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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
close this folder Unit 7: Family planning and nutrition
View the document Session 1: Family planning and nutrition
View the document Session 2: Providing the facts about family planning
View the document Session 3: Community-based distribution of family planning methods

Unit 7: Family planning and nutrition

SESSION 1: Family Planning and Nutrition

SESSION 2: Providing the Facts About Family Planning

SESSION 3: Community-Based Distribution of Family Planning Methods

UNIT OVERVIEW

Short birth intervals and large families are common causes of malnutrition in most countries. Communities can kelp prevent malnutrition by making family planning information and contraceptive methods available to all couples.

When we use the tern, "family planning" in this unit, we are talking about two things:

- Lengthening the time between births - birth spacing

- Limiting the total number of births according to what a couple desires

Session 1: Family planning and nutrition

Successful programs to improve nutrition and increase family planning acceptance provide factual information to men and women. Some also prepare adolescents for their future roles as parents by providing orientation in responsible parenthood and reproductive physiology.

Purpose:

Trainees review the benefits of family planning and the traditional and modern methods of contraception. Facts about breastfeeding and family planning are also discussed.

Time:

Family planning workers - 2 hour review

Non-family planning workers - 2 hours

Materials:

- Flipchart and marking pens

- Handout - "Facts About Family Planning methods"

- Handout - "Breastfeeding and Family Planning''

Steps:

1. Read the two problem cases below to the group.

 

Problem 1

A community worker visits the home of a middle income family in the village. The mother greets her carrying a healthy four-month-old baby boy. Behind her is a thin little girl about two years old; her dark hair is streaked with light colored areas and she is coughing. When the worker measures her arm with the three-color tape, she finds that the little girl is severely malnourished (Red). The community worker thinks, "This is a prosperous family. How can they have such a sick child?"

Problem 2
In another home, the worker meets a mother who has just come from the field. Looking around, the worker notices that the house is in very poor condition. Chickens, buffalo and people seem to share the same living space. There are two young children in this family, one about four years old and the other eighteen months old. Both children have yellow arm circumference (moderate malnutrition). The older one is sick with fever and diarrhea. The woman tells the worker that she has given birth to nine children but only four are living; all of the others died before they were four years old. The worker asks herself, "What can be done to help this family?.

Ask the following questions about each problem to promote discussion:

- What are the possible causes of malnutrition?

- What should the community worker do to help the family?

Answers should include:

- Teach them how to feed the child.

- Talk to them about family planning

2. What Is Family Planning?

Ask trainees to define "family planning" by finishing the sentence:

Family planning is________________________________________________________________.

Write five or six responses on the flipchart, and work with the group to develop a definition that all can accept. Some of the definitions from other workshops have included:

- "Family planning is having the number of children you want when you want them. "

- "Family planning is having the number of children you can support emotionally and financially."

3. Tell trainees that the term Family Planning will be used in this unit to mean two things:

- Spacing births to insure the health of mothers and children

- Limiting the number of births to control the size of one's family

4. Benefits of Family Planning

Ask trainees to brainstorm answers to the following question:

- "How does family planning contribute to improved nutrition and health for women and children?"

Write the answers on the flipchart.

5. Review the following consequences of closely spaced, repeated pregnancies:

- Maternal depletion - Women who do not allow at least two years between pregnancies are more often malnourished than those who allow two or more years between births. Women who do not space their pregnancies have a greater chance of complications during pregnancy and birth; their infants may be small and malnourished; and they may have difficulty breastfeeding.

Family planning can help a couple to allow at least two years between births. This allows a woman to regain her strength so that she and her infant will be properly nourished and healthy.

- Early termination of breastfeeding - If a woman becomes pregnant when her youngest child is less than two years old, that child will often become malnourished. In some cultures, this is because breastfeeding is stopped as soon as the woman discovers she is pregnant, or shortly before the new baby arrives. When this ha>pens, the young child doses the nutrients from breast milk at the same time that he is exposed to more contamination from new foods. Also, the mother has less time to care for the older child even though he is at a stage (weaning) when more attention should be given to feeding and hygiene. Protein energy malnutrition is frequently the result of the early termination of breastfeeding because of a new pregnancy.

Family planning can help couples space the births of their children so that one child has passed the critical weaning stage before another one is conceived.

