GUIDELINES FOR ORAL CONTRACEPTIVE PILL FOR HEALTH ASSISTANT (FEMALE) AND HEALTH WORKER (FEMALE)

Item

Title: GUIDELINES
FOR
ORAL CONTRACEPTIVE PILL
FOR
HEALTH ASSISTANT (FEMALE)
AND
HEALTH WORKER (FEMALE)
extracted text: GUIDELINES

FOR
ORAL CONTRACEPTIVE PILL
FOR
HEALTH ASSISTANT (FEMALE)

AND
HEALTH WORKER (FEMALE)

Issued by
Technical Operations Division

Ministry of Health & Family Welfare

(Department of Family Welfare)
Government of India
Nirman Bhavan, New Delhi-11.

GUIDELINES
FOR

ORAL CONTRACEPTIVE PILL
FOR

HEALTH ASSISTANT (FEMALE)

AND
HEALTH WORKER (FEMALE)

Issued by
Technical Operations Division

Ministry of Health & Family Welfare
(Department of Family Welfare)

Government of India
Nirman Bhavan, New Delhi-1.

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JOINT SECRETARY
MINISTRY OF HEALTH & FAMILY WELFARE
INDIA
NEW DELHI-110011

Mrs. ADARSH MISRA
Tela i 3017447
Fax tOII 301 7447

Dated the Sth December, 1996

PREFACE
The Government of India is giving high priority to Family
Welfare Programme, the ultimate objective being to reduce the
country's birth rate to 21 per thousand by the year 2000 AD. In
order to achieve this goal, efforts are being made to promote
various contraceptive methods for birth spacing - especially for
young couples. The oral contraceptive pill has been found to be
a simple, safe, effective and reversible method of contraception.
The composition of pill presently being used has been found to
be most suitable for the Indian woman.
This brochure on Oral Pill Contraceptive explains in detail
as to how the oral pill works, its advantages and other health
benefits as well as the dis-advantage, details about the
selection of the acceptors, instructions for use of the 28 days
pack follow up services and reporting and recording of the pill
users etc.
I hope this book will be of a great help to the
health workers (male and female) in promoting Oral Contraceptive
Pill in the National Family Welfare Programme.

I am grateful to the experts and the staff members of the
Ministry who have helped in bringing out the publication.

New Delhi

110 011

( ADARSH MISRA )
JOINT SECRETARY

CONTENTS

Page No.

Preface
Acknowledgement
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.

12.
13.
14.
15.
16.

Objectives
What is Oral Pill
How does it work
Where to get the pill
Advantages
Other Health Benefits
Disadvantages
Miner side effects
Selection of Acceptors
Instructions for use of 28 days pack
. 1 How to take the pill
.2 If a pill is missed
.3 Duration of use
.4 Back up Contraception
.5 Danger Signs
Follow up Services
.1 First Visit
.2 Second Visit
.3 Subsequent Visits
.4 Medical Check up for Oral Contraceptive Users
When to Stop Pills
When to refer to doctor
Messages to be given to community
Clearing Myths about Pills
Record of Oral Pill User
Annexures
I Check List
II Register for Users of Oral Pills
III Monthly report of Pill Usage

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OBJECTIVES
The objective of this module is to enable you to have the necessary knowledge to
provide Oral Contraceptive Pill Services including counselling, appropriate screening and
selection of clients, management of side effects and offer follow up services.

2. What is (Mala - N/ Mala-D) Oral Pill
Mala-N is a contraceptive pill. It contains:
. DI Norgestrel 0.30 mg
. Ethinyl Estradiol 0.03 mg

It is an effective, safe and reversible contraceptive for women desiring to delay their
first pregnancy or space the next child. Mala D/ Mala - N is available in packets containing
supply for one cycle. Each packet has 28 tablets; first 21 of which are white hormonal tablets
and remaining are coloured iron tablets for maintaining the continuity. Mala N is available
free of cost under National Family Welfare Programme and Mala D under the Social
Marketing Programme.
3. How does it work?

The pills act by suppressing release of the ovum (the egg cell) from ovaries.
4. Where to get the pill?
The pills are available free of charge as MalaN at all the Health and Family Welfare
Centres and Government Hospitals. They are also sold in chemist shops and social marketing
outlets under the name of Mala - D at subsidized cost.

5. Advantages
I.. Highly effective method; provided intake is correct and regular (almost 100%

effective).
ii Safe
Reversible
iii.
Decision
iv.

with woman herself

v. Noninvasive

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vi. Privacy not required.

6. Other Health Benefits
I.. Reduces menstrual blood loss, thus reduces chances of anaemia
ii. Relief from pain during menstruation.
Relief from premenstrual symptoms.
iii.
Regulates menstrual cycles if they are irregular.
iv.
v. Reduces chances of ectopic pregnancy.
vi. Provides some protection against pelvic infection.
Protects
vii.
against benign tumours of breast and ovarian cysts.
Reduces
viii.
chances of developoing cancer of uterus and ovary.

