Developing a Continuing-Client Strategy

Implications for a Continuing-Client Strategy • • • • • • • • • • • • • • •

1. Ibu Yati discontinued use of injectables because of weight gain and bleeding changes. Counseling about bleeding changes and other side effects helps women initiating use of injectables and other hormonal contraceptives to continue use, as well as to decide whether to start the method. Counseling before her first injection and repeated assurance afterward might have helped her manage the side effects and encourage continued use. Each time Ibu Yati returned for an injection was an opportunity to ask how she was doing with the method, whether she was satisfied, or if she wanted to change methods.
2. Ibu Yati fears the IUD but seems not to understand the device. Asking why the client is afraid of the IUD and providing accurate information may address concerns. Giving the client a sample IUD to hold may also convey its small and flexible nature.

¹ The names of the women have been changed to maintain confidentiality. Ibu is literally translated as "mother" and is used in speech much like the English words "ma'am" and "lady". In addition to the usual ranks and professional titles, it is customary to add bu or ibu when addressing women.

Implications for a Continuing-Client Strategy• • • • • • • • • • • • • • •

1. Ibu Lily's belief that long-term breastfeeding contributed to the four-year gap between births indicates a misconception about how long breastfeeding can reliably protect women from pregnancy. Providers can explain that with the Lactational Amenorrhea Method (LAM), fully or nearly fully breastfeeding women can be protected from pregnancy for up to six months as long as their monthly bleeding has not returned.
2. Ibu Lily's unplanned pregnancy may have occurred because she delayed her return to modern contraceptive method use—possibly because of her previous breastfeeding experience. Providers can help women make decisions about postpartum contraception by providing counseling during pregnancy and within a few weeks after delivery about LAM and other contraceptive methods appropriate for breastfeeding women such as implants, progestin-only pills, progestin-only injectables, and IUDs. A well-timed transition to a modern contraceptive method can help a client to space births and avoid unplanned pregnancies.
3. Ibu Lily continues to use temporary family planning methods because her husband disapproves of permanent contraception. Providers can offer clear, balanced information about female sterilization as well as other family planning methods to both the husband and wife. Counseling a couple who has reached their ideal family size on the longer-acting methods, such as IUDs or implants, is often appropriate.

Implications for a Continuing-Client Strategy• • • • • • • • • • • • • • •

1. Despite initial side effects, Ibu Efa continued to use OCs for eight years, partly because she received good counseling and supplies free of charge at the community health center. Providers should explain possible side effects to clients when they are starting a contraceptive method and assure them that most side effects are common and harmless. Clients who do not receive this counseling, especially during the first months of use, may stop taking the pill out of fear that their symptoms indicate illness. Providers should ensure that clients know they are welcome to return to the clinic if they have concerns about side effects.
2. Ibu Efa stopped using OCs when she moved away and lost access to her community health center. Clients without regular access to a source of pills can be given as much as one year's supply (13 packets), if possible. Extra supplies can give a client who is moving enough time to identify a new health care facility where she can obtain supplies. Providers also can suggest backup methods such as abstinence, male and female condoms, spermicides, and withdrawal.
3. Female sterilization is a safe method of contraception. Clinicians should discuss the rare possibility of complications before surgery takes place, however. If a client reports complications, the medical staff should listen to her concerns carefully, assure her that problems can be overcome with treatment, and provide treatment. Complications can be kept to a minimum by following infection-prevention procedures.²

² For more information on infection prevention and control, please see the publications and other materials provided by JHPIEGO, an international health organization affiliated with Johns Hopkins University, http://www.jhpiego.jhu.edu

Implications for a Continuing-Client Strategy• • • • • • • • • • • • • • •

1. Ibu Santi's use of an IUD to limit family size is appropriate, given her reproductive intentions. An IUD provides long-term pregnancy protection, and does not mask the onset of menopause. It is a good method to continue using until a woman is no longer fertile.
2. After a midwife spoke to Ibu Santi and her husband about using a modern contraceptive, they were able to come to a decision together. A partner's attitude often affects the client's decision to start and continue using contraception. Providers can include the client's partner in counseling and address their concerns or questions about family planning.
3. Ibu Santi should return to the health center to have her IUD replaced as soon as possible. While annual visits are not required for IUD users, providers should tell a client exactly what kind of IUD she has and how long it protects against pregnancy. They can discuss return visits, including when the client should come for a follow-up appointment after insertion (after her first monthly bleeding or 3 to 6 weeks after IUD insertion), and when the IUD needs to be removed or replaced. Providing a reminder card containing this information can help ensure that the client returns.