page FC2). • Condom causes itching? For male latex condoms: • Use only WATER-BASED lubricants, not oil-based. Can use glycerine or clean water. • Oils weaken latex condoms. Avoid oil-based materials such as cooking oil, baby oil, coconut oil, petroleum jelly, butter. For female condoms: • Any kind of lubricant can be used. • Adding lubricant can reduce noise during sex and makes sex smoother. Next Move: Continuing? Give supplies of condoms. Switching? Discuss other methods. Go to Choosing Method tab. • Lubricants can help reduce dryness or irritation (see below), but some lubricants can cause irritation. • If itching continues, could be due to infection or reaction to latex. Condoms Returning Client: condoms RC 16 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Vaginal methods return visit How can I help? • Are you happy using this method? Want more supplies of spermicides? Or need new diaphragm? • Any questions or problems? Remember: Vaginal methods do not fully protect against STIs or HIV/AIDS! Let’s check: • For any new health conditions • Need condoms too? Vaginal methods return visit • Are you happy using this method? Want more supplies of spermicides? Or need new diaphragm? How can I help? • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Continuing? Give more supplies if needed. • For any new health conditions Let’s check: • If at high risk for HIV infection, client should stop using spermicides. Help her choose another method if she wants. • Need condoms too? Vaginal Methods Returning Client: vaginal methods RC 17 • If client is satisfied, check for any new health conditions. See below. • Diaphragm should be replaced when it becomes stiff or thin or develops holes. • Diaphragm should be refitted after childbirth. • To help manage problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. Any questions or problems? Help using vaginal methods Happy to continue using vaginal methods, or want to switch methods? • Problems inserting the diaphragm? • Itching, rash, irritation? • Painful urination? If using spermicides: • Check for infection (signs: abnormal vaginal discharge, redness and/or swelling of the vagina, and itching of the vulva), and treat or refer as appropriate. • If no infection, client may be allergic to spermicide. Suggest a different type or brand. If using diaphragm: • Suggest she remove the diaphragm promptly (but not sooner than 6 hours after sex), and clean and dry it thoroughly. • If problem continues, she may need to switch to another method or refit diaphragm. • If she has a urinary tract infection, treat with antibiotics. Any questions or problems? • Problems inserting the diaphragm? • Carefully explain insertion procedure again. • She can try inserting it at the clinic. Check for correct placement. • Diaphragm may need refitting if she has given birth recently. Does client want to continue using diaphragm/spermicides or switch methods? Next Move: Continuing? Give more supplies of spermicides if needed. Help using vaginal methods • Itching, rash, irritation? • Painful urination? Switching? Discuss other methods. Go to Choosing Method tab. Vaginal Methods Returning Client: vaginal methods RC 18 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. How can I help? • Are you happy using LAM? • Need another method now? You do if: Remember: LAM does not protect you against STIs or HIV/AIDS! LAM return visit - Baby over 6 months - Or stopped fully breastfeeding - Or periods returned • Any questions or problems? Let’s check: • Need condoms too? LAM return visit • Are you happy using LAM? • Any questions or problems? Next Move: Help with problems? Go to next page. Continuing? Remind her to come back when baby is 6 months old or periods return or she stops fully breastfeeding (whichever comes first). • Need condoms too? Let’s check: How can I help? • Help her choose a different method of contraception when: - the baby reaches 6 months, - or her periods return, - or she stops fully (or nearly fully) breastfeeding (whichever comes first). • Can also use another method while breastfeeding: condoms, IUD, mini-pill, implants, or long-acting injectable do not interfere with breastfeeding. From 6 months after the birth, she can also use the pill or monthly injectable. • Need another method now? You do if: — Baby over 6 months — Or periods returned — Or stopped fully breastfeeding Switching? Discuss other methods. Go to Choosing Method tab. LAM Returning Client: LAM RC 19 • To help manage problems, go to next page. • Wants to switch methods? See box above. “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. Help using LAM • Any questions or problems? • Difficulties or concerns with breastfeeding? Happy to continue using LAM, or want to switch methods? Help using LAM • Any questions or problems? • Difficulties or concerns with breastfeeding? Not enough milk? Possible help: • Breastfeed baby more often. • Drink plenty of fluid and eat healthy foods. • Get more rest. Nipples cracked? • She can continue breastfeeding. • To help healing, she can feed baby more often, starting on less sore nipple; let nipples dry in the air after breastfeeding. • Check how she holds the baby while breastfeeding. Advise correct position if needed. • Look for signs of thrush (fungus infection). Sore breasts? • With fever and tiredness? Breasts red and tender? Hurt when touched? Breasts may be infected. Treat for infection. Advise the client to keep breastfeeding often. • If no infection, are breasts tender only in certain places? Lumps? Breasts full, hard, and tender? May be plugged milk ducts or engorgement (congestion). Advise changing position when breastfeeding. Advise her on proper breastfeeding position. Does client want to continue using LAM or switch methods? Next Move: LAM Switching? Discuss other methods. Go to Choosing Method tab. Returning Client: LAM RC 20 If problems, listen to client’s concerns. • Take all comments seriously. Don’t dismiss concerns. • Answer questions respectfully. Continuing? Remind her to come back when baby is 6 months old or periods return or she stops fully breastfeeding (whichever comes first). How can I help? • Are you happy using this method? • Any questions or problems? Let’s check: • Are your periods still regular? • Need condoms too? Remember: Standard Days Method does not protect you against STIs or HIV/AIDS ! Standard Days Method return visit Standard Days Method return visit • Are you happy using this method? • Any questions or problems? Next Move: Help with problems? Go to next page. Switching? Discuss other methods. Go to Choosing Method tab. Standard Days Method • Need condoms too? Let’s check: How can I help? • Are your periods still regular? • To use method effectively she must have regular cycles between 26 and 32 days long. • If she has had more than two cycles shorter than 26 days or longer than 32 days within one year of use, the method may be less effective. She may want to choose another method. Returning Client: standard days method RC 21 • If client is satisfied, check that periods are still regular. See below. • To help manage problems, go to next page. • Wants to switch methods? “It’s okay to change methods if that is what you decide.” • Wants to stop family planning? Discuss reasons, consequences, next steps. • Check how client is preventing STIs/HIV/AIDS. If not protected, go to Dual Protection tab. Give condoms if needed. • Needs pregnancy protection for fertile “white bead” days? Continuing? Offer condoms to use on fertile days if needed. Any questions or problems? Help using Standard Days Method Happy to continue using this method, or want to switch to another? • Problems remembering to move ring? • Difficult to use condoms or avoid intercourse on fertile days? • Had unprotected intercourse on a fertile day? Switching? Discuss other methods. Go to Choosing Method tab. Help using Standard Days Method Any questions or problems? Next Move: Standard Days Method • Problems remembering to move ring? • Difficult to use condoms or avoid intercourse on fertile days? • Had unprotected intercourse on a fertile day? • Discuss if counseling with her partner may help. • She can show her partner the CycleBeads and point out that pregnancy is possible on these days. • Practice with the client how to talk with partner. See Appendix 9. • If appropriate, discuss sexual pleasure without penetration. • Check: “Would another method be better?” • She can mark the first day of her cycle on her calendar. She can then count the days from the first day of her cycle and move the rubber ring to that bead. • She can consider using emergency contraception if she had unprotected intercourse on a fertile day. See Emergency Contraception tab. Returning Client: standard days method RC 22 Continuing? Offer condoms to use on fertile days if needed, and emergency contraception in case she needs it. Emergency Contraception • There are safe methods to prevent pregnancy after unprotected sex • How long ago did you have unprotected sex? • Could you have been exposed to STIs/HIV? Emergency Contraception (EC) • There are safe methods to prevent pregnancy after unprotected sex Emergency contraceptive pills: • She should take pills as soon as possible after unprotected intercourse. They can be taken up to 5 days after. See next page. • Counsel as appropriate. • “This can happen to anyone.” • Let client tell her story now if she wishes. • Offer support without judging the client. Does client want to use emergency contraception? Next Move: For EC pills information go to next page. For emergency copper IUD information go to page EC4. — Up to 5 days ago? • Client may want to consider EC if: — no method was used — a method was used incorrectly (for example, missed pills, late for injection) — method failed (for example, broken condom, expelled IUD) • If she can answer “yes” to any of the questions in Appendix 1, she is probably not fertile and would not need EC. However, if she is worried, she can still use EC. — More than 5 days ago? EC 1 • How long ago did you have unprotected sex? Emergency copper IUD: • More effective than pills, but those at high risk for STIs should not use it (see IUD tab page IUD2). • Can also be used up to 5 days after unprotected intercourse (see page EC4). • Good choice for women who want to keep using an IUD. Emergency Contraception • Could you have been exposed to STIs/HIV? • If she had unprotected intercourse where circumstances suggest HIV or STI transmission, offer and start post-exposure prophylaxis (PEP) for HIV immediately (within 72 hours) and/or presumptive STI treatment, if available, or refer for further counselling, support and treatment. • Need to be taken as soon as possible after unprotected sex • Do not cause abortion • Might cause nausea, vomiting, spotting or bleeding • Do not prevent pregnancy the next time you have sex • Not for regular use Emergency Contraceptive Pills Emergency Contraceptive Pills (ECPs) • She should take pills as soon as possible after unprotected intercourse, ideally take within 72 hours (3 days). They can be taken up to 120 hours (5 days) after, but become less effective with each day that passes. • If she had other acts of unprotected sex since her last menstrual period, she may already be pregnant and ECPs would then not work. If she takes ECPs when already pregnant, they do not harm pregnancy. She should return if next menstrual period is more than 1 week late. Next Move: If she chooses ECPs, provide them and go to next page. For emergency copper IUD information go to page EC4. • Discuss: ECPs do not protect against future acts of sexual intercourse. (See next page for continuing protection.) • Less effective than most regular methods. • Need to be taken as soon as possible after unprotected sex • Do not prevent pregnancy the next time you have sex • Not for regular use • Might cause nausea, vomiting, spotting or bleeding • Do not cause abortion • “ECPs prevent pregnancy. They do not cause abortion.” They work mainly by stopping ovulation (see Appendices 4 & 5). • If she is taking combined estrogen-progestogen pills, she can take antinausea medicine (meclazine hydrochloride) to prevent nausea. • If she vomits within 2 hours after taking ECPs, she should return for another dose as soon as possible. • She may have spotting or bleeding a few days after taking pills. EC 2 Levonorgestrel-only ECPs • Work better and cause less nausea and vomiting than combined ECPs. • Dosage: Take 1.5 mg of levonorgestrel in a single dose. Combined estrogen-progestogen ECPs • Use if levonorgestrel-only pills are unavailable. • Dosage: Take 2 doses of 100 mcg of ethinylestradiol plus 0.5 mg of levonorgestrel, 12 hours apart. Emergency Contraception Need continuing protection? Please consider: • Could unprotected intercourse happen again? • Do you need dual protection from pregnancy and STIs/HIV/AIDS? • Can you always choose when you have sex? • Do you have a regular method? Are you satisfied with it? Do you want to know your family planning choices? Need continuing protection? • Invite client to tell her story. • If story suggests STI exposure, refer for treatment. Discuss condoms if appropriate. • If at risk for STIs, discuss dual protection from pregnancy AND from STIs/HIV/AIDS. Go to Dual Protection tab. • Use Appendix 9 to discuss communication with partners. • If story suggests coercion or violence, refer for more help if possible. See Appendix 13. Please consider: • Can start another method straightaway, including pills. • If client chooses no regular method now, offer ECPs and condoms with instructions for use. Next Move: For emergency copper IUD information go to next page. If she chooses continuing contraception, go to Choosing Method tab. • Do you need dual protection from pregnancy and STIs/HIV/AIDS? • Can you always choose when you have sex? • Do you have a regular method? Are you satisfied with it? • Could unprotected intercourse happen again? EC 3 Emergency Contraception Emergency Copper IUD • Can use if had unprotected sex in the last 5 days • Doctor, nurse, or midwife places IUD in womb. Can cause some cramps. • IUD can be taken out later or left in place for continuing contraception Emergency Copper IUD • Can use as long-term contraceptive method if she is medically eligible, or can be removed at any time. • If kept in place, IUD keeps working up to 10 years. • If emergency IUD does not prevent pregnancy, the IUD will need to be taken out. • Can use if had unprotected sex in the last 5 days Next Move: If she chooses emergency copper IUD, go to Copper IUD tab to check medical eligibility for IUD use (page IUD2) and for information on IUD insertion. • Very effective; more