Reproductive Health

Gender Based Violence (GBV)

Gender based violence is any act that results in physical, sexual or psychological harm or suffering to women, men and children.

Key terms related to Gender-based Violence

1. Gender: Gender refers to the social and cultural expectations, roles, and behaviors assigned to men and women, boys and girls in a society. Unlike sex, which is biological, gender can vary greatly across different societies.

Example: In many societies, it is more common for men to hold leadership positions than women, illustrating a gender role.

2. Gender-based Violence: This includes any act that causes physical, sexual, or psychological harm or suffering to women, men, and children. It can occur in public or private and includes threats and coercion.

Example: Domestic abuse, where a partner uses physical or emotional harm to control the other, is a form of gender-based violence.

3. Violence Against Women: This refers to any act of gender-based violence that harms or is likely to harm women and girls, whether in private or public. It includes sexual violence.

Example: Rape and sexual assault are forms of violence against women.

4. Sexual Violence, Exploitation, and Abuse: This includes any act, attempt, or threat of a sexual nature.

Example: Forcing someone into sexual acts against their will is sexual violence.

5. Gender Equality: This is the state where men and women have equal rights, opportunities, and access to resources.

Example: Ensuring that both men and women have equal access to education and job opportunities.

6. Gender Blind: A policy or plan that does not address relevant gender issues.

Example: A workplace policy that does not consider the different needs of male and female employees, such as maternity leave.

7. Gender Responsiveness: A policy or plan with strategies to reduce inequality and ensure equal benefits for all genders.

Example: A healthcare program that ensures both men and women have equal access to medical services.

8. Sexual and Gender-based Violence: This is a serious form of discrimination, particularly against women and children, and violates human rights. It is both a public health problem and a human rights issue.

Example: Sexual harassment in the workplace is a form of sexual and gender-based violence.

9. Sex: This refers to the biological characteristics of males and females, limited to physiological reproductive functions.

Example: Being born male or female is determined by biological sex.

10. Violence: Any act that causes injury, harm, intimidation, fear, damage, or humiliation to a person. It can include emotional, social, and economic force or pressure.

Example: Threatening someone with a weapon or physically assaulting them is violence.

11. Sex Typing: The differential treatment of people based on their biological sex.

Example: Assigning certain jobs only to men or women based on their sex.

12. Gender Equity: Ensuring that women and men, boys and girls have equal opportunities to receive services that are accessible to all.

Example: Providing equal educational opportunities for both boys and girls.

13. Gender Sensitive: Being aware that women and men have different roles and needs, and planning accordingly.

Example: Designing a workplace policy that considers the different needs of male and female employees.

14. Gender Neutrality: Planning for men and women without considering their different needs and roles, which can be ineffective.

Example: A healthcare service that does not consider the specific needs of women, such as prenatal care.

15. Gender Roles: The tasks and responsibilities that society assigns to women and men, girls and boys. These roles can change over time and across different societies.

Example: In some cultures, women are expected to be primary caregivers, while men are expected to be breadwinners.

16. Coercion: Forcing someone to engage in behavior against their will using threats, manipulation, or economic power.

Example: Threatening to harm someone if they do not comply with your demands.

17. Sexual Preference/Orientation: A person’s preference for partners of the same or opposite sex.

Example: Being heterosexual (attracted to the opposite sex) or homosexual (attracted to the same sex).

18. Gender Role Stereotype: Socially determined beliefs about what gender roles should be.

Example: The belief that girls should be obedient and boys should be brave.

Forms of Violence in Uganda

Domestic Violence

Wife Battering: Physical abuse of wives by their husbands.
Oppression: Controlling behaviors that limit a partner’s freedom and autonomy.
Intimidation: Using threats and fear to control a partner.
Emotional Abuse: Verbal insults, humiliation, and constant criticism.
Economic Abuse: Controlling a partner’s access to financial resources.
Isolation: Preventing a partner from interacting with friends, family, or community.

Sexual Abuse

Rape: Forced sexual intercourse without consent.
Defilement: Sexual abuse of minors.
Incest: Sexual relations between family members.
Sexual Exploitation: Taking advantage of someone’s vulnerability for sexual purposes.
Sexual Harassment: Unwanted sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.

Harmful Cultural Practices

Female Genital Mutilation (FGM): Partial or total removal of external female genitalia for non-medical reasons.
Widow Inheritance: Forcing a widow to marry a relative of her deceased husband.
Bride Price: Payment made by the groom’s family to the bride’s family, often leading to the commodification of women.
Child Marriage: Marrying off young girls, often for economic reasons or cultural beliefs.

Forced Marriages

Economic Purposes: Marrying off girls for financial gain, such as bride price.
Cultural Beliefs: The belief that girls are destined for marriage rather than education.
Social Pressure: Families forcing marriages to maintain social status or avoid stigma.
Lack of Education: Limited access to education leading to early marriage as the only perceived option.

Other Forms of Violence

Sexual Harassment and Intimidation: Occurring in workplaces, religious institutions, and schools.
Coercion: Forcing someone to act against their will through threats or manipulation.
Arbitrary Deprivation of Liberty: Unjustified detention or restriction of movement.
Belief in Large Families: Pressure to have many children, leading to health risks and economic strain.
Forced Sex: Men having non-consensual sex with their partners.
Institutional Violence: Violence perpetrated or condoned by institutions such as the government or religious bodies.

Settings Where Gender-Based Violence Can Occur

Family

Battering of Women: Physical abuse within the home.
Sexual Abuse of Children: Incest and other forms of sexual abuse within the family.
Emotional Abuse: Verbal and psychological harm inflicted by family members.
Neglect: Failure to provide basic needs such as food, shelter, and healthcare.

Community

Sexual Abuse: Rape, defilement, and other forms of sexual violence.
Sexual Harassment and Intimidation: Unwanted sexual advances and threats.
Trafficking: Exploitation for labor or sexual purposes.
Forced Prostitution: Coercing individuals into sex work.
Mob Violence: Community-based violence targeting individuals or groups.

State

Poorly Drafted or Unenforceable Laws: Legal frameworks that do not adequately protect victims.
Violence by Law Enforcement: Abuse of power by police and other authorities.
Lack of Facilities: Inadequate healthcare and support services for victims.
Education: Insufficient education on prevention and treatment of violence.
Corruption: Officials taking bribes to ignore or condone violence.

Predisposing Factors of Sexual and Gender-Based Violence

Socio-Economic Factors

Low Socio-Economic Status: Poverty and lack of education increasing vulnerability.
Women’s Low Status: Cultural and social norms that devalue women.
Dependence on Men: Economic and decision-making dependence.

Cultural Factors

Infertility: Blaming and abusing women for not being able to have children.
Fear of Reporting: Victims afraid to report due to lack of support and fear of reprisal.
Gender Roles: Traditional roles that limit women’s autonomy and expose them to violence.
Harmful Practices: FGM, early marriage, and widow inheritance.

Health and Disability Factors

Physical and Mental Disabilities: Increased risk of abuse and stigmatization.
Ill Health: Especially from HIV/AIDS, leading to vulnerability.
Poverty: Economic hardship leading to exploitation.
Idleness: Unemployment and lack of productive activities leading to substance abuse.

Environmental Factors

Abduction: Kidnapping leading to sexual abuse and exploitation.
Land Wrangle: Property disputes leading to violence against women.
Conflict: War and displacement increasing vulnerability.
Poor Role Modeling: Lack of positive examples for children.

Risk Groups for Sexual and Gender-Based Violence

Vulnerable Populations

All Children and Women: Higher risk due to power imbalances and cultural norms.
Adolescents: Vulnerable to peer pressure and exploitation.
Displaced Persons: Including refugees and internally displaced people.
People with Disabilities: Increased risk of abuse and neglect.
Prisoners: Vulnerable to abuse by authorities and other inmates.
Men: Often reluctant to report violence due to fear of stigma.
Pregnant Mothers: Vulnerable to domestic violence and lack of support.

Specific Risk Factors

Economic Dependence: Lack of financial independence.
Social Isolation: Lack of support networks.
Cultural Norms: Beliefs that justify violence against women.
Legal Gaps: Inadequate laws and enforcement.
Health Issues: Physical and mental health problems increasing vulnerability.
Education: Lack of awareness and education on rights and protections.

Domestic Violence

This term specifically refers to violence that occurs within the domestic sphere, typically between individuals who are related by blood or intimacy. It includes intimate partner violence (IPV) and can also encompass violence against children, siblings, or grandparents within the same household. Domestic violence is a subset of GBV and is one of the most common forms of GBV.

Domestic violence is a specific form of GBV that occurs within the family or intimate relationships, GBV is a broader concept that encompasses any form of violence directed at individuals based on their gender.

Reasons for Staying in an Abusive Relationship

Hope for Change:

Belief that the abuser will change their behavior.
Optimism that the relationship can improve.
Faith in the abuser’s promises to stop the abuse.

Total Love for the Partner:

Deep emotional attachment to the abuser.
Strong feelings of love and commitment.
Belief that love can conquer all problems.

Fear of Losing the Marriage:

Concerns about the social stigma of divorce.
Fear of being alone or single.
Worries about the impact on children and family.

Purpose of the Children:

Staying for the sake of the children’s well-being.
Belief that children need both parents.
Fear of disrupting the children’s lives.

Shame:

Embarrassment about the abuse.
Fear of judgment from family, friends, and society.
Concerns about being blamed for the abuse.

Poverty – Fear of Returning the Bride Price:

Financial dependence on the abuser.
Fear of economic hardship if the relationship ends.
Cultural obligations to return the bride price, which can be a financial burden.

Security Purpose:

Dependence on the abuser for financial and physical security.
Fear of losing a stable home and lifestyle.
Belief that the abuser provides necessary protection.

Lack of Support:

Isolation from friends and family.
Lack of a support system to help leave the relationship.
Fear of being alone without emotional and practical support.

Cultural and Social Pressure:

Pressure from society to maintain the relationship.
Cultural beliefs that prioritize marriage and family unity.
Fear of being ostracized by the community.

Fear of Retaliation:

Fear that the abuser will become more violent if the victim tries to leave.
Concerns about the abuser harming the victim, children, or other family members.
Fear of the abuser stalking or harassing the victim after leaving.

Low Self-Esteem:

Belief that the victim deserves the abuse.
Feelings of worthlessness and inadequacy.
Lack of confidence in the ability to live independently.

Lack of Alternatives:

Limited options for housing, employment, and financial support.
Fear of homelessness or poverty if the relationship ends.
Belief that there are no better alternatives to the current situation.

Characteristics of Those Who Are Abused

Belief That Violence Gives Immediate Results:

The abuser believes that violence is an effective way to control and dominate the victim.
The abuser uses violence to achieve immediate compliance and obedience.

Insecure, Extremely Jealous, and Possessive:

The abuser feels threatened by the victim’s independence and relationships with others.
The abuser exhibits extreme jealousy and possessiveness, often accusing the victim of infidelity.

Emotionally Dependent on the Partner:

The abuser relies on the victim for emotional support and validation.
The abuser feels a strong need to control the victim to maintain emotional stability.

Denial That Their Actions Are Violent:

The abuser minimizes or denies the severity of their actions.
The abuser blames the victim for provoking the violence.
The abuser refuses to take responsibility for their abusive behavior.

Poor Impulse Control:

The abuser has difficulty managing anger and frustration.
The abuser acts impulsively and aggressively without considering the consequences.
The abuser struggles with emotional regulation and self-control.

Manipulative and Controlling:

The abuser uses manipulation and control tactics to maintain power over the victim.
The abuser isolates the victim from friends and family to increase dependence.
The abuser uses guilt, shame, and fear to control the victim’s behavior.

History of Abuse or Trauma:

The abuser may have experienced abuse or trauma in their past.
The abuser may repeat patterns of abuse learned from their upbringing or past relationships.
The abuser may have unresolved emotional issues that contribute to their abusive behavior.

Lack of Empathy:

The abuser shows little or no concern for the victim’s feelings and well-being.
The abuser is unable or unwilling to understand the impact of their actions on the victim.
The abuser prioritizes their own needs and desires over the victim’s.

Impacts of Sexual and Gender-Based Violence

Sexual and gender-based violence (SGBV) has profound and lasting effects on survivors, impacting their physical, mental, and social well-being. The impacts can be categorized into physical, psychological, social, and economic dimensions.

Physical Impacts

Injuries:

Bruises, fractures, and internal injuries.
Long-term physical disabilities and chronic pain.
Scars and disfigurement.

Sexually Transmitted Infections (STIs):

Increased risk of contracting STIs, including HIV/AIDS.
Long-term health complications from untreated STIs.
Stigma and discrimination associated with STIs.

Unwanted Pregnancies:

Risk of unsafe abortions, leading to lifelong health effects and potential death.
Complications during pregnancy and childbirth.
Emotional and financial burden of raising a child from an abusive relationship.

Chronic Health Issues:

Long-term health problems such as chronic pain, headaches, and gastrointestinal issues.
Weakened immune system and increased susceptibility to illnesses.
Cardiovascular problems and hypertension.

Psychological Impacts

Mental Health Issues:

Depression and anxiety.
Post-traumatic stress disorder (PTSD).
Suicidal thoughts and attempts.

Low Self-Esteem:

Feelings of worthlessness and inadequacy.
Loss of confidence and self-worth.
Difficulty trusting others and forming healthy relationships.

Trauma and Fear:

Constant fear and hypervigilance.
Nightmares and flashbacks.
Difficulty sleeping and concentrating.

Substance Abuse:

Turning to drugs or alcohol to cope with trauma.
Increased risk of addiction and related health problems.
Social and economic consequences of substance abuse.

Social Impacts

Isolation:

Withdrawal from social activities and relationships.
Loss of friends and support networks.
Difficulty forming new relationships due to trust issues.

Stigmatization:

Social judgment and blame.
Difficulty reintegrating into society.
Fear of disclosure and seeking help due to stigma.

Family Disruption:

Breakdown of family relationships.
Impact on children, including behavioral and emotional problems.
Difficulty maintaining stable housing and employment.

Economic Impacts

Poverty:

Loss of income and financial stability.
Difficulty finding and maintaining employment.
Increased dependence on social services and support.

Loss of Livelihood:

Difficulty pursuing education and career goals.
Loss of job opportunities and professional advancement.
Economic strain from medical expenses and legal fees.

Housing Instability:

Difficulty finding and maintaining safe and stable housing.
Risk of homelessness or living in unsafe conditions.
Financial burden of relocating and starting over.

Long-Term Effects

Intergenerational Trauma:

Impact on future generations, including increased risk of abuse and violence.
Cycle of violence and trauma passed down through families.
Long-term effects on community and societal well-being.

Community Impact:

Increased strain on social services and healthcare systems.
Economic burden on communities and societies.
Decreased productivity and increased social unrest.

Legal and Justice System:

Challenges in accessing justice and legal support.
Difficulty navigating the legal system and seeking redress.
Fear of reporting abuse due to lack of trust in the justice system.

Ways through which Sexual Gender-based Violence can be reduced in Uganda

Sexual and gender-based violence should be recognized as an important public health matter. Therefore, everyone in the community can contribute tremendously to reducing the acts of sexual gender-based violence by actively doing the following:

Leaders should spearhead sensitization of communities on the impacts of sexual gender-based violence throughout the country.
Reporting all acts of violence to the health centers, police, and other relevant authorities.
Ensuring that those who commit these acts are punished appropriately.
Some of the current measures to punish the perpetrators should be revised and made stronger to deter people from committing acts of violence.
Communities should be encouraged to stop the culture of silence which hampers victims from reporting fearing the repercussions e.g. imprisonment and stigmatization.
Advocacy to reduce sexual and gender-based violence must be intensified at all levels.
Review the legal systems to improve the court relationship between the legal officers and the victims.
Improve the relationship between the legal and other practitioners during court session.
Health workers should be supported to undertake their roles to manage and care for survivors of Sexual Gender-based Violence.

Roles of leaders on SGBV in their community

The following ways can be used by leaders to fight Sexual Gender-based Violence by:

Speaking out against Sexual Gender-based Violence at every opportunity for instance during community meetings, campaigns, fundraising, funerals, drinking places.
Leaders should strive to act as role models by avoiding being perpetrators of SGBV.
Assisting victims to get help and to see that the culprits such as defilers, rapists, men who batter their wives are reported to the police and punished appropriately.
Leaders can form counseling groups to help men, children and women who are perpetrators of Sexual Gender-based Violence.

