14 Family planning after pregnancy

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Contents

• Objectives
• Contraceptive counselling
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Explain the wider meaning of family planning.
2. Give contraceptive counselling.
3. List the efficiency, contraindications and side effects of the various contraceptive methods.
4. List the important health benefits of contraception.
5. Advise a postpartum patient on the most appropriate method of contraception.

Contraceptive counselling

14-1 What is family planning?

Family planning is far more than simply birth control, and aims at improving the quality of life for everybody. Family planning is an important part of primary healthcare and includes:

1. Promoting a caring and responsible attitude to sexual behaviour.
2. Ensuring that every child is wanted.
3. Encouraging the planning and spacing of the number of children according to a family’s home conditions and financial income.
4. Providing the highest quality of maternal and child care.
5. Educating the community with regard to the disastrous effects of unchecked population growth on the environment.

It is essential to obtain prior community acceptance of, and promote community participation in, any family planning programme if the programme is to succeed in that community.

14-2 Who requires family planning education?

Because family planning aims at improving the quality of life for everybody, every person, female or male, requires family planning education. Such education should ideally start during childhood and be given in the home by the parents. It is then continued at school and throughout the rest of the individual’s life.

14-3 Who needs contraceptive counselling?

Every person who is sexually active, or who probably will soon become sexually active, needs contraceptive counselling (i.e. information and advice about birth control). While the best time to advise a woman on contraception is before the first coitus, the antenatal and post-delivery periods are an excellent opportunity to provide contraceptive counselling. Some patients will ask you for contraceptive advice. However, you will often have to first motivate a patient to accept contraception before you can advise her about an appropriate method of contraception.

14-4 How should you motivate a patient to accept contraception after delivery?

A good way to motivate a patient to accept contraception is to discuss with her, or preferably with both her and her partner, the health and socio-economic effects further children could have on her and the rest of the family. Explain the immediate benefits of a smaller, well-spaced family.

It is generally hopeless to try and promote contraception by itself. To gain individual and community support, family planning must be seen as part of total primary healthcare. A high perinatal or infant mortality rate in a community is likely to result in a rejection of contraception.

14-5 How should you give contraceptive advice after delivery?

There are five important steps which should be followed.

Step 1: Discussion of the patient’s future reproductive career

Ideally a woman should consider and plan her family before her first pregnancy, just as she would have considered her professional career. Unfortunately in practice this hardly ever happens and many women only discuss their reproductive careers for the first time when they are already pregnant or after the birth of the infant.

When planning her family the woman (or preferably the couple) should decide on:

1. The number of children wanted.
2. The time intervals between pregnancies as this will influence the method of contraception used.
3. The contraceptive method of choice when the family is complete.

Very often the patient will be unable or unwilling to make these decisions immediately after delivery. However, it is essential to discuss contraception with the patient so that she can plan her family. This should be done together with her partner and, where appropriate, other members of her family or friends.

Step 2: The patient’s choice of contraceptive method

The patient should always be asked which contraceptive method she would prefer as this will obviously be the method with which she is most likely to continue.

Step 3: Consideration of contraindications to the patient’s preferred method

You must decide whether the patient’s choice of a contraceptive method is suitable, taking into consideration:

1. The effectiveness of each contraceptive method.
2. The contraindications to each contraceptive method.
3. The side effects of each contraceptive method.
4. The general health benefits of each contraceptive method.

If the contraceptive efficiency of the preferred method is appropriate, if there are no contraindications to it, and if the patient is prepared to accept the possible side effects, then the method chosen by the patient should be used. Otherwise proceed to step 4.

Step 4: Selection of the most appropriate alternative method of contraception

The selection of the most suitable alternative method of contraception after delivery will depend on a number of factors including the patient’s wishes, her age, the risk of side effects and whether or not a very effective method of contraception is required.

Step 5: Counselling the patient once the contraceptive method has been chosen

Virtually every contraceptive method has its own side effects. It is a most important part of contraceptive counselling to explain the possible side effects to the patient. Expert family planning advice must be sought if the local clinic is unable to deal satisfactorily with the patient’s problem. If family planning problems are not satisfactorily solved, the patient will probably stop using any form of contraception.