effective than ECPs. • If you can estimate the time of her ovulation, she can also have the IUD inserted more than 5 days after unprotected sex, as long as it is not inserted more than 5 days after ovulation. • There has been no research on the mechanism of action of the IUD used for emergency contraception. EC 4 Emergency Contraception • IUD can be taken out later or left in place for continuing contraception • Doctor, nurse, or midwife places IUD in womb. Can cause some cramps. Copper IUD Do you want to know more about the IUD, or talk about a different method? • Small device that fits inside the womb • Very effective • Keeps working up to 10 years, depending on type • We can remove it for you whenever you want • Very safe • Might increase menstrual bleeding or cramps • No protection against STIs or HIV/AIDS • Very effective, with little to remember. • Copper T 380A lasts for 10 years. • For older women: should be removed 1 year after last menstrual period (menopause). • Can soon become pregnant when IUD taken out. “Do you want to know more about the IUD, or talk about a different method?” • Small device that fits inside the womb About the IUD: • Small flexible plastic frame with copper sleeves and/or wire. • Give client a sample IUD to hold. • Works mainly by stopping sperm and egg from meeting. • Most women can use IUDs, including women who have never been pregnant. Check for concerns, rumours: “What have you heard about the IUD?” (See Appendix 10 on myths about contraception.) Explain common myths: • IUD does not leave the womb and move around inside the body. • IUD does not get in the way during intercourse, although sometimes the man may feel the strings. • IUD does not rust inside the body, even after many years. • Side-effects usually get better after first 3 months (see page IUD3). • For STI/HIV/AIDS protection, also use condoms. If client wants to know more about the IUD, go to next page. Next Move: Copper IUD • Very effective • We can remove it for you whenever you want • Keeps working up to 10 years, depending on type • Might increase menstrual bleeding or cramps • No protection against STIs or HIV/AIDS Copper IUD IUD 1 • Very safe To discuss another method, go to a new method tab or to Choosing Method tab. Who can and cannot use the IUD But usually cannot use IUD if : Most women can safely use the IUD • May be pregnant • Gave birth recently (more than 2 days ago) • Unusual vaginal bleeding recently • At high risk for STIs • Infection or problem in female organs Who can and cannot use the IUD • IUD should not be inserted between 48 hours and 4 weeks after childbirth because of expulsion risk. STI or Pelvic Inflammatory Disease (PID): • Treat PID, chlamydia, gonorrhoea or purulent cervicitis BEFORE inserting IUD. Offer to treat partner too. • Can insert IUD if client has genital ulcer disease or vaginitis (bacterial vaginosis, trichomonas vaginalis), but check risk for chlamydia or gonorrhoea. Treat infections. HIV or AIDS: • If client has HIV, can insert IUD. • If client has AIDS, do not insert IUD. But if client is being treated with antiretroviral drugs and is healthy, can insert IUD. Infection after childbirth or abortion: • Any infections should be fully treated before IUD insertion. Cancer in female organs or pelvic tuberculosis (TB): • Do not insert IUD if known cervical, endometrial or ovarian cancer; benign or malignant trophoblast disease; pelvic TB. Most women can safely use the IUD. But usually cannot use IUD if: • If at high risk for chlamydia or gonorrhoea infection. Those at high risk for these STIs include anyone who: • has more than 1 sex partner without always using condoms; • has sex partner who may have sex with others without always using condoms. “We can find out if the IUD is safe for you. Usually, women with any of these conditions should delay insertion or use another method.” • Unusual bleeding should be assessed before IUD insertion. Client unable to use the IUD: help her choose another method. Client able to use the IUD: go to next page. Next Move: 2 • Gave birth recently (more than 2 days ago) • Unusual vaginal bleeding recently • May be pregnant • If in any doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. Copper IUD • At high risk for STIs IUD 2 • Infection or problem in female organs Possible side-effects After insertion: • Some cramps for several days Other common side-effects: • Longer and heavier periods • Bleeding or spotting between periods • More cramps or pain during periods May get less after a few months • Some spotting for a few weeks How would you feel about these side-effects? If you choose this method, you may have some side-effects. They are not usually signs of illness. • “It can take time for the body to adjust.” • Different people have different reactions to methods. Possible side-effects Does client understand side-effects? Is she happy to use method? Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • Discuss any rumours or concerns. (See Appendix 10). • “Please come back any time you want help or have questions.” • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. Next Move: If so, go to next page. If not, discuss further or consider other methods. Copper IUD After insertion: • Some cramps for several days • Some spotting for a few weeks • For cramps after insertion, can take aspirin, paracetamol, or ibuprofen. • For longer, heavier and more painful periods, she can take ibuprofen or a similar medication (NOT aspirin). • Cramps and bleeding usually get less after 3 to 6 months. Other common side-effects: • Longer and heavier periods • Bleeding or spotting between periods • More cramps or pain during periods May get less after a few months IUD 3 If you choose this method, you may have some side-effects. They are not usually signs of illness. Steps: Pelvic examination Cleaning the vagina and cervix Placing IUD in the womb through the cervix • May hurt at insertion • Please tell us if it hurts • Rest as long as you like afterwards • May have cramps for several days after insertion What will happen when you get your IUD n o p Afterwards: you can check your IUD from time to time Are you ready to choose this method? What questions do you have? Steps: Pelvic examination Cleaning the vagina and cervix Placing IUD in the womb through the cervix • Ask if she has any questions or concerns. • Explain who will do the procedure. • No anaesthesia needed. Woman stays awake. • If it is her first pelvic exam, explain exam, including position during exam. Let client hold a speculum. Explain its use. • Done slowly and gently. • Show sample IUD with arms folded in inserter. • Any immediate pain usually lasts 30 minutes at most.• May hurt at insertion • Please tell us if it hurts • Rest as long as you like afterwards • May have cramps for several days after insertion n o p What will happen when you get your IUD Does client understand IUD insertion procedure? Is she ready to choose method? Next Move: Copper IUD When to check: • Once a week in first month. • After a menstrual period from time to time. How to check: • Wash hands, sit in squatting position, insert a finger into vagina and feel for IUD strings at cervix. Don’t pull on the strings. If unable to feel strings, or strings feel longer or shorter, she should come back to the clinic. IUD may have been expelled, and she may need emergency contraception. Afterwards: you can check your IUD from time to time IUD 4 If she has decided to use method, go to next page. If not, discuss further or consider other methods. You may be able to get your IUD now • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant • IUD can be inserted in first 2 days after you give birth Would you like to get your IUD now? After miscarriage or abortion: • Can insert immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. You may be able to get your IUD now Is she ready to get her IUD now? Next Move: If she can get her IUD now, prepare for insertion or arrange appointment for insertion as soon as possible. If she must wait, offer condoms or another method. Copper IUD • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant • If menstrual bleeding started in last 12 days, can insert IUD now. • If menstrual bleeding started more than 12 days ago, can insert IUD now if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1). No need to wait for next menstrual period. Insertion after childbirth: • Can insert within 48 hours after birth. Special training needed. • Can also insert after 4 weeks after birth. Must be reasonably certain she is not pregnant. • Between 48 hours and 4 weeks after birth, delay insertion. Offer condoms or another method if she is not fully breastfeeding. If switching from another method: • If she has been using a reliable method correctly (including LAM) or has had no sex since last period, you can insert the IUD now, not only during menstruation. • IUD can be inserted in first 2 days after you give birth IUD 5 If infection: • Can insert after infection is fully treated and cured. Offer condoms or another method to use in the meantime. What to remember • Your kind of IUD: • When to have IUD taken out: • Bleeding changes and cramps are common. Come back if they bother you. • Come back for a check-up in 3 to 6 weeks or after next menstrual period See a nurse or doctor if: • Missed a menstrual period, or think you may be pregnant • Could have an STI or HIV/AIDS • IUD strings seem to have changed length or are missing • Bad pain in lower abdomen Anything else I can repeat or explain? Any other questions? Return Signs: • “These signs mean a doctor or nurse should check if a problem is developing.” • “I want you to know about them and remember them.” • Give client an information card or copy of client’s page and explain. Tell her to keep card in a safe place. • Copper T 380A lasts for 10 years. • For older women, IUD should be left in place until 1 year after last menstrual period (menopause) for full protection from pregnancy. • See a nurse or doctor if: — Missed a menstrual period, or think you may be pregnant — Could have an STI or HIV/AIDS — IUD strings seem to have changed length or are missing — Bad pain in lower abdomen • Your kind of IUD • When to have IUD taken out What to remember “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection! Last, most important message: “Come back any time you have questions or want the IUD removed.” Last Moves: Copper IUD • Make appointment to check IUD is still in place and no infection. • Encourage her to come back any time to discuss problems or have the IUD removed. • Come back for a check-up in 3 to 6 weeks or after next menstrual period • She should tell other health care providers that she has an IUD. • Bleeding changes and cramps are common. Come back if they bother you. IUD 6 • Take a pill every day • Can be very effective • Very safe • Helps reduce menstrual bleeding and cramps • Some women have side-effects at first—not harmful • No protection against STIs or HIV/AIDS The Pill Do you want to know more about the pill, or talk about a different method? The Pill • Take a pill every day “Do you want to know more about the pill, or talk about a different method?” If client wants to know more about the pill, go to next page. • Can be very effective • Some women have side-effects at first—not harmful • Helps reduce menstrual bleeding and cramps • No protection against STIs or HIV/AIDS Next Move: P1 The Pill • Very safe • “Would you remember to take a pill each day?” • No need to do anything at time of sexual intercourse. • Very effective if taken every day. But if woman forgets pills, she may become pregnant. • Easy to stop: A woman who stops pills can soon become pregnant. • Side-effects often go away after first 3 months (see page P3). • For STI/HIV/AIDS protection, also use condoms. About the combined pill: • Contains both estrogen and progestogen hormones. • Works mainly by stopping ovulation (see Appendices 4 & 5). • Pills are not harmful for most women's health. Some clients may be concerned that the pill causes cancer, but studies show that the risk is very low for almost all women. The pill can even protect against some types of cancer. (See Appendix 10.) • Serious complications are rare. They include heart attack, stroke, blood clots in deep veins of the legs or lungs. • Less menstrual bleeding can help reduce anaemia. • Check for concerns, rumours: “What have you heard about the pill?” • Explain common myths: Pills are dissolved into blood. They do not collect in stomach. (Also see Appendix 10.) To discuss another method, go to a new method tab or to Choosing Method tab. Who can and cannot use the pill But usually cannot use the pill if: • High blood pressure • Smoke cigarettes AND age 35 or older • Breastfeeding 6 months or less • May be pregnant • Gave birth in the last 3 weeks Most women can safely use the pill • Some other serious health conditions Most women can safely use the pill. But usually cannot use the pill if: • Check blood pressure (BP) if possible. If systolic BP 140+ or diastolic BP 90+, help her choose another method (but not a monthly injectable). (If systolic BP 160+ or diastolic BP 100+, also should not use long-acting injectable.) • If BP check not possible, ask about high BP and rely on her answer. Who can and cannot use the pill “We can find out if the pill is safe for you. Usually, women with any of these conditions should use another method.” • If in doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. Client unable to use the pill: help her choose another method, but not monthly injectable. 