A guide to family planning for community health workers and their clients

Publication date: 2012

A guide to family planning for community health workers and their clients Adapted from the WHO's Decision-Making Tool for family planning clients and providers Purpose of this tool This flip-chart is a tool to use during family planning counselling or in group sessions with clients. It can: • help your clients choose and use the method of family planning that suits them best; • give you the information you need for high-quality and effective family planning counseling and care; • help you know who may need referral. Preparing to use the tool • For each topic in this tool, there is a page for the client and one for you. The client's page has pictures and key points and your page has more details. • At the back are pages which provide more information on special topics and situations. • This guide covers only the main points. When you talk with your clients, you can add information and discuss matters further, responding to the client’s needs and concerns. • Studying this tool will help you learn the information in it. Using it becomes easier with practice. Using the tool with clients • Place the tool where you and the client can easily see it. • Use only pages and information that meet the individual client’s needs. To do this, keep listening to and assessing the client’s situation, needs, and wishes. • Use language that the client will understand. Do not read the text to the client. Once you know the tool, a glance will remind you of key information and your next steps. Methods Carry with you examples of the methods (an IUD, a packet of pills, for example) so that your clients can see what they really look like. How to use pages as handouts In order to give information to the client on the method she or he chooses, the methods pages were designed to be photocopied front and back and given to the client. These pages have key information for the client about how to use the method. Introduction for the provider WHO Library Cataloguing-in-Publication Data A guide to family planning for community health workers and their clients. 1.Family planning services. 2.Contraception ± methods. 3.Community health workers. 4.Counseling. 5.Decision making. 6.Teaching materials. I.World Health Organization. ISBN 978 92 4 150375 4 (NLM classification: WA 550) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications ± whether for sale or for noncommercial distribution ± should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. 7KH�PHQWLRQ�RI�VSHFLILF�FRPSDQLHV�RU�RI�FHUWDLQ�PDQXIDFWXUHUV¶�SURGXFWV�GRHV�QRW�LPSO\�WKDW�WKH\�DUH�HQGRUVHG�RU�UHFRPPHQGHG�by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Italy Methods The pill 4 Minipill 5 Injections 6 Male condom 7 Female condom 8 Implants 9 IUD 10 Female sterilization 11 Vasectomy 12 Breastfeeding method 13 Standard Days Method 14 Withdrawal 15 Emergency contraceptive pills 16 Provider pages Special situations 17 Health conditions 19 Pregnancy checklist 20 Frequently asked questions 21 Choosing a method Why use family planning? 1 You can choose a method that is right for you 2 Comparing family planning methods 3 Job aids Male and female anatomy 23 Male condom instructions 24 Female condom instructions 25 Cycle beads instructions 26 Checklists for new and returning clients 27 Contents of the tool Why use family planning? You have the right to choose how many children to have and when --------- Family planning can save your life ---------- How can family planning help you? • Healthier mothers and children • Fewer children means more time and money for each one • Delaying pregnancy lets young people stay in school Why use family planning? Benefits – Mothers and babies are healthier when risky pregnancies are avoided. – Smaller families mean more money and food for each child. – Parents have more time to work and to be with family. – Delaying first or second pregnancy lets young people stay in school. Things to Consider – Many young people need contraceptives to delay pregnancy. Ideally, young women and men should wait until at least 18 years or have finished studies, and are ready before having children. – After having a child, it is healthier to wait at least 2 years to try to become pregnant again. – Having more than 4 children makes childbirth riskier. Why use family planning 1 There are many methods available… -----you can choose one that is right for you----- There are many methods available • Do you have children? Do you want (more) children in the future? • Do you want to prevent pregnancy now? • Are you using