Importance of Selected Procedures for Providing Family Planning Methods
Class A: Essential and mandatory in all circumstances for safe and effective use of the contraceptive method.
Class B: Contributes substantially to safe and effective use. If the test or examination cannot be done, however, the risk of not performing it should be weighed against the benefits of making the contraceptive method available.
Class C: Does not contribute substantially to safe and effective use of the contraceptive method.
The classifications below of examinations and tests apply to people who are presumed to be healthy. For a person with a known medical condition or other special condition, refer to the Medical Eligibility Criteria for Contraceptive Use.
• If a woman has a very high individual likelihood of exposure to gonorrhea or chlamydia, she generally should not have an IUD unless other methods are not acceptable. If she has current purulent cervicitis, gonorrhea, or chlamydia, she should not have an IUD inserted until these conditions are resolved and she is otherwise medically eligible.
Women at high risk of HIV Infection or AIDS should not use spermicides. Using diaphragms and cervical caps with spermicide is not usually recommended for such women unless other more appropriate methods are not available or acceptable.
Desirable, but in settings the risks of pregnancy are high, and hormonal methods are among the few methods widely available, women should not be denied use of hormonal methods solely because their blood pressure cannot be measured.
For procedures performed using only local anesthesia.
Good counseling helps clients choose and use family planning methods that suit them. Clients differ, their situations differ, and they need different kinds of help. The best counseling is tailored to the individual client.
|Client Type||Usual Counseling Tasks|
|Returning clients with no problems||• Provide more supplies or routine follow-up
• Ask a friendly question about how the client is doing with the method
|Returning clients with problems||• Understand the problem and help resolve it— whether the problem is side effects, trouble using the method, an uncooperative partner, or another problem|
|New clients with a method in mind||• Check that the client’s understanding is accurate
• Support the client’s choice, if client is medically eligible
• Discuss how to use method and how to cope with any side effects
|New clients with no method in mind||• Discuss the client’s situation, plans, and what is important to her about a method
• Help the client consider methods that might suit her. If needed, help her reach a decision
• Support the client’s choice, give instructions on use, and discuss how to cope with any side effects
Give time to clients who need it. Many clients are returning with no problems and need little counseling. Returning clients with problems and new clients with no method in mind need the most time, but usually they are few.
Tips for Successful Counseling
• Show every client respect, and help each client feel at ease.
• Encourage the client to explain needs, express concerns, ask questions.
• Let the client’s wishes and needs guide the discussion.
• Be alert to related needs such as protection from sexually transmitted infections including HIV, and support for condom use.
• Listen carefully. Listening is as important as giving correct information.
• Give just key information and instructions. Use words the client knows.
• Respect and support the client’s informed decisions.
• Bring up side effects, if any, and take the client’s concerns seriously.
• Check the client’s understanding.
• Invite the client to come back any time for any reason.
Counseling has succeeded when:
• Clients feel they got the help they wanted
• Clients know what to do and feel confident that they can do it
• Clients feel respected and appreciated
• Clients come back when they need to
• And, most important, clients use their methods effectively and with satisfaction.
Counseling Tool Available from the World Health Organization and the INFO Project
The Decision-Making Tool for Family Planning Clients and Providers, another of the World Health Organization’s 4 cornerstones of family planning guidance, helps clients and providers in counseling sessions with choosing and learning to use family planning methods. This tool is an illustrated flip chart. It offers help tailored for each type of client mentioned in the table on previous page. Key information from this handbook can be found in the Decision-Making Tool, worded in a way that may be helpful for counseling.
Who Provides Family Planning?
Many different people can learn to inform and advise people about family planning and to provide family planning methods. Countries and programs have various guidelines about who can offer which methods and where, and some have rules that differ depending on whether the client is starting a new method or is continuing a method. Still, in countries around the world these people commonly provide family planning:
• Nurses, nurse-midwives, nurse-practitioners
• Auxiliary nurse-midwives
• Physicians, including gynecologists and obstetricians
• Physicians’ assistants, physicians’ associates
• Pharmacists, pharmacists’ assistants, chemists
• Primary health care providers, community health care providers
• Community-based health workers and community members serving as community-based distributors
• Specifically trained traditional birth attendants
• Shopkeepers and vendors
• Volunteers, experienced users of family planning, peer educators, and community leaders
Specific training helps all these people do a better job at providing family planning. Training needs to cover skills in informing and counseling clients about choosing and using specific methods as well as teaching any specific technical skills such as how to give injections or insert an IUD. Checklists can help a wide range of providers and managers in various ways, such as screening clients for medical eligibility criteria, making sure all steps in a process are carried out (such as infection prevention), and assuring good quality of services.
