24.4 Contraception & Family Planning: The RH Law, Effectiveness, Natural and Barrier Methods, Hormonal Methods, IUDs, Permanent Methods, Emergency Contraception and the WHO Eligibility Criteria

Why this area matters

TOS area N asks you to:

• classify contraceptive methods;
• differentiate their mechanisms and their short- and long-term side effects;
• choose the right method for the right patient, considering precautions and contraindications.

Family planning lowers maternal and infant deaths by preventing high-risk, closely spaced and unintended pregnancies. The DOH recommends birth intervals of 3 to 5 years. Unmet need for family planning remains significant in the Philippines, especially among the poor and adolescents.

The legal framework

• The Responsible Parenthood and Reproductive Health Act of 2012 (RA 10354):
  • guarantees universal access to information and to modern, medically safe, legal and effective family planning methods;
  • includes them in public health facilities and PhilHealth benefits;
  • funds reproductive health education.
  • Abortion remains illegal, and abortifacients are excluded.
• Imbong v. Ochoa (2014): the Supreme Court upheld the law but struck down several provisions, including those that:
  • allowed minors who are already parents or had a miscarriage to get modern methods without parental consent;
  • allowed a married person to undergo reproductive health procedures (outside emergencies) without spousal consent;
  • penalized health workers who are conscientious objectors for not referring patients.
• Executive Order 12 (2017) aimed for zero unmet need for modern family planning.
• Counseling is voluntary and informed. Providers use a structured approach and must not coerce or set targets.

Effectiveness

• Effectiveness is described as pregnancies per 100 women in the first year, under perfect use and typical use. The Pearl index counts pregnancies per 100 woman-years.
• Typical-use failure rates:
  • less than 1%: implants, IUDs, sterilization;
  • about 4%: injectables;
  • about 7% to 9%: pills and patch;
  • about 13%: male condom;
  • about 2% to 23%: fertility awareness methods, which depend heavily on correct use;
  • about 20%: withdrawal.

Natural and barrier methods

• Fertility awareness methods:
  • Standard Days Method: CycleBeads, avoiding unprotected sex on days 8 to 19, for regular cycles of 26 to 32 days;
  • cervical mucus (Billings) method: slippery, stretchy mucus marks fertility;
  • basal body temperature: a rise of about 0.3 to 0.5°C after ovulation from progesterone;
  • symptothermal method, which combines these.
• Lactational amenorrhea method (LAM): more than 98% effective only while all three conditions hold:
  1. the infant is under 6 months;
  2. the mother is fully or nearly fully breastfeeding, day and night;
  3. menses have not returned.
  • When any condition ends, another method is started.
• Condoms:
  • the only methods that also protect against STIs and HIV;
  • use with water-based lubricants, because oil weakens latex;
  • "dual protection" means condoms plus a highly effective method.

Hormonal methods

• WHO Medical Eligibility Criteria (MEC) for combined hormonal contraceptives. Category 4 (unacceptable risk) includes:
  • smoking 15 or more cigarettes a day at age 35 or older;
  • migraine with aura;
  • current or past VTE or known thrombogenic mutation;
  • current breast cancer;
  • BP of 160/100 mmHg or more or vascular disease;
  • ischemic heart disease or stroke;
  • complicated valvular disease;
  • severe cirrhosis or liver tumor;
  • under 21 days postpartum;
  • breastfeeding under 6 weeks postpartum.
• MEC categories: 1 means no restriction, 2 means benefits outweigh risks, 3 means risks usually outweigh benefits, and 4 means do not use.

Intrauterine devices and permanent methods

• Copper IUD (TCu380A):
  • copper is spermicidal, impairing sperm function and fertilization; it is not an abortifacient when used routinely;
  • effective for 10 to 12 years;
  • may increase menstrual bleeding and cramps.
• Levonorgestrel IUS:
  • thickens cervical mucus and thins the endometrium;
  • reduces menstrual bleeding;
  • also used for heavy menstrual bleeding and endometrial protection.
• Risks of IUDs:
  • expulsion;
  • perforation at insertion;
  • infection, mainly in the first 3 weeks;
  • if pregnancy occurs, a higher chance that it is ectopic.
• Contraindications to IUDs: pregnancy, current PID or cervicitis, unexplained bleeding, and cavity distortion.
• Bilateral tubal ligation:
  • done postpartum (minilaparotomy) or by interval laparoscopy;
  • permanent, so careful counseling is needed, especially for younger women who may later regret it;
  • pregnancies after failure are more often ectopic.
• Vasectomy:
  • simpler and safer than tubal ligation;
  • not immediately effective: another method is used until semen analysis shows no sperm, about 3 months later.

Emergency contraception

• Copper IUD within 5 days of unprotected intercourse is the most effective method, and it continues as ongoing contraception.
• Levonorgestrel 1.5 mg as a single dose works best within 72 hours. It acts mainly by delaying ovulation. Ulipristal acetate works up to 120 hours.
• The Yuzpe method uses combined pills in two doses 12 hours apart. It is less effective and causes more nausea.
• Emergency contraception does not disrupt an implanted pregnancy. It is part of care after sexual assault, together with STI and HIV prophylaxis.