a family planning method now? • Have you used a family planning method before? • Is there a method you would like to use? What is it about that method that you like? • Are you or your partner breastfeeding an infant less than 6 months old? • Do you want to keep your method private from partner or parents? • Have you talked to your partner about using family planning? Will he or she be helpful and supportive? • Are you concerned about STIs or HIV/AIDS? • Do you have any health problems? If yes, go to page 17 Choosing a method 2 Comparing family planning methods Most effective and easiest to use Effective but must be carefully used Very effective but must be carefully used Pills Injectables Fertility awareness-based methods Male and female condom IMPORTANT! Only condoms protect against both pregnancy and STIs or HIV/AIDS Implants IUD Breastfeeding method Female sterilization Vasectomy Comparing family planning methods There are many methods to choose from. • Some are more effective than others. • Some are easier to use and some are harder to use. • Methods that are harder to use may be less effective if you don't use them correctly. Methods I can provide now: • condoms • pills • injections • breastfeeding method counselling • standard days method counselling • withdrawal counselling • emergency contraceptive pills Methods provided at the clinic: • implants • IUD • female sterilization • vasectomy Choosing a method 3 The pill • Safe • Effective when a pill is taken every day • Less monthly bleeding and cramps Week 1 Week 2 Week 3 Reminder pills The pill What it is – A pill with hormones in it that is taken every day. – Prevents release of egg, and blocks sperm from meeting egg. How to use – Take one pill every day. – When you finish a pack of pills, start a new pack the next day. If you miss a pill: – Take missed pill as soon as possible. – Okay to take 2 pills at the same time. – If you miss more than 2 days of pills in a row, use condoms for 7 days and keep taking pills. If you miss these pills in week 3, ALSO skip the reminder pills and start a new pack. What to expect – Sometimes irregular bleeding at first, then followed by lighter monthly bleeding with less cramping. – Some women have stomach upset or mild headaches that go away after first few months. Key points – Take a pill every day. – Be sure you have enough pills. Get more before you run out. – Use condoms if you need protection from STIs or HIV/AIDS. Pill 4 Minipill • Safe • Good method while breastfeeding Week 1 Week 2 Week 3 Week 4 Minipill What it is ± A pill with a hormone in it that you take every day. ± Blocks sperm from reaching the egg. How to use ± If breastfeeding, can start 6 weeks after childbirth. ± Take one pill at the same time every day. ± When you finish a pack of pills, start a new pack the next day. Late taking pill, for women who are breastfeeding: ± Take a pill as soon as you remember, and continue taking pills. Late taking pill, for women who are not breastfeeding: ± If you take a pill more than three hours late, use condoms for the next 2 days and keep taking pills. What to expect, if not breastfeeding ± Changes in monthly bleeding including irregular bleeding, spotting, heavier bleeding or no monthly bleeding, are common and safe. Key points ± Take a pill at the same time every day, if not breastfeeding. ± Be sure you have enough pills. Get more before you run out. ± Consider what method to use when you stop breastfeeding. ± Use condoms if you need protection from STIs or HIV/AIDS. Minipill 5 Injection • Safe • Hormone injection given every 2 months (NET-EN) or 3 months (DMPA) • Very effective when injections are on time • Use can be kept private Injection What it is – Hormone injection. – Prevents release of egg. How to use – Get an injection every 2 months (NET-EN) or 3 months (DMPA). – If breastfeeding, can start 6 weeks after childbirth. – Works best if you get your injections on time. If late for an injection: – DMPA: Can still get an injection up to 4 weeks late. – NET-EN: Can still get an injection up to 2 weeks late. If later, use condoms and return for an injection as soon as possible. What to expect – Irregular bleeding at first, then spotting or no monthly bleeding. This is common and safe. – Possible slight weight change. – After stopping injections, it can take several months to become pregnant. Key points – Does not cause infertility. – Be sure to get next injection on time. – Use condoms if you need protection from STIs or HIV/AIDS. Injection 6 Male condom • Prevents both pregnancy and sexually transmitted infections including HIV/AIDS • Effective when