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14 Family planning

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Family planning
and the prevention of
unintended pregnancy.
Gestosis and their
prevention.
Family planning is the planning of when to have
children, and the use of birth control and other
techniques to implement such plans. Other techniques
commonly used include sexuality education, prevention
and management of sexually transmitted infections,
pre-conception counseling and management, and
infertility management.
Family planning is sometimes used in the wrong way
also as a synonym for the use of birth control, though it
often includes more. It is most usually applied to a
female-male couple who wish to limit the number of
children they have and/or to control the timing of
pregnancy (also known as spacing children).
Purposes
Raising a child requires significant amounts of
resources: time, social, financial, and environmental.
Planning can help assure that resources are
available.
Waiting until the mother is at least 18 years old
before trying to have children improves maternal
and child health. Also, if additional children are
desired after a child is born, it is healthier for the
mother and the child to wait at least 2 years after
the previous birth before attempting to conceive
(but not more than 5 years). After a miscarriage or
abortion, it is healthier to wait at least 6 months.
Modern methods
Some families use modern medical advances in family
planning. For example in surrogacy treatments a woman
agrees to become pregnant and deliver a child for another
couple or person.
In sperm donations, pregnancies are usually achieved using
donated sperm by artificial insemination (either by ICI or IUI)
and less commonly by in vitro fertilization (IVF), usually known
in this context as ART but insemination may also be achieved
by a donor having sexual intercourse with a woman for the
sole purpose of initiating conception. This method is known as
natural insemination, or NI.
There is generally a demand for sperm donors who have no
genetic problems in their family, 20/20 eyesight, with
excellent visual acuity, a college degree, and sometimes a
value on a certain height and age.
Birth control
With assertions of overpopulation, there have been
assertions that birth control is the answer. Birth control is
techniques used to prevent unwanted pregnancy.
There are a range of contraceptive methods, each with
unique advantages and disadvantages. Any of the widely
recognized methods of birth control is much more effective
than no method. Behavioral methods that include
intercourse, such as withdrawal and calendar based
methods have little up front cost and are readily available,
but are less effective in typical use than most other
methods. Long-acting reversible contraceptive methods,
such as IUD and implant are highly effective and
convenient, requiring little user action. When cost of
failure is included, IUDs and vasectomy are much less
costly than other methods.
United States
Title X of the Public Health Service Act, is a US
government program dedicated to providing
family planning services for those in need. But
funding for Title X as a percentage of total public
funding to family planning client services has
steadily declined from 44% of total expenditures
in 1980 to 12% in 2006. Medicaid has increased
from 20% to 71% in the same time. In 2006,
Medicaid contributed $1.3 billion to public family
planning.
Pregnancy can be a beautiful thing. But it can also
be an inconvenient thing, a financially
burdensome thing, a physically dangerous thing,
an emotionally and politically charged thing, and
a scandalous thing. This is why most women
prefer to control their fertility: when pregnancy
happens to them, they want it to be at its most
beautiful.
Unintended pregnancies are those in which
conception was not intended by the female sexual
partner.
Unintended pregnancies are the primary cause of
induced abortion, resulting in about 42 million
induced abortions per year. Unintended pregnancy is
also linked to higher rates of maternal and infant
deaths.
The use of modern contraceptive methods has greatly
reduced the incidence of unintended pregnancy,
particularly in more developed countries. However
the United States has an unusually high rate of
unintended pregnancy, especially among the poor.
Causes
• Not using contraception.
• Using contraception inconsistently or
incorrectly.
• Contraceptive failure (the method was used
correctly, but did not work.) Accounts for
relatively small fraction of unintended
pregnancies when modern highly effective
contraceptives are used.
Reasons contraceptives might not have been used or
been used incorrectly include:
• Coercion. Rape or involuntary sex which sometimes
happens in the context of domestic violence.
Unintended pregnancies are more likely to be
associated with abuse than intended pregnancies.
This may also include birth control sabotage manipulation of someone's use of birth control to
undermine efforts to prevent pregnancy.
• Lack of knowledge about sex and reproduction.
Including erroneous beliefs.
• Lack of knowledge or experience with the
contraceptive, or lack of motivation to use it
correctly.
