Learning Resource Package: Family Planning Counseling

AGENDA FOR 2 DAYS FP COUNSELLING TRAINING

Day 1: 10 am to 5 pm TIME DURATION SESSION TOPIC FACILITATOR No 10:00‐10:30 30 Min 1. Introductions of Participants Participants’ Expectations, Group Norms 10:30‐10:55 25 Min 2. Course Goal and Objectives, Review of the Course Agenda, Components of the Training Package and Course Materials Given to Participants 10:55 ‐11:10 15 Min 3. Pre‐ Course Knowledge Assessment 11:20 – 11:30 TEA BREAK 11: 30 – 12:00 30 Min 4. Benefits of Family Planning, Healthy timing and spacing of pregnancies (HTSP) & Importance of Postpartum Family Planning 12:00‐1:00 60 min 5. Technical Overview of Family Planning Methods Technical update on spacing methods (Lactational Amenorrhea Method (LAM), Combined Oral Contraceptive Pills (COCs), Progestin only Pills (POPs), Centchroman (Ormeloxifene), IUCD, Condoms and Use of ECP) 1:00 ‐ 01:45 LUNCH 1:45 – 2:15 30 min 6. Technical Update on limiting methods (Female Sterilization and Male Sterilization) 2:15‐2:45 30 Min 7. Exercise on Time of initiation of various methods after childbirth and abortions. 2:45‐ 3:45 60 Min 8. Family Planning (FP) Counseling Approach & Communication Skills 3:45 ‐4:00 TEA BREAK

4:00‐4:15 30 min 9. Introduction of counselling checklists (FP General counselling checklist, method specific counselling checklists) 4:15 ‐4:45 30 min 10. Demonstration of FP Counselling Skills on informed choice and method specific counselling, when client chooses a method; by trainers , followed by discussion (includes demonstration of dispelling misconceptions about FP methods) 4:45 ‐5:00 15 min 11. Wrap up of the day Home assignments:  Preparation for mid‐course test  Going though counselling checklists thoroughly

Day 2: 10 am to 5 pm

TIME DURATION SESSION TOPIC FACILITATOR NO. 10:00 ‐10:40 40 Min 12. Warm up Recap of Day 1 and review of agenda of Day 2 Responding to queries and concerns of participants on technical information on FP methods and counselling skill 10:40 ‐ 11:00 20 Min 13. USAID FP Compliance 11:00 – 11:30 30 Min 14. Eligibility Criteria and Informed Consent for Sterilization 11:30 – 11:45 Tea

11:45‐12:00 15 min 15. Mid‐course knowledge assessment 12:00‐ 12:30 30 Min 16. Understanding and Use of FP counseling Flip Book and FP Kit; Setting up counselling corner for maintaining privacy 12:30‐1:00 30 Min 17. Practice of FP Counseling Skills through role‐play on informed choice and method specific counselling, when client chooses a method (in small groups) 1:00‐1:30 Lunch 1:30 – 30 Min 18. Practice of Counselling through Role‐ Play using 2:00 checklist in small groups by participants (groups of 3 participants) 2:00 ‐ 3:15 75 min 19. Return Demonstration of counseling on informed choice and method specific counselling, when client chooses a method by volunteers in front of the large group, followed by discussion (Each small group will pick chit (lottery) on FP method, on which they have to be prepared for demonstration of method specific counselling in front of large group) Return demonstration by different small groups on counselling on oral pills (POP/Centchroman/COCs); IUCD; Female and male sterilization) 3:15 ‐3.30 Tea time 3:30 ‐ 4.00 30 Min 20. Orientation to Counsellors Roles and Responsibilities, performance standards for Sterilization Counselling 4.00‐ 4:30 30 Min 21. Introduction to Recording and Reporting Documents (Counselling register, Oral Pill register, IUCD registers (Interval and PPIUCD) ; Sterilization register) 4.30 ‐ 4.50 20 Min 22. Course Evaluation 4:50 ‐ 5.00 10 Min 23. Closing

COURSE EVALUATION FORM

(To be completed by Participants)

Please indicate your opinion of the course components using the following rate scale: 5-Strongly Agree 4-Agree 3-No Opinion 2-Disagree 1-Strongly Disagree

COURSE COMPONENT RATING

Did you find the training methods helpful for your learning?

The interactive training approach used in this course made it easier for me to learn

This training has enhanced my knowledge on key messages of FP methods like COCs, POPs , Centchroman, Inj MPA, IUCD, Condom, Female and Male sterilization

Training has helped me develop skills in counselling on FP, COCs, POPs,

Centchroman, Inj MPA, IUCD, Condom, Female and Male sterilization

Were counseling approach like GATHER and Balanced Counseling Strategy (BCS) helpful?

The role play sessions on counselling skills were helpful.

There was sufficient time scheduled for practicing counselling through role plays

Do you feel confident for counselling women on FP methods like COCs, POPs , Centchroman, Inj. MPA, IUCD, Condom, Female and Male sterilization and dispelling misconceptions about FP methods when you go back from the training?

ADDITIONAL COMMENTS

What topics (if any) should be added (and why) to improve the course?

What topics (if any) should be deleted (and why) to improve the course?

What should be done to improve how this course was delivered or managed?

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. DAY 1, MORNING 1. 30 mins  Introduction of Participants  Open the course with a word of welcome by organizers,  PowerPoint presentation of session 1 (10:00-10:30)  Participants’ Expectations, lead trainers, etc.  Flipchart and markers Group Norms  Facilitate introduction of all the participants and trainers as suggested in PowerPoint slides.  Explore participants’ expectations for the course by brain storming and write them on flip chart.  Brainstorm on the norms to be followed with the help of participants 2. 30 mins  Discuss the course goals & objectives with the help of  PowerPoint presentation on course (10:30-11:00)  Course Goal and slides; Review which expectations of the participants can goal and objectives (session 2) Objectives, be met and which cannot be.  Copies of training agenda for  Review of the Course  Review the course agenda, including starting and ending participants Agenda, Components of times and times for breaks and lunch  Participant folder for each participant the Training Package and  Review the materials to be used in the course and those to containing full set of the training Course Materials given to be given to the participants. Ensure that participants package: Participants understand the use of the different materials. - Handbook on RMNCH counsellors (Counselling & FP sections or the whole book) - Handouts of power point presentations for all sessions - Job-aids 3. 20 mins  Pre-course knowledge  Distribute the Pre-Test questionnaire to each participant.  Copies of Pre-Test questionnaire (one (11:00-11:20) assessment  Assign a number to each participant and ask them to write for each participant) the number on the Pre-Test sheet and remember the  Slips of paper with assigned numbers number till the end of the training. Ask them to answer  One copy of answer key to Pre-Test each question. Allow 15 minutes for the Pre-Test questionnaire sheet for each trainer. questionnaire. 10 mins Tea Break (11:20-11:30)

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 4. 30 mins  Benefits of Family  Use the power point slides to present information on  PowerPoint presentation on the topic (11:30-12:00) Planning, Healthy timing benefits of family planning, risks if FP not practiced. and spacing of  Ask questions to the participants and engage them in the pregnancies (HTSP) & discussion on the updated information. Importance of  Use the power point slides to present information on Postpartum Family impact of pregnancy spacing on maternal, newborn and Planning child health and  Facilitate an interactive discussion on importance of postpartum family planning

5. 60 mins  Technical overview of  Use the power point slides to present information on each  Power point slides on technical (12:00-1:00) Family planning methods contraceptive and discuss mechanism of action, safety, overview of FP methods  Technical update on effectiveness, client assessment, side effects, warning  Handouts of key characteristics spacing methods signs and follow up - Lactational Amenorrhea  Introduce the participants with MEC wheel and its use for Method (LAM) evaluation of clients for various contraceptive methods - Combined Oral Contraceptive Pills (COCs) - Progestin only Pills (POPs) - Centchroman (Ormeloxifene) - Copper IUCD - Injection MPA - Condoms - ECP 45 min Lunch Break (1:00-1:45)

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 6. 30 min  Technical update on  Use the power point slides to discuss mechanism of  PowerPoint presentation on male and (1:45-2:15) limiting methods action, safety, effectiveness, case selection and client female sterilization - Female sterilization assessment, advantages, disadvantages and limitations  Flip chart for interactive session and of male and female sterilization - Male sterilization  Ask questions to the participants and engage them in the presentation of the information. 7. 30 mins  Exercise on Time of  Use the power point slides to present information on the  PowerPoint presentation (2:15-2:45) initiation of various methods timing of initiation of different FP methods in the  Job aid on initiation of various after childbirth and postpartum period. And facilitate the exercise on time of methods after child birth and abortions. initiation in order to assess participants understanding on abortions correct time of initiation, followed by discussion  Prepare the chart from slide -3 on A- 3 paper (6 copies for group exercise) 8. 45 mins  Family Planning (FP)  Use power point presentations on FP/ PPFP counseling  Power point presentation and flip (2:45-3:30) Counseling Approach & with a focus on GATHER approach and Balanced chart for discussion on PPFP Communication Skills Counselling Strategy (BCS) counseling  Ask questions to the participants and engage them during the presentation of the information 15 min TEA BREAK (3:30-3:45) 9. 30 min  Introduction of counselling  Participants to go through each step of the checklist by Counselling checklists (3:45-4:15) checklists (FP General reading and familiarizing themselves with FP general  FP General Counselling checklist, counselling checklist, counselling checklist and how to use FP method specific  FP Method specific counselling method specific counselling checklist for all the contraceptives checklists (applicable for all) counselling checklists)

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 10. 30 min  Demonstration of FP  Demonstrate a role play on counselling with method  Copies of counselling role- plays and (4:15-4:45) Counselling Skills on specific counselling for different contraceptives case studies informed choice and  Project role play situation on FP counselling. Trainers or  Counselling checklists (General and method specific volunteers will enact in front of all the participants. Let one method specific) counselling, when client participant be the counselor, another be the client, and chooses a method; by third one be the client’s attendant. Remaining participants trainers, followed by and trainer to observe the role play through checklist and discussion after the role play, facilitate discussion about what was done well, what was not done and what could have been done differently.  Ask participants to observe the role-play using counseling checklist to assess if the counseling approach and technical information discussed in the role plays are as per standard.  Discussion should follow on what went well and what have the scope for further improvement. 11. 15 min  Wrap up of the day  Review and recap day’s activities  Counselling checklists (General and (4:45-5:00)  Home assignments:  The facilitator should ask the participants to share their method specific)  Preparation for mid- learning with everyone on that day. course test  Give participants the assignment for reviewing at home  Going though counselling checklists thoroughly

DAY-2 MORNING 12. 40 mins  Warm up  Have a warm-up activity to ensure that the participants are  Agenda of the day 2 on a flipchart (10:00-10:40)  Recap of Day 1 and review ready to learn and you have created a positive learning of agenda of Day 2 environment.

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No.  Responding to queries  Recap previous day’s learning by playing passing the and concerns of parcel game. When music stops, the participant holding participants on technical the ball will pick up one chit containing a question from information on FP Day 1’s learning. The participant will answer the question. methods and counselling If he or she does not give correct response, the question skill will be open for any participant who volunteers to give response to the question. 13. 20 mins  USAID FP Compliance Use PowerPoint slides to share information on USAID FP  Power Point presentation on USAID (10:40-11:00) Compliance with focus on Voluntarism ( right to choose/or FP Compliance not to, no denial right of clients based on refusal to accept FP services) No targets and incentives for providers, informed consent in local language for FP services and written consent for sterilization services 14. 30 min  Eligibility Criteria and  Use PowerPoint slides to share information on eligibility  Power Point presentation on eligibility (11:00-11:30) Informed Consent for criteria for clients criteria Sterilization  Participants to be shown consent form to reinforce this  Copy of consent form important information  MEC Wheel  Lead a discussion about who all are required to sign on the consent form, what steps must be taken before the client signs the consent form 15 mins TEA BREAK (11:30-11:45)

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 15. 30 min Mid-course knowledge  Make copies of the mid-course questionnaire and give  Copies of the mid-course (11:45-12:15) assessment each participant a copy. questionnaire(one per participant )  Ask participants to put the numbers they were allotted on  Mid-course questionnaire Answer day 1 for the pre-course questionnaire on the first page. Key  The trainer(s) should score the questionnaire during break  Mark the score on the top and return the questionnaire to the participants after preparing Post-Test knowledge Matrix  Answers should be reviewed with the entire group.

16. 30 min  Understanding and Use of  Tell participants, how to use FP counselling Flip Book:  FP counseling Flip Book (12:15-12:45) FP counseling Flip Book how to use the Flip Book. Mark the section with sticky and  FP Kit; and FP Kit; ask participants to open their flip books and get familiarize  General counseling checklist  Setting up counselling with each sections  Method specific checklist corner for maintaining  Use FP kit to show samples of contraceptives to the client privacy for providing information and helping the client to choose (Informed Choice)  Discuss requirements of counselling corner and its location to allow a smooth flow of clients in the OPD. 17. 30 min  Practice of FP  Divide the participants in to small groups (of 3). Give each  Copies of role-play scenarios (12:45-1:15) Counseling Skills through group all Role play situations on FP counselling. Get  Counselling checklists (General and role-play on informed volunteers to enact in front of all the participants. Let them method specific) choice and method practice each situation in a group. By rotation they can specific counselling, once enact like counsellor, client and observer. Observer will client chooses a method, share what was good and what was missed during the in small groups counselling practical  Trainers will circulate between the groups and observe them and help them with using the counseling checklist to ensure that the counseling approach and technical information discussed in the role plays are accurate.

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 30 min LUNCH BREAK (1:15-1:4 5)

Day 2 Afternoon

18. 30  Practice of  Divide the participants in to small groups (of 3). Give each  Copies of Case study Min Counselling through group all Role play situations on FP counselling. Get  Counselling checklists (General and (1:45-2:15) Role- Play using volunteers to enact in front of all the participants. Let them method specific) checklist in small practice each situation in a group. By rotation they can groups by enact like counsellor, client and observer. Observer will participants (groups share what was good and what was missed during the of 3 participants) counselling practice.  Trainers will circulate between the groups and observe them and help them with using the counseling checklist to ensure that the counseling approach and technical information discussed in the role plays are accurate. 19. 60 min  Return (Each small group will pick up chit (lottery) on FP method, on  Copies of role-play scenarios (2:15-3:15) Demonstration of which they have to be prepared for demonstration of method  Counselling checklists (General and counseling on specific counselling in front of the larger group) method specific) informed choice and Return demonstration by different small groups on counselling method specific on oral pills (POP/Centchroman/COC); IUCD; injection MPA, counselling, once Female and male sterilization) client chooses a method, by volunteers in front of the larger group, followed by discussion

15 min Tea time (3:15-3:30)

FP COUNSELLING TRAINING-MCSP Course Outline (2 days), 10 am-5 pm

Session TIME TOPICS/ACTIVITIES TRAINING/LEARNING METHODS RESOURCES/MATERIALS No. 20. 30 mins  Orientation to Counsellors  Use power point presentation for sharing the information  Power point slides on role of (3:30-4:00) Roles and Responsibilities, with the participants on Performance Standards for counsellors and Performance Standards for counselling on sterilization  Performance standards for Counselling on Sterilization sterilization services with highlighted standards related with counselling 21. 30 min  Discuss data collection and record maintenance  Power point slides (4:00-4:30)  Introduction to Recording  Share the sample of records  Samples of Client Card and and Reporting Documents  Discuss how to fill them and prepare report in the record/register (Counselling register, Oral prescribed format Pill register, IUCD registers  Discuss key aspects of procurement and supply chain (Interval and PPIUCD); mechanisms for contraceptives Injection MPA register, Sterilization register) 22. 20 min  Course Evaluation  Explain that feedback of participants on the course content  Copies of course evaluation forms (4:30-4:50) and delivery is very important as it will help in improving (One per participant) quality of future training on FP counselling.  Make the participants fill and submit the course evaluation form

23. 10 min  Closing & certificate  Closing remarks by training organizers/trainers and  Signed certificates (4:50-5:00) distribution distribution of certificates

PRE/POST COURSE KNOWLEDGE ASSESSMENT FOR PARTICIPANTS

Name: Date:

Roll No.:

Each question has only one correct answer. Please circle the most appropriate answer out of the options given.