|Method||Who can provide?|
|Oral contraceptives, combined patch, combined vaginal ring||• All providers with training, including brief specific training.|
|Emergency contraceptive pills||• All providers.|
|Monthly and progestin-only injectables||• Anyone trained to give injections and to handle needles and syringes properly, including appropriate disposal.|
|Implants||• Anyone with training in medical procedures and training in insertion of the specific implants being used, including physicians, nurses, nurse-midwives, nurse-practitioners, midwives, physicians’ assistants and associates.|
|Intrauterine Device (copper-bearing and hormonal IUDs)||•Anyone with training in medical procedures and specific training in IUD screening, insertion, and removal including physicians, nurses, nurse-midwives, midwives, nurse-practitioners, physicians’ assistants and associates, and medical students. Training is different for the copper-bearing IUD and the hormonal IUD. In some countries pharmacists sell IUDs—the woman takes the IUD to a health care provider who inserts it.|
|Female sterilization||• Anyone with specific training in the procedure, including general physicians, specialized physicians (such as gynecologists and surgeons), medical assistants or medical students under supervision. Laparoscopy is best performed by experienced and specifically trained surgeons.|
|Vasectomy||• Anyone with specific training in the procedure, including physicians, medical officers, nurse- midwives, nurse practitioners, midwives, physicians’ assistants and associates.|
|Male and female condoms and spermicides||• All providers.|
|Diaphragms and cervical caps||• Any provider specifically trained to perform pelvic examinations and to choose the right size diaphragm or cervical cap for each woman.|
|Fertility awareness methods||• Anyone specifically trained to teach fertility awareness. Experienced users of these methods often make the best teachers.|
|Withdrawal, lactational amenorrhea method||• These methods do not require a provider. Still, knowledgeable and supportive health care providers can help clients use these methods most effectively.|
Infection Prevention in the Clinic
Infection-prevention procedures are simple, effective, and inexpensive. Germs (infectious organisms) of concern in the clinic include bacteria (such as staphylococcus), viruses (particularly HIV and hepatitis B), fungi, and parasites. In the clinic, infectious organisms can be found in blood, body fluids with visible blood, or tissue. (Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomit are not considered potentially infectious unless they contain blood.) The organisms can be passed through mucous membranes or broken skin, such as cuts and scratches, and by needlesticks with used needles and other puncture wounds. Infectious organisms can pass from clinics to communities when waste disposal is not proper or staff members do not wash their hands properly before leaving the clinic.
Basic Rules of Infection Prevention
These rules apply the universal precautions for infection prevention to the family planning clinic.
• Hand washing may be the single most important infection-prevention procedure.
• Wash hands before and after examining or treating each client. (Hand washing is not necessary if clients do not require an examination or treatment.)
• Use clean water and plain soap, and rub hands for at least 10 to 15 seconds. Be sure to clean between the fingers and under fingernails.
Wash hands after handling soiled instruments and other items or touching mucous membranes, blood, or other body fluids. Wash hands before putting on gloves, after taking off gloves, and whenever hands get dirty. Wash hands when you arrive at work, after you use the toilet or latrine, and when you leave work. Dry hands with a paper towel or a clean, dry cloth towel that no one else uses, or air-dry.
Process instruments that will be reused
• High-level disinfect or sterilize instruments that touch intact mucous membranes or broken skin.
• Sterilize instruments that touch tissue beneath the skin.
• Wear gloves for any procedure that risks touching blood, other body fluids, mucous membranes, broken skin, soiled items, dirty surfaces, or waste. Wear surgical gloves for surgical procedures such as insertion of implants. Wear single-use examination gloves for procedures that touch intact mucous membranes or generally to avoid exposure to body fluids. Gloves are not necessary for giving injections.
• Change gloves between procedures on the same client and between clients.
• Do not touch clean equipment or surfaces with dirty gloves or bare hands.
• Wash hands before putting on gloves. Do not wash gloved hands instead of changing gloves. Gloves are not a substitute for hand washing.
• Wear clean utility gloves when cleaning soiled instruments and equipment, handling waste, and cleaning blood or body fluid spills.
Do pelvic examinations only when needed
• Pelvic examinations are not needed for most family planning methods—only for female sterilization and the IUD. Pelvic examinations should be done only when there is a reason— such as suspicion of sexually transmitted infections, when the examination could help with diagnosis or treatment.
For injections, use new auto¬disable syringes and needles
• Auto-disable syringes and needles are safer and more reliable than standard single-use disposable syringes and needles, and any disposable syringes and needles are safer than sterilizing reusable syringes and needles. Reusable syringes and needles should be considered only when single-use injection equipment is not available and if programs can document the quality of sterilization.
• Cleaning the client’s skin before the injection is not needed unless the skin is dirty. If it is, wash with soap and water and dry with a clean towel. Wiping with an antiseptic has no added benefit.
Wipe surfaces with chlorine solution
• Wipe examination tables, bench tops, and other surfaces that come in contact with unbroken skin with 0.5% chlorine solution after each client.
Dispose of single-use equipment and supplies properly and safely
• Use personal protective equipment—goggles, mask, apron, and closed protective shoes— when handling wastes.
• Needles and syringes meant for single use must not be reused. Do not take apart the needle and syringe. Used needles should not be broken, bent, or recapped. Put used needles and syringes immediately into a puncture-proof container for disposal. (If needles and syringes will not be incinerated, they should be decontaminated by flushing with 0.5% chlorine solution before they are put into the puncture-proof container.) The puncture-proof sharps container should be sealed and either burned, incinerated, or deeply buried when three-fourths full.