2 Client able to use the pill: go to next page. • High blood pressure • Smoke cigarettes AND age 35 or older • Breastfeeding 6 months or less • May be pregnant *What is a migraine? Ask: “Do you often have very painful headaches, perhaps on one side or throbbing, that cause nausea and are made worse by light and noise or moving about? Do you see a bright spot in your vision before these headaches?” (migraine aura) Next Move: • Gave birth in the last 3 weeks P2 The Pill Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer) • Some other serious health conditions: • Ever had stroke or problem with heart or blood vessels. • Migraine headaches*: She should not use the pill if she is over 35 and has migraines, or at any age if she has migraine aura. Women under 35 who have migraines without aura and women with ordinary headaches CAN usually use the pill. • Ever had breast cancer. • Has 2 or more risk factors for heart disease, such as hypertension, diabetes, smokes, or older age. • Gallbladder disease. • Has ever had blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use the pill. • Soon to have surgery? She should not start if she will have surgery making her immobile for more than 1 week. • Serious liver disease or jaundice (yellow skin or eyes). • Diabetes for more than 20 years, or severe damage caused by diabetes. • Takes pills for tuberculosis, fungal infections, or epilepsy (seizures/fits). Possible side-effects • Nausea (upset stomach) • Tender breasts • Spotting or bleeding between periods • Slight weight gain or loss • Mild headaches • But many women do not have any • Often go away after a few months Most common: Do you want to try using this method and see how you like it? If you choose this method, you may have some side-effects. They are not usually signs of illness. • Dizziness • “It can take time for the body to adjust.” • Different people have different reactions to methods. • About half of all users never have any side-effects. • Side-effects often go away or lessen within 3 months. Possible side-effects Does client understand side-effects? Is she ready to choose method? • But many women do not have any • Often go away after a few months Next Move: Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. • “Please come back any time you want help or have questions.” • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. • Tell client: skipping pills may make bleeding side- effects worse and risks pregnancy. P3 Most common: • Nausea (upset stomach) • Spotting or bleeding between periods • Mild headaches • Tender breasts • Dizziness • Slight weight gain or loss The Pill If she has decided to use method, go to next page. If not, discuss further or consider other methods. If you choose this method, you may have some side-effects. They are not usually signs of illness. • Take one pill each day, by mouth If you use the 28-pill pack: • Once you have finished all the pills in the pack, start new pack on the next day If you use the 21-pill pack: • Once you have finished all the pills in the pack, wait 7 days before starting new pack How to take the pill 28-pill pack 21-pill pack How to take the pill • Most important instruction. • Show how to follow arrows on pack. • Caution the client: Waiting too long between packs greatly increases risk of pregnancy. • With 28-pill pack: No waiting between packs. • With 21-pill pack: 7 days with no pills (for example, last pill of old pack on a Saturday, then first pill of new pack on the following Sunday). • Give client her pill packs to hold and look at. • Take one pill each day, by mouth Next Move: Discuss • Easy to remember to take pills? • “What would help you to remember? What else do you do regularly every day?” • Easiest time to take the pills? At a meal? At bedtime? • Where to keep pills. • What to do if pill supply runs out. P4 Does client understand how to take the pill? Discuss further if needed, or go to next page. The Pill If you use the 28-pill pack: • Once you have finished all the pills in the pack, start new pack on the next day If you use the 21-pill pack: • Once you have finished all the pills in the pack, wait 7 days before starting new pack Also skip the reminder pills (or the pill-free week) and go straight to the next pack • AND if you miss 3 or more pills in week 3: • Throw away the missed pill(s) and continue taking pills, one each day • You must also use condoms or avoid sex for the next 7 days If you miss pills Reminder pills • ALWAYS take a pill as soon as you remember, and continue taking pills, one each day If you miss pills: Forgetting pills can lead to pregnancy! But if you miss 3 or more pills or start a pack 3 or more days late: If you miss a reminder pill (28-day packs only): Does client understand what to do if she misses pills? Give condoms for back-up when needed. Discuss further if needed, or go to next page. If you miss pills Next Move: • If she often misses pills, other methods may be more suitable. • 28-day packs contain 7 reminder pills (week 4). These pills do not contain hormones. • 21-day packs have no reminder pills, but usually the user waits 7 days and then starts a new pack. Starting sooner is not dangerous. P5 The Pill What to do with extra missed pills (if she misses more than 1 pill): • If she has pill packs marked with days of the week, or wants to start each pack on the same day of the week, she should take the first missed pill, but throw out the other pills that were missed. • Otherwise, she can just continue the pack where she stopped. Key counselling messages about missed pills: • As soon as she remembers that she missed active pills, she must take an active pill and then continue with the rest of the pack. Depending on when she remembers, this may mean she needs to take 2 pills on the same day or even at the same time. • No need for condoms or avoiding sex if she misses just 1 or 2 pills. • Starting late is the same as missing pills. If she starts a pack 3 or more days late, she needs to use condoms or avoid sex for the next 7 days. • Emergency contraception can be considered if she misses 3 or more pills in the first week or starts a pack 3 or more days late. • Skipping reminder pills or the pill-free week is not harmful. She may have no menstrual bleeding that month. • AND if you miss 3 or more pills in week 3: Also skip the reminder pills (or the pill-free week) and go straight to the next pack • Throw away the missed pill(s) and continue taking pills, one each day • You must also use condoms or avoid sex for the next 7 days • ALWAYS take a pill as soon as you remember, and continue taking pills, one each day If you miss pills: But if you miss 3 or more pills or start a pack 3 or more days late: If you miss a reminder pill (28-day packs only): You may be able to start today • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant Would you like to start now? You may be able to start today If switching from another method: • If switching from the mini-pill or implants, now is the best time to start. • If switching from injectable, should start pills at time she would have had repeat injection. • If switching from IUD, and menstrual bleeding started more than 5 days ago, can start pills now but leave IUD in place until the next menstrual period. Client ready to start now? Next Move: If yes, give her up to a year’s supply of pills. Help her to take the first pill now if she wishes. If not, give her pills to take home. Ask her to start on the first day of next menstrual period (or if breastfeeding, when baby reaches 6 months). Give condoms to use until then. Explain their use. • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant After childbirth, if breastfeeding: • Can start from 6 months after childbirth. • If baby is less than 6 months old, give her condoms to use in the meantime. After childbirth, if NOT breastfeeding: • Can start from 3 weeks after childbirth. After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. P6 The Pill If menstrual bleeding started in past 5 days: • She can start NOW. No extra protection needed. If menstrual bleeding started more than 5 days ago or if amenorrhoeic (not having menstrual periods): • She can start NOW if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1). No need to wait for next menstrual period to start pills. • She should avoid sex or use condoms for 7 days after taking first pill. What to remember • Take one pill each day See a nurse or doctor if: • Severe, constant pain in belly, chest, or legs •Very bad headaches • A bright spot in your vision before bad headaches •Yellow skin or eyes • If you miss pills, you can get pregnant • Come back for more pills before you run out, or if you have problems Anything else I can repeat or explain? Any other questions? • Side-effects are common but rarely harmful. Come back if they bother you. • Take one pill each day Return Signs: • “In many cases these signs are not related to taking the pill. But a doctor or nurse needs to check if a serious problem is developing and if you can continue taking the pill.” • “I want you to know about them and remember them.” • If possible, plan for a follow-up contact 3 months after starting pills. Always plan a yearly follow-up visit. • Invite client to return any time she wants more pills or help, information, or a new method. What to remember • If you miss pills, you can get pregnant “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection and/or back-up! Last, most important message: “Take a pill each day.” Last Moves: • See a nurse or doctor if: ― Severe pain in belly, chest, or legs ― Very bad headaches ― A bright spot in your vision before bad headaches (migraine aura) ― Yellow skin or eyes • Side-effects are common but rarely harmful. Come back if they bother you. • Come back for more pills before you run out, or if you have problems P7 • If another health care provider asks about her medications, she should mention that she is using the pill. • Make sure she knows what to do if she misses pills. The Pill The Mini-Pill • Good method while breastfeeding • Take a pill at same time every day • Very safe • Women who are not breastfeeding may notice changes in monthly bleeding • No protection against STIs or HIV/AIDS Different from the pill Ask your providerDo you want to know more about this method, or talk about a different method? • For STI/HIV/AIDS protection, also use condoms. • “Would you remember to take a pill at the same time each day?” • No need to do anything at time of sexual intercourse. • Pills are not harmful for health. • Check for concerns, rumours: “What have you heard about the mini-pill?” • Explain common myths: Pills are dissolved into blood. They do not accumulate in stomach. (Also see Appendix 10.) About the mini-pill: • Contains only progestogen. OK for women who cannot take estrogen. • Works mainly by thickening cervical mucus and by stopping ovulation (see Appendices 4 & 5). • Very effective when breastfeeding. • Easy to stop: A woman who stops pills can soon become pregnant. Compared with the combined pill: • Better if breastfeeding. Does not affect quality or amount of breastmilk. • Taking pills on time is even more important. For women not breastfeeding, taking a pill more than a few hours late can increase pregnancy risk. • Fewer side-effects except for bleeding changes.• Take a pill at same time every day The Mini-Pill “Do you want to know more about the mini-pill, or talk about a different method?” If client wants to know more about the mini-pill, go to next page. Next Move: • No protection against STIs or HIV/AIDS • Women who are not breastfeeding may notice changes in monthly bleeding • Good method while breastfeeding • Very safe The Mini-Pill MP 1 • Side-effects: see page MP3. To discuss another method, go to a new method tab or to Choosing Method tab. Who can and cannot use the mini-pill But usually cannot use the mini-pill if: Most women can safely use the mini-pill • Breastfeeding 6 weeks or less • May be pregnant • Some other serious health conditions “We can find out if the mini-pill is safe for you. Usually, women with any of these conditions should use another method.” • Give pills and tell her to start when baby is 6 weeks old. Most women can safely use the mini-pill. But usually cannot use the mini-pill if: • Ever had breast cancer. • Serious liver disease or jaundice (yellow skin or eyes). • Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use the mini-pill. • Takes pills for tuberculosis (TB), fungal infections, or epilepsy (seizures/fits). Who can and cannot use the mini-pill Client able to use the mini-pill: Go to next page. Next Move: • Breastfeeding 6 weeks or less • May be pregnant • If in doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. Client unable to use the mini-pill: Help her choose a method without hormones. The Mini-Pill MP 2 Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer) • Some other serious health conditions: • Most women who have had stroke or problems with heart or blood vessels CAN use the mini-pill. Possible side-effects • Less common: headache, tender breasts, dizziness • Common (when not breastfeeding): irregular bleeding, spotting, no monthly bleeding Do you want to try using this method and see how you like it? If you choose this method, you may have some side-effects. They are not usually signs of illness. • “It can take time for the body to adjust.” • Different people have different reactions to methods. Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. Does client understand side-effects? Is she ready to choose method? • Can take aspirin, paracetamol or ibuprofen for headache. • Most breastfeeding women do not have regular periods and so often do not notice effect of mini-pills on menstrual bleeding. • In non-breastfeeding women, irregular periods, spotting, light bleeding between periods, and amenorrhoea (no bleeding) are common and normal. • Tell client: skipping pills may make bleeding side- effects worse and risks pregnancy. Possible side-effects Next Move: The Mini-Pill • Common (when not breastfeeding): irregular bleeding, spotting, no monthly bleeding • Less common: headache, tender breasts, dizziness MP 3 • Invite client to return for help any time. • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. If she has decided to use method, go to next page. If not, discuss further or consider other methods. If you choose this method, you may have some side-effects. They are not usually signs of illness. How to take the mini-pill • Take one pill each day at the same time • Once you have finished all the pills in the pack, start a new pack the following day • Late taking a pill? — Take it as soon as you remember — You may need to follow special instructions if more than 3 hours late • Most important instruction: Take pill at same time each day. If not breastfeeding, taking a pill even a few hours late increases risk of pregnancy. (Breastfeeding itself helps prevent pregnancy.) • No wait between packets. • All pills are active (they all contain hormones). • Give client her pill packs to hold and look at. • Take one pill each day at the same time If you miss a pill by more than 3 hours and are: • Not breastfeeding OR breastfeeding but periods have returned: Avoid sex or use condoms for the next 2 days. • Breastfeeding AND periods have NOT returned: No special instructions. No extra protection needed. Special Instructions How to take the mini-pill Next Move: • Once you have finished all the pills in the pack, start a new pack the following day • Late taking a pill? — Take it as soon as you remember — You may need to follow special instructions if more than 3 hours late The Mini-Pill Does client understand how to take the mini-pill and what to do if she misses pills? Discuss further if needed, or