1. For good health of the mother and the child, how many years a couple should wait for, before attempting another pregnancy following last child birth? a) One year b) Two years c) Five years d) No time limit

2. Who should decide the contraceptive that a client should use? a) The Health Care Provider b) The Client c) The counselor d) Husband/Partner

3. During postpartum FP (PPFP) counseling, a counselor should do which of the following? a) To know if the couple plans to have more children in the future b) To inform client about healthy spacing of pregnancy c) To discuss appropriate methods a woman can use after delivery d) To answer any questions, client may have about PPFP e) All of the above

4. Which of the following is a non-verbal communication? a) Using simple language, which the client can understand b) Facial expressions which show interest and concern c) Listening what client says and answer those questions clearly d) Asking client to repeat the important information

5. Informed choice is required for which of the following methods? a) Combined Oral Contraceptive Pills (Mala-N) b) Female sterilization c) Progestin Only Pills (POP) d) Injection MPA e) All of the above

6. Which of the following defines Lactational Amenorrhea Method (LAM)? a) Mother is giving both breast milk and top feed, is menstruating and baby is 4 months old b) Mother’s menses have not yet returned, only breastfeeds her baby, and baby is less than six months c) Mother is only breastfeeding her baby, who is seven months old and she has not started her menses d) Breast feeding and LAM are same

7. Which of the following family planning method/s can be used immediately after delivery by breastfeeding women? a) IUCD and Lactational Amenorrhea Method b) Progestin only pills (POP) and Centchroman c) Combined oral contraceptive pill (Mala-N) d) Both a) and b)

8. The method specific information about the IUCD should include: a) Effectiveness, how does it work and for how long it prevents pregnancy b) Common side effects and RARE danger signs c) The IUCD can be removed at any time by a trained provider d) All of the above

9. Which of the following is true about IUCD? a) Is effective after seven days of insertion b) Can be used as an emergency contraceptive c) Can be used by postpartum women up to 7 days d) All of the above

10. When can an IUCD be inserted in the postpartum period? a) After 48 hours of delivery b) Immediately after delivery up to 48 hours c) Immediately after delivery up to 1 week of postpartum d) Only after 6 weeks of delivery

11. When can a breastfeeding woman start Combined Oral Contraceptive Pills (Mala N)? a) Immediately after delivery b) Any time 6 months after delivery c) Can start only after stopping breastfeeding d) 3 months after delivery

12. How to start Centchroman? a) Once a week b) Twice a week c) Twice a week for 12 weeks followed by once a week from the 13th week onwards d) Once a week for 12 weeks followed by twice a week for from the 13th week onwards

13. Which is NOT true for ECPs? a) It is known as ‘Morning after Pill’ b) It is known as ‘Post-coital pill’ c) It is taken within 72 hours of unprotected intercourse d) It can be used as regular contraceptive

14. Progestin Only Pills (POP) should NOT be given to women who: a) Have breast cancer b) Are breastfeeding c) Are having regular menstrual cycles d) Are unmarried

15. Which of the following is true for Combined Oral Contraceptive Pills (Mala N)? a) Regularizes menstrual periods b) Reduces risk of anaemia c) Reduces menstrual cramps during menstrual periods d) All of the above

16. Which of the following should be done if menses stop after taking inj. MPA? a) Discontinuation of injection MPA b) Ruling out pregnancy and reassuring client c) Switching over to another method d) All of the above

17. What are the common side effect/s of inj. MPA? a) Scanty period followed by cessation of menstrual periods b) Diarrhea c) Hair loss d) None of the above

18. Which of the following is true about condom? a) It provides protection from sexually transmitted infections (STIs) including HIV b) Correct and consistent use will increase its effectiveness c) It can also be used as back up method d) All of the above

19. Which of the following is true for male sterilization? a) Immediately effective after surgery b) Needs hospitalization for 1 day c) Another contraceptive as backup method to be used for 3-6 months d) Protects from STI and HIV

20. Which of the following clients can opt for female sterilization? a) Who have two children, and client is 19 years old b) Who is not sure whether she wants more children c) Who delivered 1 day ago but baby’s condition is not good d) Who wants to use a highly effective permanent method e) All of the above

PRE/POST COURSE KNOWLEDGE ASSESSMENT FOR PARTICIPANTS Answer Key

Name: Date:

Roll No.:

Each question has only one correct answer. Please circle the most appropriate answer out of the options given.

2. Who should decide the contraceptive that a client should use? a) The Health Care Provider b) The Client c) The counselor d) Husband/Partner

14. Progestin Only Pills (POP) should NOT be given to women who: a) Have breast cancer b) Are breastfeeding c) Are having regular menstrual cycles d) Are unmarried

17. What are the common side effect/s of inj. MPA? a) Scanty period followed by cessation of menstrual periods b) Diarrhea c) Hair loss d) None of the above

Welcome to 2 Days Training Workshop on Family Planning Counseling

Session 1 Know Each Other

• Participants will interact in pairs for 5 minutes • Ask your partner: - Name - Worksite - One expectation from the training • Introduce your partner to the large group by stating the above 3 points about him/her

2 Let us make some group norms for 2 days training workshop

3 Course Goal and Objectives

Session 2 Goal of Training Workshop

Build the competency of health providers for counselling women and couple on family planning to help clients choose and use contraceptive methods that suit them

2 Objectives of the Training Workshop

Participants will- • Demonstrate quality counselling on postpartum, interval and post-abortion family planning based on updated knowledge and skills • Specify steps of GATHER approach and Balanced Counselling Strategy (BCS) • Discuss the importance of informed choice and consent in selection of FP method • Describe method specific counselling for each FP method including new ones like Inj. MPA, POPs and Centchroman

3 Benefits of FP; Healthy Timing and Spacing of Pregnancy; Importance of Postpartum Family Planning

Session 4 Learning Objectives

• Recollect benefits of family planning (FP) for mothers and newborns • Define HTSP and how to achieve spacing between pregnancies • Understand the rationale and importance of family planning during postpartum period • Identify existing services for pregnant and postpartum women into which postpartum FP (PPFP) education and counseling can be integrated

2 Renewed Thrust of Family planning Program

MATERNAL POPULATION HEALTH CHILD HEALTH STABLIZATION

3 Benefits of FP for Mothers

• Reduced risk of complications associated with pregnancies • Will have more time to take care for her baby • Will breastfeed longer. Longer duration of breastfeeding is linked to reduced risk of breast and ovarian cancer • May be more rested and well nourished so as to support the next healthy pregnancy • May have more time for herself, children and family • More time to prepare for next pregnancy

4 Risks for Mothers if FP is Not Practiced

• Increased risk of pregnancy complications • Increased risk of miscarriage • More likely to induce abortion • At greater risk of maternal death

5 Benefits for the Newborn Child

• More likely to be born strong and healthy • Breastfed for a longer period, so health and nutritional benefits • Enhanced mother-baby bonding by breastfeeding, facilitating child’s overall development • Mothers are better able to meet the needs of their newborns

6 Risks for Newborns if FP is Not Practiced

• Newborn and infant mortality is higher • Greater chance of pre-term, low birth weight baby or baby small for its gestational age • If breastfeeding is stopped before 6 months: the newborn does not experience the health and nutritional benefits of breast milk diminished mother-baby bonding affecting baby’s development

7 Healthy Timing & Spacing of Pregnancy

Key Messages: • Delay the first pregnancy • For spacing after a live birth: The recommended interval before attempting the next pregnancy is at least 24 months (Minimum time between 2 successive childbirths = 3 years) • For pregnancy after an abortion: The recommended interval before attempting the next pregnancy is at least 6 months

8 When can a woman become pregnant again after her delivery?

A woman can become pregnant before her menses return after delivery

9 Importance of Postpartum and Post-abortion Family Planning

• High unmet need for family planning in postpartum period • Women are most receptive in postpartum and post- abortion periods • Women come in contact with the health facilities and providers • Inadequate spacing after childbirth or after abortion result in poor maternal and newborn health outcomes

10 Opportunities to Provide PPFP Information to Pregnant and New Mothers

• During antenatal period (ANC check ups) • During hospital admission before delivery/Cesarean section • During immediate postpartum (hospital stay before 48 hours after delivery) • During postnatal care contacts (after 6 weeks) • Child health contacts during the 1st year/immunization session

11 Technical Overview of FP Methods

Session 5 FP Methods

For delaying the first For healthy spacing between For limiting future child two childbirths pregnancies • Condoms • Condoms • Female sterilization • COCs, POPs, • COCs, POPs, • Male sterilization/ Centchroman Centchroman Vasectomy • IUCD • IUCD • IUCD (after • Inj. MPA • Inj. MPA completing the total • EC Pills (Not to be • LAM (Needs to be duration, the old used as a regular followed up by any other IUCD should be method) method, before replaced by a new completing 6 months one) after childbirth)

2 Contraceptive Methods

Spacing Limiting

3 Spacing Methods

Existing methods in Newer methods in public sectors: public sectors:  IUCDs  Progestin-only-pills (POPs)  Lactational Amenorrhea Method  Centchroman (Chhaya) (LAM)  Injection MPA (Antara Program)  Combined Oral Contraceptives (COCs)  Condom  Emergency Contraceptive Pill (ECP)

4 • To understand how various contraceptives work, it is important to know about:

- Menstruation - How reproduction happens

5 Menstruation

6 Menstruation

• Duration of bleeding: 3-5 days • Bleeding recurs after: 21-35 days • Flow: Without clots • In a regular 28-day menstrual cycle the mid 10 days (10th- 20th day) of the cycle are fertile period during which pregnancy can occur, the first day being the day when the bleeding starts • A woman can become pregnant from the age of 12-13 (when her periods begin, which is called menarche), up to 45-55 years, (when they ultimately stop). When they stop, it is called menopause

7 How Reproduction Occurs

• All female produce “egg” and male produce “sperms” which unite inside the womb of the woman and produce a foetus. This grows into a baby • A woman’s egg has X chromosome and a man’s sperm has either X or Y chromosome (which we may call girl sperm or boy sperm respectively) • If X chromosome of egg meets with X chromosome of sperm – Results in a girl child • If X chromosome of egg meets with Y chromosome of sperm – Results in a boy child

8 Checklist to be Reasonably Sure a Woman is NOT Pregnant (Important to rule out pregnancy before initiating a contraceptive)

Ask these 6 questions: 1. Ask for the following 3 criteria for LAM (All 3 must be met) • The baby is less than 6 months old • Menstrual period has not returned after last childbirth • The baby is fully or nearly fully breastfed, fed often, day and night at least 8-10 times a day, at least once in 4 hours, and at least once at night (at least 85% of feeding should be breast milk). 2. Have you abstained from sexual intercourse since your last monthly bleeding or delivery? 3. Have you had a baby in the last 4 weeks? 4. Did the first day of your monthly bleeding start within the past 7 days (or within the past 12 days if the client is planning to use an IUD)? 5. Have you had a miscarriage or abortion in the past 7 days? (or within the past 12 days if the client is planning to use an IUD)? 6. Have you been using a reliable contraceptive method consistently and correctly?

9 Checklist to be Reasonably Sure a Woman is NOT Pregnant

IF CLIENT ANSWERS THEN If the client answered “Ye s ” to You can give her the method she has at least one of the questions, chosen. and she has no signs or symptoms of pregnancy If the client answered “No” to Pregnancy cannot be ruled out. The all questions client should wait for her next monthly bleeding or do a Urine Pregnancy Test for Confirmation.

10 Comparing Effectiveness of Family Planning Methods

11 Safe Time for Initiation of Various FP Methods

12 1. IUCD

Two Types: • Copper 380 A (For use up to 10 years) • Copper 375 (For use up to 5 years)

Can be inserted in a woman immediately after childbirth up to 48 hours of delivery or after 6 weeks of childbirth How it prevents Prevents fertilization of ovum by sperms pregnancy Advantages • Very effective method (like limiting methods) • No activity needed by woman after insertion • Effective immediately after insertion and immediate return of fertility after removal (reversible) • No effect on breastfeeding • Used as both long term and short term

13 1. IUCD (Contd)

Limitations & • Possibility of minor side effects which decrease after Side effects initial few months and are not harmful: - Longer and heavier menstrual periods - Bleeding or spotting between periods - More cramps or pain during periods • Does not protect against STIs and HIV • Requires a trained health care provider to insert and remove the IUCD • May be expelled spontaneously, in a few cases

14 1. IUCD (Contd)

Who can • Have just had a delivery or an abortion (if no evidence of infection) use the • Are breastfeeding method • Have or had breast cancer • Have headaches • Have high blood pressure (>140/90 mm hg), diabetes, liver or gall bladder disease, epilepsy, non-pelvic tuberculosis • Are HIV positive and/or have AIDS who are clinically well Who • Pregnancy • Pelvic infections cannot use • Current or high risk for • 48 hours to less than 6 weeks postpartum the method infections in genital organs • Malignant trophoblastic disease • Women with AIDS who are For PPIUCD: not clinically well • Puerperal sepsis • Immediately after a septic • Prolonged rupture of membranes for more abortion than 18 hours • Pelvic tuberculosis • Unresolved postpartum haemorrhage • Distorted uterine cavity • Substantial genital trauma • Unexplained vaginal bleeding • Genital tract cancer

15 1. IUCD (Contd)

Warning signs Needs to come back to the facility soon if any of the following signs in IUCD clients develop: P: Period related problems or absence of periods and/or pregnancy symptoms A: Abdominal pain or pain during intercourse I: Foul smelling/unusual vaginal discharge N: Not feeling well, fever, chills S: String problems or expulsion of IUCD

Time for first Routine follow up for interval IUCD – after 1 month/after next follow-up menses Routine follow up for PPIUCD – after 6 weeks of childbirth

