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Post Abortion Family Planning Technical Update March 2016 Developed with support from National Technical Support Unit (NTSU), Family Planning Division, Ministry of Health & Family Welfare, Government of India Family Planning Division Ministry of Health and Family Welfare Government of India Post Abortion Family Planning Technical Update March 2016 Family Planning Division Ministry of Health and Family Welfare Government of India Prologue Women’s control over their own child birth forms the foundation of reproductive rights and is the mainstay of the family planning program in India.
However, the challenge of vicious cycle of repeated unintended pregnancies and unwanted births or abortions remains largely unattended.

This contributes to increased morbidity and mortality among mothers and newborns.

Studies reveal that 90% of the maternal mortality related to unsafe abortions could be averted by use of contraceptives in the post abortion period.
Also the unmet need for family planning in the post abortion period is very high which if bridged, can save many mothers from morbidity and mortality related to abortions and ease off burden from the health system.

Keeping this in consideration, this technical update has been developed with a view to streamline the efforts in providing family planning service in post abortion period at the field level.
It also details all the family planning methods available for women in the post abortion period and would therefore act as a technical tool for the service providers for providing quality post abortion family planning services.
First Edition March 2016 Ministry of Health & Family Welfare Government of India, Nirman Bhawan, New Delhi -110101 Any part of this document may be reproduced and excerpts from it may be quoted without permission provided the material is distributed free of cost and the source is acknowledged.

Prologue Women’s control over their own child birth forms the foundation of reproductive rights and is the mainstay of the family planning program in India.
However, the challenge of vicious cycle of repeated unintended pregnancies and unwanted births or abortions remains largely unattended.

This contributes to increased morbidity and mortality among mothers and newborns.

Studies reveal that 90% of the maternal mortality related to unsafe abortions could be averted by use of contraceptives in the post abortion period.
Also the unmet need for family planning in the post abortion period is very high which if bridged, can save many mothers from morbidity and mortality related to abortions and ease off burden from the health system.

Keeping this in consideration, this technical update has been developed with a view to streamline the efforts in providing family planning service in post abortion period at the field level.
It also details all the family planning methods available for women in the post abortion period and would therefore act as a technical tool for the service providers for providing quality post abortion family planning services.
First Edition March 2016 Ministry of Health & Family Welfare Government of India, Nirman Bhawan, New Delhi -110101 Any part of this document may be reproduced and excerpts from it may be quoted without permission provided the material is distributed free of cost and the source is acknowledged.

Contents 1.

Background 2.

Rationale 3.

Counseling for Post Abortion Contraception 4.

Eligibility for Post Abortion Family Planning Methods 5.

Return to Fertility after Abortion 6.


Time of Initiation of Contraceptive Methods after Abortion 7.

Post - Abortion IUCD 7.1 Eligibility Criteria 7.2 Clinical Assessment and Screening of Client 7.3 Technique of Post Abortion IUCD Insertion 7.4 Advise for Follow - up Visit 8.

Post-Abortion Female Sterilization 8.1 Eligibility Criteria 8.2 Steps for Post Abortion Female Sterilization 9.
Other Methods of Contraception Overview of Post Abortion Family Planning Methods References List of Contributors 7 7 7 8 9 9 11 11 11 11 12 13 13 13 16 17 20 21 100 Contents 1.

Background 2.

Rationale 3.

Counseling for Post Abortion Contraception 4.

Eligibility for Post Abortion Family Planning Methods 5.

Return to Fertility after Abortion 6.

Time of Initiation of Contraceptive Methods after Abortion 7.
Post - Abortion IUCD 7.1 Eligibility Criteria 7.2 Clinical Assessment and Screening of Client 7.3 Technique of Post Abortion IUCD Insertion 7.4 Advise for Follow - up Visit 8.

Post-Abortion Female Sterilization 8.1 Eligibility Criteria 8.2 Steps for Post Abortion Female Sterilization 9.

Other Methods of Contraception Overview of Post Abortion Family Planning Methods References List of Contributors 7 7 7 8 9 9 11 11 11 11 12 13 13 13 16 17 20 21 100 1.
Background Post abortion family planning is the initiation and use of family planning methods at the time of management of an abortion or before fertility returns after the abortion.

The World Health Organization estimates that globally, around 210 million women become pregnant each year, of which 75 million pregnancies end in either induced or spontaneous abortions or still births.

Majority of these women do not want to become pregnant again in the near future.
WHO also recommends spacing of at least 6 months between abortion and next pregnancy.

Therefore, providing family planning services as a part of post- abortion care can improve contraceptive acceptance and help break the cycle of repeated unwanted pregnancies.

2.

Rationale Post abortion family planning can avert unintended pregnancies and abortion associated problems.
Abortions account for approximately 8% of maternal mortality in India and family planning could prevent 90% of maternal mortality associated with unsafe abortions.
Since women receiving abortion services at a facility usually do not return for family planning services even though they do not want to become pregnant again in the near future, immediate post abortion period when the woman is still at the facility or in contact with the health care provider is the opportune time to provide family planning counseling and services.

3.
3.

Counseling for Post Abortion Contraception Counseling is a critical component in providing quality post-abortion family planning services and involves communication between a service provider/ counselor and a client.

It helps the client to understand the essential concepts of family planning, to have options for contraceptive methods and to choose a method based on her needs and preference.
• Timing of Counseling: w Before the abortion procedure, it should be checked that the woman’s physical condition and emotional situation is appropriate for counseling on contraception.

Provider/counselor should respect her right to accept or refuse post abortion contraception and services are provided accordingly.

Counseling before the abortion procedure offers the woman options of adopting various contraceptive methods.
Thus she would have a chance for immediate IUCD insertion procedure or sterilization procedure while she is still on the table after the completion of abortion.

w After the abortion procedure once the woman settles down, counseling on available contraceptive methods may also be provided.
• Assess Individual Situation: The service provider/counselor should consider both, the woman’s clinical condition and personal situation and discuss any potential barriers to the successful adoption of contraception in a sensitive manner.

• Information on Methods : The service provider/counselor should explain the characteristics, use (how it works), side effects and effectiveness of the available methods.
• Method Specific Counseling: The service provider/counselor should aid/support the woman in selecting the contraceptive method which best suits her.

POST ABORTION FAMILY PLANNING - Technical Update 7 1.

Background Post abortion family planning is the initiation and use of family planning methods at the time of management of an abortion or before fertility returns after the abortion.
The World Health Organization estimates that globally, around 210 million women become pregnant each year, of which 75 million pregnancies end in either induced or spontaneous abortions or still births.

Majority of these women do not want to become pregnant again in the near future.

