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Closing the Effectiveness Gap |
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| June 2007 Issue No. 13 |
The INFO Project • Johns Hopkins Bloomberg School of Public Health • Center for Communication Programs • 111 Market Place, Suite 310 • Baltimore, Maryland 21202, USA • 410-659-6300 • 410-659-6266 (fax) • www.infoforhealth.org • infoproject@jhuccp.org | |
COUNSELING FOR EFFECTIVE USE
The provider, as well as the client, plays a key role in contraceptive effectiveness. Providers can counsel family planning clients to use their chosen methods as effectively as possible. Counseling can help clients achieve the greatest protection against unintended pregnancy that their contraceptive method can provide. Family planning programs, too, play an essential role in promoting effective use (see, “How Programs Can Improve Contraceptive Effectiveness”).
In counseling, providers can focus on three issues that encourage and support clients’ effective use of contraception. Providers can:
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Discuss the effectiveness gap to encourage correct and consistent use. To emphasize the client’s role in ensuring contraceptive effectiveness, explain how clients can close the gap between the typical-use pregnancy rate of the client’s chosen method and its perfect-use pregnancy rate.
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Discuss when and whether to use two methods together. Depending on when they start, some contraceptive users will also need to use a second method at the same time until their method becomes effective. Also, couples using a less effective method who want to ensure greater protection against pregnancy can use two contraceptive methods together.
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Counsel clients on what they must do to ensure greatest effectiveness. Providers can give clients instructions and emphasize easy-to-remember tips on how to use their contraceptive method properly to ensure greatest effectiveness, particularly for methods that require user action.
Discuss the Effectiveness Gap to Encourage Correct and Consistent Use
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Once a client has chosen a family planning method, the provider can help the client get the greatest possible protection against pregnancy by counseling how to close the gap between perfect-use contraceptive effectiveness and effectiveness as the method is typically used (see “Perfect Use and Typical Use”). If the client has chosen a method with a large gap between the two rates, the provider can start by explaining that its effectiveness depends largely on how well the user can close the gap by following the method’s rules for correct and consistent use.
As mentioned, a contraceptive method can be as effective in typical use as the perfect-use pregnancy rate indicates, but only if the client uses it correctly and consistently. Because the typical-use rate is an average rate, an individual client could achieve much more or much less contraceptive protection than this rate indicates, particularly for methods with which user action plays a large role in determining actual effectiveness.
If a client has chosen a less effective method than other available methods, or one that requires more action from the client to be effective, the provider should explore with the client how important it is for the client to avoid pregnancy and how well the client will be able to use the chosen method properly. If this client wants to avoid pregnancy as much as possible but does not want to switch to a more effective method, or to a method that requires less of the user for its effectiveness, the provider can discuss whether using two methods together to lower the risk of unintended pregnancy would be feasible (see “Discuss When and Whether to Use Two Methods Together”).
The provider also can tell the client about emergency contraception. Even the best intentioned and most careful people do not always use their contraceptive methods correctly and consistently. Providers can advise clients that they still have a chance to prevent pregnancy even after having sex and making a contraceptive mistake—if they use emergency contraception within five days (see “Feature: Emergency Contraception: A Second Chance”).
For women with certain medical conditions that make pregnancy riskier to their health, providers should emphasize the special importance of ensuring contraceptive effectiveness. Such conditions include some reproductive tract infections and disorders, cardiovascular disease, and endocrine and gastrointestinal disorders (139). (For a complete list see the WHO publication, Medical Eligibility Criteria for Contraceptive Use.) Providers should advise women with these conditions that a family planning method requiring correct use on a daily basis or each time they have sex may not be the most appropriate choice (61, 139).
