HORMONAL METHOD:

COMBINED ORAL CONTRACEPTIVES

International Comprehensive Right-based Family Planning Training

ACKNOWLEDGEMENTS
Work on this training module was initiated and coordinated by the Centre for Reproductive Health
Faculty of Medicine of Universitas Gadjah Mada. The materials are adapted from The Training
Resource Package for Family Planning (TRP) by WHO, UNFPA, and USAID.

The module was developed using evidence-based technical information from World Health
Organization (WHO) publications:

 Family Planning: A Global Handbook for Providers, 2011

 WHO Medical Eligibility Criteria for Contraceptive Use, 2015
 Selected Practice Recommendations for Contraceptive Use, 2005

The module was reviewed by an expert panel from several institutions (medical society, university,
and BKKBN) with input from UNFPA consultant, Dr. Saramma Mathai.

We are also grateful for the input from Dr. Julianto Witjaksono and Dr. Ilyas Angsar as the national
experts on family planning, Prof. Siswanto Wilopo, Prof. M. Hakimi, Prof. Djaswadi Dasuki, Dr. Ova
Emilia, Ph.D, Dr. M. Nurhadi Rahman, and Dr. Savitri Shitarukmi from the Center for Reproductive
Health, and Dr. Rukmono Siswishanto, Dr. Shinta Prawitasari, Dr. Edi Patmini Setya Siswanti, Dr.
Eugenius Phyoway Ganap, Dr. Muhammad Luthfi, Dr. Ahsanudin Attamimi, Dr. Indrawarman, and
Dr. Ide Pustaka from Faculty of Medicine Gadjah Mada University/ DR. Sardjito General Hospital
Yogyakarta, and Dr. Samidjo and Dr. Melania Hidayat from UNFPA.

We also would like to express our appreciation for Mrs. Siti Fathonah, Dr. Nia Reviani, Mrs. Hitima
Wardhani, Mr. Sanjoyo, and Mr. Witono from BKKBN who gave important contribution for the
operational aspect of the training.

We also appreciate the support from Dr. Mushtofa Kamal, Dr. Primadian Atnaryan, Dr. Amirah
Wahdi, Dr. Riris Maria, Dr. Rathi Manjani, Dr. Prakoso Adhi, Dr. Nurwaida Isnaini, Dr. M. Sidharta,
Mr. Hari Murti, Ms. Tita Utami, and Ms. Aulia Ariadne during the development process of this
module.

For further information about the International Comprehensive Right-based Family Planning Training,
please visit centerofexcellencefp.fk.ugm.ac.id.

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 Table of Contents

Acknowledgements ................................................................................................... 1
Overview (Learning Objective) ................................................................................ 3
Schedule .................................................................................................................... 3
Reference ................................................................................................................... 4
Role Plays .................................................................................................................. 7
Case Studies ............................................................................................................ 12
Illustrative Competency-based Skills Checklist for COCs ..................................... 14
Applied Case Study ................................................................................................. 22
COCs Module: Course Evaluation .......................................................................... 24
Handout: Global Handbook of Combined Oral Contraceptives
Handout: Fact Sheet of Combined Oral Contraceptives
Handout: Job Aid How to Use Combined Oral Contraceptives
Handout: Rumor and Misconceptions about Combined Oral Contraceptives
Slides: Combined Oral Contraceptives

2
 Overview (LO)
By the end of the training, trainees should be able to:
1. List the key messages about COCs
2. Describe the characteristics of COCs in a manner that clients can understand, including:
a. What COCs are and how they work (mechanism of action)
b. Effectiveness (theoretical and practical gap)
c. Side effects
d. Non-contraceptive health benefits
e. Other characteristics (STI/HIV protection, ease of use, return to fertility)
f. Possible health risks (complications)
3. Demonstrate the ability to:
a. Screen clients for medical eligibility for COC use
b. Explain to clients how to use COCs and what to do when pills are missed.
c. Explain when to return to the clinic
d. Address common concerns, misconceptions, and myths
e. Conduct follow-up for COC clients in a way that enhances continuing safety, satisfaction,
and acceptance
4. Describe when to initiate COCs (postpartum, switching from another method)
5. Explain how to manage side effects
6. Identify new conditions that may require a client to switch to another method or to
temporarily stop COC use
7. Identify clients in need of referral for COC-related complications
8. Dual protection FP and STD
(hormonal pill  COC and POP)
9. (new module  cont. in special condition including emergency cont)

Schedule
Combined Oral Contraceptives (COCs): Training Schedule
Total Time: Approximately 1 1/2 hours of instruction time
Time Topic Method Resources
11:00-
Welcome and Introduction Discussion Basic Slide Set: Session I, Slide 2
11:05am

Evaluation Tool: The Combined

11:05-
Pre-test Test Oral Contraceptives (COCs) Pre-
11:10am
Test

11:10- Session I: Characteristics of COCs (25 min)