WHO also recommends spacing of at least 6 months between abortion and next pregnancy.
Therefore, providing family planning services as a part of post- abortion care can improve contraceptive acceptance and help break the cycle of repeated unwanted pregnancies.

2.

Rationale Post abortion family planning can avert unintended pregnancies and abortion associated problems.

Abortions account for approximately 8% of maternal mortality in India and family planning could prevent 90% of maternal mortality associated with unsafe abortions.
Since women receiving abortion services at a facility usually do not return for family planning services even though they do not want to become pregnant again in the near future, immediate post abortion period when the woman is still at the facility or in contact with the health care provider is the opportune time to provide family planning counseling and services.

3.
3.

Counseling for Post Abortion Contraception Counseling is a critical component in providing quality post-abortion family planning services and involves communication between a service provider/ counselor and a client.

It helps the client to understand the essential concepts of family planning, to have options for contraceptive methods and to choose a method based on her needs and preference.
• Timing of Counseling: w Before the abortion procedure, it should be checked that the woman’s physical condition and emotional situation is appropriate for counseling on contraception.

Provider/counselor should respect her right to accept or refuse post abortion contraception and services are provided accordingly.

Counseling before the abortion procedure offers the woman options of adopting various contraceptive methods.
Thus she would have a chance for immediate IUCD insertion procedure or sterilization procedure while she is still on the table after the completion of abortion.

w After the abortion procedure once the woman settles down, counseling on available contraceptive methods may also be provided.
• Assess Individual Situation: The service provider/counselor should consider both, the woman’s clinical condition and personal situation and discuss any potential barriers to the successful adoption of contraception in a sensitive manner.

: • Information on Methods The service provider/counselor should explain the characteristics, use (how it works), side effects and effectiveness of the available methods.
• Method Specific Counseling: The service provider/counselor should aid/support the woman in selecting the contraceptive method which best suits her.

POST ABORTION FAMILY PLANNING - Technical Update 7 Counsel the woman for informed choice before she leaves the health facility 5.
Return to Fertility after Abortion If she chooses an FP method Help her to initiate an FP method of her choice If she is not able to decide on any FP method/ not eligible for a method Schedule a follow up within 2 weeks Or Give her a referral appointment at a nearby family planning facility.

Additionally, take her contact no.


and send a reminder message within 2 weeks Post Abortion Family Planning Counseling Messages • She should wait at least 6 months before trying to conceive again as it reduces the chances of low birth weight, premature birth and maternal anemia.

• Fertility returns quickly - within 10 to 11 days after first trimester abortion or miscarriage and within 4 weeks after a second trimester abortion or miscarriage.
• She can choose from available family planning methods that can be started at once.

• If a woman decides not to use contraceptives at this time, providers can offer information on all available methods and from where to obtain them.

Also, providers can offer condoms, oral contraceptives or emergency contraceptive pills for women to take home and use later.
• To avoid infection, she should not have intercourse until bleeding stops - If being treated for infection or vaginal/ cervical injury; she should wait until she is fully healed.

• Method specific counseling should follow if she chooses any family planning method.

4.

Eligibility for Post Abortion Family Planning Methods For providing a family planning method to a woman after abortion, it is important to ensure: • There are no current severe complications of abortion requiring further treatment.
• The woman is offered choice on contraceptive options available, receives adequate pre-abortion counseling and gives informed consent.

• The provider screens the eligibility of woman for the particular family planning method that the woman has opted for.
Method of management Review of return to fertility for abortion First-trimester After vacuum aspiration Woman may ovulate within 10 days of an abortion (Boyd et al., 1972) and can become pregnant if she resumes sexual intercourse without using any After medical abortion with On an average, a woman will ovulate within 20 mifepristone and misoprostol days of a medical abortion with mifepristone and misoprostol, but can ovulate as early as in 8 days (Schreiber, Sober, Ratcliffe & Creinin, 2011) After medical abortion with Within 4 weeks after a second-trimester mifepristone and misoprostol abortion or miscarriage Time of Abortion abortion Second- trimester abortion 6.
Time of Initiation of Contraceptive Methods after Abortion After First-trimester Abortion Family Planning Method Time of Initiation after Abortion Combined oral contraceptive pills Can be started immediately After medical Combined oral contraceptive pills Can be started on 3 day or 15th day of medical rd Spontaneous abortion or vacuum aspiration (for incomplete / induced) Progestin only pills Centchroman Pills Injection DMPA Condoms IUCD Female sterilization abortion with mifepristone and misoprostol Progestin only Pills Centchroman Pills Injection DMPA Condoms IUCD Can be started immediately Can be started immediately Can be started immediately Can be started immediately by the male partner Can be inserted immediately, when infection and injury to the genital tract are ruled out or resolved Can be performed concurrently or within 7 days post abortion provided woman is eligible by the minilap as well as laparoscopic methods.
abortion protocol, as long as there are no medical contraindications.

Can be started immediately on the 3rd day.

Can be started on the 3 day of medical rd abortion protocol.

Can be used by the male partner as soon as sexual activity is resumed.

Can be inserted once the abortion is complete (around Day 15 ) and the presence of infection is th ruled out.
8 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 9 Counsel the woman for informed choice before she leaves the health facility If she is not able to decide on any FP method/ not eligible for a method If she chooses an FP method Help her to initiate an FP method of her choice Post Abortion Family Planning Counseling Messages • She should wait at least 6 months before trying to conceive again as it reduces the chances of low birth weight, premature birth and maternal anemia.
• Fertility returns quickly - within 10 to 11 days after first trimester abortion or miscarriage and within 4 weeks after a second trimester abortion or miscarriage.

• She can choose from available family planning methods that can be started at once.

• If a woman decides not to use contraceptives at this time, providers can offer information on all available methods and from where to obtain them.
Also, providers can offer condoms, oral contraceptives or emergency contraceptive pills for women to take home and use later.

• To avoid infection, she should not have intercourse until bleeding stops - If being treated for infection or vaginal/ cervical injury; she should wait until she is fully healed.

• Method specific counseling should follow if she chooses any family planning method.

4.
4.

Eligibility for Post Abortion Family Planning Methods For providing a family planning method to a woman after abortion, it is important to ensure: • There are no current severe complications of abortion requiring further treatment.

• The woman is offered choice on contraceptive options available, receives adequate pre-abortion • The provider screens the eligibility of woman for the particular family planning method that the counseling and gives informed consent.

woman has opted for.

5.


Return to Fertility after Abortion Time of Abortion First-trimester abortion Method of management for abortion After vacuum aspiration Review of return to fertility Woman may ovulate within 10 days of an abortion (Boyd et al., 1972) and can become pregnant if she resumes sexual intercourse without using any Schedule a follow up within 2 weeks Or Give her a referral appointment at a nearby family planning facility.