Control and prevention of Sexual Gender-based Violence

Improve girl child education at all level.
Reducing the high level of poor socio-economic status will in long run reduce women vulnerability to violence.
Increasing awareness of women‘s rights and responsibilities related to owning property and assets.
Reviewing and amending laws that safeguard women‘s rights.
Strengthening nationwide/community wide efforts to challenge the widespread tolerance and acceptance of violence against women.
Encouraging parents to bring up children who respect the rights of individuals as men or women, boys or girls
Supporting parents to bring up their boys and girls as equal partners

Reasons Why the Community and Leaders Should Be Concerned About SGBV

Damages Social Bonds:

Isolation of Victims: Women and girls who are sexually abused often isolate themselves or are isolated by their families and communities, leading to a breakdown in social cohesion.
Community Division: The stigma and shame associated with SGBV can create divisions within communities, affecting trust and cooperation.
Social Exclusion: Victims may face social exclusion, further damaging community bonds and support networks.
Intergenerational Impact: The trauma experienced by victims can affect future generations, perpetuating a cycle of abuse and social dysfunction.

Substantial Health Burden:

Difficult Diagnosis and Treatment: Victims often present with vague complaints that are challenging to diagnose and treat, placing a significant burden on healthcare systems.
Mental Health Issues: SGBV survivors frequently suffer from mental health problems such as depression, anxiety, and post-traumatic stress disorder (PTSD), requiring long-term psychological support.
Physical Health Problems: Victims may experience chronic pain, sexually transmitted infections (STIs), and other physical health issues that require ongoing medical care.
Reproductive Health: SGBV can lead to unwanted pregnancies, unsafe abortions, and reproductive health complications, further straining healthcare resources.

Economic Loss:

Loss of Productivity: Victims of SGBV, due to physical injury or emotional stress, are often unable to fulfill their roles in households and workplaces, leading to economic loss.
Financial Burden: The cost of medical treatment, legal proceedings, and support services for victims can be substantial, placing a financial burden on households and communities.
Reduced Economic Contribution: In many Ugandan villages, women are key breadwinners. SGBV can significantly reduce their economic contribution, affecting family income and community development.
Long-Term Economic Impact: The economic repercussions of SGBV can be long-lasting, affecting future generations and hindering economic growth and development.

Legacy of Bitterness:

Conflict Situations: SGBV can exacerbate tensions in conflict situations, creating a legacy of bitterness and resentment towards the group from which the perpetrators came.
Negative Impact on Reconciliation: The bitterness and mistrust resulting from SGBV can hinder reconciliation efforts and community reconstruction, prolonging conflict and instability.
Cycle of Violence: The bitterness and desire for revenge can perpetuate a cycle of violence, making it difficult to achieve lasting peace and stability.
Community Polarization: SGBV can polarize communities, making it challenging to foster unity and cooperation.

Legal and Justice System Strain:

Increased Caseload: SGBV cases can overwhelm the legal and justice system, leading to delays and inefficiencies in handling other cases.
Resource Allocation: Addressing SGBV requires significant resources, including trained personnel, infrastructure, and support services, which can strain limited resources.
Public Trust: Failure to adequately address SGBV can erode public trust in the legal and justice system, undermining its effectiveness and legitimacy.

Educational Impact:

School Dropout: Victims of SGBV, particularly girls, may drop out of school due to trauma, stigma, or pregnancy, affecting their education and future prospects.
Learning Environment: SGBV can create a hostile learning environment, affecting the educational outcomes of all students.
Teacher-Student Relationships: SGBV can damage trust between teachers and students, making it difficult to provide a safe and supportive educational environment.

Cultural and Social Norms:

Perpetuation of Harmful Practices: SGBV can reinforce harmful cultural and social norms, such as gender inequality and patriarchal attitudes, perpetuating a cycle of abuse.
Challenge to Traditional Values: Addressing SGBV may require challenging deeply ingrained cultural and social norms, which can be met with resistance and backlash.
Community Values: SGBV can undermine community values of respect, dignity, and equality, affecting the overall well-being and cohesion of the community.

Roles of health workers in managing victims and addressing gender-based violence

This is important to note that health workers play instrumental roles in ensuring that families and victims of gender-based violence are professionally attended and see that the victims get justice. Therefore, the following cited are some of roles of health worker in gender-based violence management;

Offering psychosocial support and counseling services to the affected families and individuals.
Liaising with people and other stakeholders to see that the perpetrator (culprits) is brought to book to prevent possibility of reoccurrences.
Collecting victim‘s medical information and performing required medical examination to promote continuity of care.
Creating a friendly and confidential environment (shelter) where victims needs are addressed.
Offering timely and appropriate referral services as needed.
Establishing and promoting strict reporting of all gender-based violence related cases to responsible authority and ensure victims get fair justice.
Ensuring and maintaining constant follow-up care of all affected families or victims.

Sources of Help for Victims of SGBV

Police:

Reporting and Investigation: Victims can report incidents of SGBV to the police, who are responsible for investigating and taking legal action against perpetrators.
Protection and Support: Police can provide immediate protection and support to victims, including referrals to other services.

Probation Officers:

Rehabilitation and Monitoring: Probation officers can monitor perpetrators and provide rehabilitation services to prevent future incidents of SGBV.
Victim Support: Probation officers can also support victims by ensuring that perpetrators comply with court orders and conditions of probation.

Child and Family Protection Unit:

Specialized Services: This unit provides specialized services for children and families affected by SGBV, including counseling, legal support, and referrals to other services.
Child Protection: The unit focuses on protecting children from abuse and ensuring their well-being and safety.

Local Leaders/Elders:

Community Support: Local leaders and elders can provide support and advocacy for victims within the community, helping to address SGBV at the local level.
Mediation and Reconciliation: Local leaders can facilitate mediation and reconciliation efforts to address SGBV and promote community healing.

Trusted Person or Family Members:

Emotional Support: Trusted individuals or family members can provide emotional support and a safe space for victims to share their experiences and seek help.
Practical Assistance: They can also offer practical assistance, such as helping victims access services and navigate the legal system.

Counselors:

Psychological Support: Counselors provide psychological support to help victims cope with the trauma of SGBV, including therapy and emotional healing.
Long-Term Support: Counselors can offer long-term support to help victims rebuild their lives and overcome the effects of SGBV.

Healthcare Providers:

Medical Care: Healthcare providers can offer medical care and treatment for physical injuries and health complications resulting from SGBV.
Mental Health Services: They can also provide mental health services to address the psychological impact of SGBV.

Legal Aid Services:

Legal Representation: Legal aid services can provide victims with legal representation and support to navigate the legal system and seek justice.
Advocacy: They can also advocate for victims’ rights and ensure that their voices are heard in legal proceedings.

Non-Governmental Organizations (NGOs):

Comprehensive Support: NGOs can offer comprehensive support services, including counseling, legal aid, and advocacy for victims of SGBV.
Community Outreach: NGOs can engage in community outreach and awareness campaigns to educate the public about SGBV and promote prevention efforts.

Support Groups:

Peer Support: Support groups can provide a safe and supportive environment for victims to share their experiences, receive peer support, and build a network of solidarity.
Empowerment: Support groups can empower victims to speak out against SGBV and advocate for change in their communities.

Note: In some African cultures, beating a woman or girls is part of the disciplining process; in fact some women even willingly accept to be beaten

Gender Based Violence (GBV) Read More »

Hormonal Methods of Family Planning

Hormonal family planning refers to the use of hormonal methods to prevent pregnancy. These methods involve the use of hormones, typically synthetic versions of those naturally produced by the body, to regulate a woman’s menstrual cycle and prevent ovulation (the release of an egg from the ovaries). By preventing ovulation, hormonal methods make it difficult for sperm to fertilize an egg and thus prevent pregnancy.

These include;

Oral contraceptive pills
Implants
Injectable contraceptive
Emergency contraceptive pills

Oral Contraceptive Pills

i) Progesterone Only Pills (POP)

Examples

Ovrette
microval

They contain progesterone hormone
They are recommended for breastfeeding mothers because they do not affect/suppress milk

Modes of action

It acts mainly by making cervical mucus thick and viscous, thereby preventing sperm penetration
Endometrium becomes atrophic so blastocyst implantation is also
In about 2% ovulation is inhibited and 50% of women ovulate normally

Advantages

Highly effective
Limited related side effects
Protects against unwanted pregnancy
Do not affect breastfeeding
May decrease menstrual cramps
May improve anemia
Protects against ectopic pregnancy

Contraindications

Pregnancy
Unexplained vaginal bleeding
Recent history of breast cancer
Arterial diseases
Thromboembolic diseases
Active hepatic diseases
Hypertension

Side effects

Amenorrhea
Spotting
Prolonged or heavy bleeding
Lower abdominal pain
Weight gain or lose
Jaundice
Nausea and vomiting
Headache with blurred vision
Excessive hair growth
Breast fullness or tenderness
High blood pressure

i) Combined Oral Contraceptive Pills (COC)

This contains both oestrogen and It achieves effects of both hormones
Oestrogen suppresses ovulation and progesterone creates unfavorable conditions for egg transport and thickening of the cervical mucus to impair sperm entrance into the canal.

Examples

Lo-femenal
Pillplan (duofen)
Microgynon

Advantages

Highly effective (99%)
Protects against unwanted pregnancy
It is convenient, simple to take and does not interfere with sexual intercourse
Helps to correct menstrual irregularities
Reduces risks of ovarian and endometrial cancers by 50%
Decreased menstrual cramps
Pelvic examination is not required before use
Limited related side effects
Quicker return of infertility

Disadvantages

Refer to pop Side effects

Side effects

Chest pain
Amenorrhea
Spotting
High blood pressure
Nausea, dizziness & nervousness
Acne
Breast fullness & tenderness
Depression
Jaundice
Headache

Implants

Types

Implanon ( 1 rod capsule for effective 3 years)
Jadelle (2 rod capsules for 5 years)
Norplant ( 6 rod capsules labeled for 5-7 years)

Modes of action

Thickens the cervical mucus 24 hours making it difficult for the sperm to enter the uterus.
It inhibits ovulation from taking place.

Advantages

Very effective within 24 hours after insertion
Easily reversible
No delay to return to fertility after removal
Make sickle cell crisis less frequent & less painful
Highly effective for long term
Others same as with Depo Provera

Common side effects and disadvantages

Changes in menstruations
- Spotting
- Heavy bleeding (rare)
- Amenorrhea
Does not protect against STIs including HIV/AIDs
Discomfort in the hand after insertion
Overweight or weight loss
Minor surgical procedure required for insertion and removal.

Indications

Breast feeding post-partum mothers
Adolescents
Post abortion
Women with SCD
Women waiting surgical contraception
Women on treatment e. ARVs

Contraindications

Serious problems with heart or blood vessels
Breast cancer
Liver diseases- jaundice
Pregnancy

Signs and problems that need medical attention

Soreness at the site of insertion
Capsules come out
Severe headache
Heavy bleeding twice as much and twice as long she usually bleeds
Pregnancy
Missed period after several regular period or cycles.

Injectable contraceptives

Examples

Depo provera 150mg
Injecta plan
Sayana press 104mg, 65ml subcutaneously
Noristrat 200mg intramuscularly
Norigynon 5mg intramuscularly

They both contain only one type of hormones, progestin

Depo Provera

Mode of action

Inhibits ovulation
Thickens the cervical mucus making it difficult for the sperm to enter the uterus
It also makes the lining of the womb thinner. This makes it unlikely that a fertilized egg will be able to implant in the womb.

Indications/who can use it?

Breastfeeding mothers 6 weeks after delivery or immediately if not breastfeeding
Women requiring long term contraception
Known/suspected HIV positive women who need an effective FP method
Women with sickle cell disease
Women who cannot use COC due to estrogen content
Women awaiting surgical method of contraception

Contraindications

As for POP
Women without proven fertility unless they have HIV/AIDs
Pregnancy (known or suspected)
Liver disease (jaundice)
Unexplained vaginal bleeding that has not be investigated
Hypertension 140/90mmg and above
Serious problem with the heart or blood loss
Breast or genital malignancy (known or suspected)
Women with bone thinning/osteoporosis (known or suspected)

Advantages and non-contraceptive benefits

Very effective
Does not suppress lactation
Clients only has to remember the return dates for subsequent injection
Private-no one can know that the woman is on it
No estrogen side effects
Make sickle cell crisis less frequent
If you want to stop using it you don’t have to go back to your doctor or nurse to have it removed; you just have to wait for it to wear off.
It does not interfere with sex

Disadvantages and common side effects

Changes in menstrual bleeding
- Spotting (common in the first 3 months)
- Amenorrhea (often after 1^st injection and after 9-12months of use)
- Prolonged heavy vaginal bleeding during 1^st 1-2 months after injection
Weight gain or loss
The injection cannot be removed once given. Any side-effects will last for more than 2-3 months, until the progesterone goes from your body.
Delayed return of fertility
Loss of lido
Does not protect against STI/HIV/AIDs
Alopecia
Milk headache

Signs and problems that need medical attention

Repeated severe headaches
Excessive weight gain
Depression
Prolonged abdominal pain and pain at injection site
Heavy bleeding per vagina twice as much and twice as long as she usually bleeds

Management

Medroxyprogesterone acetate depot (Depo provera) Injection 150mg deep IM into deltoid or buttock muscle
- Do not rub the area as this increases absorption and shortens depot effect

If given after day 1-7 of menstrual cycle

Advise client
- To abstain from sex or use a back-up FP method, e.g. condoms, for the first 7 days after injection
- To return for the next dose on a specific date 12 weeks after the injection (if the client returns more 2-4 weeks later than the date advised, rule out pregnancy before giving the next dose)
- On likely side effects
- To return promptly if there are any warning signs

Sayana Press

Sayana press ® is a single-dose container with 104mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension (104mg) formulated for subcutaneous
It is administered subcutaneously into the anterior thigh or abdomen or arm
The efficacy of Sayana press depends on adherence to the recommended dosage schedule of administration.

Mechanism of actions

Its‘ main mechanism of action is to suppress ovulation
It makes the endometrium unsuitable for implantation if fertilization occurs
It also increases the viscosity of cervical mucus making the mucus less easily penetrable to sperm.

Indications

Nearly all women can use it safely & effectively including women:-

Women whose partners have undergone vasectomy until vasectomy is effective
Have or have not had children
Any age including adolescents & women over 40 years old
Have just had an abortion/miscarriage
Breastfeeding women 6 weeks postpartum
HIV infected whether or not on ART

Advantages & non- contraceptive benefits

New formulation for S/C injection
30% low side effects compared to Depo-Provera
Do not interfere with sex
Private & no one else can tell that a woman is using it
May help women gain weight
Do not require daily action
Prevents pregnancy
Protects against endometrial cancer, uterine fibroids
Reduces sickle cell crisis among women with sickle cell anemia
Protects against symptomatic PID & iron deficiency aneamia

Contraindications

Sayana press is contraindicated in the following:-

Clients with a known hypersensitivity to MPA
Pregnancy (known or suspected)
women with known or suspected malignancy of the breast or genital organs
clients with undiagnosed vaginal bleeding
patients with severe hepatic impairment
patients with metabolic bone disease
patients with thromboembolic disease
patients with current or past history of cerebro-vascular disease

Disadvantages & Side effects

Weight gain or loss
Does not protect against STI/HIV/AIDs
Delayed fertility return
Hypersensitivity reactions
Decreased/increased appetite
Loss of libido & irritability
Dizziness, headache & migraine
Thromboembolic disorders
Nausea & vomiting
Jaundice
Alopecia & urticaria
Loss of bone mineral density
Back & leg pains
Mood changes
Abdominal bloating & discomfort

Problems that may need medical attention

Loss of bone mineral density
Menstrual irregularities
Thromboembolic disorders
Anaphylaxis & anaphylactoid reactions
Sudden partial or complete loss of vision

Permanent Method/Voluntary Surgical Contraceptives

Because male and female sterilization are permanent methods of contraception, thorough counseling procedures must be followed to ensure that the client fully understands his or her choice and to minimize chances of regret. Clients younger than 30 years old or with fewer than three children require particularly careful counseling and exploration of other long-term method options.