used correctly every time you have sex • Easy to get and use Male condom What it is – A thin rubber covering that fits over the erect penis. – Is a barrier that keeps sperm out of the vagina. How to use – Put a new condom onto erect penis before each sex act. – Dispose of properly, in rubbish or latrine. What to expect – No side-effects. Key points – Can be used with other family planning methods to prevent sexually transmitted infections including HIV. – Important to use correctly every time you have sex. – Be careful not to tear condom when opening package or putting on. – Partners must agree to use. – Emergency contraceptive pills can be used if condom breaks or is not used. Male condom 7 Female condom • Prevents both pregnancy and sexually transmitted infections including HIV/AIDS • Effective when used correctly every time you have sex Female condom What it is – Plastic covering inserted into the vagina before sex. – Is a barrier that keeps sperm out of the vagina. How to use – Insert new female condom into vagina before every sex act. – Dispose of properly, in rubbish or latrine. What to expect – No side-effects. Key points – Can be used with other family planning methods to prevent sexually transmitted infections including HIV. – Important to use correctly every time you have sex. – Make sure penis enters inside the condom ring and stays in during sex. – Partners must agree to use. – Emergency contraceptive pills can be used if condom slips or is not used correctly. Female condom 8 Implants • Safe to use • One of the most effective methods • Lasts for 3 to 5 years • Can be removed any time if you want to get pregnant Implants What it is – Small tubes placed under the skin of inner, upper arm. – Hormones from the tubes blocks sperm from reaching egg and prevents release of egg. How to use – Specially trained provider inserts and removes implants. – Nothing to remember to do after insertion. What to expect – Changes in monthly bleeding including irregular bleeding, spotting, heavier bleeding or no monthly bleeding, are common and safe. Key points – Use another method if waiting for appointment. – Use condoms if you need protection from STIs or HIV/AIDS. Where to go: ______________________________ Implants 9 IUD • Safe to use • One of the most effective methods • Can be used for up to 12 years • Can be removed any time if you already want to get pregnant IUD What it is – Small, flexible, plastic "T" wrapped in copper wire that is placed in the womb. – Prevents sperm from meeting the egg. How to use – Specially trained provider inserts and removes IUD. – Can be put in right after you have a baby as well as at other times. – Nothing to remember to do after insertion. What to expect – Some cramping and heavier bleeding during monthly bleeding in the first few months of use. Key points – Use another method if waiting for appointment. – Use condoms if you need protection from STIs or HIV/AIDS. Where to go: ________________ IUD 10 Female sterilization • Safe and permanent method – for women or couples who will not want more children • One of the most effective methods • Simple operation Female sterilization What it is – Specially trained provider makes one or two small cuts to reach the tubes that carry eggs to the womb. – Cuts or blocks the tubes. The womb is not removed. – Can be done right after you have a baby as well as other times. What to expect – After procedure, nothing to remember and no side-effects. – Do not need to be put to sleep during procedure. – Usually you can go home a few hours after procedure. – May have soreness for a few days after procedure. – Monthly bleeding will continue as usual for you. Key points – Permanent method. – Use condoms if you need protection from STIs or HIV/AIDS. Where to go: ________________ Female Sterilization 11 Vasectomy • Safe and permanent method – for men or couples who will not want more children • One of the most effective methods • Simple operation • Must use back-up method for first 3 months Tubes cut here Vasectomy What it is – Specially trained provider makes two small cuts to reach the tubes that carry sperm. – Cuts tubes. Testicles are not removed. – Works by keeping sperm out of semen. How to use – 3-month delay in taking effect. Couple must use another method until then. – After 3 months, nothing to remember. What to expect – Do not need to be put to sleep during procedure. – Usually you can go home a few hours after procedure. – May have bruising and soreness for a few days after procedure. Key points – Does not decrease sex drive, erection or ejaculation. – Permanent method. – Use condoms