Midwife Licensure Exam The Midwife's Public Health Service Delivery — Family Planning Provision by MidwivesStudy Notes

Republic Act 10354, signed into law in 2012, guarantees every Filipino universal access to medically safe, effective, legal, affordable, and quality reproductive health care services, including a full range of modern family planning methods. The law is built on three foundational principles: (1) **informed choice and voluntarism** - no client may be coerced into or out of any method; (2) **non-discrimination** - services are provided without regard to age, marital status, or number of children; and (3) **confidentiality and privacy** - all client information is protected. For the midwife working in the Philippine primary care system, RA 10354 translates into concrete, daily duties: **Providing Medically Accurate Information**: The midwife must counsel every client on all available methods - not just those the midwife personally prefers to provide. This includes complete information on benefits, side effects, effectiveness rates (typical-use and perfect-use), how each method is used, warning signs, when to return, and the fact that the client may switch or stop at any time. The goal is to help the client make a free and fully informed decision based on her own circumstances and preferences. **Delivering Methods Within Competency**: The midwife provides the methods for which she has been trained by the DOH (or an accredited training program). She recognizes that some methods - notably IUD insertion and implant insertion - require additional certification beyond basic midwifery. For methods outside her scope, she counsels the client and provides a referral to a trained provider. **Respecting Client Autonomy**: The midwife's role is to counsel, not to decide for the client. The method choice belongs to the woman alone, and where she wishes, to her partner. The midwife never withholds information to push a preferred method, and she never shames or judges a client for her choice - including a choice to delay family planning or use no method. **Offering FP Counseling Proactively**: Family planning counseling is not something the midwife waits for a client to request. Instead, she offers it proactively at every relevant contact point: during prenatal visits (to address interpregnancy spacing and healthy timing), at the postpartum visit (often at the 6-week check), after abortion or miscarriage, and at any well-woman or sick-child visit. This upstream counseling is what transforms family planning from a service clients ask for into a core public health duty. **Supporting Healthy Timing and Spacing of Pregnancy (HTSP)**: The midwife counsels all women of reproductive age on the health benefits of spacing pregnancies at least 24 months apart and delaying the first pregnancy until at least age 18. This spacing interval is one of the most powerful interventions to reduce maternal and child mortality, because pregnancies spaced less than 24 months apart are associated with higher risks of preterm birth, low birth weight, intrauterine growth restriction, and maternal anemia. By providing family planning, the midwife is not just responding to individual choice - she is implementing one of the MNCHN program's core prevention strategies.

A midwife who has completed the DOH Family Planning Competency-Based Training can independently provide the following contraceptive methods without additional certification. These form the core service package delivered at the BHS and during home visits. ### **2.1 Combined Oral Contraceptives (COCs)** COCs contain both an estrogen (usually ethinyl estradiol) and a progestin, and are among the most widely dispensed modern contraceptive methods globally. In the Philippine context, they are often the first choice for women who want a daily oral method and have no contraindications. **How the midwife provides COCs**: - **Screening**: The midwife takes a focused history (age, parity, breastfeeding status, smoking, headaches with visual changes, known hypertension, liver disease, diabetes, history of blood clots, or breast cancer) and measures blood pressure. Estrogen-containing methods are avoided in women with uncontrolled hypertension (MEC Category 3-4) because estrogen increases clotting risk. - **Dispensing**: The midwife gives the client a 3-month supply (or as per local protocol) of COCs and reviews the instructions. - **Counseling on use**: One pill daily at the same time each day, starting within the first five days of the menstrual cycle for immediate protection. If started after day 5, a backup method (condom) is used for the first 7 days. Missing a pill must be managed correctly: if missed by less than 12 hours, take it as soon as remembered; if missed by 12-48 hours, take two pills on the current day and continue; if missed by more than 48 hours, or if three or more pills are missed, continue the pack but use a backup method for 7 days. - **Important contraindication in breastfeeding**: COCs must **not** be given to women who are **actively breastfeeding in the first 6 months postpartum** because the estrogen component can reduce milk supply. These women are offered POPs (progestin-only pills) instead, which are safe for breastfeeding. - **What to expect**: The midwife honestly counsels that some users experience nausea, breast tenderness, headache, or slight weight gain in the first few cycles, but these usually settle within 3 months. Spotting between periods can also occur and is not harmful. She distinguishes these normal side effects from warning signs (severe abdominal pain, chest pain, severe headache with visual loss, heavy bleeding) that require prompt review. ### **2.2 Progestin-Only Pills (POPs / "Mini-Pills")** POPs contain only progestin (no estrogen) and are the **method of choice for breastfeeding mothers** and for women who cannot tolerate or have contraindications to estrogen. **Key differences from COCs**: - **Timing**: POPs must be taken at the same time every day with a much tighter window than COCs. A delay of more than 3 hours is treated as a missed pill. - **Safety while breastfeeding**: POPs do not affect milk supply and are safe throughout breastfeeding. - **Perfect use and typical use**: POPs are slightly less effective than COCs because they depend on very consistent daily timing and because the progestin-only formulation does not always suppress ovulation (instead it works mainly by thickening cervical mucus and thinning the endometrium). Despite this, they remain an excellent choice for motivated breastfeeding mothers. **Midwife's counseling**: One pill at the same time every day, starting on day 1 of the menstrual period for immediate protection. If started later, a backup method is used for 2 days. Expected side effects are similar to COCs but usually milder; amenorrhea is common and not harmful. ### **2.3 DMPA Injectable (Depot Medroxyprogesterone Acetate, "Depo-Provera")** DMPA is a