• Lack of planning or ambivalence about whether to
have a child.
Results of unintended pregnancy include:
• Prenatal care initiate later, and less adequate.
Adversely affects health of woman and of child and less
preparation for parenthood. Delay from unintended
pregnancy is in addition to that from other risk factors
for delay. Unwanted pregnancies have more delay than
mistimed.
• Unintended pregnancies preclude chance to resolve
sexually transmitted diseases (STD) before pregnancy.
Untreated STD in pregnant woman can result in
premature delivery, infection in newborn or infant
death.
• Preclude use of genetic testing to help make decisions
about whether to become pregnant.
• Women with an unintended pregnancy are more
likely to suffer depression during or after pregnancy.
• Poorer maternal mental health
• Increased risk of physical violence during pregnancy
• Reduced likelihood of breastfeeding, resulting in less
healthy children
• Lower mother-child relationship quality (see also
Maternal bond)
• More likely that mother smokes tobacco (about 30%
more likely in the US) or drinks during pregnancy.
Which results in poorer health outcomes and
additional costs for welfare system. (see also Fetal
alcohol syndrome, Fetal alcohol spectrum disorder)
Children whose births were unintended are:
• Greater likelihood of low birth weight, particularly for unwanted
pregnancies. In US eliminating all unwanted pregnancies would reduce
rate of low birth weight by 7% for blacks, and 4% for whites, helping to
decrease the large disparity in rates for whites vs. blacks. May be
through increased risk preterm delivery.
• Greater infant mortality. If all sexually active couples in the US had
routinely used effective contraception in 1980, there would have been
1 million fewer abortions, 340,000 fewer live births that were
unintended at conception, 5,000 fewer infant deaths, and the infant
mortality rate would have been 10% lower.
• likely to be less mentally and physically healthy during childhood,
• at higher risk of child abuse and neglect,
• less likely to succeed in school,
• more likely to live in poverty,
• more likely to need public assistance,
• more likely to have delinquent and criminal behavior.
Prevention
Prevention includes comprehensive sexual education,
availability of family planning services, including access
to a range of effective birth control methods. Most
unintended pregnancies result from not using
contraception, many more result from using
contraceptives inconsistently or incorrectly. Increasing
use of long-acting reversible contraceptives (such as
IUD and contraceptive implants) decreases the chance
of unintended pregnancy by decreasing the chance of
incorrect use. Method failure is relatively rare with
modern, highly effective contraceptives, and is much
more of an issue when such methods are unavailable,
unaffordable, or not used
Providing contraceptives and family planning
services at low or no cost to the user helps prevent
unintended pregnancies. Many of those at risk of
unintended pregnancy have little income, so even
though contraceptives are highly cost-effective, up
front cost can be a barrier.
Subsidized family planning services improve the
health of the population and saves money for
governments and health insurers by reducing
medical, education and other costs to society.
The United States rate of unintended pregnancies is
higher than the world average, and much higher than that
in other industrialized nations. Almost half (49%) of U.S.
pregnancies are unintended, more than 3 million
unintended pregnancies per year. Over 92% of abortions
are the result of unintended pregnancy, unintended
pregnancies result in about 1.3 million abortions/year.
The rate of abortions is high in the United States than in
other developed countries because of the higher rate of
unintended pregnancies in the US. In 2001, 44% of
unintended pregnancies resulted in births, and 42%
resulted in induced abortion and the rest in miscarriage.
It is estimated that more than half of US women have had
an unintended pregnancy by age 45.
Teens
Of the 800,000 teen pregnancies per year, over 80%
were unintended in 2001. One-third of teen
pregnancies result in abortion. In 2002, about 9% of
women at risk for unintended pregnancy were
teenagers, but about 20% of the unintended
pregnancies in the United States are to teenagers. A
somewhat larger proportion of unintended births
are reported as mistimed, rather than unwanted, for
teens compared to women in general (79% mistimed
for teens vs. 69% among all women in 1998).
Types of Birth Control
Reversible Methods of Birth Control
• Intrauterine Devices (IUDs)
Copper T IUD-An IUD is a small device that is shaped in
the form of a “T.” Your doctor places it inside the uterus
to prevent pregnancy. It can stay in your uterus for up to
10 years. This IUD is more than 99% effective at
preventing pregnancy.