11.35am
Basic Slide Set: Session I, Slides
Traits and Types Of COCs Discussion
3-4

Basic Slide Set: Session I, Slides

Effectiveness Lecturette 5-6
and Optional Advanced Slide 2

3
 Method Effectiveness Role play Handouts #1 and #2

Explaining How COCs Work Brainstorming Basic Slide Set: Session I, Slide 7

Work Group
Characteristics of COCs Basic Slide Set: Session I, Slide 8
Activity
Why Some Women Say They
Discussion
Like COCs

Menstrual-related Health
Discussion Basic Slide Set: Session I, Slide 9
Benefits

Basic Slide Set: Session I, Slide 10

Other Health Benefits Discussion
and Optional Advanced Slide 3

No Overall Increase in Breast Basic Slide Set: Session I, Slide 11

Lecturette
Cancer Risk for COC Users and Optional Advanced Slides 4-7

COCs and Cervical Cancer Lecturette Basic Slide Set: Session I, Slide 12
Basic Slide Set: Session I, Slide 13
Risk of Blood Clot is Limited Lecturette
and Optional Advanced Slides 8-9

Talking with Clients about

Group Activity
Blood Clot and Cancer Risk

Side Effects of COCs Lecturette Basic Slide Set: Session I, Slide 14

COCs Fact Sheet Brainstorming Handout #3

References
The main references for the COC module as well as for other TRPs are the World Health
Organization’s four cornerstones of family planning guidance:
1. Family Planning: A Global Handbook for Providers (2011 update).This book serves
as a quick-reference resource for all level of health care workers. It provides practical
guidance on delivering family planning methods appropriately and effectively.
2. The Medical Eligibility Criteria for Contraceptive Use (4th edition 2010. This resource
provides guidance on whether people with certain medical conditions can safely and
effectively use specific contraceptive methods.
3. Decision Making Tools for Family Planning Clients and Providers
4. The Selected Practice Recommendations for Contraceptive Use (2nd Edition 2005) and
the Selected Practice Recommendations for Contraceptive Use: 2008 Update.

Additional information and resources for use by facilitators as needed:

 World Health Organization, Department of Reproductive Health and Research.
Combined hormonal contraceptive use during the postpartum period.
http://www.who.int/reproductivehealth/publications/family_planning/rhr_10_15/en/in
dex.html
 World Health Organization, Department of Reproductive Health and Research.
Medical Eligibility Criteria for Contraceptive Use. Fourth Edition.

4
 http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/
en/index.html
• World Health Organization, Department of Reproductive Health and Research.
Carcinogenicity of combined hormonal contraceptives and combined menopausal
treatment.
http://www.who.int/reproductivehealth/publications/ageing/carcinogenicity_hrt/en/ind
ex.html
• World Health Organization, Department of Reproductive Health and Research.
Does hormonal contraception modify the risk of STI acquisition?
http://www.who.int/reproductivehealth/publications/family_planning/pbrief2/en/index.
html
• World Health Organization, Department of Reproductive Health and Research.
Hormonal contraception and bone health.
http://www.who.int/reproductivehealth/publications/family_planning/pbrief1/en/index.
html

