Getting your family planning method right key to wellbeing

Jael Atieno Lieta, 28, first heard of family planning from a friend who advised her to go for it immediately after she had her first child, now aged 12.

“I went to a doctor who was offering the services for free in Kisumu and, without any knowledge or counselling, got an implant, which was supposed to last for five years,” she recalls.

“I decided on the implant because I wanted something that would last, but the side-effects were so bad that after two years, I had it removed. I lost too much weight,” she says.

After that, she used the natural method but after four years, she had another child. “I did not want another child soon after my second born, so once again I went for an artificial method. But after my experience with the implant, I wanted a different method,” she says.

She had an intrauterine contraceptive device (IUCD) commonly known as the coil, inserted, but it turned out to be worse than the implant.

“It started with cramp-like pains in my tummy, then got worse. I head frequent headaches, dizzy spells and was always tired. I took anti-malaria tablets but they did not help,” she says. “They would come like normal pre-menstrual cramps but my periods just did not come. I kept spotting for a whole month.”

Worried, she went to see a gynaecologist to find out what the problem was. After taking her history, he decided to find out whether the coil was in position. It wasn’t, and a search for the device yielded nothing.

LOOKING FOR THE COIL

“I was referred to a facility that deals with the family planning services where, for two days, my insides were prodded by the doctors as they tried to find the coil,” she says.

The first doctor at the clinic tried to locate it but failed, so she called a more experienced colleague, who also searched for it, again in vain.

“They told me to go for an x-ray, which I did, and went back early the next morning. The x-ray showed that the coil, had indeed, moved,” she says.

She was, thereafter, referred to a gynaecologist, who said the coil might have been improperly inserted, or that the person who had inserted it had not checked the size of her uterus before inserting the device.

“I felt terrible for those two days as they tried to locate the coil,” she says of the invasive procedure.

“They said they didn’t want to rupture my uterus.”

“It’s risky,” she heard one of the doctors say. “We do not know when the coil disappeared so they should have done a pregnancy test first. An X-ray was not the best option.”

Then followed a pelvic scan, which showed that she was not pregnant.

“The bladder keeps coming and going…ooh there it is, back and full…now let’s find this thing,” the doctor said and whistled as he kept moving the mouse-like thing on my tummy,” Ms Lieta recalls one doctor saying. “There it is! I have found it and the position is not good.”

He quickly printed the report from the ultra sound with a worried look and sent them to the gynecologist.

“We have found the coil, and because it is off position, we have to do a minor surgery to remove it,” he informed her. After her experience, Ms Lieta swears, “Never again will I use any family planning method. I have suffered a lot and none of them has worked for me.”

She says she came across a number of other women who had also developed complications arising from family planning methods.

LONG-TERM METHOD

Elizabeth Wanjiku, is one such person. A first-time user, she had only heard about family planning from her friends. “I was getting into a serious relationship but did not want to have a baby soon so I wanted a long-term method. I went for the coil, and that was the first and the last time I will ever use an family planning method.”

“After one year of using the coil, I got pregnant. I was shocked because according to medics, the probability of one getting pregnant when using a contraceptive is very slim.

The problem then became how to remove the coil while Wanjiku was pregnant. Wanjiku had come to terms her situation and was anxiously waiting for the arrival of her baby.

However, she says, “The doctors convinced me that the coil would interfere with my baby if it was not removed. I accepted that they terminate the pregnancy, but Fighting back her tears, Wanjiku says a friend of hers who was on the pill also got pregnant but unwittingly continued taking the pill; she ended up losing her baby.

“I have not tried another method, but it will take a great dealing of convincing to make me do so,” she says.

Lieta and Wanjiku are among the victims of well meaning family planning programmes, which however, is seriously affected by a shortage of staff, leading to shoddy services.