Levonorgestrel intrauterine system (IUS)-The IUS is a
small T-shaped device like the IUD. It is placed inside the
uterus by a doctor. It releases a small amount of
progestin each day to keep you from getting pregnant.
The IUS stays in your uterus for up to 5 years. The IUS is
more than 99% effective at preventing pregnancy.
• Hormonal methods
Oral contraceptives - Also called “the pill,” it contains the hormones
estrogen and progestin. A pill is taken at the same time each day. If
you are older than 35 years and smoke, have a history of blood
clots or breast cancer, your doctor may advise you not to take the
pill. The pill is 92–99% effective at preventing pregnancy.
Mini pill - Unlike the pill, the mini-pill only has one hormone,
progestin, instead of both estrogen and progestin. It is prescribed
by a doctor. It is taken at the same time each day. It is a good option
for women who can’t take estrogen. They are 92–99% effective at
preventing pregnancy.
This method is prescribed by a doctor! It releases hormones
progestin and estrogen into the bloodstream. You put on a new
patch once a week for three weeks. During the fourth week, you do
not wear a patch, so you can have a menstrual period. The patch is
92–99% effective at preventing pregnancy, but it appears to be less
effective in women who weigh more than 198 pounds.
• Hormonal vaginal contraceptive ring. The ring releases the
hormones progestin and estrogen. You place the ring inside your
vagina. You wear the ring for three weeks, take it out for the week
you have your period, and then put in a new ring. It is 92–99%
effective at preventing pregnancy.
• Injection or "shot". Women get shots of the hormone progestin in
the buttocks or arm every three months from their doctor. It is 97–
99% effective at preventing pregnancy.
• Implant. The implant is a single, thin rod that is inserted under the
skin of a women’s upper arm. The rod contains a progestin that is
released into the body over 3 years. It is 99 percent effective at
preventing pregnancy.
• Emergency contraception.
Emergency contraception is NOT a regular method of birth control.
Emergency contraception can be used after no birth control was
used during sex, or if the birth control method failed, such as if a
condom broke.
Women can take emergency contraceptive pills up to 5 days after
unprotected sex, but the sooner the pills are taken, the better they
will work. There are three different types of emergency
contraceptive pills available in the United States. Some emergency
contraceptive pills are available over the counter for women 17
years of age or older. If younger than 17 years, emergency
contraceptive pills are available by prescription.
Another type of emergency contraception is having your doctor
insert the Copper T IUD into your uterus within seven days of
unprotected sex. This method is 99% effective at preventing
pregnancy.
• Barrier methods
Male condom. Worn by the man, a male condom keeps
sperm from getting into a woman’s body. Latex condoms,
the most common type, help prevent pregnancy and HIV
and other STDs as do the newer synthetic condoms.
“Natural” or “lambskin” condoms also help prevent
pregnancy, but may not provide protection against STDs,
including HIV. Male condoms are 85–98% effective at
preventing pregnancy. Condoms can only be used once,
and are most effective when used consistently and
correctly. You can buy condoms, KY jelly, or water-based
lubricants at a drug store. Do not use oil-based lubricants
such as massage oils, baby oil, lotions, or petroleum jelly
with latex condoms. They will weaken the condom,
causing it to tear or break.
Female condom. Worn by the woman, the female condom
helps keeps sperm from getting into her body. It is packaged
with a lubricant and is available at drug stores. It can be
inserted up to eight hours before sexual intercourse. Female
condoms are 79–95% effective at preventing pregnancy
when used consistently and correctly, and may also help
prevent STDs.
Diaphragm or cervical cap. Each of these barrier methods
are placed inside the vagina to cover the cervix to block
sperm. The diaphragm is shaped like a shallow cup. The
cervical cap is a thimble-shaped cup. Before sexual
intercourse, you insert them with spermicide to block or kill
sperm. The diaphragm is 84–94% effective at preventing
pregnancy. Visit your doctor for a proper fitting because
diaphragms and cervical caps come in different sizes.