go to next page. MP 4 Discuss • “What would help you remember to take a pill on time each day?” • Easiest time to take the pills? • Where to keep pills? • What if pill supply runs out? • Give client condoms to take home. You may be able to start today • If not breastfeeding, you can start any day of the menstrual cycle if we can be sure you aren’t pregnant • Can start today if you have been fully breastfeeding at least 6 weeks You may be able to start today 5 Client ready to start now? Next Move: If yes, give her up to a year’s supply of pills. Discuss when would be a good time for her to take her first pill. If not, give her pills to take home. Explain the correct time to start. Give condoms to use until then. Explain their use. The Mini-Pill • If not breastfeeding, you can start any day of the menstrual cycle if we can be sure you aren’t pregnant • Can start today if you have been fully breastfeeding at least 6 weeks MP 5 If menstrual bleeding started in past 5 days: • She can start NOW. No extra protection needed. If menstrual bleeding started more than 5 days ago or if amenorrhoeic (not having menstrual periods): • She can start NOW if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1). No need to wait for next menstrual period to start pills. • She should avoid sex or use condoms for 48 hours after taking first pill. If switching from another method: • If switching from the pill or implants, now is the best time to start. • If switching from an injectable, should start pills at time she would have had repeat injection. • If switching from IUD, and menstrual bleeding started more than 5 days ago, can start pills now but leave IUD in place until the next menstrual period. After childbirth, if breastfeeding: • If fully (or nearly fully) breastfeeding, can start pills from 6 weeks after childbirth. No extra protection needed if she is between 6 weeks and 6 months after giving birth and her periods have not returned. • If partially breastfeeding, best to start 6 weeks after birth. Waiting longer risks pregnancy. After childbirth, if NOT breastfeeding: • Can start immediately after childbirth. If in the first 4 weeks after birth, no extra protection is needed. After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. • Take a mini-pill every day at the same time each day What to remember • Side-effects are common but rarely harmful. Come back if they bother you. See a nurse or doctor if: • A bright spot in your vision before bad headaches • Yellow skin or eyes • May be pregnant, especially if pain or soreness in belly • Unusually heavy or long bleeding • If you are late taking pills, you can get pregnant Anything else I can repeat or explain? Any other questions? • Come back for more pills before you run out, or if you have problems What to remember “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection and/or back-up! Last, most important message: “Take a pill each day at the same time.” Last Moves: • Take a mini-pill every day at the same time each day The Mini-Pill Return Signs: • “In many cases these signs are not related to taking the mini-pill. But a doctor or nurse needs to check if a serious problem is developing and if you can continue taking the mini-pill.” • “I want you to know about them and remember them.” • Invite client to return any time she wants more pills or help, information, or a new method. • If possible, plan for a follow-up contact 3 months after starting pills. Always plan a yearly follow-up visit. • If breastfeeding, invite her to come back when she stops breastfeeding. She may want to switch to another method at that time. • Side-effects are common but rarely harmful. Come back if they bother you. • If you are late taking pills, you can get pregnant • Come back for more pills before you run out, or if you have problems • If another health care provider asks about her medications, she should mention that she is using the mini-pill. MP 6 • Bleeding that is more than 8 days long or twice as heavy as usual. • See a nurse or doctor if: — A bright spot in your vision before bad headaches (migraine aura) — Unusually heavy or long bleeding — Yellow skin or eyes — May be pregnant, especially if pain or soreness in belly Long-Acting Injectable • An injection every 2 or 3 months, depending on type • Very effective • Often takes longer to get pregnant after stopping • Very safe • Changes monthly bleeding • No protection against STIs or HIV/AIDS Do you want to know more about this method, or talk about a different method? Long-Acting Injectable • “Would you be able to come back on time for injections?” • “How would you remember?” • Very effective, provided client returns for injection at right time. • “Are you looking for a method that is easy to use effectively?” • Injectables are not harmful for health. For breastfeeding women, they do not affect the quality of the breastmilk. • Check for concerns, rumours: “What have you heard about these injectables?” • Explain common myths. (Also see Appendix 10.) • After stopping this injectable, there is a delay of several months before most women can get pregnant, and for some women it may be even longer. It does not make women permanently infertile. Tab: Long-Acting Injectables • An injection every 2 or 3 months, depending on type • Very effective • Very safe • Changes monthly bleeding • No protection against STIs or HIV/AIDS • Often takes longer to get pregnant after stopping “Do you want to know more about this injectable, or talk about a different method?” If client wants to know more about this injectable, go to next page. Next Move: Long-Acting Injectable About the long-acting injectable: • DMPA and NET-EN are two types of long-acting injectable. • Contains progestogen but not estrogen hormones. • Works mainly by stopping ovulation (see Appendices 4 & 5). • No supplies needed at home. LI 1 • For STI/HIV/AIDS protection, also use condoms. • Side-effects: see page LI3. To discuss another method, go to a new method tab or to Choosing Method tab. Who can and cannot use a long-acting injectable But usually cannot use this injectable if: Most women can safely use this injectable • Breastfeeding 6 weeks or less • Some other serious health conditions • Very high blood pressure • May be pregnant • May be pregnant • Very high blood pressure “We can find out if you can use this injectable safely. Usually, women with any of these conditions should use another method.” • Check blood pressure (BP) if possible. If systolic BP 160+ or diastolic BP 100+, help her choose another method (but not the pill or monthly injectables). • If BP check not possible, ask about high BP and rely on her answer. • Ask her to come back when baby is 6 weeks old. Urge her to keep breastfeeding. Who can and cannot use a long-acting injectable Client able to use injectables: Go to next page. Next Move: • Breastfeeding 6 weeks or less Client unable to use injectables: Help her choose another method. • If in doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. Most women can safely use this injectable. But usually cannot use if: LI 2 Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer) • Some other serious health conditions • Ever had stroke or problem with heart or blood vessels. • Has 2 or more risk factors for heart disease, such as hypertension, diabetes, smokes, or older age. • Diabetes for more than 20 years, or severe damage caused by diabetes. • Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use this injectable. • Ever had breast cancer. • Unexplained vaginal bleeding: if the bleeding suggests a serious condition, help her choose a method without hormones to use until unusual bleeding is assessed. • Serious liver disease or jaundice (yellow skin or eyes). Long-Acting Injectable Possible side-effects • Very common: Changes to monthly bleeding • Common: Weight gain • Less common: Some others Do you want to try using this method and see how you like it? If you choose this method, you may have some side-effects. They are not usually signs of illness. • “It can take time for the body to adjust.” • Different people have different reactions to methods. Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. • Less common side-effects: mild headaches, dizziness, mood changes, upset stomach (nausea), less sex drive. Important to explain menstrual changes: • Expected and common, especially during first few months of use. • Irregular bleeding and spotting are common at first. • Amenorrhoea (no monthly bleeding) occurs often after several months of use. Does not permanently affect fertility. Rarely a sign of pregnancy. Explain that blood does not build up inside body. • Heavy bleeding is rare. Also very common: Bone mineral density decreases slightly during DMPA use, but increases again after stopping. It is not known whether this leads to increased fracture risk. • Averages 1 to 2 kg each year but sometimes can be more. • Very common: Changes to monthly bleeding • Common: Weight gain Does client understand side-effects? Is she ready to choose method? If she has decided to use method, go to next page. Next Move: If not, discuss further or consider other methods. Possible side-effects • Less common: Some others LI 3 Long-Acting Injectable If you choose this method, you may have some side-effects. They are not usually signs of illness. • Invite client to return for help any time. • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. You may be able to start today • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant Would you like to start now? You may be able to start today Client ready to start now? Next Move: If yes, prepare to give first injection. If not, arrange another visit (during next menstrual period would be best). Give condoms to use until then. Explain their use. • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant LI 4 If menstrual bleeding started in past 7 days: • She can start NOW. No extra protection needed. If menstrual bleeding started more than 7 days ago or if amenorrhoeic (not having menstrual periods): • She can start NOW if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1). No need to wait for next menstrual period to start injections. • She should avoid sex or use condoms for 7 days after first injection. If switching from another method: • If switching from pills or implants, now is the best time to start. • If switching from a monthly injectable, should start at time she would have had repeat injection. • If switching from IUD, and menstrual bleeding started more than 7 days ago, can start injections now but leave IUD in place until the next menstrual period. After childbirth, if breastfeeding: • If fully (or nearly fully) breastfeeding, can start from 6 weeks after childbirth. No extra protection needed if she is between 6 weeks and 6 months after giving birth and her periods have not returned • If partially breastfeeding, best to start 6 weeks after birth. Waiting longer risks pregnancy. After childbirth, if NOT breastfeeding: • Can start immediately after childbirth. If in the first 4 weeks after birth, no extra protection is needed. After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. Long-Acting Injectable Getting your injection • For DMPA, every 3 months • For NET-EN, every 2 months • Come back even if you are late When to come back: Your injection: • Either in your arm or your buttock • Don’t rub the injection site afterwards Can you mark a calendar? What else will help you remember? Getting your injection • “Do you think you can remember when to come back? What will help you remember?” For example, will some event take place at about that time? • Both DMPA and NET-EN repeat injections can be given up to 2 weeks early or up to 2 weeks late. No extra protection needed. • If more than 2 weeks late, she should use condoms or avoid sex until she can get an injection. She may still be able to have the injection. Page RC8 of the returning client section explains what to do if client is late. • For DMPA, every 3 months • For NET-EN, every 2 months • Come back even if you are late Confirm that client understands how often to return and what to do if late. If not, discuss further. Next Move: When to come back: 1. Give injections in a clean, designated area of the room. 2. Wash your hands with soap and water. If client’s skin is visibly dirty, wash injection site. No need to swab skin. 3. If available, use disposable syringe and needle from a new, sealed package for each injection (not damaged and within the expiry date). Never reuse disposable syringes and needles. If disposable syringes and needles are NOT available, use ones that have been sterilized with proper equipment and technique. Throw away or resterilize any needles that touch hands, surfaces, or non-sterile objects. 4. If possible, use single-dose vials. Check expiry date. Shake gently. If using a multi-dose vial, check when opened. Pierce with a STERILE needle. No need to swab septum (vial top). Don't leave needles in the septum. 5. Insert sterile needle deep into upper arm (deltoid muscle) or into buttock (gluteal muscle, upper outer portion). Inject. 