16 Misconceptions about IUCD

• Thread can trap the penis during intercourse - Wrong • A woman with IUCD cannot do heavy work - Wrong • The IUCD might travel inside a woman’s body to her heart or her brain - Wrong • Causes pregnancy outside the uterus - Wrong • Causes cancer or rotting of the uterus - Wrong

17 2. Inj MPA (Medroxy Progesterone Acetate)

Two Types: • Intramuscular Inj MPA (One dose = one vial of 150 mg/1 ml) • Subcutaneous Inj MPA (One dose =104 mg/0.65 ml)

 Injection is given once in 3 months or 13 weeks (Can also be given up to 4 weeks late or 2 weeks early from the scheduled date)  Can be initiated in a woman after 6 weeks of childbirth How it prevents Prevents release of eggs from ovary pregnancy Advantages • Highly effective and reversible method (fertility returns 7-10 months after last injection) • Suitable for breast feeding women (after 6 weeks postpartum) • Protects against cancer of lining of uterus (endometrial cancer), uterine fibroids, may protect against iron deficiency anemia

18 2. Inj MPA (Contd)

Limitations & • Does not protect against STI/RTI and HIV infection Side effects • Once taken its action cannot be stopped immediately • Causes changes in the menstrual cycle and bleeding • Has to be repeated every three months to achieve desired contraceptive effectiveness • Return of fertility takes 7-10 months from date of last injection (Average 4-6 months after 3 month effectivity of last injection is over) • Decreases bone density, but users are not likely to have fractures. After stopping Inj MPA, bone density increases again

19 2. Inj MPA (Contd)

Who can • Have or have not had children; Are not married; Are of any age use the • Have just had an abortion or miscarriage method • Are breastfeeding (Inj can be started from 6 weeks after childbirth) • Smokers • Infected with HIV, whether or not on ARV therapy Who • Women breastfeeding infant • Current or past history of cannot use less than 6 weeks Breast Cancer the method • Unexplained vaginal bleeding • Current or history of Ischemic • High blood pressure (160/100 Heart Disease or more) • Diabetes with for more than 20 • Severe cirrhosis, liver tumors years or with complications in (benign or malignant) arteries, vision, kidneys, nervous • Migraine with aura at any age system • H/o stroke, blood clot in your legs or lungs, heart attack. Or other serious heart problems

20 2. Inj MPA (Contd)

Giving advice Thorough counselling about bleeding changes should be done on side effects before giving injection. Also, counselling about bleeding changes may be the most important help a client needs to keep using the method

Describe the • Lighter and fewer days of bleeding most common • Weight gain, headache, dizziness, breast tenderness side effects Explain about • Side effects are not harmful side effects • Usually becomes less or stop within first few months of injection • Client can come back any time, if side effects bother her

21 3. Lactational Amenorrhea Method (LAM)

Criteria for LAM: 1. Baby is being only breastfed • The baby is not receiving any other solid food or liquids; only breast milk • Breastfeeding on demand - Gap between two consecutive feeds is not more than 4 hours during day and 6 hours during night 2. Menstruation has not returned since the birth of the child 3. Baby is less than 6 months old

22 Oral Contraceptives

Hormonal Non-hormonal

Combined Oral Contraceptives Centchroman (Ormeloxifene) (COC)

Progestin Only Pill (POP)

Levonorgestrel Emergency Contraceptive Pill (ECP)

23 4. Combined Oral Contraceptives (COCs)- Mala-N

• Available in public sector as free and ASHA supply (Mala-N) • Each of the white 21 hormonal tablets contain Levonorgestrel (0.15mg) and Ethinyl Estradiol (.03 mg) • There are 7 black tablets containing 60 mg of Ferrous Fumarate

24 4. COCs (Mala-N) contd..

1. One pill to be taken daily 2. Missed pills or delay in starting packet can result in pregnancy if guidelines not followed 3. Can be started soon after abortion or 6 months after delivery in breast feeding women 4. Side effects like giddiness, nausea, breast tenderness 5. Makes menstrual cycle regular and reduces bleeding/pain and improves anemia

25 4. COCs (Mala-N) contd..

• Works primarily by preventing release of eggs from ovaries • Safe and Effective • Can be started any time if it is reasonably certain that she is not pregnant (Use pregnancy checklist) • Should not be given to breastfeeding women till 6 months postpartum

26 4. COCs (Mala-N) contd..

Non • Protection against endometrial and ovarian cancer, contraceptive • Protection against iron deficiency anemia, ovarian cysts benefits CoCs are not • Breastfeeding <6 months • With high BP appropriate postpartum • With breast cancer for women • With suspected • With DVT pregnancy • With heart disease • Who smoke >15 • With recurrent migraine cigarettes/day and ≥ 35 • On anticonvulsants years of age • With liver disease

27 4. Management of Missed Pills (COCs)

Missed pills How to manage Missed 1 or 2 pills/ • Take one hormonal pill as soon as possible or two pills started new pack 1 or at scheduled time 2 days late? Missed 3 or more • Take one hormonal pill as soon as possible and pills in the first or continue the scheduled pills second week/started • Use a backup method for the next 7 days new pack 3 or more • Also can consider taking ECPs, if she had sex in the days late? past 72 hours. Missed 3 or more • Take one hormonal pill as soon as possible and finish pills in the third all hormonal pills in the pack as scheduled. Throw away week? the 7 non-hormonal pills in a 28-pill pack. • Start a new pack the next day

28 5. Progestin-only- Pills (POPs)

• Contain very low dose of a synthetic hormone known as progestin (like natural hormone Progesterone) • All 28 pills in a packet are hormone tablets (either Levonorgestrel or Desogestrel) • One pill to be taken every day at the same time without any break • These are safe for breastfeeding women and can be started earlier than 6 weeks postpartum (MEC 2015)

Can be given to women after childbirth

29 5. Progestin-only- Pills (POPs) Contd..

• More effective along with breast feeding than when taken after breast feeding stops • Bleeding changes are common but not harmful • Decreases risk of ectopic pregnancy • Can be taken any time if it is reasonably certain that she is not pregnant (Use pregnancy checklist) • New pack to be started on the next day at the same time as starting a pack late risks pregnancy • No delay in return of fertility after POPs are stopped

30 5. POPs (Contd)…..

How POPs work • Thickening cervical mucus (this blocks sperm from meeting an egg) • Preventing the release of eggs from the ovaries (ovulation)

Common side effects of POPs: • Irregular bleeding/amenorrhea • Nausea, headache, dizziness • Breast tenderness • Occasional ovarian follicular enlargement

31 5. How to Use POPs?

• One pill to be taken every day and at same time until the packet is empty • Linking pill intake to a daily activity may help her remember to take the pill daily and reduce some side effects • When she finishes one pack, first pill from the next pack should be taken on the very next day at the same time

32 5. Conditions where POPs should be avoided

• Treatment with anticonvulsants or rifampicin • History of breast cancer • Deep vein thrombosis or Pulmonary embolism • Liver cirrhosis • Suspected pregnancy

33 5. POPs (Contd)…..

• What are the limitations and side effects of POPs?

Side-Effects: Limitations: • Changes in bleeding patterns – • Effectiveness decreases when irregular/prolonged/no bleeding breastfeeding stops • Do not protect against STIs/HIVs • Postpartum amenorrhea may be prolonged in breastfeeding women • In some women – headache, dizziness, mood changes, breast tenderness

34 5. Management of Missed Pills (POPs)

1. Three or more hours late taking a pill or misses one completely • Take a pill as soon as possible. • Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the same day) 2. If she has monthly bleeding • A backup method should be used for the next 2 days • Also, can consider taking ECPs, if she had sex in the past 72 hours 3. If she has vomiting or diarrhoea • If she vomits within 2 hours after taking a pill, she should take another pill from the pack as soon as possible and continue with the schedule pill as usual. • If her vomiting or diarrhoea continues, follow the instructions for missed pills above

35 Oral Contraceptives

Hormonal Non-hormonal

Combined Oral Contraceptives Centchroman (Ormeloxifene) (COC)

Progestin Only Pill (POP)

Levonorgestrel Emergency Contraceptive Pill (ECP)

36 6. Centchroman (Ormeloxifene)

• Non steroidal, non-hormonal and once-a week pill, which will be available in public sector as free and ASHA supply (Chhaya) • It has weak estrogenic action on bones but strong anti- estrogenic action on uterus, breasts • Safe for breast feeding mothers, even soon after childbirth

Can be given to women soon after childbirth

37 6. Centchroman (Ormeloxifene) Contd..

• Prolongation of menstruation cycle is the only side effect. It occurs in 8% cases usually in first 3 months • It makes the periods lighter and can help anemic women • Can be used safely in conditions where hormonal contraceptives are not advised • Decreases the risk of ectopic pregnancy • Return of fertility on stopping the drug is prompt

38 6. When to Start and How to Use Centchroman

• One pill (30 mg)is taken twice a week for first three months, followed by once a week thereafter • Starting from fourth month, the pill is to be taken once a week on the first pill day and should be continued on the weekly schedule regardless of her menstrual cycle

• For initiation: 1st pill is to If 1st day of First 3 months After 3 st pill is months be taken on 1 day of Sunday Sun, Wed Sun st period (1 day of bleeding) Monday Mon, Thu Mon and the 2nd pill 3 days later Tu e s d ay Tu e , F ri Tu e Wednesday Wed, Sat Wed

39 6. Centchroman (Contd)….

• Major advantages of Centchroman include that they:  Are highly effective if taken correctly  Can be given after childbirth. Safe in breastfeeding women  Decreases the risk of ectopic pregnancy • Centchroman are not appropriate for the following women:

. Polycystic ovarian disease . Severe allergic state . Cervical hyperplasia . Chronic illness, like tuberculosis or renal disease . Recent history of jaundice or liver disease

40 6. Centchroman: Managing Missed Pills

. Take a pill as soon as possible after it is missed . If pill is missed by lesser than 7 days, take the missed pill ASAP and normal schedule to be continued; and a back-up method (condom) to be used till the next period starts . If pill is missed by more than 7 days, client needs to start taking it all over again like a new user i.e. twice a week for 3 months and then once a week . if periods are delayed by more than 15 days, pregnancy needs to be ruled out

41 7. Emergency Contraceptive Pill (ECP)

• To be used within 72 hours of unprotected sex (accidental sex or contraceptive accident like condom rupture or missed pills) • Sooner it is taken, more effective • Safe for all women even for those who cannot use regular hormonal contraceptives, no known health risks • Not appropriate as a regular contraceptive method due to less effective than other contraceptives, chances of menstrual irregularities • In national program, EC pill contains only progestin - Levonorgestrel (1.5 mg per tab) and available as free and ASHA supply (ezy-pill)

42 7. Emergency Contraceptive Pill (ECP) Contd….

• Do not disrupt an existing pregnancy • Provides an opportunity for women to start using a regular contraceptive method

How to Use ECP? • To be taken immediately after unprotected/accidental intercourse or as soon as possible within next 3 days (72 hours)

43 7. How ECP Works?

• Works primarily by preventing or delaying release of eggs from ovaries (ovulation) • Does not work if woman is already pregnant

44 7. ECP: Side Effects

• Side effects like nausea, vomiting and bleeding irregularity Management of Side Effects • Nausea: Anti-nausea medication not recommended. If user had h/o nausea with previous use of ECP, client can take anti- emetic 1 or 1½ hour before taking ECP • Vomiting: If woman vomits within 2 hours of taking ECP, she should take another dose (can take anti-emetic with this repeat dose) • Slight bleeding irregularity: Subsides on it’s own

45 7. ECP: Important Counselling Points

• Counsel to choose a regular FP method • Most contraceptive methods can be started on the same day of ECP use • ECP does not protect from STI/HIV • ECP will not harm an existing pregnancy • Advise to return to health care provider, if her next monthly bleeding: - Is very light (possible pregnancy) - Period is delayed beyond one week of expected date - Is unusually painful (possible ectopic pregnancy)

46 8. Condom (Male)

• Available as free and ASHA supply • New condom required for each act of sexual intercourse • Correct use reduces chances of failure. If condom slips/ruptures, ECP can be taken • Only contraceptive providing protection against STIs and HIV • Cooperation of male partner required • No effect on breast milk • No hormonal side effects • Easy to keep stock handy, can be used by men of any age

47 Technical Overview of Limiting Methods of Family Planning

Session 6 Permanent Methods (Female and Male Sterilization)

• Female Sterilization (Minilap and Laparoscopic operation) • Male Sterilization (NSV and Conventional Vasectomy)

2 Limiting Methods of Family Planning

Limiting methods are for those women/couples, who do not want any more pregnancy, as they have completed the family. What methods can be used as limiting method ? • Female sterilization • Male sterilization/ Vasectomy • Long acting reversible method, like IUCD, can act as a limiting method (after completing the total duration of the method, the old IUCD should be replaced by a new one)

3 Female Sterilization

. Permanent method: A procedure for permanently stopping future pregnancy by occluding fallopian tubes. Reversal is difficult and may not be successful . Effectiveness: One of the most effective method. Failure occurs sometimes (5 per 1000 women) . Informed choice and written informed consent of client before the procedure are mandatory . Can be done within 7 days and after 6 weeks of delivery . Renewed focus on post-partum sterilization (PPS – within 7 days of delivery) due to increasing institutional deliveries

4 Female sterilization Contd..

How it prevents pregnancy? • Both fallopian tubes are blocked by ligating and cutting, so that the egg cannot travel beyond the blocked area and thus cannot be fertilized by sperm Two types: Minilap operation and Laparoscopic operation . Minilap –Tubes are cut or blocked after bringing them to the incision made in the abdomen: • PPS within 7 days of vaginal delivery or during cesarean section • Interval period (Anytime after 6 weeks of delivery) • Post-abortion (both after 1st and 2nd trimester abortions) . Laparoscopic –Tubal occlusion is done by a laparoscope introduced through a small incision in the abdomen: • Anytime after 6 weeks of delivery after ruling out pregnancy • Post-abortion (after1st trimester) 5 Female sterilization Contd..