Selected Research Articles

Appleby P, Beral V, Berrington de González A, Colin D, Franceschi S, et. al., Cervical
cancer and hormonal contraceptives: collaborative reanalysis of individual data for 16,573
women with cervical cancer and 35,509 women without cervical cancer from 24
epidemiological studies. Lancet 2007;370(9599):1609-21.
Belsey EM. Vaginal bleeding patterns among women using one natural and eight hormonal
methods of contraception. Contraception 1988;38(2):181-206.
(CASH) Cancer and Steroidal Hormone Study of the Centers for Disease Control and the
National Institute of Child and Human Development. Combination oral contraceptive use
and the risk of endometrial cancer. JAMA 1987;257:796-800.
Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal
contraceptives: collaborative reanalysis of individual data on 53,297 women with breast
cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet
1996;347(9017):1713-27.
Davis AR, Westhoff C, O’Connel K, et al. Oral contraceptives for dysmenorrhea in
adolescent girls: a randomized trial. Obstet Gynecol 2005;106(1):97-104.
Davis L, Kennedy SS, Moore J, et al. Modern combined oral contraceptives for pain
associated with endometriosis. Cochrane Database of Syst Rev 2007;(3):CD001019.
Farley TM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular
disease: an international perspective. Contraception 1998;57(3):211-30.
Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. Nineteenth Revised
Edition. New York: Ardent Media, Inc., 2007.
Jick SS, Kaye JA, Russmann S, Jick H. Risk of nonfatal venous thromboembolism with
oral contraceptives containing norgestimate or desogestrel compared with oral
contraceptives containing levonorgestrel. Contraception. 2006;73(6):566-70. Epub 2006
Mar 29.
Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of
breast cancer. N Eng J Med 2002;346(26):2025-32.
Milne RL, Knight JA, John EM, et al. Oral contraceptive use and risk of early-onset breast
cancer in carriers and noncarriers of BRCA1 and BRCA2 mutations. Cancer Epidemiol
5
Biomarkers Prev 2005;14(2):350-6.
Ory HW. The noncontraceptive health benefits from oral contraceptive use. Fam Plann
Perspect 1982;14(4):182-84.
Petitti DB, Porterfield D. Worldwide variations in the lifetime probability of reproductive
cancer in women: Implications of best-case, worst-case and likely-case assumptions about
the effect of oral contractive use. Contraception 1992;45(2):93-104.
Sekar VJ, Lefebvre E, Guzman SS, et al. Pharmacokinetic interaction between ethinyl
estradiol, norethindrone and darunavir with low-dose ritonavir in healthy women. Antivir
Ther 2008;13(4):563-69.
Silvera SA, Miller AB, Rohan, TE. Oral contraceptive use and risk of breast cancer among
women with a family history of breast cancer: a prospective cohort study. Cancer Causes
Control 2005;16(9):1059-63.
Smith JS, Green J, Berrington de González A, et al. Cervical cancer and use of hormonal
contraceptives: a systematic review. Lancet 2003;361(9364):1159-67.
Speroff L, Fritz MA. Oral contraception. In: Clinical Gynecologic Endocrinology and
Infertility, Seventh Edition. Baltimore: Lippincott Williams & Wilkins, 2005:861-942.
Szarewski A, Mansour D, Shulman LP. 50 years of “The Pill”: celebrating a golden
anniversary. J Fam Plann Reprod Health Care 2010;36(4): 231–8. Available:
http://jfprhc.bmj.com/content/36/4/231.full.pdf
Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404.
World Health Organization (WHO). Cardiovascular Disease and Steroid Hormone
Contraception. Report of a WHO Scientific Group, Technical Report Series, No. 877.
Geneva: WHO, 1998.
World Health Organization Collaborative Study of Cardiovascular Disease and Steroid
Hormone Contraception. Effect of different progestagens in low oestrogen oral
contraceptives on venous thromboembolic disease. Lancet. 1995 Dec 16;346(8990):1582-
8.

World Health Organization, Department of Reproductive Health and Research

(WHO/RHR). Statement: Combined Hormonal Contraceptive Use during the Postpartum
Period. Geneva: WHO/RHR, 2010.

6
Combined Oral Contraceptives (COCs)—Clinicians
Role Play Scenario 1—Adolescent client is interested in and is eligible for COCs

COCs Scenario 1—Client Information Sheet COCs Scenario 1—Observer Information Sheet

Client Description Make note of whether the provider performs these case-specific
tasks:
You are a 17-year-old female who has been counseled about the benefits of
 Asks about the client’s reproductive health goals, fertility
using family planning by a nurse at the antenatal clinic. You were pregnant
intentions, and life plans
but miscarried one month ago. You read the pamphlet on family planning
 Ensures that the client understands the contraceptive options
method options that was given to you by the provider at the clinic and have
described in the pamphlet, including emergency contraception,
made a decision about which method you believe best suits your needs.
and has made an informed choice to use COCs
Offer this information only when the provider asks relevant questions:  Determines the client’s medical eligibility using the COCs
screening checklist
 You have had a steady boyfriend for about six months.
 Provides COCs, instructions on correct use, including what to do
 Your boyfriend was taking antibiotics recently after he went to
if pills are missed, and information about resupply
see a doctor at the STI clinic.
 Encourages her to be tested for STIs
 You do not use condoms.
 Explains the benefit of using condoms and offers couples
 Your last period started five days ago and were very regular each
counseling to support correct and consistent condom use
month prior to the miscarriage.
 Discusses benefits of healthy timing and spacing of pregnancies,
 You feel healthy and have no health problems.
noting it is best to wait until at least age 18 and at least six
 You would like to have a child someday, but your boyfriend says
months after miscarriage before attempting to become pregnant
he is not ready, so you have chosen to use COCs because you
believe that COCs would best suit your needs. Methods for which the client is eligible:

 COCs
 DMPA or NET-EN
 Implants
 Male or female condoms
 Standard Days Method®

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Combined Oral Contraceptives (COCs)—Clinicians
Role Play Scenario 2—Postpartum, partially breastfeeding client is interested in and is eligible for COCs
COCs Scenario 2—Client Information Sheet
Client Description
You are a 23-year-old woman and have come to the clinic because your
seven-month-old baby has a mild fever. You use this visit to ask about
pregnancy spacing. You do not want another child for at least two years.
Offer this information only when the provider asks relevant questions:
 You are interested in COCs but your husband is not in favor of the
idea; he believes the pills could harm the baby through the
mother’s milk.
 You stopped fully breastfeeding a month ago, but you are still
partially breastfeeding.
 Your monthly bleeding returned two weeks ago, and since then
you have not had sex because your husband is traveling.
 You have no medical problems.
 You feel comfortable talking to your husband about
contraception.
COCs Scenario 2—Observer Information Sheet
Make note of whether the provider performs these case-specific
tasks:
 Asks about the client’s reproductive health goals, fertility
intentions, and life plans
 Ensures client understands pregnancy risk; no longer protected
by LAM
 Addresses her husband’s concern; provides information about
COCs and breastfeeding and corrects misunderstandings
 Confirms eligibility for COCs using the checklist
 Provides COCs, instructions on correct use, including what to do
if pills are missed, and information about resupply
 Offers couples counseling, particularly if the husband needs
further reassurance about the safety of COCs
Methods for which the client is eligible:
 COCs
 DMPA or NET-EN
 Implants
 IUD
 Male or female condoms
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Combined Oral Contraceptives (COCs)—Clinicians
Role Play Scenario 3—Client requires management of COC side effects and review of instructions for missed pills

COCs Scenario 3—Client Information Sheet COCs Scenario 3—Observer Information Sheet

Client Description Make note of whether the provider performs these case-specific
tasks:
You are a 20-year-old woman who has never been pregnant. A month ago
 Asks about the client’s reproductive health goals, fertility intentions,
you purchased COCs from a nearby pharmacy. You have been taking the and life plans
pills every day for one month but have been experiencing nausea and  Assesses the risk of pregnancy and rules it out based on the fact that
spotting. When you told your friend about this, she suggested that you stop the client took all active (hormonal) pills consistently and correctly.
taking the pills because you might be pregnant. You stopped taking the pills  Discusses common COC side effects, particularly during the first few
two days ago and have come to the clinic to see if you are pregnant. months, and offers reassurance
 Recommends taking the pills with meals or before bed to reduce
Offer this information only when the provider asks relevant questions:
nausea symptoms
 You are in school and do not want to become pregnant for at least two  Suggests taking the pills at the same time each day to reduce spotting
years.  Provides missed pill information: instructs client to throw away the
 You last had sex nine days ago, but you were taking the pills. two inactive pills that she missed and take the next pill in her pack
 You do not think that you are pregnant, but you are concerned about the today
nausea and spotting.  Offers resupply or encourages the client to purchase a new pack of
 You were taking the pill in the morning before school or after class in pills ahead of time
the late afternoon.  Reviews the benefits of using condoms (dual protection) to prevent
 The two pills that you skipped were the brown ones in the last row. HIV/STIs
 You have experienced mild nausea, but no vomiting. Methods for which the client is eligible:
 You have no health problems.  COCs
 DMPA or NET-EN
 Implants
 IUD
 Male or female condoms

9
Combined Oral Contraceptives (COCs)—Clinicians
Role Play Scenario 4—Older client with concerns about eligibility is interested in and is eligible for COCs
COCs Scenario 4—Client Information Sheet
Client Description
You are a 41-year-old woman with three teenage boys and a two-year-old girl
(who was a surprise baby following the removal of an IUD). You and your
husband have been using condoms every time you had sex, but you don’t feel
they are reliable enough. You are interested in COCs but are concerned that
you might be too old for this method.
Offer this information only when the provider asks relevant questions:
 You have no serious health problems and have a regular menstrual
cycle.
 You used the IUD in the past but were not pleased with the heavy
bleeding and cramping.
 You would like a method that maintains your normal bleeding cycle
and reduces cramping, which is why, after reading a pamphlet on FP
methods, you are interested in COCs.
 You are not interested in sterilization at this time.
 Your last period started 21 days ago.
COCs Scenario 4—Observer Information Sheet
Make note of whether the provider performs these case-specific
tasks:
 Asks about the client’s reproductive health goals, fertility intentions,
and life plans
 Asks about methods the client has used in the past and what she liked
or didn’t like about them and whether there are any methods she does
not want to consider
 After client reveals COCs as her method of choice, discusses benefits
(based on the client’s responses, COCs would be an ideal method
because this method maintains a normal bleeding pattern, reduces
cramping, and is reversible)
 Confirms medical eligibility for COCs using the checklist
 Provides COCs and instructions on correct use and on resupply
Methods for which the client is eligible:
 COCs
 DMPA or NET-EN*
 Implants*
 IUD
 Male or female condoms
 Standard Days Method®
* Although the client is medically eligible, these methods would not be
appropriate because the she wants a method that maintains regular
menstrual cycles.
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Combined Oral Contraceptives (COCs)—Clinicians
Role Play Scenario 5—Breastfeeding client with HIV is interested in but is not eligible for COCs
COCs Scenario 5—Client Information Sheet
Client Description
You are a 28-year-old woman who is HIV-positive. You have brought your
six-week-old baby for early infant diagnosis (PCR test for HIV) to the
MCH/PMTCT clinic. You want to make sure that you and your baby are
healthy before trying to have another pregnancy in about two years.
Offer this information only when the provider asks relevant questions:
 You are exclusively breastfeeding and planning to wean abruptly at six
months.
 You are interested in COCs and have used them before.
 You feel healthy, and four months ago your CD4 was 800.
 Your husband is HIV-positive and is on highly active retroviral therapy
(HAART).
COCs Scenario 5—Observer Information Sheet
Make note of whether the provider performs these case-specific
tasks:
 Asks about the client’s reproductive health goals, fertility intentions,
and life plans
 Determines the client’s eligibility using the checklist (at this time she
is not eligible; initiation of COCs should be delayed until the infant is
six months old, unless she stops breastfeeding prior to six months)
 Discusses other contraceptive options that the client may be eligible
to use including LAM; describes how LAM works and the need to
start another method if one of the criteria changes
 Discusses the importance of using condoms (dual protection) even
when both partners are HIV-positive
Methods for which the client is eligible:
 LAM
 DMPA or NET-EN
 Implants
 IUD
 Male or female condoms
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Case Study 1
Nadia is a 30-year-old mother of three children. She has been exclusively breastfeeding her youngest
child, who is 5 months old. Nadia is planning to begin supplementing her infant’s diet and weaning
her baby next month. Today, she has come to your clinic to get family planning pills.
Question Set A
During the counseling, Nadia wants to learn more about COCs and asks the following questions:

1. How does the pill prevent pregnancy?

2. What are some of the advantages of taking the pill?
3. What are some of the limitations of taking the pill?
Question Set B
During Nadia’s initial visit, you determined that she would be eligible to start using COCs when
her baby was six months old. You gave her several pill packs and instructed her to start taking
them when her baby turned six months, or sooner if she started supplementing his diet before he
was six months, or if her menses returned.
Four weeks have passed and Nadia has returned to the clinic. She says that her period returned
yesterday, and that she is now taking antibiotics for a urinary tract infection and iron supplements
for anemia. Her baby has just turned six months old.
1. What tool would you select to help screen for medical eligibility?
2. Do Nadia’s new medical conditions affect her eligibility for COCs? Will the antibiotics she is
taking interfere with the effectiveness of the COCs? Does her anemia or her intake of ferrous
sulfate affect her eligibility?
3. How does breastfeeding affect her eligibility to use COCs? What additional information about
the effect of COCs on breast milk should you offer to breastfeeding women who are
considering COCs?
Question Set C
You have determined that Nadia is still medically eligible to start COCs and told her she could
start today.
1. What information should you discuss with Nadia?
2. What should you tell her about missed pills or starting a new pack late?
3. How will you help Nadia prepare for possible side effects?
4. What will you tell her about follow-up and resupply?
Question Set D
Three months later, Nadia returns to the clinic to get more pills. During counseling, she
reports that every month since starting COCs she has had several days of spotting in the
middle of her cycle. This concerns her and she would like to know if this pattern will
continue as long as she continues using COCs. Nadia also says that she experienced
nausea and headaches often during the first month but much less frequently during the
second and third months.
1. How will you address Nadia’s concerns? What information should you gather from Nadia?
2. Is spotting normal with pills? What other conditions may cause spotting?
3. How will you advise Nadia to manage the spotting, nausea, and headaches?

12
Case Study 2
Miriam is a 38-year-old mother of four children who has been using DMPA for about two years. She
has always returned for injections on time. Today, she has come to your clinic with several questions
and a desire to start using the pill. Miriam explains that in the first year of using DMPA, she had
irregular and prolonged bleeding, and this year she has had long stretches of no bleeding. This has
made her anxious and she wants a method that will allow for more regular menstrual cycles.
Question Set A
During counseling, Miriam says she has a friend who uses COCs and is satisfied with the method.
Miriam thinks she would like to start using COCs too, but she wants to learn more about them before
making a final decision.
1. What questions would you ask Miriam?
2. How would you explain to Miriam how COCs work?
3. What do you tell Miriam about the advantages and limitations of using COCs?
4. What additional information should you provide to Miriam?

Question Set B
After discussing the advantages and limitations of using COCs and other available methods, Miriam
chooses to begin using COCs. During counseling, you learn that Miriam stopped smoking when she
first starting using injectables about two years ago and she had some headaches during the first few
months of DMPA use. She also tells you that she is scheduled to receive her reinjection on September
15. (Today’s date is September 1.)
1. What tool would you select to help screen Miriam for medical eligibility?
2. How might Miriam’s current method use and smoking history affect her eligibility for COCs?
3. Is Miriam eligible to start using COCs today? Why or why not?
4. What type of medical exam does Miriam require before starting to use COCs?