Tubal ligation/tubectomy

This is a voluntary surgical procedure for permanent termination of fertility in women.
It can be done by a mini-operation (laparatomy/laparoscopy)

Mode of Action

Blocking fallopian tube by cutting, cautery, rings or clips
Prevent sperms from reaching the ovum

Indications

In general, the majority of women who want tubal ligation can have a safe and effective procedure in a routine in a health facility equipped to provide the service, provided they have been counseled. They should also be able to give informed consent. Women who may consider tubal ligation include:

Those who are certain that they have achieved their desired family size
Women who want a highly effective permanent method of contraception
Women for whom pregnancy presents unacceptable risk Family planning should be delayed in case of:
1. Pregnancy
2. Immediately/early postpartum if woman had severe pre-eclampsia/eclampsia, early rupture of membrane (EROM), sepsis etc.
3. Complicated abortion (infection, hemorrhage)
4. Current DVT
5. Unexplained vaginal bleeding (before evaluation)
6. Malignant trophoblastic disease
7. Current PID or purulent cervicitis
8. Current gall bladder disease
9. Severe anemia
10. Acute respiratory disease
11. Acute systemic infection or gastroenteritis
12. Abdominal skin infection – peritonitis

Timing of the tubal ligation

Immediately after childbirth or within first seven days (if she made voluntary choice in advance)
Six weeks or more after childbirth
Immediately after abortion (if she made voluntary choice in advance)
any time provided pregnancy is ruled out (but between seven days and six weeks postpartum)
during caesarean section

Benefits

Highly effective
Effective immediately
It is permanent
It is a simple surgery, usually done under local anesthesia
No exposure or worries about contraception
No further expense or worries about conception
No long term side effects
Does not interfere with sexual intercourse

Disadvantage

Does not protect against STIs/AIDs
It is irreversible

Side effects

Wound infection
Post-operative fever
Bladder and intestinal injuries(rare)
Hematoma
Pain at the incision (post operatively)
Superficial bleeding

Challenges associated with tubal ligation

Desire for more children after when the operation is done
Excessive desire in reversal
Disagrees to sign the informed consent form
Pressure from the someone else
Depression
Marital problems
Single women
Women with no children

General complications of tubal ligation

Obesity
Psychological upset
Chronic pelvic pain
Congestive dysmenorrheal
Menstrual abnormalities like menorrhagia, hypomenorrhea
Alteration in libido.

2. Vasectomy

This is a voluntary surgical procedure for permanently terminating fertility in men

Mode of action

Blocking the vas deferens (ejaculatory duct) so that sperms are not present in the ejaculate.

Indications

Those who are certain that they have achieved their desired family size
Men who want a highly effective permanent method
Men whose wives face unacceptable risk in pregnancy

Contraindications

Vasectomy should be delayed in case of:

Local infections (scrotal skin infections, orchitis etc)
Current STI
Systemic infections

Benefits

Highly effective
It is permanent
It is a simple surgery done under local anesthesia
No further expense or worries about conception
No long term side effects
Does not interfere with sexual intercourse

Side effects

Wound infection
Scrotal hematoma
Granuloma
Excessive swelling
Pain at incision sites

Explain the following to the clients

When to come back for follow up visits
Common side effects of the method offered
What to do if there are changes in the menstrual periods
How soon the method is effective
How to protect against STIs
How to care for the wound in case of implants, vasectomy and tubal ligation

General instruction to the clients using permanent methods of family planning

Inform him or her when to come back for follow up visits
Explain the common side effects of the method in a simple language
Tell the client the warning signs or possible problems that may require medical attention
Tell the client what to do if there are changes in the menstrual periods
Inform the client how soon the method is effective
Let the client know that the method does not protect against HIV/AIDs and STIs and emphasize on the use of backup methods like condoms
Guide the client on how to care for the wound post operatively

Emergency /Post Coital Contraceptives

Emergency contraception (EC) refers to methods of contraception used by women to prevent unintended pregnancy following unprotected sexual intercourse. It should not be used as a routine contraceptive method. EC not a method for termination of pregnancy

Indications

Any woman who has had unprotected sexual intercourse
Women who have been raped
Any woman whose contraceptive method has failed (e.g. condom broke or slipped)
Any woman who has forgotten to take her COC pills for more than two days or who has forgotten to take her POP at the regular time
Missed injection for more than two weeks
Delay in taking pills more than 3 hours
Sexual assault or rape and the first time intercourse

Contraindications

Pregnancy
After 120 hours or 5 days of unprotected sex

Types

Emergency contraceptive pills (ECP)
Progesterone only pills regimen.

They are the preferred ECP regimen as they are more effective and have fewer side effects than COC pills

When to start?

This should be started or taken within 5 days or 120 hours but the sooner the better following unprotected sexual intercourse.

What to use and the dose

Lofemenal or microgynon 4BD for 1 day (low dose COC)
Eugynon (high dose COC) 2BD for 1day
Regular POP such as Ovrette or microval can be used in recommended dose
Levonogestrel 2stat
Postinar 2 BD for 1day
vikela orlevonelle-2 or Norlevo plan B may be used

Side effects

Nausea & vomiting

a) Intrauterine contraceptive devices (IUCDs)

Introduction of copper IUCDs with a maximum period of 5days can prevent conception following accidental unprotected sexual exposure.

Mechanism of action

Prevents implantation
Failure rate is about 1%
Effectiveness is over 99% in preventing pregnancy

Notes

Post coital contraception is only employed as emergency measure and is not effective if used as regular method of contraception with the exception of the copper IUCDs

Women who need emergency contraception should be counseled about regular contraceptive options and encouraged to use regular methods consistently and correctly. Referral:

Women should be referred for other relevant services such as HIV counseling and testing, post exposure prophylaxis (PEP) and treatment for STIs
Women should be referred to specialized services such as for sexual and gender based violence.

Basic steps of client care for ECP

Greet client, introduce yourself, and ask what he/she
Show a respectful attitude
Explain that your discussion with the client will be kept
Explain the different ECP
Screen the client for ECP use.
Tell client about ECPs; give clear information about use, side effects, and needs for referral or follow-up.
Encourage her to ask questions
Discuss options for regular contraception with client

Counseling ECP clients

When counseling a client about ECP, the provider should:

Actively involve the client in the counseling process
Reassure the client that all information she gives you is kept confidential
Provide a private and supportive environment
Do not make judgmental comments or indicate disapproval through body language (such as such as crossing your arms over your chest)
Be responsive to the client‘s needs
Be supportive of the clients choices
Be respectful

Hormonal Methods of Family Planning Read More »

Artificial Methods of Family Planning

Artificial methods of family planning refer to the use of various techniques and devices to prevent pregnancy. These methods rely on the use of physical barriers, chemicals, or surgical interventions to either prevent sperm from reaching the egg or to interfere with the fertilization process.

FAMILY PLANNING CARD

Criteria to follow before a client is put on a family planning methods

History taking

1. Personal Age, sex, address, next of kin
2. Social Marital status, education, any habits that may affect choices of some family planning methods e.g. smoking
3. Medical To identify the presence of medical diseases, problems, sickle cell, medications.
4. Reproductive /obstetric history:
  - Find out when clients started her period
  - How many children/pregnancies she had
5. Gynecological To identify any diseases affecting a woman‘s reproductive organs e.g. bleeding, cancer of the cervix, PIDs, breast cancer etc.
6. Family planning To find out about previous use of family planning methods.

General examination

Should be done from the head to toes;

Anemia, edema, jaundice, lymphadenopathy
Breast for colour changes, masses
Per abdominal examination to check for masses
Per vaginal examination to check for abnormal discharges

Note: Weight, blood pressure should be recorded when starting one on family planning especially the hormonal ones.

Artificial methods of family planning

Barrier methods

Spermicides
Condoms
IUCDs
Diaphragm
Intra-vaginal contraceptive sponge
Cervical caps

Condoms (male and female)

This is the most popular and oldest method
This is a rubber sheath that is worn by a woman or man during sexual intercourse
It is the only family planning method that prevents both pregnancy and STIs including HIV/AIDs if used consistently and correctly.

Indications

Condoms can be used by any man or woman regardless of his/her health status. People in particular need of condoms include:

Men wishing to participate more actively in family planning
Sexually active adolescents
Couples who have sexual intercourse infrequently
People in casual sexual relationships where pregnancy is not desired
Couples needing a back-up method while waiting for another contraceptive methods to become effective.
Couples who need a temporary method while waiting to receive another contraceptive method.
Those who are at increased risk of STIs, (e.g. when one or both partners have other partners)
Couples where one or both partners are HIV positive

Male Condoms

Male condoms are sheaths or coverings that fit over a man‘s erect penis. Most are made from thin latex rubber; some are polyurethane (plastic).

Primary mechanism of action

Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy
Also keep infectious agents in semen, on the penis, or in the vagina from infecting the other partner

Effectiveness

Protection against pregnancy:
As commonly used, about 18pregnancies per 100 women whose partners use male condoms over the first year
When used correctly with every act of sex, about 2 pregnancies per 100 women whose partners use male condoms over the first year

Protection against HIV and other STIs:

Male condoms significantly reduce the risk of becoming infected with HIV when used correctly with every act of sex.
When used consistently and correctly, condom use prevents 80% to 95% of HIV transmission that would have occurred without condoms.
Condoms reduce the risk of becoming infected,
- Protect best against STIs spread by discharge, such as HIV, gonorrhea, and Chlamydia
- Also protect against STIs spread by skin to skin contact, such as herpes and human papilloma virus (if condom covers lesions)

Any client concerns or questions

Reinforcing correct condom use and reminding clients that condoms should not be reused
Allergy to latex

Dispelling myths regarding condoms

Male condoms:

Do not make men sterile, impotent, or weak
Do not decrease men’s sex drive
Do not promote promiscuity
Cannot get lost in the woman’s body
Do not have holes that HIV can pass through
Are not laced with HIV
Do not cause illness in a woman because they prevent semen or sperm from entering her body
Do not cause illness in men because sperm may move back up
Are used by married couples; they are not only for use outside marriage

Who should not use condoms?

Individuals allergic to latex should consider other contraceptive options. However, for those at risks of STIs/HIV, condom use is still appropriate as there are no other methods that offer STI/HIV protection.

How to use male condoms

Use a new condom for each act of sex. Check package for damage and check the expiration Tear open carefully without using any sharp objects.
Before any physical contact, put condom on the tip of the erect penis with the rolled side out.
Unroll condom all the way to the base of the erect penis.
Immediately after ejaculation, hold rim in place and withdraw penis while it is still Slide the condom off, avoiding spilling semen.
Dispose of the used condom safely.

Practices to avoid when using condoms

Unrolling condom before putting it on
Using oil-based lubricants with latex condoms
Using condoms that may be old or damaged (e.g. dried out, brittle, sticky)
Reusing condoms

Practicing dry sex as it increases possibility of condom breakages due to friction

Female Condoms

Female condoms are sheaths, or linings, that fit loosely inside a woman‘s vagina
Most common type is Female Condom Two (FC2) made of thin, soft, synthetic rubber film, with flexible rings at both ends
Latex female condoms are available in some countries Primary mechanism of action
Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy
Also keep infectious agents in semen, on the penis, or in the vagina from infecting the other partner

Effectiveness

Protection against pregnancy:

When used correctly with every act of sex, about 5 pregnancies per 100 women using female condoms over the first year
As commonly used, about 21 pregnancies per 100 women using female condoms over the first year.
Protection against HIV and other sexually transmitted infections (STIs):
Female condoms reduce the risk of infection with STIs, including HIV, when used correctly with every act of sex.

Characteristics of female condoms

Safe
Women can initiate their use
Have a soft texture that quickly conducts body heat during sex
Provide dual protection (against STIs/HIV and pregnancy)
Outer ring provides added sexual stimulation for some women
Do not require provider‘s help
Can be inserted ahead of time so do not interrupt sex
Are not tight or constricting like male condoms
Do not dull the sensation of sex like male condoms
Do not have to be removed immediately after ejaculation
No side effects
Can be used as a temporary backup method of contraception
Protect women from conditions caused by STIs (pelvic inflammatory disease, cervical cancer, infertility)
As typically used, less effective than many other FP methods
Require partner communication and cooperation
May be difficult to insert
Can make noise during sex

Side effects of female condoms:

None
Allergic reactions to latex

Who can use female condom?

All men and women can safely use synthetic rubber female
All men and women can safely use natural latex female condoms, except those with a severe allergy to latex (extremely rare).

How to use female condoms

Use a new condom for each act of sex.
- Check the condom
- Do not use if torn, damaged or past the expiration
- Open the package
Before any physical contact, insert the condom into the vagina. It can be inserted up to eight hours before sex. Find a comfortable position for insertion—squat; raise one leg, sit, or lie down. Grasp the ring at the closed end, and squeeze it so it becomes long and With the other hand, separate the outer lips and locate the opening of the vagina. Gently insert the inner ring into the vagina as far up as it will go. Insert a finger into the condom to push it into place. (The inner ring should be pushed up just past the pubic bone.)
Ensure that the penis enters the condom and stays inside the
To remove the condom, hold and twist outer ring to seal in fluids, and gently pull condom out of the vagina. The female condom does not need to be removed immediately after sex, but any time before standing up, to avoid spilling semen.
Dispose of the used condom safely.

Tips for new users

Suggest to a new user that she practice putting in and taking out the condom before the next time she has sex. Reassure her that correct use becomes easier with practice. A woman may need to use the female condom several times before she is comfortable with it.
Suggest she try different positions to see which way insertion is easiest for her.
The female condom is Some women find insertion easier if they put it in slowly, especially the first few times.
If a client is switching from another method to the female condom, suggest that she continue with the previous method until she can use the female condom with confidence.

Provide follow up and counseling for

Any client concerns or questions
Correct condom use

Dispelling myths regarding female condoms

Female condoms:

Cannot get lost in the woman‘s body
Are not difficult to use, but correct use needs to be learned
Do not have holes that HIV can pass through
Are used by married couples; they are not only for use outside marriage
Do not cause illness in a woman because they prevent semen or sperm from entering her body

General Advantages

Effective when used correctly
No medical supervision required
Convenient to carry
Prevents both pregnancy and STIs including HIV/AIDs
Easy to use
Reduce risk of systemic side effects and reaction
Fairly cheap and available in almost every places

General Disadvantages

There is loss of spontaneity
May rupture or lose position during intercourse
It is often associated with extra marital sex and STIs
It is not suitable for poorly motivated persons
There is lack of privacy while purchasing condoms
It cannot be used by a man who cannot maintain erection
Requires male responsibility
It is considered unclean to some people

Spermicides

This involves application of chemicals into the vagina to prevent pregnancy.

Mode of action

Aims at killing or inactivating sperms

Forms of Spermicides

Jellies
Creams
Foams
Tablets
Lubricants in condoms
Ingredient in vaginal sponge

Advantages

Available without prescription
Fairly effective if used correctly
Can be used as backups
Used only if required
Control is in the hand of a woman
Provide extra-vaginal lubrication
Protects against some STIs and PIDs

Disadvantages

Not effective when used alone
Some couple find the method messy i.e. too fluidic
Associated to some allergic reaction
Interrupts sexual intercourse

Intra-Uterine Contraceptive Device (IUCDs)

These are devices inserted into the woman uterus to prevent implantation of the fertilized ovum by local inflammation.

Types of IUCDs

Copper T 380A effective for 10-12 years
Multi-load 375 for 5 years
Mirena R hormonal IUCD

Advantages

It is very effective since it starts working right way
She does not need to keep coming for refill
Can offer protection up to 10 years and above
Fertility returns is immediate
Limited side effects reported as compared to other methods
Does not interfere with sexual intercourse
Has no effects on breastfeeding
Only one follow up is needed unless there are problems

Side effects

Increases menstrual bleeding
Spotting
Abnormal vaginal discharge
Menstrual cramps
PID

Indications

Breastfeeding
Women of any age
As for POP

Contraindications

Irregular vaginal bleeding of unknown origin g. cancer of cervix
Pregnancy
Heavy and painful menstruation
Cancer of the uterus
Current PIDs
Multiple sexual partners
Pregnancy

IUCDs users who develop PID should be treated with the IUCD in place if they want to continue using it. If no improvement within 72 hours, remove it.

Insertion of IUCD Timing of IUCD insertion

Any time provided pregnancy is ruled out
The first seven days of the menstrual cycle
Immediately following delivery or any time within 46 hours after childbirth
Any time beyond four to six weeks after childbirth
Immediately or within seven days after an uncomplicated abortion
During caesarean section

Procedure

Consider aseptic technique like hand washing, wearing sterile gloves.
The device is put in an introducer and plunger.
It straightens inside the introducer.
Insert a Cusco ‘s vaginal speculum and clearly visualize the cervix.
Clean the cervix and vaginal vault with sterile swabs.
Measure the length of the uterus with a uterine sound.
Insert the introducer into the uterus through the cervix.
The plunger is gently pushed to force device out of the introducer into the uterus.
In the uterus, the device resumes its original shape and lodges against the uterine walls.
The two small strings attached to the device hang down through the cervical opening.
Cut the string with a pair of scissors to reduce the size approximately 3cm hanging out of the cervix.
After the insertion, the client She can remain on the procedure table until she feels ready to get dressed.
The woman usually feels the strings in the vagina to ensure that the device is in position.

Post insertion instructions

To use back up for a minimum of 3 days.
There may be some slight pain which does not require medication.
To check the string during menstruation to ensure that it is in place or come back if it is removed or dislodged.
To return to the facility immediately in case of any discomfort.

