What is in this session?
It is important to help women and their partners to gain increased control over their reproductive health. One of the main ways you can do this is through counselling on family planning methods during late pregnancy, the postpartum and the post-abortion periods.
What skills will I develop?
Providing information that builds on existing knowledge
Facilitating shared problem-solving and decision-making
Tailoring to specific family planning needs.
What am I going to learn?
By the end of this session you should be able to:
Assess the family planning needs of individual women
Communicate information on the importance of birth spacing and on family planning method use.
Communicate information on the importance of family planning in the postpartum and post-abortion periods.
Birth spacing and postpartum family planning
Family planning is about deciding how many children you choose to have and when you want to have them (timing of pregnancies and birth spacing). The recommended interval before attempting the next pregnancy is at least 24 months in order to reduce risks to the mother and infant. A woman can become pregnant within several weeks after birth if she has sexual relations and if she is not breastfeeding exclusively. It is important that as a health worker you discuss the importance of family planning and birth spacing, and help couples in choosing the contraceptive method that is right for them.
The role of family planning counselling is to support a woman and her partner in choosing the method of family planning that best suits them and to support them in solving any problems that may arise with the selected method. During late pregnancy, after giving birth and after an abortion, it is important that the woman or the couple receives and discusses correct and appropriate information so that they can choose a method which best meets their needs. If a woman, preferably with her partner, is able to make an informed choice, she is more likely to be satisfied with the method chosen and continue its use.
THE HEALTH BENEFITS OF BIRTH SPACING AND FAMILY PLANNING
Delaying having children can give people the opportunity to complete education or further studies
Waiting to become pregnant at least 24 months after birth can lead to health benefits for the mother and baby.
Spacing births allows the mother to recover physically and emotionally before she gets pregnant again, and faces the demands of pregnancy, birth and breastfeeding.
Limiting the number of children in a family means more resources for each child and more time for the parents to dedicate to each child.
Family planning can also help couples in a sexual relationship not to be worried about the woman getting pregnant.
STIs including HIV/AIDS can also be prevented with correct and consistent use of condoms.
Younger women (adolescents) can delay pregnancy until their bodies are mature and they are ready in terms of their life course.
Older women (over 35) can prevent unwanted pregnancies that are often risky for their health and can lead to complications for both mothers and infants.
When to counsel on birth spacing
You should begin discussing family planning during pregnancy, particularly during the third trimester, after birth and in the immediate postpartum period. Pregnant women need to know that if they are not exclusively breastfeeding they can get pregnant as soon as four weeks after the birth of their baby, even if they have not yet started their menstrual cycle. Several methods of family planning can be started immediately after birth, but others may need to be delayed if the woman is breastfeeding.
If the woman wants female sterilization or an Intrauterine Device (IUD) inserted immediately after childbirth, she should inform her birth attendant and plan to give birth in a health facility.
Advise women about the benefits of using breastfeeding as a family planning choice, known as the Lactational Amenorrhoea Method (LAM). LAM provides protection when the following three requirements are met:
the woman is exclusively breastfeeding a baby, day and night
during the first six months after birth and
her menstrual periods have not returned.
REMINDER
Exclusive breastfeeding means that the baby is not given any other food or drink, not even water. She or he is only given breast milk. See Session 13 for more information on breastfeeding.
Once the baby reaches six months, or receives complementary foods or the mothers' periods have returned, she should use another family planning method. Before this time she needs to start thinking about what method she will use after LAM.
Counselling a woman on family planning after an abortion
When advising a woman how to care for herself after an abortion (see Session 9 as well), remember that it is important to discuss the use of a family planning method to prevent another unwanted pregnancy. Explain that she can become pregnant as soon as two weeks after an abortion if she begins to have sexual relations. A woman who has recently experienced an induced or spontaneous abortion should wait at least six months before another pregnancy to reduce risks to her health and to her future baby.
You can support her and her partner in choosing a method that meets their needs:
If she has no post-abortion complications or infection, she can safely use any family planning method, and can start all methods immediately post-abortion (except for the natural calendar method, when she should wait for 3 months).
If an infection is present or suspected, advise her to avoid intercourse until the infection is ruled out or fully treated. Delay female sterilization and IUD insertion until an infection is fully treated, but offer other methods to use in the meantime.
For IUD insertion or female sterilization after a second trimester abortion, the provider may need special training because of the changed uterine size and the position of the fallopian tubes.
If she thinks she could be at risk of getting STI/HIV, she should use a condom in all sexual relations.
It may also be helpful to explain emergency contraception, and offer her emergency contraceptive pills to take home in case she needs them.
Male partner
The partner should be encouraged to take part in family planning counselling sessions, especially if the chosen method involves his cooperation, for example, condoms or natural methods. In some places research has shown that family planning method use is more successful when partners choose and agree upon a method together. First, ask the woman whether she would be happy for her partner to be involved. In some cases women may feel more comfortable if their partners are not present or if their partners are counselled on their own and/or by a male counsellor.