• Spermicides
These products work by killing sperm and come in several
forms-foam, gel, cream, film, suppository, or tablet. They
are placed in the vagina no more than one hour before
intercourse. You leave them in place at least six to eight
hours after intercourse. You can use a spermicide in
addition to a male condom, diaphragm, or cervical cap.
Spermicides alone are about 71–82% effective at
preventing pregnancy. They can be purchased in drug
stores.
• Fertility awareness and abstinence
Continuous abstinence - This method means not having vaginal
intercourse at any time. It is the only 100% effective way to prevent
pregnancy.
Natural family planning or fertility awareness - Understanding your
monthly fertility pattern can help you plan to get pregnant or avoid
getting pregnant. Your fertility pattern is the number of days in the
month when you are fertile (able to get pregnant), days when you
are infertile, and days when fertility is unlikely, but possible. If you
have a regular menstrual cycle, you have about nine or more fertile
days each month. If you do not want to get pregnant, you do not
have sex on the days you are fertile, or you use a form of birth
control on those days. These methods are 75–99% effective at
preventing pregnancy.
• Permanent Methods of Birth Control
Female Sterilization – Tubal ligation or “tying tubes.” - A woman
can have her fallopian tubes tied (or closed) so that sperm and
eggs cannot meet for fertilization. The procedure can be done in
a hospital or in an outpatient surgical center. You can go home
the same day of the surgery and resume your normal activities
within a few days. This method is effective immediately.
Transcervical Sterilization - A thin tube is used to thread a tiny
device into each fallopian tube. It irritates the fallopian tubes and
causes scar tissue to grow and permanently plug the tubes. It can
take about three months for the scar tissue to grow, so use
another form of birth control during this time. Return to your
doctor for a test to see if scar tissue has fully blocked your
fallopian tubes.
Male Sterilization . Vasectomy - this operation is done to
keep a man’s sperm from going to his penis, so his
ejaculate never has any sperm in it that can fertilize an
egg. This operation is simpler than tying a woman’s tubes.
The procedure is done at an outpatient surgical center.
The man can go home the same day. Recovery time is less
than one week. After the operation, a man visits his
doctor for tests to count his sperm and to make sure the
sperm count has dropped to zero; this takes about 12
weeks. Another form of birth control should be used until
the man’s sperm count has dropped to zero
Gestosis
Gestosis of pregnant women include a number of
pathological conditions that occur during
pregnancy, complicating its course.
There are early gestosis, usually occurring in the
first trimester of pregnancy, and late gestosis,
developing in the second half of pregnancy.
Early gestosis includes: vomiting in pregnancy (mild form),
excessive vomiting and ptializm (salivation). Etiological
factor of gestosis, according to many authors, is the failure
of mechanisms to adapt to emerged pregnancy.
Congenital and acquired deficiency of neuroendocrine
regulation of adaptive responses (hypoxia, infection,
intoxication, malnutrition in the antenatal period,
hereditary factors) contribute to gestosis development, as
well as presence of extragenital pathology in a woman (on
the part of cardiovascular system - hypertension,
hypotension, cardiac defects, endocrine disease - diabetes
mellitus, hyper-and hypothyroidism, urinary tract disease pyelonephritis, glomerulonephritis).
Early gestosis (vomiting during pregnancy) include
vomiting, which is repeated several times during the day,
accompanied by nausea, a decrease in appetite, change
in taste and olfactory sensations. In accordance with the
severity of the disease they distinguish:
• light form;
• moderate (moderate);
• excessive vomiting (severe).
Late gestational toxicosis often occurs in the third
trimester of pregnancy and is characterized by multiple
organ failure. Late gestosis is manifested by three main
symptoms - edema, proteinuria, arterial hypertension, at
least - more severe symptoms (convulsions, coma, etc.).
In modern obstetrics late gestosis is denoted as OPGgestosis (under the name of three major symptoms).
There are many classifications of late gestosis, but in
practical obstetrics they distinguish 4 main clinical forms:
• hydrocephalus of pregnant;
• nephropathy (mild, moderate, severe);
• pre-eclampsia;
• eclampsia.
