Transition Contraceptive Technology Update (CTU) for LAM ...resources.jhpiego.org/system/files/resources/ctu_participant_0.pdf · Transition Contraceptive Technology Update (CTU)

Transition Contraceptive Technology Update (CTU) for LAM Counselors

Participant’s Notebook

ACCESS-FP, a five-year, USAID-sponsored global program, is an associate award under the ACCESS Program. ACCESS-FP focuses on meeting the family planning and reproductive health needs of women in the postpartum period. Interventions are designed to complement those of the ACCESS Program in the promotion and scale-up of postpartum family planning through community and clinical interventions. ACCESS-FP will reposition family planning through integration with maternal, newborn and child health programs, including the prevention of mother-to-child transmission of HIV. For more information about ACCESS-FP, please visit www.accesstohealth.org/about/assoc_fp.htm, or contact Catharine McKaig, ACCESS-FP Program Director, at [email protected]. Copyright © 2009 ACCESS-FP (www.accesstohealth.org/about/assoc_fp.htm) ACCESS-FP Jhpiego 1615 Thames Street Baltimore, Maryland 21231 www.jhpiego.org Any part of the Transition Contraceptive Technology Update (CTU) for LAM Counselors (2009) learning resource package may be reproduced and excerpts may be quoted without permission, provided that the material is distributed free of charge and ACCESS-FP is credited as the source of all copies, reproductions, distributions and adaptations of the materials. Please use the following reference [Adapted (or Reprinted) from]: ACCESS-FP. 2009. Transition Contraceptive Technology Update (CTU) for LAM Counselors learning resource package. ACCESS-FP: Baltimore. TRADEMARKS: All brand and product names are trademarks or registered trademarks of their respective companies. August 2009


August 2009 Transition CTU for LAM Counselors - i

Transition Contraceptive Technology Update (CTU) for LAM Counselors: Participant’s Notebook12

August 2009

ACKNOWLEDGMENTS.................................................................................................................ii

INTRODUCTION....................................................................................................................... P-1

MODEL COURSE AGENDA ...................................................................................................... P-4

PRE-COURSE KNOWLEDGE ASSESSMENT (ANSWER SHEET)................................................. P-5

EXERCISES

Transitioning to Other Modern Methods of Contraception (Exercises One and Three) ................... P-7

Transition Counseling Practice Scenarios .................................................................................... P-9

TRANSITION FAMILY PLANNING COUNSELING CHECKLIST.............................................. P-10

COURSE EVALUATION........................................................................................................... P-14

12 The materials contained in this notebook are also included in the Facilitator’s Notebook, for the facilitator’s reference.


ii - Transition CTU for LAM Counselors August 2009

ACKNOWLEDGMENTS This publication was made possible through support provided by the Service Delivery Improvement Division, Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Associate Cooperative Agreement #GPO-A-00-05-00025-00, and Leader with Associates Cooperative Agreement #GHS-A-00-04-00002-00. The opinions herein are those of the editors and do not necessarily reflect the views of the U.S. Agency for International Development. Several portions of this learning resource package have been adapted from the following publication: Georgetown University, Institute for Reproductive Health, and Jhpiego. 2009. Lactational Amenorrhea Method (LAM): A Learning Resource Package for Family Planning Service Providers and Trainers. Georgetown University: Washington, D.C. www.irh.org Prepared by: Barbara Deller Reviewers: Ricky Lu Holly Blanchard Cat McKaig Editor: Rebecca Fowler Graphic Designer/Desktop Publisher: Renata Kepner