(For a more detailed discussion of breastfeeding see Session I-3)

- Limited family resources, especially food - The amount of food a family can produce or buy is an important determinant of nutrition status. The number of family members determines the amount of food given to women and children as well as the family's resources for health care, education, etc.

Family planning can help families limit the number of children to those they can feed and care for.

6. Traditional Methods of Family Planning

Point out that family planning is not a new practice in most areas. Ask trainees if couples in their areas have any traditional ways for avoiding births. These might include:

- Abstinence from sexual intercourse. In Africa, couples traditionally abstained from intercourse while a woman was breastfeeding (2-3 years). In polygamous areas, a husband would often stay with another of his wives during this period. These customs are changing rapidly in many areas.

- Breastfeeding - Breastfeeding (on demand) gives several months of natural protection from pregnancy to most women. However, use of feeding bottles and the introduction of breast milk supplements at earlier and earlier ages have shortened the natural birth-spacing effects of breastfeeding.

- Septic Abortion - For centuries, women have resorted to illegal abortion to avoid having additional children. These abortions are often performed by untrained persons under unsterile conditions. In Latin America, complications from septic abortion are estimated to cause 30-50% of maternal deaths; in Bangladesh, 26% of pregnancy-related deaths have been attributed to illegal abortions. Although underreported, septic abortion is believed to be a significant cause of maternal death throughout the developing world. (Favin, et al. "Improving Maternal Health in Developing Countries," p. 3-6)

7. Modern Methods of Family Planning - Distribute the Handout - "Facts About Family Planning Methods." Use pictures/slides and samples of contraceptives available in the areas where trainees work, to describe:

- what each method looks like;

- how it is used;

- how it functions to stop pregnancy;

- common side effects and danger signs.

Point out that, in order to be effective, some family planning methods require significantly more knowledge and more motivation on the part of the users than do other methods.

(You may need to review the physiology of reproduction with some groups.)

8. Breastfeeding and Family Planning - Distribute the Handout - "Facts About Breastfeeding and Family Planning." Review the relationship between breastfeeding and the nutrition status of an infant. List the contraceptives that are appropriate for use by a breastfeeding woman. Discuss when a couple should begin using a family planning method to delay a new pregnancy. This varies from community to community. (See WHO, Breastfeeding and Fertility Regulation, p. 377.)

9. Summary - Ask participants to list information presented during this session that was new to them.

Leave time for questions and answers. Even groups with previous family planning experience and training will have questions and doubts that need to be answered.

FACTS ABOUT FAMILY PLANNING

METHOD

WHAT IT DOES

HOW IT IS USED

POSSIBLE PROBLEMS

WARNING SIGNALS

Permanent Methods

Vasectomy - Men

A small section of the vas deferens (the tube through which sperm travels from the testes to the penis) is removed. This blocks the sperm from leaving a man's body in the semen, but has no effect on potency or ability to have intercourse. Effectiveness: 99%

A vasectomy is a surgical procedure. A local anesthetic is given and a small incision is made in the scrotum on the right or the left side. The vas is found, a small section is removed and the incision is closed. This is repeated on the other side.

Swelling and discomfort following the surgery. Infections occur in rare cases. Because a man is not immediately sterile after a vasectomy (some sperm remain in the tubes), precautions should be taken by using a temporary contraceptive for at least the first month. In rare cases, the vas may grow together again. This can result in an unwanted pregnancy.

Excessive pain or swelling Fever

Tubal Ligation - Women

A small section of each fallopian tube is removed or clamped. This blocks the eggs from traveling from the ovaries to the uterus, and it blocks sperm from reaching the egg for fertilization, but has no effect on the ability to have intercourse. Effectiveness: 99%

Mini laparoscopy is the next common and the simplest method of tubal ligation. A local anesthetic is given and a small incision (2-3 cm) is made below the umbilicus. The fallopian tubes are found, using the laparoscope, and a small section of each is either re- moved, cauterized or clamped. The incision is closed with absorbable sutures.

Pain and discomfort following surgery. In a few cases, the tubes grow back together and pregnancy occurs. If a woman misses a period, she should visit a health worker immediately to find out if she is pregnant.

