Contraception and Family Planning

Contraception is the deliberate use of a drug, device, behaviour or procedure to prevent pregnancy after sexual intercourse.

Family planning is wider: it is the ability of individuals and couples to decide whether and when to have children, how many to have and how to space them. It includes contraception, preconception care, management of subfertility and safe care after pregnancy loss.

For the clinician, contraception is a preventive medical intervention with measurable benefit, defined risks and a clear duty of informed choice.

Public health impact. Effective contraception lowers maternal deaths by preventing high-risk, unintended and closely spaced pregnancies, reduces unsafe abortion, and improves neonatal and child survival through birth spacing.

Birth spacing. An interval of at least 24 months from a live birth to the next conception, and at least 6 months after a miscarriage or induced abortion, lowers the risk of preterm birth, low birth weight, maternal anaemia and perinatal death.

Unmet need. Unmet need is the proportion of sexually active people who wish to delay or stop childbearing but use no modern method. It remains high among adolescents, postpartum women, rural populations and the poorest households.

Rights base. Contraceptive care rests on voluntary, informed and free choice, privacy, confidentiality, non-discrimination and access to the full method mix without targets, incentives or coercion.

Core principles for practice.

• Offer the widest method mix the facility can provide, including referral for methods not stocked.

• Treat the patient as the decision maker; the clinician provides accurate information and screens for safety.

• Remove barriers that have no medical basis: routine pelvic examination, laboratory tests, spousal consent, parity rules or age limits.

• Integrate contraception into antenatal, postnatal, postabortion, HIV, tuberculosis, immunisation and outpatient visits.

Who needs contraception. Every person with pregnancy potential who is sexually active, or likely to become so, and does not desire pregnancy now. This includes adolescents, postpartum and postabortion patients, people living with HIV, people with chronic disease or on teratogenic medicines, and women aged over 40 until contraception is no longer needed.

Teratogenic and high-risk medicines. Patients taking valproate, isotretinoin, warfarin, methotrexate, mycophenolate, angiotensin converting enzyme inhibitors, statins or other teratogens need highly effective contraception, preferably a long-acting reversible method, for as long as the drug is taken and for the washout period afterwards.

Medical conditions where pregnancy is dangerous. Pulmonary hypertension, severe valvular disease, cardiomyopathy with reduced function, complicated sickle cell disease, uncontrolled epilepsy, active cancer and advanced kidney or liver disease make an unplanned pregnancy a serious threat. These patients warrant priority counselling and the most effective method they can safely use.

Method groups.

• Long-acting reversible methods: implants, copper IUDs and levonorgestrel IUDs.

• Short-acting hormonal methods: combined pills, patch, ring, combined injectables, progestin-only pills and progestin-only injectables.

• Barrier methods: external and internal condoms, diaphragm, cervical cap and spermicides.

• Fertility awareness based methods, lactational amenorrhoea method and withdrawal.

• Permanent methods: female sterilisation and vasectomy.

• Emergency methods: levonorgestrel and ulipristal acetate pills, and the copper IUD.

Return to fertility. Fertility returns promptly after stopping every reversible method except injectables, where the median delay after the last DMPA injection is about 9 to 10 months, and up to 18 months in a minority.

Structure of a family planning visit.

• Establish the reason for attending and reproductive intentions.
• Take a focused medical, obstetric, menstrual, sexual and drug history.
• Measure blood pressure and weight.
• Exclude pregnancy.
• Discuss suitable methods with their effectiveness, effects on bleeding, side effects and return to fertility.
• Confirm eligibility.
• Provide the method.
• Give clear instructions on backup, missed use and warning signs.
• Plan follow up and resupply.

Minimum examination. Blood pressure is the only routine measurement needed before combined hormonal methods. Pelvic examination is needed before IUD insertion and sterilisation. Breast examination, cervical screening, haemoglobin, lipids, glucose and liver tests are not needed to start any method in a healthy patient, although cervical screening and HIV testing may be offered at the same visit.

Same-day provision. Provide the chosen method at the first visit whenever the patient is reasonably certain not to be pregnant, or start a quick-start method with backup when certainty is lower. Delay creates unintended pregnancies.

Dual protection. Counsel every patient at risk of STIs or HIV on condom use with or without another method, and offer HIV testing and pre-exposure prophylaxis where appropriate.

Documentation. Record the method, product, strength, batch number for implants and IUDs, start date, next due date, counselling given and the patient's choice.

Common errors.

• Withholding a method because of age, parity, marital status or partner consent.

• Insisting on menses before starting a method when pregnancy can be reasonably excluded.

• Ignoring enzyme-inducing medicines such as rifampicin, carbamazepine, phenytoin and efavirenz, which reduce the effect of pills, patch, ring and implants.

• Prescribing combined methods without checking blood pressure, migraine with aura, smoking over age 35 or recent childbirth.

• Failing to discuss expected bleeding changes, the main reason for early discontinuation.

Special groups. Adolescents, postpartum and postabortion patients, people living with HIV and people with disability need specific counselling and often a long-acting method; their eligibility follows the same medical criteria as other adults and is not restricted by age or status alone.

Referral and escalation. Refer for methods not available on site, for patients with complex medical conditions where eligibility is category 3 or 4 for most methods, for difficult device removal, and for sterilisation. Refer survivors of sexual violence for post-exposure prophylaxis, emergency contraception and psychosocial care at the same visit.