August 2009 Transition CTU for LAM Counselors - P - 1

INTRODUCTION

COURSE RATIONALE Worldwide, 50% of pregnancies are unintended. Pregnancies that are spaced too close together decrease the likelihood of healthy newborn, child and maternal outcomes. A postpartum woman may become pregnant, even while she is breastfeeding or before her menstrual period has returned—if she is not using contraception, such as the Lactational Amenorrhea Method (LAM). LAM is a highly effective, temporary method of contraception that is available and accessible to postpartum women who are breastfeeding. LAM is also a “gateway” to other modern methods of contraception in that while using LAM, a woman/couple has time to discuss, choose and adopt the next family planning method that they will use. Effective transition from LAM to another contraceptive (by the time any one of the three LAM criteria is no longer met, or if the woman/couple wishes to stop using LAM) is critical, helping to ensure that the woman has continuous, uninterrupted contraceptive protection. Supporting and facilitating timely transition is, therefore, a key role of the LAM counselor. This Contraceptive Technology Update (CTU) will help prepare LAM counselors to assist postpartum women who are using LAM, or discontinuing the use of LAM, in choosing and successfully transitioning to appropriate, locally available modern methods. This course is designed to work as a companion to training in LAM counseling. Successful completion of a LAM update/workshop is a prerequisite for this CTU.

COURSE GOAL The goal of this CTU is to equip LAM counselors to provide counseling on contraceptive methods that can be used by the postpartum woman who is transitioning from LAM.

ORGANIZATION OF THIS LEARNING RESOURCE PACKAGE This learning resource package (LRP) is composed of two main components: the facilitator’s materials and participants’ materials. The facilitator’s materials include everything the facilitator needs to teach this course, as described below:

A Graphics Presentation, which covers all of the basic content for the course

The Facilitator’s Notebook, which includes answer keys for the knowledge assessments and exercises, as well as detailed guidance on conducting the course


P - 2 - Transition CTU for LAM Counselors August 2009

The participants’ materials, presented in this Participant’s Notebook as well as the Facilitator’s Notebook, accompany several of the course segments and activities—enhancing the learning experience. In addition to this introduction, there is a model course agenda, answer sheets for the pre-course knowledge assessment and exercises, a “transition” family planning checklist (both a learning/assessment tool and job aid) and a course evaluation. There is also a “thumbnails” handout13 of the Graphics Presentation. An essential reference for both the facilitator and participants is Family Planning: A Global Handbook for Providers (available at: http://www.infoforhealth.org/globalhandbook/). This will provide expanded information on each method of contraception covered during the course. National/local family guidelines should also be available. And, for the discussion on “Family Planning Considerations for the HIV-Positive Woman,” the facilitator and participants should have access to national/local guidelines for prevention of mother-to-child-transmission of HIV (PMTCT).

COURSE SYLLABUS Participant Learning Objectives By the end of the course, the participant will be able to discuss: 1. The importance of postpartum family planning and transitioning from LAM 2. The benefits, limitations and counseling considerations for using:

Progestin-only pills

Progestin-only injectables

Combined oral contraceptives (COCs)

Emergency contraception (EC)

Intrauterine contraceptive devices (IUD)

Condoms

Female sterilization

Male sterilization (vasectomy)

3. Family planning considerations for the HIV-positive woman 4. Effective counseling for the woman who is transitioning from LAM to another modern method

of contraception Training/Learning Methods

Illustrated presentations and group discussions

13 This handout will be distributed at the end of the course; this ensures that participants will have key content for future reference (without having to take extensive notes)



Case studies and other exercises

Counseling demonstration/simulation through role plays Participant Selection Criteria Participants for this course should be maternal-child health or family planning service providers who are current in LAM counseling knowledge and skills. Ideally, each participant should be currently active in service provision. Course Materials The participants’ materials include the following:

Model Course Agenda

Pre-Course Knowledge Assessment (Answer Sheet)

Exercises

Transitioning to Other Modern Methods of Contraception: Three Exercises

Transition Counseling Practice Scenarios

“Transition” Family Planning Counseling Checklist

Post-Course Knowledge Assessment (Answer Sheet)

Presentation Graphics Handout

Course Evaluation Methods of Evaluation

“Transition” Family Planning Counseling Checklist (can be used for self-evaluation, peer evaluation and trainer/supervisor evaluation)