Removing the IUDs

In case a client is finding side effects difficult to tolerate, first discuss the complaints the client has. Weigh if she would rather try to manage the problem or to have the IUD removed.
Removing IUD is usually It can be done any time of the month.
Removing may also be easier during monthly bleeding, when the cervix is naturally In cases of uterine perforation or if removal is not easy, please refer the client to an experienced service provider to employ appropriate removal technique.

Steps for IUD removal

Explain what you are going to do to the client during removal
Ensure privacy & confidentiality at all times
Request the client to lie on her back
The provider inserts a vaginal speculum to visualize the cervix & UID strings
Carefully cleans the cervix & vagina with an antiseptic solution such as Savlon & do inspection
The provider requests the client to take slow, deep breaths & to Inform the client to make you know in case she feels pain or any other discomfort during the procedure
Using narrow forceps, the provider gently pulls the IUD strings & slowly until it comes completely out of the cervix
Show the removed IUD to the client & let her handle with the hands. This helps to make the client understands that nothing has remain inside the uterus.
Thank the client for cooperating throughout the procedure
Clear away

Reasons for missed threads in IUDs

Coiled thread inside
Thread torn through
Device expelled outside unnoticed by the client
Device perforated the uterine wall and is lying in the peritoneal cavity
Device pulled by the growing uterus in pregnancy

Methods of identification

History taking i.e. exclude pregnancy
Ultrasonography
Hysterectomy
Hysteroscopy
Straight x-ray

Hormonal Methods of Family Planning (Click Here)

Artificial Methods of Family Planning Read More »

Family Planning

Family Planning is defined as a process through which individuals, couples make up an informed choice on how many children to have, when to have and how often to have so that each child born is expected and properly catered for in all ways.

For instance, basic needs like good health, education, shelter, and all essential needs of humans are available.

This involves planning and proper birth spacing according to wishes rather than by chances. Birth spacing promotes the health of the mother, children and father.

Consent for family planning services

No verbal or written consent is required from parent, guardian or spouse before the client can be given family planning services except in cases of incapacitation (intellectual disability). Clients should give written consent to permanent family planning methods.

Setting of family planning clinics

Service delivery points where a health provider comes into contact with a potential or actual client

Social mobilization events for any health services
Youth clubs and schools through family life education activities
Women and men organized clubs/groups
Work places

Where to get family planning services

- Facility based outlets such as hospitals, health centers and dispensaries
- Outreach services including mobile clinics and workplaces
- Community based outlets e.g. community based distribution, drug shops and dispensing machines
- Social marketing
- Private sector facility such as clinics, maternity and nursing homes, pharmacies and drug retail shops

Counseling

In order to promote informed choice, all clients seeking contraceptives are entitled, given accurate and adequate information about family planning methods available in the common settings. This is important for the initiation and continuation of family practice. Methods (of choice) of clients will be done individually and in a dignified manner. The discussion between the service provider and client must be private, confidential and should never include incentives or coercion for the adaptation of any method.

Initial counseling should include the following:

Discussion of client’s reproductive goals, previous knowledge and/or experience with any method
Showing the FP methods available
Information on how each method prevents pregnancy
How effective the method is and what conditions make I effective
Method failure
Common side effects
The follow-up regarding each method
Where the method can be obtained
Importance of physical and pelvic examination
Information on HIV/AIDs/STIs in relation to F/P
HIV testing and screening of STIs
Symptoms of breast and cervical cancer including available services for screening
Clarification of misconceptions or rumors the client may have about each type of method

Subsequent counseling will aim at promoting and encouraging continued use of a method and should include:

A review of the client ‘s satisfaction or problem with the method
A review of the client ‘s understanding of user instructions
Dispelling rumors and/or misconceptions, if any
In indicated, a review of change of the client’s reproductive goal necessitating the need for a long term or permanent method
Counseling on STIs and HIV/AIDs
Possible method failure
Information of common symptoms of breast and cervical cancer including available services for screening
Counseling is also important:
Where a contraceptive method has failed
There is regret for having had a permanent method
In cases of rape or defilement
Where there are is need for referral for appropriate care

Screening

After a thorough counseling a client should then be ready to choose a contraceptive method. The next step is to screen for contraceptive use.

Clients opting for hormonal method should have the relevant health, social history taken and physical assessment carried out on the first or subsequent visits. Where indicated, do a complete physical check up to rule out contra-indications to method use. Where is not possible or necessary to perform routine physical assessment, the client should be screened by a qualified staff or FP trained service provider using a standard checklist to initiate or resupply oral contraceptive or Depo Provera. After screening, the important findings should be communicated to the client including any issues she/he may want clarification on. The client will then be provided with the appropriate or preferred method and important findings should be recorded according to the guidelines.

Routine physical or pelvic examinations is not obligatory for initiating or re-supply of oral contraceptives or Depo Provera, an examination could be valuable for reproductive health and may help to rule out contra-indications to methods and/or establish the presence or absence of infections or cancer.

Where selected physical assessment or laboratory tests are indicated and is not possible to carry them out at a particular clinic, clients should be referred to a health unit equipped to provide the assessment test.

Importance of family planning

a) To the mother

Allows mother to recover physically and mentally from the effects of previous pregnancy
Offers ample time for a woman to actively participate in productive activities like farming and business.
It increases social bondage between the mother and her baby
It helps to reduce on maternal mortality and morbidity the couples due to pregnancy related complications
It promotes a happy marital life and enjoyment between the couples without fear of getting unwanted pregnancy.

b) To the child

Child receives adequate emotional and social support and as a result gets emotional maturity and stability
Allows adequate nutrition of the baby while in the womb and hence a healthy newborn
There is reduction of malnutrition as there is no early weaning and likely to have enough food for the child
The child gets fewer infections since immunity is

c) To the father

Reduces domestic violence in a home
Ability to meet basic needs like foods, medical care
Reduces the cost of living in a home hence the father is able to invest in productive

d) To the Community

Healthy and productive people who enhance community stability and harmony
Reduces overcrowding hence available land can be maximize for productivity
There will be increased socio-economic development
Presence of bad characters in the community like street kids, smokers and other bad group in the community since parents have adequate time to provide for their

e) To the Nation

Reduces rapid population growth rate
Reduces the country‘s dependence on foreign aids
The government will be able to provide better social services and infrastructures like roads, health facilities
It is easy to budget for the people since the number of resources to the population is

Available family planning methods in Uganda

The family planning methods can be broadly classified into: –

Natural family methods.
Hormonal /Artificial family planning.

1. Natural /traditional methods

Calendar/rhythm
Basal body temperature
Cervical mucus method
Lactation amenorrhea methods
Abstinence
Withdrawal/coitus interrupters

2. Artificial methods

Barrier methods

Spermicides
Condoms
Intrauterine contraceptive devices (IUCDs)
Diaphragm

b) Hormonal methods

Oral pills
- Combined oral contraceptives
- Progesterone only pills
- Emergency contraceptive pills

ii. Implants

Implanon (1 rod capsule)
Jadelle (2 rod capsules)
Norplant (6 rod capsules)

iii. Injectable contraceptives

Depo Provera
Injector plan
Sayana press
Noristerat

c) Permanent methods

Tubal ligation (tubectomy) for women
Vasectomy for men

Natural methods of family planning

These are also known as fertility awareness method. They are based on the following physiological conditions.

The lifespan of a sperm is 24 hours
The lifespan of an ovum is 48 hours
Menstruation takes place between 1-16 days before the next period

General advantages

They are safe with no side effects
Cheap
They are acceptable to many groups and religious that opposes the modern methods
They teach women about their own menstruation cycle and fertility
Couples have control over their methods
Help in planning a pregnancy

General disadvantages

Some require substantial teaching before use
It is difficult as records on several cycles ought to be kept for proper references
Difficult to use if the period are irregular
Requires adjustment to sexual behaviors
Requires co-operation between the partners which in most cases is difficult
Do not protect against STIs/HIV/AIDs

Fertility awareness method

Fertility awareness methods of family planning involve identification of the fertile days of the menstrual cycle (when pregnancy is most likely to occur) and avoiding sexual intercourse (or using barrier methods) during these days. The fertile days of the menstrual cycle can be determined by one of the following methods:

Basal body temperature (BBT)
Cervical mucus
Symptom- thermal (a combination of cervical mucus and BBT methods)
Calendar (rhythm) or Standard Days method, including cycle

A woman or couples who are planning to use fertility awareness methods need special training from a trained counselor in family planning.

Indications

Any woman or couple who is willing and motivated to observe, record and interpret fertility signs daily.

- Women who find other contraceptive methods unacceptable for various reasons including religious beliefs
- Women who are unable to use some other methods for health reasons
- Couples who are willing to abstain from sexual intercourse (or use condoms) for more than one week during each days

Contraindications

There are no medical conditions that are worsened with the use of fertility awareness methods. However, there are some conditions that make their use more difficult. If these conditions are present, the method can either be delayed or the provider should offer special counseling to ensure the correct use.

These conditions include:

Breast feeding (especially until menses return)
Less than three postpartum menses
Irregular vaginal bleeding
Abnormal vaginal discharge
Disease that evaluates body temperature

Calendar /rhythm method

This is the only method approved o the Roman Catholic Church
Before starting to use this method, one needs to have an accurate record of menstrual cycles for about 6-8 months
The failure rate is between 20-30%
The method is referred to as ―safe days‖ because it aims at identifying days with least chance of conception
The woman should provide a record of her menstrual cycles to the health worker and then go into the calculation as shown below.

Calculating the fertile period

Fertile period is the time of the cycle when a woman has the ―highest ―chances of conception.

Procedure

Record the length of each Length of a cycle is the time between the first day of one menstruation period and the first day of the following period
Identify the shortest and longest cycle
Get the first fertile day (FFD) by subtracting 18 from the shortest cycle (16 + 2 days of sperm survival)
Get the last fertile day (LFD) by subtracting 11 from the longest cycle (12-1 day of ovum survival)

Examples

A woman with a regular cycle of 28 days duration report to the family planning clinic and has opted for calendar method. Demonstrate the ability to calculate this in order for her to start using the method.

Record the length of each menstrual cycle: This is the time between the first day of one menstruation period and the first day of the following period.
Identify the shortest and longest cycles: Determine the cycle with the fewest days as the shortest cycle, and the cycle with the most days as the longest cycle.
Calculate the first fertile day (FFD): Subtract 18 from the duration of the shortest cycle. This accounts for the fact that sperm can survive for about 2 days.
Calculate the last fertile day (LFD): Subtract 11 from the duration of the longest cycle. This considers the fact that the ovum (egg) can survive for about 1 day.

Here’s an example to demonstrate how to apply this method:

Examples

A woman with a regular cycle of 28 days duration report to the family planning clinic and has opted for calendar method. Demonstrate the ability to calculate this in order for her to start using the method.

Given: Number of cycles: 28 days

To calculate:

Shortest cycle: 28 – 18 = 10th day

Longest cycle: 28 – 11 = 17th day

Interpretation:

The woman is highly fertile between the 10th and 17th days of her cycle.

Comments/Remarks:

It is recommended to avoid sexual intercourse between the 10th and 17th day of her cycle.
It’s advisable to use condoms or another form of contraception as a backup method.

2. A woman with irregular cycle whose shortest cycle is 25 days and the longest cycle is 32. Calculate and interpret he finding to the client

Solution

Given number; Shortest cycle =25 days Longest cycle=32 days

Therefore:

FFD=shortest cycle=shortest cycle-18 =25-18 =7^th day

LFD=longest cycle-11 =32-11 =21^st day

Interpretation

A woman is very fertile between 7^th-21^st day of every cycle
Avoid sexual intercourse between 10^th-17^th day of her cycle
To always use condoms or any other family planning method as a dual or backup

Self-help assessment

Demonstrate your ability to calculate & interpret the following to the client:-

A client with cycle of 29 regular
A client with cycles of 24 & 30 days respectively (irregular cycles)
A client with 27 day cycle (regular)

Advantages

No cost
No side effects
Refer to general advantages of natural methods of family planning

Disadvantages

Difficult to calculate the safe period reliably
Needs several months training to use these methods
Compulsory abstinence from sexual act during certain periods
Not applicable during lactation amenorrhea when the periods are irregular
Does not protect against STIs including HIV/AIDs

Lactation amenorrhea method

Immediately after birth, there is a period of naturally decreased fertility which can be prolonged by regular breastfeeding. The hormone responsible for the suppression of fertility is prolactin that controls milk production.
The effect of breast feeding on reducing fertility awareness is well known. However, LAM is a temporary 9 short- term) method of contraception. It is highly effective for the first six months after delivery, providing the woman breastfeed fully and remains amenorrhoeic.
In non- lactating mothers, prolactin gradually decreases within weeks after child birth reaching normal levels in about 4 weeks post-partum.
Regular nipple stimulation by sucking is necessary to maintain milk production and lactation amenorrhea method.
LAM may last up to 24 months during a regular prolactin release which inhibits the ovarian functions
When all three criteria of LAM are met, it is about 98%

Indications

Women who are fully breastfeeding and
Who are amenorrhoeic (no menses) and
Whose baby is not older than six months

Fully breastfeeding means:

Breast feeding whenever the baby desires (at least every four hours)
Night time feeding (at least every six hours)
Not substituting other food or drink in place of breast milk

Who cannot use LAM/contraindications?

Women whose menses have returned.
Women whose babies have turned six months old.
Women who have introduced supplementary feedings.

Note: Women with HIV should be counseled about the infant feeding options to reduce risk of mother-to-child transmission and be supported in their choice. Women without reliable access to safe alternative feeding options should be encouraged to breast feed exclusively for six months

Standard Days Method (Moon beads/cycle beads)

The Standard Days Method® is a fertility awareness-based family planning method that identifies a fixed fertile window for women with cycles that are between 26 and 32 days long. For women with cycles in this range, the method identifies days 8 through 19 as potentially fertile days. A user simply tracks the start date of her period and the days of her cycle to know if she is on a day when pregnancy is possible or not.

What are moon beads?

They are string of colored beads
The colors of moon beads help you know the days when you can get pregnant
They also help you know the days you are not likely to get pregnant
To prevent a pregnancy do not have sex on the days you can get pregnant, or use a barrier method.

Note: Moon beads are based on a natural method of family planning that is 95% effective when used correctly. This means that only 5 out of 100 women may become pregnant when the method is used correctly.

Modes of action

If a woman wants to prevent pregnancy using this family planning method, then she should avoid intercourse or use a back-up birth control method such as condoms during her fertile days (days 8-19). The patented Cycle Beads tools help a woman use this method by tracking her cycle, identifying her fertile and non-fertile days based on when her period started, and confirming that her cycles are in range for effective use of this family planning method.

Moon beads and the menstrual cycle

Moon beads represent a woman‘s menstrual cycle
Each bead is a day of the

Note: The menstrual cycle is not the same as the woman‘s period. The period is when a woman has menstrual bleeding while cycle includes all days from the start of one period to the day before the next period.

Indications/Eligibility/who can use it

Couples who communicate well and agree not to have unprotected sex when the woman is likely to get pregnant
Women who have failed to use other modern methods
Women who have cycles that is between 26 and 32 days

Advantages

Refer to natural methods
More than 95% Effective
Side-Effect Free
Easy to Use
Inexpensive
Educational & Empowering

How to use moon beads

The day you get your period, move the ring to the RED bead.
Also mark that day on the calendar
Move the ring, one bead each day
Do not have unprotected sex when the ring is on any WHITE bead. You can get pregnant on those days
You can have sex when the ring is on any brown beads. You are not likely to get pregnant on those days
Move the ring to the RED bead again when your next period starts. Skip over any beads that are left.

When to contact the healthcare provider

Had unprotected sex on a WHITE bead If she thinks she might be pregnant because she has not gotten her period.
If she gets her period before she reaches the DARK BROWN beads, this means that her cycle is shorter than 26 days.
If her period does not start by the DAY AFTER she reaches the last brown bead, this mean that her cycle is longer than 32

Family Planning Read More »

Antenatal Care in Reproductive Health

Antenatal care; antenatal care is a planned program of medical management of pregnant women directed towards making pregnancy, labour a safe and satisfying experience.

The health of pregnant women would be improved if effective antenatal care (ANC) was available to all. Antenatal care therefore, constitutes one of the cornerstones to safer motherhood. It is suggested that more flexibility concerning the place of consultation and timing of visits could lead to better attendance and consumer satisfaction. The ministry of health therefore recommends integration of services, e.g. family planning, EMTCT focused antenatal care, immunization etc.

