Guidelines for Selecting Contraception, by Method

Method Timing postabortion Advantages Remarks

Nonfitted barrier methods:

latex and vinyl male/female condoms; and vaginal sponge and suppositories (foaming tablets, jelly, or film) Fitted barri- ers used with spermicides: diaphragm or cervical cap with foam or jelly Oral contra- ceptives: combined and progestin-only

■ _{Are less effective than}

IUD or hormonal methods

■ _{Require use with each}

episode of intercourse

■ _{Require continued}

motivation

■ _{Require resupply to be}

available

■ _{May interfere with}

intercourse

■ _{Are less effective than}

IUD or hormonal methods

■ _{Require use with each}

episode of intercourse

■ _{Require continued}

motivation

■ _{Require resupply to be}

available

■ _{Are associated with}

urinary tract infections in some users

■ _{Require fitting by}

trained service provider

■ _{Require continued}

motivation and daily use

■ _{Require resupply to be}

available

■ _{May have reduced effec-}

tiveness if client has used certain medications (e.g., rifampin, dilantin, or griseofulvin) long-term

■ _{Necessitate condom use}

if client is at risk for STIs, including HIV

■ _{Are inexpensive} ■ _{Are good interim}

method if use of another method must be post- poned

■ _{Require no medical}

supervision

■ _{In the case of condoms}

(latex and vinyl), provide protection against sexu- ally transmitted infections (STIs), including HIV

■ _{Are easily discontinued} ■ _{Are effective immediately} ■ _{Are inexpensive}

■ _{Require no medical}

supervision for use

■ _{Provide some protec-}

tion against STIs, including HIV

■ _{Are easily discontinued} ■ _{Are effective immediately}

■ _{Are highly effective} ■ _{Can be started immedi-}

ately, even if infection is present

■ _{Can be provided by}

nonphysicians

■ _{Do not interfere with}

intercourse These methods may be

used as soon as sexual intercourse is resumed.

The diaphragm can be fitted immediately after first- trimester abortion; after second-trimester abortion, fitting should be delayed until uterus returns to prepregnancy size (four to six weeks).

Fitting the cervical cap should be delayed until bleeding has stopped and the uterus has returned to its prepregnancy size (four to six weeks).

Pill use may begin immediately, preferably on the day of treatment.

Counseling the Postabortion Client: A Training Curriculum

Method Timing postabortion Advantages Remarks

Injectables: DMPA and NET-EN Progestin- only implants: Norplant implants IUD

■ _{May cause irregular}

bleeding, especially amenorrhea (excessive bleeding may occur in rare instances)

■ _{May cause delayed}

return to fertility

■ _{Require injections every}

two or three months

■ _{Necessitate condom}

use if client is at risk for STIs, including HIV

■ _{May cause irregular}

bleeding (especially spot- ting) or amenorrhea

■ _{Require a trained}

provider to insert and remove

■ _{Are cost-effective only if}

used long-term

■ _{Necessitate condom}

use if client is at risk for STIs, including HIV

■ _{May increase menstrual}

bleeding and cramping during the first few months

■ _{Can result in uterine per-}

foration during insertion

■ _{May increase risk of PID}

and subsequent infertility for women who have chlamydia or gonorrhea infection at the time of insertion

■ _{Necessitates condom}

use if client is at risk for STIs, including HIV

■ _{Requires a trained pro-}

vider to insert and remove

■ _{Are highly effective} ■ _{Can be started immedi-}

ately, even if infection is present

■ _{Can be provided by}

nonphysicians

■ _{Do not interfere with}

intercourse

■ _{Are not user-dependent}

(except for injection every two or three months

■ _{Do not require client to}

obtain supplies

■ _{Are highly effective} ■ _{Provide long-term contra-}

ceptive protection (effective for at least five years)

■ _{Allow immediate return}

to fertility upon removal

■ _{Do not interfere with}

intercourse

■ _{Do not require client to}

obtain supplies

■ _{Is highly effective} ■ _{Provides long-term con-}

traceptive protection

■ _{Allows immediate return}

to fertility upon removal

■ _{Does not interfere with}

intercourse

■ _{Does not require client}

to obtain supplies

■ _{Requires only monthly}

checking for strings (by client)

■ _{Requires only one}

follow-up visit, unless there are problems Injection may be given

immediately after first- or second-trimester abortion. Method may be appropriate for use if a woman wants to delay choice of long-term method.

Implants may be inserted immediately after abortion. If adequate counseling and informed decision making cannot be guaran- teed, insertion must be delayed and an interim method provided.

Insertion should be delayed until serious injury is healed, hemorrhage is controlled, or acute anemia improves. Insertion should be delayed until infection has been resolved (three months).

First-trimester abortion:

IUD can be inserted if risk or presence of infection can be ruled out.

Second-trimester abor- tion:Insertion should be delayed for six weeks

unlessequipment and expertise for immediate postabortal insertion are available.

