1. Benefits of Family Planning, WHO tools and publications
Combined Oral Contraceptive Pills
Adapted by Dr Rodica Comendant, based on Training Resource Package for Family Planning:

2. Defining Contraception and Family Planning
What is the definition of contraception?
Contraception is the intentional prevention of pregnancy by artificial or natural means.
What is the definition of family planning?
Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility.
– World Health Organization, Department of Reproductive Health and Research
Instructions for facilitator:
Show the questions to the participants without showing the definition. Ask participants to construct a definition of contraception and then family planning. Record participant suggestions on a flip chart—each response can build on previous responses until participants have cited the primary features of family planning and the group collectively arrives at comprehensive definition. Ask the group- What is the difference between contraception and family planning?
After the group has crafted their definition, show the definition from WHO as an example. Ask the participants to compare the features included in their definition with the WHO definition.

3. Family Planning Saves Lives
Region/
country
Number of maternal deaths
Lifetime risk of maternal death 1 in:
Sub-Saharan Africa
162,000 39
Southern Asia
83,000
160
These 2 regions account for 85% of maternal deaths worldwide
Developed regions
1,700
4,300
Suggested script: One of most important benefits of family planning is the potential to save lives. Each minute of every day, a woman dies from pregnancy or childbirth-related causes. The middle column of the table, shows the number of women who die each year in pregnancy or childbirth. Notice that most of the deaths occur in developing countries in Africa and Asia. The column on the right shows the lifetime risk of maternal death for each of these regions, which is the probability of dying from a pregnancy or childbirth-related cause during a woman’s reproductive lifespan. It is influenced by both the risks associated with an average pregnancy and the number of times the average woman gives birth.
Over 287,000 women per year die from pregnancy or childbirth. Nearly 47,000 women die each year due to the complications of unsafe abortion. Complications of pregnancy and childbirth are the leading cause of death in young women aged between 15 and 19 years. Promoting policies and implementing programs that help young women delay their first pregnancy until the age of 18 can have a significant impact on girls’ health, education and life prospects.
Approximately 94,000 maternal deaths could be avoided each year if all women who said they want to avoid pregnancy were able to stop childbearing either temporarily or permanently that is one of the ways that family planning saves lives. Unfortunately, the benefits from family planning are not realized in many locations around the world where the unmet need for family planning remains substantial.
As described on the next series of slides, family planning has substantial benefits, especially for those women more likely to experience problems during pregnancy and delivery.
Note to facilitator:
Present and discuss country-specific or district/local data regarding maternal deaths. For example, see the following:
Country profiles produced by UNFPA and PRB at
Demographic and Health Surveys (DHS) from Measure at
Guttmacher International Data Center at
Over 287,000 women per year die in pregnancy or childbirth
47,000 women per year die from complications of unsafe abortion
Complications of pregnancy and childbirth are the leading cause of death in young women
94,000 maternal deaths could be prevented if all women who said they want to avoid pregnancy were able to stop childbearing.
Sources: WHO, UNICEF, UNFPA and The World Bank, 2010; WHO 2009; Guttmacher Institute, 2010.

4. Family Planning and Human Rights
All individuals and couples have the right:
“…to decide freely and responsibly the number, spacing and timing of their children and to have the information, education, and means to do so, and the right to attain the highest standard of sexual and reproductive health...”
– ICPD Programme of Action
Suggested script:
• Explain that the 1994 International Conference on Population and Development (ICPD) in Cairo was a milestone in the history of population and development, as well as in the history of women's rights. At the conference the world agreed that population is not just about counting people, but about making sure that every person counts.
• Ask participants to explain what the quotation means. Note their responses on a flip chart.
• Ask participants to generate ideas about how they can help ensure the ICPD Program of Action. Answers should include basic principles such as providing full access to information on contraceptive choices and to counseling, services, and supplies that allow a client to choose freely and allowing clients to make decisions independently, without the influence of any special incentives or forms of coercion.
Explain that:
• Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for.
• When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family.
• Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld.
• FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size.
Source: United Nations, 1995.

5. Benefits of Providing FP Services
Improves well-being of families and communities
Helps achieve the healthiest outcomes for women and their children
Allow women and couples to delay, space, and limit pregnancies
Suggested script:
Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for.
When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family.
Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld.
FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size.
Note to facilitator:
For participants who desire more information about the Benefits of FP and healthy timing and spacing of pregnancy, distribute copies of the optional handout
Family Planning Saves Lives Backgrounder, Population Reference Bureau, 2009
FP services are most effective when clients are free to make informed choices.