Fever greater than 100 F Fainting spells Abdominal pain that in creases over 12 hours Bleeding from the incision

Temporary Methods

Oral Contraceptives

Oral contraceptives contain hormones similar to those produced in a woman's body. These hormones keep the ovaries from releasing eggs. Menstruation continues but may be lighter than before. Effectiveness: 98%

Take oral contraceptives as directed (usually 1 pill each day for 28 days or 21 days with 7 days rest). If pregnancy is desired, stop taking the pills and wait for menstrual periods to resume normally.

Women with high blood pressure, diabetes and excessive weight should not take pills. Women 35 years or older should also be given another method. Breastfeeding women should not take combined oral contraceptives during the first months post-partum because they may decrease milk production.

Swelling or pain in legs Yellowing of skin or eyes Pain in abdomen, chest. arms Shortness of breath Severe headaches Severe depression Blurred or double vision

Intrauterine Device (IUD)

The IUD is a small device made of plastic. The Copper-T and Copper-7 IUD's also contain small amounts of copper. When placed in the uterus, the IUD prevents pregnancy by changing the lining of the uterus. Effectiveness: 96%

An IUD is inserted through the cervix into the uterus by a clinically trained person. The IUD remains in place until it is clinically removed. Some IUD's can remain indefinitely; others using copper must be replaced every 3-4 years.

Many women experience cramping and heavier than normal bleeding during menstruation. The device can also fall out of the uterus, in which case pregnancy may occur. Women should be taught to check the string of the IUD in the vagina to make sure it is in place. If pregnancy occurs, the IUD should be removed immediately to avoid infection.

Severe pain in the lower abdomen Pain during intercourse Unexplained fever and/or chills Increased bad-smelling discharge Inability to find the string

Injection (Medroxy-progesterone acetate (Depo Provera)

A hormone similar to that produced by a woman's body acts to prevent the release of eggs by the ovaries. Effectiveness: 98%

An intramuscular injection is given once every three months to non-pregnant women. The injection should be taken again after three months to insure lasting protection from pregnancy.

Irregular menstrual bleeding; delayed return of fertility after suspending injections; weight gain. Should not be taken by women with irregular genital bleeding, diabetes, cancer.

Prolonged, excessive bleeding Chest pains

Condom

The condom is a sheath of thin rubber or animal tissue worn by the man to keep sperm from entering a woman's vagina Condoms also prevent spread of venereal disease. Effectiveness: 90%(If the woman uses a vaginal spermicide at the same time, effectiveness is increased.)

The condom is put on the man’s erect penis before insertion into the vagina during intercourse. About one-half inch at the top of the penis is left slack to catch the semen. After climax, the condom should be held against the penis as the man withdraws so that the semen does not spill into the vagina. A new condom must be used for each act of intercourse.

Rough handling may tear the condom. Exposure to excessive heat can also weaken rubber and make it more susceptible to tearing.

None

Vaginal Spermicides

Foams, foaming tablets, jellies and creams contain chemicals (spermicides) that stop the sperm from entering the uterus but do not harm the vagina. Effectiveness: 85%(If a man uses a condom at the same time, effectiveness is increased.)

One of these methods is inserted in the vagina before intercourse. It spreads over the entrance to the uterus and the chemical halts sperm movement. Some should be inserted not more than one hour before intercourse; others not more than 10 minutes. More spermicide must be inserted for each act of intercourse.

No known side effects except occasional itching.

None

Breastfeeding

Breastfeeding stimulates certain hormones in the woman's body that keep he ovaries from releasing eggs. Menstruation may be suspended for many months when breast- feeding is frequent (on-demand). Effectiveness: 91-97% Before return of Menstruation.

To be an effective, family planning method, breastfeeding must be on-demand and supplements to breast milk must not be given until 4-6 months. Breastfeeding is an effective contraceptive method for most women until 1-2 months before the return of menstruation. Since it is not possible to know exactly when this will occur, another temporary method of contraception is usually recommended after the(sixth) month.

Breastfeeding-women should not be given combined oral contraceptives during the first months post-partum, as they may reduce milk production. Early return of menstruation. Pregnancy.

