Family Planning Provision by Midwives - Cheat Sheet
Your 30-minute exam companion covering RA 10354, contraceptive methods, screening criteria, counseling frameworks, and PRC Midwife Licensure Examination high-yield facts.
RA 10354 (RH Law 2012) & Midwife Mandate
Important facts
- RH Law mandates non-discriminatory, confidential FP services without judgment
- Midwife must offer FP counseling at every relevant contact (postpartum, post-abortion, prenatal, well-woman visits)
- Method choice belongs to the woman; midwife counsels, does not decide
- Services must respect privacy and confidentiality
- Core principle: informed choice + voluntarism = ethical FP delivery
Key definitions
RA 10354 (Responsible Parenthood & Reproductive Health Act)
Example
Midwife counsels client on all methods without coercion; client freely chooses or declines
Guarantees universal access to medically safe, effective, legal, affordable, quality reproductive health care and modern family planning methods based on informed choice and voluntarism.
Informed Choice
Example
Midwife presents COCs, DMPA, LAM equally; does not push one method
Client receives complete, accurate information on all available methods (benefits, side effects, effectiveness, use) and freely decides without pressure.
Voluntarism
Example
Client cannot be denied FP services based on marital status, age, or number of children
No method may be forced on or withheld from a client; contraception is voluntary.
Diagrams to know
- Hierarchy of midwife FP duties under RA 10354
- Informed choice decision tree
- Non-discrimination checklist in FP service provision
Methods a Trained Midwife CAN Independently Provide
Common values
Value
Every 3 months (13 weeks)
Symbol
DMPA Q3mo
Quantity
DMPA injection interval
Value
Up to 2 weeks early (11 weeks total)
Symbol
Grace early
Quantity
DMPA grace window (early)
Value
Up to 4 weeks late (17 weeks total)
Symbol
Grace late
Quantity
DMPA grace window (late)
Value
Under 6 months
Symbol
LAM <6mo
Quantity
LAM age limit for baby
Value
26–32 days
Symbol
SDM 26–32d
Quantity
SDM cycle regularity requirement
Value
150 mg intramuscular
Symbol
DMPA 150mg IM
Quantity
DMPA dose (IM)
Value
Beyond 24 hours (standard window 24 hours ± flexibility)
Symbol
COC missed >24h
Quantity
COC missed-pill definition window
Value
Beyond 3 hours (strict timing)
Symbol
POP missed >3h
Quantity
POP missed-pill definition window
Important facts
- COCs are AVOIDED in breastfeeding mothers (first 6 months) — estrogen lowers milk supply
- POPs are THE PILL FOR BREASTFEEDING mothers
- DMPA dosage: 150 mg IM every 3 months (every 13 weeks); grace window: 2 weeks early to 4 weeks late
- LAM is a BRIDGE METHOD — always counsel on follow-on method
- SDM requires partner cooperation; only for regular cycles (26–32 days)
- Condoms are the ONLY STI/HIV-protective method — always promote dual protection
- All seven methods are free under RA 10354 at RHU/BHS
Key definitions
Combined Oral Contraceptives (COCs)
Example
Yasmin, Drenovil; common side effects: spotting, headache, breast tenderness
Estrogen + progestin pills taken daily; start within first 5 days of cycle for immediate protection; contraindicated in first 6 months postpartum if breastfeeding.
Progestin-Only Pills (POPs / Mini-pills)
Example
Microlut; ideal for lactating mothers in first 6 months postpartum
Progestin-only pills for breastfeeding mothers and estrogen-intolerant women; must be taken at same time daily (strict 3-hour window).
DMPA Injectable (Depo-Medroxyprogesterone Acetate)
Example
Depo-Provera; site: deltoid or gluteal muscle; common effect: irregular spotting/amenorrhea (expected, not harmful)
Progestin-only IM injection; 150 mg every 3 months (13 weeks); no daily action needed; safe while breastfeeding.
Condoms
Example
Male condom + COC = dual protection against pregnancy and infection
Barrier method; only method providing STI/HIV protection; non-hormonal; requires user compliance.