6. WHO’s Family Planning Guidance Documents and Job Aids
Suggested script:
This presentation provides an introduction to the World Health Organization’s evidence-based guidance documents related to family planning including the Medical Eligibility Criteria for Contraceptive Use, Selected Practice Recommendations for Contraceptive Use, and Family Planning: A Global Handbook for Providers. Also introduced are several job aids that providers can use to determine whether a client is medical eligible to use the method she has chosen.
Although providers like yourselves are not the typical audience for the guidance included in the Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use it is helpful for you to be aware of how eligibility criteria and practice recommendations evolve—on both a global and national level—so that you can be assured that what you learn during this training, and the services you in turn provide to your clients, are based on scientific evidence available to family planning experts and policy-makers

7. Medical Eligibility Criteria for Contraceptive Use
Evidence-based recommendations
Use by policy-makers and program managers to improve access to, and quality of, family planning services
19 contraceptive methods
Variety of medical conditions and client characteristics
Periodic reviews and updates
Suggested script:
Since 1994, WHO has convened a body of international experts in family planning including clinicians, program managers, and scientists to review the available evidence on safe use of contraceptive methods and organize the findings in a manner that could be used to determine a client’s medical eligibility for a particular method. The recommendations of the expert review team are presented in the document Medical Eligibility Criteria for Contraceptive Use, or MEC.
The MEC guidance is intended to be used by policy-makers, program managers, and the scientific community to provide guidance to national family planning and reproductive health programs in the preparation of guidelines for service delivery of contraceptives. Many countries use the guidance in this document as the foundation for their national service delivery guidelines to help ensure safe, high quality services while avoiding medical barriers that limit access to contraception.
The MEC document provides guidance on the safety of 19 contraceptive methods for women and men with specific individual characteristics or known pre-existing medical conditions. These characteristics and conditions range from age, smoking habits, and parity to cardiovascular disease, cancer, and infections. In all, the MEC makes over 1700 recommendations on who can use various contraceptive methods.
The team of experts meets every four to five years to review new research findings and update their recommendations. WHO introduced updates to the MEC in April of 2008 and published an update on the postpartum use of combined hormonal contraceptives in These updates are reflected in the fourth edition of the MEC and in the technical information included in this training resource package.

8. Selected Practice Recommendations for Contraceptive Use
Evidence-based recommendations on safe and effective use
33 questions related to contraceptive methods
Range of issues including initiation, continuation, incorrect use, treatment of side effects, and some programmatic issues
Use by policy-makers and program managers
Periodic reviews and updates; latest update 2008
Suggested script:
Similar to the process used to develop the medical eligibility criteria, WHO assembled a team of experts to review existing evidence and make recommendations about how to use contraceptive methods safely and effectively when clients are determined to be medically eligible.
The recommendations are conveyed in the answers to thirty-three questions included in the Selected Practice Recommendations for Contraceptive Use. The questions were selected based on 1) important controversies or inconsistencies in existing guidance, 2) the likelihood that relevant evidence was available, and 3) proposals from expert working group participants and family planning organizations or agencies.
The SPR provides guidance on the use of hormonal contraceptives, IUDs, emergency contraception, fertility awareness-based methods, and sterilization on a range of issues including: initiation and continuation, adjustments for incorrect use such as missed pills or other problems during use such as vomiting or diarrhea, treatment of menstrual abnormalities, and what to do if an IUD user is diagnosed with pelvic inflammatory disease or becomes pregnant. The document also includes recommendations on several programmatic issues such as, which examinations or tests should be done routinely before providing a method of contraception, advice on how many packs of oral contraceptive pills should be given at initial and return visits, what type of follow-up is appropriate for combined oral contraceptive (COC), progestin-only pill (POP), implant and IUD users; and guidance that providers can use to be reasonably sure that a woman is not pregnant.
The SPR guidance is intended to be used by policy-makers, program managers, and the scientific community to provide guidance to national family planning and reproductive health programs in the preparation of guidelines for service delivery of contraceptives. Much like the MEC, many countries have incorporated the guidance in this document into their national service delivery guidelines.
The team of experts meets every four to five years to review new research findings and update their recommendations. WHO introduced updates to the SPR in April of At that time, very few changes were made, so instead of reprinting the whole document, a short  document just giving the updates was developed as an insert to the book.  These updates are reflected in the technical information included in this training resource package.