 In Jordan a health worker counsels a family planning client that she must remember to obtain a repeat injection of the progestin-only DMPA injectable every three months. Emphasizing the most important action for effective use of contraceptive methods helps clients ensure greatest effectiveness against unintended pregnancy. © 1998 Jennifer Knox/CCP, Courtesy of Photoshare |
Discuss When and Whether to Use Two Methods Together
Using two family planning methods simultaneously can dramatically lower the risk of unintended pregnancy, particularly if a couple uses both methods consistently and correctly (66, 119). To obtain extra contraceptive protection, combining some of the less effective nonhormonal methods with a more effective hormonal method, or combining a barrier method with any other type of method, could be a good choice. It is not practical, however, and probably also not advisable medically, for a woman to use two hormonal methods together—for example contraceptive implants and oral contraceptive pills.
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Dual method use also could be a good option for couples who want to reduce the risk of pregnancy as much as possible but do not want to or cannot use a long-term or permanent method, such as an IUD or sterilization. Couples who do not always use a single method correctly, as well as women for whom pregnancy is especially risky, also could benefit from using two methods together, provided they use both methods consistently (66). Using male or female condoms along with another contraceptive method would offer more effective protection against pregnancy than using just one method, and would also help protect the couple from sexually transmitted infections, including HIV.
Starting hormonal methods or vasectomy. Some people just starting contraceptive use, as well as some current users switching to another method, need to use an immediately effective backup method along with their new method (or should abstain from sex) until the new method becomes effective. Whether the user needs to use a backup method, and for how long, depends on both the new method itself and when the client starts using it (136).
For example, for hormonal methods not started early in the menstrual cycle, the need for a backup method ranges from two days to seven days. For vasectomy, a couple needs to use another method as well for the first three months (136). (For more information on whether and when to use a backup method when starting a method, see the publication Family Planning: A Global Handbook for Providers (136).)
Appropriate backup methods include male and female condoms, spermicides, and withdrawal. These methods provide immediate protection against pregnancy when used correctly and consistently. Male condoms are more effective than either spermicides or withdrawal in both perfect and typical use. Female condoms also are more effective than spermicides or withdrawal in perfect use. Effectiveness of female condoms and withdrawal in typical use is similar (see Table 1).
Counsel Clients on What They Must Do to Ensure Greatest Effectiveness
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Providers should counsel clients on what specific behavior is required to ensure greatest effectiveness of their chosen method—particularly for methods that require substantial user action. During counseling, providers can emphasize the most important action for effective use of their method and can offer tips on how to stick to the key action. Focusing on the most important action will avoid the possibility of overwhelming clients with too much information, as most people can grasp only two or three important pieces of information in a brief time (43).
Providers can give clients take-home materials to reinforce the full set of instructions for effective use. For example, Table 2, offers instructions and tips for effective use of the most widely used contraceptive methods that require user action.
For users of oral contraceptives, the most important action needed for effective use is taking a pill every day. The provider can emphasize this behavior and suggest that the client keep her pill pack next to something she uses every day, such as her toothbrush, to help her remember (23).
Technological solutions also have been developed to help women solve the problem of remembering to take a pill every day. They range from having the client set her mobile phone’s reminder alarm to go off when it is time to take her pill, or having the family planning clinic send automatic daily text-message reminders to clients’ mobile phones, to having clients carry electronic reminder devices that make a beeping sound each day when it is time to take the pill (9, 10, 70, 82). In developing countries mobile phone technology is being used in many health service delivery areas, for example, to encourage patients with diabetes, tuberculosis, or HIV to continue and complete their treatment regimens (9, 16, 125).
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Providers are responsible for explaining contraceptive effectiveness so that clients have the understanding to make informed choices. Providers also can help clients close the gap between the inherent effectiveness of a method and its effectiveness as typically used. They can offer counseling and practical guidance on instructions for effective use of clients’ chosen methods.
Family planning programs also have a responsibility to offer good-quality services. Clients who have convenient and continuous access to a range of contraceptive methods are better able to choose the methods most suitable to their individual situations and to use them continuously, as long as they want to avoid pregnancy.
Working together, family planning clients, providers, and programs can improve contraceptive effectiveness—enabling women and men around the world to choose more effective methods, and to use their chosen methods more correctly and consistently. In doing so, they could help avoid millions of unintended pregnancies.
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