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Family Planning Counseling and Service Provision, STI Evaluation and Treatment, and HIV Counseling and/or Testing Module 3 - Session 1 FP Counseling and Provision Module 3 - Session 1 Objectives At the end of this session, participants will be able to: 1. State the essential information about family planning that all postabortion clients must have before they leave the service site 2. Explain the importance of informed choice for effective FP services 3. Describe personal and clinical factors that should be considered in family planning counseling for postabortion clients 4. Demonstrate appropriate family planning counseling during different phases of care 5. State one consensus point of the consensus statement by FIGO, ICM, ICN and USAID on postabortion family planning 2 Postabortion Family Planning • Receiving emergency PAC services may be one of the few points of contact with the health care system for many women. • This is an important opportunity to provide contraceptive information and services that should not be overlooked. 3 Postabortion FP: Role of the PAC Provider • • • Role of the PAC provider will vary from country to country or even site to site. Recent studies indicate an increase in postabortion family planning use: – When services are provided in the same place as emergency treatment – When couples are counseled together regarding family planning options Therefore, offering family planning and treatment for incomplete abortion services in the same place can result in: – More effective family planning use – Reduction of repeat abortions 4 Postabortion FP: Role of the PAC Provider (2) • The PAC provider is a crucial link in helping PAC clients: – Recognize their need for contraception – Overcome possible misconceptions and fears regarding contraceptive method – Gain confidence and trust in the health care system • These behavior changes increase the likelihood of a PAC client accepting a contraceptive method and of following through on a family planning referral. 5 Consensus Statement on Postabortion FP • In 2009, a consensus statement by the International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), International Council of Nurses (ICN) and the United States Agency for International Development (USAID) on postabortion family planning was signed. • This statement presents evidence on postabortion family planning. • The three professional organizations agree that doctors, midwives and nurses have a special role to play in ensuring that quality postabortion family planning services are provided. • FIGO, ICM, and ICN health professionals have a special advocacy role with policymakers and governments for ensuring quality postabortion family planning services, sharing responsibilities, strengthening professional education and improving health outcomes. 6 Integrating Emergency Treatment and FP • Offering family planning and treatment for incomplete abortion services in the same place can result in: – More effective family planning use – Reduction of repeat abortions – Healthy timing and spacing of pregnancies Adapted from: Senlet et al., 2001. 7 Healthy Timing and Spacing of Pregnancy (HTSP) • A technical working group from WHO states that: – After a live birth, the recommended interval before attempting the next pregnancy is at least 24 months, in order to reduce the risk of adverse maternal, perinatal and infant outcomes. – After a miscarriage, or induced abortion, the recommended interval to the next pregnancy should be at least 6 months, in order to reduce risks of adverse maternal and perinatal outcomes. – Young women should wait until they are at least 18 years of age for their first pregnancy. 8 FP Counseling and Information Even where methods are not provided, family planning information and counseling should be offered to all PAC clients regardless of the method of treatment for uterine evacuation (sharp curettage, electric, foot pump or manual vacuum aspiration). Remember: PAC is incomplete without family planning. 9 Client Knowledge about Postabortion FP The PAC client needs to know: • She can become pregnant again before the next menses, as fertility returns in as little as 2 weeks. • Safe contraceptive methods to prevent or delay pregnancy can be used immediately. • The risk for an adverse outcome to a pregnancy is less when there is an interval of at least 6 months between this miscarriage and her next pregnancy. • Where and how to obtain family planning services and methods, either at the time of treatment or after discharge, especially if they are not available in the same facility where PAC services are provided. Adapted from: Report of a WHO Technical Consultation on Birth Spacing, June 2005. 10 Content of Postabortion FP As with all FP services, PAC clients should receive: • Information and counseling about methods, their characteristics, effectiveness and side effects • Choices among methods (e.g., short- and long-acting, hormonal and non-hormonal) • Assurance of contraceptive re-supply • Access to follow-up care • Counseling about contraceptive needs in the context of personal reproductive health goals and needs 11 Goals of FP Counseling • Help the woman and her partner (if she agrees to his participation in counseling) to: – Understand the factors that led to an unwanted pregnancy (if appropriate) in order to avoid repeating the situation – Understand that fertility can return almost immediately – Decide if she wants to use a contraceptive method – Choose an appropriate method – Use the method effectively – Space or prevent future pregnancies 12 FP Counseling: Informed Choice • Free and informed choice means that the client chooses a contraceptive method voluntarily, and without pressure or coercion. • It is based on a clear understanding of the benefits and limitations of the methods that are available. 