What approach should be used for contraceptive counseling in an outpatient clinic office?

Contraceptive Counseling in the Outpatient Clinic

Follow the CDC's structured 5-step approach: establish rapport, obtain clinical/social history, interactively select methods using a tiered effectiveness approach, perform only essential physical assessments, and provide same-day contraception with a full year's supply. 1

Step 1: Establish Rapport

Build trust through specific communication strategies:

• Use open-ended questions rather than yes/no questions to encourage dialogue 1
• Ensure complete privacy and confidentiality by explicitly explaining how personal information will be protected and used 1
• Demonstrate empathy without judgment, actively listening to the client's concerns and observing non-verbal cues 1
• Encourage questions throughout the encounter, making yourself accessible for follow-up 1

Step 2: Obtain Essential Clinical and Social Information

Medical History (Required Elements)

For female clients, document:

• Menstrual history: last menstrual period, cycle frequency, bleeding patterns 1
• Obstetric history: pregnancies, deliveries, miscarriages, terminations, current breastfeeding status 1
• Contraceptive history: current and past methods used, difficulties experienced (side effects, adherence problems), use at last intercourse 1
• Medical conditions: chronic diseases, thromboembolism risk factors, hypertension, diabetes 1
• Smoking status and age (critical for combined hormonal contraception eligibility) 1
• Allergies to medications or latex 1
• Recent sexual activity and timing of last intercourse 1

Reproductive Life Plan

Ask directly: "Do you want to have any children or more children? If yes, when?" This clarifies pregnancy intentions and guides method selection 1

Sexual Health Assessment (The "5 P's")

• Practices: Types of sexual activity (vaginal, anal, oral) 1
• Pregnancy prevention: Current contraceptive use and partner's contraceptive involvement 1
• Partners: Number, gender, and concurrency of partners 1
• Protection from STDs: Condom use patterns and barriers to consistent use 1
• Past STD history: Personal and partner STD history 1

Step 3: Interactive Method Selection Using Tiered Approach

Present Methods by Effectiveness (Most Effective First)

Start with long-acting reversible contraception (LARC) before discussing less effective methods 1, 2:

1. Tier 1 - Most Effective (<1% failure rate):

   • Implant (0.05% failure rate) 2
   • IUDs: levonorgestrel and copper (0.2-0.8% failure rate) 2
   • Emphasize that LARCs are safe for all women, including adolescents and nulliparous women 1, 2

2. Tier 2 - Moderately Effective (6-9% typical use failure rate):

   • Injectable contraception 1
   • Combined hormonal methods (pills, patch, ring) 1
   • Progestin-only pills 1

3. Tier 3 - Less Effective (12-28% typical use failure rate):

   • Barrier methods (condoms, diaphragm, cervical cap) 1
   • Fertility awareness methods 1

4. Permanent Methods:

   • Female and male sterilization for those who have completed childbearing 1

Essential Information for Each Method

Discuss for all medically appropriate methods:

• Typical use effectiveness rates (not just perfect use) 1
• Correct usage instructions and adherence requirements 1
• Common side effects, particularly bleeding changes 1
• Non-contraceptive benefits (e.g., reduced menstrual pain, acne improvement) 1
• Return to fertility after discontinuation 1

Address Barriers and Preferences

• Identify socio-behavioral barriers: mental health issues, substance abuse, intimate partner violence 1
• Assess partner involvement and preferences 1
• Discuss cost and accessibility concerns 1

Critical Counseling Point for STI Risk

All clients at STI risk must use condoms regardless of their primary contraceptive method - hormonal contraception and IUDs provide zero STI protection 2. This dual-method approach is mandatory, not optional 2.

Step 4: Physical Assessment (Only When Warranted)

Required Assessments

• Blood pressure measurement before initiating combined hormonal contraception 1, 3
• Pregnancy test only if clinical uncertainty exists - detailed history is usually sufficient 1, 3
• Weight/BMI measurement for baseline monitoring (not for eligibility determination, as obesity is not a contraindication to any method) 1, 3

Examinations NOT Required Before Contraception

Do not delay contraception for these unnecessary procedures 1:

• Pelvic examination (except for IUD insertion or diaphragm fitting) 1
• Cervical cytology/Pap smear 1
• Clinical breast examination 1
• HIV screening 1
• Laboratory tests for lipids, glucose, liver enzymes, hemoglobin, or thrombogenic mutations 1

Common pitfall: Requiring unnecessary exams creates barriers to contraceptive access, particularly for adolescents and low-income women 1.

Step 5: Provide Method and Ensure Understanding

Same-Day Provision

• Dispense contraception onsite at the visit - do not require return visits 1
• Use "quick start" approach: Begin the method immediately rather than waiting for next menses if reasonably certain the client is not pregnant 1

A provider can be reasonably certain of non-pregnancy if the client meets any one of these criteria 1:

• ≤7 days after menses start
• No intercourse since last normal menses
• Using reliable contraception correctly and consistently
• ≤7 days post-abortion
• Within 4 weeks postpartum
• Fully breastfeeding, amenorrheic, and <6 months postpartum

Prescribing Strategy

Provide or prescribe a full year's supply of pills, patch, or ring at the initial visit 1. This eliminates refill barriers and improves continuation 1.

Instructions and Follow-Up Plan

• Demonstrate correct usage with hands-on instruction when applicable 1
• Provide written instructions for missed doses or problems 1
• Develop a specific follow-up plan addressing when to return and how to contact the clinic 1
• Confirm understanding by having the client explain back key points 1
• Discuss backup contraception (condoms) for the first 7 days if not starting during menses 1

Emergency Contraception Education

Proactively discuss emergency contraception availability and provide advance prescriptions when appropriate 1.

Common Pitfalls to Avoid

• Never limit discussion to only methods available onsite - provide referrals for all medically appropriate methods 1, 2
• Never assume method preferences based on age, parity, or demographics - present all options and let the client choose 2
• Never delay contraception waiting for menses when quick start is appropriate 1, 3
• Never provide only 1-3 month supplies when a full year can be prescribed 1, 3
• Never require pelvic exams or Pap smears before providing non-IUD contraception 1, 3
• Never omit LARC discussion with adolescents or nulliparous women - these are first-line options for all ages 1, 2