Post-Course Knowledge Assessment

Course Evaluation (to be completed by each participant) Course Duration

4.5 hours Suggested Course Composition

Up to 24 family planning service providers

One or two facilitators



MODEL COURSE AGENDA

TRANSITION COURSE AGENDA (4.5 HOURS)

Activity Brief Content Description Time Allotted

1 Overview of Course Course objectives and materials 15 minutes

2 Knowledge Assessment Knowledge assessment 20 minutes

3 Presentation/Discussion Review: What is “transition” and why is it important?

15 minutes

4 Activity

Exercises

Review: Appropriate timing for “transition” to other modern methods of contraception

20 minutes

5 Presentation/Discussion Factors contributing to contraceptive choice 5 minutes

6 Presentation/Discussion Progestin-only pills (POPs): Characteristics, key benefits, limitations and counseling considerations

15 minutes

7 Presentation/Discussion Progestin-only injectables: Characteristics, key benefits, limitations and counseling considerations

10 minutes

8 Presentation/Discussion Combined oral contraceptives (COCs): Characteristics, key benefits, limitations and counseling considerations Introduction to medical eligibility criteria

20 minutes

9 Small Group Work

Presentation/Discussion

Emergency contraception (EC): Characteristics, key benefits, limitations and counseling considerations

20 minutes

10 Presentation/Discussion

Debate

Presentation/Discussion

Intrauterine contraceptive devices (IUDs): Characteristics, key benefits, limitations and counseling considerations

20 minutes

11 Presentation/Discussion Condoms: Characteristics, key benefits, limitations and counseling considerations

10 minutes

12 Presentation/Discussion Female sterilization: Characteristics, key benefits, limitations and counseling considerations

10 Minutes

13 Presentation/Discussion Vasectomy: Characteristics, key benefits, limitations and counseling considerations

10 minutes

14 Presentation/Discussion Family planning considerations for the HIV-positive woman

10 minutes

15 Counseling Demonstration/Practice

Effective counseling for the woman who is transitioning from LAM to another modern method of contraception

40 minutes

16 Knowledge Assessment Knowledge assessment 25 minutes

17 Wrap-up/Evaluation Closing remarks 5 minutes



PRE-COURSE KNOWLEDGE ASSESSMENT— ANSWER SHEET

1. Short birth-to-pregnancy intervals are associated with:

a. Miscarriage b. Low birth weight c. Preterm birth d. Maternal death e. All of the above

2. For the best maternal, newborn and child health outcomes, a couple should wait at least how

long before attempting to become pregnant? a. 6 months b. 18 months c. 2 years d. 30 months e. 3 years

3. According to research findings, what percentage of women globally become pregnant during the

first year postpartum? a. 0.5–1% b. 1–2% c. 5–10% d. >10%

4. According to research findings, the mean average time for first ovulation by non-breastfeeding

mothers is: a. 30 days b. 45 days c. 3 months d. 5 months e. 6 months

5. Progestin-only injectables help protect against endometrial cancer,

uterine fibroids and iron-deficiency anemia.

True or False

6. Combined oral contraceptives (COCs) can be used by the non-breastfeeding woman as early at three weeks postpartum.

True or False



7. COCs should not be prescribed for any woman who is more than 35 years old.

True or False

8. Emergency contraception is a method of preventing pregnancy after

implantation.

True or False

9. Emergency contraception can still be effective if taken up to five days after intercourse.

True or False

10. An intrauterine contraceptive device (IUD) can be safely inserted up to

one week postpartum or after six weeks postpartum.

