Describe the spacing methods of contraception.

Barrier and Hormonal Methods

• Barrier methods:
• The condom (Nirodh) — the only method that also protects against sexually transmitted infection and HIV, which is its decisive advantage and the reason for dual protection, meaning a condom used alongside another method
• It is cheap, safe, has no systemic effects, requires no medical supervision, and involves the male partner; but is use-dependent, so its typical-use failure is considerably higher than its perfect-use failure, and it requires consistent motivation at every act
• The female condom, diaphragm and cervical cap are female-controlled but little used in India; spermicides alone are unreliable
• Intrauterine devices:
• The copper T 380A is effective for 10 years and the Cu 375 for 5 years; LNG-IUS releases levonorgestrel and additionally reduces menstrual bleeding
• Its mechanism — copper is spermicidal and impairs sperm motility and viability, with a foreign-body inflammatory reaction in the endometrium; it acts chiefly by preventing fertilisation rather than by preventing implantation, which is worth knowing since the belief that it is abortifacient is a common reason for refusal
• Its advantages — highly effective; long-acting and reversible; requires a single act of motivation rather than daily compliance; cost-effective; no systemic hormonal effect with copper; and immediately reversible on removal
• Its disadvantages — increased menstrual bleeding and cramping, which is the commonest reason for removal and matters greatly in an anaemic population; expulsion, particularly in the first year; perforation, which is rare and related to insertion technique; increased risk of pelvic infection in the first 20 days after insertion only; and if pregnancy occurs, a higher proportion is ectopic
• That last point requires care — the IUCD reduces the absolute risk of ectopic pregnancy compared with using no method, because it prevents pregnancy overall; it is only the proportion of the few pregnancies that occur which is higher
• Contraindications — known or suspected pregnancy; active pelvic infection; undiagnosed abnormal uterine bleeding; distorted uterine cavity; and genital malignancy
• Postpartum IUCD insertion may be done within 48 hours of delivery or after 6 weeks, and is promoted in India because it uses the institutional delivery contact
• Hormonal methods:
• Combined oral contraceptives (Mala-N, Mala-D) — containing oestrogen and progestogen, acting chiefly by suppressing ovulation, with thickened cervical mucus and endometrial change
• Their non-contraceptive benefits should be mentioned, since they are substantial and frequently forgotten — regular, lighter and less painful periods; reduced iron deficiency anaemia; and reduced risk of ovarian and endometrial cancer, ovarian cysts, benign breast disease and pelvic inflammatory disease
• Their risks — venous thromboembolism, the most important; raised blood pressure; a small increase in stroke and myocardial infarction, particularly in smokers over 35; and nausea, breast tenderness and breakthrough bleeding
• The absolute contraindications — smoking over the age of 35; history of thromboembolism; ischaemic heart disease or stroke; migraine with aura; uncontrolled hypertension; active liver disease; breast cancer; and breastfeeding in the early postpartum period

Progestogen-only Methods, Natural Methods and Counselling

• Progestogen-only pills — acting chiefly by thickening cervical mucus; their key advantage is that they are safe in breastfeeding and in women in whom oestrogen is contraindicated; but they require strict daily timing
• Injectable contraceptives — DMPA (Antara programme) given 3-monthly
• Their advantages — highly effective, long-acting, private (requiring no visible supplies at home), safe in breastfeeding, and independent of intercourse
• The privacy point matters in the Indian context, since it allows a woman to use contraception without her family knowing
• Their disadvantages — menstrual irregularity progressing to amenorrhoea, which is the commonest reason for discontinuation and must be explained in advance; delayed return of fertility, of several months, which makes them unsuitable for a couple wanting to conceive soon; weight gain; and reversible loss of bone density
• Counselling that amenorrhoea is expected and harmless is what determines whether a woman continues, and its omission is the commonest programme failure with this method
• Implants — subdermal, effective for 3 to 5 years; centchroman (Ormeloxifene, Chhaya) — a non-hormonal, non-steroidal weekly pill developed in India, taken twice weekly for 3 months then weekly, which is safe in breastfeeding
• Natural and traditional methods:
• The calendar (rhythm) method, based on the fertile period; basal body temperature; cervical mucus (Billings) method; symptothermal method; and standard days with CycleBeads
• They have NO side effects and are acceptable where other methods are refused on religious grounds, but have high typical-use failure, require regular cycles, need considerable motivation and cooperation from both partners, and demand prolonged abstinence
• Withdrawal (coitus interruptus) — widely practised and better than nothing, but with high failure
• The lactational amenorrhoea method is effective only while all three conditions hold — infant under 6 months, breastfeeding fully or nearly exclusively day and night, and menses not returned
• The principles of contraceptive counselling, which is what an examiner most wants to see:
• There is NO single "best" method — the best method is the one the couple will use correctly and consistently
• Offer an informed choice from the full range, describing effectiveness, how it is used, side effects, non-contraceptive benefits, return of fertility and protection against infection
• Consider the couple’s age, parity, whether they want to space or to stop, breastfeeding status, medical conditions and their own preference
• Warn about the expected side effects IN advance, since an unexpected side effect causes discontinuation while an expected one usually does not — which is the single most useful practical rule in contraceptive counselling
• Explain what to do if a dose is missed, and provide follow-UP
• Distinguish perfect-use from typical-use failure honestly, since the gap between them is what actually determines outcomes in a programme, and it is widest for the methods requiring the most user action
• That reasoning is the argument for long-acting reversible contraception — the IUCD, implant and injectable have typical-use failure close to their perfect-use failure, because they do not depend on daily behaviour
• The best method is the one they will use, which is why counselling matters more than any ranking of effectiveness
• Warn about side effects in advance, since an expected one is tolerated and an unexpected one ends the method
• Typical use diverges most from perfect use in the methods needing daily action, which is the argument for long-acting methods
• Condoms are the only method preventing infection, which is the basis of dual protection alongside another method
• The IUCD prevents fertilisation, not implantation, which matters because the abortifacient belief causes refusal
• Heavier bleeding is why IUCDs are removed, and matters greatly in an already anaemic population
• Infection risk is confined to the first twenty days after insertion, not to the whole period of use
• The IUCD reduces absolute ectopic risk; only the proportion of the few pregnancies occurring is higher
• Combined pills reduce ovarian and endometrial cancer, alongside lighter periods and less anaemia
• Smoking over thirty-five contraindicates combined pills, which is the contraindication most often overlooked in practice
• Migraine with aura rules out combined pills, though migraine without aura generally does not
• Progestogen-only methods are safe in breastfeeding, unlike combined pills in the early postpartum period
• Injectables are private, needing nothing kept at home, which allows use without the family knowing
• Amenorrhoea on injectables is expected and harmless, and explaining that in advance determines whether she continues
• Injectables delay return of fertility by months, so they suit a couple who do not want to conceive soon
• Centchroman is non-hormonal and weekly, developed in India and safe during breastfeeding
• Postpartum IUCD uses the delivery contact, inserted within forty-eight hours or deferred to six weeks
• Natural methods demand cooperation from both, and prolonged abstinence, which is why typical-use failure is high
• Spacing is where the unmet need lies, since the programme has historically served those wanting to stop
• Explain what to do about a missed pill, which is a routine part of counselling and routinely omitted
• The copper T 380A lasts ten years, which makes it among the most cost-effective methods available
• LNG-IUS reduces bleeding rather than increasing it, which makes it suitable where menorrhagia is the concern