9. Family Planning: A Global Handbook for Providers
Essentials needed to provide family planning clients with good-quality care
Latest guidance for delivering 19 contraceptive methods appropriately and effectively
Use by clinical providers
Periodic reviews and updates; latest update 2011
Suggested script:
As the title suggests, Family Planning: A Global Handbook for Providers, translates scientific evidence on family planning into practical guidance for health providers. The handbook reflects the consensus of experts from leading health organizations and is based on the guidance from the Medical Eligibility Criteria for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use.
The Global Handbook provides guidance on the provision of 19 contraceptive methods and other key reproductive health issues. Each of the method chapters describe the characteristics of the method, explain who can and cannot use the method, give instructions on providing the method, provide information on how to assist continuing users, and include a collection of frequently asked questions and answers. The handbook also includes recommendations on other programmatic and reproductive health issues, such as guidance on serving diverse client groups and an overview of sexually transmitted infections. There are also several useful job aids and tools such as instructions for using condoms and a description of the menstrual cycle that can be used when counseling clients.
The Global Handbook is intended to be used by facility-based clinicians although the guidance can be used by any cadre of provider authorized to provide the services described.
Similar to WHO’s MEC and SPR guidelines, the Global Handbook is periodically reviewed and updated to ensure that it reflects the most current practice recommendations. WHO introduced an updated version of the Global Handbook in 2011based on the latest recommendations from the MEC and SPR. These updates are reflected in the technical information included in this training resource package.
Note to facilitator:
The Global Handbook is an excellent reference manual and job aid for providers. It is available in multiple languages in both print and electronic form. Available from: .

10. Categories for IUDs, Hormonal and Barrier Methods
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
Description
When clinical judgment is available 1
No restriction for use
Use the method under any circumstances 2
Benefits generally outweigh risks
Generally use the method
Suggested script:
For each contraceptive method, the MEC classifies medical conditions and client characteristics into categories based on the risks and benefits associated with use of the method among clients with those conditions or characteristics. Some conditions fall into multiple categories depending on the severity of the condition.
For IUDs, hormonal contraceptive methods and barrier methods, the MEC uses four categories to classify medical conditions or client characteristics. These categories are defined as follows:
Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions.
Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required.
Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required.
Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used.
In some cases, a particular condition or characteristic is assigned to one category for initiation and another for continuation of the method. In other words, the category may depend on whether a woman with the condition wishes to initiate the contraceptive method or was already using that method when she developed the condition. . 3
Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable 4
Unacceptable health risk
Method not to be used
Source: WHO, 2010.

11. Combined Oral Contraceptive Pills (COCs)
Session I: Characteristics of COCs

12. Combined Oral Contraceptives Objectives
Participants will be able to:
Describe the characteristics of COCs in a manner that clients can understand
Demonstrate how to screen clients for eligibility for COC use
Describe when to initiate COCs
Explain how to use COCs, what to do when pills are missed, and when to return
Address common concerns, misconceptions, and myths
Explain how to manage side effects
Identify conditions that require switching to another method
Identify clients in need of referral for COC-related complications
The learning objectives for this module are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>.
The objectives of this module are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.

13. COCs Key Points for Providers and Clients
Take a pill every day.
Contains both estrogen and progestogen hormones.
Works mainly by stopping ovulation.
Effectiveness depends on the user. Can be very effective.
“Would you remember to take a pill each day?”
No need to do anything at time of sexual intercourse.
Very effective if taken every day. But if woman forgets pills, she may become pregnant.
Easy to stop: A woman who stops pills can soon become pregnant.
Very safe.
Pills are not harmful for most women’s health and studies show very low risk for cancer due to pills for almost all women. The pill can even protect against some types of cancer.
Serious complications are rare. They include heart attack, stroke, blood clots in deep veins of the legs or lungs.
Some women have side-effects at first–not harmful and often go away after first 3 months.
Side-effects often go away after first 3 months.
No protection against STIs or HIV/AIDS.
For STI/HIV/AIDS protection, also use condoms.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