Lactational Amenorrhea Method (LAM)
Example
Postpartum mother, fully breastfeeding, no menses = LAM effective; if menses return, must switch to DMPA or COC
Natural temporary method requiring ALL THREE: baby < 6 months, exclusive/near-exclusive breastfeeding, amenorrhea; switch methods when any condition fails.
Standard Days Method (SDM)
Example
CycleBeads: red = menses, brown = avoid intercourse, white = safe days
Fertility awareness method using CycleBeads; suits regular cycles 26–32 days; avoid unprotected intercourse days 8–19 (fertile window).
FP Counseling
Example
GATHER: Greet, Ask, Tell, Help, Explain, Return; REDI: Rapport, Exploration, Decision, Implementation
Structured information-giving using frameworks (GATHER, REDI) to ensure informed, voluntary choice.
Diagrams to know
- DMPA injection sites and scheduling (3-month cycle calendar)
- LAM eligibility checklist (3 conditions)
- SDM CycleBeads color coding
- GATHER counseling framework steps
- COC vs POP use by breastfeeding status
Methods Requiring ADDITIONAL DOH Certification (Counsel & Refer Without It)
Important facts
- IUD and implant are HIGHLY EFFECTIVE long-acting reversible methods (>99% effective)
- IUD and implant are OUTSIDE midwife scope WITHOUT specific DOH certification
- Midwife role: counsels on IUD/implant, screens for eligibility, refers to certified provider
- Certification is method-specific: IUD certification ≠ implant certification
- IUD and implant counseling is still the midwife's responsibility at community level
Key definitions
Intrauterine Device (IUD)
Example
Copper T 380A (Paragard); insertion needs trained, certified provider at RHU or health center
Long-acting reversible contraceptive; requires DOH competency-based IUD insertion/removal certification to provide; non-certified midwife counsels and refers.
Subdermal Contraceptive Implant
Example
Implanon NXT; 3-year duration; needs certified provider for insertion/removal
Long-acting reversible single-rod progestin implant; requires DOH competency-based implant insertion/removal certification; non-certified midwife counsels and refers.
Diagrams to know
- IUD types and duration (copper, hormonal)
- Implant insertion site (upper arm)
- Referral pathway for IUD/implant certification
Methods OUTSIDE Midwife Scope Entirely (Refer Only)
Important facts
- Tubal ligation and vasectomy are SURGICAL procedures — not midwife-provided
- Midwife provides pre-procedure counseling (permanent, reversibility, alternatives)
- Referral is to surgeon (RHU physician, health center, or provincial/tertiary hospital)
- Post-procedure follow-up may be midwife role (wound care, complications detection)
Key definitions
Bilateral Tubal Ligation (Female Sterilization)
Example
Client counsels on permanent nature, counsels partner involvement where appropriate, refers to provincial hospital
Surgical permanent contraceptive method for women; OUTSIDE midwife scope — midwife counsels and refers to surgeon/BEmONC facility.
Vasectomy (Male Sterilization)
Example
Couples counseling on permanent nature; refer to RHU physician or BEmONC facility
Surgical permanent contraceptive method for men; OUTSIDE midwife scope — midwife counsels and refers to surgeon.
Diagrams to know
- Referral pathway for permanent methods
- Pre-surgical counseling checklist
Screening: WHO Medical Eligibility Criteria (MEC) & Practical Checks
Common values
Value
Systolic ≥140 or diastolic ≥90 mmHg = caution/refer
Symbol
BP ≥140/90
Quantity
BP threshold for COC/DMPA screening
Value
Smokers ≥35 years (Category 3–4)
Symbol
Age ≥35+smoking
Quantity
Age limit for smoking + COCs
Important facts
- ALWAYS check blood pressure BEFORE starting COCs or DMPA (estrogen-containing methods)
- ALWAYS screen for migraine WITH AURA (contraindication to COCs/estrogen) — distinguish from migraine without aura
- ALWAYS use pregnancy checklist before starting hormonal methods or IUD
- Screen for smoking (smokers ≥35 years + COCs = Category 3–4)
- Screen for liver disease, diabetes, history of blood clots, breast cancer
- Check last menstrual period (LMP) and cycle regularity
- Assess breastfeeding status and postpartum interval
- Identify red flags: headaches with vision changes, chest pain, leg swelling, severe headache
Key definitions
WHO Medical Eligibility Criteria (MEC)
Example
Migraine with aura = Category 3–4 for COCs (avoid estrogen); hypertension = Category 2–3 depending on BP level
Four-category classification of a woman's suitability for each contraceptive method based on medical/obstetric conditions.