Question Set C
You determine that Miriam is eligible to start using COCs today. You give her three cycles of
pill packs to take home and ask her to return in two-and-a-half months for resupply.
1. When should Miriam start taking the pills?
2. What topics should you cover during counseling?
3. How would you explain about how to manage missed pills?
4. What should you say about when to return?

Question Set D
Two months later, Miriam returns to your clinic complaining that she has had some severe
headaches. She says that these headaches remind her of the headaches she experienced when
first using injectables, but now they are much more painful and are usually on the left side of
her head.

1. How will you respond to Miriam’s report of headaches?

2. Is Miriam eligible to continue using COCs? Why or why not?
3. What is your plan of action, and why?

13
 Illustrative Competency-based Skills
Checklists for Combined Oral Contraceptives (COCs)
Date of Assessment:____________________ Dates of Training:____________________
Place of Assessment: Facility:____________________ Classroom:____________________
Name of Facility:
______________________________________________________________
Type of Facility:  MOH/Gov’t  NGO  Other
Level of Facility:  Primary  Secondary  Tertiary
Name of the Service Provider:
___________________________________________________
Name of the Assessor:
__________________________________________________________
This assessment tool contains the detailed steps that a service provider should follow in
counseling and providing client instructions for COCs. The checklist may be used during
training to monitor the progress of the trainee as s/he acquires the new skills and it may be
used during the clinical phase of training to determine whether the trainee has reached a level
of competence in performing the skills. It may also be used by the trainer or supervisor when
following up or monitoring the trainee. The trainee should always receive a copy of the
assessment checklist so that s/he may know what is expected of her/him.

Instructions for the Assessor

1. Always explain to the client what you are doing before beginning the assessment. Ask for
the client's permission to observe.
2. Begin the assessment when the trainee greets the client.
3. Use the following rating scale:
1= Needs Improvement. Step or task not performed correctly or out of sequence (if
necessary) or is omitted.
2= Competently Performed. Step or task performed correctly in proper sequence (if
necessary) but participant does not progress from step to step efficiently.
3= Proficiently Performed. Step or task efficiently and precisely performed in the proper
sequence (if necessary).
Not observed: Step, task, or skill not performed by the trainee during evaluation by the
trainer.
4. Continue assessing the trainee throughout the time s/he is with the client, using the rating
scale.
5. Observe only and fill in the form using the rating numbers. Do not interfere unless the
trainee misses a critical step or compromises the safety of the client.
6. Write specific comments when a task is not performed according to standards.
7. Use the same copy for several observations.
8. When you have completed the observation, review the results with the trainee. Do this in
private, away from the client or other trainees.

14
 TASK/ACTIVITY CASES COMMENTS
INITIAL INTERVIEW 1 2 3
Greets client in a friendly and respectful manner.

Maintains eye contact with the client

Concentrates fully on what the client is saying

Asks what MCH/FP service she is seeking and

respond to any general questions she may have.
Provides general information about MCH services and
FP methods available.

Explains what to expect during clinic visit.

Asks client if she has a method in mind

Asks client her feelings about or experience with a

method
Helps client to make an informed choice: e.g.,
• Asks client about reproductive goals, to space
or limit births
• Explores any attitudes or religious beliefs that
may favor or rule out one or more methods
• Briefly explains contraceptive choices available
• Briefly explains benefits/advantages of each
• Briefly explains risks/disadvantages of each
• Asks client if she has any questions and
responds to these
• Asks client which method she prefers
METHOD-SPECIFIC COUNSELING 1 2 3
Ensures necessary privacy.
Obtains necessary biographical data (name, address,
age, etc.).
If the client chooses COCs:
• Asks her what she knows about COCs. Corrects
any myths, rumors or misinformation she may
express
• Asks if she has used COCs in the past. What
was her experience?
• Gives client a package of COCs to look at and
handle
TASK/ACTIVITY CASES COMMENTS
METHOD-SPECIFIC COUNSELING, continued 1 2 3
• Explains advantages of the COC, including
non- contraceptive benefits
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 TASK/ACTIVITY CASES COMMENTS
• Briefly explains how COCs work and the
importance of taking it every day
• Explains potential common side effects of the
COC. Stress that she may experience some (or
possibly none) of these and that they can all be
managed:
– changes in bleeding patterns (lighter,
irregular, infrequent or no monthly period)
– nausea (upset stomach)
– headaches
– mood changes
– breast tenderness/fullness
– dizziness
– weight gain or weight loss
• Reassures client that most side effects are not
serious and will decrease or stop after a few
months of use
• Responds to any questions or concerns the
client may have
• Explains that s/he will ask the client some
questions and performs a minimal physical
examination to be sure that the COC is
medically appropriate
CLIENT SCREENING 1 2 3
Screens client using Checklist for Screening Clients Who Want to Initiate COCs.
Asks all questions on checklist and record responses.
1. Are you currently breastfeeding a baby less
than 6 months of age?
2. Do you smoke cigarettes and are you more
than 35 years of age?
3. Have you ever been told you have breast
cancer?
4. Have you ever had a stroke, blood clot in your
legs or lungs, or heart attack?
5. Do you have repeated severe headaches, often
on one side, and/or pulsating, causing nausea,
and which are made worse by light, noise, or
movement?
CLIENT SCREENING continued 1 2 3
6. Do you regularly take any pills for
tuberculosis (TB), seizures (fits), or ritonavir
for ARV therapy?
7. Have you given birth in the last 6 weeks?
8. Do you have gall bladder disease or serious
liver disease or jaundice (yellow skin or
eyes)?

