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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

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.