Advantages Limitations • Highly effective method • Requires a physical examination and • Has no lasting side effects surgical procedure • No need to think about • Does not provide protection from contraception again sexually transmitted infections (STIs), including HIV • Does not affect sexual activity, menstruation or • Complications of surgery: Uncommon to breastfeeding extremely rare, but include: • Nothing to do or to - Adverse reactions to anesthesia remember by woman - Infection of the incision site - Bleeding in abdomen (from the cut fallopian tubes)

6 Eligibility of Client for Female Sterilization (GoI Guidelines)

Based on self declaration by the client: • Client should be ever-married • Woman should be above 22 years and below 49 years of age • Couple should have at least 1 child of above 1 year • Client or partner must not have undergone sterilization in the past • Client must be in a sound state of mind • Mentally ill clients, certified by a psychiatrist, needs to give legal guardian’s/spouse’s statement • Clinical screening (history, physical exam, lab tests) are needed to ascertain eligibility of client for procedure

7 Steps Before Procedure

• Ensure client should be eligible as per GOI’s guidelines • Pregnancy to be ruled out • Consent form to be filled up and woman’s signature/thumb impression to be taken • Woman should be fit medically • Woman should be fasting • Blood and urine test should be normal

8 Care after Operation

• Rest for the remaining day following surgery • Resume normal diet as soon as possible • Take medications as instructed • Keep the incision area clean and dry until stitches are removed • Have the dressing changed in case it becomes wet • Resume light work after 48 hours • Remember to have a follow-up visit on 7 day of surgery or as soon as possible after 7 days and bring client card

9 Don’ts after Female Sterilization

• Do not bathe for 24 hours following surgery • Do not allow the dressing to get wet while bathing • Do not disturb or open the dressing • Do not lift heavy objects for 1 week

10 Routine Follow-up after Female Sterilization

3 follow-ups: . 1st follow-up: With in 48 hours of surgery . 2nd follow-up: On 7th day of surgery . 3rd follow-up (At facility):  One month after surgery or after the next menstrual period (Certificate to be issued)  Client to be told to return to the facility if there is any missed period/suspected pregnancy, within two weeks to rule out pregnancy

11 Emergency Follow-up after Female Sterilization

To come to the hospital immediately if woman has any of the following complaints • Excessive pain in abdomen • Fainting or dizziness • Soakage of dressing • Fever or not feeling well • Unable to pass urine • Unable to pass gas or bloating of abdomen

12 Misconceptions about Female Sterilization

• Woman after sterilization loses desire for having sex- Wrong • Woman becomes sick and unable to do heavy work- Wrong • Need for hospitalization for few days- Wrong • Shortens the life span of woman and may cause early menopause- Wrong • Makes the woman fat or obese- Wrong

13 Male Sterilization/Vasectomy

. Permanent method and reversal difficult . Involves cutting or blocking the vas deferens, the tubes that carry sperms to penis . Ty p e s : 1) Conventional 2) No scalpel vasectomy (NSV)- No cut on the skin nor any skin stitch, after the procedure is completed . Can be done on men anytime under local anesthesia (Simpler operation than female sterilization)

14 Male Sterilization/Vasectomy Contd..

How it prevents pregnancy? • Tubes those carry the sperms (the vas deferens) will be cut so that sperms cannot pass through semen. So there will be no sperms during the ejaculation, which occurs after 3 months of operation Effectiveness: • Highly effective • Failure rate- 2 pregnancy in 1000 women in the first year

15 Male sterilization/Vasectomy Contd..

Advantages Limitations • Very effective method • Not effective immediately after • Simpler operation than female the procedure. Client has to sterilization use condom or wife to use another FP method for 3 • Usually takes 10-15 minutes months • Acceptor can walk back home • Does not protect against STIs within 30 minutes including HIV • Failure rate less than female sterilization • No major complication usually

16 Steps Before Procedure

• Man should be eligible as per GOI’s guidelines • Consent form to be filled up and man’s signature/thumb impression to be taken • Man should be fit medically • Blood and urine test should be normal • To have a light meal on day of surgery

17 Care after Vasectomy

• Return home and rest for the remaining day • Scrotal support or snug undergarment for 48 hours • Resume normal diet as soon as possible • The client may bathe after 24 hours, with the operated part of the body protected. • If the dressing becomes wet, it should be changed. After 48 hours, the dressing can be taken off. • Resume light work after 48 hours and return to full activity, including cycling, within one week following surgery

18 Follow-up after Vasectomy

Routine: • After 48 hours for check-up • On the 7th day for stitch removal (for conventional vasectomy) • After 3 months- return to the facility for semen examination. If no sperm- certificate is issued (If semen still shows sperm, return to facility every month till 6 months). Emergency: • excessive pain, fainting, fever, bleeding, increase in scrotal size, or pus discharge from the operated site. • As and when required

19 Misconceptions about Male Sterilization

• Vasectomy is same as castration (removal of testicles) - Wrong • Man will not enjoy sex or will not be able to perform sexual activity- Wrong • Man will become weak- Wrong • Scrotum will burst with sperms- Wrong

20 Sterilization related Incentives in Public Health Facilities

Type of Sterilization Total Acceptor ASHA/Motivator Surgeon in Rs in Rs in Rs Minilap Interval 2000 1400 200 150 Tubectomy PPS 3000 2200 300 250 Male Sterilization 2700 2000 300 250

21 Time of Initiation of Various Methods after Childbirth and Abortions 2 Time of Initiation of Different FP Methods after Delivery/Abortion

Breastfeeding Women Not Breast Feeding Post-Abortion Women Women Female Sterilization

Male Sterilization

IUCD

COP

POP

ECP

Inj. MPA

LAM

Condom

3 Counselling and Effective Communication

Session 8 What is Counselling?

Counselling is a two way communication between a health care worker and a client (or a couple) for the purpose of confirming or facilitating a decision by the client, or helping the client address problems or concerns

2 Think…

Think of a situation from your own life, when the counselling or a discussion with another person helped you to make a decision in life

3 Purpose of Family Planning Counselling

The purpose of family planning counseling is to help women and couples to choose family planning method according to their choice to prevent unwanted pregnancy. • Choose the best option for them from available contraceptive methods • Correctly use the chosen method • Continue use of chosen method

Clients who start method of their choice after complete information are satisfied clients and then the possibility of continuation of the method is high

4 Informed Choice and Informed Consent

Informed Choice Is a voluntary decision by woman/man/couple after complete and correct information about whether or not they want to use any/chosen contraceptive method

Informed Consent Is a consent given by woman/man/couple after complete and correct information to accept and use the chosen method or any procedure related to it’s use

5 Counselling: Key Components

• Mutual trust between client and counsellor • Provider shows respect for the client • Provider identifies and address client’s concerns, doubts and fears • Exchange of relevant, accurate and complete information between counsellor and client

6 Counselling: Tasks Involved

• Helping clients assess the needs • Providing information appropriate to clients’ identified problems and needs • Assisting clients in making their voluntary and informed decisions • Helping clients develop the skills they will need to carry out the decision

7 Verbal and Non-verbal Communications

• Verbal Communication- • Non-verbal Words & tone Communication- Actions, • Skills: gestures, behavior, facial expression - Active listening - Verbal encouragement • Positive Cues: - Positive tone of voice - Leaning towards client - Using simple language - Smiling, not showing - Giving feedback tension - Empathy - Facial expression showing interest, concern - Being non- judgemental - Maintaining eye contact - Nodding

8 6 Steps of Family Planning Counseling- GATHER

First step - G: Greet Second step - A: Ask Third step - T: Te l l Fourth step - H: Help Fifth step - E: Explain Sixth step - R: Return Visit

9 What is Balanced Counseling Strategy (BCS)?

Latest approach for a practical, interactive, client-friendly counseling for family planning

Why BCS? Providers can: • Discuss client’s reproductive goals • Give tailored information as per client’s need • Provide detail information on the chosen method

10 BCS-3 Stages

Pre Choice Stage

• Greet, Ask and Tell

Method Choice Stage

• Help and Explain

Post Choice Stage

• Return/follow up

11 How to counsel pregnant/delivered/post- abortion women on family planning?

12 Family Planning Counselling

• Start communication on family planning by asking a simple question to woman or couple- “when are you planning to have next child”? • If the answer is, they have not yet decided - Then, counsel on spacing pregnancies and its benefits • When they understand and say that we do not want a baby for few years - Then tell them, that to prevent unwanted pregnancy, they should use any reliable and effective contraceptive method - Tell woman/couple that whenever they want a baby or another family planning method, they can stop the chosen method

13 FP counselling based on BCS

Step-I: Pre-choice stage: If the couple has already decided to have the next baby after years and not early, then • Tell them- to prevent unwanted pregnancy and for good health of mother and baby, they should use a contraceptive method for at least 2 years after childbirth • Ask – If they have thought of using any contraceptive method? o If yes, find out what do they know about the method and provide correct information, remove myths/misconceptions, evaluate her eligibility for the method.

14 FP counselling based on BCS contd…

• If client has not thought about a particular method, ask following 4 questions and eliminate method/s according to client’s response: i. Do you want more children in the future? If yes, do not discuss male and female sterilization ii. Are you breastfeeding an infant of less than 6 months old? If yes, do not discuss combined oral contraceptive pills

15 FP counselling based on BCS contd… iii. Will your partner use condoms? If yes, discuss about condoms. Also assess woman’s risk for STIs and HIV and explain that condoms are the only method that can protect from STI and HIV iv. Did you have any problem tolerating an FP method in the past? If yes, ask which method. Do not discuss the method further if the problem experienced was really related to the method

This strategy will help client to choose a method that matches with her needs

16 FP counselling based on BCS contd…

Step-II: Method choice stage: Give detailed information of the chosen method like: . How does the method act . How effective is the method . What are its benefits . Does it affect breastfeeding or not . Does it protect from sexually transmitted infections . Common side effects of the method and their treatment . When to come for follow-up

17 FP counselling based on BCS contd…

Step III: Post-choice stage: • Ask the woman to repeat important information about her chosen method • Respond to her questions and concerns • Schedule the follow-up visit • Record relevant information

18 How to do Follow-up of Family Planning Clients

Follow-up counseling . Greet client and ask the purpose of visit . Encourage to continue the method if client has no concerns or problems . Repeat if client has forgotten any important information . Reassure client about side effects that these will get resolved on their own within a few months . Explain warning signs to client for early return to the provider/facility. . If IUCD was accepted, warning signs to look out for: P: Period related problems or pregnancy symptoms A: Abdominal pain or pain during intercourse I: Infections or unusual vaginal discharge N: Not feeling well, fever, chills S: String problems . If client wants to change the method, help her/couple to choose another method

19 FP and PPFP Counseling (BCS using GATHER approach)

• G-Greet: o Establish a supportive and trusting relationship with the woman o Allow the woman to express her ideas and listen to her o Engage the woman’s family members – Husband, Mother in law • A-Ask: o Explore understanding of client about spacing between two children o Ask the four questions to rule out method/s depending on client’s response:

20 FP and PPFP Counseling (BCS using GATHER approach) i. Do you want more children in the future? If yes, do not discuss male and female sterilization) ii. Are you breastfeeding an infant of less than 6 months old? If yes, do not discuss combined oral contraceptive pills) iii. Will your partner use condoms? If yes, discuss about condoms.Also, irrespective of client’s response, assess woman’s risk for STIs and HIV and explain that condoms are the only method that can protect from STI and HIV. iv. Did you have any problem tolerating an FP method in the past? If yes, ask which method. Do not discuss the method further if the problem experienced was really related to the method. 21 FP and PPFP Counseling (BCS using GATHER approach) contd.

T-Tell: Give following information to the woman/client: • Effectiveness of contraceptive methods • Expected actions from client • Need to remember • Chance of method failure • Permanence • Return to fertility • Common side effects and what to do • Other health benefits

22 FP and PPFP Counseling (BCS using GATHER approach) contd.

H-Help: • Provide additional information as per need • Answer any questions client might have • Help client choose a method E-Evaluate and Explain: • Evaluate client’s eligibility for the chosen method and proceed if eligible

23 FP and PPFP Counseling (BCS using GATHER approach) contd.

R- Return: Plan for next steps • If a method was chosen, provide information when to come back and record her choice • If no method was chosen, ask client to come back after a discussion with family members

24 USAID’s Requirements for Family Planning Compliance & Supreme Court Directives for Female Sterilization – An Overview

Session 13 Why compliance

• MCSP is a USAID funded program • Compliance is essential to maintain quality FP programs supported by US funds • MCSP is governed by certain statutory requirements of US Government

2 Applicability of USG Requirements

• The abortion restrictions apply to all US foreign assistance activities, even those unrelated to FP • The FP requirements only apply to FP activities

3 Voluntarism and Informed Choice

• USAID supports the freedom of individuals to choose voluntarily the number and spacing of their children. • Guiding principles: Voluntary - Decisions based on free choice and not obtained by any special inducements or forms of coercion Informed choice - Access to correct and complete information on family planning methods

4 Voluntarism and Informed Choice

• USAID’s family planning programs are guided by the principles of voluntarism and informed choice. Under these principles:

People have the opportunity to Individuals have access to choose voluntarily whether to information on available family use family planning methods at all planning methods, including and if so, a specific family planning benefits, side-effects and limitations method of their choice of particular method/s

A voluntary and informed Clients are offered, either consent in local language by the directly or through referral, a client is essential, and in case of broad range of methods and sterilization, it is in written form services and signed by the client

5 Statutory requirements applicable to MCSP

USAID/MCSP DOES NOT…

Allow any targets or Allow any for service quotas incentives/financial providers For Number of rewards to an individual in FP Users, Users of exchange for becoming an FP Particular FP Methods, acceptor or program or Total Number of Tiahrt personnel for achieving a Births Amendment numerical target

Allow denial of rights or benefits as a consequence of an individual’s decision not to accept FP

6 Statutory requirements applicable to MCSP Under USAID/MCSP

FP acceptors must receive comprehensible Tiahrt information on the health benefits and risks Amendment of the method chosen

Counseling should help in assisting a woman in making a choice whether or not she wants to opt Leahy for an FP method, and Amendment which method she wants to opt for

7 Statutory requirements applicable to MCSP USAID/MCSP DOES NOT…

Allow use of its funds to pay for the performance of abortion as a method of Helms family planning or to Amendment motivate or coerce any person to practice abortions

Allow use of its Siljander funds to lobby for Amendment or against abortion

Allow use of its funds for any biomedical Biden research related to Amendment abortion

8 Supreme Court Directives for Quality of Sterilization Services in India

9 Petitions on Female Sterilization in India

• Ramakant Rai vs. Union of India (2005) • Devika Biswas vs. Union of India & Ors. petition: 9th February 2008

10 SC Directives in the c/o Ramakant Rai (order dt. 1/3/2005)

All states to ensure enforcement of Union Government’s Guidelines for conducting sterilization procedures and norms for bringing out uniformity in sterilization procedures by:

• Introducing a system of an • Conducting enquiry in case of approved panel of doctors breach on guidelines • Implementing a checklist for • Bringing an insurance policy into sterilization procedure effect • Laying down a proforma of consent • Laying down uniform standards for states • Setting-up Quality Assurance Committees • Formulating norms for compensation • Maintaining sterilization statistics

11 SC Directives in c/o Devika Biswas (order date: 14/09/2016)

Complaints related to deaths in sterilization camp held in Bihar on 7/01/2012 provoked Devika Biswas in filing a writ petition

• Approved panel of doctors, for carrying out sterilizations must be accessible through MoHFW website • Contents of checklist prepared should be explained to client in a language that he/she understands • Details and necessary particulars of each member of QAC and DQAC should be accessible from MoHFW website • Halt the system of holding sterilization camps within a period of three years • Ensure that targets are not fixed so that health workers and others do not compel persons to undergo what would amount to a forced or non-consensual sterilization • Ensure strict adherence to the guidelines and standard operating procedures in the various manuals

