Contraceptive Counselling

Person centred contraceptive counselling is a structured, two-way conversation in which the clinician provides accurate, unbiased information and the patient makes a voluntary, informed choice that reflects their own values, priorities and circumstances. Its aim is a method the patient chooses, understands and can use well, not uptake of a particular method.

Principles.

• Voluntarism: no pressure, targets, incentives or penalties tied to any method.

• Respect: the patient's preferences about bleeding, hormones, privacy, partner involvement and future fertility are valid reasons for choice.

• Accuracy: effectiveness, side effects and return to fertility described honestly, including uncertainty.

• Confidentiality and privacy: counselling in a private space, with no information shared without consent.

• Non-discrimination: equal care regardless of age, marital status, parity, HIV status, disability, gender identity or income.

Effect on outcomes. Good counselling increases satisfaction, correct use and continuation, and reduces unintended pregnancy and discontinuation due to expected side effects.

Elements to assess.

• Reproductive intentions: desire and timing of future pregnancy.

• Priorities: effectiveness, bleeding pattern, frequency of visits, privacy, hormones, return to fertility.

• Medical history relevant to eligibility.

• Sexual history: number of partners, condom use, STI and HIV risk.

• Social factors: partner support or opposition, risk of violence or coercion, ability to return for resupply.

• Past experience with methods and reasons for stopping.

Structured approaches. Frameworks such as GATHER (Greet, Ask, Tell, Help, Explain, Return) and BCS+ (balanced counselling strategy) organise the visit. Use a method chart or tiered effectiveness tool so the patient can compare options at a glance.

Conducting the session.

• Open with an invitation: "What matters most to you in a method?"

• Narrow options based on priorities and eligibility rather than presenting every method in detail.

• For the method chosen, explain: how it works, effectiveness, how to use it, expected bleeding changes, common side effects and how long they last, warning signs, when protection starts, backup needs, what to do with missed or late use, and how to stop.

• Check understanding with teach-back.

• Agree a follow up and resupply plan and give the patient a written or card reminder.

Bleeding counselling. Expected bleeding change is the strongest predictor of early discontinuation. Explain in advance: irregular bleeding with implants and progestin-only methods, amenorrhoea with DMPA and the levonorgestrel 52 mg IUD, heavier or longer periods in the first months after copper IUD insertion.

Couple counselling. Involve partners only when the patient wishes. Consent for any method lies with the patient alone.

Special groups. Adolescents need nonjudgemental, confidential counselling with emphasis on long-acting methods and condoms. Postpartum patients should be counselled during antenatal care. People with disability may need adapted materials, sign language interpretation or accessible examination.

Common errors.

• Provider bias toward or against particular methods, especially long-acting methods for young or nulliparous patients.

• Overloading the patient with every method in detail.

• Withholding information on side effects for fear of discouraging uptake.

• Refusing removal of an implant or IUD on request, or making removal difficult.

Reproductive coercion. Ask privately about partner pressure, contraceptive sabotage and violence. Offer discreet methods such as IUDs with trimmed strings, injectables and implants.

Referral and escalation. Refer patients disclosing intimate partner or sexual violence for medical, legal and psychosocial care at the same visit. Refer those with complex medical conditions for specialist eligibility review without delaying an interim method.