Series J, Number 55
Family Planning Programs

Developing a Continuing-Client Strategy

How to meet clients' changing family planning needs

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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"

From INFO's Toolbox
• 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

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

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See INFO Reports, FOCUS ON...Improving Hormonal Method Continuation
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	Table 4. Managing Method Changes^†

Client is switching to a combined hormonal contraceptive method
Client's situation	Guidance: When to start the method	Guidance: When to use a backup method¹
Having menstrual cycles or switching from a nonhormonal method	Any time of the month Any time within 7 days after the start of her monthly bleeding (5 days if switching to combined oral contraceptives (COCs)) Any other time it is reasonably certain she is not pregnant²	Backup method needed for the first 7 days after switching, if: She is switching to monthly injectables more than 7 days after the start of her monthly bleeding She is switching to COCs more than 5 days after the start of her monthly bleeding
Switching from a hormonal method	Immediately if she has been using the hormonal method consistently and correctly Any other time it is reasonably certain she is not pregnant	No need for a backup method
Switching from an intrauterine device (IUD)	Any time within 7 days after the start of her monthly bleeding (5 days if switching to COCs) Any time after the first 7 days of monthly bleeding (5 days if switching to COCs) and, if: She has had intercourse since her last monthly bleeding, keep the IUD in place until her next monthly bleeding She has not had intercourse since her last monthly bleeding, the IUD can stay in place and be removed during her next monthly bleeding or the IUD can be removed	No backup method needed when starting within 7 days after the start of her monthly bleeding (5 days for COCs) Backup method needed for the first 7 days, if: She is switching more than 7 days after the start of her monthly bleeding (5 days if switching to COCs), and She has not had intercourse since her last monthly bleeding, and The IUD has been removed The IUD can serve as a backup method if left in place until her next monthly bleeding
No monthly bleeding (not related to childbirth or breastfeeding)	Any time it is reasonably certain she is not pregnant	Backup method needed for the first 7 days after switching to her new method
After miscarriage or abortion	Immediately	Backup method needed for the first 7 days if she is switching to her new method more than 7 days after first- or second-trimester miscarriage or abortion
After taking emergency contraceptive pills (ECPs)	Monthly injectables: Same day that the client finishes taking the ECPs COCs: The day after the client finishes taking the ECPs³	Backup method needed for the first 7 days after switching to her new method
Client is switching to a progestin-only hormonal contraceptive method
Client's situation	Guidance: When to start the method	Guidance: When to use a backup method¹
Having menstrual cycles or switching from a nonhormonal method	Any time of the month Any time within 7 days after the start of her monthly bleeding (5 days if switching to progestin-only pills (POPs) or Implanon) Any other time it is reasonably certain she is not pregnant	Backup method needed for the first 7 days after switching, if: She is switching to progestin-only injectables (POIs) or implants more than 7 days after the start of her monthly bleeding She is switching to POPs or Implanon more than 5 days after the start of her monthly bleeding
Switching from a hormonal method	Immediately if she has been using the hormonal method consistently and correctly Any other time it is reasonably certain she is not pregnant	No need for a backup method
Switching from an IUD	Any time within 7 days after the start of her monthly bleeding (5 days if switching to POPs) Any time after the first 7 days of monthly bleeding (5 days if switching to POPs) and, if: She has had intercourse since her last monthly bleeding, keep the IUD in place until her next monthly bleeding She has not had intercourse since her last monthly bleeding, the IUD can stay in place and be removed during her next monthly bleeding or the IUD can be removed	No backup method needed when starting within 7 days after the start of her monthly bleeding (5 days if switching to POPs) Backup method needed for the first 7 days (2 days for POPs), if: She is switching more than 7 days after the start of her monthly bleeding (5 days if switching to POPs), and She has not had intercourse since her last monthly bleeding, and The IUD has been removed The IUD can serve as a backup method if left in place until her next monthly bleeding
No monthly bleeding (not related to childbirth or breastfeeding)	Any time it is reasonably certain she is not pregnant	Backup method needed: For the first 7 days after switching to POIs or implants For the first 2 days after switching to POPs
After miscarriage or abortion	Immediately	Backup method needed if it is more than 7 days after first- or second-trimester miscarriage or abortion: For the first 7 days after switching to POIs or implants For the first 2 days after switching to POPs
After taking emergency contraceptive pills	Progestin-only injectables: Same day that she finishes taking the ECPs⁴ POPs: The day after she finishes taking the ECPs Implants: Can be inserted within 7 days after the start of her next monthly bleeding (within 5 days for Implanon) Any other time it is reasonably certain she is not pregnant	Backup method needed: For the first 7 days after switching to POIs or implants For the first 2 days after switching to POPs For the time period between taking ECPs until implants are inserted
