Developing a Continuing-Client Strategy Q&A 

New Perspectives on Continuing Clients

1. Why should family planning programs focus on continuing clients?

As more and more people use family planning, continuing clients outnumber new clients by a widening margin. A family planning program that focuses on clients not only when they first choose contraceptive methods but also throughout their lives can offer better care than one that focuses on new clients alone.  

2. Why should programs adopt a life-stage perspective?

Adopting a life-stage perspective can help programs identify clients’ continuing family planning needs and thus provide information and services as their needs change.  This perspective can form the basis for a continuing-client strategy. 

3. How does the life-stage perspective help identify continuing needs?

People’s family planning needs last for a reproductive lifetime, and often change as their life stage changes. A program that can adapt to these changing needs will be better equipped to meet client expectations. From a life-stage perspective, continuing family planning clients can be seen as a broad spectrum of people, including couples who are newly married or have had their first child and would like to limit births, currently pregnant women, women trying to become pregnant, and people who are satisfied with their family size and want to stop having children. 

4. How does the life-stage perspective form the basis for a continuing-client program strategy?

A life-stage perspective can form the basis for a continuing client program strategy that provides for a continuum of care. From a life-stage perspective, clients who want to switch contraceptive methods are not just discontinuers of one method or new users of another one but continuing users whose family planning needs have changed. From the same perspective, clients who stop contraceptive use to become pregnant are not discontinuers but rather continuing clients whose reproductive intentions have changed. 

5. Are continuing clients at risk for unintended pregnancy?

Yes. Many continuing clients discontinue use of their contraceptive method even though they do not want to get pregnant, and expose themselves to the risk of unintended pregnancy.   

6. What are the most common reasons women have for discontinuing their contraceptive method?

The two most common reasons that women discontinue a contraceptive method other than desire for pregnancy are: (1) becoming pregnant while using a contraceptive, and (2) side effects.  

7. Why do unintended pregnancies occur among women using contraception?

Among women using contraception, the majority of unintended pregnancies occur because of inconsistent or incorrect use of the method, or because the user discontinued one method without immediately switching to another effective method. Data from Demographic and Health Surveys (DHS) reveal that, among women who became pregnant while using a contraceptive method, most were relying on periodic abstinence and withdrawal—among the least effective methods—followed by oral contraceptives (OCs) and condoms—methods that are user-dependent and that people often use inconsistently and incorrectly. 

Realigning Program Goals to Assist Continuing Clients

8. Why should programs 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 methods.  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.  

9. In what ways can family planning programs reach out to clients in their communities?

The community based distribution (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%).  A cost-effective variation to the CBD approach is creating a “depot holder” system, where a community member stores several months’ supply of condoms and OCs and is responsible for distributing them.  

10. How can integrating services help continuing clients?

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

11. What types of services can be integrated?

In addition to family planning, clinics can offer 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.  

12. Are there any tools that family planning clinics can use to integrate services?

Yes. 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. 

13. Why are creating links with other service organizations and establishing referral systems vital to a continuing-client strategy?

Not all services can be or should be offered at all health facilities.  Family planning programs can therefore establish referral procedures both within facilities and between facilities. 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. These sources often include pharmacists and other private-sector providers in the community, as well as other nearby clinics. 

14. Why is it important to 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. People consider personal, social, and economic issues as well as fertility desires and health concerns when they make contraceptive decisions. Many women discontinue family planning because their husbands, other family members, and community authorities disapprove. Communication with the community can build approval and support. 

15.  Are men important to a continuing-client strategy?

Yes. Men can be crucial to a continuing-client strategy. 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. Involving men is also important because two family planning methods—vasectomy and condoms—are male methods. 

16. How can family planning providers encourage men to participate in family planning?

Family planning providers can involve men and serve them better if they take four steps: (1) offer men family planning and 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. Programs can encourage men to talk with their wives about practicing family planning and sharing decision-making often by appealing to their sense of responsibility in family matters. 

17. Is using the mass media important in a continuing-client strategy?

The mass media can be used to encourage contraceptive continuation. The mass media has an impressive record of conveying important family planning and reproductive health messages through entertainment, TV and radio spots, short serials, and other programming. Exposure to family planning messages in the mass media can lead 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. 

Adapting Service Delivery to Continuing Clients 

18.  Why is it important to offer a continuous supply of a range of methods?

People are more likely to continue to use contraception when many contraceptive methods are readily available, because they have more options to meet their changing reproductive health needs. No single family planning method works for everyone, and seldom does one method suit anyone for a lifetime. If the right method is not available when needed, some clients abandon contraception altogether. 

19. How can family planning programs ensure a continuous supply of a range of methods?

To offer a range of contraceptives without interruption, programs need efficient logistics systems. Failure of the contraceptive supply chain leads to erratic supply or stockouts. The effects on clients can be severe: widespread discontinuation, loss of confidence and trust in services, an increase in unintended pregnancies, and more exposure to the risk of STIs, including HIV/AIDS. A family planning logistics management information system (LMIS) can help programs support the continuous delivery of supplies to clients. 

