The Continuing Relationship
|
Providers can advise users of long-term methods such as Implants and IUDs when their methods need to be replaced. Discuss how to remember the date, for example, by linking it to a child's birthday or year in school. Illustration by Rafael Avila/CCP
|
In a continuing relationship with clients, family planning providers not only supply contraceptive methods but also do much more. Providers help clients manage side effects, identify health conditions that may affect contraceptive use, offer counseling and provide assistance on switching methods without risking pregnancy, and respond to other concerns clients may have about their reproductive health (see Suggested Provider Checklist for Continuing Clients).
Clinics can serve continuing clients best if they have an organized system in place to help clients return to the clinic when they should and find ways to strengthen follow-up and sustain contact with clients (16). When programs provide good-quality services, avoid unnecessary requirements, and focus on contraceptive users' individual needs, they can help clients continue to make informed choices.
Discuss Follow-Up Visits With Clients
Discussing follow-up and scheduling appointments can encourage clients to return to the clinic. Telling clients when and where to return for a visit makes it clear whether follow-up is necessary at all, a point that clients are not always aware of. Providers can explain the routine reasons for return, such as resupply of OCs or repeat injections, and discuss the importance of coming back on time.
A client who is using injectable contraceptives should be aware of the period of time when she should have another injection. Some clients may think that they need to return on a certain day when in fact the window of opportunity is several weeks. For example, with progestin-only injectables, DMPA and norethisterone enanthate (NET-EN), clients can return to the clinic up to two weeks early or two weeks late and still have a repeat injection. For combined injectables, the clients can come up to seven days early or seven days late and still have the injection (71, 134).
Reminder systems can help. Reminder systems can help clients return to the clinic. Providers can advise users of long-term methods such as IUDs and implants when their methods need to be replaced. They can discuss how to remember the date to return, perhaps tying it to the growth of a child ("Come back when your child is X years old") or a child's year in school. If possible, providers can give clients a reminder card that explains the type of IUD or implant the client is using, date inserted, removal date, and where to go if the client experiences problems. (For a sample reminder card, see Figure 2, IUD Reminder Card.)
Figure 2. IUD Reminder Card
|
Providers can give clients a reminder card that explains the type of IUD the client is using, date inserted, removal date, and where to go if they experience problems. Illustration by Rafael Avila/CCP
|
|
Providers should be aware of the variety of reasons for return and be prepared to adjust their approach to the individual client.
|
With OCs, pill vials or reminder cards that give an electronic beep each day when it is time for clients to take their next pill may help clients stay on schedule. In a study in family planning clinics in Kenya, 140 women received medication vials containing 30 daily vitamins. Half of the vials were programmed to beep each day at a time picked by the users, and half were not. After one month, the percentage of pills taken on a daily basis was significantly higher among the group with the beeping vials, at 100 % versus 93% for the other group. This approach has not been tested for OC use, however, and a potential barrier to widespread use is the high cost per vial (47).
In France a study showed that use of a small programmable reminder card developed by the pharmaceutical company Organon significantly improved OC compliance. Among women using the card, 41% reported that they had not missed any pills compared with 19% of those who were not using it (70).
Mailing reminder cards to clients can also help them return to the clinic. In the US a study of DMPA users found that women who received a mailed reminder postcard were significantly more likely than those who received no reminders to receive their next injection on time (76% versus 64%) (79).
Reaching clients in the community. Access often influences whether a woman continues to use her chosen method. It can be a particularly important issue for methods such as pills or injections that require frequent return visits to clinics or other sources of supply (11). Studies show that many women discontinue hormonal methods within the first three months—for example, not taking a second cycle of pills or not returning to a clinic for the second injection (8, 16).
Rather than requiring trips back to the clinic, family planning programs can send field workers to visit clients at home. Community follow-up visits outside the clinic can reach clients who stop using their hormonal method soon after starting because they fail to return to the clinic for scheduled follow-up (60, 64).
Postpartum clients can also benefit from community outreach. The 40-day period following childbirth is a good time for programs to help guide the mother on a path for good health for herself and her newborn (28, 39, 59, 136). In Egypt the Communication for Healthy Living Program conducts postpartum home visits to provide new mothers with information on proper breastfeeding, the importance of starting to use family planning within 40 days of childbirth, and other information on good hygiene, nutrition, and immunization. These actions help new mothers avoid accidental pregnancy, ensure proper birth spacing, and help them care for their newborns (48).
Counsel Clients Based on Their Reasons for Returning
Continuing clients have a variety of reasons for returning to the clinic. Some are satisfied with their contraceptive method and are returning for recommended consultations or resupply. Others have concerns about their method or want additional counseling, while still others want a different method or want to remove their IUD or implants.
Providers should be aware of the variety of reasons for return and be prepared to adjust their approach to the individual client (16, 101, 133, 134). In general, providers should determine returning clients' satisfaction with their method and offer to discuss any concerns they may have about its use or their health. They should also use the return visit as an occasion to discuss whether clients' reproductive intentions have changed since the last visit, so that they can counsel and assist continuing clients appropriately.