True or False

11. An IUD is effective immediately after insertion. True or False 12. Counseling for a client who will begin using condoms includes:

a. Discussion of limitations and precautions in use of the method b. Instruction on correct use of the method c. Discussion of skills and techniques for negotiating condom use with partner d. b) and c) e. All of the above

13. Female sterilization can be performed:

a. Within 48 hours postpartum or after 6 weeks b. Within 6 weeks postpartum c. Within 1 week postpartum or after 6 weeks d. Within 1 week postpartum or after 4 weeks e. After 6 weeks postpartum

14. Vasectomy is effective in preventing pregnancy:

a. Immediately after the procedure b. After 6 weeks following the procedure c. After 3 months following the procedure d. After 6 months following the procedure

15. Which of the following contraceptive methods can be used by an HIV-positive woman who is

on antiretroviral (ARV) drugs, does not have AIDS and does not have any method-specific contraindication? a. COCs b. IUD c. Injectable contraception d. a) and c) e. All of the above

P -

7 -

Tran

sitio

n C

TU fo

r LA

M C

ouns

elor

s A

ugus

t 200

9

TRAN

SITI

ONIN

G TO

OTH

ER M

ODER

N M

ETHO

DS O

F CO

NTRA

CEPT

ION:

THR

EE E

XERC

ISES

Ex

ercis

e On

e: In

itiat

ion

of P

ostp

artu

m C

ontra

cept

ion—

Answ

er S

heet

(bla

nk g

raph

)



Exercise Three: Case Studies for Transition—Answer Sheet 1. Jane has a four-month-old baby, is only/exclusively breastfeeding and has been using LAM to

prevent pregnancy. Her menses returned last week and she is not sure which family planning method would be best for her while she continues breastfeeding. She has been told that hormonal methods are bad for milk production.

Q. Can this woman continue to rely on LAM? Why or why not?

Q. Based on the information provided, what are some methods that may be appropriate for her at this time and/or what counsel would you provide?

2. For the last six months (since delivery), Mrs. Smith has been only/exclusively breastfeeding her

baby. She believes that breastfeeding will continue to protect her from pregnancy until her menstrual bleeding returns.



3. Celia had her baby two weeks ago and has been using LAM. She is returning to work and will no

longer be only/exclusively breastfeeding the baby.



4. Stephanie is the mother of three children; her youngest is three months old. She believes that she

has been using LAM to space her pregnancies, but she began to give the baby a daily bottle of formula when he was two months old. She has not yet had any menstrual bleeding. Stephanie plans to continue breastfeeding but seems confused about LAM. She is not sure how much longer she will be protected from pregnancy.



5. While counseling Sophie after delivery about initiating LAM, you learn that she lives far away

from the clinic. She is concerned that she may not be able to return soon enough when one of the criteria can no longer be met. What should she do?





TRANSITION COUNSELING PRACTICE SCENARIOS Participant pairs will be assigned one of the following six scenarios to use as the basis of their interaction in the counseling simulation.

Each scenario provides basic information about the client, a role that one of the participants will assume during the first counseling practice session.

The other participant, assuming the role of provider, will provide appropriate counseling to this client according to the Transition Family Planning Counseling Checklist.

In the second counseling practice session, the participants will switch roles. 1. You have a four-month-old baby, are exclusively breastfeeding and have been using LAM to

prevent pregnancy. Your menses returned last week, so you know that you need to start another family planning method immediately. However, you are not sure which methods would be the best options for you, given that you intend to continue breastfeeding. You have been told that hormonal methods are bad for your milk supply.

2. For the last six months, since your baby was born, you have been giving him only breast milk. You believe that you cannot get pregnant until your menstrual bleeding returns.

3. You are two months postpartum and have come to the family planning clinic because you do not want to become pregnant. You breastfeed your baby most of the time, but because you work outside of the home, you also give her a bottle once a day. You and your husband plan to begin having sex again this week. This is your first baby and you have never before used contraception.

4. You had your baby two months ago and have been using LAM. However, you plan to return to work next week and will no longer be able to only/exclusively breastfeed your baby.

5. You are a mother with three children, including a three-month-old baby. You have been using LAM since the birth, but a week ago you began giving your baby one bottle of formula each day. You have not had any menstrual bleeding since the birth of your baby.

