Contraceptive Interruption From Stockouts or Missed Visits

Interruption of contraception happens when a method is not available at the facility or when a patient misses a resupply, injection or review visit. The clinician must work out which method was interrupted, how long the gap has lasted, whether the patient is at risk of pregnancy, and what bridging option can be offered the same day. The patient should be welcomed whenever she returns, regardless of how late she is.

Assessment. Method, last dose or insertion date, planned return date, sex since the last protected date, last menses, pregnancy symptoms, and reason for the gap.

Pregnancy exclusion. Reasonably certain if no intercourse since last menses, consistent use of a reliable method, within 7 days of the start of menses, within 4 weeks postpartum, or fully breastfeeding amenorrhoeic under 6 months postpartum. Otherwise test.

Common situations. Stockout of the chosen method, missed injection, running out of pills, overdue implant or device expiry, and lost contact after the first visit.

Differential diagnosis. Gap within the allowed window with continued protection, gap beyond the window with risk of pregnancy, existing pregnancy, and expired device.

Allowed windows.

Note. DMPA users may develop amenorrhoea without pregnancy, so a pregnancy test or examination may be needed.

Stockout of the preferred method.

1. Do not send the patient away without a method.
2. Offer an available method that is medically suitable, as a bridge.
3. Provide condoms.
4. Give emergency contraception when sex has taken place without protection.
5. Record the plan and the return date, and arrange the preferred method when stock returns.

Switching between DMPA and norethisterone enanthate. The two are not used interchangeably. If a switch is needed because of a stockout, it is done when the repeat injection would have been given.

Missed injection beyond the window. Test for pregnancy when not reasonably certain. Inject if not pregnant. Give condoms or advise abstinence for 7 days.

Dispensing to prevent gaps.

• Combined pills: up to 3 cycles of pills in one visit.
• DMPA subcutaneous: self-injection supported, up to 4 doses dispensed with training.
• Condoms with all methods for dual protection.

Emergency contraception. Levonorgestrel 1.5 mg orally as a single dose within 120 hours, or ulipristal acetate 30 mg orally as a single dose within 120 hours, or a copper device within 5 days.

Community providers. Refer clients who miss 3 or more pills to a health facility.

Missed appointment for follow up. Welcome the patient back at any time and continue the method if eligible and pregnancy is excluded.

Follow up. Review within 2 to 4 weeks after a bridging method. Check for pregnancy where the window was exceeded.

Method decisions. Return to the preferred method when stock is available. If stockouts recur, choose a long-acting method with a longer interval, or a self-administered method.

Referral and escalation. Refer pregnancy, suspected ectopic pregnancy, expired devices that cannot be located, and recurrent stockouts for facility level supply review.