long-acting, reversible progestin-only injectable contraceptive that the midwife administers herself at the BHS or during home visits. It is one of the most popular methods in the Philippine public sector because it is discreet, requires no daily action, and is safe for breastfeeding mothers. **Dosing and administration**: - **Dose**: 150 mg intramuscularly (IM), either into the deltoid (upper arm) or the gluteal muscle (buttock). - **Interval**: Every 3 months (13 weeks). The midwife counsels the client to return on the expected date. A grace period allows re-injection up to 2 weeks early or 4 weeks late; after 4 weeks late, the client must be re-screened for pregnancy before re-injection. - **Technique**: The midwife uses a 23-gauge needle (1.5 inches) and injects deeply into the muscle to ensure complete absorption. The injection is given as soon as the client arrives, before counseling, to prevent "counseling out." **Effectiveness and return to fertility**: - **Perfect-use effectiveness**: Over 99% (0.2 pregnancies per 100 woman-years). - **Return to fertility**: Can be delayed. On average, return to ovulation occurs 9-10 months after the last injection, but some women may take longer. This is an important point to discuss with women who want to conceive soon. **Counseling on side effects**: - **Irregular spotting or amenorrhea**: Very common, especially in the first year. The midwife reassures the client that this is normal, not harmful, and often resolves by month 12. - **Weight gain**: Some women report a 1-2 kg increase; the midwife can suggest dietary and activity counseling. - **Return of menses may be delayed**: After stopping DMPA, it may take several months for menstruation and fertility to return. - **Does not protect against STIs/HIV**: The client is counseled to use condoms with DMPA if STI/HIV risk exists. **Breastfeeding**: DMPA is progestin-only and is safe for breastfeeding mothers from day 1 postpartum onward. ### **2.4 Condoms (Male and Female)** Condoms are the only contraceptive method that also protects against HIV and sexually transmitted infections (STIs). In the Philippine context, the midwife promotes condoms not only as a contraceptive but as part of a comprehensive prevention strategy. **Male condoms**: - **Typical-use effectiveness**: About 82% (18 pregnancies per 100 woman-years with typical use). - **Perfect-use effectiveness**: About 98%. - The midwife dispenses male condoms free at the BHS and counsels on correct use: apply before any genital contact, leave a small reservoir at the tip, and withdraw while still erect. Water-based lubricant can be used but not oil-based products (which degrade latex). **Female condoms** (less common in the Philippine BHS but increasingly available): - Inserted into the vagina before intercourse. - Provide dual protection and can be inserted hours in advance. **Dual protection**: The midwife promotes **"dalawang proteksyon"** (dual protection) - using a condom plus another more effective method (e.g., COC, DMPA, or implant) - especially for clients at risk of STIs or HIV. This combines the contraceptive benefits of the second method with the STI/HIV protection of the condom. ### **2.5 Lactational Amenorrhea Method (LAM)** LAM is a natural, temporary breastfeeding-based method the midwife teaches to all new mothers at the postpartum visit. It is based on the biological fact that exclusive breastfeeding suppresses ovulation in many women. **Effectiveness of LAM**: - **Perfect use**: Over 99% effective (0.5 pregnancies per 100 woman-years). - **Typical use**: About 98% effective (2 pregnancies per 100 woman-years). - Effectiveness depends entirely on meeting all three of the following conditions. **The three requirements for LAM**: 1. **Baby is under 6 months old**: Once the baby reaches 6 months, LAM can no longer be relied upon. 2. **Exclusive or nearly exclusive breastfeeding**: The baby receives breast milk as the main source of nutrition, on demand, day and night. Introduction of formula, other foods, or frequent bottle-feeding reduces LAM effectiveness. 3. **Mother is amenorrheic**: Menstruation has not yet returned. The return of menses (or any vaginal bleeding after the first 56 days postpartum) signals that ovulation has resumed. **What happens when any condition fails**: The moment the baby turns 6 months old, or the mother introduces formula or other foods, or her menses return, LAM's protection ends. The mother must **immediately switch to another method** - a transition that the midwife plans in advance during the postpartum visit. LAM is therefore always taught as a **bridge method** to a follow-on contraceptive, not as a standalone method. **Midwife's counseling on LAM**: - Affirm the mother's commitment to breastfeeding, explain the biological mechanism (frequent breastfeeding suppresses prolactin), and clarify the three conditions. - Discuss the transition plan: "When your baby is 5 months old, we'll discuss your next method so you're ready when LAM ends. If your period comes back before 6 months, come to the clinic and we'll start another method." - Provide a LAM card or calendar to help the mother track the 6-month window. ### **2.6 Standard Days Method (SDM)** SDM is a simple, evidence-based fertility-awareness method using **CycleBeads**, a string of colored beads that the couple uses to identify fertile and non-fertile days of the menstrual cycle. It suits women with regular menstrual cycles and couples who prefer a natural method. **Who can use SDM**: - Women with menstrual cycles that are consistently **between 26 and 32 days long**. A woman with cycles of 24 days or 35 days is not suited for SDM because the fertile window is harder to predict. - Couples who are motivated and able to cooperate (the method requires the partner's participation and willingness to abstain or use condoms on fertile days). **How SDM works**: - The CycleBeads string has 32 beads: a dark bead marking day 1 of the cycle (first day of menses), a red bead marking the start of the fertile window, white beads for the fertile days, and brown beads for the non-fertile days. - The couple is instructed to avoid unprotected intercourse on **cycle days 8 through 19** - the fertile window when pregnancy is most likely. - The woman moves a small ring along the beads daily to track her position in the cycle. **Counseling on SDM**: - The midwife must verify cycle regularity by reviewing the last 3-6 months of menstrual dates. - She counsels the **couple together**, not just the woman, because the method depends on the partner's cooperation and understanding. - She explains that intercourse is safe on non-fertile days (beads 1-7 and 20-32) and must be avoided or protected on fertile days (beads 8-19). - She clarifies that if the cycle becomes irregular, or if the woman is not sure of the day, a backup method (condom) should be used. **Effectiveness**: - **Perfect use**: About 95% effective. - **Typical use**: About 88% effective - lower because couples sometimes misjudge the fertile window or use the method inconsistently. ### **2.7 Counseling as a Contraceptive Service** Counseling itself - delivering complete, honest, non-judgmental information in a way that helps a client make a free and informed choice - is a contraceptive service the midwife provides at every contact. It is not ancillary to method provision; it is central to it. **Evidence-based counseling frameworks**: **GATHER Framework** (from WHO): - **G - Greet**: Welcome the client warmly, establish rapport, ensure privacy. - **A - Ask**: Ask open-ended questions about her reproductive goals, fears, past contraceptive experience, and preferences. Listen without judgment. - **T - Tell**: Provide complete, medically accurate information on the methods suitable for her situation, including benefits, side effects, effectiveness, and how to use each. - **H - Help**: Help her think through her own circumstances and what matters most to her (ease of use, effectiveness, privacy, side effects). Avoid pushing your preferred method. - **E - Explain**: Explain how to use the chosen method correctly, what to expect, and what warning signs require her to come back. - **R - Return**: Set the return date (for resupply, re-injection, or follow-up), and ask her to return if she has questions, side effects, or wants to switch methods before then. **REDI Framework** (for more complex situations): - **R - Rapport-building**: Establish trust; listen actively to the client's concerns and values. - **E - Exploration**: Explore the client's reproductive intentions, constraints (religious beliefs, partner approval, health conditions), and past experiences. - **D - Decision-making**: Present options, clarify the client's priorities, and support her in making a choice that fits her life. - **I - Implementation**: Give clear, practical instructions and ensure she knows when to return. **Counseling on sensitive topics**: - Some clients may face barriers - a partner who objects to family planning, religious or cultural beliefs, fear of side effects, or past negative experiences. The midwife listens without judgment, acknowledges the concern, provides evidence, and sometimes involves the partner in counseling. She never dismisses the client's fears; instead, she addresses them with information and, where appropriate, a trial period with a reversible method. ### **2.8 Follow-Up and Retention** The midwife builds follow-up into every FP service: - **For pills (COCs/POPs)**: Set a return date for resupply (usually 3 months), and flag the client on the Target Client List (TCL) to contact her if she misses the appointment. - **For DMPA**: Schedule the next injection 13 weeks out, with a grace window of up to 2 weeks early or 4 weeks late. If the client does not return within this window, trace her: she may have switched methods, become pregnant, or experienced a barrier that the midwife can help overcome. - **For condoms**: Ensure a 3-month supply is available at the clinic and that clients know they can return anytime. - **For LAM and SDM**: Plan the transition to a follow-on method before the bridge method ends; do not let the client "fall off" into an unintended pregnancy. **Why follow-up matters**: Large numbers of family planning dropouts occur not because a method failed but because a client was frightened by an expected side effect she was not warned about, or because she ran out of pills, or because she never received a recall appointment. Proactive follow-up is a quality-of-care measure and a retention strategy.

Two of the most effective modern contraceptive methods - the intrauterine device (IUD) and the subdermal contraceptive implant - require that the midwife complete **additional DOH competency-based training and certification** beyond the standard midwifery curriculum. This is a **high-yield MLE point**: many exam questions test whether students know the difference between methods a trained midwife can independently provide and those requiring extra certification. ### **3.1 Intrauterine Device (IUD)** The IUD is a small, T-shaped device inserted into the uterine cavity. It is one of the most effective reversible contraceptive methods (over 99% effective in both perfect and typical use) and is increasingly promoted by the DOH as a long-acting, reversible contraceptive (LARC). **Types of IUDs**: - **Copper IUD** (e.g., TCu380A, Copper T 380): Relies on copper ions to create a toxic environment for sperm. Effective for 10-12 years. Can be used as emergency contraception if inserted within 5 days of unprotected intercourse. - **Levonorgestrel-releasing IUD** (e.g., Mirena, Skyla, Kyleena): Releases a small amount of the progestin levonorgestrel directly into the uterus. Highly effective and often causes lighter or absent periods. Effective for 3-7 years depending on the brand. **Why IUD insertion requires certification**: - IUD insertion is an invasive procedure requiring knowledge of uterine anatomy, aseptic technique, and management of potential complications (perforation, expulsion, infection). - The inserter must perform cervical dilation, sound the uterus to measure cavity depth, and carefully guide the IUD into position - skills that require supervised, hands-on training. - Post-insertion complications, though rare, require prompt recognition and referral. **The midwife's role in IUD provision WITHOUT certification**: - **Counsel the client** on IUD benefits (highly effective, long-acting, reversible, non-hormonal option with copper IUD), mechanism of action, side effects (heavier or longer periods with copper IUD; lighter or absent periods with levonorgestrel IUD), and the insertion and removal process. - **Screen for eligibility** using the WHO Medical Eligibility Criteria (MEC). IUDs are generally suitable for most women, including adolescents and women without prior pregnancies, **except** those with active STIs, unexplained vaginal bleeding, or anatomical uterine abnormalities. - **Provide a referral** to a trained and certified provider (usually a midwife at a higher-level RHU, a physician, or a specialist clinic) with complete information on timing and location. - **Perform follow-up**: After insertion, the midwife may see the client at the first post-insertion check (4-12 weeks) to ensure proper placement by assessing that the strings are palpable and the client has no infection signs. **The midwife's role in IUD provision WITH certification**: - With additional training and certification in IUD insertion, the midwife can insert and remove IUDs at the BHS or RHU, expanding access to LARC in underserved areas. - She maintains competency through regular practice and continuing education. ### **3.2 Subdermal Contraceptive Implant** The subdermal implant (or progestin implant) is a single, thin plastic rod containing a progestin (usually etonogestrel or levonorgestrel), inserted under the skin of the inner upper arm. It is one of the most