None

Natural Family Planning

A woman's body changes each month as it completes the cycle of ovulation and menstruation. Specific signs of ovulation (release of eggs by the ovaries) can tell a woman when she is most likely to become pregnant. By avoiding intercourse several days before, during and after ovulation, a couple can avoid pregnancy. Effectiveness: 81%

A woman's body temperature rises a little when an egg is released and stays up until she begins menstruating. The vaginal mucus increases just before an egg is released, and is clear and slippery. After ovulation it becomes cloudy and sticky. In natural family planning, the temperature is taken and/or the vaginal mucus is checked daily. A woman can learn to recognize the signs of ovulation and take steps to avoid intercourse during this period.

Care must be taken when keeping records and interpreting signs. Illness can produce a rise in temperature. Vaginal infections or use of medications can make it impossible to detect changes in natural vaginal mucus. Mistakes in calculating when ovulation will occur will result in pregnancy.

None

 

HANDOUT

FACTS ABOUT BREASTFEEDING AND FAMILY PLANNING

1. In most parts of the developing world, more births are avoided by breastfeeding than by any other method of family planning.

2. The suckling of an infant at the breast inhibits ovulation, or the release of eggs by the ovaries. This in turn stops menstruation until some months after birth. While a woman is not ovulating, she cannot become pregnant.

3. Frequent breastfeeding (on-demand), including night feeds, increases the number of months of natural protection from pregnancy.

4. There is no sure way to predict when ovulation will return: In some women it will return at six months; in others between twelve and twenty-four. Still others may have more than two years of protection.

5. Because it is impossible to say exactly when a woman will again be fertile, most programs decide on a specific number of months post-partum (i.e., six months) when they begin advising women to use another family planning method to avoid pregnancy.

6. Studies indicate that combined oral contraceptives (estrogen and progesterone) may reduce breast milk production.

7. During the first 4-6 months post-partum, breastfeeding-women should be advised to use a family planning method that does not affect breastfeeding. These include:

- Intrauterine Device

- Vaginal Spermicides

- Condoms

- Vasectomy

- Tubal Ligation

- Injectables (Depo Provera)

- Progestogen-only Oral Contraceptives

8. Breastfeeding should be encouraged for its nutritional and natural child-spacing effects. The trend away from breastfeeding is very serious. It will result in more malnutrition and higher birth rates in many parts of the world, if it is not reversed.

Session 2: Providing the facts about family planning

Purpose:

Trainers list rumors and attitudes that have a negative effect on Family planning acceptance in their areas. They then identify facts that counter these attitudes and rumors and discuss ways for making factual information about family planning available.

Time: 1 hour

Materials:

- Flipchart and marking pens

Steps:

1. Introduction: Couples may reject the use of family planning for different reasons:

- They want to have another child in the near future

- They have heard rumors about family planning methods

- They have cultural or religious reasons for not accepting family planning

- In-laws are opposed

- Etc.

In many cases, couples do not have the factual information they need to make an informed decision about contraception. In this session, we will discuss some of the specific facts about child-spacing and family planning methods that couples need in order to make an informed choice. We will also identify different methods for providing information to couples in their communities.

2. Ask trainees to begin by listing all of the rumors and negative beliefs that they have heard about family planning. When they finish, make a group list of rumors and beliefs on the chalkboard. Do this by asking each trainee for a rumor or belief from their list.

Ask trainees to list facts that would disprove each incorrect rumor. For each belief or attitude against family planning ask them to think of a logical response that might help change the negative attitude. Write these on the right side of the chalkboard across from the rumors and attitudes they refer to.

3. Role Play: Conduct several role plays based on the rumors and negative beliefs listed above. In the role plays, a "Family planning promoter" should try to convince a woman, man or couple that a rumor they have heard about family Planning is untrue. Encourage the rode players to provide facts, use examples and develop persuasive arguments to dispel these rumors. Make sure that "family planning promoters" are courteous and respectful of other people's beliefs and attitudes. They won't change attitudes by offending their clients.

4. Community Education: Ask trainees to list different types of community activities and events in which information about family planning could be presented and discussed.

Examples:

- discussions with organized groups (women's groups, cooperatives, teachers, etc.)

- education sessions in the clinic

- home visits

- community meetings

Encourage trainees to tell the group about successful activities they have conducted or participated in that increase people's knowledge about family planning.