Aims/purposes of antenatal care

To promote and maintain the physical, mental and social health during pregnancy.
To detect and treat conditions pre-existing or arising during pregnancy whether medical, surgical or obstetric.
To prepare the mother for the safe birth of the child for emergencies, complications.
To achieve delivery of a full term healthy baby or babies with minimal morbidity to mother.
To help the mother to experience normal puerperium and in conjunction with the partner to take good care of the Childs‘ physical, psychological and social needs.
To recognize deviation from normal and provide management or treatment as required by ensuring privacy at all times.
To prepare the mother for successful breastfeeding and give advice about adequate preparation for lactation.
To offer nutritional advice to the mother.
To offer advice on parenthood either in a planned program or an individual basis taking into consideration the clients‘ concerns.
To build up a trusting relationship between the family, the mother and health workers which will encourage them/her to share their anxieties, fears about pregnancy and care being given through adequate communication and counseling.
During this time, the pregnant woman is provided with previous preventive and advisory services. The health worker makes consultation with her regarding the most appropriate place of delivery of the baby and the things she needs to prepare emphasizing the concept of a clean safe delivery e.g. having maama kits.

Goals of Focused/Oriented Antenatal Care

Important:

– Goals are different depending on the timing of the visit. 4 visits are aimed for an uncomplicated pregnancy.
– If a woman books later than in the first trimester, preceding goals should be combined and attended to. At all visits, address any identified problems, check BP and measure the symphysio-fundal height (SFH)

To promote maternal and newborn health survival through:

∙ Early detection and treatment of problems and complications.
∙ Prevention of complications and disease.
∙ Birth preparedness & complication readiness.

Scheduling and timing of goal/focused antenatal care visits

∙ First visit: by 0-16 weeks or when a woman first thinks she is pregnant.
∙ Second visit: at 16-28 weeks or at least once in the second trimester.
∙ Third visit: at 28-32 weeks
∙ Fourth visits: if complication occurs, follow-up or referral is needed, woman wants to see a provider, or provide changes frequently based on findings (history, exam, testing) or local policy.
∙ Refer

Risk factors during pregnancy

The following conditions are considered to have adverse effect on the course and outcome of pregnancy and therefore are considered risk factors:

Conditions likely to recur and cause bleeding:

– Previous hemorrhage, APH, PPH, retained placenta
– Too many pregnancies of five (5) or more
– Aneamia
– Multiple pregnancy
– Uterine scar.

Conditions that affect intrauterine fetal growth and may cause abortion or premature – Preeclampsia

– Aneamia
– Malnutrition
– HIV
– Malaria, smoking, maternal underweight due to malnutrition
– Birth less than 2 years apart
– Diabetes
– Multiple pregnancy
– Excessive alcohol
– Sickle cell disease
– Abortion in the last 3 months

Conditions that pose risk of infections to mother and baby and may cause abortion – HIV infection

– STIs e.g. syphilis
– Early rupture of membranes
– Diabetic mellitus
– Malaria

Conditions where delivery may have to be assisted by cesarean section or vacuum extraction.

– Short stature below 150cms
– Young primigravida below 18 years
– Elderly primigravida above 35 years
– Previous uterine scar
– Cardiac disease
– Diabetes mellitus
– Injury or deformity of the pelvis and lower part of the spine. 5. Severe pre-eclampsia and eclampsia

Other conditions which are likely to:

a) Recur

– Abortion
– Stillbirth
– Premature delivery
– Eclampsia

b) Worsen with pregnancy

– Renal disease
– Mental illness
– Epilepsy
– Pulmonary tuberculosis
– Heart disease
– AIDs
– Diabetes mellitus

c) Cause social discomfort

– Lack of support from partner/family
– GBV
– Low socio-economic status
– Unwanted pregnancy

Conditions likely to cause abnormalities or disease to the baby – Age of mothers above 35 years

– STDs such as syphilis, HIV infection etc.
– Some drugs used to treat other conditions in the mother e.g. Tetracycline

Methotrexate
Efavirenz
Ciprofloxacin

– Alcohol consumption and smoking including passive smoking. – Some genetic diseases e.g. hemophilia, Sickle cell disease

Common problems that may complicate pregnancy and its management

– Aneamia
– Malaria
– STDs
▪ HIV
▪ Gonorrhea
▪ Syphilis
▪ Vaginal/vulvar warts
– Urinary tract infection

Roles of health workers in reducing the dangers of risk factors facing pregnant women

Health education targeted at the community and pregnant women , giving them sufficient time to express their concerns and discuss them
Identification of pregnant women at risk of recurrent conditions or developing complications such as pre-eclampsia and eclampsia, cephalo-pelvic disproportion etc. and refer them appropriately
Discuss the birth plan and emergency preparedness with the mother and another person of her choice.
Prepare management of pregnancy
Appropriate referral of women with risk factors.

Services offered during antenatal care

✔ Health education
✔ Counseling
✔ Screening and risk assessment through

– History taking
– General and abdominal examination
– Investigations
– Vaginal pelvic examination where applicable
– STIs testing including HIV

✔ Provision of hematinic
✔ Deworming
✔ Immunization against tetanus (TT)
✔ Intermittent presumptive treatment of malaria (IPT)
✔ Early recognition, management and referral of high risk mothers and those who develop complications
✔ Delivery and postpartum care plan for every woman.
✔ Treatment of medical conditions e.g. malaria, hypertension, diabetes, STIs, Pulmonary tuberculosis
✔ PMTCT, EMTCT

In order to offer the services at ANC, the clinic should have at least the following:

Waiting room: space where mother assemble for antenatal education: – Reception table

– Benches for clients to sit on

An examination room with privacy
A stable and firm examination couch
Weighing scale, a height measure in centimeters, a tape measure, a clinical thermometer, urine testing kits, BP machine, a stethoscope and a fetoscope.
A small laboratory capable of screening for common problems such as aneamia, hookworm infestations, syphilis, pre-eclampsia and diabetes.
Essential drugs spelt out for health centre including vaccines such as TT, SP, hematinic, elimination of mother to child transmission of HIV/AIDs (EMTCT) drugs.

The following are also recommended

Mothers should be advised to attend ANC as early as possible preferably to have the first attendance during the first sixteen (16) weeks of pregnancy
ANC should be integrated in other family health services and offered on a daily basis
Outreach ANC services outside the established health facilities should be held on specified and regular days of the week which should be known by the general public in the area.

Health Education

Aims

To provide clients with information that will help a pregnant woman to ensure that she remains healthy throughout pregnancy and delivery.
The information should be given at appropriate periods including during follow up visits.

Some key messages include the following:

– Services offered to pregnant women during ANC and benefits of ANC. – How to keep health during pregnancy
– STIs and other effects on pregnancy and newborn
– Malaria and its complications during pregnancy
– Minor disorders of pregnancy and how to cope with them
– Diet during pregnancy and lactation
– Danger signs during pregnancy and labour
– Pregnant women who must be attended to and delivered in hospital
– Benefit of family planning and different options
– Women who are likely to get problems if they become pregnant
– What to prepare for delivery
– Signs of labour
– Benefits of delivery under a skilled provider in a health unit
– Family planning methods of postpartum mothers
– Postnatal care
– Benefits of breastfeeding

Steps in planning maternal health client education session

✔ Identify target group
✔ Identify needs of target groups e.g.

– Present knowledge and practices in R.H
– The priority message related to problem

✔ Best media approach and language
✔ Identify resources such as:

– Leaders in the community
– Influential supporters of RHS for example, old acceptors of RHS
– Materials/visual aids relevant to the topic
– Venue/ that is conducive for effective RHS client education session

Preparation

✔ Prepare venue, which is conducive for the session delivery
✔ Notify target group through their leaders in the community
✔ Prepare yourself
✔ Identify satisfied clients
✔ Prepare influential supporters of RHS
✔ Prepare materials/visual aids
✔ Prepare contents and channels for delivering it, e.g. a song or a talk

Steps in conducting education session talks;

Introduction of self and colleagues
Acknowledge leaders and group present
State purpose of the session in a stimulating way by use of a slogan, poster or small story
Deliver content allowing groups to participate and use visual aids where appropriate
Allow for questions and answers
Evaluate the sessions, using simple methods e.g. observing group participation, asking a few questions while referring to the contents, getting to know and understand their feelings, learning and how they will use this knowledge
Summarize key points
Give follow on information e.g. where one can obtain individual attention
Allow them to select a topic among R.H topics
Announce where the next session will be held
Thank the group for participating

Antenatal Risk Assessment

This is an evaluation carried out on pregnant women during the antenatal period to screen them from the probability of these women who are likely to develop poor pregnancy outcome during childbirth, detection and management of any illness or pregnancy complications as they arise.

First Antenatal Visits/Booking Visit

The purpose of this visit is to obtain the baseline information against which subsequent findings in a woman will be assessed.

This baseline information is obtained through:-

✔ History taking
✔ Physical taking – General, systemic and abdominal examination
✔ Investigations

History taking

This is done in a proper and orderly manner to assess the health status of the mother and fetus.

History must include:-

✔ Name and place of residence, noting accessibility to medical and maternity care
✔ Age: noting the high risk age of below 18 and above 35 years
✔ Parity: noting the young and elderly primigravida, those above Para 4 and closely spaced pregnancies (>2 years in between)
✔ Social history, inquire whether married, source of social and financial support, education status, genital mutilation, where applicable, alcohol, smoking, health of partner.
✔ Medical history e.g. hypertension, renal disease, epilepsy, diabetes mellitus, sickle cell disease, asthma, TB and HIV, surgical history, operation, blood transfusion, skeletal deformity, fractures of pelvis, spine and femur.
✔ Obstetric and gynecological history, inquire about previous pregnancy and their outcomes such as previous cesarean section, previous retained placenta, PPH, still birth, prolonged labour and early maternal death, ectopic pregnancies, D & C , APH, pre-eclampsia etc.
✔ Family e.g. history of hypertension, diabetes in her family, twins, sickle cell disease.
✔ Menstrual history:-

– Information on the woman‘s‘ menstrual history is obtained and recorded e.g. age at menarche, length and regularity of the cycle, duration and amount of menstrual flow.
– Contraceptive history e.g. use of modern contraceptive methods and dates of discontinuation should be noted.

✔ History of present pregnancy:- Information regarding the first day of LNMP is obtained and the expected date of delivery (EDD) calculated. This will guide the provider during examination to compare the weeks of amenorrhea with the height of fundus. If pregnancy is over 20 weeks, dates of quickening should be noted. Any problems encountered since she became pregnant should be probed into and noted e.g. bleeding, vomiting, hospitalization, HIV sero-status and diseases like fever, cough, and diarrhea.

Physical examination

General

A physical examination from head to toe should be performed and note nutritional state and illness which may not be related to pregnancy:-

✔ Measure the weight, noting those that are underweight or over- weight (below 45 Kg and above 80 Kg)
✔ Measure height and note those below 159Cms and check for skeletal deformities or limping.
✔ Take blood pressure- note those with BP 140/90 mmHg and above
✔ Check for anemia and jaundice by examination of the conjunctiva, tongue, palm of the hand and capillary refilling in the nail beds
✔ Check for oedema of feet, hands, face and sacral area
✔ Carry out a systematic examination of the respiratory and cardiovascular systems to exclude abnormalities.
✔ Examine breasts for possible masses and signs of breast malignancy, educate women to care the nipples and teach herself breast examination
✔ Assessment of physical abuse:

– Drug abuse
– Bruising

✔ Assessment of any complaints

Abdominal examination

The abdomen should be adequately exposed to show important landmarks.

✔ Inspect the abdomen and note:

– size, shape of abdomen and presence of scar that may indicate a previous uterine operation
– presence of fetal movements

2. ✔ Palpation of abdomen noting:

– presence of enlarged liver, spleen and tenderness of renal angles
– Height of fundus and compare it with the weeks of gestation. excessive enlargement of abdomen, maybe an indication of multiple pregnancy or presence of polyhydramnios
– The lie, presentation, position, any tenderness and the amount of liquor.

3. ✔ Auscultation. listen to fetal heart noting the rate, volume and rhythm

Inspection of the vulva

This should be done to detect lesions of the vulva, vagina and abnormal discharge. Note any scars at the perineum or vulva. If an abnormal discharge is detected and there are facilities for gram stain, take of specimen for analysis. If there are no laboratory services, use the STI ―syndromic approach to provide treatment to the mother.

Laboratory Investigations during Antenatal Care

Baseline investigations:

– Hb (normal 10.5-15gm)
– Blood group (ABO and Rhesus factor)
– Urinalysis (protein and sugar)
– VDRL, RPR for syphilis

Special Investigations (Refer When Necessary)

– Rhesus antibodies for RH-ve mothers
– Random blood sugar where there is a history or presence of glycosma
– Mid-stream urine for culture and sensitivity
– High vaginal swab (HVS)
– Elisa test for HIV
– Sickling test

Others

– Provide TT to complete the recommended schedule for immunization against tetanus. this is routinely done to protect the mother and neonate from tetanus
– Explain to the mother the importance of tetanus immunization

Recording, Assessing Findings and Planning For Management

✔ After examination, all finding should be recorded on ANC clients‘ card and register
✔ Review findings on history, examination and investigations
✔ Share plans for next steps
✔ If the woman has to be referred, a referral note should be filled, handed to the client and she should be explained on where to go for further management

The health worker should refer a client/patient to health facility that is able to handle the types of obstetric condition identified to avoid wastages of time and transport costs encountered by the patient/family. The health worker with assistance of relatives should organize quick means of transport. A relative/health worker escorts the mother where applicable.

Conducting Follow up Visits for Pregnant Women

Purpose

Monitor progress of pregnancy and the well-being of the mother and foetus
Identify and manage arising conditions such as STIs or HIV risk, pre-eclampsia, anemia, syphilis
Provide information on planning to delivery, preparing for the newborn, postpartum care and family planning
Get opportunity to deal with the woman‘s‘ concerns

Frequency of Follow-Up Visits

Routine

More frequently if the mother has recurrent risk factor
Every 4 weeks until 30 weeks
Then every 2 weeks until 36 weeks
And then every week until delivery

More frequently if the client has risk factors (past or present such as:

– Vaginal bleeding during pregnancy late
– Unsure of dates and booked
– Past history pre-eclampsia, premature labour, small or large gestation
– Not gaining weight or fundal height not growing
– Gaining weight exclusively

Antenatal Care in Reproductive Health Read More »

DELAYS IN SAFE MOTHERHOOD

DELAYS IN SAFE MOTHERHOOD MEANS DEATH

Many women die due to delay at several levels while seeking medical help. The community and health workers must work hand in hand to prevent this delay and addressing this problem will reduce maternal death and promote safe motherhood.

Some causes of delay in acquiring medical care

Delay in decision making.

✔ Lack of information on health services available
✔ Communication barrier in language or bad roads and physical barriers like lakes or mountains
✔ Lack of resources e.g. no money or husbands is away and transport cannot be got to transport mother to the hospital
✔ Inappropriate care e.g. mother taken to TBAs first
✔ Lack of decision making by the mother since she is waiting for the husband to come back to give her permission and money.

Delay in reaching the health facility

✔ Distance may delay the mother so that by the time she reaches the hospital is too late
✔ Transport may not be available to take mother quickly to hospital
✔ Road may be bad and impossible taking a longer time to reach hospital
✔ Cost of transport may be too high for the mother

Delay in receiving adequate care

✔ Unskilled staffs who lack knowledge on what to do for the mothers and dealing with high risk pregnancy
✔ Drugs may not be available in the health units, this includes blood for transfusion, antibiotics, analgesics, etc
✔ Lack of equipment e.g. sterile supplies which may delay cesarean section or syringes which may delay giving an oxytocic drugs
✔ Few varieties of services offered at the health facilities.

Factors that affect delay to seek medical care

Family – mother may be single or young and does not know whether she is pregnant or fears to go to health unit – mothers may wait for a decision to be made by the husband who may be away – mother -in- law may delay as she tries to manage giving herbs for contraction
Husband – she may take time to decide or may be away looking for money
Education level – if lowly educated, mother may not think of seeking the advice
Socio-economic status – poverty may prevent quick action
Natural barriers – like rivers, likes, mountains and floods
Security; wars and insurgencies

Maternal Mortality

This is the death of a woman/mother while pregnant or within 42 days of the termination of pregnancy irrespective of the duration and the sites of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Maternal mortality rate

This is the ratio of the total number of maternal deaths occurring in a period of time (usually a year) to the total number of live births occurring in the same period expressed as a percentage (or per 1,000 or 100,000).

Incidence

Worldwide, every year approximately 8 million women suffer from pregnancy related complications. Over half a million of them die as a result. The problem of maternal mortality and morbidity are greatest (99%) for the poor women in the developing countries. One woman of 11 may die of pregnancy related complications in developing countries compared to one in 5000 in developed countries. It is further estimated that for 1 maternal death at least 16 more suffer from severe morbidities.