effective reversible contraceptive methods (over 99% effective) and is increasingly available in Philippine public clinics. **Mechanism of action**: - The progestin is slowly released from the implant over its lifespan (3-5 years depending on the type), suppressing ovulation and thickening cervical mucus. - No daily action required; protection is continuous. **Why implant insertion requires certification**: - Implant insertion requires a small surgical approach: the midwife must make a small incision in the skin of the upper arm, guide the implant into the subcutaneous plane, and close the incision with adhesive strips or sutures. - The midwife must know the anatomy (location relative to radial nerve and artery), use aseptic technique, anesthetize the insertion site, and manage any bleeding or infection. - Removal (often requested when the client wants to conceive or the implant is reaching end-of-life) also requires a small incision to retrieve the rod. - Complications, though rare, include infection, expulsion, or nerve injury. **The midwife's role in implant provision WITHOUT certification**: - **Counsel the client** on implant benefits (highly effective, long-acting, discreet, no daily action), mechanism, side effects (irregular spotting, amenorrhea, potential breast tenderness), how long it lasts (3-5 years), and how it is inserted and removed. - **Screen for eligibility** using WHO MEC. Progestin implants are suitable for most women, including adolescents, breastfeeding mothers (from day 1 postpartum), and those without prior pregnancies. There are few absolute contraindications. - **Provide a referral** to a certified provider with complete client information. - **Perform follow-up**: After insertion, the midwife may see the client at 4-12 weeks to check the insertion site for infection or excessive swelling and to confirm the implant is palpable in the upper arm. **The midwife's role in implant provision WITH certification**: - With additional training and certification in implant insertion and removal, the midwife can provide the full service at the BHS or RHU. - She must maintain a sterile environment, use proper anesthesia and aseptic technique, and keep detailed records of insertion and removal dates. ### **3.3 High-Yield MLE Pattern: "Counsel and Refer"** Exam questions often test the midwife's recognition of her scope. A typical question pattern is: **"A woman requests an IUD. The trained midwife has NOT completed IUD insertion certification. What is the appropriate action?"** - A) Perform the IUD insertion (WRONG - requires certification). - B) Tell the client IUDs are not available at the BHS (WRONG - IUDs can be referred to another facility). - C) Counsel the client on IUD benefits and side effects, screen for eligibility, and provide a referral to a certified provider (CORRECT). - D) Tell the client to come back when she is older (WRONG - age is not a contraindication for most methods). The correct answer always follows the pattern: **counsel on all aspects, screen for safety using MEC, and refer to a qualified provider.** This pattern applies to IUD, implant, and any method outside the midwife's competency. ### **3.4 Comparison: Independently-Provided vs. Certification-Required Methods** | **Method** | **Type** | **Midwife Can Provide Independently** | **Requires Additional Certification** | **Role Without Certification** | |---|---|---|---|---| | COCs | Oral | Yes | No | - | | POPs | Oral | Yes | No | - | | DMPA Injectable | Injectable | Yes | No | - | | Condoms | Barrier | Yes | No | - | | LAM | Natural | Yes | No | - | | SDM | Natural | Yes | No | - | | IUD | LARC | No | Yes | Counsel, screen, refer | | Implant | LARC | No | Yes | Counsel, screen, refer | | Tubal Ligation | Surgical | No | Surgeon | Counsel, refer | | Vasectomy | Surgical | No | Surgeon | Counsel, refer |

Safe family planning provision depends on correct screening. Before providing any contraceptive method, the midwife must ensure the client is medically suitable - that the benefits of the method outweigh the risks. The standard tool for this is the **WHO Medical Eligibility Criteria (WHO MEC)**, and the midwife must know how to apply it in a busy BHS or RHU setting. ### **4.1 The WHO Medical Eligibility Criteria (WHO MEC) Framework** The WHO MEC classifies the suitability of each contraceptive method for women with various medical conditions into four categories: **Category 1** - **Use the method in any circumstance**: No restriction or precaution needed; the method can be given without further consideration. **Category 2** - **Generally use the method**: The benefits of using the method generally outweigh the risks. The method can be used, but the client should be counseled on side effects and when to return if problems develop. **Category 3** - **Method not usually recommended unless other options are unavailable**: The risks usually outweigh the benefits, but the method can be offered if no alternatives exist. This is the "proceed with caution" category - the midwife counsels thoroughly, explores why other methods are not suitable, and may ask for informed consent in writing. **Category 4** - **Method must not be used**: The medical condition represents an unacceptable health risk if the method is used. The method is contraindicated and the midwife must not provide it or refer the client elsewhere. ### **4.2 Practical Screening Steps in the Clinic** The midwife does not memorize the entire WHO MEC manual (which runs to hundreds of pages). Instead, she learns the **highest-yield and most common contraindications** for the methods she provides, and uses a **simple checklist** during counseling. **Step 1: Take a focused reproductive and medical history** - **Age**: Important for risk stratification (e.g., COCs are used with caution in women over 35 who smoke because of thromboembolism risk). - **Parity**: Have you been pregnant? Do you have living children? (Parity affects IUD eligibility and is important for long-acting method counseling.) - **Breastfeeding status and postpartum interval**: Determines POPs vs. COCs, and timing of LAM transition. - **Menstrual history**: Last menstrual period (LMP), cycle regularity and length (needed for SDM), abnormally heavy bleeding (copper IUD may worsen this). - **Smoking**: Do you smoke? How many cigarettes per day? (Smoking + estrogen contraceptive increases thromboembolism risk.) - **Headaches**: Do you get headaches? Do you ever have visual disturbances (loss of vision, flashing lights, or visual field loss) with them? (Migraine with aura is Category 3-4 for estrogen-containing methods.) - **Blood pressure history**: Have you been told you have high blood pressure? (Uncontrolled hypertension is Category 3-4 for COCs.) - **History of blood clots, stroke, or heart disease**: "Have you or a close family member (mother, sister, brother) ever had a blood clot, stroke, or heart attack?" (This raises thromboembolism risk and may limit