Handout 5-E (continued)

Guidelines for Selecting Contraception, by Method

Method Timing postabortion Advantages Remarks Female sterilization Natural family planning ■ _{Requires adequate}

counseling and fully informed consent before being performed, which often is not pos- sible at the time of emergency care

■ _{Has slight possibility of}

surgical complications

■ _{Requires trained staff}

and appropriate equipment

■ _{Necessitates condom}

use if client is at risk for STIs, including HIV

■ _{Is difficult to use imme-}

diately after abortion

■ _{Necessitates use of}

alternative methods until normal cycles have resumed

■ _{Requires extensive in-}

struction and counseling

■ _{Necessitates condom}

use if client is at risk for STIs, including HIV

■ _{Requires the woman}

and her partner to have continued motivation and a thorough under- standing of how to use the method

■ _{Is a permanent method} ■ _{Is the most effective}

female method

■ _{Requires no further}

action once completed

■ _{Does not interfere with}

intercourse ■ _{Produces no change in} sexual functioning ■ _{Causes no long-term} side effects ■ _{Is immediately effective} ■ _{Is associated with no} cost ■ _{Produces no change in} sexual function

■ _{Has no long-term side}

effects Sterilization after a first-

trimester abortion is similar to an interval procedure; sterilization after a second-trimester abortion is more similar to a post- partum procedure. Technically, sterilization procedures usually can be performed immediately after treatment of postabortion complications, unless infection or severe blood loss are present. Sterilization should not be performed until an infection is fully resolved (three months) or an injury healed.

Natural family planning is not recommended for immediate postabortion use. The first ovulation after an abortion will be difficult to predict, and the method is unreliable until after a regular menstrual pattern has returned.

Handout 5-E (continued)

Guidelines for Selecting Contraception, by Method

Counseling the Postabortion Client: A Training Curriculum

Method Timing postabortion Advantages Remarks

■ _{Requires adequate}

counseling and fully informed consent before being performed

■ _{Has slight possibility of}

surgical complications

■ _{Requires trained staff}

and appropriate equipment

■ _{Necessitates condom}

use if client is at risk for STIs, including HIV

■ _{Is not effective until}

after 12 weeks following the procedure

■ _{Is a permanent method} ■ _{Is the most effective}

male method

■ _{Requires no further}

action once completed

■ _{Does not interfere with}

intercourse ■ _{Produces no change in} sexual functioning ■ _{Causes no long-term} side effects ■ _{Is effective after 12}

weeks following the procedure

Vasectomy may be performed at any time.

Handout 5-E (continued)

Guidelines for Selecting Contraception, by Method

Adapted from: Winkler, J., Oliveras, E., and McIntosh, N. (eds.) 1995. Postabortion care: A reference manual for improving

quality of care. Postabortion Care Consortium.

Vasectomy

Session 6:

Related Reproductive Health Needs and Other Issues

Objectives

■ _{To explain why postabortion clients may need information about reproductive tract}

infections (RTIs) and STIs

■ _{To identify the essential information that all postabortion clients must have about RTIs}

and STIs before they leave the service site

■ _{To describe the medical, social, economic, emotional, or other issues that postabortion}

clients may face that do not directly relate to PAC

■ _{To identify referral resources that are available for clients’ non–PAC-related needs} ■ _{To explain how to recognize the need for referral}

■ _{To help clients with threatened abortion manage their feelings related to the condition of}

their pregnancy

Training Methods

■ _Discussion ■ _{Small-group work} ■ _Presentation ■ _Brainstorm ■ _{Role play}

Materials

■ _{Flipchart paper, easel, markers, and tape}

■ _{Flipcharts of the client case studies (from Session 3)} ■ _{Paper and pens or pencils for each participant}

■ _{Transparency 6-A: Sample Case Study 1: “Daisy” (page 168)} ■ _{Transparency 6-B: Sample Case Study 2: “Diana” (page 169)}

■ _{Handout 6-A: Background Information on STIs (including HIV) and RTIs (page 105)} ■ _{Handout 6-B: Sexuality and HIV/STI Risk: Broaching the Subject with Clients (page 107)} ■ _{Blank index cards (two per participant)}

Advance Preparation

1. Prepare a flipchart listing the objectives of this session. 2. Review all handouts and make one copy for each participant.

3. Prepare transparencies or flipcharts of Transparencies 6-A and 6-B, or make one copy each of case studies for distribution to small groups.

4. Prepare a flipchart like the example shown below

5. Prepare two flipcharts as shown below (one for each of the two case studies):

Session Time (total): 2 hours, 15 minutes

Counseling the Postabortion Client: A Training Curriculum

Other Reproductive Health Issues and Resources for Referral

Category Example(s) Resource(s)

Medical

Social

Economic

Emotional

Other

Addressing the Feelings of Clients with Threatened Abortion

Client’s name: ________________

SESSION 6 TRAINING STEPS

In document Counseling the Postabortion Client: (Page 97-103)