New Perspectives on Continuing Clients
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A family planning program that focuses on clients throughout their reproductive lives can offer better care. Illustration: Rafael Avila/CCP
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Family planning programs conventionally have paid primary attention to attracting new clients. Yet, each new family planning user is also a potential continuing client. 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 a contraceptive method but also throughout their reproductive lives can offer better care than one that focuses on new clients alone (16, 86). People's family planning needs last for a reproductive lifetime, and often change as their life stage changes (11). 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 program strategy.
Life-Stage Perspective Helps Identify Continuing Needs
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 space births, couples who would like to limit their births, currently pregnant women, women trying to become pregnant, and people who are satisfied with their family size and want to stop having children (98).
Most people change contraceptive methods a number of times over their reproductive lives, and also have times when they are not using contraception (11, 90). Some continue using their first method for several years, then discontinue its use to have a child, and later either resume using the same method or choose a new one, depending on their reproductive intentions. Others change methods because they want to find a more effective or convenient method, are dissatisfied with side effects, have problems obtaining their method, or just want to try something new (15) (see Continuing Clients: Women's Stories).
Ideally, people would continue using contraception for as long as they want to avoid pregnancy. But many people discontinue use even though they do not want to get pregnant—and thus expose themselves to the risk of unintended pregnancy. The most common two reasons that women discontinue a contraceptive method other than desire for pregnancy are: (1) becoming pregnant while using a contraceptive, and (2) side effects (4, 6, 18, 19, 37, 57, 64, 102, 121, 123) (see Table 1, Discontinuation of Contraceptive Methods).
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 one (49, 122, 137). Analysis of data from the Demographic and Health Surveys (DHS) reveals 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 (87).
Family planning providers and programs can help continuing clients who want to avoid pregnancy by addressing their concerns about using contraception and providing encouragement and counseling for maintaining effective contraceptive use. Clients who stop using contraception even though they want to avoid pregnancy often need counseling to help them manage side effects or to choose another method.
Continuing clients who are satisfied with their current contraceptive method often return to the clinic for resupply or for answers to questions about their method. Return visits offer an opportunity for providers to counsel about correct and consistent contraceptive use and to address clients' concerns about side effects or other problems. Similarly, clients whose reproductive circumstances have changed often need help from providers to switch to other methods that are more appropriate. Clients who are supported in their family planning choices and who receive high-quality care are more likely to continue using their methods and experience fewer unintended pregnancies (99).
When women are able to continue using contraception to control their childbearing effectively, they benefit in other ways as well. They can have more access to schooling, jobs, and community involvement (10, 12, 107, 124). Many people who continue to use contraception experience a freedom from the fear of pregnancy that improves their sexuality, marital relations, and family well-being (69).
Toward a Continuing-Client Program Strategy
A life-stage perspective can form the basis for a continuing-client program strategy that provides 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 in order to become pregnant are not discontinuers but rather continuing clients whose reproductive intentions have changed.
Programs can adopt a continuing-client strategy by realigning their activities to focus more on continuing clients, as well as continuing to focus on new users. Most family planning programs already offer substantial counseling and support for contraceptive use. But they could provide even better service by concentrating on reducing unintended pregnancies among current clients, reaching out to continuing clients in their communities, and taking other steps to support continued contraceptive use (see Realigning Program Goals to Assist Continuing Clients).
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Family planning providers and programs can help continuing clients by addressing their concerns about using contraception and by providing encouragement and counseling for maintaining effective contraceptive use.
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Programs also can make changes in their clinic operations to strengthen their relationship with continuing clients and help them meet their contraceptive needs. Programs can offer a continuous supply of a range of family planning methods, train providers to respond better to continuing clients, reorganize client flow within clinics to differentiate better between new and continuing clients, and maintain records that help them serve continuing clients over the course of their reproductive lives (see Adapting Service Delivery to Continuing Clients).
For family planning providers, a continuing-client strategy begins with a structured initial meeting with a new client during which the provider identifies the client's health care needs and offers counseling—and establishes the basis for a sustained relationship (see The Initial Visit: Establishing a Relationship). Then, follow-up including continued counseling in return visits and community outreach can ensure an enduring partnership for good health (see The Continuing Relationship).
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| Table 1. Discontinuation of Contraceptive Methods |
| Percentage distribution of discontinuation of the last contraceptive method discontinued in the five years preceding the survey by main reason for discontinuation, total of all contraceptive methods |
| Region & Countries |
Became Pregnant While Using |
Wanted to Become Pregnant |
Side Effects |
Health Concerns |
Wanted More Effective Method |
Access,
Availa-
bility or
Cost |
Incon-
venient
to Use |
Husband Disapproved |
All Other Reasons* |
| Sub-Saharan Africa |
| Tanzania 2004 |
10 |
38 |
21 |
1 |
8 |
4 |
3 |
4 |
11 |
| Zimbabwe 1999 |
12 |
35 |
11 |
7 |
5 |
7 |
3 |
4 |
18 |
| North Africa/West Asia/Europe |
| Armenia 2000 |
53 |
9 |
2 |
7 |
8 |
2 |
3 |
4 |
14 |
| Egypt 2000 |
9 |
28 |
36 |
5 |
4 |
0 |
2 |
1 |
15 |
| Jordan 2002 |
21 |
31 |
13 |
9 |
11 |
0 |
5 |
2 |
7 |
| Morocco 2003/2004 |
15 |
29 |
3 |
15 |
14 |
0 |
2 |
0 |
22 |
| Turkey 1998 |
21 |
20 |
11 |
6 |
8 |
1 |
1 |
3 |
29 |
| Central Asia |
| Turkmenistan 2000 |
5 |
10 |
3 |
9 |
5 |
0 |
1 |
1 |
66 |
| South & Southeast Asia |
| Bangladesh 2004 |
11 |
22 |
28 |
6 |
6 |
2 |
5 |
6 |
15 |
| Indonesia 2002/2003 |
10 |
34 |
14 |
10 |
8 |
4 |
2 |
0 |
18 |
| Philippines 2003 |
24 |
16 |
17 |
9 |
7 |
3 |
4 |
3 |
18 |
| Vietnam 2002 |
25 |
26 |
17 |
4 |
12 |
1 |
3 |
2 |
10 |
| Latin America & Caribbean |
| Bolivia 1994 |
31 |
15 |
7 |
9 |
8 |
1 |
2 |
2 |
23 |
| Brazil 1996 |
15 |
16 |
18 |
3 |
11 |
2 |
3 |
1 |
32 |
| Colombia 2005 |
17 |
13 |
16 |
6 |
16 |
4 |
7 |
2 |
21 |
| Dominican Rep. 2002 |
13 |
19 |
20 |
5 |
7 |
2 |
5 |
3 |
25 |
| Guatemala 1998/1999 |
18 |
21 |
25 |
6 |
11 |
2 |
2 |
3 |
12 |
| Nicaragua 1997/1998 |
12 |
19 |
22 |
10 |
8 |
3 |
3 |
2 |
22 |
| Paraguay 1990 |
17 |
16 |
20 |
9 |
7 |
4 |
2 |
2 |
22 |
| Peru 2000 |
18 |
13 |
26 |
4 |
13 |
3 |
3 |
2 |
18 |
| Source: DHS STATcompiler <http://www.statcompiler.com/> |
| For countries where there have been multiple surveys, only data from the most recent survey are included. |
| * All other reasons include the following categories: infrequent sex, fatalistic, menopause, marital dissolution, other, don't know, and missing data. |
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