The maternal mortality rate in Uganda has been declining over the years, from 506/100,000 in 2004 to 435/100,000 in 2011. However, this is one of the highest in the world and demands for more concerted efforts towards its reactions. The new report released by the World health organization (WHO) has shown a remarkable decrease in maternal mortality by 44% worldwide due to fully implemented millennium development goals. However, there is not much difference in the reduction in the developing countries like Uganda.

Factors contributing to the high maternal mortality in Uganda

There is no single factor that can be counted on as responsible for the high maternal mortality in Uganda. It is rather an interplay of factors. Any approach therefore, aimed at effectively addressing maternal mortality has to pay a close look at all those factors. The easily identifiable ones in Uganda include the following:

Poverty

Several women are engaged in productive work at home and do not have means of earnings. Such women cannot afford to meet even simple costs like transport in case any emergencies develop. Poverty also means that the woman will not be able to afford basic human needs like food which will predispose the woman to further complications during pregnancy and/or labour. They are also likely to be less privileged in the fields of nutrition, housing, education and antenatal care.

Gender issue

In Uganda, men are decision makers on all matters in the home including health care seeking. This means that the woman may have to wait for the man to grant her permission in order to seek medical care. Some women are even prevented from attending antenatal care by their husbands. This predisposes the mother to developing complications in the absence of a trained health worker who can offer help.

Inadequate and inaccessible health services

There are very few health facilities equipped to handle and manage conditions associated with pregnancy and delivery. Despite government policy of bringing services close to the people, some women need to travel long distances in order to access a health facility. This usually keeps those who feel unwell away as they may not be in position to walk or have the money for transport.

Limited health workers

The number of trained health workers in Uganda is still very low compared with the skyrocketing population. This has resulted in long queues observed daily at the various rural and urban health facilities as clients wait to be attended to. Unfortunately others go back without attention. This discourages many and at the end, women prefer to be

attended to by the village traditional healer or herbalist who may not have the necessary skills to manage incase complications develop.

Poor attitudes of health workers towards mothers.

On many occasions, health workers have been reported of being rude, arrogant and unfriendly while attending pregnant women and those in labour. This scares such women away and finally ends up in the hands of untrained people for help. Health workers need to develop better attitudes and make the caring environment friendly so as to motivate mothers to seek health services from them.

Early marriages

For a long, the girl child has been seen as a source of wealth for the family. Girls are forced into marriages at a tender age for the family to acquire cattle and money. These girls get pregnant before their bones and bodies are fully developed which predisposes them to various complications during pregnancy and/or labour.

Illiteracy

Women, over the years, have comprised the highest number of those who cannot read and write. This means that they cannot effectively influence policy on matters that affect them like reproductive health. As such, they surrender all rights of decision making to the men

including the number of children to have and sometimes the age of marriage. Education keeps girls in school until they are old enough to marry and have children. It also empowers them to stand out for their rights and freedom.

Beliefs, customs and taboos(harmful traditional practices)

Some traditional customs, beliefs and taboos predispose women to developing complications during pregnancy or labour. Denying women some nutritious foods like chicken, eggs etc. predispose them to malnutrition which in turn has a negative bearing to reproductive life. Practices like female genital mutilation predispose the woman to extensive perineal tears that may lead to excessive hemorrhage during child birth and yet the use of some traditional herbs (Cytoxic herbs) may predispose to uterine rupture. Some communities perceive women who deliver from health units as not strong being enough. This is dangerous as it predisposes any woman to unnecessary complications during labour.

Poor transport and communication infrastructures

Statistically, seventy five percent (75%) of the Ugandan population lives in rural areas and yet most of the health facilities are located in urban centers. The road network linking up these areas are very poor in most of the areas which delay transfer of women in case complications develop during pregnancy or labour. This is more common in geographically impassible areas like mountainous parts of Kigezi, areas encircled by water bodies.

High child mortality

Uganda‘s child mortality is still high though it has been declining over the years. Parents are filled with uncertainties as to how many of their children will make it to adulthood. As such, they prefer to produce many for a few to survive. For example, in post war Northern Uganda, many people claim that they have lost their relatives more than expected in the war and so the need to produce more children is valued currently.

Desire for more children

Many people perceive children as a source of prestige in the community. A family with many children was always looked at as being very strong and secure and as a result, many people desire to have many children and yet more children mean more deliveries and moiré risk for maternal mortality.

Sex preferences in children

Some women may keep on giving birth in an attempt to get a child of their preferred sex. Parents tend to rate children of different children sex differently as a result may prefer a particular sex. This is risky to the mother who carries and delivers the pregnancy and also unhealthy to the father and children due to inadequate care that will be provided and received.

High fertility rate

Uganda has a very high fertility rate estimated at about 7 children per woman per reproductive life span. It is one of the highest in the world. This implies that women are exposed to the risks many times.

Underutilization of the existing services
Inadequate drug supplies and other medical related equipment is most often interrelated and are responsible for an increased number of avoidable deaths. Poor referral systems for handling emergency
Poor attitudes by the health workers
Noninvolvement of the husbands
Lack of awareness/ignorance
Disrespect for human rights
Gender stereotypes and inequalities

Delays that can lead to maternal mortality

In most instances, women who die in childbirth experienced at least one of the following delays:

1. Delays at the individual woman‘s levels

– Inability to make decision on life threatening health conditions in time for appropriate response
– Late recognition that there is a problem,
– Fear of the hospital or of the costs that will be incurred there,

Delay at the level of the family and community levels in decision making to assist the woman to more/husband‘s issues/ in laws‘ issues.
Delay at the level of accessing services. Usually transport is a major problem and or lack of resources. Many villages has very limited transportation options and poor roads.
Delay in the health units to institute the necessary interventions.

– Inadequate skills and poor staffing
– Failure to make appropriate decision
– Lack of drug supplies etc.

Note: Not only mothers die, babies too die. 4000,000 newborn deaths occur globally yet almost all are due to preventable conditions.

Causes of maternal mortality

There are several causes of maternal mortality broadly grouped into direct and indirect causes. In Uganda 506 per 100,000 women die of pregnancy and birth related and recent data shows that 16 women die every day during giving birth related complications in Uganda.

A direct death is one resulting from obstetric complications of pregnancy, delivery or from interventions, omissions or incorrect treatment or a chain of events resulting from the above.

An indirect death is one resulting from a previously existing diseases (present before) or developed during pregnancy and was not due to obstetric causes but aggravated by the physiological effects of pregnancy.

Direct Causes of Maternal Mortality

i) Sepsis

This is a common cause of maternal mortality. All women get infections when membranes rupture early, delivered in dirty environments like gardens or following operative procedures where the aseptic technique was compromised. All women should be given prophylactic antibiotics following cesarean section. Women who had prolonged labour or early rupture of membranes should be given antibiotics. If such a woman develops fever, she should be carefully assessed, admitted and appropriate treatment instituted as soon as possible.

ii) Hemorrhage

This is a serious condition especially in women with underlying anemia or bleeding disorders. It may present as APH due to placental retention, uterine inertia etc. women should be encouraged and given micronutrient supplements during pregnancy, screened for anemia and always book some units of blood for mothers in labour.

iii) Early pregnancy deaths

This is death resulting from ectopic pregnancies and abortions. This is one of the major causes of maternal mortality in Uganda. Criminal abortions account for the highest number of deaths in this category.

iv) Hypertensive conditions

Severe pre-eclampsia and eclampsia are common causes of maternal mortality. If any mother develops any of these complications should be managed effectively. Magnesium sulphate is the drug of choice. Ensure proper fluid management. Always identify any risk factors of developing pre-eclampsia in a mother during antenatal care and manage them promptly and effectively whenever possible.

v) Others

– Thrombosis and thrombo-embolism
– Genital trauma

Indirect causes of maternal mortality

i) Cardiovascular diseases

– Pulmonary hypertension
– Endocarditis

ii) HIV/AIDs

iii) Malnutrition

iv) Diabetes
v) Thyroid diseases
vi) Anemia

Predisposing factors to maternal mortality and morbidity

∙ Early pregnancy (less than 20 years old);
∙ Uncontrolled fertility;
∙ Low socioeconomic status of women;
∙ Poverty and lack of empowerment of women;
∙ Lack of access to quality services;
∙ Inadequate referral systems;
∙ Lack of support from spouses.

Prevention of maternal mortality

Eighty percent (80%) of these deaths can be prevented through actions that are effective and available in developing country‘s settings. This is a coordinated long term effort within the families, countries and health systems, national legislation and policy.

Primary prevention

Girl child education

Education keeps girls at school until they are old enough to marry and have children. This means that they get fewer pregnancies and produce fewer babies. Educated women will also have more chances of getting employed and have money to look after themselves better. Education also empowers them to stand out for their rights and freedom.

Proper nutrition of the girl child

Malnutrition during childhood and puberty has been closely related to the inadequate development of the pelvis (contracted). This usually predisposes the woman to developing obstetric complications like Cephalopelvic disproportion (CPD). Parents should be educated that girl children need more to eat as much as boys and adolescent girls should be encouraged to eat adequate food for proper body development and functioning.

Family planning

Maternal mortality is common in women who get pregnant while too young (below 20 years of age). Most cases of criminal abortion that turns out with complications are as a result of unwanted pregnancies. Family planning provides an absolute answer to all these questions by enabling the mother (couple) to have children by chop ice and not by chance.

Quality antenatal care

All pregnant women should be encouraged to have timely attendance of at least 4 quality antenatal visits, where the woman is fully assessed for presence of any risk factors that may predispose her to developing complications. Once any risk factor has been identified, it should be managed effectively and appropriately during antenatal care.

Immunization

All women in the reproductive age should be immunized against tetanus, HepB. This is because; such women are at higher risk of developing the infections during any time in the reproductive cycle.

Provision of information, education and communication about maternal mortality. Individuals and families should be given adequate information about the causes of maternal mortality and how they can be prevented. It is important that such messages spell out the roles of each individual in preventing maternal mortality. Individuals should be empowered to take action and stop thinking that the sole role of government is to protect and care for their lives.

Secondary prevention

A skilled attendant should be present at every birth. Functional referral systems is very essential here
Emergency obstetric care services are to be provided and made accessible to the people
Transport and communication networks need to be improved to gain access to all health facilities. Transport means like ambulances should be made available and accessible.
Health facilities should be equipped with adequate equipment, operating theaters which should be functional, blood storage facilities in case of any emergency, equipment in good working conditions and drugs. The government should always ensure a steady supply of essential drugs.
Adequate referral systems for complications should be instituted. Clients should be in position to get assistance from a higher level in the shortest time possible. Some clients decline referrals because they are not sure of obtaining any better help at the next level. In most cases, such clients either refuse and stay at the referring health units or go home and wait for whatever may happen next.
Proper evaluation and reporting of maternal deaths and timely intervention taken
Decentralization of services to make them available to all women
Barriers to the access to health care facilities should be removed; policies should increase women‘s decision making power as regards to their own health and reproduction.
Recruitment of skilled staffs to balance of the workload
Improving the standard and quality of care by organizing refresher courses for the health care personnel.

Tertiary prevention

This involves the control and management of complications that may arise
Emergency obstetric care services should be provided.

Maternal Morbidity

Although considerable attention has been given to maternal mortality, very little concern has been expressed for maternal morbidity. It is estimated that for one maternal death at least 15 more suffer from severe morbidities. As such about an optimistic 5-7 million suffer a severe impaired quality of life as a result of short term or long term disability.

Definitions

Obstetric morbidity originates from any cause related to pregnancy or its management any time during antepartum, intrapartum and postpartum period, usually up to 42 days ( weeks) after confinement.

Parameters of Maternal Morbidity

✔ Fever more than 38 degree centigrade
✔ Blood pressure greater than 140/90mmHg
✔ Recurrent vaginal bleeding
✔ Hb less than 10.5g/dl irrespective of gestational age
✔ Asymptomatic bacteriuria of pregnancy

Classifications

i) Direct obstetric morbidity

– Temporary
– Permanent

ii) Indirect obstetric morbidity

Direct

∙ Temporary (mild)

– APH, PPH, eclampsia, obstructed labour
– Rupture uterus
– Sepsis
– Ectopic pregnancy
– Molar pregnancy etc.

∙ Permanent (chronic)

– Vesico-vaginal fistula and rectovaginal fistula
– Dyspareunia
– Prolaps
– Secondary infertility
– Obstetric palsy

Indirect

These conditions are only expressions of aggravated previous existing diseases like malaria, hepatitis, tuberculosis, anemia etc. by changes in the various systems during pregnancy.

Perinatal Mortality

This is defined as deaths among fetuses weighing 1000 g or more at birth (greater than 28 weeks gestation) that die before or during delivery or within the first 7 days of delivery. The Perinatal mortality rate is expressed in terms of such deaths per 1000 total births. The Perinatal mortality rate closely reflects both the standards of medical care and effectiveness of public and social health measures. According to WHO, the limit of viability is brought to a fetus weighing 500g (22 weeks).

Incidence

∙ Worldwide nearly 4 million newborns die within the first week of life and another 3 million are born dead.
∙ Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied for the newborn.
∙ Perinatal mortality is less than 10 per 1000 total births in the developed countries while in the developing it is much higher.
∙ The major health problem in the developing world arise from the synergistic effects of malnutrition, infections and unregulated fertility combined with lack of adequate obstetric care
∙ Majority of feotal deaths (70-90%) occur before the onset of labour. The important causes.

Predisposing factors to perinatal mortality

Many factors influence the perinatal mortality in Uganda and theses are briefly discussed below;

Maternal factors

a) Epidemiology

– Age over 35 years
– Teenage pregnancies
– Multiparity
– Low socio economic condition(poverty)
– Poor maternal nutritional status

Note. All the above adversely affect the pregnancy outcome

b) Medical disorders

– Anemia (Hb less than 8g/dl)
– Hypertensive disorders
– Syphilis
– Diabetic mellitus
– Prematurity
– Congenital malformation (baby)
– Malaria
– Other infections

c) Obstetric complications

– Antepartum hemorrhage (APH) particularly abruptio placentae is
responsible for about 10% of perinatal death due to severe hypoxia
– Pre-eclampsia, eclampsia is associated with high perinatal loss either due to placental insufficiency of prematurity
– Rhesus Iso-immunization
– Cervical incompetence which may lead to premature effacement and
dilatation of cervix between 24-36 weeks

d) Complications of Labour

– Dystocia from disproportion, mal-presentation and abnormal uterine action
– Premature rupture of membranes (PROM) may result in hypoxia, amnionitis and birth injuries contributing to perinatal death

Feto-placental factors (causes)

– Multiple pregnancy, most often leads to preterm delivery and usual complications
– Congenital malformation and chromosomal abnormalities are responsible for 15% of perinatal death
– Intrauterine growth restriction and low birth weight babies

Unexplained causes

About 20% of stillbirths have no obvious fetal, placental, maternal or obstetric causes.

4. Other causes/risk factors refer to maternal mortality

Causes of perinatal mortality

Infection

– Sepsis
– Meningitis
– Pneumonia
– Neonatal tetanus, congenital

Birth asphyxia and trauma

Hypothermia

Prematurity and/ low birth weight
Congenital malformation

Control and prevention of perinatal mortality

As every mother has a right to conclude her pregnancy safely, so also the baby has a right to be born alive, safe and healthy. As such improvement of obstetric services will not minimize perinatal death appreciably therefore simultaneously demographic and social changes help in the reduction of perinatal mortality rate significantly. The following measures are helpful in reducing perinatal mortality.

Pre pregnancy health care and counseling
Genetic counseling in high risk cases and prenatal diagnosis to detect genetic, chromosomal or structural abnormalities are essential
Regular antenatal care with advice regarding health, diet and rest
Detection and early management of medical disorders in pregnancy such as anemia, diabetes, hypertension
Screening of high risk clients where mandatory hospital delivery is instituted like those from poor socioeconomic status, high parity, extreme of age etc.
Careful monitoring and management of Labour to detect hypoxia, early evidence of traumatic vaginal delivery etc.
Skilled birth attendance to minimize sepsis
Provision of neonatal referral services especially to look after the preterm babies
Health education of the mothers about the care of a new born such as early exclusive breastfeeding and prevention of hypothermia
Educating the community to utilize family planning services and also to utilize the available maternity and child health care services
Increased resource allocation towards maternal and child health services
Regular review of perinatal death cases and ensuring effective supervision, monitoring and evaluation to realize the missing gaps
Improving on social infrastructures like health care, transport and communication network
Continuous decentralization of maternal and child health care services

Preconception Care

The outcome of pregnancy depends so much on the factors that operate during the period of growth and development of the mother from childhood. Some of the factors which influence proper growth and development of the mother are;

– type of birth and circumstances surrounding her birth
– her birth weight
– breast feeding and nutrition
– childhood infections
– formal education
– sexual and reproductive health education and services utilization
– Socio-cultural practices

Therefore it is important that the girl child is given adequate care during this period of development.