Additionally, take her contact no.


and send a reminder message within 2 weeks Second- trimester abortion After medical abortion with mifepristone and misoprostol On an average, a woman will ovulate within 20 days of a medical abortion with mifepristone and misoprostol, but can ovulate as early as in 8 days (Schreiber, Sober, Ratcliffe & Creinin, 2011) After medical abortion with mifepristone and misoprostol Within 4 weeks after a second-trimester abortion or miscarriage 6.
Time of Initiation of Contraceptive Methods after Abortion Spontaneous abortion or vacuum aspiration (for incomplete / induced) After medical abortion with mifepristone and misoprostol After First-trimester Abortion Family Planning Method Time of Initiation after Abortion Combined oral contraceptive pills Can be started immediately Progestin only pills Centchroman Pills Injection DMPA Condoms IUCD Female sterilization Combined oral contraceptive pills Progestin only Pills Centchroman Pills Injection DMPA Condoms IUCD Can be started immediately Can be started immediately Can be started immediately Can be started immediately by the male partner Can be inserted immediately, when infection and injury to the genital tract are ruled out or resolved Can be performed concurrently or within 7 days post abortion provided woman is eligible by the minilap as well as laparoscopic methods.
rd Can be started on 3 day or 15th day of medical abortion protocol, as long as there are no medical contraindications.

Can be started immediately on the 3rd day.

Can be started on the 3 day of medical abortion protocol.

Can be used sexual activity is resumed.

by the male partner as soon as rd Can be inserted once the abortion is complete (around Day 15 ) and the presence of infection is ruled out.
th 8 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 9 Family Planning Method Time of Initiation after Abortion 7.

Post-Abortion IUCD Spontaneous abortion or dilatation and evacuation (Note: on Day 15, the provider should take relevant history and carry out pelvic examination to ensure completion of abortion.
If pelvic examination does not confirm the expulsion of POC or completion of abortion process or bleeding continues, the provider should assess clinical condition of the client and manage accordingly.

USG is also an option available to check for retained POCs/ completion of abortion process).

Female sterilization Can be performed after the first menstrual cycle.
After Second-trimester Abortion Family Planning Method Time of Initiation after Abortion Combined oral contraceptive pills Can be started immediately Progestin only pills Centchroman Pills Injection DMPA Condoms IUCD Female sterilization Can be started immediately Can be started immediately Can be started immediately Can be started immediately by the male partner Can be inserted immediately, when infection and injury to the genital tract are ruled out by a specially trained provider as per postpartum IUCD insertion technique.
Can be performed concurrently or within 7 days post abortion (uncomplicated abortion), if she has made a voluntary, informed choice in advance.

In this case the woman is eligible for sterilization by minilap method only.

(Laparoscopic tubal occlusion is contraindicated as there are chances of injury to the fallopian tubes/uterus since the tubes are oedematous.

There is also the possibility of slipping of the rings from the tubes leading to failures).
*The National Family Planning programme offers male sterilization services also which can be availed of by the male partner anytime.

The provider should ensure that the woman has received counseling and made an informed choice prior to IUCD insertion in the post abortion period.

Cu IUCD 380 A/Cu IUCD 375, providing contraception for 10 years/5 years respectively, can be inserted as per the preference of the client.
7.1 Eligibility Criteria Condition Immediately following first trimester abortion (spontaneous/ induced) (Provided there is no evidence or potential for infection) Immediately following second trimester abortion (Spontaneous/ Induced) (Provided there is no evidence or potential for infection, bleeding and other contraindications) 7.2 Clinical Assessment and Screening of Client Assessment for immediate post-abortion IUCD is done in two phases: MEC Category for IUCD insertion 1 2 w The first assessment is a review of the woman’s general, medical, reproductive, contraceptive and obstetric history and eligibility for the method along with pre-procedure assessment.
w A second assessment is done immediately prior to insertion to rule out current genital tract infection, risk of infection or hemorrhage and genital tract injury.
7.3 Technique of Post Abortion IUCD Insertion Condition Technique of insertion immediately after abortion After surgical evacuation when uterine size is below 12 weeks (or uterus size after evacuation is similar to the size of first trimester pregnant uterus) Interval IUCD insertion technique (no touch and withdrawal technique) with little adaptation • Use of uterine sound for measuring the height of uterus for fundal placement is not recommended, as it may cause perforation.
• Right after the confirmation of the completion of evacuation in vacuum aspiration and before withdrawing the cannula, check the depth of uterus using the last cannula before completely withdrawing the cannula.
• Then, load the IUCD inside the sterile package and fix the blue gauge at the length measured by the cannula • Rest of the steps are same as in interval IUCD insertion technique (Note: Dilatation and curettage (D & C), the previously used technique, is no longer a recommended method of surgical evacuation as it is more invasive, has higher risk of injury, including perforation.
However, for IUCD insertion after D & C, the height of uterus can be confirmed by introducing the last curette up to the fundus before completely withdrawing the curette and keeping the index finger on the curette at the cervical os.

Measure the length of the last curette up to the index finger and matching this with the gradations on measurement insert in IUCD package.
After loading the IUCD by ‘No Touch’ technique, fix the blue gauge at a length corresponding to the measured length of uterus with the last curette.)

10 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 11 Family Planning Method Time of Initiation after Abortion 7.

Post-Abortion IUCD Female sterilization Can be performed after the first menstrual cycle.
After Second-trimester Abortion Family Planning Method Time of Initiation after Abortion Combined oral contraceptive pills Can be started immediately Spontaneous abortion or dilatation and evacuation Progestin only pills Centchroman Pills Injection DMPA Condoms IUCD Female sterilization Can be performed concurrently or within 7 days (Note: on Day 15, the provider should take relevant history and carry out pelvic examination to ensure completion of abortion.
If pelvic examination does not confirm the expulsion of POC or completion of abortion process or bleeding continues, the provider should assess clinical condition of the client and manage accordingly.

USG is also an option available to check for retained POCs/ completion of abortion process).
Can be started immediately Can be started immediately Can be started immediately Can be started immediately by the male partner Can be inserted immediately, when infection and injury to the genital tract are ruled out by a specially trained provider as per postpartum IUCD insertion technique.

post abortion (uncomplicated abortion), if she has made a voluntary, informed choice in advance.

In this case the woman is eligible for sterilization by minilap method only.
(Laparoscopic tubal occlusion is contraindicated as there are chances of injury to the fallopian tubes/uterus since the tubes are oedematous.

There is also the possibility of slipping of the rings from the tubes leading to failures).

*The National Family Planning programme offers male sterilization services also which can be availed of by the male partner anytime.
The provider should ensure that the woman has received counseling and made an informed choice prior to IUCD insertion in the post abortion period.