Category 1 (MEC)
Example
Healthy 25-year-old nulligravida taking POPs
Use the method in any circumstance; no medical restriction.
Category 2 (MEC)
Example
Breastfeeding mother 3 months postpartum using DMPA
Generally use; advantages outweigh risks.
Category 3 (MEC)
Example
Woman with uncontrolled hypertension using COCs (switch to progestin-only or non-hormonal)
Method not usually recommended unless other options unavailable; risks usually outweigh advantages.
Category 4 (MEC)
Example
Woman with history of thromboembolism using COCs; migraine with aura + COC
Method must NOT be used; unacceptable health risk.
Pregnancy Checklist (Rule Out Pregnancy Before Hormonal Methods/IUD)
Example
No unprotected intercourse since LMP? Menstruating regularly? Fully/exclusively breastfeeding with amenorrhea? Use of reliable contraception? If yes to all, not pregnant
Objective questions to reasonably exclude pregnancy before starting a hormonal method or IUD, allowing immediate initiation.
Diagrams to know
- Blood pressure categories and COC/DMPA eligibility
- Pregnancy checklist flowchart
- MEC Category decision tree for common conditions
- Red flag symptom alert list
Counseling Frameworks & Best Practices
Common values
Value
≥24 months
Symbol
Spacing ≥24mo
Quantity
Minimum birth-to-birth interval (healthy spacing)
Value
≥6 months
Symbol
Post-abort ≥6mo
Quantity
Minimum interval after miscarriage/abortion to next pregnancy
Important facts
- Counseling is itself a service the midwife provides — it is not free to skip
- Good counseling prevents dropouts and unintended pregnancies
- Counsel on advance side effects (spotting on DMPA/POPs is normal, not harmful)
- Distinguish between expected side effects and RED FLAG warning signs
- Always counsel on healthy timing and spacing of pregnancies (≥24 months after live birth, ≥6 months after miscarriage/abortion)
- Promote dual protection, especially for STI/HIV-at-risk clients
- Respect client autonomy; never withhold information to push a preferred method
- Offer method switch if client is unhappy (prevents discontinuation)
Key definitions
GATHER Framework (Counseling Mnemonics)
Example
Greet warmly → Ask about fertility intentions, history → Tell about methods → Help decide → Explain use/side effects → Return for follow-up
Step-by-step counseling approach: Greet, Ask, Tell, Help, Explain, Return — ensures thorough, client-centered FP information.
REDI Framework (Alternative Counseling Model)
Example
Build rapport (listen, non-judgment) → Explore client priorities → Help client decide → Implement method together
Rapport-building, Exploration, Decision-making, Implementation — client-centered approach emphasizing exploration of client needs and shared decision-making.
Dual Protection
Example
Client uses DMPA + condom for comprehensive protection against pregnancy and infection
Using a barrier method (condom) PLUS a more effective method (hormonal/IUD) to prevent both pregnancy and STI/HIV.
Diagrams to know
- GATHER framework steps
- REDI framework sequence
- Expected vs. warning side effects flowchart
- Healthy timing and spacing messaging
Managing Side Effects, Follow-Up & Recording
Important facts
- Irregular spotting/amenorrhea on DMPA or POPs = NORMAL and HARMLESS; counsel reassurance and counsel switch option if distressing
- Set return date BEFORE client leaves for each method (pill resupply, DMPA injection, condom restocking)
- Use Target Client List to identify and retrieve overdue clients
- Record FP data on client record and TCL, feeding FHSIS for monitoring
- Follow up on discontinuers and reasons for dropout
- Healthy timing and spacing counseling at every FP contact bridges to maternal health benefits
Key definitions
Expected Side Effects (Hormonal Methods)
Example
Spotting on DMPA/POPs, amenorrhea on DMPA, headache, breast tenderness, mild weight change
Predictable, non-serious effects that typically resolve within first few months; reassurance and counseling suffice.