16
 TASK/ACTIVITY CASES COMMENTS
9. Have you ever been told you have high blood
pressure?
10. Have you ever been told you have diabetes
(high sugar in your blood)?
11. Do you have two or more conditions that
could increase your chances of a heart attack
or stroke, such as old age, smoking, obesity,
or diabetes?
12. Have you ever been told that you have a
rheumatic disease such as lupus?
13. Did your last menstrual period start within the
past 7 days?
14. Did you have a baby less than 6 months ago,
are you fully or nearly-fully breastfeeding,
and have you had no menstrual period since
then?
15. Have you abstained from sexual intercourse
since your last menstrual period or delivery?
16. Have you had a baby in the last 4 weeks?
17. Have you had a miscarriage or abortion in the
last 7 days?
18. Have you been using a reliable contraceptive
method consistently and correctly?

Understands that if the clients answers No to all of

questions 1-12, she may use COCs and if the client
answers Yes to at least one of questions 13-18 and is
free of signs and symptoms of pregnancy, provider
can assume the client is not pregnant.

CLIENT SCREENING continued 1 2 3

Reassures client of confidentiality and uses judgment
concerning the necessity of asking the following
questions:
• Do you or your husband/partner have other sex
partners?
• What medicines do you regularly take?
Manages or refers for follow-up any positive findings.
Performs physical exam:
• Explains procedure(s) to be performed and
reassures client of her safety

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 TASK/ACTIVITY CASES COMMENTS
• Checks blood pressure: Is BP elevated?
– Systolic over 140
– Diastolic over 90
• Checks weight.
• Checks cardiovascular function:
– Extreme shortness of breath observed?
– Severe pallor or cyanosis observed?
– Resting heart rate greater than 100, or
markedly irregular?
– Legs edematous?
– Severe varicosities?
• Performs breast exam:
– Any suspicious lumps?
– Is she jaundiced?
– Does she have an enlarged or tender liver?
– Records findings
• Manages or refers for follow-up any positive
findings as recommended by local guidelines.
PROVISION OF COCs 1 2 3
Gives client her pill packet to hold and look at.
Shows her how to follow the arrows on the pack.
If the client uses a 28-pill pack: instructs her to start a
new pack the day after she finishes all of the pills in
the packet.

If the client uses a 21-pill pack, instructs her to wait 7

days before starting a new pack.

PROVISION OF COCs continued 1 2 3

Instructs the client to start the pill on first day of her
next menstrual period (or on fifth day of her menstrual
period, or use local guidelines for this instruction). If
the client starts the pill after day five of her cycle she
should use a back-up method for the first 7 days.
Gives the following client instructions about missed
pills:
• Explain to the client that if she forgets to take
her pills, she may become pregnant. If she
forgets to take her pills, she should do the
following:
• If she misses one pill, the client should take it as
soon as she remembers. Take the next one at
the regular time.

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 TASK/ACTIVITY CASES COMMENTS
• If she misses two pills, the client should take
two pills as soon as she remembers. She should
take two pills the next day, and use a backup
method for the next week. The client should
finish the packet normally.
• If she misses more than two pills, or starts a
pack 3 or more days late the client Take a pill as
soon as possible, continue taking 1 pill each
day, and use condoms or avoid sex for next 7
days. If these pills missed in week 3, the client
should ALSO skip the inactive pills in a 28-pill
pack and immediately start a new pack. If
inactive pills are missed, the client should throw
away the missed pills and continue taking pills,
1 each day
Cautions client that she may feel queasy or nauseated
if she takes two pills in one day, but taking two pills
reduces her chances of becoming pregnant.
Explains other situations in which a back-up method is
needed:
• Diarrhea/vomiting: Start using a back-up
method on the first day of diarrhea or vomiting,
and use it for at least 7 days after the
diarrhea/vomiting is over. Meanwhile, continue
to take your pills as usual.
• If taking certain medications used in the
treatment of tuberculosis and seizures
(rifampin, phenytoin, carbamazepine).