Assess satisfaction and answer questions during resupply visits. At resupply or medically recommended visits, providers should ask clients whether they are satisfied with their method and whether they have any questions or issues to discuss. Ask each female client whether she is concerned about bleeding changes or other side effects, and give her any information or help that she needs. Let her know that she can switch methods anytime, and if she wants to change methods, help her choose another one. Provide the client with additional contraceptive supplies as needed, and plan the next resupply visit (133, 134).
|
If a client returns because she is experiencing side effects, a provider should take her concerns seriously, help her manage side effects, and provide assistance on choosing another method, if appropriate. Illustration by Rafael Avila/CCP
|
The resupply visit is also a good occasion to ask whether a client has developed a new health condition or if a preexisting condition has become worse—conditions that may require a change in contraceptive methods. Health conditions can vary widely, depending on the type of contraception a woman is using. Complicated screening with a Medical Eligibility Criteria (MEC) checklist is almost never needed for continuing clients, however. Most new problems can be detected by asking, "Do you have any new health conditions or problems?" and then referring to the MEC to determine if the conditions mentioned are relevant to the client's contraceptive use (131). (For more information on the MEC, see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy)
Clients who have not developed any new health problems that affect use of their contraceptive method and who want to continue using their current contraception can safely do so. For a few conditions the criteria for starting the method differ from the criteria for continuing it. (For these criteria, see Table 3, WHO Medical Eligibility Criteria That Differ for Initiation and Continuation of a Contraceptive Method.)
Discuss and address any problems with the client's method. When clients return to the clinic because they are having problems with their method, providers should listen carefully and then offer counseling and advice. For instance, if a client is having problems using OCs, ask her how she uses them and repeat instructions about correct use. To help her remember to take her pills, try suggesting that she link taking them to a daily activity such as cleaning teeth or after an evening meal (134).
If a client is experiencing side effects, the provider should take her concerns seriously and reassure her that most side effects are common, not signs of serious illness, and usually lessen over time. Reassurance about side effects, while important, is not always enough. Clients should be offered a choice among various courses of action—for example, waiting to see if bothersome side effects resolve over time, and taking medications (such as nonsteroidal anti-inflammatory drugs for spotting). Mention clearly that if the treatment does not help, changing family planning methods is always an option. Give the client an idea of how long it will take to see if the treatment works, and if she does not want to wait that long, or still feels that the problems cannot be overcome, offer to help her choose another method (134).
Determine if reproductive desires and intentions have changed. When clients return to the clinic, providers should determine whether their reproductive intentions or life circumstances have changed since the last visit. This information can help providers counsel continuing clients. For example, if a woman wants to discontinue contraceptive use to have a baby, providers can counsel her on when and where to obtain prenatal care.
Providers can also help new mothers make a transition to a family planning method without risk of pregnancy by providing counseling on appropriate methods—both hormonal methods such as progestin-only pills (POPs), progestin-only injectables (POIs), and implants, and nonhormonal methods such as the copper IUD and LAM—and when to start them (30, 113, 133, 134). When offering to help a client shift to another method, providers must be sure to help her switch without risk of pregnancy. (For guidance on helping women switch to appropriate methods, see Table 4, Managing Method Changes.)
A client may have changed partners, or may now have multiple partners. Providers can help clients avoid the risk of STIs, including HIV/AIDS, by encouraging them to think about their level of risk and explain how to protect themselves and their partners, including explaining dual protection and condom use (134).
Ensure That Care Is Necessary, Appropriate, and of Good Quality
Continued care should be tailored to the client's reproductive intentions and personal preferences and appropriate to the contraceptive method the client is using. Providers and programs must guard against excessive requirements. Unnecessary requirements for follow-up visits to the clinic can be barriers to contraceptive continuation (25, 105, 114). Revisits entail costs to clients (including clinic fees, transportation costs, and lost wages) as well as to providers and other clients (including limiting time available for clients who return with medical problems) (56).
WHO has issued a minimum recommended follow-up schedule for safe and effective use of each contraceptive method. These recommendations vary according to the user's situation, as well as method (132). (For follow-up requirements, see Table 5, Follow-up Guidance for Continuing Users.)
The components of a continuing-client strategy are also among the essential elements of good-quality services. Offering good quality of care has become a priority for most family planning programs because it improves clients' satisfaction, increases knowledge about their chosen methods, and encourages more effective and longer use of contraception (21, 62, 88, 100, 108).
|
When clients return to the clinic, providers should determine whether their reproductive intentions or life circumstances have changed since their last visit.
|
WHO advises that providers can improve the quality of care for continuing clients by: assessing how well clients are doing with their contraceptive methods; offering help to deal with side effects, incorrect or inconsistent use, and any other problems related to contraceptive use; addressing changing family planning and reproductive health needs throughout the life cycle; and offering new methods when clients want them, or as they become available (133, 134).
Some factors can lead clients to continue using family planning, while others often lead them to discontinue use. Both sets of factors reflect individual needs and preferences, a client's relationship with partners, friends, and extended family, the influence of community, society, and culture, the social and economic setting, the policy and service delivery environment, clients' experience with health services, and characteristics unique to each family planning method. Programs and providers can influence some of these factors, while others are beyond their scope.
Understanding how family planning providers and program services can help individual clients make informed decisions about continued contraceptive use and then acting on this knowledge are at the heart of a continuing-client strategy. The strategy can enable clients to continue contraceptive use as long as they want to avoid unintended pregnancy by removing obstacles to sustained use, improving quality of care, and focusing on people's health care needs and reproductive intentions. Ultimately, the decision to continue using family planning—like the decision to start using it—is an individual choice.
|
Order this report
Download PDF
View Q & A
E-mail this page 
See companion INFO Reports, Measuring Success of a Continuing-Client Strategy