12 Eligibility Criteria and Informed Consent form for Sterilization

Session 14 Eligibility Criteria for Sterilization Clients (Self declaration by the client)-As per GOI Manual

• Clients should be ever married • Female clients should be above the age of 22 years and below the age of 49 years • Male clients should be above the age of 22 years and below the age of 60 years • The couple should have at least one child, whose age is above one year unless the sterilization is medically indicated • Clients or their spouses/partners must not have undergone sterilization in the past (not applicable in cases of failure of previous sterilization) • Clients must be in a sound state of mind so as to understand the full implications of sterilization • Mentally challenged clients must be certified by a psychiatrist and a statement should be taken from the legal guardian /spouse regarding the soundness of the client’s state of mind

2 Informed Consent • The consent of the partner is not required for sterilization. • However the partner should be encouraged to come for counseling. • Consent for sterilization should not be obtained when physical or emotional factors may compromise a client's ability to make a carefully considered decision about contraception • Client’s signature/thumb impression compulsory (If thumb impression, witness to sign consent form)

3 Consent Form

I, Smt/Shri …………………………………… (client) hereby give consent for my sterilization operation. I am ever married. My age is ……years and my husband/wife’s age is …… years. I have …(Nos.) male and …. (Nos.) female living children. The age of my youngest living child is …… years. a) I have decided to undergo the sterilization / re-sterilization operation on my own without any outside pressure, inducement or force. I declare that I / my spouse have/has not been sterilized previously (not applicable in case of re- sterilization). b) I am aware that other methods of contraception are available to me. I know that for all practical purposes this operation is permanent and I also know that there are chances of failure of the operation for which the operating doctor and health facility will not be held responsible by me or by my relatives or any other person whomsoever. c) I am aware that I am undergoing an operation, which carries an element of risk. d) The eligibility criteria for the operation have been explained to me and I affirm that I am eligible to undergo the operation according to the criteria. 4 Consent Form Contd.. e) I agree to undergo the operation under any type of anaesthesia, which the doctor/health facility thinks suitable for me and to be given other medicines as considered appropriate by the doctor/health facility concerned. I also give consent for any additional life-saving procedure, if required. f) I agree to come for follow-up visits to the Hospital/Institution/Doctor/health facility as instructed, failing which I shall be responsible for the consequences, if any. g) If, after the sterilization operation, I experience a missed menstrual cycle, then I shall report within two weeks of the missed menstrual cycle to the doctor/health facility and may avail of the facility to get an MTP done free of cost. I shall be responsible for the consequences, if any. h) I understand that Vasectomy does not result in immediate sterilization. *I agree to come for semen examination 3 months after the operation to confirm the success of sterilization surgery (Azoospermia) failing which I shall be responsible for the consequences, if any. (* Applicable for male sterilization cases) 5 Consent Form Contd.. i) In case of complications, failure and the unlikely event of death attributable to sterilization, I/my spouse and dependent unmarried children will accept the compensation as per the existing provisions of the Government of India “Family Planning Indemnity Scheme” as full and final settlement and will not be entitled to claim any other compensation including compensation for upbringing of the child, if any, born on account of failure of sterilization, over and above the one offered, from any court of law in this regard. I have read the above information or the above information has been read out and explained to me in my own language and that this form has the authority of a legal document. I am aware that I have the option of deciding against the sterilization procedure at any time without sacrificing my rights to other reproductive health services.

6 If Sterilization can not be performed

• Client record should specify: o The reasons for not doing operation o Action taken by the service provider

These records should be kept at the service facility where the client was evaluated and the sterilization found unsuitable for her/ him.

7 Certificate of Sterilization

Female Sterilization Issued one month after the surgery or after the first menstrual period, whichever is earlier. If periods do not return even after 1 month, UPT to be done. If negative, issue certificate. Male Sterilization Issued only after three months once the semen examination shows no sperm

8 ROLE PLAYS

Situation-1 (PPFP Counselling-POP)  Kusum has come to hospital for ANC checkup. This is her second pregnancy. She is seven months pregnant.  Counselor asks about her condition and also starts talking on family planning with her and her husband.  Kusum and her husband want some method to delay the next pregnancy for 3-4 years. Counselor counsels them about temporary methods but they don’t want IUCD.

Situation-2 (PPFP Counselling-LAM & COC)  Sushila is pregnant for the first time. She is eight months pregnant. She has come to the hospital for ANC check-up. Doctor checks her and also starts talking on importance of family planning and various methods.  Sushila says that she will not need any family planning method after delivery as she has heard that while breastfeeding there is no fear of getting pregnant for one-two years.  Counsellor explains and counsels her.

Situation-3 (PPFP Counselling-PPIUCD)  Kiran is admitted in hospital for cesarean operation tomorrow.  Counsellor counsels her and her mother-in-law on family planning, gives information about all the methods and tells them that if they want, copper IUCD can be inserted during cesarean operation.  They like copper IUCD but are scared that it might move upwards in the body.  Counsellor addresses their misconceptions and provides them with method specific counseling on PPIUCD.

Situation-4 (PAFP Counselling-PAIUCD)  Sita is 25 year old woman, who has two children, younger one aged 10 months old. She was two and half months pregnant and had spontaneous abortion.  She has come to the facility for management of spontaneous abortion. The doctor examined and found that the abortion is complete, there is no bleeding and no signs of infection.  She had taken oral pills in the past, but usually forgets to take the pills regularly. She has heard that Copper IUCD travels up inside the body. Counsellor removes her myths and counsels her for copper IUCD once she chooses it.

Situation-5 (PAFP Counselling-Centchroman)  Reena, a 23 year old woman married for last one year, was 2 months pregnant. She started having pain in lower abdomen and severe bleeding P/V for which she was admitted in a hospital. The doctor performed pelvic examination and told her that she had incomplete abortion.  Reena had to undergo surgical evacuation.  Before she was discharged, the doctor informed her about contraceptives she could start right away.  But her husband says they will come back again after her period starts and wants her to rest for some time and become strong before starting any contraceptives. He is apprehensive about hormonal side effects and thus reluctant.  The Counsellor counsels the couple and explains the risk of becoming pregnant soon and informed her about the need of healthy spacing before another pregnancy.

Situation-6 (PPFP Counselling-POP) A 20 year old lactating woman wants to postpone her next pregnancy. Her sister uses some pills and she likes that method very much. Client says she wants to use the same pill. The health provider counsels her.

Situation-7 (FP counselling-COC)  A 24 year old woman comes to see her service provider because she has heavy menstrual periods lasting for 3 days each month. She feels run down since birth of her last child and is anaemic.  She has two children, a boy of 7 months and a daughter of 3 years. She has never used a contraceptive method in the past and they want to have one child more. The health provider counsels the couple.

Situation-8 (FP Counselling- Female sterilization) A 41 year old woman with two teen age boys and one 6 months old girl (unintended pregnancy) does not want any more children. She has used an IUCD in the past but got it removed because of heavy bleeding, cramping and pain. Counsel her.

Situation-9 (FP Counselling-Inj. MPA) A 27-year-old woman with one daughter comes to see you as she has heard about the new “FP Injection" and wants to use it. She has an IUCD in place but doesn't like the menstrual cramps and prolonged bleeding that, she is experiencing each month. The service provider counsels her.

Situation-10 (FP Counselling-Male sterilization) A 37 year old woman with two children wants contraceptive protection. She doesn’t want more children and is planning for female sterilization. Woman is not in a good condition for the procedure due to her poor health and PID. Her husband is apprehensive about having weakness and becoming impotent following male sterilization. Health provider will counsel.

EXPECTATIONS FROM FAMILY PLANNING COUNSELOR

As a FP Counsellor you should: For all Clients: method, procedure, and related information. • Be aware of the choices of contraceptives available in under the program in your • For women who have not yet made a facility decision for family planning: • Provide the clients with the basket of A. For a woman who want another child: choice containing different methods and o Counsel for healthy timing and help them choose a method that suits spacing pregnancy their needs o LAM or other contraceptive • Take an on-going counselling approach to options as reproductive intentions maximize the utilization of each contact of indicate a woman with your facility. o PPIUCD counselling, confirmation Be able to communicate to every woman, in and provision if requested the child bearing age, regarding HTSP. B. For women who have completed During antenatal period their family, discuss options for permanent methods or long acting 1st Trimester temporary methods • Introduce concepts of Healthy Timing and Spacing of During postnatal care contact (within 6 weeks) Pregnancy and importance of • Counsel on exclusive Postpartum Family Planning breastfeeding and LAM 2nd Trimester • Discuss return to fertility • Reinforce information about family and return to sexual planning and encourage choosing an activity appropriate contraceptive method. • Determine family planning use based on 3rd Trimester breastfeeding status and provide appropriate method • Reinforce information about family planning and encourage choosing an Child health contacts during the 1st year/ appropriate contraceptive method immunization sessions Counsel on exclusive • Encourage thinking about a preferred breastfeeding and LAM family planning method and help decision • Discuss the importance of making. pregnancy spacing and encourage use of During immediate postpartum period (within 48 appropriate contraceptive hours of delivery) method • Discuss exclusive breastfeeding for 6 Women seeking safe abortion services: months • Pre abortion counselling-Discuss the • Describe Lactational family planning options and encourage Amenorrhea Method (LAM) and thinking on the method of choice transition to other contraceptive options • Post abortion Counselling- Discuss the as reproductive intentions indicate family planning options and help reach a • For Woman who have already made a final decision on the method of choice decision for family planning, discuss the Checklist: General Family Planning Counselling

(To be used for practice and assessment of the FP counselling skill)

This checklist is for counselling woman/couple at any time on various methods of family planning.

Participant ______Date Observed ______

CHECKLIST FOR FAMILY PLANNING COUNSELLING (Some of the following steps/tasks should be performed simultaneously) STEP/TASK CASES PREPARATION FOR COUNSELLING 1. Ensures room/counselling corner is well lit and there is availability of chairs and table. 2. Prepares equipment and supplies. 3. Ensures availability of writing materials and job-aids (e.g. client file, daily activity register, FP job-aids, handouts, client education material, Flip Book, FP Kit). 4. Ensures privacy. SKILL/ACTIVITY PERFORMED SATISFACTORILY GENERAL COUNSELLING SKILLS 5. Greets the woman with respect and kindness. Introduces self. 6. Uses body language to show interest in and concern for the woman. 7. Asks the woman the purpose of her visit. Reassures the woman that the information in the counselling session will be confidential. 8. Tells the woman that this session is going to help client to take decision on her own as per her needs and for ensuring good health for woman and her children (if any). Responds to the woman’s questions/concerns. 9. Uses language that the woman can understand. 10. Discusses the health benefits to mother and baby of waiting at least two years after the birth of her last baby before she tries to conceive again. CHECKLIST FOR FAMILY PLANNING COUNSELLING (Some of the following steps/tasks should be performed simultaneously) STEP/TASK CASES 11. Rules out pregnancy by asking the 6 questions (use job aid) to be reasonably sure that the woman is not pregnant. 12. Displays the Counselling Kit/Flip Book, samples of contraceptives showing all the FP methods, and  If client has a method in mind, provides method specific counselling on that method.  If client does not have any specific method in mind, asks the following 4 questions and eliminates methods according to client’s response: i. Do you want more children in the future? (If yes, does not discuss male and female sterilization) ii. Are you breastfeeding an infant of less than 6 months old? (If yes, does not discuss combined oral contraceptive pills) iii. Will your partner use condoms? (If yes, discusses about condoms. Also, irrespective of client’s response, assesses woman/couple risk for STIs and HIV and explains that condoms are the only method that can protect from STI and HIV) iv. Did you have any problem with any FP method in the past? (If yes, asks which method. Does not discuss the method used if the problem experienced was really related to the method) 13. Briefly provides general information about those contraceptive methods that are appropriate for woman based on her facts to questions asked in step 12.  How to use the method  How does it prevent pregnancy  Effectiveness  Benefits  Common side effects  Need for protection against STIs including HIV/AIDS 14. Clarifies any misconception the woman may have about family planning methods. 15. Asks which method interests the woman. Helps the woman choose a method. Method-Specific Counselling – once the woman has chosen a method, please provide method specific counselling for the method chosen (Please refer to checklists for method specific counselling for chosen contraceptive)

Brief Technical Overview of Contraceptive Methods

HANDOUT-1: CONDOM

HOW DOES IT HOW TO WHO CAN WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS WORK USE THE USE THE NOT USE THE EFFECTS METHOD METHOD METHOD

 Barrier method,  To be worn  Men of any  In rare case  Effective and start  Condom should Correct and consistent physically by male on age of allergy to working immediately not be reused use is very important prevents the erect latex and should be  Perfect use: 98% sperms from penis  Only contraceptive discarded after providing protection meeting an egg every act of  Common use: 85% (fertilization)  To be used against STIs and HIV intercourse correctly  Male with each  No effect on breast milk  Cooperation of condoms are sexual activity  No hormonal side male partner made of from the effects required latex beginning of the act  Can be stopped  No side effects anytime  New condom  Few complain required for  Easy to keep stock reduced each act of handy, can be used by pleasure sexual men of any age  Supply to be intercourse  May be used as back up maintained method for missed oral pill,, delay in getting injection MPA, and delay in starting a new FP method  Following vasectomy for at least three months

HANDOUT-2: LACTATIONAL AMENORRHEA METHOD (LAM)

HOW DOES IT HOW TO USE WHO CAN USE WHOSHOULD BENEFITS LIMITATIONS/ EFFECTIVENESS WORK THE METHOD THE METHOD NOT USE THE SIDE EFFECTS METHOD Can be used for Start breastfeed  Women who are  Women who are  Effective (1 to 2 pregnancies  All three criteria Failure rate: the first 6 immediately after fully not exclusively per 100 women during first need to be met for  Consistent and months childbirth (within breastfeeding, breastfeeding six months of use) effectiveness Correct Use postpartum as one hour) whose menses  Postpartum  Immediate breastfeeding  May be difficult to (for 6 months): long as ALL three  Women who are have not women whose provides additional practice due to 0.9 criteria for LAM returned fully menses have protection against infections social  Typical Use: 2 are met breastfeeding,  Women who are returned for the newborn circumstances, like 1) whose menses Woman less than six  Women who are  Exclusive breast feeding lack of privacy for have not exclusively months more than six (EBF) promotes health breastfeeding in a returned, and breastfeed her postpartum months benefits to the infant and joint family, who are less than baby postpartum increases survival working woman 2) Baby is less six months  Promotes mother and infant  Does not protect than 6 month postpartum bonding against STIs and 3) Woman’s  Women with HIV HIV who use  Helps mother’s uterus menses have  Women who are LAM, should also return to normal size not returned infected with HIV be encouraged to quicker than non- or who have AIDS use condom breastfeeding women or taking  Effective immediately antiretroviral  Does not interfere with (medicines for intercourse AIDS) can use  No systemic side effects LAM, however there is a chance  No medical supervision that some necessary percentage of  No supplies required and no infants will get HIV cost through breast milk  Helps reduce the amount of bleeding after delivery by keeping the uterus contracted