Pre-conception refers to the care of women and men during their reproductive years, which are the years they can have a child. It focuses on taking steps now to protect the health of a baby they might have sometimes in the future.

However all women and men can benefit from preconception care, whether or not they plan to have a baby one day. This is because part of preconception health is about people getting and staying healthy overall, throughout their lives. In addition, no one expects an unplanned pregnancy. But it happens often.

Preconception care is the medical care a woman or man receives from trained medical professionals that focus on the parts of health that have been shown to increase the chance of having a healthy baby.

Preconception health is important for every woman, not just those planning pregnancy. It means taking every woman, not just those choosing healthy habits. It means living well, being healthy and feeling good about your life. Preconception care is about making plans for the future and taking the steps to get there.

Preconception care is important for men too. It means choosing to get and stay as healthy as possible and helping others to do the same as well. As a partner it means encouraging and supporting the health of your partner. As a father, it means protecting your children.

Healthy babies

Preconception care is a precious gift to babies. For babies it means their parents took steps to get healthy before pregnancy. Such babies are less likely to be born early (preterm) or have a low birth weight; they are likely to be born without birth defects or other disturbing conditions. Preconception care gives babies the best gift of all the best chance for a healthy start in life.

Healthy families

Ensuring preconception health is a great way to create a healthy family. The health of a family relies on the health of the people in the family. Taking care of your health now will help to ensure a better quality of life for yourself and your family in the coming year.

Objective

Assess clients‘ readiness for pregnancy by ensuring adequate mental, physical and socio economic readiness.
Prevent, treat and manage medical conditions that affect pregnancy and the newborn. 3. Prepare for pregnancy and childbirth
Promote safer and responsible sexual behaviors
Promote delay of age at first pregnancy
Prevention of HIV and sexually transmitted disease

Services offered during Preconception Care

Education and information on:

– Sexuality
– Growth and development of the coming child
– Pregnancy and child birth
– Responsible parenthood
– Family planning
– STI/HIV
– Malaria prevention
– Personal hygiene
– Nutrition
– Use of drug during pregnancy (drugs of abuse and medicine )
– Previous health intervention – repair of Vesico-vaginal fistula, ruptured uterus, treatment for infertility etc.
– Diabetes mellitus

Screening for and managing conditions which may complicate pregnancy, childbirth and health of the mother and child thereafter e.g.

– HIV
– Syphilis
– Sickle cell diseases – Heart disease
– Hypertension

Provision of services

– Congenital abnormalities – Aneamia
– Diabetes Mellitus
– Mental illness
– Folic acid supplementation 3 months for woman before pregnancy
– Immunization
– Deworming for women
– Management of STI/STDS and other identified diseases
– Provision of long other insecticide treated nets
– Routine screening for reproductive health cancers
– Family planning
– VCT for HIV

Support channels.

– Identify and locate the organization that will support the groups and work with them.
– Appropriate counseling of individuals and couples about their pregnancy needs
– Establishing the pre pregnancy health status/profile for the purpose of follow up.
– Identify special group women such as, disabilities, adolescence and HIV infection
– Develop appropriate intervention to address the needs of the different special groups
– Mobilize and sensitize the community to be supportive to the needs of the special groups.

Responsible motherhood and fatherhood
Contraception and family planning information and service.

Where Can Preconception Care be done.

∙ Health units
∙ Community based group.

Ways to reach out to special groups.

∙ Health education in the community
∙ Mass media
∙ Church groups
∙ Appropriate ITC materials
∙ Opinion leaders.

DELAYS IN SAFE MOTHERHOOD Read More »

Obstetrical Emergencies

Obstetrical Emergency is the situation when the life of the mother or baby is in danger of death and something must be done quickly to save lives.

There is a need for the midwife to take quick action in provision of emergency treatment and consideration of proper referral systems.

List of Obstetrical Emergency

AntePartum Hemorrhage
Postpartum hemorrhage
Cord prolapse
Ruptured uterus
Fetal distress
Vasa previa
Intrapartum hemorrhage
Obstructed labour
Retained placenta
Severe preeclampsia and eclampsia
Pulmonary embolism
Severe anemia
Inversion of the uterus
Impending rupture of uterus
Obstetric shock.

Roles of a Nurse/Midwife in Obstetrical Emergencies

At The Community Level

✔ Health education of the community about obstetrical emergencies and their roles in management and prevention
✔ Educate, supervise and evaluate the TBAs in management given to the mother during pregnancy, labour and puerperium
✔ To create awareness on the available health facility like dispensary, clinics, maternity centre and hospitals
✔ To encourage them to attend antenatal clinics, intranatal clinics, postnatal clinics, young child clinics and family planning clinics
✔ Advice women to start self-help project to minimize over dependency on their husbands
✔ Help them realize the importance of taking a well-balanced diet
✔ Discourage harmful traditional practices and beliefs which expose a girl child to early sex marriages as a result of lack of education, boy preferences
✔ Husband should take over tiring duties from their wives when pregnant to relieve them psychologically and physically
✔ Encourage the community to help to transport in case of obstetrical emergencies.

2. During Pregnancy

✔ Identify cases of high risk pregnancies which may end in obstetrical emergencies and refer in time
✔ Thorough history taking, examination and early investigations on every mothers during pregnancy
✔ Early preparation of mothers for labour and successful lactation
✔ Prompt treatment of mothers with minor conditions like morning sickness etc
✔ Early referral of mothers with serious conditions for further management
✔ Proper referral systems.

During Labour

✔ Proper admission of mothers in labour inform of a warm welcome, reassurance and counseling
✔ Proper history taking, examination and investigation on every mother in labour ✔ Proper monitoring of mothers in labour by use of a partograph
✔ Early detection of danger signs. the midwife should summon for help in time
✔ Avoid prolonged and exhausting labour by administration of analgesics, reassurance and avoid early pushing plus rehydration with IV fluids or per Os
✔ Give assisted timely episiotomy in case of assisted delivers to prevent; extended tears, hemorrhage; give episiotomy in mal-presentation and malposition
✔ Use aseptic techniques throughout labour, infection prevention and control techniques
✔ Ensure proper management of 3rd stage of labour to prevent PPH.

After Delivery

✔ Carryout proper observation to the mother and baby especially in the 1st 2 hours to prevent 4th stage complications
✔ Health education of the mothers about the need of;

– Taking a well-balanced diet
– Breastfeeding on demands
– Carrying out postnatal exercise
– Maintain personal and environmental hygiene
– Come back for review after 6 weeks to postnatal clinic
– Attending family planning clinic
– Bringing the baby in YCC for immunization

General Management

Principles applied in this management

Readiness with everything used in management used in management of high risk pregnancy this includes facilities such as:

✔ Emergency tray containing the following; ▪ Drugs i.e. Ergometrine, hydrocortisone, diazepam, dexamethasone, mannitol, digoxin, lasix, dextrose 5%, 50%, vitamin K, aminophylline, atropine, pethidine, morphine, pitocin, magnesium sulphate, others are adrenaline, oxygen cylinder, solutions like normal saline, needles and syringes, adequate staffs, Umbu bags and any facility needed for resuscitation
✔ The midwife/nurse should be calm, quick and knowledgeable and should summon for help
✔ Start with the most urgent need first e.g. arresting hemorrhage, rehydration or delivery of the baby
✔ Quick general history taking, examination and investigations
✔ Apply the essential care systematically according to the emergency such as delivery, manual removal of the placenta, resuscitation etc (apply nursing process) ✔ Reassure the mother and the relatives
✔ Some mothers with HRP are cared for in the maternity centre during pregnancy and referred at full term for delivery in the hospital. others are referred on the first contact
✔ Early detection and referral are very important
✔ Prepare for transport
✔ Writing referral notes which includes the following:-

▪ Time of arrival
▪ Personal history of the mother
▪ General conditions on arrival
▪ All what has been found on examination and admission
▪ Treatment given plus obstetrical management
▪ Reasons for referral
▪ Conditions at referral

Complications

To the mother

Obstetrical emergency exposes the mothers and fetus to a higher chance of morbidity and mortality. This becomes worsened in case the management is delayed or even wrongly applied. There is lack of facilities or poor knowledge; however the mothers and fetus may face the following;

✔ Hemorrhage due to APH, PPH and intra-partum hemorrhage
✔ Shock as a result of severe bleeding
✔ Infections following delay in 2nd stage and in manual removal of the placenta
✔ General ill health
✔ Anemia
✔ Puerperal psychosis
✔ Venous thrombosis
✔ Poor lactation
✔ Sterility
✔ Assisted deliveries
✔ Premature labour
✔ Low resistance to infections
✔ ABO incompatibility
✔ Amniotic fluid embolism
✔ Infertility as a result of infections and damage to the reproductive system.

To The Baby

✔ High neonatal and infant morbidity and mortality
✔ Failure to thrive
✔ Cerebral damage leading to mental retardation
✔ Premature deliveries with their complications
✔ Abortions (pregnancy wastage)
✔ Assisted deliveries and its complications
✔ Intrauterine fetal growth retardation
✔ Low resistance to infections.

Prevention of Obstetric Emergencies

✔ The role of a midwife in the obstetric emergencies
✔ The nurse/midwife should be knowledgeable of how to deal with the obstetric emergencies
✔ Update herself in obstetrical conditions
✔ Equip her maternity center and be able to deal with such emergencies efficiently
✔ Make sure she can transfer the mother to the hospital immediately.

Pediatric Emergencies

Pediatric Emergencies are conditions where the life of the baby is in danger of death or complications.

They are considered right from birth up to 5 years of age.

List of pediatric emergencies

✔ Asphyxia as seen in below conditions
✔ Intrauterine anoxia due to cord prolapsed and APH
✔ Cerebral damage
✔ Hemorrhagic of a newborn

As The Child Grows

Swallowed objects and aspiration
Poisons
Insect bites
Falling
Burns
Cuts
Fractures and diseases.

Causes of Neonatal Morbidity and Mortality

Asphyxia neonatorum
Birth injuries
Low birth weights
Hypothermia
Congenital abnormalities
Sepsis like neonatal sepsis, pneumonia, acute respiratory infection, diarrhea, tetanus, meningitis and septicemia.

Causes of infant mortality and morbidity in Uganda

✔ Measles
✔ Diarrhea
✔ URTI
✔ Malaria
✔ Malnutrition

Management of pediatrics emergencies

Depends on the causes BUT you have to consider the following;

Resuscitation
Induced emesis if the substances taken is not acidic
Give milk to drink
Give oxygen
Put up a drip

Complications of pediatric emergencies

Depends on the type of pediatric emergencies
Complications may happen permanently or temporarily at birth or later in life

Prevention of Pediatric Emergencies

Health education to the public of pediatric emergencies, their causes and prevention. Since most of the maternal conditions leads to paediatric emergencies, neonatal/infant morbidity and mortality. Therefore in preventing such emergencies, neonatal /infant morbidity and mortality such as high risk pregnancies
Knowledge of life saving skills in pediatric e.g. resuscitation is essential.

Obstetrical Emergencies Read More »

High Risk Pregnancies

High Risk Pregnancy is the pregnancy that is likely to end up with complications, death of the mother or baby or both and the mother must be cared for or delivered from a well-equipped health unit under doctor‘s supervision.

Risk : This is the possibility that an event will occur. It is used in reference to un avoidable events e.g. getting pregnancy when one has an underlying serious medical conditions like diabetes puts the mother‘s life and her unborn child at danger
Risk Factors : These describe anything which actually causes or increases the chances of complication e.g. diabetes illness increases the chances of maternal morbidity and mortality

Some High Risk Mothers

Young primigravida age 16 below
Elderly PG age 35 and above
Multigravida of 5 and above
Mothers who have had 3 or more miscarriages
Mothers in small statues- (153cm and below)
Limping mothers
Mothers with history of pelvic fractures
Cephalopelvic disproportion which is compound
Multiple pregnancy
Mothers with intrauterine fetal death (IUFD)
PPH on previous deliveries
Mothers with history of retained placenta on previous delivery
Pre-eclampsia, eclampsia and any mother with a history of post eclampsia toxemia
Mothers with cardiac or renal diseases, essential hypertension, diabetes, anemic, asthmatic, APH, Rhesus negative (medical conditions)
Mothers with history of instrumental deliveries
Mothers with history of mental illness
Mothers with history of premature deliveries
Mothers with history of 2 or more stillbirth

Roles of a Midwife/nurse in High Risk Pregnancy

Aims

∙ To educate the community
∙ Educate mothers
∙ Care mothers during pregnancy
∙ Care mothers during labour
∙ Care mothers after delivery

At Community Level

Educate the community about the following;

To value all children especially girl
To educate children and provide proper nutrition including all girls
Dangers of harmful practices to girls before, during pregnancy and after delivery
To provide transport to pregnant women and to support them
To utilize the health facilities available or health services
To recognize danger services
To recognize danger signs of pregnancy and refer them to health units.

To The Mother

Educate mother about the following:

Importance of preparing for pregnancy
Use of family planning services so as to conceive when ready
Utilize the antenatal, intranatal and postnatal services
Eat well and know/learn how to prepare a balanced diet as well as sources and storage food
Recognize danger signs of pregnancy
Avoid substance abuse.

At the Health Centre

During Pregnancy

Health workers must ensure the following:

Proper ANC
Health education about proper nutrition, rest and sleep and good hygiene
Early detections of danger signs and management
Emergency care and referrals to facilities/hospitals
Give TT, Iron, Folic acid, Fansidar and Mebendazole to prevent complications e.g. anemia and TT at birth
Discourage use of native medicine
Counseling mothers not to place blame on themselves for their situations like frequent child bearing.

During Labour

Health worker should do the following:

Provide safe and clean delivery services
Kindness and understanding
Proper nutrition
Monitor mothers in labour properly, early detections of problems and use of partograph and management
Follow proper referral systems to prevent delay in accessing medical care 6. Prevent complications.

Baby

Offer the 9 needs of a newborn baby:

Establish of respirations and maintain it
Dry and keep warm
Immediate breastfeeding
Immunize earlier
Clean cutting of the cords and further care
Prevent blindness by instilling tetracycline eye ointment
Maintain warm.

The Roles of a Husband in Safe Motherhood

They are subdivided into:

During pregnancy
During child birth/labour
After delivery
In family planning
During child rearing

During Pregnancy

To understand & appreciate the discomfort, anxiety & tiredness that pregnancy may cause in a mother
Take over physically tiring tasks like working in the field, lifting heavy loads, washing and scrubbing floors to avoid any work load on a woman
Take care of other children
Provide encouragement and emotional supports by trying not to make demands on her and not criticizing
Learn about pregnant related conditions along with the mother to enable him to help her more effectively and understand what she is going through especially danger signs in pregnancy
Accompany the wife when going to the health center for antenatal care and health education
Understand that good nutrition and medical care during pregnancy are important and should provide it
Provide whatever money necessary to pay for transport fees, or medication
Arrange to have transport ready in case of any emergency during pregnancy and postnatal care.

During Labour/Child Birth

Give money, clothing, transport, etc.
Stay with his wife during labour and delivery to provide comfort and support.

After Delivery

Adopt to a new person (baby) in his new life and meets the baby‘s demands and needs especially breastfeeding
Give the mother and the baby understanding, support, attention and help her with day to day tasks
Contribute to having a healthy and happy family by ensuring that the mother is well fed and that both the mother and the baby receive medical care
Should be aware of danger signs that might necessitate seeking for medical health

In Family Planning

To ensure that the mother has fully recovered from the demands of pregnancy and birth thus after 2 or more years after delivery and protect her from becoming pregnant for at least 2 years after childbirth of the last baby
Seek advice from the Doctor or family planning clinic about methods of contraception, either alone or even better with the mother
Support and cooperate when using whatever method was selected
He should accept male family planning methods or co-operate when the woman is using one.

During Child Bearing

Protect and provide the resources e.g. foods, clothing, shelter, school fees for the family
Participate in the upbringing of the children
Involve the wife in decision making
Counsel and advice the children as teenagers, discussing issues like when to get married and what career or job to transfer
Ensure that his daughters are given the same opportunities as his sons, in terms of education, health care and other benefits; including home education, sex education of the children.
Be available at home for your wife, children and show warmth.

