The Initial Visit: Establishing a Relationship
For health care providers, establishing a good connection with each client right from the start helps create the basis for a sustained relationship (101, 110). When providers establish open communication and trust with a new family planning client, the client is more likely to become a continuing client.
Several provider-related factors particularly affect whether new clients will continue to use family planning. These include establishing a friendly and productive interaction, offering a range of family planning methods, helping clients choose a suitable one, advising on its proper use and side effects, providing adequate supplies, and discussing follow-up (see Provider Checklist for New Clients).
Good client-provider interaction is an important element of quality of care. The quality of care that providers offer in an initial visit affects whether their clients adopt contraception and continue to use it. The level of quality can influence clients' interest in returning to the same provider or clinic and their understanding and effective use of contraceptive methods (1, 2, 94, 99, 100, 108).
Clients say that they appreciate friendly treatment and meaningful interaction with providers, as well as value the cleanliness of the clinic and the availability and promptness of services (50, 100). In a Bangladesh study, for example, the most powerful predictor of client satisfaction with government family planning services was the provider's professional behavior—particularly how respectful and polite the provider was. The next most powerful predictors were privacy and short clinic waiting times (5).
At the clinic, staff members should welcome each client in a friendly and respectful way. When clients feel comfortable, they are more likely to talk openly with the provider. New clients are often uncertain about what to expect during their visit. Providers can assure them that they will have privacy during counseling sessions and physical examinations and that everything they say will be kept confidential (101, 120).
Help New Clients Choose an Appropriate Contraceptive Method
Counseling is most effective when it is tailored to the individual client (2, 88). 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. In Indonesia, for example, a study found that, one year after starting a method, the continuation rate among women who received their chosen method was 91% compared with 28% among those who did not (93).
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Providers can help clients choose an appropriate contraceptive method based on their reproductive intentions and the characteristics they are looking for in a method. Illustration: Rafael Avila/CCP
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Providers should offer to discuss the client's chosen method. This practice helps ensure consistent and correct use—keys to contraceptive effectiveness (134). For example, if a client chooses OCs, the provider should discuss the need to take a pill every day for the method to be effective. If the choice is injectable contraceptives, the provider should discuss whether the client will be able to return to the clinic regularly for repeat injections. Inability to return to clinics often causes women to discontinue injectable contraceptive use. In Kenya, for example, a study found that the second most cited reason for discontinuation of CyclofemTM, a combined injectable contraceptive, was inability to attend the clinic at the specified time (the reason cited most often was menstrual changes) (105).
The provider can also discuss dual protection—that is, how condoms protect against HIV/AIDS and other STIs as well as against pregnancy. Condoms also can be used with any other family planning method for increased effectiveness at preventing pregnancy (24, 133, 134).
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A client's reproductive intentions often determine the family planning method she would be most interested in.
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Clients who are unsure of the contraceptive method they want often need more counseling (16). Engaging the client in a dialogue about family planning, perhaps including the client's previous experience with contraceptive use, 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.
Reproductive intentions. A client's reproductive intentions often determine the family planning method she would be most interested in. Does she want to have more children, and if so, when? If she wants to have children in the near future, a method that allows her to space her births, such as OCs or injectable contraceptives, probably would be most suitable. If she wants to wait several years before having children, longer-term methods such as the IUD or implants would be an appropriate choice. If she does not want to have more children, the provider can suggest permanent methods.
Method characteristics. Many clients are interested in a method's characteristics as the basis for choice. For example, if a client wants a method that is easily reversible, highly effective, and she does not want others to know she is using contraception, she might be most interested in a method that can be used privately, such as injectable contraceptives (3). Some clients want to avoid modern methods altogether and still be able to avoid pregnancy. For clients interested in fertility awareness methods, providers have a key role in counseling on how to use them consistently and correctly, because their effectiveness depends primarily on the user, including their partner's cooperation (52, 134).
How to Encourage New Clients to Continue Use
Once clients have chosen a contraceptive method, providers can help them continue effective contraception—whether the initial method or a subsequent different one—for as long as they want to avoid pregnancy. Especially valuable steps to take in the first visit that encourage continued contraceptive use are to (133, 134):
- Assure clients that they can switch methods at any time, and enable them to do so conveniently.
- Help clients understand and know how to manage contraceptive side effects.
- Provide clients with adequate supplies and avoid gaps in coverage that can lead to unintended pregnancies.
- Offer continuing care—inviting clients to return to the clinic for any reason at any time.
Assure that clients can conveniently switch methods. Programs and providers should anticipate that clients may want to switch contraceptive methods—perhaps several times in the course of their reproductive lives. Some people want to switch methods soon after starting their first method, particularly if their first method proves unsatisfactory. Others want to switch later, if their circumstances change. When providers let clients know that they can switch methods whenever they want to, clients are more likely to continue contraceptive use. When programs offer a range of methods, clients can switch methods more conveniently. They are better able to find a method that suits them and thus more likely to continue using a method (6, 7, 58, 62).
