Recommendations for Contraceptive Use
		CBS (Community Based Services) Checklists

Guide For Applying Or Adapting COC And DMPA (or NET-EN) Checklists

Goal:

These checklists provide an easy-to-use screening tool for community based services (CBS) workers. They are based on the guidance provided in the 1996 document from the World Health Organization (WHO) entitled: Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Similar to the WHO recommendations, the checklists should be adapted to meet the needs of the local CBS program.

Purpose:

The checklists allow CBS workers to identify women who can safely initiate use of combined oral contraceptives (COCs) and DMPA (or NET-EN). This is done through a series of simple yes/no questions with further guidance/directions based on client responses. The checklists are not intended to identify or to newly diagnose conditions which may be "contraindications" for the method. Instead, the questions are intended to verify whether a client has or has had a known condition or disease. Women with either active conditions or a history of particular conditions will need further evaluation by a higher level health care provider before the method is initiated.

The following section of this guide is meant to assist PROGRAM MANAGERS, POLICY-MAKERS, ADMINISTRATORS and TRAINERS.

1. The DMPA (or NET-EN) checklist is intended to be used to determine eligibility only for three- or two-month progestin-only injectables. Similarly, the COC checklist is intended to be used to determine eligibility only for low-dose combined estrogen-progestin oral contraceptives.
2. Adapt both the language and style to meet the cultural and linguistic needs of your clients.
3. As you make the adaptations please be careful that you do not inadvertently change the intent of the question. Explanations of the intent of each question are provided with each checklist to help with these adaptations. The following is an example of a poorly adapted checklist question:

Original COC checklist question: Do you smoke and are you over age 35?

Poorly adapted question: Do you smoke? Are you over age 35?

This adaptation has separated the original question into two different parts. By doing so, the most important aspect of the original question could be misinterpreted: that only women who both smoke and who are over 35 years old have an increased risk of cardiovascular disease. This poor adaptation could prevent an eligible woman who desires COCs from receiving them. (See explanation of the COC checklist).

4. The purpose of the questions is to verify whether a client has a known condition or disease which needs to be further evaluated before she can receive COCs, DMPA or NET-EN. The purpose is not for CBS workers to make a diagnosis about conditions or diseases.
5. CBS workers and clients may not recognize the generic names of certain drugs. The following question requires that programs supply the locally available names for particular drugs:

COC checklist question 10:

"Do you regularly take any pills for tuberculosis (TB), fungal infections or seizures (fits)?" (Only these particular drugs interact with COCs.)

• rifampicin (for tuberculosis)
• griseofulvin (an antifungal medication)
• phenytoin (for epilepsy/seizures)
• carbamezapine (for epilepsy/seizures)
• barbiturates (for epilepsy/seizures)

6. The WHO Eligibility Criteria for Contraceptive Use classifies history of hypertension where blood pressure cannot be evaluated (such as CBS programs), and known mild-to-moderate hypertension as conditions where DMPA (or NET-EN) may generally be used (Category 2). However, DMPA (or NET-EN) is not usually recommended for women with known severe hypertension (at least 180+/110+), or with vascular disease, unless other more appropriate methods are unavailable or unacceptable (Category 3).
7. Please keep in mind that the questions on the checklists are meant to identify women who should be seen by a higher level provider prior to initiating the method; the conditions listed are not necessarily contraindications for use of the method.

The following section applies to both PROGRAM MANAGERS and CBS TRAINERS:

1. The checklists are not meant to replace counseling. Providers should make sure the client makes an informed and voluntary choice to use either COCs or DMPA.
2. Once it has been determined that a client is eligible to initiate use of the method she has chosen, instruct her on how to use the method correctly and consistently and how to manage side effects and identify warning signs of more serious complications.
3. As mentioned above, the checklists identify clients eligible to initiate use of either COCs or DMPA (or NET-EN), under the supervision of the CBS worker. However, they may be used or adapted to identify clients eligible to continue the use of these methods. It is not thought to be necessary to repeat each of the questions at each visit.
4. Establish an appropriate training system for use of the checklists to assure that CBSworkers use them in the correct way. Periodically evaluate the correct use of the checklists.
5. Be certain that a referral system to accessible clinical sites or private providers is established and that CBS workers are familiar with the referral site and procedures.

Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.