14. What Are COCs? Traits and Types
Content
Combination of two hormones: estrogen and progestin
Phasic
Monophasic, biphasic, triphasic (in the past)
Dose
Low-dose: µg of estrogen (common), 20 µg or less (rare in most places)
Pills per pack
21: all active pills (7-day break between packs)
28: 21 active + 7 inactive pills (no break between packs)

15. Effectiveness of COCs
In this progression of effectiveness, where would you place combined oral contraceptives (COCs)?
Less effective
More effective
Implants
Male Sterilization
Female Sterilization
Intrauterine Devices
Progestin-Only Injectables
Male Condoms
Standard Days Method
Female Condoms
Spermicides
Ask participants: Where would you put combined oral contraceptives on this list?
After participants respond, click the mouse to reveal the answer
COCs

16. Relative Effectiveness of FP Methods
# of unintended pregnancies among
1,000 women in 1st year of typical use
No method
850
Withdrawal
220
Female condom
210
Male condom
180
Pill 90
Injectable 60
IUD (CU-T 380A / LNG-IUS)
8 / 2
Female sterilization 5
Vasectomy
1.5
Implant
0.5
Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) , Elsevier Inc.

17. COCs: Mechanism of Action
Suppresses
hormones
responsible for
ovulation
Illustration credit: Salim Khalaf/FHI
Thickens
cervical mucus to block sperm
COCs have no effect on an existing pregnancy.

18. COCs: Characteristics
Safe and more than 99% effective if used correctly
Can be stopped at any time
No delay in return to fertility
Are controlled by the woman
Do not interfere with sex
Have health benefits
Less effective when not used correctly (91%)
Require taking a pill every day
Do not provide protection from STIs/HIV
Have side effects
Have some health risks (rare)
Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

19. COCs: Menstrual-Related Health Benefits
5/25/2012
COCs: Menstrual-Related Health Benefits
Decreased amount of flow and fewer days of bleeding; no bleeding (less common)
Regular, predictable menstrual cycles
Reduced pain and cramps during menses
Reduced pain at time of ovulation
Source: Davis, 2005.

20. COCs: Other Health Benefits
Protection from:
Risks of pregnancy
Ovarian cancer
Endometrial cancer
Symptomatic PID
Reduced risk of:
Ovarian cysts
Iron-deficiency anemia
Decreased symptoms of endometriosis (pelvic pain, irregular bleeding)
Decreased symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body)
Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.

21. No Overall Increase in Breast Cancer Risk for COC Users
Analysis of a large number of studies:
No overall increase in breast cancer risk among women who had ever used COCs
Current use and use within past 10 years: very slight increase in risk
May be due to early diagnosis or accelerated growth of pre-existing tumors
More recent study:
No increase in breast cancer risk regardless of age, estrogen dose, ethnicity, or family history of breast cancer
Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.

22. COCs and Cervical Cancer
Cervical cancer is caused by certain types of human papillomavirus (HPV)
Some increase in risk among women with HPV and others who use COCs more than 5 years
Risk of cervical cancer goes back to baseline after 10 years of non-use
Cervical cancer rates in women of reproductive age are low. Risk of cervical cancer at this age group is low compared to mortality and morbidities associated with pregnancy.
COC users should follow the same cervical cancer screening schedule as other women.
Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011.

23. Risk of Blood Clots is Limited
COCs may slightly increase risk of blood clots:
Stroke
Heart attack
Risk is concentrated among women who have additional risk factors, such as:
Hypertension
Diabetes
Smoking
Deep vein thrombosis
Pulmonary embolism
Stop COCs immediately if a blood clot develops.
Source: World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998.

24. Possible Side-Effects
If a woman chooses this method, she may have some side- effects. They are not usually signs of illness.
But many women do not have any side-effects.
Side-effects often go away after a few months and are not harmful.
Most common:
Mood changes or headaches
Tender breasts
Changes in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding)
Slight weight gain or loss
Nausea (upset stomach)
Dizziness
Adapted from WHO’s Decision-making tool for family planning clients and providers.