if you need protection from STIs or HIV/AIDS. Where to go: ________________ Vasectomy 12 Breastfeeding method Lactational Amenorrhea Method (LAM) • Safe with no side-effects • Effective if: - you are breastfeeding often, day and night, and giving no other food or liquids - your baby is less than 6 months old, and - your monthly bleeding has not returned. Breastfeeding method (Lactational Amenorrhea Method) What it is – Breastfeeding in a way that prevents pregnancy. – Prevents release of egg. How to use: – Breastfeed often, day and night (breastfeed fully or nearly fully) and give no other food or liquids. – If you breastfeed less, your monthly bleeding starts, or it is 6 months after you have had your baby, the method will not work. What to expect – No monthly bleeding. Key points – Very effective for 6 months if fully or nearly fully breastfeeding. – Have another method ready to start at 6 months or before, if monthly bleeding returns or breastfeeding decreases. – Use condoms if you need protection from STIs or HIV/AIDS. Breastfeeding method 13 • Helps you know what days during the month you could get pregnant • To prevent pregnancy, either avoid sex OR use condoms on those days • Best used by women with regular monthly bleeding Standard Days Method: Using calendar or Cycle Beads Standard Days Method: Using calendar or Cycle Beads What it is – Learning which days each month you could get pregnant (fertile days). – Avoiding sex or use a condom during fertile days. How to use – Use cycle beads or calendar to count days of the cycle. Start with first day of monthly bleeding. – Days 8 through 19 of every cycle are 'fertile days'. – Avoid unprotected sex during fertile days. What to expect – Partners must avoid sex or use condoms for 12 days in a row, every month. – No side-effects. Key points – Both partners must agree to avoid sex or use condoms on fertile days. – If monthly bleeding becomes less regular, you may need to choose another method. – Use condoms if you need protection from STIs or HIV/AIDS. Standard Days Method 14 • No supplies • No side-effects • Can be used at any time • Not as effective as other methods Withdrawal Withdrawal What it is – The man withdraws his penis from his partner's vagina and ejaculates outside the vagina. – Works by keeping sperm out of the woman's body. How to use – When the man feels he is close to ejaculation he withdraws his penis from the woman's vagina. What to expect – Learning to do this correctly can take time. – May not be good for men who ejaculate quickly. Key points – Other methods provide greater protection from pregnancy for most people. – Emergency contraceptive pills can be used if ejaculation occurs before withdrawal. – Use condoms if you need protection from STIs or HIV/AIDS. Withdrawal 15 Emergency contraceptive pills • Prevent pregnancy after unprotected sex • Work best when taken as soon as possible, up to 5 days after unprotected sex • Do not cause abortion Emergency contraceptive pills What it is – Pills taken after unprotected sex to prevent pregnancy. – Prevents or delays release of egg. – Does not cause abortion. How to use __________________________ – Can take up to 5 days after unprotected sex. – Works best when taken as soon as possible after unprotected sex. What to expect – Sometimes cause nausea, vomiting, vaginal spotting or bleeding for a few days. Key points – Does not prevent pregnancy the next time you have sex. Does not protect against future acts of sexual intercourse. – Regular methods are more effective, consider if there is a method you would like to use. – Seek treatment if you may have been exposed to STIs or HIV/AIDS. Where to get emergency contraceptive pills: _____________________ Emergency Contraception 16 Special situations After childbirth – Breastfeeding method prevents pregnancy effectively for up to 6 months if used correctly, and provides baby with best food. When to start other methods: – IUD: just after childbirth or wait 4 weeks after childbirth. – Female sterilization: just after childbirth or wait 6 weeks after childbirth. – Vasectomy: ideally 3 months before due date, as it takes 3 months to be effective. – Minipills, injections, implants: 6 weeks after childbirth if breastfeeding. Immediately after childbirth if not breastfeeding. – Pills: 6 months after childbirth if breastfeeding. 