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Issue-5 : Client Information and counselling for Safe usage of emergency contraception

Background

Client information and counselling form a very important aspect of the reproductive healthcare and family planning programmes. Counselling is a process of face to face communication between a counsellor and an individual or couple, whereby the counsellor gives accurate and complete factual information to the clients and assists them in making an informed and voluntary decision about their fertility and contraceptive option. In helping clients to choose a suitable method, account is taken of their social and cultural background. Besides making an informed choice, clear instructions are also crucial for successful use of a user-dependent method like emergency contraception. The counsellor must not go into unnecessary personal details but focus on safe and appropriate usage. Training in counselling and communication skills is an essential component of training in Emergency Contraception.

Questions to be answered

A. How much information should be given to the clients?

B. How to remove misconceptions about EC?

C. How to involve the male partner?

A need was also expressed to provide user guidelines emphasizing on timing, side-effects, cautions, emphasis on one-time use and need for follow-up and counselling for regular method.

Views of the Group

It was felt that a new programme should be started properly. The discussion Group identified following guidelines for information and effective counselling:

Develop a rapport with client

Maintain confidentiality

Written informed consent

Explain about EC method

Screening for suitability for specific method

Provide accurate information (written in local language/pictorial) including

- indications

- mode of action

- type of methods available

- dosage

- drug regimen

- failure rate

- side-effects and management

- next menstruation

- follow-up

Counselling for regular contraception and EC not a substitute for regular method.

Need for abstinence/barrier method subsequently till periods.

To report if periods delayed.

Information regarding no protection from STI/HIV.

EC not an abortifaciant.

EC not effective for multiple exposures.

Discussion

There was a heated debate on the issue of informed consent. The discussion Group recommended that the consent should be taken in duplicate with one copy given to the client. But the Expert Forum felt that it might not be very practical, and it may hamper people from coming forward for EC use. Besides, no written consent is required for COC use. A verbal consent is obtained whenever a prescription is given. A few suggested having a consent form in regional languages. Most disagreed with having the need of an informed written consent, especially when OTC availability is being considered. Dr Peter Fajans informed the Forum that no written consent is obtained in other countries having EC programme. In fact, obtaining consent will result in women getting suspicious of something serious.

It was also suggested that the information about EC should not only be told to the patient, but also given to her along with the prescription. It needs to be very clearly explained that it is ineffective after missing a period. Schedule of pill-taking is to be explained and, usually, the first dose is given in front of the doctor in the clinic and the client can be made to wait for about 2 hours to watch for side-effects. Consuming pill empty or full stomach or with food is immaterial.

Counselling should also include willingness for MTP in case of failure. The issue of teratogenesis was debated. Though there are no adverse reports if pregnancy is continued in case of failure, but caution is warranted.

As regards screening for suitability, except for exclusion of pregnancy, no other test is required for providing EC pills. Even a pelvic examination is not considered necessary.

Initially, the EC delivery should be restricted to existing RCH services where trained staff for contraceptive counselling is already available. Client information should be in a simple, easily understandable language including regional languages.

Unresolved issue

None

Recommendations

2.5.1 Appropriate counselling is a must for safe and effective use of EC.

2.5.2 Written consent is not required.

2.5.3 Only contra-indication for EC use is pregnancy which should be excluded.

2.5.4 Proper information about the EC should be provided to the client in a format that she can understand, along with the tablets.

2.5.5 No protection from STI/AIDS as well as any subsequent sexual exposure should be clearly told to the client.

2.5.6 Client should be informed about the potential side-effects and how to cope with them.

2.5.7 Risk of failure should always be explained and the client asked to report if menstruation does not start within one week of the expected period.

2.5.8 In case of failure, if pregnancy continuation is desired, she should be informed about no adverse effect of EC on pregnancy.

 

 

 

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