Cu IUCD 380 A/Cu IUCD 375, providing contraception for 10 years/5 years respectively, can be inserted as per the preference of the client.
7.1 Eligibility Criteria Condition Immediately following first trimester abortion (spontaneous/ induced) (Provided there is no evidence or potential for infection) Immediately following second trimester abortion (Spontaneous/ Induced) (Provided there is no evidence or potential for infection, bleeding and other contraindications) 7.2 Clinical Assessment and Screening of Client Assessment for immediate post-abortion IUCD is done in two phases: MEC Category for IUCD insertion 1 2 w The first assessment is a review of the woman’s general, medical, reproductive, contraceptive and obstetric history and eligibility for the method along with pre-procedure assessment.
w A second assessment is done immediately prior to insertion to rule out current genital tract infection, risk of infection or hemorrhage and genital tract injury.
7.3 Technique of Post Abortion IUCD Insertion Condition Technique of insertion immediately after abortion After surgical evacuation when uterine size is below 12 weeks (or uterus size after evacuation is similar to the size of first trimester pregnant uterus) Interval IUCD insertion technique (no touch and withdrawal technique) with little adaptation • Use of uterine sound for measuring the height of uterus for fundal placement is not recommended, as it may cause perforation.
• Right after the confirmation of the completion of evacuation in vacuum aspiration and before withdrawing the cannula, check the depth of uterus using the last cannula before completely withdrawing the cannula.
• Then, load the IUCD inside the sterile package and fix the blue gauge at the length measured by the cannula • Rest of the steps are same as in interval IUCD insertion technique (Note: Dilatation and curettage (D & C), the previously used technique, is no longer a recommended method of surgical evacuation as it is more invasive, has higher risk of injury, including perforation.
However, for IUCD insertion after D & C, the height of uterus can be confirmed by introducing the last curette up to the fundus before completely withdrawing the curette and keeping the index finger on the curette at the cervical os.

Measure the length of the last curette up to the index finger and matching this with the gradations on measurement insert in IUCD package.
After loading the IUCD by ‘No Touch’ technique, fix the blue gauge at a length corresponding to the measured length of uterus with the last curette.)

10 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 11 Condition Technique of insertion immediately after abortion 8.
Post-Abortion Female Sterilization The technique of insertion is same as that of postpartum IUCD insertion with little modification • The insertion can be done with ring forceps or sponge holders because it might be difficult to introduce PPIUCD insertion forceps through the cervical os.

(The height of uterus after evacuation is smaller as compared to the size of uterus after full term vaginal delivery and the cervical os may be tighter.
So it might be difficult to introduce PPIUCD insertion forceps into the cervix.

Therefore, it is advisable to do the insertion with ring forceps/sponge holder following the same technique as that of immediate postpartum IUCD insertion).

The technique of insertion is same as that of interval IUCD insertion • The provider should be very careful while introducing uterine sound to measure the length of uterus.
Uterine sound should be introduced gently by holding it like a pen/pencil, moving it in the right direction till the resistance is felt without applying any force.

After surgical evacuation when uterine size is above 12 weeks (or uterus size after evacuation is similar to the size of second trimester pregnant uterus) After medical abortion (Mifepristone + Misoprostol), which can be offered to eligible women within 7 weeks of gestation, as per Govt.

of India guidelines 7.4 Advise for Follow-up Visit 1.
Before the woman leaves the health facility, she should be advised to • Come for post abortion follow up within one to two weeks for w Assessment of her physical condition, w Ruling out continuing pregnancy, sepsis and incomplete abortion w Any problem with IUCD.

• Come for a routine follow-up of IUCD after 1 month, preferably after the next menstrual bleeding.

• Come back immediately if any warning signs appear.

2.

Follow‐up care and management of problems of IUCD will be same as that of interval IUCD.
Important: 1.

A back- up method is not needed • If the IUCD is inserted within 12 days after first or second trimester spontaneous or induced abortions, when there is no infection.

• If it is more than 12 days after first or second trimester spontaneous or induced abortion, no infection is present and the IUCD has been inserted after it is reasonably ascertained that the woman was not pregnant.

2.

If infection is present, treat or refer and help the woman choose another method.
If she still wants an IUCD, it can be inserted after the infection has completely resolved.

3.

If insertion is delayed, a backup method is needed.

Post‐abortion female sterilization should be performed after confirming that the woman has received counseling and made an informed choice.

The procedure should be performed only by providers who have been trained to perform the procedure.
Post abortion female sterilization can be performed through minilap tubectomy procedure after first as well as second trimester abortions.

Laparoscopic tubal occlusion is not recommended following second trimester abortions as there are chances of injury to the fallopian tubes/ uterus.
* 8.1 Eligibility Criteria Post-abortion condition Uncomplicated Post-abortal sepsis or fever Severe post-abortal hemorrhage Uterine perforation Acute heamatometra Severe trauma to genital tract, cervical or vaginal tears MEC Categories for Female sterilization A D D D S D A = (accept): there is no reason to deny sterilization to a person with this condition.

C = (caution): the procedure is normally conducted in a routine setting, but with extra precautions.
D = (delay): the procedure is delayed until the condition is evaluated and/or corrected S = (special): the procedure should be undertaken in a setting with an experienced surgeon and staff; equipment is needed to provide general anesthesia, another back-up medical support.
8.2 Steps for Post Abortion Female Sterilization Step 1: Clinical History taking (Medical, obstetric and contraceptive history), physical examination assessment and screening of client and laboratory examination; if not done earlier Step 2: Written Provider must ensure that the client has signed the consent form for sterilization informed consent Step 3: Preoperative Instructions Step 4: Part preparation & Pre- medication before surgery.
The operating surgeon must ensure that the medical record and checklist are filled properly after reviewing the client’s suitability for sterilization and conducting final assessment prior to surgery.

Refer Medical Record checklist provided in ‘Reference Manual for Female Sterilization (2014)’.

Provide preoperative instructions to the client.

Client should be advised to bathe, not consume anything 6 hours prior to surgery and empty her bowel and bladder before entering the Operation Theatre.
Part should be trimmed or shaved, if warranted, just prior to surgery.

The operative site should be prepared immediately preoperatively with an antiseptic solution, such as iodophor (Povidone iodine) or chlorhexidine gluconate.

• Usually premedication is discouraged and in anxious clients reassurance is sufficient.