Warning Signs (Red Flags)
Example
Severe abdominal pain, chest pain, shortness of breath, severe headache with vision changes, heavy/prolonged bleeding, leg swelling/pain
Urgent symptoms requiring immediate evaluation and possible method discontinuation; midwife counsels client to seek care promptly.
Target Client List (TCL)
Example
DMPA client due 24 Jan; midwife flags overdue on 7 Feb and sends barangay health worker for retrieval
RHU/BHS record tracking FP clients due for resupply/re-injection; enables midwife to follow up overdue clients and prevent dropouts.
FHSIS (Family Health Information System)
Example
Monthly FHSIS report shows 45 new DMPA acceptors, 12 COC dropouts; tracks Contraceptive Prevalence Rate progress
National health database recording FP service data (new acceptors, current users, method mix, dropouts) from RHU/BHS; feeds DOH reporting.
Diagrams to know
- Expected vs. warning side effects decision tree
- DMPA re-injection appointment tracking (grace window)
- Target Client List (TCL) structure and update frequency
Quick Method Comparison & Decision Tree
Important facts
- COC: daily pill, estrogen + progestin, avoid first 6 months postpartum if breastfeeding, start within 5 days LMP
- POP: daily pill, progestin-only, IDEAL FOR BREASTFEEDING, stricter timing (3-hour window)
- DMPA: Q3 monthly injection, progestin-only, safe breastfeeding, no daily action, irregular spotting expected
- Condom: each use, barrier + STI/HIV protection, dual protection essential
- LAM: natural, postpartum only, requires 3 conditions (baby <6mo, exclusive BF, amenorrhea), bridge method
- SDM: fertility awareness, regular cycles 26–32 days only, partner cooperation needed, days 8–19 avoid
- IUD: long-acting reversible, requires certification, midwife counsels/refers
- Implant: long-acting reversible, requires certification, midwife counsels/refers
- Tubal/Vasectomy: surgical, OUTSIDE scope, refer only
Diagrams to know
- Method selection flowchart by client scenario
- Postpartum FP timeline (when to start each method)
Must remember
- RA 10354 (RH Law 2012) mandates INFORMED CHOICE + VOLUNTARISM — no coercion, full information, non-discrimination. Every client has the right to choose or refuse any method.
- DMPA dosing: 150 mg IM every 3 months (13 weeks), grace window 2 weeks early to 4 weeks late; progestin-only so SAFE in breastfeeding.
- COCs (estrogen-containing) are CONTRAINDICATED in first 6 months postpartum if breastfeeding because estrogen reduces milk supply; POPs (progestin-only) are THE IDEAL PILL for lactating mothers.
- LAM requires ALL THREE: baby <6 months, exclusive/near-exclusive breastfeeding, amenorrhea; if any condition fails, SWITCH METHODS immediately. LAM is a bridge, not long-term.
- IUD and IMPLANT are NOT independent midwife services without DOH competency-based certification for each; midwife role is to counsel and refer to certified provider.
- Surgical methods (bilateral tubal ligation, vasectomy) are COMPLETELY OUTSIDE midwife scope — midwife counsels and refers to surgeon; cannot be provided at BHS/lying-in.
- WHO Medical Eligibility Criteria (Categories 1–4) are the screening standard. ALWAYS check blood pressure before COCs/DMPA; ALWAYS screen for migraine WITH AURA (Category 4 for COCs); ALWAYS use pregnancy checklist before starting hormonal method/IUD.
- Condoms are the ONLY method protecting against STI/HIV — promote DUAL PROTECTION (condom + hormonal method) for at-risk clients.
