Series J, Number 55
Family Planning Programs

CONTENTS

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New Perspectives on Continuing Clients

Table 1: Discontinuation of Contraceptive Methods

Realigning Program Goals to Assist Continuing Clients

Table 2: Key Resources for Developing and Maintaining a Continuing-Client Strategy

Adapting Service Delivery to Continuing Clients

Spotlight: In Mali CBD Helps People Continue Family Planning

The Initial Visit: Establishing a Relationship

Continuing Clients: Women's Stories

The Continuing Relationship

Bibliography

Credits

Also See: "Family Planning: A Global Handbook for Providers"

• Checklist: Suggested Provider Checklist for New Clients
• Checklist: Suggested Provider Checklist for Continuing Clients
• Table 3: WHO Medical Eligibility Criteria That Differ for Initiation and Continuation of a Contraceptive Method

• Table 4: Managing Method Changes
• Table 5: Follow-up Guidance for Continuing Users

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See companion INFO Reports, Measuring Success of a Continuing-Client Strategy
See INFO Reports, FOCUS ON...Improving Hormonal Method Continuation
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Realigning Program Goals to Assist Continuing Clients

In a continuing-client strategy family planning programs realign their goals to focus more on the changing reproductive health needs of continuing clients. A focus on continuing clients can help programs serve clients better and more efficiently, reduce levels of unmet need, and prevent unintended pregnancies.

Extending follow-up and outreach within communities can help continuing clients who need counseling or resupply, often without requiring clinic visits for these services. Integrating services at the clinic level can be a cost-effective way of serving continuing clients, particularly if community outreach is not feasible.

In addition, creating links between family planning programs and other organizations can offer continuing clients a range of care and help avoid gaps in services. Supporting these approaches with focused communication strategies within communities can foster widespread participation and support for continued contraceptive use.

Focus on Reducing Unintended Pregnancies Among Current Users

Programs conventionally have focused on meeting unmet need for family planning by reaching new clients—married women who do not want to become pregnant but are not using any contraceptive method (the essential definition of unmet need). Yet, many continuing clients have unmet need if they discontinue contraception for any reason other than to become pregnant. If family planning programs could help more continuing clients avoid the risk of unintended pregnancy, levels of unmet need for family planning would fall substantially (61).

Based on a study of data from Peru, for example, if the family planning program had focused on reducing levels of unmet need only by attracting new contraceptive users, 17% of women would have had unintended pregnancies over a two-year period. But if the program also had emphasized avoiding unmet need among continuing contraceptive users, only 6% of women would have had unintended pregnancies (61).

Providing continuity of care can raise levels of contraceptive use even more than focusing on attracting new clients. An analysis using a simulation model compared contraceptive prevalence between two programs with different acceptance rates. One program attracted many new users (20% a year) but did not provide continuity of care. This program had high discontinuation rates (60% a year), and the contraceptive prevalence rate was 33%.The other program attracted fewer new users (5% a year) but provided continuity of care. This program had substantially lower discontinuation rates (10% a year), and contraceptive prevalence was 50% (21, 62).

Reach Out to Clients in Their Communities

Reaching contraceptive users in their communities for resupply, counseling, and other follow-up services, instead of requiring them to return to clinics, can be an effective way to ensure that they continue to use family planning as long as they want to. In many countries family planning community-based distribution (CBD) workers follow up with continuing clients, offering counseling and help with resupply (14, 60).

The CBD approach has proved successful at increasing contraceptive continuation. In Iran, for example, a study found that over a six-month period continuing clients visited by CBD workers knew more about contraception compared with a control group (75% versus 64%), were more likely to use their method correctly (83% versus 74%), and were more likely to continue contraceptive use (99% versus 85%) (60).

In Bangladesh a study found that clients who had contact with family planning community outreach workers were more likely to switch from one modern contraceptive method to another one if they became unhappy with their method, rather than discontinuing contraceptive use altogether (55). Another Bangladesh study found that women who were not visited by family planning outreach workers were more likely to discontinue OC use due to side effects (64).

In rural areas, where family planning services often are scarce, CBD programs can not only extend services to new users but also reach continuing users who cannot return to a clinic for resupply. In Mali, for example, a CBD approach attracted new clients and also helped clients continue using their methods by providing personalized counseling and intensive follow-up care (see Spotlight).

A variation on the CBD approach is creating a "depot holder" system. In this arrangement a community member stores several months' supply of condoms and OCs and is responsible for distributing them. The program often pays the community member a small fee as compensation. The depot holder system ensures that the community has continuous access to contraceptive information and supplies. This approach may be more cost-effective for some programs than the standard CBD approach because it requires involvement from only a few community members, rather than a network of field workers (83).