However, if needed, preferably Tablet Alprazolam (0.25 to 0.50 mg) or Tablet Diazepam (5 to 10 mg) can be given before the operation.
• For sedation/Analgesia: dosage according to body weight is recommended (Pethidine 0.5 to 1 mg/Kg or Petazocine 0.5 mg/kg and Promethazine 0.3 - 0.5 12 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 13 Condition Technique of insertion immediately after abortion 8.
Post-Abortion Female Sterilization After surgical The technique of insertion is same as that of postpartum IUCD insertion with little modification • The insertion can be done with ring forceps or sponge holders because it might be difficult to introduce PPIUCD insertion forceps through the cervical os.

(The height of uterus after evacuation is smaller as compared to the size of uterus after full term vaginal delivery and the cervical os may be tighter.
So it might be difficult to introduce PPIUCD insertion forceps into the cervix.

Therefore, it is advisable to do the insertion with ring forceps/sponge holder following the same technique as that of immediate postpartum IUCD insertion).

After medical The technique of insertion is same as that of interval IUCD insertion • The provider should be very careful while introducing uterine sound to measure the length of uterus.
Uterine sound should be introduced gently by holding it like a pen/pencil, moving it in the right direction till the resistance is felt without applying any force.

evacuation when uterine size is above 12 weeks (or uterus size after evacuation is similar to the size of second trimester pregnant uterus) abortion (Mifepristone + Misoprostol), which can be offered to eligible women within 7 weeks of gestation, as per Govt.

of India guidelines 7.4 Advise for Follow-up Visit 1.
Before the woman leaves the health facility, she should be advised to • Come for post abortion follow up within one to two weeks for w Assessment of her physical condition, w Ruling out continuing pregnancy, sepsis and incomplete abortion w Any problem with IUCD.

• Come for a routine follow-up of IUCD after 1 month, preferably after the next menstrual bleeding.

• Come back immediately if any warning signs appear.

2.

Follow‐up care and management of problems of IUCD will be same as that of interval IUCD.
Important: 1.

A back- up method is not needed • If the IUCD is inserted within 12 days after first or second trimester spontaneous or induced abortions, when there is no infection.

• If it is more than 12 days after first or second trimester spontaneous or induced abortion, no infection is present and the IUCD has been inserted after it is reasonably ascertained that the woman was not pregnant.

2.

If infection is present, treat or refer and help the woman choose another method.
If she still wants an IUCD, it can be inserted after the infection has completely resolved.

3.

If insertion is delayed, a backup method is needed.

Post‐abortion female sterilization should be performed after confirming that the woman has received counseling and made an informed choice.

The procedure should be performed only by providers who have been trained to perform the procedure.
Post abortion female sterilization can be performed through minilap tubectomy procedure after first as well as second trimester abortions.

Laparoscopic tubal occlusion is not recommended following second trimester abortions as there are chances of injury to the fallopian tubes/ uterus.
* 8.1 Eligibility Criteria Post-abortion condition Uncomplicated Post-abortal sepsis or fever Severe post-abortal hemorrhage Severe trauma to genital tract, cervical or vaginal tears Uterine perforation Acute heamatometra MEC Categories for Female sterilization A D D D S D A = (accept): there is no reason to deny sterilization to a person with this condition.

C = (caution): the procedure is normally conducted in a routine setting, but with extra precautions.
D = (delay): the procedure is delayed until the condition is evaluated and/or corrected S = (special): the procedure should be undertaken in a setting with an experienced surgeon and staff; equipment is needed to provide general anesthesia, another back-up medical support.
8.2 Steps for Post Abortion Female Sterilization Step 1: Clinical assessment and screening of client Step 2: Written informed consent History taking (Medical, obstetric and contraceptive history), physical examination and laboratory examination; if not done earlier Provider must ensure that the client has signed the consent form for sterilization before surgery.
The operating surgeon must ensure that the medical record and checklist are filled properly after reviewing the client’s suitability for sterilization and conducting final assessment prior to surgery.

Refer Medical Record checklist provided in ‘Reference Manual for Female Sterilization (2014)’.

Step 3: Preoperative Instructions Provide preoperative instructions to the client.
Client should be advised to bathe, not consume anything 6 hours prior to surgery and empty her bowel and bladder before entering the Operation Theatre.

Step 4: Part preparation & Pre- medication Part should be trimmed or shaved, if warranted, just prior to surgery.

The operative site should be prepared immediately preoperatively with an antiseptic solution, such as iodophor (Povidone iodine) or chlorhexidine gluconate.
• Usually premedication is discouraged and in anxious clients reassurance is sufficient.

However, if needed, preferably Tablet Alprazolam (0.25 to 0.50 mg) or Tablet Diazepam (5 to 10 mg) can be given before the operation.
• For sedation/Analgesia: dosage according to body weight is recommended (Pethidine 0.5 to 1 mg/Kg or Petazocine 0.5 mg/kg and Promethazine 0.3 - 0.5 12 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 13 Note: In the unlikely events of failure, complications or deaths attributable to sterilization operations, Family Planning Indemnity Scheme indemnifies the clients of sterilization and doctors performing the procedure in public health facilities and accredited private/NGO facilities.
The client or her kin reports the # incidence to the District Quality Assurance Committee/District FP Indemnity Sub Committee which is responsible for processing and settlement of claims and reporting these incidences to the State Quality Assurance Committees/State FP Indemnity Sub Committee for final settlement.
* refer ‘Reference Manual for Female Sterilization, (2014)’ **refer to Annexure 3 in ‘Standards and Quality Assurance in Sterilization Services, (2014)’ # refer‘Manual for Family Planning Indemnity Scheme, (2013)’ mg/kg).

Refer to ‘Reference Manual for Female Sterilization (2014)’ for dosage and regimes.

The drugs should be diluted with equal quantity of normal saline or distilled water before IV administration.
• Lignocaine is the recommended local anaesthetic and the recommended concentration is 1% lignocaine without adrenaline.

Step 5: Surgical procedure The routine surgical procedure for sterilization (Minilap or Laparoscopic) to be followed as mentioned in ‘Reference Manual for Female Sterilization (2014)’.
Approach to incision for Minilap and Laparoscopic sterilization depends on the timing and type of abortion: Step 6: Postoperative care Step 7: Discharge Minilap Tubectomy: • Supra pubic: in case of an uncomplicated first-trimester abortion or with medical termination of pregnancy (MTP) • Sub umbilical: in case of immediate uncomplicated second trimester abortion, depending on the size of uterus Laparoscopic Tubal occlusion: • Inferior Umbilical: in case of first trimester abortion or MTP up to 12 weeks In the postoperative period, the client should be kept under observation of a nurse/ doctor for about 4-6 hours.
The client should be monitored for vitals and dressing at all stages and never be left unattended.

The client can be discharged after 4 hours, when the vital signs are stable and the client is fully awake, passed urine, can talk, drink or walk.

The provider should evaluate the client and ensure that she is accompanied by a relative or friend.