20. Can programs meet the needs of continuing clients in other ways?

Programs also can help meet the needs of continuing clients by including family planning methods that do not require either supplies or a medical procedure. Such alternatives include the Lactational Amenorrhea Method (LAM) for postpartum women, fertility awareness methods, and withdrawal. Particularly in countries where supplies of modern methods are scarce and stockouts are common, these alternatives to supply and clinical methods can encourage continued contraceptive use. 

21. How can programs help providers respond to individual client needs?

Providers often require training to improve their ability to help clients choose an appropriate method, to counsel continuing clients on problems with using their methods, and to help them switch methods if necessary. Providers can benefit from expert guidance that specifies what topics to cover at clients’ initial and continuing visits, including handbooks and job aids that help them identify client concerns and answer questions about contraceptive use and side effects. 

22. Are there specific guidance tools that can help providers improve their counseling techniques?

There are a number of tools that providers can use.

a.       Family Planning: A Global Handbook for Providers (forthcoming). The most recent evidence-based expert guidance on contraceptive methods is contained in this handbook. It can help family planning providers to assist clients in choosing a family planning method, to support effective use, and to solve clients’ problems with contraceptive use. The handbook also contains specific information on how to help continuing users of each contraceptive method (developed by the World Health Organization and the Johns Hopkins INFO Project).

b.      Counseling for Effective Family Planning Use: A Curriculum (forthcoming). This curriculum stresses the importance of preparing new clients for the possibility of side effects, and provides specific guidance about meeting the needs of continuing clients, whose counseling needs are often overlooked (developed by the ACQUIRE Project).

c.       Decision-Making Tool for Family Planning Clients and Providers (DMT). This two-sided flipchart (developed by WHO and the Johns Hopkins INFO Project) assists both clients and providers with decision-making about family planning methods. The DMT also contains a counseling section focused on continuing clients.

d.      Balanced Counseling Strategy. A decision tree that should be used in combination with several job aids, or visual memory aids (developed by the Population Council).

e.       Checklists for reproductive health services. Checklists improve the quality of care by helping providers accurately screen clients for safe contraceptive use. Increasing a program’s ability to provide contraceptives safely at the community level helps to overcome unnecessary medical barriers for contraceptive use (developed by Family Health International). 

23. How can client flow be organized to encourage continuation?

Express lanes for continuing clients are a good way to help improve client flow. When clients come into the clinic, the receptionist can identify those who can be served quickly and separate them from others who will require more time. Alternatively, clinics can set up separate registration areas for new clients and continuing clients. In smaller clinics, managing provider and clinic schedules is an alternative, in which specific days are assigned for continuing clients versus new clients. 

The Initial Visit: Establishing a Relationship 

24. Why is record keeping important to a continuing-client strategy?

A good client record-keeping system can make sure that providers have ready access to each client’s medical history, clinical information, and family planning experience for every return visit. Keeping accurate records on continuing clients promotes better continuity of care for returning clients and also helps identify clients who do not return to the clinic for supplies or a follow-up visit. 

25. Should all methods be discussed with new clients? 

No. Clients vary widely in their preferences, practices, and concerns about family planning. Some new clients know exactly what contraceptive method they want when they first visit a clinic; others are unsure.  New clients who know the method they want usually are best served when providers offer their chosen method.  

26.   How can providers help new clients choose an appropriate contraceptive method?

For clients who know what method they want, providers should offer to discuss the client’s chosen method.  This practice helps ensure consistent and correct use—keys to contraceptive effectiveness. Clients who are unsure of the contraceptive method they want often need more counseling. Engaging the client in a dialogue about family planning, can help her choose a method that she feels comfortable using. If a woman does not have a specific method in mind, providers can help her choose an appropriate one by: (1) focusing on her reproductive intentions and (2) discussing the characteristics she is looking for in a method.  

27.   How can providers encourage new clients to continue use?

Once clients have chosen a contraceptive method, providers can help them continue effective contraception by:

·        Assuring clients that they can switch methods at any time, and enable them to do so conveniently.

·        Helping clients understand and know how to manage contraceptive side effects.

·        Providing clients with adequate supply and avoid gaps in coverage that can lead to unintended pregnancies.

·        Offering continuing care—inviting clients to return to the clinic for any reason at any time. 

The Continuing Relationship 

28. Why should providers 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. 

29. Why do continuing clients return to the clinic?

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.  

30. How should providers handle return visits?

Providers should be aware of the variety of reasons for return and be prepared to adjust their approach to the individual client. In general, providers should determine a returning client’s 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 the client’s reproductive intentions have changed since the last visit, so that they can counsel and assist continuing clients appropriately. 

31. How can programs and providers improve the quality of care for continuing clients?

Programs and 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.