6 weeks if not breastfeeding. HIV/AIDS – HIV+ (not AIDS): Can use any method except spermicides. – On ART or sick: Can usually use most methods, refer for advice. – On TB drugs: Can usually use most methods, refer for advice. – Condoms recommended to prevent transmission of HIV, even if using another method. – If a women with HIV chooses to breastfeed, she should be counselled to: • Breastfeed exclusively until her infant is 6 months old. • After 6 months, add foods and continue to breastfeed for 12 months. • Then stop breastfeeding when safe and adequate food is available. Special situations 17 Men or women who do not want more children – Discuss permanent methods (female sterilization and vasectomy) and long term methods (IUD, implant). Age – Younger: Can use all methods. Emphasize STI/HIV/AIDS protection. – Older: Can use all methods. Discuss permanent and long term methods. After abortion – Can use any method immediately post abortion. – If infection is present, wait to insert IUD until treated. People living with disabilities – Can use all methods. – Important to discuss family planning needs and STI/HIV/AIDS prevention. After rape – Use emergency contraception if not on regular method. – Refer for STI/HIV counselling. Conflict/Disaster/Displaced persons/Street families – Can use all methods. – Think carefully about availability of resupply and offer back up methods (condoms, barriers, emergency contraceptive pills). – Preventing both pregnancy and STI/HIV/AIDS is especially important. Special situations 18 If she has high blood pressure She cannot use the pill She can use injections or the minipill If she smokes and is age 35 or older She cannot use the pill She can use injections or the minipill If she has repeated severe headaches, often on one side, and/or pulsating, causing nausea, and which are made worse by light, noise, or movement (migraine)? She cannot use the pill She can use injections or the minipill If she regularly takes pills for tuberculosis (TB), seizures (fits), or ritonavir for ARV therapy? She cannot use the pill She can use injections or the minipill If she has bleeding between menstrual periods, which is unusual for her, or bleeding after intercourse (sex) She cannot use injections She can use the pill or the minipill If she ever had serious heart condition or stroke She cannot use the pill or injections She can use the minipill If she has diabetes (high sugar level in her blood) for more than 20 years She cannot use the pill or injections She can use the minipill If she has ever had a blood clot in her legs or lungs She cannot use the pill, injections or the minipill She can use condoms or other method without hormones (refer if needed) If she has ever had breast cancer She cannot use the pill, injections or the minipill She can use condoms or other method without hormones (refer if needed) If she has serious liver condition or jaundice (yellow skin or eyes)? She cannot use the pill, injections or the minipill She can use condoms or other method without hormones (refer if needed) Using pills, injections or the minipill if she has health conditions Ask her if she has any serious health conditions. • If she reports having a problem, check to see if it is listed below. • If it is listed, check to see what methods she can use. Health conditions 19 Questions to be reasonably sure a woman is not pregnant Women who are not currently having their monthly bleeding may still be able to start hormonal methods (pills, injectables, or the minipill) NOW. Ask these questions to be reasonably sure she is not pregnant. Pregnancy checklist 20 If the client answers NO to ALL of the questions, pregnancy cannot be ruled out. She should wait until next menstrual period (and avoid sex or use condoms until then) or else take pregnancy test. If the client answers YES to AT LEAST ONE of the questions and has no signs or symptoms of pregnancy,* provide her with the method. NO YES 1. 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? 2. Have you abstained from sexual intercourse since your last menstrual period or delivery? 3. Have you had a baby in the last 4 weeks? 4. Did your last menstrual period start within the past 7 days? 5. Have you had a miscarriage or abortion in the past 7 days? 6. Have you been using a reliable contraceptive method consistently and correctly? Signs of pregnancy If a woman has a late menstrual period or several other signs, she may be pregnant. Try to confirm by pregnancy test or physical examination. Early signs Later signs Late menstrual period Breast tenderness Nausea Vomiting Urinating more often Weight change Always tired Mood changes Changed eating habits Larger breast Darker nipples More vaginal discharge than usual Enlarged abdomen Movements of a baby Frequently Asked Questions Do family planning methods make people sterile?  