Postoperative and follow up instructions should be given along with postoperative instruction card at the time of discharge of the client.
** Following should be emphasized at the time of discharge: • The client can resume sexual intercourse one week following sterilization if bleeding has stopped or whenever she feels comfortable provided there is no bleeding.

• She should return for a follow-up visit on the 7th day of surgery or as early as possible after 7 days.

The client is also advised to return to the clinic, if there is any missed period/suspected pregnancy within two weeks to rule out pregnancy.
Step 8: Certificate of Sterilization The certificate of sterilization should be issued one month after the surgery or after the first menstrual period, whichever is earlier, by the medical officer of the facility.
If the client does not resume her period even after one month of surgery, rule out pregnancy before issuing sterilization certificate 14 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 15 Note: In the unlikely events of failure, complications or deaths attributable to sterilization operations, Family Planning Indemnity Scheme indemnifies the clients of sterilization and doctors performing the procedure in public health facilities and accredited private/NGO facilities.
The client or her kin reports the incidence to the District Quality Assurance Committee/District FP Indemnity Sub Committee which is responsible for processing and settlement of claims and reporting these incidences to the State Quality Assurance Committees/State FP Indemnity Sub Committee for final settlement.
# * refer ‘Reference Manual for Female Sterilization, (2014)’ **refer to Annexure 3 in ‘Standards and Quality Assurance in Sterilization Services, (2014)’ # refer‘Manual for Family Planning Indemnity Scheme, (2013)’ mg/kg).

Refer to ‘Reference Manual for Female Sterilization (2014)’ for dosage and regimes.

The drugs should be diluted with equal quantity of normal saline or distilled water before IV administration.
• Lignocaine is the recommended local anaesthetic and the recommended concentration is 1% lignocaine without adrenaline.

Step 5: Surgical The routine surgical procedure for sterilization (Minilap or Laparoscopic) to be procedure followed as mentioned in ‘Reference Manual for Female Sterilization (2014)’.
Approach to incision for Minilap and Laparoscopic sterilization depends on the Step 6: Postoperative care Step 7: Discharge timing and type of abortion: Minilap Tubectomy: termination of pregnancy (MTP) depending on the size of uterus Laparoscopic Tubal occlusion: • Supra pubic: in case of an uncomplicated first-trimester abortion or with medical • Sub umbilical: in case of immediate uncomplicated second trimester abortion, • Inferior Umbilical: in case of first trimester abortion or MTP up to 12 weeks In the postoperative period, the client should be kept under observation of a nurse/ doctor for about 4-6 hours.
The client should be monitored for vitals and dressing at all stages and never be left unattended.

The client can be discharged after 4 hours, when the vital signs are stable and the client is fully awake, passed urine, can talk, drink or walk.

The provider should evaluate the client and ensure that she is accompanied by a relative or friend.

Postoperative and follow up instructions should be given along with postoperative instruction card at the time of discharge of the client.
** Following should be emphasized at the time of discharge: • The client can resume sexual intercourse one week following sterilization if bleeding has stopped or whenever she feels comfortable provided there is no bleeding.

• She should return for a follow-up visit on the 7th day of surgery or as early as possible after 7 days.

The client is also advised to return to the clinic, if there is any missed period/suspected pregnancy within two weeks to rule out pregnancy.
Step 8: Certificate of Sterilization The certificate of sterilization should be issued one month after the surgery or after the first menstrual period, whichever is earlier, by the medical officer of the facility.

If the client does not resume her period even after one month of surgery, rule out pregnancy before issuing sterilization certificate 14 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 15 9.
Other Methods of Contraception Other methods of contraception like combined oral contraceptive pills (OCPs), Progestin-only-pills (POPs), Centchroman, injection DMPA, condoms and Male Sterilization can be started immediately (as mentioned in earlier section), after appropriate method specific counseling.

• If the woman is starting OCPs, POPs, Centchroman and Injection DMPA within 7 days after first or second trimester miscarriage or induced abortion, there is no need for a backup method.
• If it is more than 7 days after first or second trimester miscarriage or induced abortion, she can start OCPs or POPs or Centchroman or Injection DMPA any time if it is reasonably certain she is not pregnant.

She will need a backup method for the first 7 days for OCPs or Injection DMPA or Centchroman and for the first 2 days in case of POPs.
Overview of Post Abortion Family Planning Methods Family Planning Methods Advantages Limitations Condoms • Only method that protects • Some people may have allergy Fairly effective.
against both pregnancy and to latex STIs, HIV • Require correct use with every Contraceptive Effectiveness Failure rate: 2 pregnancies/ 100 women* • No hormonal side effects act of sex • Used as a temporary or back up method • Can be used without seeing a health care provider Combined • Can be provided by all • Must be taken every day Highly effective.
Contraceptives • Does not interfere with Oral (COCs) health workers sexual activity • Re‐supply must be available • Not suitable for women, who is Failure rate: < 1 pregnancy/100 breast-feeding her baby of less women • Immediate return to fertility than 6 months old on discontinuation • Not suitable for women with (0.3/100)*, when n o p i l l s a r e missed certain medical illnesses • Medications like Rifampicin, Dilantin, and GriseofulvinR have drug interactions and lower the effectiveness of OCPs • Changes in menstrual bleeding like lighter bleeding, dizziness, nausea, headaches, and breast tenderness Progestin only • Can be provided by all • Less effective for women not Breast feeding Pills (POP) health workers breast feeding women: Failure rate: 1 • Does not interfere with • Must be taken every day sexual activity • Re‐supply must be available pregnancy/100 • Immediate return to fertility • Not suitable for women with women (.3/100)*, on discontinuation certain medical illnesses when no pills • Suitable for women below • Changes in menstrual bleeding are missed six weeks post-partum and like lighter bleeding, dizziness, Less effective in breast feeding nausea, headaches, and breast non-breast tenderness feeding women: Failure rate: < 1 pregnancy/100 women (.9/100)*, when no pills are missed 16 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 17 • If the woman is starting OCPs, POPs, Centchroman and Injection DMPA within 7 days after first or second trimester miscarriage or induced abortion, there is no need for a backup method.
• If it is more than 7 days after first or second trimester miscarriage or induced abortion, she can start OCPs or POPs or Centchroman or Injection DMPA any time if it is reasonably certain she is not pregnant.

She will need a backup method for the first 7 days for OCPs or Injection DMPA or Centchroman and for the first 2 days in case of POPs.

9.
9.