estrogen-containing methods.) - **Liver disease**: "Have you ever been told you have liver disease, hepatitis, or cirrhosis?" (Significant liver disease is Category 3-4 for estrogen-containing methods because the liver metabolizes estrogen.) - **Diabetes**: Are you diabetic? Is your blood sugar controlled? (Diabetes alone is not a contraindication, but uncontrolled diabetes may warrant caution with some methods.) - **History of breast cancer**: "Have you ever been diagnosed with breast cancer?" (Hormone-sensitive breast cancer is a relative contraindication to some methods; counsel and refer.) **Step 2: Measure blood pressure** Before dispensing COCs or giving DMPA, the midwife measures the client's blood pressure. The WHO MEC specifies: - **Systolic <140 and diastolic <90 mmHg**: Category 1 for COCs and DMPA (use in any circumstance). - **Systolic 140-159 or diastolic 90-99 mmHg (elevated/Stage 1 HTN)**: Category 2-3 for COCs; Category 2 for DMPA. The midwife counsels on the risk and offers to switch to a progestin-only method (POPs, DMPA, implant) if the client has no other contraindications. - **Systolic ≥160 or diastolic ≥100 mmHg (Stage 2 HTN)**: Category 3-4 for COCs; avoid them. DMPA and POPs are safer options. ### **4.3 Screening for Pregnancy Before Starting a Hormonal Method or IUD** One of the most practical questions in the clinic is: **"Is the client pregnant?"** The WHO has provided a simple checklist called the **"Reasonably Sure the Client is Not Pregnant" checklist**. If the client meets any one of these criteria, she is reasonably sure not to be pregnant, and a hormonal method or IUD can be started immediately without waiting for a pregnancy test or the next menses: 1. **Less than 2 days after the start of her last menstrual period**: If the client is within 2 days of menses, she is almost certainly not pregnant. 2. **Has not had sexual intercourse in the past 5 days**: If no unprotected intercourse has occurred in the past 5 days, pregnancy is very unlikely. 3. **Within 4 weeks of a live birth or abortion**: Pregnancy is very unlikely in the immediate postpartum period. 4. **Exclusive or nearly exclusive breastfeeding, amenorrheic, within 6 months of delivery**: LAM is protecting her. 5. **No symptoms or signs of pregnancy**: No nausea, breast tenderness, abdominal bloating, or other pregnancy signs. If the client does NOT meet any of these criteria (e.g., she cannot remember her LMP, she had unprotected intercourse 2 weeks ago, she has nausea and breast tenderness), the midwife should offer a pregnancy test or delay starting the method until the next menses or until pregnancy is ruled out. **Starting a hormonal method on an undetected early pregnancy is not harmful to the pregnancy, but the client deserves to know her status.** ### **4.4 Screening for Reproductive Tract Infection (RTI) and STIs** Before inserting an IUD, the midwife must screen for active reproductive tract infection or STIs (particularly chlamydia and gonorrhea), because IUD insertion during an active STI can introduce infection into the upper reproductive tract and cause pelvic inflammatory disease (PID). Although the IUD itself does not increase the long-term risk of PID if inserted in a clean environment, insertion during active infection is unsafe. **Screening questions**: - "Do you have any vaginal discharge, pelvic pain, or painful urination?" - "Has your partner had any urethral discharge or genital sores?" - "Have you or your partner had any new sexual partners in the past 3 months?" **If RTI/STI is suspected**: - Perform a speculum exam to visualize any cervical discharge, erosion, or ulcers. - Treat the infection before IUD insertion (usually with azithromycin or another first-line STI agent). - Counsel on safer sex and partner notification. - Defer IUD insertion until infection is confirmed treated. **For other methods** (pills, DMPA, condoms, LAM, SDM): - RTI/STI is not a contraindication; provide the method and counsel on STI prevention and the need for partner treatment. ### **4.5 Contraindications to Specific Methods: Quick Reference** **COCs (Estrogen + Progestin) - Avoid (Category 3-4) if**: - Breastfeeding (first 6 months postpartum) - may reduce milk supply. - Smoking 15+ cigarettes per day and age >35 years - increased thromboembolism risk. - Migraine with aura (visual disturbance) - increased stroke risk with estrogen. - Known thrombosis (blood clots) or family history of clots at young age - thromboembolism risk. - Uncontrolled hypertension (≥160/100 mmHg or on 3+ agents) - stroke risk. - Significant liver disease (cirrhosis, active viral hepatitis) - impaired metabolism of estrogen. - Known breast cancer - estrogen may promote growth. **POPs - Few contraindications**: - POPs are appropriate for nearly all women, including breastfeeding mothers, women over 35, and those with migraine with aura (because there is no estrogen). - The main concern is adherence: the pill must be taken at the same time daily, within a 3-hour window. If the client cannot commit to this, a different method may be better. **DMPA - Avoid (Category 3-4) if**: - Few absolute contraindications. DMPA is progestin-only, so many of the estrogen-related concerns (thromboembolism, stroke with migraine aura) do not apply. - Caution in women who are overweight or have diabetes (DMPA may cause modest weight gain and affect glucose metabolism, though data are mixed). - DMPA is safe for breastfeeding from day 1. **Condoms - No medical contraindications**: - Condoms are appropriate for everyone and have no medical contraindications. - The main barrier is acceptability (some partners resist) and use consistency (typical-use effectiveness is lower than perfect-use). **LAM - Requires all three conditions**: - Not suitable for women who cannot or do not want to exclusively breastfeed. - Not suitable after 6 months postpartum or if menses have returned. **SDM - Requires cycle regularity**: - Only suitable for women with regular 26-32 day cycles. - Not suitable for women with irregular cycles, those using hormonal methods that affect cycle length, or those with conditions (PCOS, thyroid disorders) that cause irregular cycles. **IUD - Active STI is contraindication**: - Active chlamydia, gonorrhea, or other STIs must be treated before IUD insertion. - Unexplained vaginal bleeding must be evaluated before IUD insertion. - Anatomical abnormalities of the uterus (severe uterine fibroids, septate uterus) may make insertion difficult or unsafe - refer to a specialist. - Adolescents and nulliparous women are increasingly recognized as appropriate candidates for IUD use (contrary to older guidelines). **Implant - Few contraindications**: - Implant is progestin-only, so estrogen-related concerns do not apply. - Active thrombophilia or thromboembolism is not a contraindication (because progestin implant is systemic but very low dose and does not increase clotting risk). - Safe for breastfeeding from day 1 postpartum.