NO – Only female sterilization and vasectomy are permanent  With all other methods, couples can have a child soon after stopping  Couples who have never had a child can safely use family planning and have a baby soon after stopping Do family planning methods cause cancer?  NO – In fact, some family planning methods can help prevent certain cancers Does family planning cause birth defects?  NO – No method of family planning causes birth defects, even if used during pregnancy Frequently asked questions 21 How is vasectomy different from castration?  Castration is the removal of testes. In vasectomy, however, the testes are not touched at all. The tube that carries sperm is cut. This keeps sperm out of semen, but it does not decrease sexual function or affect ejaculation. Do family planning methods cause weight gain?  Some women have some change in weight when using hormonal methods. The weight changes are usually small Can young people use family planning safely?  YES – Young people can use non-permanent methods and go on to have children after stopping All people at risk of STIs/HIV or AIDS should use condoms even if they also use another method Add any questions that are often asked in your community. Frequently asked questions 22 Male and female anatomy Fallopian tubeOvary Womb lining (endometrium) Womb (uterus) Cervix Vagina Male and female anatomy 23 Seminal vesicles Penis Scrotum Foreskin Urethra Testicles Vas deferens Prostate How to use a male condom Use a new condom for each sex act Before any contact, place condom on tip of erect penis with rolled side out Unroll condom all the way to base of penis After ejaculation, hold rim of condom in place, and withdraw penis while it is still hard Use only once Throw away used condom safely      How to use male condom 24 How to use a female condom Use a new condom each time Open package carefully Make sure the condom is well- lubricated inside Choose a comfortable position To remove, twist outer ring and pull gently Throw away condom safely Gently insert the inner ring into the vagina Place the index finger inside condom, and push the inner ring up as far as it will go Make sure the outer ring is outside the vagina and the condom is not twisted Be sure that the penis enters inside the condom and stays inside it during intercourse Squeeze the inner ring, at the closed end Inner ring Open end Inner ring Outer ring How to use female condom 25     How to use Cycle Beads      How to use Cycle beads 26 Move ring to RED bead when period starts Move ring to next bead every day. Move ring even on bleeding days Use condoms or abstain when ring is on WHITE beads BROWN beads are safe days of no pregnancy When period starts again move ring to red bead to begin again. Always check your period comes between dark brown bead and last brown bead. For new clients, did you … • Help the client choose a method that will suit her or him? • Discuss possible side-effects of the method? • Whenever possible, give the client the method that she or he wants, or else refer for it? • Make sure that the client who wants a referral method has a method to use while waiting for it? • Give the method, information and hand-out? • Make sure the client has condoms and emergency contraceptive pills if needed? • Discuss prevention of STIs and HIV/AIDS, and give condoms when needed? • Explain when to come back for more supplies or if she is having a problem, before stopping the method? • Answer all questions? • Invite the client to come back any time? Checklists 27 For returning clients, did you… • Check that the client is happy with the method? • Check that the client is using the method correctly? • Address client concerns, for example: – problems using methods, such as missing pills or problems with condoms – problems with partner – bleeding changes, such as spotting, no monthly bleeding – other side effects such as dizziness, mild headaches, mood changes, acne – Ask whether side-effects are a problem. Reassure they are common and safe and often go away on their own. If she wants to switch methods, help her to choose another. • Check if the client has any more concerns or questions? • Help her to choose a method to use during or after breastfeeding, if she is pregnant or has recently had a baby? • Make sure the client has condoms and emergency contraceptive pills if needed? • Give enough supplies? Checklists 28 A Guide to Family Planning for Community Health Workers and their Clients Acknowledgements: This tool is a work of the World Health Organization’s Department of Reproductive Health and Research (RHR). The tool was developed by RHRs Promoting Family Planning Team in 2009, particularly