Within the community, men also need to participate in discussions on the importance and benefits of family planning and birth spacing. Men need to understand their role in reproduction so that they can share the responsibility for family planning and birth spacing. This can be done through outreach work or through discussion with men when they accompany their wives or partners to the health facility.
Women with special needs
Women with special needs may require extra time for family planning counselling. For example, adolescents who are not in a stable relationship, need emphasis placed on the importance of dual protection from STIs/HIV, as well as from pregnancy (see box next page). They may also need special assistance in obtaining the family planning method that suits them best. Women who are in violent relationships may also need special counselling and support to explore their alternatives (i.e. condom use may be unlikely). These women may also not be able to discuss family planning with their partners and may need extra help and support in using family planning methods. Women with physical disabilities may have special requirements in terms of which methods are suitable for their situation and disability. Women with severe physical or mental disabilities may have become pregnant due to rape or abuse. The family needs to be involved in such instances to ensure that this does not recur and also possibly to be involved in discussions around family planning for this woman. Women with HIV must be counselled on the necessity of using dual protection methods, even if their partner is HIV-positive, to prevent other STIs and strains of HIV developing.
REMINDER
Adolescents or unmarried women should also be offered family planning counselling. Sometimes this is difficult if the family or community disapproves of adolescent sexual activity and pregnancy. Explore ways you can work with adolescents, youth groups and schools to reach adolescents who may need support. Consider the counselling context, specifically any cultural norms you identified in Session 4 to help you locate any key gatekeepers in the community to help you address this topic with adolescents.
When working with a pregnant adolescent, it is particularly important to discuss birth spacing and support her in planning when she would be ready for a next pregnancy.
Dual protection (also see Session 14 on HIV)
REMINDER
Correct and consistent use of condoms with another family planning method for every sexual encounter is the best way to ensure dual protection against unwanted pregnancy and HIV/AIDS transmission.
Dual protection against both pregnancy and STIs, including HIV/AIDS, is an increasing concern for many women. You may need to counsel women and their partners about their options for dual protection.
Issues for women and their partners to consider are:
Some people are more at risk than others (for example, those with new or multiple partners).
Often people do not know if they or their partner has an STI as they may have no symptoms.
A person with HIV can look and feel healthy.
If someone is unsure about sexually transmitted infections, a test may be available.
If you are sexually active (and are not 100% sure that your partner is not infected) then consistent and correct condom use is the only way to protect fully against STIs/HIV.
Condoms can be used together with another method to ensure very effective protection from pregnancy and STIs.
Remember that only condoms protect against both pregnancy and STIs/HIV.
Helping a woman to choose a method that is right for her
There is no single method of family planning which should be recommended for everyone. Family planning counselling can help a woman, and/or her partner choose which method best suits him or her.
There are various models of family planning counselling that can be applied, including the GATHER model (Greet the client, Ask about situation and needs, Tell about different methods and options, Help clients choose, Explain how to use a method, Return) or the REDI model (Rapport-building, Exploration, Decision-making, and Implementing the decision). In general, the steps or actions outlined below should be covered to counsel on family planning. To start the counselling process, remember the steps and skills outlined in Session 2.
Assess the situation, her needs and information gaps
In order to help counsel a woman on family planning, it is very important to discuss her and her partner's specific needs and situation.
you can ask if she knows about family planning, what she has heard about it, and if she knows it is important;
explain that it is important to know that she can become pregnant soon after giving birth if she is not exclusively breastfeeding;
you should also ask whether the woman or couple already have a family planning method in mind – those people who receive the method that they have planned for are much more likely to use it successfully. You can then help them assess if this method suits their situation and needs (e.g., Are you confident you could remember to take a pill every day?), or it may also be helpful to discuss other options in case there is a method that better suits his/her or their needs.
When discussing her needs and situation, you can ask about:
plans for having more children;
whether she and/or her partner want to use family planning;
previous methods used and reasons for success or failure;
experience with side-effects;
popular beliefs about family planning and how these affect her decision to choose a particular method;
her relationship and situation; Is she in a stable relationship? How often does she see her partner? How many partners does she have?; Is there need for dual protection from STIs, including HIV?
her and her partner's HIV status or risk factors for HIV;
regularity of sexual intercourse (especially for adolescents or unmarried women);
partner's or family's views about family planning methods;
ability to keep to routines.
Help to prioritize solutions, narrow down options and make a good choice
You can then discuss various family planning methods based on the needs and situation of the woman and her partner. Possible methods are listed in the below. Key method characteristics that can be discussed include:
Can the method be used while breastfeeding?
How effective is it?
Are there any side-effects?
Does it provide protection from STIs or HIV?
Does it impact on sexual relations?
How easy is it to use?
Is it easy to stop using the method?
Is the method reversible?
How quickly will fertility return once method is stopped?