After delivery the reproductive career of each patient must be discussed with her in order to decide on the most appropriate method of family planning to be used.

14-6 What contraceptive methods can be offered after delivery?

1. Sterilisation. Either tubal ligation (tubal occlusion) or vasectomy.
2. Long-acting reversible contraceptives (LARCS):
   • An intra-uterine contraceptive device (IUCD).
   • A progesterone-containing contraceptive implant (Implanon or Nexplanon).
   • Injectables (an intramuscular injection of depot progestogen).
3. Oral contraceptives. The progestogen-only pill (the ‘minipill’) for 3 months after which you may decide to switch to a combined pill (containing both oestrogen and progestogen).
4. The male or female condom.

Breastfeeding, spermicides alone, coitus interruptus and the ‘safe period’ are all very unreliable. All women should know about postcoital contraception.

Oestrogen increases the risk of thombo-embolism during the puerperium and reduces milk production while lactation is being established. Combined pills should not be used in the first 3 months after delivery.

14-7 How effective are the various contraceptive methods?

The most effective permanent contraceptive methods are female sterilization or male vasectomy. The most effective reversible methods are the intra-uterine contraceptive devices and progesterone implants.

Methods that are effective if carefully used are injectable and oral contraceptives. Condoms are less effective and if used for contraception require very careful use.

14-8 How effective is postcoital contraception?

1. Norlevo, E-Gen-C or Ovral are effective within five days of unprotected sexual intercourse, but are more reliable the earlier they are used.
2. A copper intra-uterine contraceptive device can be inserted within six days of unprotected intercourse.
3. Postcoital methods should only be used in an emergency and not as a regular method of contraception.
4. If Norlevo is used, 1 tablet should be taken as soon as possible after intercourse, followed by another 1 tablet after exactly 12 hours.
5. If Ovral or E-Gen-C is used, 2 tablets are taken as soon as possible after intercourse, followed by another 2 tablets exactly 12 hours later.

The tablets for postcoital contraception often cause nausea and vomiting, which reduces their effectiveness. These side effects are less with levonorgestrel (Norlevo and Escapelle) which contains no oestrogen. Therefore levonorgestrel (Norlevo and Escapelle) is a more reliable method and should be used if available. Norlevo and Escapelle as a single dose method are available in South Africa.

14-9 What are the contraindications to the various contraceptive methods?

The following are the common or important conditions where the various contraceptive methods should not be used:

1. Sterilisation
   • Marital disharmony.
   • Psychological problems.
   • Forced or hasty decision.
   • Gynaecological problem requiring hysterectomy.
2. Long acting reversible contraceptives (LARCS):
   • Intra-uterine contraceptive device:
     • A history of excessive menstruation.
     • Anaemia.
     • Multiple sex partners when the risk of genital infection is high.
     • Current pelvic inflammatory disease.
   • Implant
     • Pregnancy planned within 1 year.
     • Current breast cancer.
     • A HAART regimen that contain efavirenz, rifampicin for TB and anti-epileptic drugs
   • Injectables
     • Pregnancy planned within 1 year.
     • Current breast cancer.
3. Combined pills
   • A history of venous thromboembolism.
   • Age 35 years and smoking 15 or more cigarettes per day.
   • Risk factors for cardiovascular disease e.g. obesity with a body mass index (BMI) of 40 or more.
   • A HAART regimen that containing a protease inhibitor e.g. lopinavir/ritonavir
   • Migraine and 35 years or older.
   • Oestrogen-dependent malignancies such as breast or uterine cancer.
4. Progestogen-only pill (minipill)
   • Current breast cancer.

A menstrual abnormality is a contraindication to any of the hormonal contraceptive methods (injectables, implants, combined pill or progestogen-only pill) until the cause of the menstrual irregularity has been diagnosed. Thereafter, hormonal contraception may often be used to correct the menstrual irregularity. However, during the puerperium a previous history of menstrual irregularity before the pregnancy is not a contraindication to hormonal contraception.