6. Do not massage the injection site. Tell client not to rub site. 7. Dispose of needles and syringes properly. After injection, do not recap needles. Place in sharps container immediately after use. See handbook or clinic guidelines for more information. Your injection: • Either in your arm or your buttock • Don’t rub the injection site afterwards LI 5 Long-Acting Injectable • Name of your injectable: What to remember See a nurse or doctor if: • Yellow skin or eyes • Unusually heavy or long bleeding • When to come for next injection: Anything else I can repeat or explain? Any other questions? • Bleeding changes and weight gain are common. Come back if they bother you. • A bright spot in your vision before bad headaches • Give her condoms in case she is more than 2 weeks late for injection. • Name of your injectable What to remember “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection and/or back-up! Last, most important message: “Remember to come back for your next injection.” Last Moves: • See a nurse or doctor if: ― A bright spot in your vision before bad headaches (migraine aura) ― Unusually heavy or long bleeding ― Yellow skin or eyes Return Signs: • “In many cases these signs are not related to the injections. But a doctor or nurse needs to check if a serious problem is developing and if you can continue getting injections.” • “I want you to know about them and remember them.” • Bleeding changes and weight gain are common. Come back if they bother you. • If another health care provider asks about her medications, she should mention that she is using a long-acting injectable. LI 6 • You can give client a copy of client’s page and write information on the sheet. • Write date of next injection and note how often to return (every 3 months for DMPA; every 2 months for NET EN). Long-Acting Injectable • Bleeding that is more than 8 days long or twice as heavy as usual. • When to come for next injection Monthly Injectable • An injection every month • Very effective • Easy to stop • Very safe • Some women have side-effects at first—not harmful • No protection against STIs or HIV/AIDS Do you want to know more about this method, or talk about a different method? • Very effective “Do you want to know more about this injectable, or talk about a different method?” • An injection every month Monthly Injectable • Very effective, provided client comes back at right time for injection. • A woman who stops injections can soon become pregnant. Next Move: If client wants to know more about this injectable, go to next page. • Very safe Monthly Injectable • Some women have side-effects at first—not harmful • No protection against STIs or HIV/AIDS MI 1 • Side-effects often go away after first 3 months (see page MI3). • For STI/HIV/AIDS protection, also use condoms. About the monthly injectable: • Monthly injectables include Cyclofem and Mesigyna. • Contains both estrogen and progestogen hormones. • Works mainly by stopping ovulation (see Appendices 4 & 5). • These injectables have effects similar to the pill’s. • No supplies needed at home. • Injections are not harmful for most women’s health. For more information see Appendix 10. • Serious complications are rare. They may include heart attack, stroke, blood clots in lung or deep veins of the legs. • Check for concerns, rumours: “What have you heard about these injections?” • Explain common myths. (Also see Appendix 10.) • Easy to stop • “Would you be able to come back on time for injections?” • “How would you remember?” To discuss another method, go to a new method tab or to Choosing Method tab. Who can and cannot use a monthly injectable But usually cannot use this injectable if: Most women can safely use this injectable • High blood pressure • Smokes heavily AND age 35 or older • Breastfeeding 6 months or less • May be pregnant • Gave birth in the last 3 weeks • Some other serious health conditions Who can and cannot use a monthly injectable • Check blood pressure (BP) if possible. If systolic BP 140+ or diastolic BP 90+, help her choose another method (but not the pill). (If systolic BP 160+ or diastolic BP 100+, also should not use long-acting injectable.) • If BP check not possible, ask about high BP and rely on her answer. “We can find out if you can use this injectable safely. Usually, women with any of these conditions should use another method.” • If in doubt, use checklist in Appendix 1 or perform pregnancy test. Client unable to use monthly injectable: Help her choose another method, but not the pill. Client able to use monthly injectable: Go to next page. Most women can safely use this injectable. But usually cannot use if: • High blood pressure • Smokes heavily AND age 35 or older • Breastfeeding 6 months or less • May be pregnant • Gave birth in the last 3 weeks Next Move: MI 2 • Light smoking (fewer than 15 cigarettes/day) is OK. Risk increases with age and number of cigarettes. Monthly Injectable • Ever had stroke or problem with heart or blood vessels. • Migraine headaches*: She should not use a monthly injectable if she is over 35 and has migraines, or at any age if she has migraine aura. Women under 35 who have migraines without aura and women with ordinary headaches CAN usually use a monthly injectable. • Ever had breast cancer. • Has 2 or more risk factors for heart disease, such as hypertension, diabetes, smokes, or older age. • Has ever had blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use this injectable. • Soon to have surgery? She should not start if she will have surgery making her immobile for more than 1 week. • Serious liver disease or jaundice (yellow skin or eyes). • Diabetes for more than 20 years, or severe damage caused by diabetes. • Takes pills for tuberculosis, fungal infections, or epilepsy (seizures/fits). Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer) • Some other serious health conditions: *What is a migraine? Ask: “Do you often have very painful headaches, perhaps on one side or throbbing, that cause nausea and are made worse by light and noise or moving about? Do you see a bright spot in your vision before these headaches?” (migraine aura) Possible side-effects • Nausea (upset stomach) • Tender breasts • Spotting or bleeding between periods • Slight weight gain • Mild headaches • But many women don’t have any • Often go away after a few months Most common: Do you want to try using this method and see how you like it? If you choose this method, you may have some side-effects. They are not usually signs of illness. • Dizziness Does client understand side-effects? Is she ready to choose method? • “It can take time for the body to adjust.” • Different people have different reactions to methods. • Some women never have any side-effects. • Side-effects often go away or lessen within 3 months. Possible side-effects • But many women do not have any • Usually go away after a few months Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. • “Please come back any time you want help or have questions.” • “It is okay to switch methods any time.” • For dealing with side-effects, see Returning Client tab. Next Move: MI 3 Monthly Injectable Most common: • Nausea (upset stomach) • Spotting or bleeding between periods • Mild headaches • Tender breasts • Slight weight gain If she has decided to use method, go to next page. If not, discuss further or consider other methods. If you choose this method, you may have some side-effects. They are not usually signs of illness. You may be able to start today • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant Would you like to start now? Client ready to start now? You may be able to start today If yes, prepare to give first injection. If not, arrange another visit (during next menstrual period would be best). Give condoms to use until then. Explain their use. • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant Next Move: MI 4 Monthly Injectable If switching from another method: • If switching from pills or implants, now is the best time to start. • If switching from a long-acting injectable, should start at time she would have had repeat injection. • If switching from IUD, and menstrual bleeding started more than 7 days ago, can start now but leave IUD in place until the next menstrual period. After childbirth, if breastfeeding: • Can start from 6 months after childbirth. • If baby is less than 6 months old, give her condoms or the mini-pill to use in the meantime. After childbirth, if NOT breastfeeding: • Can start from 3 weeks after childbirth. After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. If menstrual bleeding started in past 7 days: • She can start NOW. No extra protection needed. If menstrual bleeding started more than 7 days ago or if amenorrhoeic (not having menstrual periods): • She can start NOW if reasonably certain she is not pregnant (see questions in Appendix 1). No need to wait for next menstrual period to start injections. • She should avoid sex or use condoms for 7 days after first injection. Getting your injection • Every 4 weeks • Come back even if you are late Can you mark a calendar? What else will help you remember? When to come back: Your injection: • Either in your arm or your buttock • Don’t rub the injection site afterwards Getting your injection • Every 4 weeks • Come back even if you are late Confirm that client understands when to return and what to do if late. If not, discuss further. Next Move: Your injection: • Either in your arm or your buttock • Don’t rub the injection site afterwards When to come back: MI 5 Monthly Injectable • “Do you think you can remember when to come back? What will help you remember?” For example, will some event take place at about that time? • Can be given up to 7 days early or 7 days late. No extra protection needed. • If more than 7 days late, she should use condoms or avoid sex until she can get an injection. She may still be able to have the injection. Page RC11 in the returning client section explains what you can do if the client is late. 1. Give injections in a clean, designated area of the room. 2. Wash your hands with soap and water. If client’s skin is visibly dirty, wash injection site. No need to swab skin. 3. If available, use disposable syringe and needle from a new, sealed package for each injection (not damaged and within the expiry date). Never reuse disposable syringes and needles. If disposable syringes and needles are NOT available, use ones that have been sterilized with proper equipment and technique. Throw away or resterilize any needles that touch hands, surfaces, or non-sterile objects. 4. If possible, use single-dose vials. Check expiry date. Shake gently. If using a multi-dose vial, check when opened. Pierce with a STERILE needle. No need to swab septum (vial top). Don't leave needles in the septum. 5. Insert sterile needle deep into upper arm (deltoid muscle) or into buttock (gluteal muscle, upper outer portion). Inject. 6. Do not massage the injection site. Tell client not to rub site. 7. Dispose of needles and syringes properly. After injection, do not recap needles. Place in sharps container immediately after use. See handbook or clinic guidelines for more information. What to remember • Name of your injectable: • Day of the week when you come for your injection (every 4 weeks) Anything else I can repeat or explain? Any other questions? • Side-effects are common but rarely harmful. Come back if they bother you. See a nurse or doctor if: • Severe, constant pain in belly, chest, or legs • A bright spot in your vision before bad headaches •Yellow skin or eyes •Very bad headaches What to remember • Name of your injectable • Day of the week when you come for your injection (every 4 weeks) • Give her condoms in case she is more than 7 days late for injection. • You can give client a copy of client’s page and write information on the sheet. “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection and/or back-up! Last, most important message: “Remember to come back for your next injection.” Last Moves: Return Signs: • “In many cases these signs are not related to the injections. But a doctor or nurse needs to check if a serious problem is developing and if you can continue getting injections.” • “I want you to know about them and remember them.” • If another health care provider asks about her medications, she should mention that she is using a monthly injectable. • Side-effects are common but rarely harmful. Come back if they bother you. MI 6 Monthly Injectable • See a nurse or doctor if: ― Severe pain in belly, chest, or legs ― Very bad headaches ― A bright spot in your vision before bad headaches (migraine aura) ― Yellow skin or eyes Norplant Implants • 6 small plastic tubes placed under skin of upper arm • Very effective • Last up to 7 years, depending on your weight • Very safe • Usually change monthly bleeding • No protection against STIs or HIV/AIDS Do you want to know more about this method, or talk about a different method? • Very effective with nothing to remember for up to 7 years. “Are you looking for a method that is easy to use effectively?” • Side-effects: see page IM3. • For STI/HIV/AIDS protection, also use condoms. Norplant Implants • 6 small plastic tubes placed under skin of upper arm • Heavy women may need them removed after 4 or 5 years (see page IM4). Another set of capsules can be inserted if client wants to continue using implants. • Can get pregnant soon after capsules are taken out. “Would you like to know more about implants, or talk about a different method?” If client wants to know more about implants, go to next page. Next Move: • Very effective • Last up to 7 years, depending on your weight • Very safe • Usually change monthly bleeding • No protection against STIs or HIV/AIDS Implants IM 1 • Implants are not harmful for health. They do not bother her or affect strength. For breastfeeding women, they do not affect the quality of breastmilk. • Check for concerns, rumours: “What have you heard about implants?” • Explain common myths. Capsules do not break inside the body. They are bendable. (Also see Appendix 10.) About Norplant implants: • Contain progestogen but not estrogen hormones. • Work mainly by thickening the cervical mucus and by stopping ovulation (see Appendices 4 & 5). • Soft capsules that are just visible under the skin. Do not leave noticeable scar if inserted and removed correctly. • Inserted and removed by trained personnel in simple surgical procedure. To discuss another method, go to a new method tab or to Choosing Method tab. But usually cannot use implants if: Who can and cannot use implants Most women can safely use implants • Some other serious health conditions • Breastfeeding 6 weeks or less • May be pregnant • Breastfeeding 6 weeks or less “We can find out if Norplant implants are safe for you. Usually, women with any of these conditions should use another method.” Who can and cannot use implants • Ask her to come back when baby is 6 weeks old. Urge her to keep breastfeeding. Client is unable to use implants: Help her choose another method. Client is able to use implants: Go to next page. Next Move: • If in doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. Implants Most women can safely use implants. But usually cannot use implants if: IM 2 Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer) • Some other serious health conditions • Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use implants. • Ever had breast cancer. • Unexplained vaginal bleeding: if the bleeding suggests a serious condition, help her choose a method without hormones to use until unusual bleeding is assessed. • Serious liver disease or jaundice (yellow skin or eyes). • Takes pills for tuberculosis (TB), fungal infections, or seizures (fits). • May be pregnant Possible side-effects • Very common: Light spotting or bleeding • Common: Irregular bleeding, no monthly bleeding • Less common: Some others How would you feel about these side-effects? If you choose this method, you may have some side-effects. They are not usually signs of illness. Important to explain menstrual changes: • Expected and common. • Amenorrhoea (no monthly bleeding): Does not permanently affect fertility. Rarely a sign of pregnancy. Explain that blood does not