• Dressings and other soiled solid waste should be collected in plastic bags and, within 2 days, burned and buried in a deep pit. Liquid wastes should be poured down a utility sink drain or a flushable toilet, or poured into a deep pit and buried.
• Clean waste containers with detergent and rinse with water.
• Remove utility gloves and clean them whenever they are dirty and at least once every day.
• Wash hands before and after disposing of soiled equipment and waste.
• Wash linens (for example, bedding, caps, gowns, and surgical drapes) by hand or machine and line-dry or machine-dry. When handling soiled linens, wear gloves, hold linens away from your body, and do not shake them.
Little Risk of HIV Infection in the Clinic
Health care providers may be exposed to HIV through needle sticks, mucous membranes, or broken skin, but the risk of infection is low:
• Needle sticks or cuts cause most infections in health care settings. The average risk of HIV infection after a needle stick exposure to HIV-infected blood is 3 infections per 1,000 needle sticks.
• The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be about I infection per 1,000 exposures.
Following universal precautions is the best way that providers can avoid workplace exposure to HIV and other fluid-borne infections.
Make Infection Prevention a Habit
With each and every client, a health care provider should think,”What infection prevention is needed?” Any client or provider may have an infection without knowing it and without obvious symptoms.
Infection prevention is a sign of good health care that can attract clients. For some clients cleanliness is one of the most important signs of quality.
The 4 Steps of Processing Equipment
1. Decontaminate to kill infectious organisms such as HIV and hepatitis B and to make instruments, gloves, and other objects safer for people who clean them. Soak in 0.5% chlorine solution for 10 minutes. Rinse with clean cool water or clean immediately.
2. Clean to remove body fluids, tissue, and dirt. Wash or scrub with a brush with liquid soap or detergent and water. Avoid bar soap or powdered soap, which can stay on the equipment. Rinse and dry. While cleaning, wear utility gloves and personal protective equipment—goggles, mask, apron, and enclosed shoes.
3. High-level disinfect or sterilize.
• High-level disinfect to kill all infectious organisms except some bacterial endospores (a dormant, resistant form of bacteria) by boiling, by steaming, or with chemicals. High-level disinfect instruments or supplies that touch intact mucous membranes or broken skin, such as vaginal specula, uterine sounds, and gloves for pelvic examinations.
• Sterilize to kill all infectious organisms, including bacterial endospores, with a high-pressure steam autoclave, a dry-heat oven, chemicals, or radiation. Sterilize instruments such as scalpels and needles that touch tissue beneath the skin. If sterilization is not possible or practical (for example, for laparoscopes), instruments must be high-level disinfected.
4. Store instruments and supplies to protect them from contamination. They should be stored in a high-level disinfected or sterilized container in a clean area away from clinic traffic. The equipment used to sterilize and high-level disinfect instruments and supplies also must be guarded against contamination.
Managing Contraceptive Supplies
Good-quality reproductive health care requires a continuous supply of contraceptives and other commodities. Family planning providers are the most important link in the contraceptive supply chain that moves commodities from the manufacturer to the client.
Accurate and timely reports and orders from providers help supply chain managers determine what products are needed, how much to buy, and where to distribute them. Clinic staff members do their part when they properly manage contraceptive inventory, accurately record and report what is provided to clients, and promptly order new supplies. In some facilities one staff member is assigned all the logistics duties. In other facilities different staff members may help with logistics as needed. Clinic staff members need to be familiar with, and work within, whatever systems are in place to make certain that they have the supplies they need.
Logistics Responsibilities in the Clinic
Each supply chain operates according to specific procedures that work in a specific setting, but typical contraceptive logistics responsibilities of clinic staff include these common activities:
• Track the number and types of contraceptives dispensed to clients using the appropriate recording form (typically called a “daily activity register”).
• Maintain proper storage conditions for all supplies: clean, dry storage, away from direct sun and protected from extreme heat.
• Provide contraceptives to clients by “First Expiry, First Out” management of the stock of supplies. “First Expiry, First Out,” or FEFO, sees to it that products with the earliest labeled expiry dates are the first products issued or dispensed. FEFO clears out older stock first to prevent waste due to expiry.
Regularly (monthly or quarterly, depending on the logistics system)
• Count the amount of each method on hand in the clinic and determine the quantity of contraceptives to order (often done with a clinic pharmacist). This is a good time to inspect the supplies, looking for such problems as damaged containers and packages, IUD or implant packaging that has come open, or discoloration of condoms.
• Work with any community-based distribution agents supervised by clinic staff, reviewing their consumption records and helping them complete their order forms. Issue contraceptive supplies to community-based agents based on their orders.
• Report to and make requests of the family planning program coordinator or health supplies officer (typically at the district level), using the appropriate reporting and ordering form or forms. The quantity that is ordered is the amount that will bring the stock up to the level that will meet expected need until the next order is received. (A plan should be made in advance to place emergency orders or borrow supplies from neighboring facilities if there are sudden increases in demand, potential for running out of inventory, or large losses, for example, if a warehouse is flooded.)
• Receive the ordered contraceptive supplies from the clinic pharmacist or other appropriate person in the supply chain. Receipts should be checked against what was ordered.