While the midwife's role in family planning is broad, there are two contraceptive methods that are **entirely surgical and outside any midwife's scope of practice**: bilateral tubal ligation (female sterilization) and vasectomy (male sterilization). Understanding that these methods exist, that they are highly effective and permanent (or very difficult to reverse), and knowing the midwife's role (counsel and refer) is important for the MLE. ### **5.1 Bilateral Tubal Ligation (Female Sterilization)** Tubal ligation is a surgical procedure in which the fallopian tubes are cut, tied, or blocked to prevent sperm from reaching the egg. It is a **permanent** method of contraception with effectiveness greater than 99%. **Surgical approaches**: - **Minilaparotomy**: A small incision above the pubic bone through which the tubes are located, lifted out, and ligated. This is the most common approach in the Philippines and can be done under local or regional anesthesia at a BEmONC facility. - **Laparoscopy**: A minimally invasive procedure using a camera and instruments through small incisions. Requires specialized equipment and is more commonly available at larger hospitals. - **Postpartum tubal ligation**: Often performed within 48 hours of vaginal delivery or at the time of cesarean section, when the uterus is enlarged and the tubes are easier to access. **Reversibility**: - Tubal ligation is considered **permanent**. While tubal reversal surgery exists, it is expensive, not widely available in the Philippines, and success is not guaranteed (pregnancy rates after reversal are 40-80% depending on technique and the woman's age). - The midwife must counsel the client that this method is essentially irreversible and should only be chosen if the woman is certain she does not want more children. **Timing and informed choice**: - The RH Law and the DOH guidelines specify that tubal ligation should be offered to women who have **at least 3 living children** or are **at least 35 years old**, or those meeting both criteria (2 children and 30 years old in some guidelines). The exact criteria may vary; check the current DOH guidelines. - The midwife must ensure **informed consent**, ideally obtained before delivery (for postpartum ligation) or at a separate visit before the planned procedure. The client must understand that the method is permanent, and she must sign a consent form. - Spousal consent is not required by law (per RA 10354), but the midwife may encourage the couple to discuss the decision together. **Counseling on tubal ligation**: - The midwife explains the procedure (tubes are cut or tied, often through a small cut above the pubic bone), the permanence, the very high effectiveness (>99%), and the risks (rare complications such as bleeding, infection, or bowel injury). - She clarifies that tubal ligation does **not** affect menstrual bleeding, sexual function, or hormones (the tubes are separate from the ovaries and uterus). - She explores the client's motivations: "Why have you decided not to have more children? How long have you felt this way? How would you feel if you could not become pregnant again?" If the client has doubts, the midwife may recommend waiting or choosing a reversible long-acting method instead. - She provides a referral to a qualified surgeon (OB-GYN) at a hospital or BEmONC facility where the procedure can be performed. ### **5.2 Vasectomy (Male Sterilization)** Vasectomy is a surgical procedure in which the vas deferens (the tube carrying sperm) is cut or blocked, preventing sperm from being ejaculated. It is a **permanent** method with effectiveness greater than 99% and is simpler, safer, and less invasive than tubal ligation. **The procedure**: - A small incision or puncture is made in the skin of the scrotum, and the vas deferens is located, cut, and often tied or cauterized. - The procedure is usually performed under local anesthesia in an office or clinic setting and takes 15-20 minutes. - No general anesthesia is needed. **Reversibility**: - Like tubal ligation, vasectomy is considered **permanent**. While vas reversal surgery (vasovasostomy) exists and has better success rates than tubal reversal (pregnancy rates 50-75%), it is expensive, not widely available, and the man should be counseled that reversal is uncertain. - The client must understand he is choosing a permanent method. **Post-procedure fertility**: - **Important**: After vasectomy, sperm are still produced but cannot exit the body. The man remains fertile for several weeks or months until existing sperm are ejaculated or reabsorbed. A semen analysis is required at 4-6 weeks and at 12-16 weeks postprocedure to confirm azoospermia (no sperm in ejaculate). **Until two consecutive semen analyses confirm azoospermia, the couple must use another contraceptive method.** - Once azoospermia is confirmed, the method is 99.9% effective with no ongoing action required. **Counseling on vasectomy**: - The midwife explains the procedure, emphasizing that it is a minor surgical procedure with very low risk (minimal bleeding or infection). - She clarifies that vasectomy does **not** affect sexual function, erections, libido, or the volume of ejaculate (the sperm are only a small part of semen). - She explores motivation and certainty: "Why have you decided not to have more children? How long have you felt this way? Would you be devastated if you could not have more biological children?" - She provides a referral to a surgeon trained in vasectomy (sometimes a family medicine doctor, urologist, or OB-GYN). - She counsels the couple that another method must be used until two semen analyses confirm no sperm (azoospermia). ### **5.3 The Midwife's Role in Promoting Permanent Methods** Under the MNCHN and family planning mandate, the midwife is not just a provider of contraceptives; she is also an educator and advocate for **all methods**, including permanent ones. In a context where many clients have never heard of vasectomy (let alone considered it for their partner), the midwife's role in counseling men and women on this highly effective, partner-friendly method is important. **How to promote male involvement in family planning**: - Invite partners to FP counseling visits and ask the partner what his concerns are. - Present vasectomy and condoms as methods the man can take responsibility for, which can strengthen couple communication and reduce the contraceptive burden on the woman. - Reassure men that vasectomy does not affect sexual performance and is simpler and safer than female sterilization. - Provide referrals to vasectomy services, including private clinics if available, since vasectomy may not be available at all RHUs. **Recording and data**: - Sterilization procedures are recorded on the FP client record and the Target Client List, contributing to the national Family Health Survey and family planning statistics. These data show whether the FP program is reaching all segments of the population, including those with completed fertility.