- Expected side effects (spotting, amenorrhea, headache, breast tenderness) settle within months and warrant reassurance + counseling; RED FLAGS (severe abdominal pain, chest pain, severe headache with vision changes, leg swelling) warrant immediate referral.
- Set return date BEFORE client leaves; use Target Client List to track overdue clients and retrieve them before dropout; record on FP client record and FHSIS to monitor Contraceptive Prevalence Rate and method mix.
Last minute tips
- Distinguish COC vs. POP: COC is estrogen-based (avoid if breastfeeding <6 months); POP is progestin-only (ideal for lactating mothers). Missed-pill window: COC 24 hours, POP 3 hours (STRICT).
- LAM is a classic exam trick: all THREE conditions must be present (baby <6mo, exclusive/near-exclusive BF, amenorrhea). If menses return or baby is ≥6 months or mother is not fully breastfeeding, LAM fails and mother MUST switch methods.
- IUD & implant certification: Midwife without certification counsels and refers — this is a high-yield distinction. Know which methods are 'counsel & refer' (IUD, implant, sterilization) vs. independently provided (COC, POP, DMPA, condoms, LAM, SDM, counseling).
- Blood pressure is a screening gate for COCs and DMPA: BP ≥140/90 mmHg is a caution/contraindication (Category 3–4); always measure before dispensing these methods. Migraine WITH aura is a Category 4 for COCs (absolute contraindication to estrogen).
- DMPA grace window: 2 weeks early (minimum 11 weeks total) to 4 weeks late (maximum 17 weeks total). Beyond 17 weeks = pregnancy test required; client is out of protection. Know the exact numbers for the exam.
Comparison tables
Oral Contraceptives: COC vs. POP at a Glance
| Feature | COC (Combined Pill) | POP (Progestin-Only / Mini-pill) |
|---|---|---|
| Hormones | Estrogen + progestin | Progestin only |
| Timing strictness | 24-hour window (flexible) | 3-hour window (strict) |
| Best for breastfeeding | NO (avoid first 6 months) | YES (ideal choice) |
| Reason for BF restriction | Estrogen reduces milk supply | Progestin does not affect milk |
| Start timing | Within 5 days LMP | Anytime if not pregnant |
| Common side effects | Spotting, headache, breast tenderness | Irregular spotting, amenorrhea |
| Missed-pill rule (missed dose = >timing window) | >24 hours | >3 hours |
| Contraindication example | Migraine with aura, smoking ≥35y, BP ≥140/90 | Fewer contraindications; safer in more conditions |
Long-Acting Methods: IUD vs. Implant vs. DMPA
| Feature | IUD | Implant | DMPA Injectable |
|---|---|---|---|
| Type | Intrauterine device | Subdermal rod implant | Intramuscular injection |
| Duration | 5–12 years (type-dependent) | 3 years | 3 months per dose |
| Effectiveness | >99% | >99% | >99% if on time |
| Reversibility | Immediate upon removal | Immediate upon removal | Delayed (weeks to months) |
| Insertion/removal | Requires DOH certification | Requires DOH certification | Midwife administers (no cert needed) |
| Midwife role (without certification) | Counsel & refer | Counsel & refer | Provide independently |
| Safe for breastfeeding | Yes (copper); hormonal types safe too | Yes (progestin-only) | Yes (progestin-only) |
| User action needed | None after insertion | None after insertion | Return Q3 months for injection |
Screening Red Flags by Method Category
| Red Flag Condition | COCs (Estrogen) | Progestin-Only (POP/DMPA) | IUD | Condom | LAM |
|---|---|---|---|---|---|
| Migraine WITH aura | Category 4 (avoid) | Category 1–2 (OK) | Category 1–2 (OK) | Safe | Safe |
| BP ≥140/90 mmHg | Category 3–4 (caution/avoid) | Category 1–2 (OK) | Category 1–2 (OK) | Safe | Safe |
| History of thromboembolism | Category 4 (avoid) | Category 1–2 (OK) | Category 1–2 (OK) | Safe | Safe |
| Breastfeeding <6 months | Category 3–4 (avoid) | Category 1 (ideal) | Category 1 (ideal) | Safe | Eligible |