13 FP Counseling: Informed Choice (2) • Help the client to understand that: – Almost all methods can be used safely and effectively immediately after treatment of an incomplete abortion, and that – With the exception of permanent methods (tubal ligation, vasectomy), she can choose another method later if she wishes to change. 14 FP Counseling: Informed Choice (3) • Many women do not want to become pregnant again immediately, but some women may not want to make a decision about contraception at the time of PAC services. • A mechanism should be in place to ensure that these women can return for contraceptive services or are referred to a facility in their community. Meanwhile, the provider may: – Offer condoms to take home – Give an appointment to return in 1–2 weeks for a FP method – Refer to a local facility or community-based distributor for further counseling 15 FP Counseling: Informed Choice (4) • It is possible that the client may choose not to use a family planning method. • The use of contraceptives should be completely voluntary. • Patients CANNOT BE DENIED RIGHTS OR BENEFITS such as food, social benefits or medical care if they decide not to use family planning services. • Acceptance of contraception or a particular method should never be a prerequisite for obtaining emergency postabortion care. 16 Advantages of Free and Informed FP Choice • Clients who have made a free and informed choice of a family planning method are: – More likely to be satisfied with the method – More likely to use the method effectively 17 How FP Counseling Helps the Client FP counseling should help a client to: • Consider her reproductive goals, including the need for protection against STIs, including HIV • Make free, informed choices about family planning • Understand how to effectively use the method 18 FP Information The PAC client also needs to know: • Characteristics of all methods (e.g., effectiveness, reversibility, protection from STIs/HIV, side effects) • How to use the selected method correctly, including where and how to get additional supplies (e.g., pills, condoms, injectables) • How to stop using the method or switch to another 19 FP Counseling: GATHER Method • This method of counseling has 6 elements, or steps. Each letter in the word GATHER stands for one of these elements. • An effective, skilled counselor understands the client's feelings and needs and adapts counseling to meet these needs. • All PAC FP counseling should be tailored to each client. Not all clients need to be counseled in this order and not all clients need all 6 GATHER elements. Some will need an element repeated. 20 Elements of GATHER Counseling G — Greet (Greet the client) – Be polite, friendly and respectful: greet client, introduce yourself, and offer a seat. Give her your full attention as soon as you meet her. A — Ask (Ask the client about herself) – Ask clients about their reasons for coming; ask for any info needed to complete their records. T — Tell (Tell the client about her choices) H — Help (Help the client choose) – Tell client that the choice is hers. Offer advice, but avoid making decisions for her. After the client has made a choice, give supplies, if appropriate. E — Explain (Explain what to do) – After the client has made a choice, explain how to use the method and demonstrate, where possible; have client repeat key instructions to help ensure that she remembers and understands the information; if the method or services cannot be given now, explain how, when and where they will be provided. R — Return (Return for follow-up visit) – Conduct follow-up visit and assess client satisfaction with method. 21 Tailoring Postabortion FP to the Client’s Needs • FP services should be based on the assessment of a each woman’s unique situation, taking into account: – Her personal characteristics, needs and reproductive goals – Her clinical condition – The service delivery capabilities where she receives treatment and in the community where she lives A woman’s personal preferences, constraints and social situation may be as important in postabortion FP as her clinical condition. 22 Client’s Personal Situation • Some aspects pf the client’s personal situation: – May be related to the unplanned pregnancy or incomplete abortion – May be a barrier to contraceptive use • While maintaining confidentiality, the provider can obtain information to help clients select a suitable method. 23 Personal Situation Issues Affecting Selection of a Method • • • • Does she want to become pregnant again soon? Was the client a survivor of sexual abuse or rape? Is the client a victim of physical abuse? Is she under stress, in pain or not prepared to make a long-term decision? • Has she ever used a family planning method? If not: – Did she lack information about it or did she choose not to use FP? – What are some of the factors that led to her decision not to use FP? – Does she desire family planning counseling now? 24 Personal Situation Issues Affecting Selection of a Method (2) • Was she using a contraceptive method when she became pregnant? If so: – Was she using it correctly and consistently? – Were there particular reasons why the method failed? – Would she be able to use the method effectively in the future? – Would she prefer a different method? 