Management of High Risk Factors

General principles applied in this management:

Readiness with everything used in management used in management of high risk pregnancy this includes facilities such as:

✔ Emergency tray containing the following; drugs i.e. Ergometrine, hydrocortisone, diazepam, dexamethasone, mannitol, digoxin, lasix, dextrose 5%, 50%, vitamin K, aminophylline, atropine, pethidine, morphine, pitocin, magnesium sulphate, others are adrenaline, oxygen cylinder, solutions like normal saline, needles and syringes, adequate staffs, Umbu bags and any facility needed for resuscitation
✔ The midwife/nurse should be calm, quick and knowledgeable and should summon for help
✔ Start with the most urgent need first e.g. arresting hemorrhage, rehydration or delivery of the baby
✔ Quick general history taking, examination and investigations
✔ Apply the essential care systematically according to the emergency such as delivery, manual removal of the placenta, resuscitation etc (apply nursing process)
✔ Reassure the mother and the relatives
✔ Some mothers with HRP are cared for in the maternity centre during pregnancy and referred at full term for delivery in the hospital. others are referred on the first contact
✔ Early detection and referral are very important
✔ Prepare for transport
✔ Writing referral notes which includes the following:-

▪ Time of arrival
▪ personal history of the mother
▪ General conditions on arrival
▪ All what has been found on examination and admission
▪ Treatment given plus obstetrical management
▪ Reasons for referral
▪ Conditions at referral.

Prevention of High Risk Pregnancies

The roles of a midwife, husband and community in safe motherhood
The midwife/nurse should be knowledgeable on how to deal with HRP
Update herself in obstetrical conditions
Equipped her maternity center and be able to deal with such cases efficiently.

High Risk Pregnancies Read More »

Safe Motherhood

Safe motherhood is defined as a series of initiative, practices and protocols and service delivery guideline designed to ensure that women receive high quality gynecological, family planning, prenatal, delivery and postpartum care in order to achieve optimal health for the mother, fetus and infants during pregnancy, childbirth and postpartum

Safe motherhood means that no woman and child should die or be harmed by pregnancy or birth. Safe motherhood begins with the assurance of basic safety living as a girl and a woman in society.

❖ Safe motherhood is founded on freedom to choose when and whether to have children and family planning for all couples.

❖ Safe motherhood encourages active participation during health care. It is founded on the freedom from discrimination of any form.

❖ Safe motherhood values the girl child.

❖ Safe motherhood implies the availability, acceptability and easy access to health care for a woman’s prenatal, birth, postpartum, family planning and gynecological needs.

❖ Safe motherhood requires involvement and commitment from each community and the nation to fairly allocate resources that promote the health of all women and infants.

❖ Safe motherhood means: social equity for women, maternal health care within PHC and access to emergency obstetrics and newborn care for management of complications when they arise.

Note: Safe motherhood is the concept that no woman or fetus or baby should die or be harmed by pregnancy or childbirth.

This is made possible by providing timely appropriate and comprehensive quality obstetric care during:

✔ Preconception
✔ Pregnancy
✔ Childbirth
✔ Puerperium

The Road Map to Safe Motherhood

This is the way the health of a woman is maintained throughout their child bearing age and during pregnancy, labor and puerperium so that the mother remains in good physical and mental conditions to avoid complications which may put her life at risk.

In order to achieve a safe motherhood, the health of the mother has to be monitored during pregnancy so that she remains in a good physical condition and delivers a normal healthy well breastfed baby without any abnormality.

During childhood, female children should have good nutrition so that they remain healthy as a good diet promotes good growth and adequate pelvis with fewer complications of future deliveries.

Children should be fully immunized against the killer diseases which may interfere with normal development and growth of the children.

Adequate and early hospitalization of children to avoid serious complications which may occur due to diseases

During adolescence, girls should be educated about safe sexuality and thus should be done before the sexual period experiment and, to risk early and unplanned pregnancy with all its risks of sexually transmitted diseases.

Information and education to young girls about maternal and child health and family planning so that mothers may avoid many children will make her work hard without having adequate rest.

Community and family support. A woman needs to be valued and protected both in an emotional and physical way. She should not be allowed to work too much hard especially when she is pregnant in order to avoid complications which may put her life in danger.

Mothers during pregnancy should be encouraged to attend antenatal clinics early and regularly so that the pregnancy and her condition is monitored , disorder detected and investigated, mother is given adequate treatment and the more serious ones sent for advanced management.

Education of traditional birth attendants (TBAs) and healers about safe motherhood, management of mothers during pregnancy, labour and puerperium; and to identify at risk cases in time and to refer them to hospital.

Community should participate in organizing referral system in case of emergency Adequate management of delivery to avoid complications to the mother and baby

Proper management during puerperium to detect early any complications so that proper management is given in Post natal clinic.

The history of global safe motherhood programs began in 1987, the global strategy for safe motherhood was launched in Nairobi, Kenya in 1987 at the international conference on safe motherhood. This conference was co-sponsored by the WHO in partnership with the World Bank, the United nation Funds for Development Activity (UNFPA) and United Nation

Development Program (UNDP).

During the program of Action of the international conference on population and Development (ICPD) in 1994, a consensus was reached that meeting the reproductive health needs of women and men is a critical requirement for human and social development. The conference affirmed that reproductive health care is an integral component of primary health care and should be provided in that context. The elements (components) of reproductive health have a profound impact on the course and outcome of pregnancy and health service requirements for addressing them are closely related.

It was during this conference that consensus was built to adopt a strategy that addresses all aspects of reproductive health and provides an opportunity to develop an integrated approach to safe delivery and hence the WHO Mother Baby Package.

After about 5 years of introduction of the Mother Baby Package, WHO and partners introduced the need to improve maternal health and reduce maternal mortality through the making pregnancy safer strategy highlighted below:-

The making pregnancy safer strategy emphasizes the importance of the health sector interventions highlighted:

– Advocacy
– Partnerships
– Improving national capacity
– Standard setting and tool development
– Research and development
– Monitoring and evaluation

If these are well implemented they have the capacity to significantly reduce maternal mortality in countries.

What is known worldwide about adverse maternal health is that a country’s overall economic wealth is not the only important determinant.

According to national and internal human right treaties, safe motherhood is considered a human right issue. Therefore it is considered that maternal death is the reflection of ―social disadvantage not merely a― health disadvantage.

Aims of Safe Motherhood

To ensure that all deliveries are conducted hygienically and according to accepted medical practices, thereby preventing complications that are caused or exacerbated by poor care.
Identify complications promptly and manage them appropriately either by treating or referring them to a higher level of care.
Provision of high quality, culturally appropriate care, ensuring necessary follow up and linkages with other services including antenatal and post-partum care as well as family planning, post abortion care and treatment of STIs.
To enhance the quality and safety of girls‘ and women‘ lives through adaptation of a combination of health and non-health related strategies.

Note: Maternal and child health promotion is one of the key commitments in the WHO constitutions.

Safe motherhood initiative is a global effort and it is designed to operate through its partner i.e.

– Government agencies
– NGOs
– Other groups and individuals

It aims to improve women‘s health through social, community and economic interventions.

Pillars of Safe Motherhood

Family planning; to ensure that individuals and couples have the information and services to plan the timing, number and spacing of pregnancies and thus the number of unsafe abortion.
Antenatal care; to prevent complications where possible and ensure that complications of pregnancy are treated appropriately and very serious conditions referred within the shortest possible time.
Clean/safe delivery and postnatal care; to ensure that all birth attendants have the knowledge, skills and equipment to perform a clean and safe delivery and provide postpartum care to the mother and baby, all women should have access to basic maternity care during delivery.
Emergency obstetric care; to ensure that essential care for high risk pregnancies and complications is made available to all women and girls who need it. It is estimated that about 15 % of all normal pregnancies end up with complications therefore the need to always be prepared for emergency obstetric care.

Basic maternity care
Primary health care
Equity for women

Components of safe motherhood

Per-conception care
Antenatal care
Postpartum care
Post abortion care
Emergency obstetric care
Care of the newborn

Requirements for safe motherhood

Achieving safe motherhood and reducing maternal mortality requires a 3 way strong strategy:

All women have access to contraception to avoid unintended pregnancies.
All pregnant women have access to skilled attendance at the time of birth.
All women with complications have timely access to quality emergency obstetric care.

The roles of community in safe motherhood

The community can give support in several ways to make motherhood safer:

Share the workload so that mother can avoid heavy physical work
Encourage pregnant mother to eat a balanced diet and rest than usual especially during the last three months
Encourage mothers to take their non-pills or other medication as provided
Help with looking after children so that mother can go for antenatal care and delivery in the hospital
Establish transport readiness for emergency referral and obstetrical complications
Encourage risk mothers to use maternity waiting areas, if advised to do so during antenatal care
Creates inform and motivated community based safe motherhood groups

High Risk Pregnancies Click Here

Safe Motherhood Read More »

Integration of Reproductive Health Services

Integration; this is defined as an approach in which health care providers use opportunities to engage clients in addressing broader health & social needs than those promoting health encounters.

It‘s a phenomenon or a process where several services are made available to clients or groups of people so that people who need specific RHS can access them within their vicinity, for instance family planning with safe motherhood, Cancer of the cervix screening.
This is the process of providing a variety of Reproductive Health services by either one or more competent service providers within one facility on a daily basis.

In order to maximize use of resources, Sexual Reproductive Health Services (SRHS) should be provided as an integrated health care package that is convenient to clients and service providers. Clients should be able to receive/access various SRHS during one visit at a given static or outreach health units.

Integration provides anticipatory assessment, plan and evaluates services relevant to the clients‘ desires, needs and/ or risks.

When an integration approach is applied in RHS the goal is to provide more than one service other than unique needs of the clients. Integrated services may be provided by one facility where the client gets all of his/her health needs met during one encounter. Depending on the service capacity, integrated services will be offered at the same facility or location during the same operating hours. Services may be by the same provider in one visit or the provider of one services may actively encourage the client to consider using another recommended services during that same visit available within the same facility or if the needed services are beyond the capacity of the facility or the skills of the attending provider then appropriate referral should be effected.

However, for integration to be effective in the latter future an effective referral system must be in place to provide accessible, timely and affordable coordinated care.

Factors that can promote Integration of Sexual Reproductive Health Services

Several factors can help in the smooth running of Reproductive Health Services in an integral manner. It includes the following;

Capacity building (training).This involves improving the ability of the already existing staffs and recruiting more skilled staffs to counter balance work load.
Improving infrastructures. The government and her partners in development should improve on transport and communication networks as well as upgrading and improving on her health centers, referral systems in a view to improve on clients‘ turn up and accessibility.
Increasing the range of commodities and sustaining availability. This can be achieved by making constant and timely supply of Reproductive Health Services items to the overwhelming number of clients.
Constant and timely integrated supervision, monitoring and evaluation to ascertain RHS successes.
Facilitating effective referral across services. This will help to address and help clients who need specialized care to be treated within the shortest time possible.
Community sensitization about the existence of integrated services in a bid to improve on the health care seeking behaviors and make them aware of the available services.

Reasons for Integration of Reproductive Health Services

To make various services available at the same time
To help reach the community who may not be able to access distant RHS
To make people with specific reproductive related problems assisted and those with complicated cases referred for specialized attention.
To create awareness and improve on community contact.

Benefits of integration

For clients:

✔ Convenient and time saving.
✔ Confidentiality is respected because information is shared with one provider.
✔ The service is perceived to be complete because all clients‘ reproductive health needs are addressed at the same time.
✔ Improve client provider relations.
✔ Increase client satisfaction.

Providers:

✔ Better distribution and more effective sharing of duties.
✔ Resources accessible to every provider.
✔ Increased client confidence in the providers.
✔ Work load spread out over all service hours.

Service:

✔ Increase accessibility and availability of services.
✔ Complete-improves quality of care.
✔ Available and accessible ―ONE STOP SHOP
✔ User- friendly.
✔ Efficient, effective and quick.
✔ Meet various clients‘ reproductive needs at the same time.
✔ Reduces missed opportunities.
✔ Maximizes utilization of the available resources, example; equipment, staff time.
✔ Increases client satisfaction.
✔ Improves clients‘ provider relation.

Principles for integration of Reproductive Health Services

Build on existing opportunities for integration

✔ Assess the existing health services offered at the clinic particularly Reproductive Health services.
✔ Type, age of clients being served and client load.
✔ Identify the strengths and limitations of the services offered and modes of offering the services.

Involve other stakeholders.
Hold meetings with supervisors, colleagues as well as health unit management committees to:

✔ Review personnel tasks and make a list for each cadre.
✔ Draw a work plan and re-allocate services according to providers‘ training and interest.

Reorganize services:

✔ Create space and ensure smooth client flow in order to:

– Serve clients on first come first served basis

– Prioritize the very ill clients who need immediate care

– Avoid clients to queue twice

– Avoid unnecessary delays

✔ The waiting areas should include:

– Reading materials on RH issues

– Television and radio to help clients be educated as they are waiting and to reduce on boredom

– Health talks by providers and peers

✔ Counseling /consultation rooms should:

– Ensure privacy and confidentiality

– Be well equipped with supplies

– Minimize referrals

✔ Include recreation space/room to allow:

– Group discussion

– Peer education

– Indoor games especially for adolescent friendly services

Orient the community to create demand for services through:

✔ Client recruitment activities
✔ Identifying and offering services to young persons who come for other services
✔ Putting up notices in public places about services offered at the health Centre
✔ Work with community leaders to reach the community
✔ Liaise with community health workers to spread the news and refer clients for services
✔ Link up with peer educators and providers

Note. Counselling and IEC (Information, and communication (IEC)) form the backbone of all reproductive health services

Modes of Reproductive Health service delivery

Community outreaches:

– Health promotion and education
– Immunization
– Antenatal
– Family planning
– STI and HIV/AIDS screening and management
– Malaria prevention and treatment
– Treatment of minor ailments
– Deworming

Static clinics:

All the above plus,

– Adolescent health
– Male friendly Reproductive Health services
– Infertility
– Screening of RH cancers example cancer of cervix, breast, prostate and testicles

3. Community based services:

– Distribution of contraceptives and condoms
– Distribution of iron and folic acid distribution of anti-malarial
– Delivery services and referral
– Home-based care example. for HIV and postpartum mothers

Social marketing

– Health promotion and education
– Provision of family planning services
– Provision of medical supplies example. Mama kits, insecticide treated nets and anti-malarial.

Disadvantages of Integration

It increases workload especially where the number of staff is limited.
Tiresomeness since service providers have to spend great time serving clients.
It‘s costly especially where financial support is very poor.
It‘s very difficult to perform the outreach integration especially where geographical barriers, impassable roads e.t.c.

Integration of Reproductive Health Services Read More »

Gender Based Violence (GBV)

Forms of Violence in Uganda

Settings Where Gender-Based Violence Can Occur

Predisposing Factors of Sexual and Gender-Based Violence

Risk Groups for Sexual and Gender-Based Violence

Reasons for Staying in an Abusive Relationship

Characteristics of Those Who Are Abused

Impacts of Sexual and Gender-Based Violence

Ways through which Sexual Gender-based Violence can be reduced in Uganda

Roles of leaders on SGBV in their community

Control and prevention of Sexual Gender-based Violence

Reasons Why the Community and Leaders Should Be Concerned About SGBV

Roles of health workers in managing victims and addressing gender-based violence

Sources of Help for Victims of SGBV

Hormonal Methods of Family Planning

Oral Contraceptive Pills

i) Progesterone Only Pills (POP)

Examples

Modes of action

Advantages

Contraindications

Side effects

i) Combined Oral Contraceptive Pills (COC)

Examples

Disadvantages

Implants

Advantages

Common side effects and disadvantages

Indications

Contraindications

Signs and problems that need medical attention

Injectable contraceptives

Examples

Depo Provera

Mode of action

Indications/who can use it?

Contraindications

Advantages and non-contraceptive benefits

Disadvantages and common side effects

Signs and problems that need medical attention

Management

Sayana Press

Mechanism of actions

Indications

Advantages & non- contraceptive benefits

Contraindications

Disadvantages & Side effects

Problems that may need medical attention

Permanent Method/Voluntary Surgical Contraceptives

Tubal ligation/tubectomy

Mode of Action

Indications

Timing of the tubal ligation

Benefits

Disadvantage

Side effects

Challenges associated with tubal ligation

General complications of tubal ligation

2. Vasectomy

Mode of action

Contraindications

Benefits

Side effects

Explain the following to the clients

General instruction to the clients using permanent methods of family planning

Emergency /Post Coital Contraceptives

Indications

Contraindications

Types

When to start?

What to use and the dose

Side effects

a) Intrauterine contraceptive devices (IUCDs)

Mechanism of action

Notes

Women who need emergency contraception should be counseled about regular contraceptive options and encouraged to use regular methods consistently and correctly. Referral:

Basic steps of client care for ECP

Counseling ECP clients

Artificial Methods of Family Planning