Is there a need to do something before sex? (e.g. putting a condom on, inserting a diaphragm)
Is it used continuously, or only used when needed?
Is there a need to touch genitals?
Check if she is eligible to use the chosen method
Before giving out detailed information on method use, check if the woman is eligible to use the method. Some women who have recently given birth or who are breastfeeding may be unable to use certain methods (see below). You can also check if she is able to start using the family planning method straight away. Some health conditions may prevent a woman from using certain methods.
Provide useful information on the chosen method
Women and their partners need accurate information to use a family planning method correctly. Although too much information can be unhelpful or off-putting, there are some key pieces of information that must be explained:
What the method is and how it works
How effective it is at preventing pregnancy
Side-effects: what the user can expect, and what to do about them
How to use the method correctly
What to do in case of a mistake in the use of the method or problems (missed pills, late for injection, condom splits)
Information on when to return to the clinic
Signs of complications to watch out for.
The best way to check whether a woman knows how to use the method is to ask her to explain to you in her own words how to use the method. You could also ask her to demonstrate the use of certain methods such as condoms or diaphragms, or you could consider demonstrating their use to her first, asking for her to repeat back the demonstration afterwards to ensure that she has fully understood.
TableStarting family planning methods after childbirth
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| Method | Breastfeeding | Not breastfeeding | Effectiveness |
|---|
LAM
(Breastfeeding) | Start immediately after childbirth; can use if exclusively breastfeeding day and night for up to 6 months or until periods return | N/A | Very effective with correct use, few side effects |
| IUD | Insert within 2 days of childbirth, or from 4 weeks after childbirth | Insert within 2 days of childbirth, or from 4 weeks after childbirth | Always very effective, long term method but may have side-effects |
| Female sterilization | Perform within 7 days, or from 6 weeks after childbirth | Perform within 7 days, or from 6 weeks after childbirth | Always very effective, permanent method, fewer side-effects |
| Combined pill (estrogenprogestogen) | From 6 months after childbirth | From 3 weeks after childbirth | Very effective with careful use, may have side-effects |
Monthly injection
(combined) | From 6 months after childbirth | From 3 weeks after childbirth | Very effective with careful use, may have side-effects |
Mini-pill
(progestogenonly) | From 6 weeks after childbirth | From immediately after childbirth | Very effective with careful use, may have side-effects |
| DMPA and NET-EN (3 or 2 month injection) | From 6 weeks after childbirth | From immediately after childbirth | Very effective with careful use, may have side-effects |
| Implants | From 6 weeks after childbirth | From immediately after childbirth | Always very effective, long term method but may have side-effects |
| Condoms | From immediately after childbirth | From immediately after childbirth | Effective with careful use |
| Diaphragm | From 6 to 12 weeks after childbirth (depending on when the uterus and cervix return to normal) | From 6 to 12 weeks after childbirth (depending on when the uterus and cervix return to normal) | Effective with careful use |
| Fertility awareness-based methods | When periods return to normal | When periods return to normal | Effective with careful use |
Activity 1
variable
To practise your skills at family planning counselling
If you are working in a group carry out this activity as a role-play rotating the roles. Take time in advance to come up with a number of different roles. If you are working alone, ask a colleague to observe you counselling women.
Review the material covered in this session and make your own notes or reminders to help you with family planning counselling. Focus on:
finding out what is already known
dispelling any myths or misunderstandings regarding contraception
engaging the woman and her partner in interactive discussion
filling information gaps
discussing the woman's/couples needs
tailoring methods to their circumstances (physical, social)
discussing characteristics of different methods
joint decision-making
Get the person who will be observing you to review this session beforehand. Remember to get permission from the woman or couple for the observer to be present if you will be carrying out this activity in a real situation rather than a role-play
Ask the observer to give you feedback on your strengths and weaknesses during the counselling process using the points outlined above as a checklist. You can also refer back to
Session 9 Activity 2 for a more general observer's checklist.
Our View
Because of expertise and knowledge and the respect person in the community have for this knowledge, we can sometimes inadvertently push people towards decisions that they are not ready to make or are not happy with. Skilled counsellors facilitate the process while taking a ‘back seat’ when it comes to making a decision. In other words they let the woman or couple reach their own decision. Your questioning and listening skills will help you to make accurate assessments and know where to provide guidance and where to take a step back, as people work through the information.
What did I learn?
The importance of establishing family planning during the post-abortion and postpartum periods cannot be underestimated. Providers need to work in an interactive way with women and their partners to discuss their family planning needs and to establish which methods will best satisfy their particular needs. Are you confident that you can discuss family planning issues with women and their partners during pregnancy and the postpartum period? Which skills do you need to develop and practise? Do you have access to Family Planning tools to assist you? Do you know where to refer women and their partners for specialist family planning advice?
Write down the answers to this information in your notebook, but also consider putting it together as a resource to share with your colleagues. Remember also that as you practise your counselling skills you should try and reflect on where you have improved and areas you feel you need to strengthen.