25 Personal Situation Issues Affecting Selection of a Method (3) • Are there partner/family or other issues to consider, such as: – A partner who may not be monogamous – A partner who is unwilling to use condoms – A partner or mother-in-law who disapproves of contraception – A partner desiring more children or children of a specific gender – Religious or cultural restrictions – Limited resources or access to health services 26 Involving Men in FP Counseling • Studies on male involvement in counseling show that: – Many men want to have more information about their partner’s condition during PAC and more information on family planning. – With the client’s consent, counseling the husbands/partners of PAC clients separately can increase both use of family planning and support for PAC clients during recovery. – Some women want their husbands to be informed about family planning methods and to be present for family planning counseling with them. • Whichever approach is preferred by the couple should be supported and implemented. 27 Working with Adolescents • Adolescents who have experienced incomplete abortion: – May not have the support of their partners or parents – Are more likely to experience isolation and emotional stress – May have been victims of coercive sexual encounters • Counselors need to: – Be supportive and non-punitive – Take extra care to express openness and compassion; personal judgments about adolescent sexual activity should not affect the interaction – Understand that thorough counseling is needed, as it may be more difficult for adolescents to use methods consistently and correctly 28 Working with Adolescents (2) • Providers should: – Not deny young women access to contraception because of their age or marital status – Keep in mind that pregnancy, especially in very young women, may be the result of rape or ongoing sexual abuse. In these cases, referral to community services (if available) should be initiated. 29 Working with Adolescents (3) • If the young woman wishes to avoid sexual behavior: – Counsel her on how to resist sexual advances from peers and adult males. • Many adolescents, especially those who are single, experience specific barriers to accessing and using reproductive health services. If possible, refer these clients to any special programs that focus on adolescent reproductive health needs. 30 Clinical Condition • In general, all modern methods of family planning can be used immediately after emergency postabortion care, provided: – There are no severe complications requiring further treatment, – The client receives adequate counseling, and – The provider screens for any precautions for using a particular contraceptive method. • Natural family planning methods can be used when a regular menstrual pattern returns. • To prevent infection, women should not have sexual intercourse until: – Postabortal bleeding stops (usually 5–7 days) – Any complications are resolved 31 Community Resources for Referral and Follow-Up • A client’s ability to use a method effectively depends, in part, on: – Her access to services – Support for use of her chosen method – Continuous supply of contraceptives – Ability of the service delivery facility to maintain an adequate supply of methods • The FP provider can assist with matters such as side effects or changing methods, if desired. • If a client has traveled far from home for PAC services: – Begin the family planning method before she leaves the facility if she desires – Refer her to follow-up family planning services in her community 32 Community Resources for Referral and Follow-Up (2) • If all methods not offered at PAC site, what other options are available? • What public sector family planning resources are available? • Where are they located and what are the costs? • Are there private sector sources of family planning? What are they and what is the cost? • What other community services are available, such as services for clients who are victims of domestic violence? • Are there established referral arrangements with community clinics and providers so clients can be referred if they cannot or choose not to select a method at the time of PAC services? 33 Community Resources for Referral and FollowUp: PAC Provider Role • Help clients think through issues: – Convenience of the method – Ease in getting the method – Where to go to if they experience problems with the method • Help clients to choose a method that they will be able to access and continue using in their communities. • Discuss the full range of methods without a bias toward any method(s), leaving as many options for the client as possible. • If injectables, IUD or tubal ligation is not available at your facility, refer clients to a facility that can offer these methods. Provide a short-term method along with condoms until a longer-acting method can be obtained. 34 Referral Information: What Clients Need to Know • Directions, telephone numbers, which transportation to access and a street address for the referral facility. • Whether they need to take a referral card. • Whether the providers will know about her incomplete abortion and treatment, or if this information is confidential within the treatment facility. What, if any, information about her incomplete abortion and treatment she should take along or tell her family planning provider. • Hours or days of operation. Clients should be told if some methods are available only at certain times or on certain days. 35 Referral Information: What Clients Need to Know (2) • • • • • The name of whom to see, if they need to see someone specific What family planning counseling services are available What contraceptive methods are available What follow-up services are available What additional services are available: STI information, screening for cervical cancer; social or legal services (counseling for such issues as domestic violence); antenatal care, well-baby care, follow-up care for spontaneous abortion • What the approximate charges will be • Answers to any questions she may have 36 Contraceptive Methods for Postabortion FP • International standards in selecting a contraceptive method can be found in the World Health Organization’s (WHO) Medical Eligibility Criteria for Contraceptive Use (4th edition, 2010). • Family Planning: A Global Handbook for Providers (WHO/CCP, 2007) is also an excellent technical resource. • National and local guidelines and protocols will provide additional information on dispensing contraceptive methods. 