Family planning is not just a clinical service; it is a **public health intervention**. All FP services are recorded on standardized forms that feed into the DOH's Family Health Survey Information System (FHSIS) and the monthly health reports (RHU/BHS monthly returns). Understanding the midwife's role in recording and data management is important for MLE and for understanding FP's place in the broader MNCHN program. ### **6.1 The FP Client Record** Each woman who receives FP counseling or a method at the BHS or RHU is given an **FP client record card** (or the information is entered into a digital system if available). This card documents: **Basic information**: - Name, age, address, contact number. - Date of first visit for FP. **Reproductive history**: - Number of living children, spacing of previous pregnancies. - Last menstrual period (LMP). - Breastfeeding status. - Pregnancy history (miscarriages, abortions, ectopic pregnancies). **Medical screening**: - Blood pressure and other vital signs. - Relevant medical history (smoking, hypertension, migraine, diabetes, etc.). - Checklist confirming the client is reasonably sure not pregnant (if starting a hormonal method). **Method chosen**: - Date method started. - Specific method (COC brand and pack size, DMPA lot number and injection site, implant insertion details, etc.). - WHO MEC category for the chosen method. - Counseling given (topics covered: effectiveness, side effects, STI/HIV prevention, return date, etc.). **Follow-up information**: - Return date for resupply (pills) or re-injection (DMPA). - Date of any follow-up visits. - Side effects reported and actions taken (reassurance, switch to another method, referral). - If the client discontinues a method, the reason (wanted to get pregnant, side effects, partner preference, switched to another method, lost to follow-up, etc.). ### **6.2 Target Client List (TCL) for Family Planning** The **Target Client List (TCL) for FP** is a simple tracking tool the midwife maintains at the BHS to identify clients due for resupply or re-injection. It is typically a list or a manual card system (in facilities without computers) organized by: **For DMPA clients**: Sorted by expected return date (every 13 weeks). The midwife uses the TCL to: - Identify clients who are overdue for their next injection. - Contact the client (via home visit, phone call, or message) to remind her of her appointment. - Investigate why she did not return: Has she switched methods? Has she become pregnant? Is there a barrier (transportation cost, clinic hours) preventing her return? **For pill clients**: Tracked by expected resupply date (usually every 3 months). Similar follow-up is done for overdue clients. **For long-acting methods** (IUD, implant): The TCL tracks insertion date and removal/follow-up date, so the client is contacted for removal at end-of-life or if she requests it early. **Why the TCL matters**: - It prevents **method discontinuation due to access barriers**. A DMPA client who misses her injection appointment may not be avoiding the method; she may have overlooked the date or had transportation difficulty. A phone call reminder can bring her back. - It identifies **unintended pregnancies early**. If a client on DMPA is overdue and unreachable, a home visit may reveal she has become pregnant (perhaps because her method failed, which is very rare, or because she discontinued and did not switch to another method). - It documents the **public health impact**: By tracking dropouts, the midwife can see if certain side effects or access barriers are repeatedly causing women to stop their method, and she can adjust her counseling, supply chain, or clinic hours accordingly. ### **6.3 Monthly and Annual Reporting** Data from FP client records and the TCL feed into monthly reports (RHU Form 001, BHS monthly return, or equivalent depending on region) that are submitted to the municipal health office and eventually to the DOH. Key indicators include: **New acceptors**: The number of new clients who started a FP method during the month. **Current users**: The total number of women currently using any modern FP method (counted as of a specific date, e.g., end of month). **Method mix**: The breakdown of current users by method (e.g., 40% DMPA, 25% COCs, 15% implants, 10% condoms, etc.). Method mix shows whether the FP program offers a good range of methods and whether vulnerable populations (e.g., breastfeeding mothers) have access to appropriate methods. **Dropout rate**: The percentage of clients who discontinued a method during the month. High dropout rates may indicate side effects, access problems, or poor counseling. **Contraceptive prevalence rate (CPR)**: The percentage of married or in-union women of reproductive age (15-49 years) who are using any modern contraceptive method. This is a key national health indicator tracked by DHS (Demographic and Health Survey) and is used to monitor progress toward national reproductive health goals. ### **6.4 Integration with MNCHN Programs** Family planning data are integrated with other maternal and child health data at the facility and district level: **Healthy Timing and Spacing of Pregnancy (HTSP)**: FP data are linked to pregnancy surveillance data to show how many pregnancies are spaced less than 24 months apart (high-risk). The goal is for FP services to **prevent** these high-risk pregnancies before they begin. **Maternal mortality and morbidity**: FP data are linked to maternal death surveillance to understand whether women who died or had severe complications were using family planning. Areas with low CPR often have higher maternal mortality because unintended, closely-spaced, or high-parity pregnancies carry higher risks. **Newborn health outcomes**: Infants born after pregnancies spaced <24 months apart have higher rates of preterm birth, low birth weight, and neonatal death. By promoting HTSP through FP, the midwife is directly reducing neonatal mortality. **Child nutrition**: Closely-spaced pregnancies deplete maternal micronutrient stores, increasing the risk of anemia, nutritional deficiency, and stunting in subsequent children. HTSP improves child nutrition outcomes. ### **6.5 Quality of Care in FP Service Delivery** In addition to numbers (how many clients, how many methods), the DOH and the MNCHN program emphasize **quality of care** in FP provision. Quality indicators include: **Counseling quality**: Did the client receive counseling on all available methods, or only the one the provider preferred? Was she given honest information on side effects and effectiveness, or was she "sold" on one method? **Informed choice**: Did the client's choice match her expressed preferences and circumstances, or was she steered toward a particular method? **Continuity of care**: Does the client know when to return? Does the facility have a mechanism to recall overdue clients? **Privacy and confidentiality**: Are FP services provided in a private setting, and is client information protected? **Availability of methods**: Does the facility stock all the methods it claims to offer? Are stock-outs preventing clients from accessing their chosen method? **Counseling on side effects and warning signs**: Are clients prepared for expected side effects (spotting on DMPA, amenorrhea on POPs)? Do they know the warning signs requiring immediate return (severe abdominal pain, heavy bleeding, signs of infection)? The midwife improves quality of care by using standardized counseling tools (GATHER, REDI), maintaining a well-organized TCL, and regularly reviewing FP data to identify gaps and areas for improvement.