Other Methods of Contraception Overview of Post Abortion Family Planning Methods Other methods of contraception like combined oral contraceptive pills (OCPs), Progestin-only-pills (POPs), Centchroman, injection DMPA, condoms and Male Sterilization can be started immediately (as mentioned in earlier section), after appropriate method specific counseling.
Family Planning Methods Condoms Advantages Limitations • Some people may have allergy to latex • Require correct use with every act of sex • Only method that protects against both pregnancy and STIs, HIV • No hormonal side effects • Used as a temporary or back up method • Can be used without seeing a health care provider Combined Oral Contraceptives (COCs) • Can be provided by all health workers • Does not interfere with sexual activity • Immediate return to fertility on discontinuation Must be taken every day • • Re‐supply must be available • Not suitable for women, who is breast-feeding her baby of less than 6 months old • Not suitable for women with certain medical illnesses • Medications like Rifampicin, Dilantin, and GriseofulvinR have drug interactions and lower the effectiveness of OCPs • Changes in menstrual bleeding like lighter bleeding, dizziness, nausea, headaches, and breast tenderness Progestin only Pills (POP) • Can be provided by all • Less effective for women not health workers breast feeding • Does not interfere with sexual activity • Immediate return to fertility on discontinuation • Suitable for women below six weeks post-partum and breast feeding • Must be taken every day • Re‐supply must be available • Not suitable for women with certain medical illnesses • Changes in menstrual bleeding like lighter bleeding, dizziness, nausea, headaches, and breast tenderness Contraceptive Effectiveness Fairly effective.
Failure rate: 2 pregnancies/ 100 women* Highly effective.
Failure rate: < 1 pregnancy/100 women (0.3/100)*, when n o p i l l s a r e missed Breast feeding women: Failure rate: 1 pregnancy/100 women (.3/100)*, when no pills are missed Less effective in non-breast feeding women: Failure rate: < 1 pregnancy/100 women (.9/100)*, when no pills are missed 16 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 17 Female Sterilization • Permanent method • Woman must understand that it Highly effective.
• Immediately effective is a permanent method and Failure rate: • No long term side effects reversal is difficult <1 pregnancy/ • No interference with sex • Permanence of the method 1 0 0 w o m e n increases the importance of (0.5/100)* adequate counseling and fully informed consent.

• Slight possibility of surgical complications Male Sterilization (Vasectomy) • Permanent method • Not immediately effective.
• No interference with sex • Couple must use another FP • Enables man to take method for at least the first 3 responsibility for preventing months.

Semen analysis pregnancy should be done after 3 months to confirm absence of sperms Highly effective.

Failure rate: <1 pregnancy/ 100 women (0.5/100)* Centchroman • Can be used safely by lactating mothers • Does not require daily action and does not interfere with sex.
Taken orally twice a week in first 3 months and then once a week • Can be provided by non- medical staff • Immediate return of fertility on discontinuation • No hormonal side-effects • Prolongation of menstrual cycle • Requirement of regular supply • Cannot be provided to women with Polycystic ovarian disease, cervical hyperplasia, Tuberculosis, renal disease, clinical evidence of jaundice/ liver disease and severe allergic states Fairly effective.
Failure rate: 1.63 pregnancy /100 women (1.63/100) Injection DMPA • Does not interfere with • Client must return for injection sexual activity every 3 months • Suitable for women after six • May cause irregular bleeding, weeks post-partum and breast feeding IUCD • Effective as soon as it is inserted • Long term contraception, effective for 5 years (IUCD Cu 375) or 10 years (IUCD CU 380A) • Immediate return to fertility on removal • Does not require daily action and does not interfere with sex spotting and amenorrhea • Return of fertility after stopping Inj DMPA takes an average of 4 to 6 months longer than with most other reversible methods.
This means women can become pregnant on average 7-10 months after their last injection • Reversible reductions in bone density, but users are not likely to have more fractures • Increased menstrual bleeding and pain during the first few months • Trained provider needed for insertion and removal • Cannot be provided to women with current pelvic infections Highly effective.

Failure rate: <1 pregnancy/100 women (0.3/100)*, when women take injections on Highly effective.
Failure rate: <1 pregnancy/ 100 women (0.6/100)* 18 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 19 Female Sterilization • Permanent method • Immediately effective • No long term side effects • No interference with sex Highly effective.
Failure rate: <1 pregnancy/ 1 0 0 w o m e n (0.5/100)* • Woman must understand that it is a permanent method and reversal is difficult • Permanence of the method increases the importance of adequate counseling and fully informed consent.

• Slight possibility of surgical complications Male Sterilization (Vasectomy) • Permanent method • No interference with sex • Enables man to take responsibility for preventing pregnancy • Not immediately effective.
• Couple must use another FP method for at least the first 3 months.

Semen analysis should be done after 3 months to confirm absence of sperms Highly effective.

Failure rate: <1 pregnancy/ 100 women (0.5/100)* Centchroman • Can be used safely by • Prolongation of menstrual cycle lactating mothers • Requirement of regular supply • Does not require daily action • Cannot be provided to women 1.63 and does not interfere with with Polycystic ovarian pregnancy /100 sex.
Taken orally twice a week disease, cervical hyperplasia, in first 3 months and then Tuberculosis, renal disease, women (1.63/100) Fairly effective.
Failure rate: once a week clinical evidence of jaundice/ • Can be provided by non- liver disease and severe allergic medical staff states • Immediate return of fertility on discontinuation • No hormonal side-effects Injection DMPA • Does not interfere with • Client must return for injection Highly sexual activity every 3 months • Suitable for women after six • May cause irregular bleeding, weeks post-partum and spotting and amenorrhea effective.
Failure rate: <1 pregnancy/100 breast feeding • Return of fertility after stopping women Inj DMPA takes an average of 4 (0.3/100)*, when women take injections on to 6 months longer than with most other reversible methods.
This means women can become pregnant on average 7-10 months after their last injection • Reversible reductions in bone density, but users are not likely to have more fractures IUCD • Effective as soon as it is • Increased menstrual bleeding Highly inserted and pain during the first few effective.
• Long term contraception, months Failure rate: effective for 5 years (IUCD • Trained provider needed for <1 pregnancy/ Cu 375) or 10 years (IUCD insertion and removal 100 women • Cannot be provided to women (0.6/100)* • Immediate return to fertility with current pelvic infections CU 380A) on removal • Does not require daily action and does not interfere with sex 18 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 19 References 1.
Unsafe Abortion, Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, 6th Edition, WHO 2.

Population Reference Bureau: Unsafe Abortion, Facts and Figures, 2005 3.

Trends in Maternal mortality: 1990 to 2013, Estimates by WHO, UNICEF, UNFPA, The world Bank and the United Nations Population Division, May 2014 4.

Reference Manual for Female Sterilization (2014)’ 5.

Manual for Family Planning Indemnity Scheme, (2013)’ 6.
Annexure 3 in ‘Standards and Quality Assurance in Sterilization Services, (2014) 7.