| Known/suspected pregnancy | Defer (use pregnancy checklist) | Defer (use pregnancy checklist) | Screen before insertion | Safe | Not eligible |
| Smoking ≥35 years | Category 3–4 (avoid) | Category 1 (OK) | Category 1 (OK) | Safe | Safe |
| Liver disease | Category 3–4 (caution) | Category 1–2 (generally OK) | Category 1–2 (OK) | Safe | Safe |
DMPA Scheduling: Key Dates & Grace Windows
| Scenario | DMPA Timing | Grace Window | Action | Pregnancy Risk |
|---|---|---|---|---|
| Injection due on Day 1 (on time) | Every 13 weeks (91 days) | N/A | Administer; protection continuous | No break |
| Client comes 2 weeks EARLY (Day 77) | At least 11 weeks from last dose | Up to 2 weeks early allowed | Administer; extend interval | No break |
| Client comes on Day 104 (13 days LATE) | Up to 17 weeks (4 weeks late) | Up to 4 weeks late allowed | Administer; document; reinforce schedule | Small risk; use backup ≤7 days |
| Client comes >17 weeks late (e.g., Day 120) | Exceeded grace window | Outside 4-week grace period | Pregnancy test; if negative, restart series | Higher risk; rule out pregnancy |
Expected vs. Warning Side Effects (When to Reassure vs. Refer)
| Side Effect | DMPA / POPs | COCs | Action |
|---|---|---|---|
| Irregular spotting or light bleeding | Expected (months 1–3) | Expected (months 1–3) | Reassure; common; will likely settle |
| Amenorrhea (no periods) | Expected (70% of DMPA users) | Possible if hormonal dose high | Reassure; normal; not pregnancy (if on-time injection); rule out pregnancy if COC |
| Headache (mild, intermittent) | May occur | May occur | Reassure; simple analgesic OK; monitor |
| Breast tenderness | May occur | Common early side effect | Reassure; usually subsides in weeks |
| SEVERE abdominal pain | RED FLAG | RED FLAG | Refer immediately; rule out acute abdomen, ectopic, appendicitis |
| Chest pain or shortness of breath | RED FLAG | RED FLAG | Refer immediately (r/o PE, MI, cardiac) |
| Severe headache WITH vision changes | RED FLAG | RED FLAG (stop COC) | Refer immediately (r/o stroke, hypertensive crisis) |
| Leg swelling or calf pain | RED FLAG | RED FLAG | Refer immediately (r/o DVT, thromboembolism) |
| Heavy or prolonged bleeding | RED FLAG if >2–3 months | RED FLAG | Evaluate; consider method switch; rule out pathology |
Diagrams
Midwife Family Planning Scope of Practice
Visual hierarchy of midwife family planning responsibilities, showing independent provision, referral-with-counseling, and out-of-scope methods.
Contraceptive Method Selection Flowchart
Step-by-step flowchart for client presentation through method dispensing, including pregnancy screening, blood pressure check, breastfeeding assessment, and return scheduling.
LAM Eligibility Check (All 3 Conditions Required)
Decision tree showing the three mandatory conditions for LAM eligibility, emphasizing that ALL THREE must be present simultaneously or the method is not appropriate.
When to Screen, When to Reassure, When to Refer (Side Effects)
Rapid-reference flowchart distinguishing expected (reassure) vs. warning side effects (refer), with specific red-flag symptoms that require immediate action.
DMPA Injection Schedule & Grace Window Management
Visual timeline of DMPA injection scheduling, showing on-time administration, grace window boundaries, late-arrival protocols, and out-of-protection thresholds.
Contraceptive Method Lifecycle (Example: DMPA User)
State diagram showing the lifecycle of a DMPA user from screening through ongoing injection cycles, including decision points for on-time/late returns and discontinuation scenarios.
Distribution of Methods a Midwife Independently Provides
Pie chart illustrating the approximate distribution of family planning methods and services provided by trained midwives, emphasizing the large counseling and follow-up component.