6. Your baby is five months old. You have been using LAM, but now you want to stop breastfeeding.



“TRANSITION” FAMILY PLANNING COUNSELING CHECKLIST14 Place a “√” in case box if step/task is performed satisfactorily, an “” if it is not performed satisfactorily, or N/O if not observed.

Satisfactory: Performs the step or task according to the standard procedure or guidelines

Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines

Not Observed: Step or task not performed by participant during evaluation by facilitator

“TRANSITION” FAMILY PLANNING COUNSELING CHECKLIST (Note: Some of the following steps/tasks should be performed simultaneously.)

STEP/TASK CASES

PREPARATION FOR COUNSELING

1. Ensures room is well lit and there is availability of chairs and table.

2. Prepares equipment and supplies.

3. Ensures availability of writing materials (e.g., client file, daily activity register, follow-up cards).

4. Ensures privacy.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

GENERAL COUNSELING

5. Greets the woman with respect and kindness; introduces self.

6. Confirms woman’s name, address and other required information.

7. Offers the woman a place to sit; ensures her comfort.

8. Reassures the woman that the information in the counseling session is confidential.

9. Tells the woman how the visit will proceed and encourages questions; responds to the woman’s questions/concerns.

10. Uses body language to show interest in and concern for the woman.

14 About this tool: This tool can be used—during the course (as in the counseling demonstration and practice session) and after the course—by the learner for self-assessment, by colleagues for peer assessment and/or by the trainer or supervisor for comprehensive skills assessment. A print-ready PDF version of this document is included in the Resources folder of the CD-ROM.



“TRANSITION” FAMILY PLANNING COUNSELING CHECKLIST

(Note: Some of the following steps/tasks should be performed simultaneously.)

STEP/TASK CASES

11. Asks questions appropriately and with respect; elicits more than “yes” and “no” answers.

12. Uses (non-technical) language that the woman can understand.

13. Appropriately uses available visual aids, such as posters, flipcharts, drawings, samples of methods and anatomic models.


GENERAL FAMILY PLANNING COUNSELING (for the postpartum woman)

14. Asks the woman if she is still using LAM, ensuring that each criteria (no menstrual bleeding, breastfeeding only/exclusively, baby less than 6 months old) has been met up until this time.

• If discontinued LAM already and has not been using another method of contraception, ascertains that she is not pregnant.

15. Asks the woman what she knows about family planning and if she has ever used a contraceptive method, other than LAM, before. If yes:

• What methods did she use? • Did she have any problems with that method or does she have

any questions or concerns about that method?

16. Asks the woman about her reproductive goals.

17. Asks the woman whether she plans to continue breastfeeding

18. Discuss with the woman the benefits of healthy timing and spacing of pregnancy.

19. Asks the woman if she has any history of medical problems (STIs/HIV/AIDS, irregular vaginal bleeding, unusual vaginal discharge, pelvic pain, breast or genital cancer, TB, seizures, liver disease, clotting disorder, etc.)

20. Assesses the woman’s risk for STIs and HIV/AIDS, as appropriate.

21. Briefly provides general information about each contraceptive method available:

• How it prevents pregnancy • How it is administered • Effectiveness • Advantages and disadvantages • Side effects • Whether it offers protection against STIs including HIV/AIDS

22. Corrects any misinformation the woman may have about family planning methods.





STEP/TASK CASES

23. Asks which method interests the woman; helps the woman chose a method.


METHOD-SPECIFIC COUNSELING (once the woman has chosen a method)

24. Performs a physical assessment that is appropriate for the method chosen (e.g., blood pressure for hormonal methods, pelvic examination for IUD, etc.).

• If indicated, refers the woman for further evaluation.

25. Ensures there are no conditions that contraindicate the use of the chosen method.15

• If necessary, helps the woman to find a more suitable method.