Note

If a woman has a medical complication, then a more detailed list of contraindications may be obtained from the standard reference manual such as the World Health Organisation (WHO) medical eligibility criteria for contraceptive use which is also available on a WHO website (www.who.int/reproductive -health/publications/mec/).

14-10 What are the major side effects of the various contraceptive methods?

Most contraceptive methods have side effects. Some side effects are unacceptable to a patient and will cause her to discontinue the particular method. However, in many instances side effects are mild or disappear with time. It is, therefore, very important to counsel a patient carefully about the side effects of the various contraceptive methods, and to determine whether she would find any of them unacceptable. At the same time the patient may be reassured that some side effects will most likely become less or disappear after a few months’ use of the method.

The major side effects of the various contraceptive methods used after delivery are:

1. Sterilisation
   • Tubal ligation and vasectomy have no medical side-effects and, therefore, should be highly recommended during counselling of patients who have completed their families.
   • Menstrual irregularities are not a problem.
   • About 5% of women later regret sterilisation.
2. Copper-containing intra-uterine contraceptive device
   • Expulsion in 3–15 cases per 100 women who use the device for 1 year.
   • Pain at insertion.
   • Dysmenorrhoea.
   • Menorrhagia (excessive and/or prolonged bleeding).
   • Increase in pelvic inflammatory disease.
   • Perforation of the uterus is uncommon.
   • Ectopic pregnancy is not prevented.
3. Progesterone-containing intra-uterine contraceptive devices (Mirena)
   • Fewer side effects and reduce menstrual blood loss.
   • Expensive and not generally available in South Africa.
4. Implants
   • A change in bleeding pattern is common, usually transient and stabilizes in 3 to 6 months.
   • Headaches.
   • Weight gain.
5. Injectables
   • Menstrual abnormalities, e.g. amenorrhoea, irregular menstruation or spotting.
   • Weight gain.
   • Headaches.
   • Delayed return to fertility within a year of stopping the method. There is no evidence that fertility is reduced thereafter.
   • With Nur-Isterate there is a quicker return to fertility, slightly less weight gain and a lower incidence of headaches and amenorrhoea than with Depo-Provera or Petogen.
6. Combined pill
   • Reduction of lactation.
   • Menstrual abnormalities, e.g. spotting between periods.
   • Nausea and vomiting.
   • Depression.
   • Fluid retention and breast tenderness.
   • Chloasma (a brown mark on the face).
   • Headaches and migraine.
7. Progestogen-only pill
   • Menstrual abnormalities, e.g. irregular menstruation.
   • Headaches.
   • Weight gain.
8. Condom
   • Decreased sensation for both partners.
   • Not socially acceptable to everyone.

If a couple have completed their family the contraceptive method of choice is tubal ligation or vasectomy.

Additional contraceptive precautions must be taken when the effectiveness of an oral contraceptive may be impaired, e.g. diarrhoea or when taking antibiotics. There is no medical reason for stopping a hormonal method periodically to ‘give the body a rest’.

14-11 What are the important health benefits of contraceptives?

The main objective of all contraceptive methods is to prevent pregnancy. In low and middle income countries pregnancy is a major cause of mortality and morbidity in women. Therefore, the prevention of pregnancy is a very important general health benefit of all contraceptives.

Various methods of contraception have a number of additional health benefits. Although these benefits are often important, they are not generally appreciated by many patients and healthcare workers.

1. Injectables
   • Decrease in dysmenorrhoea.
   • Less premenstrual tension.
   • Less iron-deficiency anaemia due to decreased menstrual flow.
   • No effect on lactation.
2. Combined pill
   • Decrease in dysmenorrhoea.
   • Decrease in menorrhagia (heavy and/or prolonged menstruation).
   • Less iron-deficiency anaemia.
   • Less premenstrual tension.
   • Fewer ovarian cysts.
   • Less benign breast disease.
   • Less endometrial and ovarian carcinoma.
3. Progestogen-only pill and implants
   • No effect on lactation.
4. Condom
   • Less risk of HIV infection and other sexually transmitted diseases.
   • Less pelvic inflammatory disease.
   • Less cervical intra-epithelial neoplasia.

The condom is the only contraceptive method that provides protection against HIV infection.