HANDOUT-3: COMBINED ORAL CONTRACEPTIVE PILLS (COC)-Mala N

HOW DOES IT HOW TO USE WHO CAN USE WHOSHOULD NOT BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS WORK THE METHOD THE METHOD USE THE METHOD EFFECTS  Preventing the  One pill to be taken  Women and  Breastfeeding women  Highly effective  Must be taken every (Expressed in no. of release of eggs every day couples who want <6 months postpartum  Reversible day pregnancies per 100 from the ovaries an effective, women using the  After a pack of 28  Non breastfeeding  Easy to use and  Require regular/ (ovulation) pills is over, the next reversible method women <3 weeks dependable supply method over the safe for most first year)  Prevent pack needs to be  Women of any postpartum women  May cause side attachment of started from next age including  Perfect Use: 0.3  Women who smoke  Regulate the effects in some embryo day itself, without adolescents and >15 Cigarettes and ≥35 women, such as  Typical Use: 8 (implantation) any break women over 40 menstrual years old cycle nausea, headache,  Causing  Any time, within 5 years of age bleeding between  Women with the  Reduces thickening of days after the start  Women having following conditions: menses or weight cervical mucus, anaemia due to menstrual flow gain of her mensuration – Deep vein which makes it heavy menstrual (which is useful to  Any time, after 5 thrombosis (DVT) anemic women)  Do not protect difficult for bleeding against STIs and HIV sperms to pass days of start of her – Heart disease  Decrease the risk monthly bleeding,  Women with  Risk of developing through menstrual cramps – Bleeding disorders of ovarian and and if it is certain uterine cancer, cardiovascular  Women with an – Liver disease or disease in women that she is not tumors benign breast pregnant. A irregular disease and over 35 years of age – Recurrent migraine menstrual cycle incidence of acne and who smoke backup method  HIV positive headaches with focal (e.g. Condom) is  Do not interfere women, whether neurological needed for first 7 symptoms with sexual or not on ARV intercourse days of taking pills – Unexplained vaginal  Postpartun woman bleeding  Pelvic exam not mandatory - If breast feeding – Breast cancer before starting then after 6 – On Anticonvulsants pills months for epilepsy or  Immediate return - If non breast Rifampicin for tuberculosis of fertility on feeding then discontinuation after 4 weeks

PROGESTIN ONLY PILLS (POP)

HOW DOES HOW TO WHO CAN USE WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS IT WORK USE THE THE METHOD NOT USE THE EFFECTS METHOD METHOD  Works by  One pill to be  Who wants an  Has breast cancer  Highly effective in  Effectiveness decreases (Expressed in no. of thickening taken every day effective, reversible or history of breast breastfeeding when breastfeeding pregnancies per 100 cervical mucus and at the same method cancer women, reversible, stops women using the (this blocks time  Breastfeeding women  Acute blood clot in easy to use  Require regular/ method over the sperm from  Any time, (may start soon after deep veins of legs  Can be started dependable supply first year) meeting an within 5 days childbirth) soon after Breastfeeding egg)  Severe liver  Side effects like changes after the start  Women of any age disease, infection childbirth in in bleeding patterns women:  Preventing the of her monthly including adolescents or tumor breast feeding including: Irregular/  Perfect Use: 0.3 release of eggs bleeding and women over 40 mothers Prolonged bleeding/ from the  Taking medicines  Typical use: 1  Any time, after years of age for seizures and  Do not interfere No bleeding ovaries 5 days of start with sexual Not breastfeeding (ovulation)  Women just after tuberculosis.  Postpartum amenorrhea of her monthly abortion, miscarriage intercourse may be prolonged in women:  Thinning of bleeding, and if or ectopic pregnancy  Can be provided breastfeeding women  Perfect Use: 0.9 endometrial it is certain by trained non-  Typical Use: 3- lining. that she is not  Women who smoke  Some woman may have medical staff 10 pregnant. A  Women having headaches, dizziness, backup anaemia  Immediate return mood changes, breast method (e.g. of fertility on tenderness, abdominal  Women, who have discontinuation condom) is varicose veins pain and nausea needed for  HIV positive women,  In non- breast feeding first 2 days of whether or not on women, ovarian follicle taking pills ARV may be enlarged.  Immediately  Do not protect against after delivery STIs, HIV irrespective of her breast feeding status

Handout-5: Centchroman (Ormeloxifene)

HOW DOES HOW TO WHO CAN WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS IT WORK USE THE USE THE NOT USE THE EFFECTS METHOD METHOD METHOD  No effect on  One tablet  Who wants an  Polycystic  Highly Safe and highly effective,  Require regular/ (Expressed in no. of the production (30 mg) effective, ovarian disease non-steroidal non-hormonal dependable supply pregnancies per 100 of estrogen or twice a week reversible  Cervical reversible method  Prolongation of women using the progesterone for first 3 method hyperplasia  Easy to use menstruation cycle method over the hormone months first year)  Women who  Recent history  Safe for breastfeeding women and less bleeding  It has weak  From fourth don’t want oral during mensuration  Perfect Use: 1.63 of jaundice or  Free from side effects associated estrogenic month hormonal pills liver disease in some women action on onwards with hormonal oral  Breastfeeding  Severe allergic contraceptives (such as nausea,  Do not protect bones but once a week women against STIs and HIV strong anti- only states, chronic dizziness, weight gain, etc.) estrogenic  Any age illnesses such as  Does not interfere with sexual  The 1st pill adolescents to tuberculosis, action on is to be intercourse uterus, breasts over 40 years of renal disease taken on the age etc.  No need of pelvic examination  Prevents first day of before starting implantation of period and  Women having anemia  Immediate return of fertility on zygote the 2nd pill discontinuation three days  Following  Has no effect on platelet later abortion, miscarriage or aggregation, lipid profile and  Postpartum HDL cholesterol. woman can ectopic  No teratogenic effect start pregnancy immediately  HIV positive  Reduces bleeding during periods after birth women, whether  Can prevent breast cancers, irrespective or not on ARV uterine cancers and protection of her breast against demineralization of bone feeding status

HANDOUT-6: EMERGENCY CONTRACEPTIVE PILLS (ECP)

HOW DOES IT WORK HOW TO USE WHO CAN WHOSHOULD BENEFITS LIMITATIONS/ EFFECTIVENESS THE METHOD USE THE NOT USE THE SIDE EFFECTS METHOD METHOD  Action of ECP depends on  To be taken as  All women  There are no  Moderately effective,  Possibility of side (Expressed in no. the time in the menstrual soon as possible who have had medical if taken within 3 days effects like of pregnancies per cycle when the intercourse or within 3 days) unprotected conditions that of unprotected sex/ nausea, vomiting, 100 women using has occurred and when of unprotected intercourse/ make ECPs accidental act headache, the method over ECP is taken intercourse accidental act unsafe for any  1-3% women may still dizziness, fatigue the first year)  ECP causes inhibition or  Taking it sooner for any reason woman conceive despite and breast If 100 women each delay of ovulation when is more effective  Women in  Pregnant taking ECP tenderness. had unprotected These side sex once in used prior to ovulation  Should not be whom are women should effects menstrual cycle,  It also acts by thickening of contraindicated not use ECP, used as regular generally do not cervical mucus resulting in for hormonal however if  With no ECPs, 8 contraceptive last more than trapping of sperms. EC is contraceptive accidentally can become method few hours not effective once the can take ECP taken it will not pregnant cause abortion. process of implantation has  Next menstrual  With Progestin- bleeding may be begun. only ECP, 1 can earlier or later become pregnant than expected in some women  It does not provide contraception from subsequent unprotected intercourse  Does not protect against STIs and HIV

HANDOUT-7: INTRA UTERINE CONTRACEPTIVE DEVICE (IUCD)

HOW DOES HOW TO USE WHO CAN USE WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS IT WORK THE METHOD THE METHOD NOT USE THE EFFECTS METHOD  Does not  Any time  Any women of  Pregnant woman  Highly effective  Side effects are not More than 99% allow - Within first 12 reproductive age  Current Pelvic  Most women can use harmful and get effective (6-8 fertilization days of menstrual better within 3-6 pregnancy/1000  Any parity inflammatory disease  Convenient by: cycle months on their woman)  Used for both  Septic abortion Decreasing - After 12 days  One time action own sperm spacing and  Puerperal sepsis required anytime when limiting births − Increased motility and confirmed that  Woman suffering from  Safe for breastfeeding menstrual bleeding function  Following normal woman is not STI (gonorrhea or women − delivery (within Intermenstrual  Does not pregnant Chlamydia) or at high  Reversible (Cu 380 A bleeding 48 hours of individual risk of STI allow  In women with for 10 and Copper 375 − Cramps during implantation delivery) or lactational during operative  Unresolved PPH in for 5 years) menstruation by: Altering Postpartum women amenorrhea, after delivery  Effective for long term Limitations tubal and excluding  Chorioamnionitis  Immediate reversal of uterine pregnancy  Post abortion-  Health facilities environment immediately  Cancers of genital fertility after removal equipped for  Vaginal delivery-can tract  As emergency insertion and be inserted within  Congenital anomalies contraceptive (within removal 10 minutes of of uterus affecting its five days of delivery of placenta  Trained providers shape unprotected sexual and up to 48 hours for insertion and  Pelvic Tuberculosis activity) removal  During operative delivery  Does not protect immediately after against STIs and HIV delivery of placenta  6 weeks after delivery, when pregnancy is ruled out  Within 5 days of unprotected sex

HANDOUT-8: INJECTION DEO MEDROXY PROGESTERONE ACETATE (INJECTION MPA)

HOW DOES IT HOW TO USE WHO CAN USE WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS WORK THE METHOD THE METHOD NOT USE THE EFFECTS METHOD  Inhibit ovulation  Can be started  Are of any age, Women who:  Very effective and  Return of fertility  Correct and - by suppressing by the including  Are pregnant easily reversible. takes 7-10 months consistent use is breastfeeding mid cycle peaks adolescents and  Are breastfeeding Few side effects from date of last very important woman after 6 of LH and FSH women over 45 and <6 weeks  Does not injection  With a standard weeks of child  Thicken cervical years old postpartum interfere with  Once taken its action regimen the 1st mucus - due to birth  Have or do not sexual intercourse cannot be stopped year effectiveness  Non-  Have high blood depletion of have children  No daily action immediately is 99.7% breastfeeding pressure (>160 /100 oestrogen. The  Are unmarried mm Hg) required  It causes changes in  The perfect use thick mucus women-any time  Just had an  No effect on the menstrual cycle failure rate of 3% prevents sperm after child birth  Have diabetes with abortion or breastfeeding, if and bleeding and penetration into  Within 7 days of vascular disease miscarriage started 6 weeks amenorrhea the upper menstruation  Have current or after childbirth  It has to be repeated reproductive with no need of  Are smoker, past ischemic heart every three months tract back up method regardless of age disease  May help prevent iron deficiency  Available at a cost in  Thinning of  After 7 days of  Are breastfeeding  Have unexplained anemia the private health endometrial mensuration, (starting 6 weeks vaginal bleeding facilities and at the lining - due to any time after after child birth)  Pelvic exam not  Have or had breast chemists’ shop high excluding  Are at risk of STI/ cancer required before use  Available in the progesterone pregnancy. Use HIV infection  Have liver disease and depleted backup method public health  Are infected with  Older age, smoking, oestrogen, (Condom) facilities HIV, whether or not diabetes, and making it  Does not protect  Given by on antiretroviral hypertension unfavorable for injection once therapy. Encourage against STIs and HIV  Have deep vein implantation of every 3 months. these women for fertilized ovum condom use by their thrombosis, vascular  Can be given 2 disease or stroke weeks before or husbands 4 weeks after the scheduled date of injection

HANDOUT-9: FEMALE STERILIZATION

HOW DOES HOW TO USE WHO CAN WHOSHOULD BENEFITS LIMITATIONS/ SIDE EFFECTIVENESS IT WORK THE METHOD USE THE NOT USE THE EFFECTS METHOD METHOD By preventing  Surgical method  Married/ever  Pregnancy  Most effective  Trained provider and  Most effective sperms from under local married  Current Pelvic  Permanent recognized health  More than 99% (5 meeting an egg anesthesia and  Most woman inflammatory method facility is must pregnancy/1000 woman ) (fertilization) as sedation or genera/ disease  Surgical method fallopian tubes local anaesthesia by Age 22-49  No effect on are ligated and mini-lap method or  At least one  Purulent cervicitis breast milk  Irreversible cut or blocked laparoscopic ligation alive child caused by  One time  No protection by Falope rings using laparoscope more than 1 chlamydia and decision and against STIs and HIV gonorrhoea  Within 7 days of year of age surgery  Short term

menstruation,  Women who  Unresolved PPH required discomfort/ pain surgical or have completed  Septic abortion spontaneous their families  Puerperal sepsis abortion  Breast feeding  Suffering from  After 7 days of women severe mensuration, any  Women with Preeclampsia or time when HIIV who are eclampsia pregnancy is ruled clinically well out  During next cycle following medical abortion  Postpartum mini-lap (PPS) Within 7 days of normal delivery  PPS-With operative delivery

Written consent is required from the woman undergoing the procedure

HANDOUT-10: MALE STERILIZATION

HOW DOES IT HOW TO WHO CAN WHOSHOULD BENEFITS LIMITATIONS/ EFFECTIVENESS WORK USE THE USE THE NOT USE THE SIDE EFFECTS METHOD METHOD METHOD  Blocks the vas  Surgical  Most men who  Men with any of  Most effective  Can be provided  Most effective deferens (tubes method want to limit the following  Permanent method in facility equipped  More than 99% carrying sperms) and (under local their family/ conditions should with trained (2 pregnancy /1000 prevent sperms from anesthesia) completed their delay vasectomy  Simple surgery provider is must woman) entering the semen family until the performed under local  No cut or anesthesia  Irreversible  Methods: stitches for  Age between 22 condition is resolved:  Does not interfere with  Not effective - Conventional NSV and 60 years immediately after – Current STI sexual intercourse/sexual - No Scalpel  At least one pleasure the procedure

Vasectomy (NSV) alive child, – Scrotal skin  The couple needs whose age infection  No known long-term side effects to use a backup should be – Acute genital method such as one or more tract infection  No repeat clinic visits condom for the required than one year – Acute Systemic first 3 months  Ever married infection  No supplies needed, after the  Men with HIV – Men with AIDS except the use of backup procedure, for the or who are on who are not method/ condoms for the semen to be sperm ARV clinically well first 3 months free – Inguinal hernia  Easier to perform than  No protection female against STIs and – Large HIV varicocele  sterilization  No change in sexual  Scrotal support function required for initial few days  No effect on hormone production Written consent is required from the man undergoing the procedure

TIME OF INITIATION OF POSTPARTUM FAMILY PLANNING METHODS

Delivery 48 hr 1wk 3 weeks 4 weeks 6 weeks 6 months 12 months

Condom

IUCD IUCD

All Female Sterilization Female Sterilization Women Emergency Contraceptive Pill (ECP)*

Male Sterilization

Lactational Amenorrhea Method (LAM)

Injection MPA

Breast-Feeding Progestin Only Pill (POP) Women Combined Oral Contraceptive (COC) Pill

Centchroman

Progestin Only Methods (POP/Injection MPA) Non-breast Combined Oral Contraceptive (COC) Pill Feeding Women

Centchroman

* This pill is to be used only in an emergency. For regular contraceptive use, take advice from ANM/Doctor at government health centre.