25. Combined Oral Contraceptive Pills (COCs)
Session II: Who Can and Cannot Use COCs?
Illustration credit: Salim Khalaf/FHI

26. COCs Are Safe for Nearly All Women
Almost all women can use COCs safely, including women who:
Have or have not had children
Are not married
Are of any age
Smoke (if under age 35)
Have anemia now or had it in the past
Have varicose veins
Have an STI or HIV/AIDS
Most health conditions do not affect safe and effective use of COCs

27. Who Can and Cannot Use COCs
Most women can safely use the pill.
But usually cannot use the pill if:
Adapted from WHO’s Decision-making tool for family planning clients and providers.
High blood pressure
Smoke cigarettes AND age 35 or older
Breastfeeding 6 months or less
May be pregnant
Gave birth in the last 3 weeks
Some other serious health conditions

28. Who Should Not Use COCs (part 1)
5/25/2012
My period is late…
Breast
feeding a baby less than 6 months old
Breast
feeding a baby less than 6 months old
Are
pregnant
Think they may be pregnant
Are
pregnant
Think they may be pregnant
Illustration credit: Ambrose Hoona-Kab.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Smoke and are age 35 or older
Had a heart attack or stroke
Had blood clots in legs or lungs
Have or had breast cancer
Had a heart attack or stroke
Had blood clots
in legs or lungs
Source: WHO, 2010.

29. Who Should Not Use COCs (part 2)
5/25/2012
Have rheumatic disease, such as lupus
Take pills for TB, seizures (fits), or HIV
Have high blood pressure
I cannot eat sweets.
Have diabetes (high sugar in blood)
Have serious
liver disease or
gall bladder disease
Have bad headaches with nausea or vision problems
Gave birth in last 6 weeks
Breast
feeding a baby less than 6 months old
Think they may be pregnant
Illustration credit: Ambrose Hoona-Kab.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Had a heart attack or stroke
Had blood clots
in legs or lungs
Source: WHO, 2010; Chu, 2005.
Source: WHO, 2010.

30. Medical Eligibility Criteria
5/25/2012
Medical Eligibility Criteria
What are medical eligibility criteria?

31. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
Description
When clinical judgment is available 1
No restriction for use
Use the method under any circumstances 2
Benefits generally outweigh risks
Generally use the method 3
Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable 4
Unacceptable health risk
Method not to be used
Source: WHO, 2010.

32. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
When clinical judgment is available 1
Use the method 2 3
Do not use the method 4
Source: WHO, 2010.

33. Conditions (selected examples)
Category 1 and 2 Examples (not inclusive): Who Can Use COCs
WHO Category
Conditions (selected examples)
Category 1
menarche to 39 yrs; nulliparous; endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; anemia; STI/PID; hepatitis (chronic/carrier)
Category 2
≥40 yrs; breastfeeding ≥6 months postpartum; superficial thrombophlebitis; uncomplicated diabetes; cervical cancer; unexplained vaginal bleeding; undiagnosed breast mass
Source: WHO, 2010.

34. Conditions (selected examples)
Category 3 Examples (not inclusive): Who Should Generally Not Use COCs
WHO Category
Conditions (selected examples)
Category 3
Postpartum:
Breastfeeding between 6 weeks and 6 months
Non-breastfeeding <21 days (if no additional risk factors for blood clots)
Vascular conditions:
Hypertension (history of or BP /90–99)
Migraine without aura (older than 35 yrs)
Gastrointestinal conditions:
Symptomatic gall bladder disease (current and medically-treated)
Drug interactions:
Use of rifampicin, rifabutin, ritonavir
Source: WHO, 2010.

35. Conditions (selected examples)
Category 3 Examples (not inclusive): Who Should Generally Not Use COCs
WHO Category
Conditions (selected examples)
Category 4
Breastfeeding: <6 weeks postpartum
Smoking: ≥15 cigarettes/day and ≥ 35 yrs old
Vascular conditions:
Hypertension (≥160/≥100)
Migraines with aura
Ischemic heart disease or stroke
Diabetes with vascular complications
Deep venous thrombosis (history or acute)
Pulmonary embolism (history or acute)
Liver conditions:
Acute hepatitis
Severe liver disease and most liver tumors
Breast cancer: current or within 5 yrs
Source: WHO, 2010; Sekar, 2008.

36. COC Use by Women with HIV
WHO Eligibility Criteria
Condition
Category
HIV-infected 1
AIDS
ARV therapy
(which does not contain ritonavir) 2
Ritonavir/ ritonavir-boosted PIs
(as part of ARV regimen) 3
Women with HIV or AIDS can use without restrictions
Women on ARVs other than ritonavir can use COCs safely
Should not be used by women who take ritonavir (may reduce effectiveness of COCs).
Using low-dose COCs is appropriate
Condom use should be encouraged in addition to COCs
Source: WHO, 2010; Sekar, 2008.