14-12 What is the most appropriate method of contraception for a patient after delivery?

The most suitable methods for the following groups of patients are:

1. Lactating patients
   • Tubal ligation or vasectomy for patients who have completed their families.
   • An intra-uterine contraceptive device.
   • An implant but not if a further pregnancy is planned within the next year.
   • An injectable, but not if a further pregnancy is planned within the next year.
   • A progestogen-only pill (minipill) for 3 months, then the combined pill.
   • An intra-uterine contraceptive device.
2. Teenagers and patients with multiple sexual partners.
   • An implant.
   • An injectable, as this is a reliable method with patients who might forget to use another method.
   • Additional protection against HIV infection by using a condom is essential. It is important to stress that the patient should only have intercourse with a partner who is willing to use a condom or allows her to use a female condom.
3. Patients living with HIV
   • Condoms must be used in addition to the appropriate contraceptive method (dual contraception).
   • An intra-uterine contraceptive device.
   • An injectable.
   • An implant if not on FDC/efavirenze
4. Patients whose families are complete
   • Tubal ligation or vasectomy is the logical choice.
   • Long acting reversible contraceptives (LARCS):
     • Intra-uterine contraceptive device
     • Implants
   • An injectable, e.g. Depo-Provera or Petogen (12 weekly) or Nur-Isterate (8 weekly).
   • A combined pill until 35 years of age if there are risk factors for cardiovascular disease, or until 50 years if these risk factors are absent.
5. Patients of 35 years or over with risk factors for cardiovascular disease
   • Tubal ligation or vasectomy is the logical choice.
   • Long acting reversible contraceptives (LARCS):
     • Intra-uterine contraceptive device
     • Implants
   • Injectable contraceptives.
   • Progestogen-only pills.

The puerperium is the most convenient time for the patient to have a bilateral tubal ligation performed.

HAART treatment with TDL can be used with any of the hormonal contraceptives.

Every effort should be made to provide facilities for tubal ligation during the puerperium for all patients who request sterilisation after delivery.

Remember that sperms may be present in the ejaculate for up to 3 months following vasectomy. Therefore, an additional contraceptive method must be used during this time.

14-13 What are the risk factors for cardiovascular disease in women taking the combined pill?

The risk of cardiovascular disease increases markedly in women of 35 or more years of age who have one or more of the following risk factors:

1. Smoking.
2. Hypertension.
3. Diabetes.
4. Hypercholesterolaemia.
5. A personal history of cardiovascular disease.
6. Obesity (BMI 40 or more)

Smoking is a risk factor for cardiovascular disease.

14-14 When should an intra-uterine contraceptive device be inserted after delivery?

Within 48 hours of birth but always as soon as possible, ideally within 15 minutes after completion of the third stage of labour. Although the expulsion rate is higher as compared to insertion 6 weeks postpartum, the method is immediately effective and loss to follow-up is ruled out.

If not inserted within 48 hours after birth it should not be inserted before six weeks as the uterine cavity would not yet have returned to its normal size. At six weeks or more after delivery there is the lowest risk of:

1. Pregnancy.
2. Expulsion.

Postpartum patients choosing this method must be discharged on an injectable contraceptive or progestogen-only pill until an intra-uterine contraceptive device has been inserted.

Case study 1

You have delivered the fourth child of an unbooked 36-year-old patient. All her children are alive and well. She is a smoker, but is otherwise healthy. She has never used contraception.

1. Should you counsel this patient about contraception?

Yes. Every sexually active person needs contraceptive counselling. This patient in particular needs counselling as she is at an increased risk of maternal and perinatal complications, should she fall pregnant again, because of her age and parity.

2. Which contraceptive methods would be appropriate for this patient?

Tubal ligation or vasectomy would be the most appropriate method of contraception if she does not want further children. Should she not want sterilisation, either an intra-uterine contraceptive device, implant or injectable contraceptive would be the next best choice.

3. If the patient accepts tubal ligation, when should this be done?

The most convenient time for the patient and her family is the day after delivery (postpartum sterilisation). Every effort should be made to provide facilities for postpartum sterilisation for all patients who request it.