Checklist: General Family Planning Counselling

(To be used for practice and assessment of the FP counselling skill)

This checklist is for counselling woman/couple at any time on various methods of family planning.

Participant ______Date Observed ______

CHECKLIST: METHOD SPECIFIC COUNSELING ON CONDOM (To be used for practice and assessment of the method specific counselling for Condom)

This checklist is for counselling woman/couple at any time on Condom.

Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or ‘N/O’ if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step or task not performed by participant during evaluation by trainer

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses Condom during general FP Counselling STEP/TASK CASES 1. Ensures that client has chosen condom voluntarily after getting information on various contraceptive options 2. Asks him if she knows about condoms. Corrects any myths, rumours or misinformation he may express 3. Asks his past experience with condoms (if any) and rule out allergy to latex 4. Give detail information about condom and explain how he can use it correctly i. Safe and an effective method if correctly used with every intercourse. ii. Easily available; can also be taken from ASHAs in the community iii. Can be started anytime by men iv. No side effects like hormonal contraceptives v. Only FP method, which provides dual protection. It protects from pregnancy as well as STIs like HIV. vi. May be used as back up method for missed oral pills 5. Responds to any question or concerns the clients may have

6. Corrects any myths, rumours or misinformation he may express 7. Asks to repeat the instructions: . How to use routinely and as a back-up method . To come to facility to replenish the supply or can also be taken from ASHA 8. Asks and responds if he has any questions or concerns 9. Records the relevant information. Information for Other Services 10. Educates the client/couple about prevention of STIs and HIV/AIDS. Inform them that condom is the only method that can protect from STIs including HIV

Start method specific counselling after woman/couple chooses Condom during general FP Counselling STEP/TASK CASES 11. Using information collected in earlier steps, determines client’s needs for postpartum, new-born, and infant care services. . If client’s wife reported giving birth recently, discuss or refer for postpartum care, new-born care . For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILL/ACTIVITY PERFORMED SATISFACTORILY Follow up counselling 12. Greets the client/couple and asks the purpose of visit 13. Checks whether the client is satisfied with the method and is still using it 14. Asks if he has any questions, concerns, or problems with the method 15. Explores changes in the client’s health status or lifestyle that may mean he needs a different family planning method 16. If he wants to continue the method, give/help him to get more packs 17. In case the client does not want to continue with the method, help him/partner to choose another method 18. Schedules return visit for follow up and replenish supplies

Checklist: Method Specific Counseling of Male Sterilization

(This checklist is for practice and assessment of counselling woman/couple at any time on Male Sterilization counselling) This checklist is for counselling woman/couple at any time on Male Sterilization.

Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if not observed. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step or task not performed by participant during evaluation by trainer Participant Date Observed Start method specific counselling after woman/couple chooses Male Sterilization during general FP Counselling STEP/TASK CASES 1. Ensures that client has chosen Male Sterilization voluntarily after getting information on various contraceptive options 2. Confirms clients reproductive goals and ensures that he understood the difference between reversible and permanent contraceptive methods 3. For assessing the medical eligibility of clients for Male Sterilization, provider asks questions to ensure that the following conditions are not present, in which Sterilization surgery cannot be performed in the man: i. Current STI ii. Scrotal skin infection iii. Acute genital tract infection iv. Acute systemic infection v. Men with AIDS who are not clinically well vi. Inguinal hernia vii. Large varicocele  If any of the conditions i– vii exists, he is not a good candidate for Sterilization. Counsels about other available methods or refer. Sterilization cannot be performed once conditions resolved, without further evaluation. 4. Ask him what he knew about sterilization. Corrects any myths, rumours or misinformation he may express like:  Vasectomy is same as castration  Man will not enjoy sex or will not be able to perform sexual activity  Man will become weak after the operation and would not be able to perform day-to-day function 5. Clearly discuss the benefits of Sterilization. Emphasize that it is a permanent method but there is a small risk of failure. 6. Explain the importance of the spouse being involved in decision for voluntary sterilization. 7. Explain that Sterilization does not protect against RTI/STIs (If the client is at risk than he should use barrier method also). 8. Explain common side effects of the surgical procedure and be sure that they are fully understood. Start method specific counselling after woman/couple chooses Male Sterilization during general FP Counselling STEP/TASK CASES 9. Explain the Surgical procedure briefly and what to expect during and after the procedure. 10. Discuss scheduling procedure and possible need for contraception prior to sterilization 11. Responds to any questions or concerns the client may have. 12. Obtain client’s signature or thumb print on the informed consent form after he reads or explaining in simple language 13. Explain that he will feel a little pain during the procedure and he should inform a member of the surgical team if she feels any discomfort at any time 14. Asks to repeat the instructions:  Understands the permanent nature of operation or not  What are side effects  When to come for follow up (routine and emergency)? 15. Explain to client, once done, difficult to reverse and outcome of such reversal surgery is not good. 16. Explains that Post-surgery he or his partner will need to use condom or any other contraceptive method for 3 months, as semen might contain sperm till 3 months. 17. Responds to any questions or concerns the client may have. Post Procedure Counselling 18. After the procedure explained about wound care. 19. Asks to repeat the instructions: i. Understand the permanent nature of operation or not ii. Side effects iii. When to come for follow up (routine and emergency)? 20. Records the relevant information. Information for Other Services 21. Educates the man/couple about prevention of STIs and HIV/AIDS. Informs him that male sterilization does not protect from STIs including HIV. 22. Using information collected in earlier steps, determines client’s needs for postpartum, new-born, and infant care services.  If client’s wife reported giving birth recently, discuss or refer for postpartum care, new-born care  For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILL/ACTIVITY PERFORMED SATISFACTORILY Follow up counselling 23. Greets the man and asks him the purpose of visit. 24. Checks whether the man is satisfied with the method. 25. Asks if he has any questions, concerns, or problems after operation. 26. Reassures about side effects if any. 27. Schedules return visit for follow up. Reminds him for follow-up at 3 months for semen test and take the certificate if semen test shows no sperm.

CHECKLIST: METHOD SPECIFIC COUNSELING ON CENTCHROMAN (ORMELOXIFENE) (This checklist is for practice and assessment of counselling woman/couple at any time on Centchroman (Ormeloxifene).

This checklist is for counselling woman/couple at any time on Centchroman.

Not Observed: Step or task not performed by participant during evaluation by trainer

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses Centchroman during general FP Counselling STEP/TASK CASES 1. Ensures that client has chosen Centchroman (Ormeloxifene) voluntarily after getting information on various contraceptive options. If the client is identified with a medical condition in which hormonal contraceptives cannot be started, she can start Centchroman (Ormeloxifene), if she wants 2. For assessing the medical eligibility of clients for Centchroman (Ormeloxifene), provider asks questions to ensure that the following conditions are not present, in which Centchroman cannot be used by the woman: i. Polycystic ovarian disease ii. Cervical hyperplasia iii. Recent history of clinical evidence of jaundice or liver disease iv. Severe allergic states v. Chronic illness such as tuberculosis or renal disease If any of the conditions i.– iv. exists, she is not a good candidate for Centchroman. Counsels about other available methods or refer. If case of conditions v. Centchroman cannot be initiated without further evaluation. 3. Asks her if she knows about Centchroman. Corrects any myths, rumours or misinformation she may express 4. Centchroman is safe with breast feeding. Can be started immediately after childbirth. 5. It can be safely given in women who cannot take hormonal contraceptives Start method specific counselling after woman/couple chooses Centchroman during general FP Counselling STEP/TASK CASES 6. If client is eligible for Centchroman (Ormeloxifene), tells the woman following points about the Centchroman (Ormeloxifene):  How to take the pills and what to do if she misses the pills  How does it work  Effectiveness  Advantages  Disadvantages including side effects

7. Asks the woman to repeat the instructions about Centchroman (Ormeloxifene):  How to use the method  Side effect  When to get the next supply (before her pills are finished)

8. Asks and responds if the woman has any questions or concerns 9. Record the relevant information Information on Other Services 10. Educates the woman about prevention of STIs and HIV/ AIDS. Informs her that Centchroman (Ormeloxifene) does not protect from STIs including HIV/AIDS 11. Using information collected in earlier steps, determines client’s needs for postpartum, newborn and infant care services.  If client reported giving birth recently, discuss or refer for postpartum care, newborn care  For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILL/ACTIVITY PERFORMED SATISFACTORILY Follow-up Counselling 12. Greets the woman and asks her the purpose of visit 13. Checks whether the woman is satisfy with Centchroman (Ormeloxifene) and is still using it 14. Check whether the woman has missed any pill (Biweekly schedule in fi three months and once a week pill schedule thereafter 15. If yes show her the way of taking pill with help of an example and discuss the way to remember 16. Asks if she has any questions, concerns or problems with the method 17. Explores changes in the woman’s health status or lifestyle and off her other methods if she has issues with current method (compliance and bleeding) 18. Reassures and counsel about side effects 19. Refers to the doctor for any physical examination, if needed 20. Schedules return visit for providing more pills before supply

CHECKLIST: METHOD SPECIFIC COUNSELING ON COMBINED ORAL CONTRACEPTIVE PILLS (COC)

(To be used for practice and assessment of counselling woman/couple at any time on method specific counselling for COC)

This checklist is for counselling woman/couple at any time on COC.

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses COC during general FP Counselling STEP/TASK CASES 1. Ensures that client has chosen COCs voluntarily after getting information on various contraceptive options 2. For assessing the medical eligibility of clients for COCs, provider asks questions to ensure that the following conditions are not present, in which COC cannot be used by the woman:  Breastfeeding her baby less than 6 months of age  High blood pressure  Smoking cigarette and more than 35 years of age  Breast cancer  Stroke (suddenly some part of brain stop working), blood clot in legs or lungs or heart attack  Repeated severe headaches, often on one side and/or pulsating, causing vomiting like feeling and which are made worse by light, noise or movement  Taking Rifampsin/Refabutin for tuberculosis (TB) or any pills for seizures (fits) regularly  Gall bladder disease or serious liver disease or jaundice (yellow skin or eyes)  Diabetes (High sugar in blood) 3. COC can be started any time, within 5 days after the start of her monthly bleeding or anytime when woman is sure that she is not pregnant. It can be started after 6 months of child birth in postpartum woman 4. Asks her if she knows about COCs. Corrects any myths, rumours or misinformation she may express 5. Asks her past experience with COCs (if any) Start method specific counselling after woman/couple chooses COC during general FP Counselling STEP/TASK CASES 6. Explains contraceptive and non-contraceptive benefits of COCs

7. Briefly explains how COC works 8. Explains potential common side effects of COCs. Tells her that she may experience few (or possibly none) of these but they can all be managed

9. Reassures client that these side effects are not serious and many will decrease or stop after a few months of use

10. Describes how to take pills and what to do if she misses the pills

11. Responds to any question or concerns the client may have

12. Informs the client when to come for routine follow-up visit. Tells her that she can come to health facility also when she has any problem 13. Asks to repeat the instructions:  How to take the pills  When to come for follow up  Side effects 14. Ensures that the client gets the pill packets after screening 15. Records the relevant information Information on Other Services 16. Educates the woman about prevention of STIs and HIV/ AIDS. Informs her that COCs do not protect from STIs including HIV/AIDS 17. Using information collected in earlier steps, determines client’s needs for postpartum, newborn and infant care services  If client reported giving birth recently, discuss or refer for postpartum care, newborn care  For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILL/ACTIVITY PERFORMED SATISFACTORILY Follow-up Counselling 18. Greets the woman and asks her the purpose of visit 19. Checks whether the woman is satisfied with the method and still using it 20. Asks if she has any questions, concerns or problems with COCs 21. Reassures her about side effects 22. Explores changes in the woman’s health status or lifestyle that may mean she needs a different family planning method 23. Schedules follow-up visit for providing more pills before supply finishes

CHECKLIST: METHOD SPECIFIC COUNSELING ON FEMALE STERILIZATION (This checklist is for practice and assessment of counselling woman/couple at any time on Female Sterilization) This checklist is for counselling woman/couple at any time on Female Sterilization.

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses Female Sterilization during general FP Counselling STEP/TASK CASES 1. Ensure that client has chosen Female Sterilization voluntarily after getting information on various contraceptive methods 2. Confirms clients reproductive goals and ensures that she understood the difference between reversible and permanent contraceptive methods 3. For assessing the medical eligibility of clients for Female Sterilization, provider asks questions to ensure that the following conditions are not present, in which Sterilization surgery cannot be performed in the woman: i. Woman is pregnant ii. Current pelvic inflammatory disease iii. Purulent cervicitis caused by chlamydia and Gonorrhea iv. Unresolved PPH v. Septic abortion vi. Puerperal sepsis vii. Suffering from severe Preeclampsia or eclampsia viii. Uncontrolled Diabetes and HT, Chronic Lung disease, Pelvic tuberculosis and AIDS  If any of the conditions i – viii exists, she is not a good candidate for Sterilization. Counsels about other available methods or refer  If any of conditions i-vii, Sterilization cannot be performed once conditions resolved without further evaluation  If condition viii present, instructs her to seek medical advise 4. Asks her if she knows about sterilization. Corrects any myths, rumours or misinformation she may express 5. Clearly discuss the benefits of Sterilization. Emphasize that it is a permanent method but there is a small risk of failure 6. Explain the importance of the spouse being involved in decision for voluntary sterilization 7. Explain that Sterilization does not protect against RTI/STIs (If the client is at risk, she may need to use a barrier contraceptive method also) Start method specific counselling after woman/couple chooses Female Sterilization during general FP Counselling STEP/TASK CASES 8. Explain common side effects of the surgical procedure and be sure they are fully understood 9. Explain the Surgical procedure briefly and what to expect during and after the procedure 10. Discuss scheduling procedure and possible need for contraception prior to sterilization 11. Obtain client’s signature or thumb print on the informed consent form after she reads or explaining in simple language 12. Responds to any questions or concerns the client may have 13. Explain that she will feel a little pain during the procedure and she should inform a member of the surgical team if she feels any discomfort at any time 14. Asks to repeat the instructions:  Understand the permanent nature of operation or not  What are side effects  When to come for follow up (routine and emergency) 15. Records the relevant information. Post Procedure Counselling 16. After sedation has worn off give postoperative instructions orally and in writing if appropriate. She is explained about wound care and stitch removal 17. Ask client to repeat instructions 18. Discuss what to do if the client experiences any problems 19. Schedule a return visit within 7 days and after her next menstrual period 20. Appraise her that if she misses her next menstrual period she must report to this or nearby clinic within two weeks of the expected date of her period to rule out pregnancy 21. Discuss arrangement for discharge (e.g. person accompanying client home). 22. Assure client she can return to the same or any nearby clinic at any time to receive advice or medical attention Information for Other Services 23. Educates the woman about prevention of STIs and HIV. Informs her that female sterilization does not protect from STIs including HIV 24. Using information collected in earlier steps, determines client’s needs for postpartum, new-born, and infant care services . If client reported giving birth recently, discuss or refer for postpartum care, new-born care . For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILLS/ACTIVITY PERFORMED SATISFACTORILY Follow up counselling 25. Greets the woman and asks her the purpose of visit 26. Checks whether the woman is satisfied with the method. Check her wound Start method specific counselling after woman/couple chooses Female Sterilization during general FP Counselling STEP/TASK CASES and remove the stitch 27. Asks if she has any questions, concerns, or problems after operation 28. Reassures about side effects if any 29. Schedules return visit for follow up. Reminds her to come for follow-up after 1 month or next menstrual period, whichever is earlier and to take certificate if menses return or urine pregnancy test is negative in case periods do not return after a month 30. Informs her about reporting to the hospital within 2 weeks of her expected date of menses, if she misses her next menstrual period (To rule out pregnancy)

CHECKLIST: METHOD SPECIFIC COUNSELING ON INJ. MPA (DEPOT MEDROXY PROGESTERONE ACETATE) (This checklist is for practice and assessment of counselling woman/couple at any time on Inj. MPA) This checklist is for counselling woman/couple at any time on Inj. MPA.