26. Provides basic information about the family planning method she has chosen:

• Brief description of method • How to use it correctly, if applicable, and what to do if problems

arise in use (e.g., what to do if she is late taking an oral contraceptive)

• How it works • Effectiveness • Advantages and non-contraceptive benefits • Disadvantages and limitations • Common side effects and what to do about them • Danger signs and where to go (immediately) if any arise

27. Provides the method of choice if available or refers woman to the nearest health facility where it is available.

28. Asks the woman to repeat the instructions about her chosen method of contraception:

• How to use it • Side effects • Danger signs • When to return to the clinic

29. Educates the woman about prevention of STIs and HIV/AIDS; provides her with condoms if she is at risk.

30. Educates the woman about the benefits of continued breastfeeding, even after introducing foods and/or discontinuing LAM.

15 For specific guidance, see World Health Organization/Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (JHU/CCP), INFO Project. 2007. Family Planning: A Global Handbook for Providers. CCP and WHO: Baltimore and Geneva.





STEP/TASK CASES

31. Asks the woman if she has any questions or concerns; listens attentively and addresses her questions and concerns.

32. Schedules the follow-up visit; encourages the woman to return to the clinic at any time if she has any problems, questions or concerns.

33. Records the relevant information in the woman’s chart.

34. Thanks the woman politely, says goodbye and—again—encourages her to return to the clinic for any reason.


FOLLOW-UP COUNSELING

1. Greets the woman with respect and kindness; introduces self.

2. Confirms the woman’s name, address and other required information.

3. Asks the woman the purpose of her visit.

4. Reviews her record/chart.

5. Checks whether the woman is satisfied with her family planning method and is still using it; asks if she has any questions, concerns or problems with the method.

6. Explores changes in the woman’s health status or lifestyle that may indicate the need for a different family planning method.

7. Reassures the woman about side effects she may be having; offers treatment if necessary.

8. Asks the woman if she has any questions; listens to her attentively and responds to her questions or concerns.

9. Performs any physical assessment if indicated.

• If indicated, refers the woman for further evaluation.

10. Provides the woman with a resupply of her contraceptive method (e.g., the pill, DMPA, condoms, etc.), if applicable and as needed.

11. Schedules the follow-up visit; encourages the woman to return to the clinic at any time.

12. Records the relevant information in the woman’s chart.

13. Thanks the woman politely, says goodbye and—again—encourages her to return to the clinic for any reason.



COURSE EVALUATION16

TRANSITION CONTRACEPTIVE TECHNOLOGY UPDATE (CTU) FOR LAM COUNSELORS

(To be completed by participants) 5—Strongly Agree 4—Agree 3—No Opinion 2—Disagree 1—Strongly disagree

COURSE COMPONENT RATING

1 The teaching methods were effective in helping me to learn.

2 The teaching materials were effective in helping me to learn.

3 I am now able to discuss transition and why it is important.

4 I am now able to explain the appropriate timing for “transition” to other modern methods of contraception.

5 I am now able to counsel on the use of progestin-only pills.

6 I am now able to counsel on the use of progestin-only injectables.

7 I am now able to counsel on the use of combined oral contraceptives.

8 I am now able to counsel on the use of emergency contraception.

9 I am now able to counsel on the use of the IUD

10 I am now able to counsel on the use condoms.

11 I am now able to counsel on female sterilization.

12 I am now able to counsel on vasectomy (male sterilization).

13 I am now able to discuss family planning considerations for the HIV-positive woman.

Circle one: The course was: Too Long Too Short Correct Length We needed more time for: We spent too much time on: What topics (if any) should be added (and why) to improve the course? What topics (if any) should be deleted (and why) to improve the course? The best aspect of the course was: The least helpful aspect of the course was:

16 A print-ready PDF version of this document is included in the Resources folder of the CD-ROM.

Documents

Transition Contraceptive Technology Update (CTU) for LAM ...resources.jhpiego.org/system/files/resources/ctu_participant_0.pdf · Transition Contraceptive Technology Update (CTU)