4. If the couple decides not to have a tubal ligation or vasectomy, how will you determine whether an implant or an intra-uterine contraceptive device would be the best choice?

Assessing the risk for pelvic inflammatory disease will determine which of the two methods to use. If the patient has a stable relationship, an intra-uterine contraceptive device may be more appropriate. However, if she or her partner has other sexual partners, an implant would be indicated. A contra-indication for an implant will be a HAART regimen that contains efavirenz (i.e. FDC), rifampicin for TB and anti-epileptic drugs.

5. What other advice must be given to a patient at risk of sexually transmitted infections?

The patient must insist that her partner wears a condom during sexual intercourse. This will reduce the risk of HIV infection.

Case study 2

A 15-year-old primigravida had a normal delivery in a district hospital. She has never used contraception. Her mother asks you for contraceptive advice for her daughter after delivery. The patient’s boyfriend has deserted her.

1. Does this young teenager require contraceptive advice after delivery?

Yes, she will need contraceptive counselling and should start on a contraceptive method before discharge from hospital. She needs to learn sexual responsibility and must be told where the nearest family planning clinic to her home is for follow-up. She also needs to know about postcoital contraception.

2. Which contraceptive method would be most the appropriate for this patient?

An intra-uterine contraceptive device or implant be the best method for her as she needs reliable contraception for a long time. An injectable contraceptive could be offered as a third choice as it would be a more reliable method than oral contraceptive pills.

3. Why would she need a long-term contraceptive?

Because she should only have her next child when she has completed school, is in a stable relationship and able to take care of her children by herself.

4. If the patient prefers to use an oral contraceptive, would you regard this as an appropriate method of contraception for her?

No. A method that does not depend on her reliable and correct use would be more appropriate. Oral contraceptives are only reliable if taken every day.

5. The patient and her mother are worried that the long-term effects of an implant or injectable form of contraception could be harmful to a girl of 15 years. What would be your advice?

Implants and injectable contraception are extremely safe and, therefore, appropriate methods for long-term use. These methods will not reduce her future fertility.

Case study 3

You have just delivered the first infant of a healthy 32-year-old patient. In discussing contraception with her, she mentions that she is planning to fall pregnant again within a year after she stops breastfeeding. She is a schoolteacher and would like to continue her career after having two children.

1. The patient says that she has used an injectable contraceptive for five years before this pregnancy and would like to continue with this method. What would your advice be?

Injectable contraception would not be appropriate as she plans her next pregnancy within a year, and there may be a delayed return to fertility.

2. If the patient insists on using an injectable contraceptive, which drug would you advise her to use?

An injectable such as Nur-Isterate is preferable, as the return to fertility may be quicker.

3. Following further counselling, the patient decides on oral contraception and is given a combined pill. Do you agree with this management?

No. As she plans to breastfeed, she should be given a progestogen-only pill. Combined oral contraceptive pills may reduce milk production while breastfeeding is being established and increase the risk for thromboembolism. Progestogen-only pills have no effect on breastfeeding.

Case study 4

A married primipara from a rural area has just been delivered in a district hospital. She has a stable relationship with her husband and they decide to have their next infant in five years’ time. The patient would like to have an intra-uterine contraceptive device inserted.

1. Is this an appropriate method for this patient?

Yes, as the risk of developing pelvic inflammatory disease is low.

2. When should the device be inserted?

There are 2 options:

1. Within 48 hours of completion of the third stage of labour, but ideally within 15 minutes, OR
2. Six weeks or more after delivery, as there is an increased risk of expulsion if the device is inserted earlier.

3. The patient decides to come back after 6 weeks for the insertion. Could she, in the meantime, rely on breastfeeding as a contraceptive method?

No. The risk of pregnancy is too high. She should use reliable contraception, such as injectable contraception or the progestogen-only pill, until the device is inserted.

4. The patient asks if the intra-uterine contraceptive device could be inserted before she is discharged from hospital. Would this be appropriate management?

Yes, although the expulsion rate is higher as compared to insertion 6 weeks postpartum, the method is immediately effective and loss to follow-up is ruled out.