Provider’s Manual on Comprehensive Abortion Care, April 2014, Maternal Health Division, MOHFW, Govt.

of India 8.

Clinical Updates in Reproductive Health, July 2013, Ipas 9.

Nguyen Thi Nhu Ngoc.

Immediate post-abortion insertion of intrauterine devices: RHL commentary (last revised: 18 January 2005).

The WHO Reproductive Health Library; Geneva: World Health Organization.

10.
10.

Handbook of Medical Methods of Abortion by Government of Madhya Pradesh and Ipas to expand access to new technologies for safe abortion, 2013 11.

Family Planning, A Global Handbook for Providers, 2011 Update, USAID; Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, World Health Organization 12.

Centchroman – A brief overview of contraceptive effect.
Document, September 2015, Council of Scientific and Industrial Research (CSIR) – Central Drug Research Institute (CDRI), Lucknow, India 13.

Centchroman, a Selective Estrogen Receptor Modulator, as a Contraceptive and for the Management of Hormone-Related Clinical Disorders, MM Singh, Division of Endocrinology, CDRI, Lucknow, India.

Medicinal Research Reviews, Vol 21, No.
4, 302-347, 2001, Clinical Services and Training List of Contributors Dr. Sunita Singhal Senior Clinical Advisor Engender Health New Delhi Dr. Saswati Das Director Jhpiego, New Delhi Dr. Minati Rath Senior Clinical Officer Jhpiego New Delhi Dr. Alok Banerjee Technical Advisor Parivar Sewa Sanstha New Delhi Dr. Bimla Upadhyay Director- Health Systems IPAS Development foundation New Delhi Dr. Pratima Mittal HOD, Obs and Gyn Safdarjung Hospital New Delhi Dr. Basab Mukherjee Chairperson Family Welfare Committee FOGSI Dr. Jyoti Vajpayee FP lead BMGF New Delhi Dr. Bulbul Sood Country Director Jhpiego New Delhi Dr. Rupali Diwan Dept.
of Obs.

And Gyn.
Safdarjung Hospital New Delhi Dr. Vasanthi Krishnan Project Director IPAS Development Foundation Reproductive Health Advisor New Delhi Dr. Amit Shah USAID New Delhi Dr. Rajkumar Deputy Director FW Karnataka Dr. S. K. Sikdar Deputy Commissioner (In-charge) Family Planning Division MOHFW Dr. Teja Ram Deputy Commissioner Family Planning Division MOHFW Ms. Shikha Bansal Program Officer National Technical Support Unit - FP New Delhi Dr. Pragati Singh Senior Consultant FP division MoHFW Dr. Nidhi Bhatt Program Officer New Delhi New Delhi Ms. Shilpa John Consultant FP Division MoFHW National Technical Support Unit- FP Mr. Nadeem Akhtar Khan Program Manager National Technical Support Unit- FP 20 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 21 References 1.
Unsafe Abortion, Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, 6th Edition, WHO 2.

Population Reference Bureau: Unsafe Abortion, Facts and Figures, 2005 3.

Trends in Maternal mortality: 1990 to 2013, Estimates by WHO, UNICEF, UNFPA, The world Bank and the United Nations Population Division, May 2014 4.

Reference Manual for Female Sterilization (2014)’ 5.

Manual for Family Planning Indemnity Scheme, (2013)’ 6.
Annexure 3 in ‘Standards and Quality Assurance in Sterilization Services, (2014) 7.

Provider’s Manual on Comprehensive Abortion Care, April 2014, Maternal Health Division, MOHFW, Govt.

of India Organization.

8.

Clinical Updates in Reproductive Health, July 2013, Ipas 9.

Nguyen Thi Nhu Ngoc.

Immediate post-abortion insertion of intrauterine devices: RHL commentary (last revised: 18 January 2005).

The WHO Reproductive Health Library; Geneva: World Health 10.
Handbook of Medical Methods of Abortion by Government of Madhya Pradesh and Ipas to expand access to new technologies for safe abortion, 2013 11.

Family Planning, A Global Handbook for Providers, 2011 Update, USAID; Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, World Health Organization 12.

Centchroman – A brief overview of contraceptive effect.
Document, September 2015, Council of Scientific and Industrial Research (CSIR) – Central Drug Research Institute (CDRI), Lucknow, India 13.

Centchroman, a Selective Estrogen Receptor Modulator, as a Contraceptive and for the Management of Hormone-Related Clinical Disorders, MM Singh, Division of Endocrinology, CDRI, Lucknow, India.

Medicinal Research Reviews, Vol 21, No.
4, 302-347, 2001, List of Contributors Dr. Sunita Singhal Senior Clinical Advisor Engender Health New Delhi Dr. Saswati Das Director Clinical Services and Training Jhpiego, New Delhi Dr. Minati Rath Senior Clinical Officer Jhpiego New Delhi Dr. Alok Banerjee Technical Advisor Parivar Sewa Sanstha New Delhi Dr. Bimla Upadhyay Director- Health Systems IPAS Development foundation New Delhi Dr. Pratima Mittal HOD, Obs and Gyn Safdarjung Hospital New Delhi Dr. Basab Mukherjee Chairperson Family Welfare Committee FOGSI Dr. Jyoti Vajpayee FP lead BMGF New Delhi Dr. Bulbul Sood Country Director Jhpiego New Delhi Dr. Rupali Diwan Dept.
of Obs.

And Gyn.
Safdarjung Hospital New Delhi Dr. Vasanthi Krishnan Project Director IPAS Development Foundation New Delhi Dr. Amit Shah Reproductive Health Advisor USAID New Delhi Dr. Rajkumar Deputy Director FW Karnataka Dr. S. K. Sikdar Deputy Commissioner (In-charge) Family Planning Division MOHFW Dr. Teja Ram Deputy Commissioner Family Planning Division MOHFW Ms. Shikha Bansal Program Officer National Technical Support Unit - FP New Delhi Dr. Pragati Singh Senior Consultant FP division MoHFW Dr. Nidhi Bhatt Program Officer National Technical Support Unit- FP New Delhi Mr. Nadeem Akhtar Khan Program Manager National Technical Support Unit- FP New Delhi Ms. Shilpa John Consultant FP Division MoFHW 20 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 21 22 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 23 22 POST ABORTION FAMILY PLANNING - Technical Update POST ABORTION FAMILY PLANNING - Technical Update 23 24 POST ABORTION FAMILY PLANNING - Technical Update Post Abortion Family Planning Technical Update March 2016 Developed with support from National Technical Support Unit (NTSU), Family Planning Division, Ministry of Health & Family Welfare, Government of India Family Planning Division Ministry of Health and Family Welfare Government of India