37. COC Use by Postpartum Women
WHO Eligibility Criteria
Condition
Category
Non-breastfeeding <3 weeks 3
Breastfeeding <6 weeks 4
Breastfeeding >6 weeks and < 6 months
Breastfeeding ≥6 months 2
Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (6 weeks postpartum for multiple VTE risk factors)
Breastfeeding women
Should not use COCs before 6 weeks postpartum
Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available
Can generally initiate COCs at 6 months postpartum
Source: WHO, 2010.

38. Read questions 1–12 in the checklist.
Group Activity Understanding the Checklist
Read questions 1–12 in the checklist.
How have you determined medical eligibility in the past?
The checklist also gives instructions about initiating COCs.
This set of questions identifies women who should not use COCs.
This set of questions identifies women who are not pregnant.

39. Combined Oral Contraceptive Pills (COCs)
Session III: Providing COCs
Illustration credit: Salim Khalaf/FHI

40. When to Start COCs (part 1)
Anytime you are reasonably certain the woman is not pregnant
Pregnancy can be ruled out if the woman meets one of the following criteria:
Started monthly bleeding within the past 7 days
Is breastfeeding fully, has no menses and baby is less than 6 months old
Has abstained from intercourse since last menses or delivery
Had a baby in the past 4 weeks
Had a miscarriage or an abortion in the past 7 days
Is using a reliable contraceptive method consistently and correctly
If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or waiting until next menses
Source: WHO, 2004 (updated 2008).

41. When to Start COCs (part 2)
If starting during the first 5 days of the menstrual cycle, no backup method needed
After day 5 of her cycle, rule out pregnancy and use backup method for the next 7 days
Postpartum
Not breastfeeding: May start 3 to 6 weeks after giving birth, depending on presence of risk factors for blood clots
Breastfeeding: May start 6 months after giving birth
Source: WHO, 2004 (updated 2008).

42. When to Start COCs (part 3)
After miscarriage or abortion
If within 5 days after miscarriage or abortion, no backup method needed
If more than 5 days after, rule out pregnancy, use backup method for 7 days
Switching from hormonal method
May start immediately, no backup method needed (with injectables, initiate within reinjection window)
Switching from nonhormonal method
If starting within 5 days of start of menstrual cycle, no backup method needed
If starting after day 5 of cycle, use backup method for 7 days
After using emergency contraceptive pills
Initiate next day, use backup method for 7 days
Source: WHO, 2004 (updated 2008).

43. How to Take COCs Take one pill each day, by mouth.
The Pill
Take one pill each day, by mouth.
Most important instruction:
Give client her pill pack to hold and look at.
Show how to follow arrows on pack.
Discuss:
Easy to remember to take pills?
“What would help you to remember? What else do you do regularly every day?”
Easiest time to take the pills? At a meal? At bedtime?
Where to keep pills.
What to do if pill supply runs out.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

44. How to Take COCs
The Pill
28-pill pack
21-pill pack
If you use the 28-pill pack:
No waiting between packs.
Once you have finished all the pills in the pack, start new pack on the next day.
If you use the 21-pill pack:
7 days of no pills
Once you have finished all the pills in the pack, wait 7 days before starting new pack. For example: If you finish the old pack on Saturday, take the first pill of the new pack on the following Sunday.
Caution the client: Waiting too long between packs greatly increases risk of pregnancy.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
21-pill pack

45. Missed Pills Instructions
The Pill
Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late:
Always take a pill as soon as possible.
Continue to take one pill every day.
No need for additional protection.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

46. Missed Pills Instructions, continued
The Pill
Source: WHO, 2004; updated 2008; CCP and WHO, 2011.
Miss 3 or more active pills in a row or start a pack 3 or more days late:
If these pills missed in week 3, ALSO skip the inactive pills in a 28-pill pack and start a new pack
Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or avoid sex for next 7 days
If inactive pills are missed, throw away the missed pills and continue taking pills, 1 each day OR
week 3
Inactive pills
AND
Adapted from WHO’s Decision-making tool for family planning clients and providers.