7. Disadvantages
I. Daily intake
ii. No protection from STD/aids

8. Minor side effects
Oral contraceptive user may experience the following side effects in the first few
months:
I. Nausea, vomiting
ii. Breast tenderness
Headache
iii.
Depression
iv.
v. Weight gain
Breakthrough bleeding; Slight bleeding or spotting while taking pills.
vi.
However, these symptoms disappear on continued use of pills. You should
explain this and reassure the user and motivate her to continue taking pills.
If the bleeding continues, refer to the Medical Officer.
9. Selection of Acceptors
Any woman in the reproductive age group who wishes to delay the first pregnancy
or wants to postpone the next pregnancy can use oral pills provided she does not have any
contraindications for its use.

It is necessary to screen the acceptor for finding out her suitability for use of pills.
You should fill the Check List (Annexure -1) before selecting an acceptor for
oral pill.

I. Ask menstrual history:
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. Date of last Menstrual period
. Number of days she bleeds during period
. Interval between two periods.

ii. Ask Obstetric History:
. Number of children
. Age of last child
. Whether the child is breastfed.
iii. Ask the questions serially from the check list.
iv. Look for gross malnutrition or obesity.
v. Examine eyes for jaundice.
vi. Look for oedema over legs and face.
Count
vii.
pulse rate.
Palpate
viii.
breasts for lump.
ix. Perform urine analysis for sugar and albumin.

After filling up the check list, if answer to all the points are ‘NO’, then she can be
selected for oral contraceptives. If any of the answer is ‘YES’, then she should be
referred to the medical officer.
10. Instructions for use of 28 day pack
10.1 How to take pill?
Before starting the pills, read the instructions-leaflet carefully.
The first course should be started on day five of menstrual cycle (First day of
bleeding is counted as day one) by taking the pill marked as START from
the pack.
Subsequently one pill should be taken daily from the pack in order
indicated by the arrows, till all the pills are over.
The pill should be taken every day at the fixed time, preferably while
retiring to bed.
The new pack should be stalled the very next day by taking the first pill
marked as START from the pack.
Keep the pills away from children.
Consult the doctor within three months after starting the pill.

10.2 If a pill is missed

If a Pill is Missed
If a woman misses a pill on a particular
night, the missed pill should be taken the next day
as soon as she remembers. She should take another
pill at night as usual. In other words, on the day
following a missed pill day, she has to take two pills.
If she misses 2-3 pills, she should continue taking pills
regularly but in addition, she should also use
another contraceptive method like condoms till the
next cycle is started. In case bleeding occurs, she
should be reassured and asked to continue
taking the pills.

10.3 Duration of use

Oral Pills can be used safely for five years continuously. During this period,
there is no need for periodic discontinuation in taking the pills. However, a
regular medical check up is necessary.
10.4 Back up Contraception

Give 10 condoms to pill-user as back up contraception:
. If two or more pills are forgotten
. During diarrhoea and vomiting
. If she taking following drugs for more than one week:
Rifampicin, Antibiotics, Anticonvulsant, Anti fungal drugs

4

10.5 Danger Signs

Ask the oral contraceptive users to report immediately if:
ACHES
Abdominal pain (severe)
Chest Pain, shortness of breath
Headache - Severe throbbing unilateral
Eye problems (visual loss, double vision, blurring of vision)
Severe leg pains or swelling.

Refer such cases directly to the nearest District Hospital/Medical College
Hospital.

11. Follow up Services
Provide follow up services during your routine home visits. Initially a woman
can be given one packet of oral contraceptive pills. Later when the pills are found
to be uitable for her, she can be given a supply for three months. She must
return regularly to the clinic/service centres for getting the required supply
and for necessary check-up at regular intervals. Arrange follow up services/visits
to the acceptors of oral pills as per the following schedule:
11.1. First Visit

Within 2 weeks after she has been put on pills:
I. Enquire as to how she is feeling.
ii. Treat any minor ailments and reassure her
iii. Check the pill count from the packet
iv .Stress the need to take the pill regularly and to return for more pills
before the packet is over.

11.2 Second Visit
One month after she has been put on oral pills:
I. Find out whether she is taking pills regularly; if not enquire as to why she
has discontinued the pills.

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ii. Ask if she has any complaints; if none give her three packets. Stress the
need to take pills regularly and to return for more pills before the third
packet is over.
Reassure the beneficiary in case of any complaints and persuade her to
iii.
continue the pills.
11.3 Subsequent Visits
Monthly - until the side effects cease and the woman is well adjusted to the pills
regularly.
Six months and then annually.

