Effective Family Planning Methods
Long-acting reversible contraception (LARCs)—specifically intrauterine devices (IUDs) and implants—should be presented first as the most effective contraceptive methods, followed by other hormonal methods, barrier methods, and fertility awareness-based methods, using a tiered approach that prioritizes effectiveness. 1
Contraceptive Counseling Framework
The CDC recommends a structured five-step approach to family planning services: 1
- Establish rapport by using open-ended questions, ensuring privacy and confidentiality, and demonstrating empathy 1
- Obtain clinical and social information including medical history, menstrual history, contraceptive experiences, pregnancy intentions, and sexual health assessment 1
- Work interactively to select methods by presenting all safe options using a tiered effectiveness approach 1
- Conduct physical assessment only when warranted (blood pressure measurement before combined hormonal contraceptives; pregnancy testing if indicated) 1
- Provide the method with instructions and develop a follow-up plan 1
Contraceptive Methods by Effectiveness
Most Effective Methods (Failure Rate <1%)
Long-Acting Reversible Contraception (LARCs):
- Implants: 0.05% failure rate with typical use; safe and effective for all women including adolescents and nulliparous women 1
- Copper IUD (ParaGard): 0.8% failure rate with typical use; also serves as emergency contraception when inserted within 5 days of unprotected intercourse 1, 2
- Levonorgestrel IUD (Mirena): 0.2% failure rate with typical use 1
Permanent Sterilization:
- Female sterilization: 0.5% failure rate; safe outpatient procedure for those who have completed childbearing 1
- Male sterilization (vasectomy): 0.15% failure rate; highly effective and safe 1
Highly Effective Methods (Failure Rate 1-9%)
Hormonal Methods:
- Combined oral contraceptives: 9% failure rate with typical use, 0.3% with perfect use 1, 3
- Progestin-only pills: 9% failure rate with typical use, 0.3% with perfect use; preferred for breastfeeding women 1, 4
- Contraceptive patch (Evra): 9% failure rate with typical use, 0.3% with perfect use 1
- Vaginal ring (NuvaRing): 9% failure rate with typical use, 0.3% with perfect use 1
- Injectable contraceptive (Depo-Provera): 6% failure rate with typical use, 0.2% with perfect use 1
Moderately Effective Methods (Failure Rate 10-20%)
Barrier Methods:
- Male condoms: 18% failure rate with typical use, 2% with perfect use; only method providing STD protection 1
- Female condoms: 21% failure rate with typical use, 5% with perfect use 1
- Diaphragm with spermicide: 12% failure rate with typical use, 6% with perfect use 1
Less Effective Methods (Failure Rate >20%)
Fertility Awareness-Based Methods:
- Standard days method: 5% failure rate with perfect use 1, 5
- Ovulation method (Billings): 3% failure rate with perfect use 1, 5
- Symptothermal method: 0.4% failure rate with perfect use, but 24% with typical use 1, 5
- Withdrawal: 22% failure rate with typical use, 4% with perfect use 1
Lactational Amenorrhea Method (LAM):
- 0.45% to 2.45% pregnancy rate at 6 months when criteria are met (exclusive breastfeeding, amenorrhea, infant <6 months old) 6
Key Counseling Points
Method Selection Considerations
Effectiveness Discussion:
- Present typical use failure rates, as these reflect real-world effectiveness better than perfect use rates 1
- Emphasize that LARCs are 20 times more effective than pills, patches, or rings due to elimination of user error 1
Correct Use and Adherence:
- Assess the client's ability to remember daily pills or tolerate injections when selecting methods 1
- Discuss barriers to consistent use including social factors, mental health, substance abuse, and partner violence 1
Noncontraceptive Benefits:
- Many hormonal methods reduce heavy menstrual bleeding and dysmenorrhea 1
- Combined hormonal contraceptives protect against ovarian and endometrial cancer 7
Side Effects and Safety:
- Inform clients that many side effects (irregular bleeding, mood changes) may resolve over time 1
- Discuss warning signs for serious adverse events: stroke and venous thromboembolism with combined hormonal methods 1
- Screen for smoking in women considering combined hormonal contraception 1
STD Protection
Dual Protection Strategy:
- Only condoms provide protection against STDs including HIV 1
- Recommend condom use in addition to other contraceptive methods for clients at STD risk (multiple partners, partner concurrency) 1
- Conduct sexual health assessment including number and gender of partners, condom use patterns, and past STD history 1
Special Populations
Adolescents and Nulliparous Women
- LARCs (IUDs and implants) are safe and appropriate first-line options 1
- No medical reason to withhold any contraceptive method based solely on nulliparity 1
Postpartum Women
- Progestin-only methods can be initiated immediately after delivery 4
- Combined hormonal methods should be deferred until at least 3-6 weeks postpartum due to venous thromboembolism risk 8
Perimenopausal Women
- Continue contraception until menopause or at least age 50-55 years 8
- Balance pregnancy risks in advanced maternal age against contraceptive risks, particularly with estrogen-containing methods 8
Emergency Contraception
Available Options:
- Copper IUD: Most effective emergency contraception; can be inserted up to 5 days after unprotected intercourse 2
- Ulipristal acetate (ella): More effective than levonorgestrel, especially 72-120 hours after intercourse 2
- Levonorgestrel (Plan B One-Step): Available over-the-counter; most effective within 72 hours 2
Common Pitfalls to Avoid
Do not delay contraceptive initiation:
- Use "quick start" approach rather than waiting for next menstrual cycle 8
- Provide pregnancy testing if indicated, but history is usually sufficient 1
Do not limit contraceptive supply:
- Prescribe a full year supply rather than providing limited refills 8
Do not omit methods due to site availability:
- Discuss all appropriate methods even if not available at your facility 1
- Establish strong referral networks for methods you cannot provide 1
Do not require unnecessary examinations:
- Pelvic exam is not required before initiating most contraceptive methods 1
- Blood pressure measurement is needed only before combined hormonal contraceptives 1