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses Inj. MPA during general FP Counselling STEPS/TASK CASES 1. Ensures that client has chosen Inj. MPA voluntarily after getting information on various contraceptive options 2. For assessing the medical eligibility of clients for Inj. MPA, provider asks questions to ensure that the following conditions are not present, in which Inj. MPA cannot be used by the woman: i. Woman is pregnant ii. Has ever had a stroke, blood clot in her legs or lungs, or heart attack iii. Has current or past history of breast cancer iv. Has a serious liver disease or jaundice (yellow skin or eyes) v. Has diabetes (high sugar in blood) vi. Has high blood pressure vii. Has bleeding between menstrual periods, which is unusual, or bleeding after sexual intercourse viii. Breastfeeding a baby less than 6 weeks old:  If any of the conditions i – iv exists, she is not a good candidate for Inj. MPA. Counsels about other available methods or refer.  If any of conditions v-vii, Inj. MPA cannot be initiated without further evaluation.  If condition viii is present, instructs her to return for Inj. MPA as soon as possible after the baby is 6 weeks old 3. Asks her if she knows about Inj. MPA. Corrects any myths, rumours or misinformation that she may express 4. Asks her past experience with Injection MPA (if any) 5. Explains contraceptive and non-contraceptive benefits of Inj. MPA 6. Briefly explains how Inj. MPA works 7. Explains potential common side effects of Inj MPA. Tells her that she may experience few (or possibly none) of these but they can all be managed. 8. Reassures client that these side effects are not serious and many will decrease or stop after a few months of use. 9. Describes the injection process and what the client should expect Start method specific counselling after woman/couple chooses Inj. MPA during general FP Counselling STEPS/TASK CASES during and after giving injection 10. Responds to any question or concerns the client may have. 11. Asks to repeat the instructions:  When to come for follow up  Side effects 12. Ensures that the client gets the Inj. MPA after screening 13. Records the relevant information Post Injection Counselling 14. Emphasizes on importance of Inj. MPA client card and date of return for injection 15. Advises the client not to do massaging of injection site and hot fomentation 16. Instructs the client to return early if she has questions or concerns 17. Provides back up method, if appropriate Information for Other Services 18. Educates the woman about prevention of STIs and HIV. Informs her that Inj. MPA does not protect from STIs including HIV 19. Determines client’s needs for postpartum, new-born, and infant care services.  If client has given birth recently, discusses or refers for postpartum care, new-born care  For clients with children less than 5 years of age, discusses and arranges or refer for immunizations and growth monitoring services Counselling at the time of repeat visit following Injection 20. Asks how the client is doing with the method and whether she is satisfied. Asks if she has any question or anything to discuss 21. Asks especially if she is concerned about bleeding changes. Gives her information or help she needs 22. Ensures that she gets Inj. MPA even if she is up to 4 weeks late or is up to 2 weeks early 23. Plans for her next injection. Agrees on a date for her next injection (in 3 months/13 weeks for Inj. MPA). Reminds her that she should try to come on time but she should come back no matter how late she is Counselling a client who is more than 4 months late for injection 24. A client who is more than 4 weeks late for injection, determines if injection can be given to her, only if:  She has not had sex since last 2 weeks after she should have had her last injection, or  She has used a backup method (condom) or has taken emergency contraceptive pill (ECPs) after any unprotected sex since after she should have had her last injection If the client is more than 4 weeks late for Inj. MPA and she does not meet above criteria 25. Takes additional steps to be reasonably certain that she is not pregnant 26. Discusses with the client why she was late and provides solutions 27. If coming back on time is often a problem, discusses using a backup method when she is late for her next injection, taking ECPs or choosing Start method specific counselling after woman/couple chooses Inj. MPA during general FP Counselling STEPS/TASK CASES another method

CHECKLIST: METHOS SPECIFIC COUNSELLING ON IUCD (This checklist is for practice and assessment of counselling woman/couple at any time on IUCD) This checklist is for counselling woman/couple at any time on IUCD.

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses IUCD during general FP counselling STEP/TASK CASES 1. Ensure that client has chosen IUCD voluntarily after getting information on various contraceptive options 2. Asks her if she knows about IUCD. Corrects any myths, rumors or misinformation she may express 3. Asks her past experience with IUCD ( if any) 4. For assessing the medical eligibility of clients for IUCD, provider asks questions to ensure that the following conditions are not present, in which IUCD cannot be used by the woman: Interval IUCD: Local infection/prone for STI and Irregular and heavy periods) PPIUCD: Rupture of membrane more than 18 hours/ Chorioamnionitis/ PPH If any of such conditions present guide the client appropriately and suggest suitable method till condition resolved 5. Briefly explains about IUCD i. Safe and very effective method like sterilization. ii. Acts immediately after insertion iii. Fertility returns soon after removal of IUCD iv. It is a reversible method v. It primarily prevents meeting of sperm and ovum, required for fertilization vi. Can act as regular as well as emergency contraceptive vii. Can be used as short term and long term contraceptive 6. Explain woman about when she can get IUCD inserted depending on her condition Start method specific counselling after woman/couple chooses IUCD during general FP counselling STEP/TASK CASES INTERVAL IUCD/PAIUCD PPIUCD Can be inserted within first 12 days of Can be inserted immediately menstrual cycle and any time of the after childbirth and till 48 menstrual cycle, once pregnancy is hours ruled out It does not affect breast milk Can be inserted immediately after the hence can be used by abortion, once it is confirmed that breastfeeding mothers soon procedure is complete after delivery Ask woman to come after next period in case of Medical abortion 7. Explains about potential common side effects like increased amount of bleeding P/V or abdominal cramps during menstrual period may occur in some clients. However, such side effects are reduced after initial months and are not harmful. After PPIUCD, side effects like pain abdomen and bleeding P/v get masked by the same symptoms occurring after delivery-explained to the client 8. Reassures client that these side effects are not serious and stop after a few months of use 9. Talk about the limitation of the method:  Only trained provider can insert and remove IUCD  Does not protect against STI/RTI and HIV infection  Sometimes can get expelled 10. Explains the client why follow up is needed and when she has to come Client should come to facility for routine follow-up at:  4 weeks after interval/post-abortion IUCD insertion or after next period (Whichever occurs earlier)  6 weeks after PPIUCD insertion 11. Tell her about warning signs and she should come back to the facility in case she has any of these symptoms: P: Period related problems or pregnancy symptoms A: Abdominal pain or pain during intercourse I: Infections or unusual vaginal discharge N: Not feeling well, fever, chills S: String problems 12. Asks to repeat the instructions:  What is the time of insertion for Interval IUCD/PPIUCD  Side effects and what to do  When to come for follow up  What are the warning signs 13. Asks and responds if she has any questions or concerns 14. Records the relevant information Start method specific counselling after woman/couple chooses IUCD during general FP counselling STEP/TASK CASES Post Insertion Counselling 15. Ask the client how she feels and resolve if she have any apprehension 16. Explains the client why follow-up is needed once again and when she has to come. Client should come to facility for routine follow-up at:  4 weeks after interval/post-abortion IUCD insertion or after next period (whichever occurs earlier)  6 weeks after PPIUCD insertion 17. Ask to repeat the important key messages 18. Complete the records and give the client IUCD card with follow date mentioned Information for Other Services 19. Educates the woman about prevention of STIs and HIV/AIDS. Informs her that IUCDs do not protect from STIs including HIV/AIDS. 20. Using information collected in earlier steps, determines client’s needs for postpartum, new-born, and infant care services. If client reported giving birth recently, discuss or refer for postpartum care, new-born care For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILLS/ACTIVITY PERFORMED SATISFACTORILY Follow up counselling 21. Greets the woman and asks her the purpose of visit 22. Checks whether the woman is satisfied with the method and is still using it 23. Asks if she has any questions, concerns, or problems with IUCD 24. Explores changes in the woman’s health status or lifestyle that may mean she needs a different family planning method 25. Reassures about side effects 26. If she wants to continue the method, encourage to continue using 27. In case the woman does not want to continue with the method, help her to choose another method 28. Schedules return visit for follow up if required or assure her to visit in case of presence of any warning sign

Checklist: Method Specific Counselling for Progestin-Only-Pills (POPs)

(To be used for practice and assessment of counselling woman/couple at any time on POP)

This checklist is for counselling woman/couple at any time on POP.

Participant ______Date Observed ______

Start method specific counselling after woman/couple chooses POPs during general FP counselling STEP/TASK CASES 1. Ensures that client has chosen POPs voluntarily after getting information on various contraceptive options 2. For assessing the medical eligibility of clients for POPs, provider asks questions to ensure that the following conditions are not present, in which POPs cannot be used by the woman:  Jaundice/Cirrhosis of liver/liver infection/ liver tumour  Blood clot in her legs or lungs  Client taking medication for seizures  Client taking Rifampicin/Rifabutin for tuberculosis  Breast cancer or history of breast cancer 3. Asks her if she knows about POPs. Corrects any myths, rumours or misinformation she may express 4. Asks her past experience with POPs (if any) 5. Explains contraceptive and non-contraceptive benefits of POPs 6. POP can started before 6 weeks of postpartum period. It can also be started immediately after birth 7. Briefly explains how POPs works 8. Its acts best with breast feeding, and its efficacy reduces after 6 months 9. Explains potential common side effects of POPs. Tells her that she may experience few (or possibly none) of these but they can all be managed 10. Reassures client that these side effects are not serious and many will decrease or stop after a few months of use 11. Describes how to take pills and what to do if she misses the pills 12. Responds to any question or concerns the client may have 13. Informs the client when to come for routine follow-up visit. Tells her that she can come to health facility any time if she has any problem Start method specific counselling after woman/couple chooses POPs during general FP counselling STEP/TASK CASES 14. Asks to repeat the instructions:  How to take the pills  When to come for follow up  Side effects 15. Ensures that the client gets the pill packets after screening 16. Records the relevant information

INFORMATION ON OTHER SERVICES

17. Educates the woman about prevention of STIs and HIV/AIDS. Informs her that POPs does not protect from STIs including HIV/AIDS. 18. Using information collected in earlier steps, determines client’s needs for postpartum, newborn and infant care services.  If client reported giving birth recently, discuss or refer for postpartum care, newborn care  For clients with children less than 5 years of age, discuss and arrange or refer for immunizations and growth monitoring services SKILL/ACTIVITY PERFORMED SATISFACTORILY FOLLOW-UP COUNSELLING 19. Greets the woman and asks her the purpose of visit 20. Checks whether the woman is satisfied with the method and still using it 21. Asks if she has any questions, concerns or problems with POPs 22. If she is satisfied with POPs, give her more pill packets 23. Explores changes in the woman’s health status or lifestyle that may require her to change to a different family planning method

Consent Form for Sterilization

I, Smt/Shri ………………………………………… (client) hereby give consent for my sterilization operation. I am ever married. My age is ……years and my husband/wife’s age is ……… years. I have ….… (Nos.) male and ……..(Nos.) female living children. The age of my youngest living child is ……… years. 1. I have decided to undergo the sterilization / re-sterilization operation on my own without any outside pressure, inducement or force. I declare that I / my spouse have/has not been sterilized previously (not applicable in case of re‐sterilization). 2. I am aware that other methods of contraception are available to me. I know that for all practical purposes this operation is permanent and I also know that there are still some chances of failure of the operation for which the operating doctor and health facility will not be held responsible by me or by my relatives or any other person whomsoever. 3. I am aware that I am undergoing an operation, which carries an element of risk. 4. The eligibility criteria for the operation have been explained to me and I affirm that I am eligible to undergo the operation according to the criteria. 5. I agree to undergo the operation under any type of anaesthesia, which the doctor/health facility thinks suitable for me and to be given other medicines as considered appropriate by the doctor/health facility concerned. I also give consent for any additional life‐saving procedure, if required. 6. I agree to come for follow‐up visits to the Hospital/Institution/Doctor/health facility as instructed, failing which I shall be responsible for the consequences, if any. 7. If, after the sterilization operation, I experience a missed menstrual cycle, then I shall report within two weeks of the missed menstrual cycle to the doctor/health facility and may avail of the facility to get an MTP done free of cost. I shall be responsible for the consequences, if any. 8. I understand that Vasectomy does not result in immediate sterilization. *I agree to come for semen examination 3 months after the operation to confirm the success of sterilization surgery (Azoospermia) failing which I shall be responsible for the consequences, if any. (* Applicable for male sterilization cases). 9. In case of complications, failures and the unlikely event of death attributable to sterilization, I/my spouse and dependent unmarried children will accept the compensation as per the existing provisions of the Government of India “Family Planning Indemnity Scheme” as full and final settlement and will not be entitled to claim any other compensation including compensation for upbringing of the child, if any, born on account of failure of sterilization, over and above the one offered, from any court of law in this regard.

I have read the above information or the above information has been read out and explained to me in my own language and that this form has the authority of a legal document.

I am aware that I have the option of deciding against the sterilization procedure at any time without sacrificing my rights to other reproductive health services.

Date: ……………… Signature or Thumb Impression of the Client

Name of client: ……………………………………………………

Signature of Witness (Clients side): ……………………………………………..

Full Name: …………………………………………………………………………………..

Full Address: ……………………………………………………………………………….