During routine visits to that area, visit the user and cany out the following
I. Ascertain that she is taking the pills regularly.
ii. Reassure her as needed.
iii.Treat or refer her for side effects.
iv. Give her supplies of pills.
v. Get following information:
. Date of LMP.
. Any irregularity in periods
. If there are major problems (as per check list) or any danger sign refer to
the doctor.

11.4 Medical Check up for Oral Contraceptive Users
Arrange for a medical check up for your client by the medical officer
First: Before starting the pills or within three months of starting the pills
Subsequent: 6 months and 12 months after starting the pill then yearly.
Anytime if any danger sign appears.

12. When to Stop Pills?
. After 5 years of continuous use.
. If she desires pregnancy.
. If she misses menstrual period for 2 months continuously
. If she develops or experiences:
> Discomfort in chest
> Any disturbances in vision
> Pain and swelling in legs
> Continuous headache
> Jaundice

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13. Wh en to refer to doctor?
I. Within 3 months of starting pills
ii. After one year of continuous use
iii.Every year subsequently
If any danger sign appears
iv.
v. No menstrual period for 2 months.

14. Messages to be given to community
I. Pills are to be used regularly for avoiding pregnancy
ii. It is the optimum method to postpone first pregnancy.
iii.Pills can be used for spacing the next pregnancy especially if the woman
cannot use IUD.
iv . Pi Ils can be used continuously for 5 years safely.
v. Mala - N or Mala - D tablets contain very low doses of hormones; hence
these pills are safe.
vi. For appropriately selected acceptors pills are safe.
vii.
Pills
do not lead to cancer
viii. Pills have many other health benefits in addition to contraception

15. Clearing Myths about Pills
To promote pill acceptance, the prevailing myths should be removed and
the facts should be explained.

Reality

Myths

1. Pills may lead to cancer

. Pills offer protection against cancer of
ovary and endometrium.
. No demonstrated increased risk of
breast cancer.

2. Pills cause infertility

. Pills do not lead to permanent infertility.
. After discontinuation of pills fertility
returns rapidly in majority women.

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3. Pills harm women’s health
Permanently

. Observations on millions of women
have proved that there are no
permanent ill effects.
. Taking pills is safer than pregnancy
and childbirth.

. Pills in current use contain very low
amounts of hormones; and hence do not
lead to major complications.

4. Baby may be deformed

. Even if pills are accidentally used during
undiagnosed early pregnancy, there is
no increase in risk of foetal abnormalities.

5. Pills should be discontinued
Intermittently

. Pills can be safely used continuously
for 5 years.
. Interruption of pills without use of
other contraceptive can result in
unwanted pregnancy.

16.
-

Record of Oral Pill User
Record the detailed information of oral pill user in the register as per
Annexure I.

-

Monthly reports of usage be submitted to MO/PHC as per details at
Annexure II.

8

ANNEXURE-I
Check List

I ill the following check list before selecting an acceptor for oral pill.
If any of them is positive, then she should be referred to medical officer.
Yes

No

1. Age above 40 years

2. Smoker aged above 35 years
3. Taking Oral Pills continuously for more than 5 years
4. Pregnancy
5. Lactating less than 6 months
6. Complaint of prolonged/frequent headache
7. Visual disturbances
8. Breathlessness on exertion
9. Fits
10. Persistent/frequent attacks of pain in abdomen
11. Irregular vaginal bleeding
12. History of taking drugs
13. Repeated skin rashes
14. Gross malnutrition
15. Gross obesity
16. Yellow skin and conjunctiva (Jaundice)
17. Pulse rate above 120/min
18. Oedema of extremities
19. Lump in breast
20. Sugar in urine - Diabetes
21. Albumin in urine

If the above are answered in negative, except No. 2 the may be selected for oral
contraceptive. If any of the above, except 2, are answered in positive the patient must be seen
by a physician before oral contraceptive is prescribed.
Patient with history of toxaemia of pregnancy should not be put on oral pill.

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Annexure -II
Check list
Fill the following check list before selecting an acceptor for oral pill.
If any of them is positive, then she should be referred to the medical officer.

YES
1. Age above 40 years
2. Smoker aged above 35 years
3. Taking Oral Pills continuously for more than 5 years
4. Pregnancy
5. Lactating less than 6 months
6. Complaint of prolonged/frequent headache
7. Visual disturbances
8. Breathlessness on exertion
9. Fits
10. Persistent/frequent attacks of pain in abdomen
11 .Irregular vaginal bleeding
12. History of taking drugs
13. Repeated skin rashes
14.Gross malnutrition
15. Gross obesity
16. Yellow skin and conjunctiva
17. Pulse rate above 120/ min
18. Oedema of extremities
19. Lump in breast
20. Sugar in urine - Diabetes
21. Albumin in urine

10

NO

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