5. Ask: "Who should provide family planning information to the community?"

Examples:

- doctors, nurses

- chief or village leaders

- satisfied family planning users (men and women)

- volunteer health workers

- extensionists

Discuss the advantages and disadvantages of involving each type of- individual listed. What kind of training would each need?

6. Summarize:

Community programs to improve nutrition must provide correct information about:

- the benefits of child spacing and small families;

- modern methods of family planning;

- family planning for the breastfeeding mother.

Negative attitudes and rumors about family planning can be changed by providing factual information about family planning methods, and by stressing the benefits of small families and birth spacing to the family and the community.

Activities to spread family planning information could include presentations and discussions with groups as well as counseling of individuals and couples. Promotion of family planning by community leaders, medical professionals, satisfied family planning acceptors and other respected individuals can be important in changing community attitudes towards family planning.

Session 3: Community-based distribution of family planning methods

Once couples know about and want to use family planning, they must be able to obtain an effective contraceptive method without excessive expenditures of time and money. Community-based programs can help couples obtain contraceptives and/or learn about natural family planning in several ways:

- Provide contraceptives in the community through a clinic or community workers

- Provide referral for contraceptive services and transportation to a nearby clinic

- Provide follow-up of contraceptive users to encourage continuation and solve problems with side effects

- Keep records of the eligible couples and family planning acceptors in the community

Purpose:

Trainees discuss the availability of family planning services in their areas and the socioeconomic barriers to the use of these services. The advantages of community-based distribution (CBD) of contraceptives are listed and the components of a CBD program discussed.

Time: 2 hours

Materials:

- Handout - Case Study: Community-Based Family Planning Service Delivery

- Flipchart and marking pens

Time: 2 hours

Steps:

1. Ask trainees to complete the following chart:

Where do people in your area currently go to obtain family planning services:

Location

How far is this from village(s)?

Cost Round Trip

Time Round Trip

What methods are provided?

         
         

2. Discuss the effects that distance, cost and time for travel have on family planning acceptance and continuing use. Brainstorm other reasons why women who want to avoid pregnancy may not visit family planning clinics. These may include:

- Cultural restrictions on women's movement

- Negative attitudes toward family planning

- Poor treatment by health workers

- Lack of privacy

3. Role Play: Divide into work groups (5-6 people). Assign each work group the task of developing and presenting a role play based on the following situation:

Elizabeth has had four children. She and her husband have decided that they should wait for a few years before having another child. A family planning worker visited her several months ago and referred her to the clinic in Kisumu. Two months ago she traveled to Kisumu. Kisumu is 15 km away from Elizabeth's village. On most days the bus ride is about two hours. However, on the day she traveled to Kisumu, it was raining so hard that the bus became stuck and they arrived late. At the clinic, she was made to wait for a long time until she finally saw the nurse. It was so late when she finished that she had to wait until the next day to return to her village. Her husband was angry and accused her of lying about the wait at the clinic and the money she had spent on the bus and the contraceptives. The nurse gave Elizabeth three packages of oral contraceptive pills and told her that she must come back at the end of three months to get more.

In this role play, the family planning motivator is again visiting Elizabeth. Elizabeth explains to her why she has decided not to return to the clinic in Kisumu to fetch more contraceptives.

Trainer: Write your own role play situations based on local problems of transportation, culture! restrictions, health worker/client interactions, etc.

4. Case Study: Distribute the Handout - Case Study: "Community-Based Family Planning Service Delivery. " Ask trainees to read the case study individually and then to work with their groups to answer the questions et the end of the case study.

5. Go over the group's answers to the case study questions. Point out that community-based distribution:

- makes family planning methods easily available in the community;

- helps overcome geographic and financial barriers to contraceptive use;

- helps overcome restrictions on women's mobility and contact between female clients and workers;

- allows for rapid follow-up of "family planning acceptors to insure continuation of use.

6. Management Decisions: Review the important decisions managers must make when planning a CBD program:

- What contraceptives should be provided in the community

- Who should provide contraceptives in the community? (Selection, qualifications)

- What kind of training will community workers need? - How to supply and monitor contraceptive supplies?

- Where to refer? For what reasons? For v/hat services?

- How to supervise CBD workers?