Integrate Family Planning With Other Services

Where the need for reproductive health services is high, integration of reproductive health services at the provider level can be an effective and efficient alternative to outreach services (45). A client visit to a provider for family planning presents an opportunity also to offer other health care services—even if the client did not visit the facility for this purpose.

The types of services that clinics can offer in addition to family planning include antenatal care, nutritional assessments related to pregnancy, and treatment or counseling for sexually transmitted infections (STIs). Also, vaccinations, nutrition, and growth monitoring for children can be provided for clients who have newborns or young children.

Systematic screening can increase the number of services that clients receive at a single visit. In the systematic screening approach, developed by the Frontiers in Reproductive Health Program (FRONTIERS), providers use a checklist or brief questionnaire to identify each client's needs and desires for health services. Then, based on responses to the questionnaire, providers offer the services either during the same visit, through a follow-up appointment at the same clinic, or through referral to another facility (44, 45). (For more information on systematic screening, see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy.)

Table 2. Key Resources for Developing and Maintaining a Continuing-Client Strategy
The resources found in this table can help program managers and providers strengthen their continuing-client strategy. The table includes counseling and decision-making tools that providers can use with their clients.
Resource	Availability
Title: The Decision-Making Tool Organization: World Health Organization (WHO), Department of Reproductive Health and Research and the INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health Description: A decision-making aid for family planning clients, a job-aid and reference manual for providers, and a training resource. Includes evidence-based technical information on 14 family planning methods, including medical eligibility criteria, side effects, when to start, and how to use each method. Includes a section focused on returning clients.	For more information or to download the tool see: http://www.who.int/reproductive-health/family_planning/counselling.html Or contact: The INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health 111 Market Place, Suite 310 Baltimore, MD 21202 USA Tel: +1 410 659 6300 Fax: +1 410 659 6266 E-mail: orders@jhuccp.org
Title: Balanced Counseling Job Aids Organization: Population Council, Frontiers in Reproductive Health (FRONTIERS) Description: Combines an algorithm for family planning counseling with a set of job aids, such as cards and pamphlets on available methods. Designed to improve client-provider interaction by encouraging focus on the client's needs, support of the client's chosen method, and provision of accurate family planning information.	User's guide is forthcoming. For more information see Enhancing Quality For Clients: The Balanced Counseling Strategy at http://pdf.dec.org/pdf_docs/PNADD850.pdf Or contact: FRONTIERS Population Council, c/o Laura Raney 4301 Connecticut Ave. N.W., Suite 280 Washington, DC 20008 USA Tel: +1 202 237 9400 Fax: + 202 237 8410 E-mail: LRaney@pcdc.org
Title: Counseling for Effective Family Planning Use: A Curriculum Organization: The ACQUIRE Project, EngenderHealth Description: In an effort to address discontinuation of family planning use, this curriculum focuses on improving providers' ability to conduct counseling tailored to the unique needs of individual clients in an efficient manner that increases clients' satisfaction and the overall quality of family planning services. It brings renewed focus to addressing the needs of returning clients and places family planning counseling within the broader context of sexual and reproductive health.	Curriculum is forthcoming, Spring 2007. To obtain more information contact: The ACQUIRE Project EngenderHealth 440 9th Ave. New York, NY 10001 USA E-mail: info-acquire@acquireproject.org
Title: Adding Systematic Screening To Your Program: A Manual Organization: Population Council, FRONTIERS Description: Designed to assist program decision-makers, managers, supervisors, and providers to implement systematic screening in their health services. It provides the information and tools needed for adding systematic screening including: how to implement systematic screening, how to select clinics, services to screen for, systematic screening checklist development, and advice for training screeners, providers, and supervisors.	To obtain a copy of the manual contact: FRONTIERS at frontiers@pcdc.org
Title: Family Planning: A Global Handbook for Providers and The Essentials of Contraceptive Technology Organization: WHO, Department of Reproductive Health and Research and the INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health Description: The Global Handbook improves on its predecessor, the Essentials of Contraceptive Technology, by covering more methods and more related topics, strengthening the evidence base for its guidance, and substantially increasing the content developed through organized consensus-development processes.	The Global Handbook is forthcoming, Spring 2007. For more information see http://www.fphandbook.org Download The Essentials of Contraceptive Technology at http://www.infoforhealth.org/pubs/ect/ Or contact: The INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health 111 Market Place, Suite 310 Baltimore, Maryland 21202 USA Tel: +1 410 659 6300 Fax: +1 410 659 6266 E-mail: orders@jhuccp.org
Title: Medical Eligibility Criteria for Contraceptive Use, Third Edition–2004 Organization: WHO Description: Reviews the medical eligibility criteria for use of contraception, offering guidance on the safety of use of 19 different methods for women and men with specific characteristics or known medical conditions. Updates the 2nd Edition, entitled Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use, which was published in 2000.	Download at http://www.who.int/reproductive-health/publications/mec/index.htm Or contact: WHO Department of Reproductive Health and Research Documentation Centre 1211 Geneva 27 Tel: +41 22 791 4447/3346 Fax: +41 22 791 4189 E-mail: rhrpublications@who.int

Link With Other Organizations to Provide a Continuum of Care

Creating links with other service organizations and establishing referral systems are vital to a continuing-client strategy because not all services can be or should be offered at all health facilities. Family planning programs can establish referral procedures both within facilities (as in large facilities with multiple departments) and between facilities (as when a small clinic refers clients to services at a larger one) (112).