build up inside body. Possible side-effects Does client understand side-effects? Is she happy to use method? Next Move: If so, go to next page. If not, discuss further or consider other methods. Implants IM 3 • “It can take time for the body to adjust.” • Different people have different reactions to methods. Discuss: • “If these side-effects happened to you, what would you think or feel about it?” • “What would it mean to you?” • “What would you do?” • Discuss any rumours or concerns. See Appendix 10 on myths. Less common side-effects: • Headaches, lower abdominal pain, dizziness, breast tenderness, upset stomach (nausea), nervousness. • Can take paracetamol or ibuprofen for headache. Rare side-effects: • Acne or rash, change in appetite, weight gain, hair loss or more hair on face. • Invite client to return for help any time. • “It is okay to switch methods any time. Please come back if you want the implants taken out.” • For dealing with side-effects, see Returning Client tab page RC 13. • Very common: Light spotting or bleeding • Common: ― Irregular bleeding ― No monthly bleeding • Less common: Some others If you choose this method, you may have some side-effects. They are not usually signs of illness. Implant insertion and removal • Insertion and removal should be quick and easy • Injection prevents pain • Provider puts 6 capsules just under the skin of inside upper arm • Provider bandages opening in skin and wraps the arm — no stitches • Need to be removed after 4 to 7 years, depending on your weight Are you ready to choose this method? What questions do you have? Does client understand the insertion and removal procedure? Is she ready to choose method? Implant insertion and removal • Explain that procedure will be done by a specially trained provider. • Insertion usually takes 5 to 10 minutes. • Removal usually takes about 15 minutes, sometimes longer. • Let her feel a sample capsule. • If possible, show her a photo of capsules under skin. • Insertion and removal are done gently. • Just one small opening in the skin. May be slight pain, swelling, bruising for a few days. • Keep area dry for 5 days. Can remove bandage after 5 days. • “Please come back if arm stays sore for more than 5 days or if opening becomes red or has yellow liquid.” • Insertion and removal should be quick and easy Next Move: Implants • Local anaesthetic stops pain during insertion. Woman stays awake. IM 4 When to remove or replace implants? • Norplant implants need to be removed or replaced 4 to 7 years after insertion, depending on client's weight, as the method becomes less effective in heavier women. – Weighs less than 70 kg: She can keep implants for up to 7 years unless her weight reaches 70 kg or more. – Weighs 70 to 79 kg: She should come back after 5 years to have implants removed unless her weight reaches 80 kg or more. – Weighs 80 kg or more: She should come back after 4 years to have implants removed. • All women can have new implants or another method. • Injection prevents pain • Provider puts 6 capsules just under the skin of inside upper arm • Provider bandages opening in skin and wraps the arm — no stitches • Need to be removed after 4 to 7 years, depending on your weight If she has decided to use method, go to next page. If not, discuss further or consider other methods. You may be able to start today • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant Would you like to start now? You may be able to start today Client ready to start now? Next Move: Implants If yes, insert implants or arrange for insertion as soon as possible. If not, arrange another visit (during next menstrual period would be best). Give condoms to use until then. Explain their use. • You can start any day of the menstrual cycle if we can be sure you aren’t pregnant IM 5 If menstrual bleeding started in past 7 days: • She can start NOW. No extra protection needed. If menstrual bleeding started more than 7 days ago or if amenorrhoeic (not having menstrual periods): • She can start NOW if reasonably certain she is not pregnant (use pregnancy checklist in Appendix 1). No need to wait for next menstrual period to get implants. • She should avoid sex or use condoms for 7 days after insertion. If switching from another method: • If switching from pills, now is the best time to start. • If switching from an injectable, should start at time she would have had repeat injection. • If switching from IUD, and menstrual bleeding started more than 7 days ago, can get implants now but leave IUD in place until the next menstrual period. After childbirth, if breastfeeding: • If fully (or nearly fully) breastfeeding, can start from 6 weeks after childbirth. No extra protection needed if she is between 6 weeks and 6 months after giving birth and her periods have not returned. • If partially breastfeeding, best to start 6 weeks after giving birth. Waiting longer risks pregnancy. After childbirth, if NOT breastfeeding: • Can start immediately after childbirth. If in the first 4 weeks after giving birth, no extra protection is needed. After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. What to remember • Come back when it is time to have the implants removed See a nurse or doctor if: • Yellow skin or eyes • May be pregnant, especially if pain or soreness in belly • Unusually heavy or long bleeding • Infection or continued pain in the insertion site Anything else I can repeat or explain? Any other questions? • Side-effects are common but rarely harmful. Come back if they bother you. • Come back any time if you have problems or want implants removed • A bright spot in your vision before bad headaches What to remember • Women under 70 kg: Come back in 7 years. If a woman gains much weight, she should come back sooner. • Woman 70 to 79 kg: Come back in 5 years. • Woman 80 kg or more: Come back in 4 years. • At this time all women can have their implants replaced or choose a new method • If possible, give client a durable card that states date of insertion and date (with month) when she should return. “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection! Last, most important message: “Please come back any time you have questions or want to have implants removed.” Last Moves: Implants • See a nurse or doctor if: ― A bright spot in your vision before bad headaches (migraine aura) ― May be pregnant, especially if pain or soreness in belly ― Infection or continued pain in the insertion site ― Unusually heavy or long bleeding ― Yellow skin or eyes Return Signs: • “In many cases these signs are not related to the implants. But a doctor or nurse needs to check if a serious problem is developing and if you can continue using implants.” • “I want you to know about them and remember them.” • If another health care provider asks about her medications, she should mention the implants. IM 6 • Bleeding that is more than 8 days long or twice as heavy as usual. • Come back when it is time to have the implants removed • Remind client that implants can be removed any time she wishes. • Side-effects are common but rarely harmful. Come back if they bother you. • Come back any time if you have problems or want implants removed • Simple surgical procedure • Permanent. For men who will not want more children. • Very effective • Very safe • No effect on sexual ability • No protection against STIs or HIV/AIDS Vasectomy for Men Do you want to know more about this method, or talk about a different method? Tubes cut here Vasectomy for Men • Simple surgical procedure • Usually cannot be reversed. • “Please consider carefully: Might you want more children in future? What if you could no longer father children?” • Ask about partner’s preferences or concerns. • Can also consider female sterilization. Vasectomy is simpler and safer to perform and slightly more effective. • One of the most effective family planning methods. • Not effective immediately. Must use condoms or partner must use an effective method for 3 months after. “Would this be difficult?” • For STI/HIV/AIDS protection, also use condoms. “Would you like to know more about vasectomy, or talk about a different method?” If client wants to know more about vasectomy, go to next page. Next Move: • Check for concerns, rumours: “What have you heard about vasectomy?” Explain common myths: • NOT castration. Can still have erections. Can still ejaculate. • Does NOT affect masculinity. Does NOT make men more feminine. V1 • Permanent. For men who will not want more children. • Very effective • Very safe • No effect on sexual ability • No protection against STIs or HIV/AIDS About vasectomy: • Works by keeping sperm out of semen. Tubes that carry sperm are cut. • During procedure man stays awake and gets injection to prevent pain (local anaesthetic). • Usually can go home in a few hours. • May hurt for a few days. Vasectomy To discuss another method, go to a new method tab or to Choosing Method tab. When you can have vasectomy But may need to wait if: • Any problems with genitals such as infection, swelling, injuries, lumps in penis or scrotum • Some other serious conditions or infections Most men can have vasectomy at any time When you can have vasectomy Most men can have vasectomy at any time • Delay (until problem resolved) if STI; inflammation of tip of penis, sperm ducts, testicles; scrotal skin infection or mass in scrotum. Refer for care of these conditions. • Refer or caution for other problems with genitals. No conditions rule out vasectomy, but some require delay, referral, or special caution. • Delay (until problem resolved) if acute systemic infection or serious gastroenteritis. • Refer if current AIDS-related illness or coagulation disorders. Procedure should be done by experienced surgeon and in well-equipped facility. • Caution if diabetes. Procedure can still be done but check carefully for wound infections after procedure. If client is unable to have vasectomy now or in this facility, refer as needed. If client is able to have vasectomy, go to next page. Next Move: V2 But may need to wait if: • Any problems with genitals such as infection, swelling, injuries, lumps in penis or scrotum • Some other serious conditions or infections Vasectomy Before you decide Let’s discuss: • Temporary methods are also available • Vasectomy is a surgical procedure • Has risks and benefits • Prevents having any more children • Permanent—decision should be carefully considered • You can decide against procedure any time before surgery Are you ready to choose this method? Want to know more about the procedure? Before you decide Let’s discuss: • Explain so client understands. • Discuss as much as needed. • Confirm that client understands each point. Risks • Surgical complications are uncommon. They include bleeding or infection. • A few men report pain in scrotum that lasts for months or years. Benefits • Single quick procedure leads to lifelong, safe, and effective family planning. • No known long-term health risks. • And will not lose rights to other medical, health or other services or benefits. • See next page for details. • Should be very sure he will want no more children. • May not be suitable for younger clients. Make sure client understands all points, then ask what he has decided. Next Move: If client understands and wants vasectomy, explain consent form (if any) and ask him to sign. Go to next page. If he decides against vasectomy, help him choose another method. • Temporary methods are also available • Vasectomy is a surgical procedure • Has risks and benefits • Prevents having any more children • Permanent—decision should be carefully considered • You can decide against procedure any time before surgery V3 Vasectomy • Mention condoms and available methods for women. The procedure 1. You will stay awake and get medication to stop pain 2. Small opening made in scrotum — not painful 3. Tubes that carry sperm are cut and tied 4. The opening is closed 5. Rest 15 to 30 minutes What questions do you have? or 1 opening made here Either 2 openings made here Afterwards: • You should rest for 2 days • Avoid heavy work for a few days • Important! Use condoms for next 3 months Does client understand surgical procedure and feel confident to continue? The procedure Describe the steps in vasectomy procedure. Explain: • Vasectomy can be done in a clinic or office with proper infection-prevention procedures. It does not always have to be done in hospital. • Usually, the whole procedure can take less than 30 minutes. • Explain local anaesthetic. • Can get more pain medication if needed. • Explain incision or no-scalpel puncture. • If stitches will be used, mention them. 1. You will stay awake and get medication to stop pain 2. Small opening made in scrotum — not painful 3. Tubes that carry sperm are cut and tied 4. The opening is closed 5. Rest 15 to 30 minutes Next Move: If procedure will be done now, go to next page to advise client on what he must remember after surgery. If procedure planned for another day, arrange a convenient time for client to return. Offer condoms to use in the meantime. Afterwards: • You should rest for 2 days • Avoid heavy work for a few days • Important! Use condoms for next 3 months • Because sperm will still be in the tubes, he must use condoms or his partner must use another effective family planning method for the next 3 months. • He should continue with usual sexual activity during this time to clear the tubes of sperm. V4 Vasectomy Medical reasons to return Come at once if: • Swelling in first few hours after surgery • Fever in first 3 days • Pus or bleeding from wound • Pain, heat, redness of wound Medical reasons to return • Over 38°C in first 4 weeks (and especially in first 3 days). • If fever develops early, it can be serious. May require surgical drainage of wound site. • Becomes worse or does not stop? Signs of infection. Come at once if: • Swelling in first few hours after surgery • Fever in first 3 days • Pus or bleeding from wound • Pain, heat, redness of wound “Do you feel happy with your choice of method? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection! Last, most important message: “Use condoms or another method for 3 months after the procedure.” Last Moves: V5 Vasectomy Female Sterilization • A surgical procedure • Womb is NOT removed. You will still have menstrual periods. • Permanent—for women who will not want more children • Very effective • Very safe • No long-term side-effects • No protection against STIs or HIV/AIDS Tubes blocked or cut here Do you want to know more about this method, or talk about a different method? Female Sterilization • A surgical procedure About female sterilization: • Fallopian tubes that carry eggs to the womb are blocked or cut and sealed (womb is left untouched). • May hurt for a few days after. • Usually woman not put to sleep but gets injection to prevent pain. • Usually can go home in a few hours. • Usually cannot be reversed. • “Please consider carefully: might you want children in the future?” • Ask about partner’s preferences or concerns. • Vasectomy might be another good choice. Vasectomy is simpler and safer to perform and slightly more effective. • One of the most effective family planning methods for women. • Very rarely, pregnancy does occur. • For STI/HIV/AIDS protection, also use condoms. • Serious complications of surgery are rare (risk of anaesthesia, need for further surgery). “Do you want to know more about sterilization, or talk about a different method?” If client wants to know more about sterilization, go to next page. Next Move: • Permanent—for women who will not want more children • Very effective • No long-term side-effects • No protection against STIs or HIV/AIDS • Very safe • Check for concerns, rumours: “What have you heard about problems with sterilization?” Use Appendix 10 to talk about myths about contraception. • Explain that all women can have sterilization if they want, even those with no children. • Womb is NOT removed. You will still have menstrual periods. S1 Female Sterilization To discuss another method, go to a new method tab or to Choosing Method tab. When you can have sterilization But may need to wait if: Most women can have sterilization at any time • May be pregnant • Gave birth between 1 and 6 weeks ago • Infection or other problem in female organs • Some other serious health conditions When you can have sterilization Most women can have sterilization at any time But may need to wait if: • Procedure can be done any time except between 7 days and 6 weeks after delivery. • Can be done up to 7 days after delivery, if she decided in advance. Delay sterilization until these conditions are fully treated: • Pelvic inflammatory disease. • Chlamydia, gonorrhoea or purulent cervicitis. • Infection after abortion or childbirth. • Cancer in female organs. May need to delay with serious health conditions: • Such as stroke, high blood pressure, or diabetes with complications that require management before surgery. No conditions rule out female sterilization, but some situations require delay, referral, or special caution. If client is unable to have sterilization now or in this facility, refer as needed. Next Move: If client is able to have sterilization, go to next page. • If in any doubt, use pregnancy checklist in Appendix 1 or perform pregnancy test. • Gave birth between 1 and 6 weeks ago • May be pregnant • Infection or other problem in female organs • Some other serious health conditions S2 Female Sterilization Before you decide Let’s discuss: • Temporary methods are also available • Sterilization is a surgical procedure • Has risks and benefits • Prevents having any more children • Permanent—decision should be carefully considered • You can decide against procedure any time before surgery Are you ready to choose this method? Want to know more about the procedure? Before you decide Let’s discuss: • Explain so client understands. • Discuss as much as needed. • Confirm that client understands each point. Risks • Any surgery, including sterilization, carries risks. • Complications are uncommon. They include infection, bleeding, injury to organs, need for further surgery. • Rarely, allergic reaction to local anaesthetic or other serious complications from anaesthesia. Benefits • Single procedure leads to lifelong, safe, and very effective family planning. • Nothing to remember; no supplies. • May help protect against ovarian cancer. • And will not lose rights to medical, health or other services or benefits. • Discuss available temporary methods. • Probably, procedure cannot be reversed. • May not be suitable for younger women. Make sure client understands all points. Then ask what she has decided. Next Move: If client understands and wants sterilization, explain consent form (if any) and ask her to sign. Go to next page. If she decides against sterilization, help her choose another method. S3 • Temporary methods are also available • Sterilization is a surgical procedure • Has risks and benefits • Prevents having any more children • Permanent—decision should be carefully considered • You can decide against procedure any time before surgery Female Sterilization The procedure 1. Medication helps you keep calm and helps prevent pain 2. You stay awake 3. Small cut is made — not painful 4. Tubes are blocked or cut 5. Opening closed with stitches 6. Rest a few hours What questions do you have? Small cut either here or here Afterwards: • You should rest for 2 or 3 days • Avoid heavy lifting for a week • No sex for at least 1 week The procedure 1. Medication helps you keep calm and helps prevent pain Describe the steps in sterilization procedure. Explain: • It is a simple, safe surgical procedure that can be done in a hospital or health centre with the right facilities. • Often, the whole procedure (including rest time) can take just a few hours. • Explain how light sedation will be given—oral or intravenous. • Explain incision—where and how. • Encourage her to let providers know if she feels pain during procedure.“You can ask for more pain medicine if you want it.” • Rest in the clinic before going home. Does client understand surgical procedure and feel confident to continue? Next Move: If procedure will be done now, go to next page to advise client on what she must remember after surgery. If procedure planned for another day, arrange a convenient time for client to return. Offer condoms to use in the meantime. 2. You stay awake 3. Small cut is made — not painful 4. Tubes are blocked or cut 5. Opening closed with stitches 6. Rest a few hours Afterwards: • You should rest for 2 or 3 days • Avoid heavy lifting for a week • No sex for at least 1 week • No sex until all the pain is gone. S4 Female Sterilization Medical reasons to return In first week, come at once if: At any time in the future, come at once if: • High fever • Pus or bleeding from wound • Pain, heat, swelling, redness of wound • Steady or worsening pain, cramps, tenderness in belly • Fainting or very dizzy • Pain or tenderness in belly, or fainting • You think you may be pregnant Medical reasons to return In first week, come at once if: • Over 38°C in first 4 weeks and especially first week. • Signs of infection. • Pregnancy after sterilization is rare. But when it does occur, 20% to 50% of these pregnancies are ectopic. • These are signs of ectopic pregnancy. • She should come back immediately at any time in the future if she thinks she might be pregnant. “Do you feel happy with your choice of method? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection! Last, most important message: “Please come back any time you have questions or problems.” Last Moves: S5 • High fever • Pus or bleeding from wound • Pain, heat, swelling, redness of wound • Steady or worsening pain, cramps, tenderness in belly • Fainting or very dizzy At any time in the future, come at once if: • You think you may be pregnant • Pain or tenderness in belly, or fainting Female Sterilization The Male Condom Do you want to know more about this method, or talk about a different method? Would you like to see a condom and learn how to use it? • Protects against both pregnancy AND STIs including HIV/AIDS • Very effective when used EVERY TIME you have sex • Can be used alone or with another family planning method • Easy to get, easy to use • Usually partners need to discuss “Do you want to know more about condoms, or talk about a different method?” If client wants to know more about the male condom, go to next page. • Protects against both pregnancy AND STIs including HIV/AIDS Client needs condom whenever:• Client is unsure whether he/she or his/her partner has an STI including HIV. • Client has other sex partners or is not sure if current partner has had other sex partners. • When condoms are used correctly every time, they are very effective in preventing pregnancy, HIV and other STIs. • Best if used during ALL sexual contact. • Sold in many shops. • Use becomes easy with a little experience. • Most couples find that they still enjoy sex with condoms. Next Move: The Male Condom • If partner does not want to use condoms, “We can discuss and practice what you might say.” • Practice with client how to talk with partner. Use Appendix 9. • You can use another family planning method along with condoms for extra protection from pregnancy (but not the female condom). • Also used as back-up for another method of family planning (for example, missed pills, late for injection). • Very effective when used EVERY TIME you have sex • Can be used alone or with another family planning method • Easy to get, easy to use • Usually partners need to discuss MC 1 Condoms About the male condom: • A rubber sheath that covers the penis during sex. • Almost all men can use male condoms, even men with large penises. Only those with a serious allergy to latex cannot use them. To discuss another method, go to a new method tab or to Choosing Method tab. How to use a condom Use a new condom for each sex act Place condom on tip of penis with rolled rim facing away from body Unroll condom all the way to base of penis After ejaculation, hold rim of condom so it will not slip off, and withdraw penis from vagina while still erect Throw away used condom properly Are you ready to choose this method? n o p q r How to use a condom After ejaculation, hold rim of condom so it will not slip off, and withdraw penis from vagina while still erect Use a new condom for each sex act • Open package carefully. • Check the expiry or manufacturing date. • Condoms should be used within 3 years of the manufacturing date. • Move away from partner first. • Do not spill semen on vaginal opening. Unroll condom all the way to base of penis • If condom does not unroll easily, it may be backwards or too old. If old, use a new condom. • Lubricants can be used (water-based, not oil- based) and should be used during anal intercourse. Throw away used condom properly Always throw away in bin or trash can as appropriate. Place condom on tip of penis with rolled rim facing away from body • Put condom on before penis touches vagina. • If uncircumcised, pull back foreskin. Does client understand how to use the condom? Is he/she ready to choose method? If he/she has decided to use method, go to next page. If not, discuss further or consider other methods. Next Move: MC 2 Condoms rqpon • Use a condom EVERY TIME you have sex • Make sure you always have enough supplies of condoms • If a condom breaks, consider emergency contraception as soon as possible What to remember • Use only water- based lubricants • Store condoms away from direct sunlight and heat Anything else I can repeat or explain? Any other questions? • If a condom breaks, consider emergency contraception as soon as possible What to remember • Use a condom EVERY TIME you have sex “You need to use a condom EVERY TIME you have sex for full protection from pregnancy and STIs.” • Cannot reuse condoms. Must use a new condom for each act of intercourse. • If cannot use a condom every time, consider also using another method of family planning. • Condoms rarely break if properly used. • If condoms break often, make sure they are not damaged or old. Review instructions for proper use. Also try lubricated condoms, or else water or water-based lubricant on outside of condom. • Do not use if unopened package is torn or leaking, or the condom is dried out. • Offer emergency contraceptive pills for women to take home in case condom breaks or slips. • Clients that may have been exposed to HIV or STIs may also need post-exposure prophylaxis (PEP) for HIV and/or presumptive STI treatment. • Store condoms away from direct sunlight “Do you feel happy with this choice of method? Is there anything I can repeat or explain? Please come back any time!” Last, most important message: “Use a condom every time.” Last Moves: • Sunlight and heat can make condoms weak and they can break. • Make sure you always have enough supplies of condoms • “Get more condoms before you run out.” • Use only water-based lubricants • Oils weaken condoms so condoms can break. Avoid oil-based materials such as cooking oil, baby oil, coconut oil, petroleum jelly, butter. • Water-based materials are OK. They include glycerine, certain commercial lubricants, clean water. • Tell client whether condoms offered are lubricated or not. MC 3 Condoms The Female Condom • Helps protect against both pregnancy and STIs/HIV/AIDS • Effective when used EVERY TIME you have sex • Can be used alone or with other family planning methods • May be expensive • Inserted by the woman, but need to discuss with partner Do you want to know more about this method, or talk about a different method? • Inserted by the woman, but usually need to discuss with partner • Can be used alone or with other family planning methods • May be expensive Female Condom Client needs condom whenever: • Client is unsure whether he/she or his/her partner has an STI including HIV. • Client has other sex partners or is not sure if current partner has had other sex partners. • When condoms are used correctly every time, they are effective in preventing pregnancy. • May be less effective than the male condom in preventing pregnancy, HIV and other STIs. • Best if inserted before any sexual contact. • May be more effective against pregnancy when combined with another method, but cannot be used with the male condom. • Also used as back-up for another method of family planning (for example, missed pills, late for injection). • More expensive than the male condom and may not be as easily available. • Helps protect against both pregnancy and STIs/HIV/AIDS “Do you want to know more about the female condom, or talk about a different method?” If client wants to know more about the female condom, go to next page. Next Move: Female Condom • Effective when used EVERY TIME you have sex • If partner does not want to use condoms, “We can discuss and practice what you might say.” • Practice with client how to talk with partner. Use Appendix 9. FC 1 About the female condom: • A loose plastic sheath that is inserted into the vagina before sex. • No medical conditions limit use (NOT made of latex). No allergic reactions. To discuss another method, go to a new method tab or to Choosing Method tab. How to use a female condom • Open package carefully • Make sure the condom is well- lubricated inside • Choose a comfortable position – squat, raise one leg, sit or lie down • To remove, twist the outer ring and pull gently • Throw away condom properly • Gently insert the inner ring into the vagina • Place the index finger inside condom, and push the inner ring up as far as it will go • Make sure the outer ring is outside the vagina and the condom is not twisted • Be sure that the penis enters inside the condom and stays in it during intercourse Are you ready to choose this method? • Squeeze the inner ring at the closed end Inner ring Outer ring n p r Inner ring Open end qo • Choose a comfortable position―squat, raise one leg, sit or lie down How to use a female condom • Couples should use a new condom for each act of intercourse. • Condom should be inserted before penis touches vagina. • Condom can be inserted up to 8 hours ahead of time. • Condom is lubricated, but it may need extra lubricant inside so it is not moved out of place during sex. More lubricant can be added either inside condom or to the penis. • When finished, the woman must move away from partner and take care not to spill semen on vaginal opening. • The condom should be thrown away properly, in a bin or trash can as appropriate. • Open package carefully • Make sure the condom is well- lubricated inside • To remove, twist the outer ring and gently pull • Throw away condom properly • Gently insert the inner ring into the vagina • Place the index finger inside condom, and push the inner ring up as far as it will go • Make sure the outer ring is outside the vagina and the condom is not twisted • Be sure that the penis enters inside the condom and stays in it during intercourse Does client understand how to use the female condom? Is she ready to choose method? If she has decided to use method, go to next page. If not, discuss further or consider other methods. Next Move: Female Condom FC 2 • Squeeze the inner ring at the closed end Inner ring Outer ring n p r Inner ring Open end qo • Use a condom EVERY TIME you have sex • Make sure you always have enough supplies of condoms • If a condom is not used correctly, consider emergency contraception as soon as possible • Can use more lubricant if needed What to remember Anything else I can repeat or explain? Any other questions? • If condom is not used correctly, consider emergency contraception as soon as possible What to remember • Use a condom EVERY TIME you have sex “You need to use a condom EVERY TIME you have sex for full protection from pregnancy and STIs.” • If cannot use a condom every time, consider also using another method of family planning. • If female condom does not stay in place or if it gets pushed inside the vagina, emergency contraception may help prevent pregnancy. • Do not use if unopened package is torn or leaking, or the condom is dried out. • Clients that may have been exposed to HIV or STIs may also need post-exposure prophylaxis (PEP) for HIV and/or presumptive STI treatment. “Do you feel happy with this choice of method? Is there anything I can repeat or explain? Please come back any time!” Last, most important message: “Use a condom every time.” Last Moves: • Make sure you always have enough supplies of condoms • “Get more condoms before you run out.” • Can use more lubricant if needed Female Condom • All female condoms are lubricated. This may make the female condom slippery at first. • Can use additional lubricant inside if needed. Can reduce noise during sex and makes sex smoother. • Any kind of lubricant can be used with the female condom. • Can also reduce itching. FC 3 • Includes spermicides and diaphragm • Must be placed in the vagina each time before sex • Some users have side-effects • May be messy Spermicides: • Less effective than other methods • No protection against STIs or HIV/AIDS Diaphragm: • Can be effective when used correctly every time • Needs pelvic exam to check for size • Possible protection against some STIs Vaginal Methods Do you want to know more about these methods, or talk about a different method? • Side-effects: possible irritation, burning or bladder infection. • Diaphragms (together with spermicide) are most effective when used correctly every time. • For STI/HIV/AIDS protection, also use condoms. “Do you want to know more about vaginal methods, or talk about a different method?” If client wants to know more about vaginal methods, go to next page. Next Move: • Includes spermicides and diaphragm • Protection by diaphragms against HIV/AIDS is uncertain. For STI/HIV/AIDS protection, also use condoms. • “Would putting something in your vagina be uncomfortable for you?” • “Do you feel comfortable with a method that may be messy after sex?” Vaginal methods VM 1 Vaginal Methods About vaginal methods: • The diaphragm is a soft flexible piece of rubber that blocks the sperm from entering the womb. • Spermicides are gels, creams, foaming tablets, suppositories, foam or melting film that kill the sperm. • Both are inserted by the woman into her vagina ahead of time. They don't have to interrupt sex. Spermicides: • Less effective than other methods • No protection against STIs or HIV/AIDS Diaphragm: • Can be effective when used correctly every time • Needs pelvic exam to check for size • Possible protection against some STIs • Must be placed in the vagina each time before sex • Some users have side-effects • May be messy To discuss another method, go to a new method tab or to Choosing Method tab. • Have a medical condition that makes pregnancy dangerous Who can and cannot use vaginal methods And if you are thinking about the DIAPHRAGM, tell me if you: Most women can safely use vaginal methods But usually should not use SPERMICIDES or DIAPHRAGM with spermicides if: • More than one sex partner or partner has sex with others (high HIV risk) • Have HIV/AIDS • Recently had a baby or abortion • Are allergic to latex • Ever had toxic shock syndrome • Generally should wait 6 to 12 weeks after childbirth or second-trimester abortion to fit diaphragm, depending on when the uterus and cervix return to normal size and shape. • She should not use a latex diaphragm. • Generally should not use diaphragm. • Spermicides should NOT be used if woman is at high risk for HIV infection. • The effectiveness of diaphragms without spermicides is not known. Client unable to use vaginal methods: Help her choose another method. Client able to use method: Go to next page to discuss diaphragm or page VM4 to discuss spermicides. Next Move: Who can and cannot use vaginal methods Most women can safely use vaginal methods. VM 2 Vaginal Methods • Have a medical condition that makes pregnancy dangerous But usually should not use SPERMICIDES or DIAPHRAGM with spermicides if: • More than one sex partner or partner has sex with others (high HIV risk) • Have HIV/AIDS And if you are thinking about the DIAPHRAGM, tell me if you: • Recently had a baby or abortion • Are allergic to latex • Ever had toxic shock syndrome • Conditions include high blood pressure, diabetes, heart disease, stroke, some cancers, STIs including HIV/AIDS, liver disease, anaemia, tuberculosis. • A more effective method may be more suitable for women with these conditions. Squeeze plenty of spermicidal cream or jelly into diaphragm and around rim Press the rim together and push the diaphragm into the vagina as far as it goes Touch the diaphragm to make sure it covers the cervix ALSO: For each additional act of intercourse, use an applicator to insert additional spermicide into the vagina. DO NOT remove the diaphragm. How to use the diaphragm Do you want to try using this method and see how you like it? n o p q After sex: • Leave the diaphragm in place for AT LEAST 6 hours but NO MORE THAN 24 hours • To remove, gently slide a finger under the rim and pull the diaphragm down and out Touch the diaphragm to make sure it covers the cervix Squeeze plenty of spermicidal cream or jelly into diaphragm and around rim • Use about a tablespoon of jelly or cream. • Be careful not to tear the diaphragm when removing. • Wash diaphragm with mild soap and clean water after each use. • Check for holes in the diaphragm by filling it with water or by holding it up to the light. • Dry the diaphragm and store it in a clean, dark, cool place, if possible. For each additional act of intercourse, use an applicator to insert additional spermicide into the vagina. DO NOT remove the diaphragm. After sex: • Leave the diaphragm in place for AT LEAST 6 hours but NO MORE THAN 24 hours • To remove, gently slide a finger under the rim and pull the diaphragm down and out • Through the dome of the diaphragm, make sure you can feel the cervix, which feels like the tip of the nose. Does client understand how to use diaphragm? Is she ready to choose method? If she has decided to use method, go to next page to discuss spermicides if needed. If not, discuss further or consider other methods. Next Move: Press the rim together and push the diaphragm into the vagina as far as it goes How to use the diaphragm VM 3 Vaginal Methods n o p q How to use spermicides Film Tablets or suppositories • Insert before sex (up to 1 hour before) • Insert deep into vagina using applicator or fingers • Do not wash vagina for at least 6 hours after sex • If possible, store in a cool, dry place Do you want to try using this method and see how you like it? Does client understand how to use spermicides? Is she ready to choose method? • Helps keep foaming tablets from melting. If she has decided to use method, go to next page. If not, discuss further or consider other methods. Next Move: How to use spermicides VM 4 Vaginal Methods • Insert before sex (up to 1 hour before) • Insert deep into vagina using applicator or fingers • Do not wash vagina for at least 6 hours after sex • If possible, store in a cool, dry place With tablets, suppositories, film • Must insert at least 10 minutes before sex. • If using film, fold in half and insert with dry fingers near the cervix. With foam • Shake container well first. Come back if: • You need more spermicide • Diaphragm becomes stiff or thin or develops holes • You or your partner has reaction (itching, rash, irritation) • You feel pain when urinating What to remember Anything else I can repeat or explain? Any other questions? • Discuss where she can get resupply − at clinic or pharmacy. • Important to get more spermicide before she runs out. • Could be due to spermicide or latex, of could be infection or vaginitis. • May need to switch brand of spermicide, or switch methods. • Sign of urinary tract infection. • These diaphragms should be replaced. • Also, diaphragms should be refitted after childbirth or abortion. “Do you feel confident you can use this method successfully? Is there anything I can repeat or explain?” Remember to offer condoms for dual protection and/or back-up! Last, most important message: “Use method every time.” Last Moves: • You feel pain when urinating What to remember VM 5 Vaginal Methods • You or your partner has reaction (itching, rash, irritation) • Diaphragm becomes stiff or thin or develops holes • You need more spermicide Come back if: LAM Lactational Amenorrhoea Method • A contraceptive method based on breastfeeding • LAM means breastfeeding often, day and night, and giving baby little or no other food • Effective for 6 months after giving birth • Breast milk is best food for babies • No protection against STIs or HIV/AIDS Do you want to know more about this method, or talk about a different method? LAM Lactational Amenorrhoea Method • A contraceptive method based on breastfeeding About LAM: • “Lactational”—related to breastfeeding. “Amenorrhoea”—not having menstrual bleeding. • Using LAM means choosing to breastfeed in a way that prevents pregnancy. It works by stopping ovulation (see Appendices 4 & 5). • Giving baby ONLY breast milk (with little or no other food) gives best protection from pregnancy and is best for the baby’s health. • See page L3 for how to breastfeed for best protection. • “How would breastfeeding your baby in this way suit you?” • If periods have not returned. • Very effective when used correctly. • But as commonly used it is less effective. • Healthiest way to feed most babies for first 6 months. Breast milk contains the exact nutrients the baby needs and helps protect the baby from infections. Breastfeeding benefits the mother’s health too. • Breastfeeding should be started within 1 hour after birth, and babies should be given no other food or drink until they are 6 months old. • Breast milk can be a major part of diet for 2 years or more. • For woman’s STI/HIV/AIDS protection, also use condoms. • Breastfeeding can pass HIV from mother to baby. “Would you like to discuss LAM more, or would you like to think about another method?” To discuss another method, go to method tabTo discuss LAM further, go to next page. Next Move: 1 “Do you want to know more about LAM, or talk about a different method?” If client wants to know more about LAM, go to next page. Next Move: L1 • LAM means breastfeeding often, day and night, and giving baby little or no other food • Effective for 6 months after giving birth • Breast milk is best food for babies • No protection against STIs or HIV/AIDS To discuss another method, go to a new method tab or to Choosing Method tab. LAM When you can use LAM If breastfeeding now, can use LAM if: n Baby is less than 6 months old AND o Baby gets little or no food or drink except breast milk AND p Menstrual periods have not come back But please tell me if: • Have AIDS? Or infected with HIV, the AIDS virus? When you can use LAM But please tell me if: • Have AIDS? Or infected with HIV, the AIDS virus? • It is best for the baby to breastfeed for at least 2 years. Once her baby is 6 months or older: • She should use another method of family planning. • If she continues to breastfeed, nonhormonal methods are best. She can also use progestogen-only methods (mini-pill, long-acting injectable or implants). • Cannot use LAM if she has had 2 or more straight days of menstrual bleeding. (Bleeding in first 8 weeks after childbirth does not count.) • HIV may be passed to the baby in breast milk. • Where a safe replacement infant formula is available (either home-prepared or bought), a woman with HIV should not breastfeed and should use another family planning method. • If no safe replacement infant formula is available, a woman with HIV should breastfeed exclusively. After 6 months, or if safe replacement food becomes available, she should stop breastfeeding. • See Special Needs tab (page SN1) for special advice for women with HIV/AIDS. If client can no longer use LAM or is unable to use LAM, help her choose another method.

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