47. Key Counseling Topics for COC Users
Safety and efficacy (requires taking pills on time)
How COCs work
Health benefits
Possible side effects
How to take pills and what to do if pills are missed
No protection from STIs/HIV
Inform provider she is taking COCs
in case of serious new health problem
Reasons to return: questions, concerns or experiencing any warning signs
Photo credit: Karl Grobl

48. Correcting Rumors and Misconceptions
COCs:
Do not build up in a woman’s body. Women do not need a “rest” from taking COCs.
Must be taken every day, whether or not a woman has sex that day.
Do not make women infertile.
Do not cause birth defects or multiple births.
Do not change women’s sexual behavior.
Do not collect in the stomach. Instead, the pill dissolves each day.
Do not disrupt an existing pregnancy.
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49. Anything else I can repeat or explain? Any other questions?
What to Remember
Take one pill each day
If you miss pills, you can get pregnant
Side-effects are common but rarely harmful. Come back if they bother you.
Come back for more pills before you run out or if you have problems.
See a nurse or doctor if:
Severe, constant pain in belly, chest, or legs
Very bad headaches
A bright spot in your vision before bad headaches
Yellow skin or eyes
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Anything else I can repeat or explain? Any other questions?

50. Follow-up for COCs No fixed schedule; return any time.
Resupply: Give more than 1 cycle of pills, if possible.
Assess for method satisfaction and any health problems or circumstances that may restrict COC use.
Manage and reassure about side effects.
Review correct pill taking and what to do when pills are missed.

51. The Pill Return Visit How can I help you? Let’s check:
5/25/2012
The Pill Return Visit
How can I help you?
Are you happy using the pill?
Want more supplies?
Any questions or problems?
Let’s check:
For any new health conditions
When do you take your pills?
What do you do if you forget a pill?
Need condoms too?

52. Management of COC Side Effects
Counseling and reassurance are key.
Problem
Action/Management
Ordinary headaches
Reassure client: usually diminish over time; take painkillers
If side effects persist and are unacceptable to client:
if possible, switch pill formulations or switch to another method.
Nausea and vomiting
Take pills with food or at bedtime
Breast tenderness
Recommend supportive bra; suggest pain reliever

53. Management of COC Side Effects: Bleeding Changes
Problem
Action/Management
Irregular bleeding
Reassure client: reinforce correct pill taking and review missed pill instructions; ask about other drugs that may interact with COCs; administer short course of non-steroidal anti-inflammatory drugs
If side effects persist and are unacceptable to client: if possible, switch pill formulations or offer another method.
Amenorrhea
Reassure client: no medical treatment necessary.
Source: CCP and WHO, 2011.

54. When to Return: Warning Signs of Rare COC Complications
5/25/2012
Severe, constant pain in belly, chest, or legs
Very bad headaches
Adapted from WHO’s Decision-making tool for family planning clients and providers.
A bright spot in your vision before bad headaches
Yellow skin or eyes
Advise to stop taking COCs, use a backup method, and see a health care provider.
Source: Hatcher, 2007.

55. Problems That May Require Stopping COCs or Switching to Another Method
Action
Unexplained vaginal bleeding
Refer or evaluate by history and pelvic exam
Diagnose and treat as appropriate
If an STI or PID is diagnosed, the client may continue using COCs during treatment
Migraines
If the client develops migraines with or without aura, or her migraine headaches worsen, stop COC use
Help the client choose a method without estrogen
Circumstances that keep her from walking for one week or more
Tell the client she should:
Tell her doctors she is using COCs
Stop taking COCs and use a backup method
Restart COCs 2 weeks after she can move about
Proceed to next slide for more information on this topic
Source: CCP and WHO, 2011.

56. Problems That May Require Stopping COCs or Switching to Another Method
(continued)
Problem
Action
Starting treatment with anti- convulsants or rifampicin, rifabutin, or ritonavir
These drugs make COCs less effective; COCs may make lamotrigine less effective.
Advise the client to consider other contraceptive methods (except progestin-only pills).
Blood clots, heart or liver disease, stroke, or breast cancer
Tell the client to stop COC use
Give the client a backup method to use
Refer for diagnosis and care
Suspected pregnancy
Assess for pregnancy
If confirmed, tell the client to stop taking COCs
There are no known risks to a fetus conceived while a woman is taking COCs
Source: CCP and WHO, 2011.

57. COCs: Summary Safe for almost all women
Effective if used consistently and correctly
Fertility returns without a delay
Screening and counseling are essential
Photo credits: © 1995 Lamia Jaroudi/CCP, Courtesy of Photoshare; © 2009 Nguyen Quoc Phong, Courtesy of Photoshare