In a small-clinic setting, offering referral services could be as simple as having providers inform clients about alternative sources of contraceptive supply, so that in the event of a stockout, they will know the nearest available source for their method (16, 58, 61).These sources often include pharmacists and other private-sector providers in the community, as well as other nearby clinics.

Providing access to a wide range of services helps assure that continuing clients safeguard their health. The Greenstar program in Pakistan links family planning and other reproductive health services nationwide through a network of private doctors, pharmacists, and community-based workers. Providers deliver family planning services based on their position in the referral network, and clients seeking services that are not offered by a particular Greenstar provider are referred to other providers in the system (85, 97).

Develop Communication Strategies Focused on Communities

A continuing-client strategy should take into account the social, cultural, and community beliefs that influence people's family planning decisions (104). People consider personal, social, and economic issues as well as fertility desires and health concerns when they make contraceptive decisions (54, 118).

Clients are family members and often belong to extended families, informal social networks, and the larger community. Before making a family planning choice, people often participate in an information-gathering and decision-making process, where they seek out contraceptive users among their family and friends to discuss their experiences (106). After they start using a contraceptive method, they usually continue to talk about it with others (104). When programs involve community members as well as clients themselves, they help make the behavior changes that using family planning requires more acceptable and consistent with community norms (83, 104).

Many women discontinue family planning because their husbands, other family members, and community authorities disapprove (11). Communication with the community can build approval and support. In Bangladesh, for example, government field workers organized group discussions on family planning with women in the homes of leaders in each village's social network. Among the community women participating in the social network approach, the rate of increase in modern contraceptive use was five times greater than among women who were visited by family planning field workers at home (67).

Encourage men to participate in family planning. Involving men can be crucial to a continuing-client strategy (16, 27). Men are more likely to support continued contraceptive use when they participate. A study in Egypt, for example, found that women whose husbands knew that they had visited a clinic to initiate IUD use were almost twice as likely to continue its use as those whose husbands did not know (121).

Family planning providers can involve men and serve them better if they take four steps: (1) offer men family planning and other reproductive health services, (2) provide men with accurate information about family planning, (3) explain how men can assure their own reproductive health as well as that of their partners, and (4) encourage couples to talk to each other about family planning, as well as talking to health care providers (134).

Programs can encourage men to talk with their partners about practicing family planning and sharing decision-making often by appealing to their sense of responsibility in family matters (27). Studies in Brazil, Colombia, and Mexico found that men's concerns for their wives played an important role in deciding to have a vasectomy. Men said they had vasectomies because it provided freedom from unintended pregnancy, had advantages over female sterilization and temporary methods, they believed it would help protect their wives' health, and they wanted to share responsibility for family planning (128).

Involving men is also important because two family planning methods—vasectomy and condoms—are male methods (134). In much of the world, however, condoms and vasectomy suffer from misinformation, rumors, and undeserved poor reputations. Men need clear, factual information from reliable, trusted sources in order to make informed decisions about using these methods (34).

Use mass media to encourage contraceptive continuation. The mass media have an impressive record of conveying important family planning and reproductive health messages through entertainment, TV and radio spots, short serials, and other programming (96). Exposure to family planning messages in the mass media leads to more contraceptive use. For example, in Tanzania a study found that women's exposure to at least one source of media messages about family planning was associated with an 18% increase in contraceptive use compared with a 3% increase among women who had not heard or seen the messages (63). Similarly, in Gambia a survey to determine the effects of a radio drama about family planning found that people who heard the program were more than twice as likely to use modern methods as those who did not hear the program (35% versus 16%) (127).

In Nepal the Radio Communication Project, which ran from 1995 through 2001, included two entertainment-education radio programs about family planning, an interactive distance education program for health care workers, and a national dramatic series. Female health volunteers moderated community meetings at which people listened to the radio programs and discussed each episode. Evaluation showed that people who participated in these listening groups and were exposed to the radio programs were eight times more likely to be informed about contraceptive methods than others. This group was also three times more likely to discuss family planning methods with their spouses and six times more likely to have discussions with friends and other family members. They were also almost twice as likely to be using modern contraception (116).