Download Family Planning and Counseling and Provision

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