Sarah Johnson (WHO). The other main contributors to the original product and several early modifications/revisions include: Pamela Lynam (Jhpiego/Kenya), Douglas Huber (External Expert, WHO Temporary Adviser), Emily Jean Jackson (WHO), Barbara Garner (WHO Temporary Adviser), Lilian Achieng (Korogocho), Kelly Culwell (WHO), Mario Festin (WHO), Charles Fleischer-Djoleto (WHO Ghana Office), Mary Gathitu (Kenya Ministry of Public Health and Sanitation, Division of Reproductive Health (MOPHS/DRH), Rosemary Kamunya (Jhpiego/Kenya), Nancy Kidula (WHO Kenya Office), Joyce Lavussa (WHO Kenya Office), Rose Ngahu (Family Health Options Kenya), David O. Nyaberi (MOPHS/DRH), Nellie Luchemo (Organization for Health Education and Research Services), Margaret Mwaila (GTZ Options Kenya), Susan Scull-Carvallo (Jacaranda Design), Jane Otai (Jhpiego/Kenya), Amamanta Sumani (Ghana Health Service), and Queen Wambua (AMREF, Maendeleo Ya Wanawake). The training and adaptation guide and the field testing instrument for the Philippines and Guyana was written by Emily Jean Jackson and Dalia Brahmi. The focus group discussion guide was developed by Dalia Brahmi and Sheila Krishnan. For the orientation and training workshops, Mary Lyn Gaffield and Dalia Brahmi were involved in Guyana along with Derven Patrick (UNFPA) and Deslyn Fraser and Terry Davis (Ministry of Health). Mario Festin conducted the orientation and training in the Philippines with the support of Ana Maria Leal (UNFPA), Ethelyn Nieto (UNFPA consultant), and Dahlia al Zeny (UNFPA). The field tests were supported by the country offices of UNFPA in Guyana (Mandy Lafleur and Gillian Butts Garnett) and in the Philippines. Support for this project was provided by United States Agency for International Development (USAID), through the Knowledge for Health project. This tool is an adaptation of the Decision Making Tool for Family Planning Clients and their Providers, which constitutes one of the Four Cornerstones of WHO's evidence-based guidance in family planning. The technical content of this tool was developed using international evidence-based family planning guidance, including Medical eligibility criteria for contraceptive use (WHO, Fourth Edition, 2010), Selected practice recommendations for contraceptive use (WHO, Second Edition, 2005, Updates 2008), and Family planning: a global handbook for providers, (JHU/CCP, 2011). The development, adaptation, translation and field-testing of the guide in Ethiopia was coordinated by Kidest Lulu (WHO), and others Abner Tewoldeberhan, Family Health International (FHI), Adeba Tasissa, Integrated Family Health Program (IFHP), Almaz Yirga, Integrated Family Health Program (IFHP), Atnafu Setegn, DKT, Ayele D. Gemechu, Engenderhealth, Beyeberu Assefa, UNFPA, Demeke Desta, IPAS, Dessie Ayalew, Integrated Family Health Program (IFHP), Etenesh G/Yohannes, Federal Ministry of Health (FMOH), Feleke Mulatu, Ethiopian Medical Association, Gemu Tiru, Federal Ministry of Health (FMOH), Haregewoin Kiflom, Federal Ministry of Health (FMOH), Kasahun Sime, Federal Ministry of Health (FMOH), Mengistu Asnake, Integrated Family Health Program (IFHP), Michael Tekie, UNFPA, Mohammed Dilbi, Federal Ministry of Health (FMOH), Mulat Woldegiorgis, Marie Stopes International, Nega Tesfaw (Dr), Engender Health, Shewaynesh Gebru, Federal Ministry of Health (FMOH), Teferi Girma, Marie Stopes International, Tesfa Demelew, Ethiopian Public Health Association (EPHA), Tesfaye Endrias, Venture Strategies Initiative (VSI), Tilaye Gudina, Federal Ministry of Health (FMOH), Woinshet Nigatu, USAID/DELIVER, Yenew Berhan, Engenderhealth, Zinash Moges, Federal Ministry of Health (FMOH). We would like to thank FHI 360, and Suzanne Reier, Laura Guarenti, Victoria Camacho, and Katherine Ba-Thike at WHO for their review and comments. The tool is also based on expert advice from many international organizations in the field of family planning. We would like to thank the following interagency groups for their expert reviews and guidance, Lucy Harber and Irina Yacobson (Family Health International - 360), Victoria Jennings and Jeannette Cachan (Institute of Reproductive Health, Georgetown University), Kiran Asif (International Planned Parenthood Federation), Enriquito Lu (Jhpiego), and Ward Rinehart (Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs). Illustrations by Rita Meyer, Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs. Additional illustrations by the Institute of Reproductive Health, Georgetown University (pages 14 and 26). 33387_CopING.pdf 33387_intING

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