|Reproductive Health in refugee situations - An Inter-Agency Field Manual (United Nations Fund for Population Activities - United Nations High Commission for Refugee - World Health Organisation, 1999, 142 p.)|
|Chapter Six: Family Planning|
Providers and users must be aware of the particularities of each method, its effectiveness, safety, side effects. They should also know its effect on the risk of STD transmission, its appropriateness for breastfeeding women and the usual length of time between discontinuation of the method and return to normal fertility. Information on the common methods is presented here. "In no cases should abortion be promoted as a method of family planning" (ICED para 8.25).
In most refugee situations, the most important barrier method will be male latex condoms. Consistent and correct use of condoms can play the dual role of protection against STD and HIV infection and prevention of conception. They can be used alone or in combination with another method to increase effectiveness. Only water-based lubricants should be used with condoms.
Other barrier methods, such as spermicides and female condoms, may be requested by refugees who are familiar with these methods from their country of origin. If requested, every effort should be made to supply these methods.
Oral Contraceptive Pills should include at least:
· one combined oral contraceptive (COC): ethinyl oestradiol < 0.035 mg and levonorgestrel 0.15 mg;
· one progestogen-only oral contraceptive (POP): levonorgestrel 0.03 mg or norethisterone 0.35 mg.
Injectable Contraceptives could include depotmedroxyprogesterone acetate (DMPA, Depoprovera), one injection every three months, norethisterone enatharem (NET-EN) one injection every 2 months, or Cyclofem, one injection per month. Trained health professionals should administer injectables. It is recommended that only one injectable method should be used to avoid confusion and misunderstanding over the schedule for reinjection.
Supportive counseling and continued reassurance during follow-up visits will help clients tolerate common side effects, such as changed patterns of menstrual bleeding.
See Chapter Four for details about the provision of Emergency Contraceptive Pills (ECPs). National policies and the demands of well-informed users should guide the use of ECPs in refugee situations.
Copper IUDs (Intra-Uterine Devices)
IUD insertion, like sterilisation and implants, requires special training, facilities and equipment that must be in place before these methods are provided.
Women known to be infected or at high risk for an STD, including HIV, should not have an IUD inserted. For nulliparous women, an IUD is not the method of first choice.
Natural Family Planning (NFP) Methods
Natural Family Planning methods include the basal body temperature method, the cervical mucus or ovulation method, the calendar method and the sympto-thermal method. NFP is particularly appropriate for people who do not wish to use other methods for medical reasons or because of religious or personal beliefs. Counseling must be provided to both partners when choosing these methods and when practising them. The methods require initial training and regular follow-up until confidence is achieved in detecting fertility signs. Teaching these methods to potential users is relatively time consuming, and requires separate sessions for those refugees who wish to use them.
Breastfeeding is effective as a contraceptive method if a woman is exclusively breast-feeding on demand her infant (no other food being given to the baby), she is not menstruating and her infant is less than six months old. If any one this these three criteria are not met, then an additional method of contraception is advised.
Family planning methods recommended for breastfeeding mothers are:
· from delivery up to six weeks postpartum: barrier methods, postpartum IUD insertion and sterilisation;
· from six weeks to six months postpartum: barrier methods, progestin-only methods (pills, injectables, implants), IUDs, and sterilisation;
· after six months postpartum: COCs and combined injectables, and natural family planning methods.
An implant is a long-lasting progestogen-only contraceptive. The most widely used types (Norplant and Norplant 2) consist, respectively, of six or two silastic capsules containing the progestogen levonorgestrel. The capsules, inserted under the skin of the arm, slowly release the progestogen. These implants are effective for five years. They should only be inserted or removed by properly trained personnel.
Before using any long-term contraceptive within a refugee situation, service providers must be sure that the necessary facilities and skilled personnel exist in the country of origin to reverse or remove the method, since refugees may return home at any time. If such facilities do not exist in the country of origin, the method should not be used.
Voluntary Surgical Contraception
Both male (vasectomy) and female sterilisation are desirable methods of contraception for some clients. As a surgical method, sterilisation should only be performed in safe conditions, with the formal consent of the user and by trained personnel with the necessary equipment. Sterilisation should not be excluded especially if it is familiar to the refugees from their country of origin and is allowed within the host country.