Client is switching to a copper-bearing (Cu-IUD) or levonorgestrel-releasing intrauterine device (LNG-IUD)
Client's situation	Guidance: When to start the method	Guidance: When to use a backup method
Having menstrual cycles or switching from a nonhormonal method	Any time of the month Cu-IUD: Any time within 12 days after the start of her monthly bleeding LNG-IUD: Any time within 7 days after the start of her monthly bleeding Cu-IUD and LNG-IUD: Any other time it is reasonably certain she is not pregnant	No backup method needed when starting or switching to a Cu-IUD Backup method needed for the first 7 days after insertion of LNG-IUD if it is more than 7 days after the start of her monthly bleeding
Switching from a hormonal method	Immediately if she has been using the hormonal method consistently and correctly Any other time it is reasonably certain she is not pregnant	No backup method needed when starting or switching to a Cu-IUD Backup method needed for the first 7 days after insertion of LNG-IUD if it is more than 7 days after the start of her monthly bleeding No backup method needed when switching from injectables to an LNG-IUD and the IUD is inserted when the repeat injection would have been given
No monthly bleeding (not related to childbirth or breastfeeding)	Any time it is reasonably certain that she is not pregnant	Backup method needed for the first 7 days after insertion of LNG-IUD
After miscarriage or abortion	Immediately if no infection present⁵	No need for a backup method
After taking emergency contraceptive pills	Cu-IUD: Same day that she finishes taking ECPs LNG-IUD: Within 7 days after the start of her next monthly bleeding Any other time it is reasonably certain she is not pregnant	No backup method needed when starting or switching to a Cu-IUD Backup method needed for time period between taking ECPs until LNG-IUD is inserted
Client is switching to female sterilization
Client's situation	Guidance: When to start the method	Guidance: When to use a backup method
Having menstrual cycles or switching from another method	Any time of the month Any time within 7 days after the start of her monthly bleeding Any other time it is reasonably certain she is not pregnant⁶	If it is more than 7 days after the start of her monthly bleeding and she is switching from COCs or POPs, she should continue taking pills until she has finished the pill pack If it is more than 7 days after the start of her monthly bleeding and she is switching from an IUD, the IUD can be kept in place until her next follow-up visit or her next monthly bleeding No need for a backup method
Switching from an IUD	Any time within 7 days after the start of her monthly bleeding Any time after the first 7 days of monthly bleeding, keep IUD in place and perform the procedure. IUD can be kept in place until follow-up visit or her next monthly bleeding. If a follow-up visit is not possible, remove the IUD at the time of sterilization.	No need for a backup method
No monthly bleeding	Any time it is reasonably certain she is not pregnant	No need for a backup method
After miscarriage or abortion	Within 48 hours after an uncomplicated abortion, if she has made a voluntary, informed choice in advance	No need for a backup method
After taking emergency contraceptive pills	Within 7 days after the start of her next monthly bleeding Any time after her next monthly bleeding it is reasonably certain she is not pregnant	Backup method needed for time period until she can have the procedure
Client is switching to male sterilization
Client's situation	Guidance: When to start the method	Guidance: When to use a backup method
Any time of the month	Any time a man requests it, if there is no medical reason to delay	Backup method needed for 3 months after the procedure His partner can keep using her method for 3 months to keep preventing pregnancy until the vasectomy is fully effective
^†For more detailed information concerning managing method changes for breastfeeding women, the contraceptive methods mentioned in this table, and other contraceptive methods not mentioned including the combined patch, combined vaginal ring, and cervical cap, please see the forthcoming Family Planning: A Global Handbook for Providers. For ordering information see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy. ¹ Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. ² To be reasonably certain a client is not pregnant, use the FHI pregnancy checklist (see http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/pregnancy/index.htm). ³ New COC users should begin a new pill pack. Continuing users who needed ECPs due to pill-taking errors can continue where they left off with their current pack. ⁴ The client should return if she has signs or symptoms of pregnancy other than not having monthly bleeding. ⁵ IUD insertion after second-trimester abortion or miscarriage requires specific training. If not specifically trained delay insertion until four weeks after miscarriage or abortion. ⁶ If the procedure is performed within seven days after the start of her monthly bleeding, no need to use another method before the procedure. If it is more than seven days after the start of her monthly bleeding, she can have the procedure any time it is reasonably certain she is not pregnant. Source: WHO 2007 (134)

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Developing a Continuing-Client Strategy

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