Dr Aggrey Otieno Akula, an obstetrician gynaecologist, acknowledges that in government hospitals, there are too few medics handling too many people seeking family planning services, which makes it difficult to discuss the methods available in detail with every patient, so cases like Lieta’s and Wanjiku’s can occur.

“It is the system at the public hospital that is poor because one medic is expected to attend to a large number of clients,” he says. The medics who insert the coils and implants and give injections are expected to discuss the methods in detail with every patient and at the same time attend to other patients, which leaves them minimal time for every patient.

Dr Akula says that the coil’s failure in different women might be attributable to failure by the service provider to assess a woman’s uterus properly.

“Women’s uteri differ, so it is necessary to assess a woman’s uterus properly before inserting the coil to avoid any complication, although it is very expensive,” he says, adding that cases in which the coil gets displaced are few.

Dr Akula says the service providers should not choose a method for a client but should give them information on the methods available, as well as the pros and cons of each, and then counsel them so that they can make informed choices.

He says service providers should adhere to the National Family Planning Guidelines before offering any service.

“Counseling is a vital part of reproductive health care, and it should be part of every interaction with the client. The role of the FP counselling is to support the woman in choosing the method and helping her solve any problem that might arise in the process of using her chosen method,” he adds.

He says that according to the National Family Planning Guidelines, effective counselling is important and any service provider offering the services without training and not following the guideline is contravening the law.

He confirmed that only doctors, clinical officers and nurses who have attended special training are competent to handle clients. They are given special training and certified. If something goes wrong, there are acceptable limits. If the guidelines and standards are not followed and the method fails, that calls for discipline.

“If the standards are followed and a method fails, then there is a need for a review, that’s why we have the medical practitioners’ board, the clinical officers’ council and the nurses’ council,” he explains.

“The questions that would be asked if the method fails are: Who fixed it? Is it someone qualified? Has s/he performed the procedure on others? How many have been unsuccessful? These would then be treated as per the guidelines.

“I don’t expect a community health worker or pharmacist to insert a coil or give an injection, unless they have undergone training and are certified to give the services,” he says.

The doctor acknowledges that a method can fail even when administered by a qualified doctor, but added that such cases were few.

Dr Akula advises women to go for a thorough medical check-up and ensure they are in good health before using a family planning method.

“Some can have cancer of the stomach, ovarian tumors or uterine fibroids which they blame on the method when a problem occurs, yet the problem is not with method or the service provider,” he explains.

Dr Akula added that all family planning providers should assess the risk of reproductive organ cancer in all clients seeking FP services and should be familiar with, and competently apply, appropriate techniques concerning reproductive health cancer screening.

THOROUGH ASSESSMENT

“These are some of the diseases that the service providers should be conversant with because you can provide the service when the client has cancer, which will later be blamed on you so it’s necessary to do thorough assessment,” he notes.

Still, most clients will go to public hospitals, which are affordable although they might not be the best equipped.

“In private hospitals, the methods are given at a fee while in public hospitals the prices are standard and at some point, they are offered for free by non-governmental organisations,” Dr Akula notes.

A Spot check by the DN2 to find out if the service providers follow the National Family Planning Guidelines and standards was an eye opener.

At the first facility, when we requested to see the medic in charge of the family planning services, the nurse simple asked, “Which method do you want?”

Notably, the guidelines say client assessment is very important because it enables the provider to identify whether the client has any conditions that require additional evaluation, or that make the her ineligible to use a particular method to avoid complications in future. Besides, the information provided through counselling would enable her to choose a method that best meets her needs and help her choose the method safely and effectively.

At the second facility, a the knock at the door with a request for family planning services, was answered by a voice from inside asking which method we wanted. When we said we did not know anything about the methods, the person

answered that she was very busy and would only attend to those who knew the method they wanted. “I cannot take you through all the methods. As you can see, the queue is long. You can come back later when you are sure of the method you want, or when the queue is shorter,” she dismissed us.

With such a casual attitude towards family planning, it is not surprising that some women make the wrong choice, leading to complications.