7. Stress the importance of an effective referral system for any CBD project. The referral system must support the work of the community worker and provide clinical assessment and services as needed.

8. Summarize the unit:

Spacing births and limiting the size of a family means better health and nutrition for women and young children.

Modern and traditional methods of family planning make it possible for couples to have the number of children they can support.

Two important reasons why couples do not practice family planning are lack of information (or misinformation) and lack of access to contraceptives and contraceptive services.

Communities can play an important role in making information about family planning and contraceptive methods available to of their members.

Community-based family planning distribution programs can be organized with the active participation of community members to make contraceptive services available to all interested couples.

HANDOUT

CASE STUDY: COMMUNITY-BASED FAMILY PLANNING SERVICE DELIVERY

Concerned Women for Family Planning was started in 1976 to provide family planning services to poor women living in the crowded slums of Dhaka, Bangladesh. The founders of the organization had come to realize that low-income women throughout the city were eager to obtain the baby preventing medicine" they had heard about but could not visit family planning clinics for a variety of reasons. In Bangladesh, the majority of women live in "prudish," or behind the veil. Their contacts are limited to the members of their families, and they seldom leave their own homes or compounds. Traveling to a family planning clinic, staffed by male and female workers, poses serious cultural as well as economic problems for most women.

To overcome these barriers, Concerned Women for Family Planning started a pilot program for the household distribution of family planning information and contraceptives. A team of four field assistants and one supervisor began working in a neighborhood of approximately 74,000 people. The neighborhood was divided into four sections, with each field assistant responsible for the families in one of the sections.

Field assistants began by visiting and getting to know the women in each of their sections. At the same time, they carried and distributed oral contraceptives and condoms and provided information on other clinical methods of family planning. Each field assistant eventually reached all of the homes in her section; however, more emphasis was placed on acceptor satisfaction and continuation than on the total number of new acceptors she recruited. Other programs had shown that many couples who decided to try family planning methods would discontinue use because of minor side effects or general dissatisfaction with the contraceptive method they had chosen. Concerned Women found that follow-up visits, during the first few months after a couple began using a contraceptive, would help them adjust to the method or change to a more satisfactory method without discontinuing family planning use.

Besides household distribution of contraceptives and active follow-up of acceptors, the Concerned Women's program provided referral and transportation to women who were interested in clinical family planning methods, sterilization, IUD insertion and Depo Provera injections. These clinical services were provided to clients referred by Concerned Women at two clinics in Dhaka.

During the first month of the Concerned Women project, 268 couples accepted family planning methods. Of these, 70 percent were still using family planning methods a year later. These high levels of acceptance and continuation proved that the Concerned Women's strategy worked!

Because of its success, the Concerned Women's program has continued to expand. By 1977, 88 field assistants and supervisors had been trained, and were providing information and delivering contraceptives house-to-house in 17 neighborhoods. In 1978, Concerned Women opened its women's clinic in the heart of the most crowded area of the old city, and the program is still growing. Today, the Concerned Women's program includes counseling, maternal/child health care, nutrition education as well as family planning services.

Trainer:

This case study describes an urban, community-based distribution program designed to overcome cultural restrictions on women's movement outside the home.

It is best to develop a case study for a program that increases access to family planning methods by overcoming the most important barriers in your region. For example, in rural areas, distance and cost of transportation may be major barriers to the acceptance of family planning.

HANDOUT

CASE STUDY QUESTIONS

1. What barriers to family planning acceptance did the program in the case study overcome?

2. What family planning methods were provided in the community?

3. Where did the community workers (field assistants) refer clients for clinical services? What family planning methods and services were provided at these referral points?

4. Why do you think this program has been so successful?

(List as many possible reasons as you can think of.)

REFERENCES

Baer, Edward C. and Winikoff, Beverly. Breastfeeding, Program. Policy and Research Issues, Studies in Family Planning, Vol. 12, No. 4, April 1981.

Center for Population and Family Health. Family Planning: Impact on the Health of Women and Children. Columbia University, 1981.

Favin, M., Bradford, B., and Abula, D. Improving Maternal Health in Developing Countries. World Federation of Public Health Associations. August, 1984.

Hatcher, Robert et. al. Contraceptive Technology 1984-1985. Irving Publishers, Inc., New York, 1985.