Nephropathy of pregnancy is divided into three levels:
• mild (hypertension is not higher than 150/100 mm
Hg. Art., swelling of feet not higher than shins,
proteinuria less than 1 g / l, the fundus has uneven
caliber of retinal vessels);
• moderate (blood pressure not higher than 175/115
mm Hg. Art., swelling extended to the lower
extremities and abdominal wall, proteinuria of 1 g / l to
3 g / l, there is swelling of the retina);
• severe degree (blood pressure above 175/115 mm
Hg. Art., anasarca, proteinuria more than 3 g / l, the
fundus has hemorrhage, marked degenerative
changes).
Pre-eclampsia - a critical, but a reversible condition, which
developed against the background of severe gestosis. In addition
to the triad of symptoms of gestosis (OPG), a patient has a
headache, nasal congestion, visual disturbances. These signs are
regarded as cerebral circulation disorder.
Eclampsia - the most severe form of pregnancy problem called
gestosis, which is characterized by seizures with loss of
consciousness. The duration and number of seizures of eclampsia
may be different. During a seizure there develop abnormalities of
cerebral blood flow, bleeding in the brain and its membranes.
Hemorrhages in internal organs are frequent. Hypoxia and
metabolic disease are sharply increasing, there occurs acidosis.
Renal function is rapidly deteriorating, oliguria increases. Internal
organs often have degenerative changes. Eclampsia is lifethreatening for both mother and fetus.
The most frequent complication of pregnancy is a threat
of interruption and premature birth - one of the main
perinatal cause of morbidity and mortality. The main
reasons for threat of abortion and miscarriage are:
• infectious diseases of mother;
• complications related to pregnancy;
• traumatic injuries;
• iso serological incompatibility of blood between mother
and fetus;
• developmental anomalies of female genitalia;
• neuroendocrine pathology;
• various non-communicable diseases of mother;
• chromosomal abnormalities.
Prevention and treatment of pregnancy induced
hypertension
Prophylaxis and Early Treatment
Because women are usually asymptomatic and seldom
notice the signs of incipient pre-eclampsia, its early
detection demands careful observation at appropriate
intervals, especially in women known to be predisposed
to preeclampsia. Major predisposing factors are (1)
nulliparity, (2) familial history of pre-eclampsia–
eclampsia, (3) multiple fetuses, (4) diabetes, (5) chronic
vascular disease, (6) renal disease, (7) hydatidiform
mole, and (8) fetal hydrops.
Rapid weight gain any time during the latter half of
pregnancy, or an upward trend in diastolic blood
pressure, even while still in the normal range, is
worrisome. Every woman should be examined at least
weekly during the last month of pregnancy and every 2
weeks during the previous 2 months. At these visits,
weight and blood pressure measurements are made. All
women should be advised to report immediately any
symptoms or signs of preeclampsia, such as headache,
visual disturbances, epigastric distress, and puffiness of
hands or face. The reporting of any such symptoms calls
for an immediate examination to confirm or exclude
preeclampsia.
Natriuretic drugs, such as chlorothiazide and its
congeners, have been overused severely in the past.
Although diuretics have been alleged to prevent
preeclampsia, Collins and colleagues (1985) reviewed
results of nine studies of more than 7000 women and
concluded that perinatal mortality was not improved
when diuretics were given. Furthermore, thiazides can
induce serious sodium and potassium depletion,
hemorrhagic pancreatitis, and severe neonatal
thrombocytopenia. The failure of natriuretic drugs to
prevent preeclampsia raises serious doubt about the
efficacy of rigid dietary sodium restriction.
In a study by the Royal College of Obstetricians and
Gynecologists (CLASP, 1994), it was concluded that lowdose aspirin was ineffective to prevent preeclampsia.
Similarly, the ECPPA Collaborative Group (1996), in a
study from 12 Brazilian teaching hospitals, concluded
that low-dose aspirin did not decrease the incidence of
proteinuric preeclampsia in 1009 women randomized to
aspirin or placebo.
Low-dose aspirin therapy appears to be safe for the
fetus. Although most clinical trials have resulted in no
apparent maternal risks, Brown and colleagues (1990)
noted a rapid clinical deterioration if therapy was
stopped suddenly.
Thank you
for your attention
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