The following are the standards for midwives to independently prescribe, order and administer hormonal contraceptives in the community, hospital or other sites of midwifery practice for clients in care, as designated under specialized practice certification. Midwives without Specialized Practice Certification in Hormonal Contraceptive Therapy are required to refer their clients to an appropriate health care practitioner for treatment.
In Canada, the progestin-only contraception is available as an injectable depot medroxyprogesterone acetate (DMPA) or oral norethindrone (progestin only pill or POP).
Depot Medroxyprogesterone (DMPA)
DMPA is highly effective form of contraception, with a failure rate of less than 0.3% per year. It inhibits the secretion of pituitary gonadotropins which suppresses ovulation, increases the viscosity of cervical mucus and induces endometrial atrophy. As DMPA is estrogen free, those with known contraindications or sensitivity to estrogen can take it, including those who: 1) smoke and are >35; 2) have frequent migraine headaches; 3) are breastfeeding, 4) have endometriosis or 5) sickle cell disease, or 6) take anti-convulsant medications.
The use of condoms is still recommended in DMPA users for protection against sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection. As it is delivered by injection and lasts 12 weeks it is also very helpful for those who may not be able to be compliant with a daily pill regime.
Dosage and Administration:
150 mg intramuscular injection every 12 weeks. The IM injection can be given in the deltoid or gluteus maximus muscles. Initial dose can be given at any time when pregnancy can definitely be ruled out; however, ideally it is given within first 5 days of menses. Contraception is assured within 24 hours of injection. However, if given after the first 5 days of the menstrual cycle, advice should be provided on use of a backup method of birth control for at least 1 week. If switching from using a combined oral contraceptive (OC) to DMPA, DMPA should be given within the first 5 days of stopping the combined OC.
- pregnancy (known or suspected),
- unexplained vaginal bleeding,
- current diagnosis of breast cancer.
- severe cirrhosis,
- active viral hepatitis,
- benign hepatic adenoma.
Warnings and Precautions:
Delayed return to fertility, loss of bone density.
Those with a history of depression may be at greater risk of mood disorders. With severe depression, the use of Depot Medroxyprogesterone (DMPA) needs to be discontinued, depression may take longer to resolve.
Menstrual cycle disturbance, hormonal (headache, acne, decreased libido, nausea, and breast tenderness), weight gain, and mood disturbances.
As noted above, prescribing contraceptives requires certification as a specialized practice. (See Framework for Certification in Prescribing Contraceptives).