Discuss how to manage side effects. Side effects and how a woman reacts to them play pivotal roles in women's family planning decisions—not only whether to start using family planning and which method to choose, but also whether to continue a method or to abandon contraceptive use (12, 64, 126). A client who knows about possible side effects beforehand is more likely to keep using the method even if side effects occur (57, 73, 129). Information about bleeding and other side effects that a provider gives—or fails to give—during the initial visit often shapes a new client's expectations about contraceptive use (121).
Providers can help new clients by preparing them to expect common side effects, reassuring them that these side effects usually are harmless. Providers can advise that clients are free to switch to another method if they prefer and should encourage clients to return to the clinic at any time for help with side effects (58, 133). Advise the client to seek medical help if the client feels that something is seriously wrong (134). For more information on how to help women manage side effects, consult the forthcoming "Family Planning: A Global Handbook for Providers"(see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy).
Bleeding changes can be particularly upsetting, especially if providers do not tell women about them in advance. They are the most frequent method-related reason why women discontinue modern contraceptive methods. Providers should counsel women that bleeding changes are often to be expected and that most are not harmful to their health. Let the client know that, if she is worried, she should feel free to come back to consult with the provider.
Common but normally harmless bleeding changes range from heavier or prolonged bleeding, as with copper IUDs, to lack of monthly bleeding (amenorrhea), as with the depot medroxyprogesterone acetate (DMPA) injectable contraceptive. They also include bleeding or spotting at unexpected times during the menstrual cycle, as with OCs (4, 13, 29, 33, 43, 103, 121).
Structured counseling about specific side effects is an effective strategy for improving continuation, especially for hormonal contraception. Structured counseling entails informing clients about how the contraceptive works, the common effects of hormonal methods, and possible side effects, including bleeding changes (22, 73). Studies in China and Mexico have demonstrated the effectiveness of structured counseling for injectable contraceptives.
In China among two groups of users of DMPA, half received structured pretreatment counseling, while the other half received routine counseling that did not include the detailed information included in structured counseling, unless the client asked for it. The first group was almost four times more likely to continue using DMPA at 12 months than the second group (42% versus 11%) (73). Similarly, in Mexico half of DMPA users in a study received structured counseling, while the other half received routine counseling. Twelve months later 43% of the structured counseling group were still using DMPA compared with 17% of the routinely counseled group—even though the incidence of bleeding changes did not differ significantly between the two groups (22).
Provide adequate supplies. Providers can encourage new clients to become continuing clients by giving an adequate supply of contraceptives right at the start, particularly for OCs. Providers can give clients one year's supply of pills, or even more. If limited contraceptive supplies or poor logistics are a concern, programs should provide clients with as many pill packs as feasible (132).
A recent study in the U.S. found that clients who were given a full year's supply of OCs were somewhat more likely to be continuing users at 15 months than those who received only a three-month supply (49% versus 42%). Also, women who received a greater supply were much less likely to experience gaps in coverage (4% versus 19%) (46).
Some family planning providers avoid giving new clients OCs and other hormonal method supplies until they can be certain the client is not pregnant (130). Clients often have to go home, wait for their menses, and then return to the clinic for their pills. Providers can use a simple pregnancy checklist to be reasonably certain that a woman is not pregnant when she is seeking contraception. If pregnancy is ruled out, clients can initiate their method of choice without having to wait for their menstrual period or results from a pregnancy test. (For more information see Family Health International's pregnancy checklist, http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/pregnancy/index.htm)
Two recent approaches—advance provision and Quick Start—have been developed to avoid requiring women to return to the clinic before starting OC use. In the advance provision approach, providers give clients at least one packet of pills to take home and to begin using on the Sunday after their next menstrual period (11). In the Quick Start approach, which was developed in the U.S. as an alternative to advance provision, a client starts OC use under the supervision of a health care provider during her first clinic visit,regardless of the time in her menstrual cycle (11, 72, 130).
A study in Nicaragua that compared women using advance provision with those using Quick Start showed high continuation rates among both groups, at 98% and 97% respectively at six months (92). With Quick Start, however, women do not have to wait after their next period to start a new pill pack. This approach, therefore, might be more convenient for some women and could avoid pregnancies that might occur before OC use can begin (130).
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When providers let clients know that they can switch methods whenever they want to, clients are more likely to continue contraceptive use.
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Offer continuing care. Encouraging clients to come back to the clinic whenever they want to and for any reason can help build a continuing relationship that makes it easier for people to continue using family planning as long as they want to. Clients should be able to come back to the clinic if they are having problems with their contraceptive method, want to switch to another method, or just have questions.
Also, clients should know that, if they think they might be pregnant, they can come back to the clinic for consultation and care (134). Where clinics offer multiple related services in addition to family planning, providers can describe the range of services available and invite clients to come whenever they need care.
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