37 Contraceptive Methods for Postabortion FP (2) • Be sure protocols are up-to-date: – For example, in some places there are still limits on providing methods containing estrogen to postabortion clients or on offering methods before 6 weeks after an incomplete abortion. – Providers need to be familiar with their national and local protocols and be aware of such barriers. – When appropriate, providers may be able facilitate a change process to bring protocols in line with international standards. – See USAID’s Global Postabortion Care Resource Package for information on how to assess your countries protocols for postabortion family planning. At: http://www.postabortioncare.org. 38 Medical Eligibility Criteria for Contraceptive Use (MEC) • • • Covers 17 contraceptive methods, 120 medical conditions Over 1,700 recommendations on who can use various contraceptive methods Gives guidance to providers for clients with medical problems or other special conditions At: http://www.who.int/reproductive-health/publications/mec/mec.pdf. 39 Purpose of the Medical Eligibility Criteria (MEC) • • • • To guide family planning practices based on the best available evidence To address and change misconceptions about who can and cannot safely use contraceptive methods To reduce medical policy and practice barriers (i.e., not supported by evidence) To improve quality, access and use of family planning services 40 Medical Eligibility Criteria • Medical Eligibility Criteria identify which contraceptive method can be used in: – Given medical condition – Given individual characteristics 41 Contraceptive Methods: Oral Contraceptives • Oral contraceptives: – Combined – Progestin-only • Timing for postabortion use: – Pill use may begin immediately, preferably on the day of treatment. 42 Contraceptive Methods: Injectables • Injectables: – Depo-Provera (DMPA) and NET-EN – Mesigyna®, Cyclofem® (monthly injectables) • Timing for postabortion use: – Injection may be given immediately after treatment 43 Contraceptive Methods: Implants • Progestin-only implants: – Norplant® implants, Jadelle®, Implanon™ • Timing for postabortion use: – Implants may be inserted immediately after abortion. – If adequate counseling and informed decision-making cannot be guaranteed, insertion must be delayed and an interim method provided. 44 Contraceptive Methods: Intrauterine Device • IUD: – Timing for postabortion use: • First-trimester miscarriage/abortion: IUD can be inserted if risk or presence of infection can be ruled out. • Second-trimester miscarriage/abortion: Insertion should be delayed for 6 weeks unless equipment and expertise for immediate postabortal insertion are available. • If there are complications: Insertion should be delayed until serious injury is healed, hemorrhage is controlled or acute anemia improves. 45 Contraceptive Methods: Non-Fitted Barrier Methods • Non-fitted barrier methods: – Latex and vinyl male/female condoms – Vaginal sponge – Suppositories • Timing for postabortion use: – May be used as soon as intercourse is resumed 46 Contraceptive Methods: Fitted Barrier Methods • Fitted barrier methods: – Diaphragm (with foam or jelly) – Cervical cap (with foam or jelly) • Timing for postabortion use: – The diaphragm can be fitted: • Immediately after first trimester miscarriage or abortion • 6 weeks after second-trimester miscarriage/abortion until uterus returns to pre-pregnancy size – Delay cervical cap fitting until bleeding has stopped and the uterus has returned to its pre-pregnancy size (6 weeks). 47 Contraceptive Methods: Female Sterilization • Female sterilization—timing for postabortion use: – Can be performed immediately after treatment of postabortion complications (except with severe bleeding or infections) – Delay until infections fully resolved (3 months) or injuries healed – Ensure adequate counseling – Follow local guidelines regarding informed consent for sterilization (e.g., spouse consent or waiting period) 48 Contraceptive Methods: Vasectomy • Vasectomy can be performed at any time: – Not effective for the first 12 weeks immediately following the procedure 49 Contraceptive Methods: Fertility Awareness Methods • Natural family planning (or fertility awareness methods): – Standard Days Method® (cycle beads) – Basal body temperature/cervical secretions – Calendar calculations • Natural family planning methods usually involve periodic abstinence during fertile period, so couples must be highly motivated 50 Contraceptive Methods: Fertility Awareness Methods (2) • Timing for postabortion use: – Not recommended for immediate postabortion use – The first ovulation after an abortion will be difficult to predict – Method is unreliable until after a regular menstrual pattern has returned 51 Dual Protection • Though FP methods protect against pregnancy, few provide effective protection against HIV and other STIs. • Dual protection achieves the simultaneous prevention of STIs and unplanned pregnancy. • There are 2 main ways to practice dual protection: – Condoms alone – Condoms with another FP method (such as OCs or an injectable) 52 Dual Protection (2) • The primary goal of dual protection will influence which dual protection approach a woman should use. • If goal is to prevent pregnancy, dual method use may be appropriate, especially if she is not able to use condoms correctly and consistently. • If primary goal is prevention of infection, condoms alone may be a good choice. • Providers need to help PAC clients to determine their risks and goals and select the best form of dual protection for their needs. 53