TASK/ACTIVITY CASES COMMENTS

PROVISION OF COCs continued 1 2 3
Stresses the importance of informing other
doctors/health workers who may care for her, that she
is using the COC.
Asks client to repeat back in her own words
instructions for when to start the pills, which pill she
will begin with, how she will take the second and
subsequent pills, and what she will do if she misses a
pill or pills.
Explains in a non-alarming way the early pill warning
signs, stressing the rarity of these:
• Severe, constant pain in belly, chest or legs or
very bad headaches that start or become worse
after she begins to take COCs.
• Brief loss of vision, seeing flashing lights or
zigzag lines (with or without bad headaches).

• Jaundice (skin and eyes look yellow).

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 TASK/ACTIVITY CASES COMMENTS
Asks client a few questions to ensure that she
understands and remembers key instructions.

Prescribes or provides client with at least three- month

supply of COCs.

Reassures client that she may change the pills or try

another method if she does not like these COCs.

Reassures client that s/he is available to see her if she

has any problems or questions or needs advice.

Plans for a return visit and gives client a definite

return date.
• Asks client to bring her pill packets with her on
the return visit.
Documents/records the visit according to local clinic
guidelines.

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 TASK/ACTIVITY CASES COMMENTS
RETURN VISIT COUNSELING 1 2 3
1. Asks client if she is satisfied with the COC.
2. Asks if she is having any problems or
experiencing any side effects. If yes, manage
these as appropriate
3. Asks client how she is taking the COCs and
to demonstrate for you with the package she
is using.
4. Repeats the history checklist. If history
suggests client has developed a precaution,
does an appropriate physical examination to
rule out or verify.
5. Checks client's blood pressure.
6. Briefly reviews key messages/instructions
concerning missed pills, use of back-up
method, and danger signs.
7. Asks client to repeat these back.
8. If the client is satisfied with the COC, is
tolerating the COC well, is not experiencing
any serious side effects, and no precautions
exist:
– Prescribes/provides at least another three
cycles of COCs. (She may be provided with
13-18 cycles.)
– Provides her with a sufficient supply of
condoms, if at risk of an STD.
9. If client wants to discontinue the COC, helps
her make an informed choice of another
method.
10. Encourages client to see her/him at any time
if she has questions or problems.

Comments: ________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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21
 The Combined Oral Contraceptives (COCs)
Applied Learning Case Studies

Participant Name________________________________________________________

Case 1
Read the case and answer the questions.
Ester is a healthy 27-year-old mother of a six-month-old infant. She has been exclusively
breastfeeding, and her menses have not yet returned. She is planning to start giving her baby
supplementary foods this week and begin weaning the baby off breast milk. Ester has come to
the clinic and asks about COCs. She is somewhat informed about them and wants to start
using them as soon as possible.

a) Is Ester eligible to initiate COCs? Why or why not?

b) What are the key counseling messages you should share with Ester?

(For facilitator’s use only)

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Case 2
Joyce is a 25-year-old mother of two children; her youngest child is 11 months old. Joyce has
been using COCs for two months. She returns to the clinic for resupply and complains of mild
headaches. Joyce quit smoking before her last pregnancy, but she has recently begun smoking
again, as many as five cigarettes a day. Other than the headaches, she has no health problems.

a) Is Joyce eligible to continue COC use? Why or why not?

b) Describe your course of action.

(For facilitator’s use only)

Course Evaluation

23
Instructions: Rate each of the following statements as to whether or not you agree with them,
using the following key:
1 Strongly disagree
2 Somewhat disagree
3 Neither agree nor disagree
4 Somewhat agree
5 Strongly agree

Overview
• The objectives of the module were clearly defined. 1 2 3 4 5
• The material was new to me. 1 2 3 4 5
• The trainer understood the material being presented. 1 2 3 4 5
• The time spent on this module was sufficient. 1 2 3 4 5
• Time for discussion and questions was sufficient. 1 2 3 4 5
• The material in this module has provided me with sufficient 1 2 3 4 5
information to conclude the safety and effectiveness of COCs.
• The module has offered me the skills to provide COC services, 1 2 3 4 5
including counseling, appropriate client screening and selection, and
management and follow-up of clients.
• The pre-/post-test accurately assessed my course learning. 1 2 3 4 5

Meeting Conditions/Locations
• The training was held on a convenient day and time. 1 2 3 4 5
• Necessary supplies were available. 1 2 3 4 5

Training Methods and Materials

• The trainers' presentations were clear and organized. 1 2 3 4 5
• I learned practical skills in the role plays and case studies. 1 2 3 4 5
• Class discussion was helpful. 1 2 3 4 5
• The trainers encouraged my questions and input. 1 2 3 4 5

Course Length
The length of the course was (circle your answer): Too long Too short Just right

What topics in this training do you think would be most useful to you in your work?
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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_______________________________________________________________________________

_______________________________________________________________________________

On which topics would you have liked more information or preferred to spend more time on?
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

What was the least useful aspect of this training?

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

On which topics would you have liked less information or preferred to spend less time?
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Suggestions
What suggestions do you have to improve the training? Please feel free to refer to points above.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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