One of the most underappreciated causes of family planning dropout is not method failure but **unmanaged side effects**. A woman who was not warned that spotting is common on DMPA may panic, think the method is harming her, and discontinue it. A woman on COCs who develops headache may fear she is having a stroke and stop taking the pill. The midwife's role in **counseling prospectively on expected side effects, normalizing them, and providing support through the first few months** is crucial for retention. ### **7.1 Common Side Effects of Hormonal Methods and How to Counsel** **Irregular spotting or breakthrough bleeding**: - **When it occurs**: On POPs, DMPA, and progestin implants, especially in the first 3-6 months. - **Why it happens**: The progestin-only formulation does not suppress the endometrium as completely as estrogen-containing methods do, so the uterine lining may shed erratically. - **What it looks like**: Scanty, unpredictable spotting between periods; sometimes heavier; sometimes lighter. - **Midwife's counseling**: "Some women on this method experience spotting or light bleeding between periods. This is very common - about half of women have it. It is NOT dangerous or a sign the method is failing. The bleeding usually improves after 3-6 months as your body adjusts. We can continue the method and see if it settles, or if it bothers you very much, we can switch to a different method." Reassurance is the key. **Amenorrhea (absent periods)**: - **When it occurs**: Common on DMPA and progestin implants; also possible (though less common) on POPs and even on COCs if used back-to-back to skip periods. - **Why it happens**: Progestin suppresses menstrual bleeding by thinning the endometrium. - **What it means**: It is **not** a sign of pregnancy or disease; it is a harmless and often welcomed side effect. - **Midwife's counseling**: "Your periods may become lighter or stop altogether on this method. This is normal and safe. Your ovaries are still working normally - it's just that the endometrium (the lining of the uterus) becomes very thin, so there is little bleeding. Many women like not having periods. If you want to check that you are not pregnant, we can do a test, but if your periods stopped after starting the method and you have not had unprotected intercourse, you are almost certainly not pregnant." Some women worry amenorrhea means the method is not working; reassure that the hormonal effect is still active. **Headache**: - **When it occurs**: On hormonal methods, especially COCs with estrogen; can appear in the first month or develop later. - **What it might indicate**: In most cases, it is a mild, transient side effect unrelated to serious disease. **However**, migraine with aura (headache with visual disturbances such as flashing lights, loss of vision, or visual field defects) is a **warning sign** that may indicate increased stroke risk on estrogen-containing methods, and the client must stop the method and be referred. - **Midwife's counseling**: "Some women on birth control pills experience headaches, especially in the first month. Usually it settles within a few months. If you develop a very severe headache, or if your headaches are accompanied by vision changes (blurred vision, flashing lights, or loss of part of your vision), vision loss, trouble speaking, weakness, or numbness, stop the pill and come to the clinic immediately - these are warning signs." Teach the client to distinguish between benign headache and warning signs. **Breast tenderness**: - **When it occurs**: On hormonal methods, especially COCs with higher estrogen doses. - **What it might indicate**: Usually benign; the hormones are affecting breast tissue. - **Midwife's counseling**: "Some women notice their breasts feel tender or swollen in the first month. Usually this settles in a few months. If it persists or is severe, let me know and we can try a different brand or method." Reassurance and the option to switch are key. **Weight gain or change**: - **When it occurs**: On progestin-dominant methods (DMPA, progestin implant, some POPs). - **Why it happens**: Progestin may increase appetite or slightly slow metabolism; weight gain is typically modest (1-2 kg average). - **What counseling should address**: "Some women notice a small change in weight on this method - on average about 1-2 kilos. It is usually modest and stabilizes after a few months. Eating healthily and staying active help. If you gain more than a few kilos or if it bothers you very much, we can discuss other options." Some women are very sensitive to any weight gain and may prefer a different method (e.g., copper IUD) if it matters to them. ### **7.2 Warning Signs Requiring Immediate Return** The midwife must teach clients the **difference between expected side effects and warning signs** that require prompt medical review. Warning signs for hormonal methods and IUDs are often remembered by the acronym **ACHES** (for COCs) or **ALARM** (broader): **ACHES (for COCs)**: - **A - Abdominal pain** (severe) - **C - Chest pain** (or chest tightness) - **H - Headache** (severe) **especially with vision changes** - **E - Eye problems** (vision loss, blurred vision, flashing lights) - **S - Severe leg pain** (calf pain, swelling, warmth - signs of deep vein thrombosis) If a client reports any of these, she should **stop the pill immediately and seek medical attention**. These symptoms may indicate thromboembolism (blood clot), stroke, or other serious conditions. **Additional warning signs for all methods**: - **Heavy vaginal bleeding** (soaking through more than 2 pads per hour for several hours). - **Severe or persistent abdominal or pelvic pain**. - **Signs of infection at the insertion site** (for IUD or implant): warmth, redness, swelling, discharge, fever. - **Vaginal discharge that is foul-smelling, thick, or accompanied by fever** (sign of reproductive tract infection). - **Signs of early pregnancy** (nausea, breast tenderness, missed period) - if the client suspects pregnancy while on a method, she should come in for testing (the method did not fail; she may not have been using it correctly, or in rare cases, a method failure occurred). **Midwife's action**: If a client reports a warning sign: 1. Stop the method immediately. 2. Assess the symptom (take BP, ask about associated symptoms, do a focused exam if indicated). 3. If serious (e.g., severe chest pain, sudden vision loss, severe leg swelling), refer to the emergency department immediately. 4. If less urgent but concerning (e.g., persistent heavy bleeding, signs of infection), refer to the physician or RHU for evaluation and management. 5. Switch the client to a safer method or hold off on restarting until the concern is resolved. 6. Document the warning sign, the action taken, and the referral. ### **7.3 Common Myths and Fears About Contraceptive Methods** Many women hold beliefs about contraception that are factually incorrect but deeply felt. The midwife's role includes gently addressing these myths with evidence-based information. **Myth: "Hormonal methods cause infertility"** - **Fact**: Hormonal methods are reversible. Fertility returns quickly after stopping COCs or POPs (same cycle), and within a few months after stopping DMPA. Implants and IUDs also have rapid return to fertility after removal. No modern contraceptive causes permanent infertility if used correctly. - **How to address it**: "I understand this worry. It is not true. Once you stop the pill or injection, your fertility comes right back - usually within a month or two. You can get pregnant right away if you want to. Many women have used this method and later had children without any problem." **Myth: "IUDs cause infertility or are 'lost' inside the uterus"** - **Fact**: IUDs do not migrate into the abdomen or get lost; they remain in the uterine cavity. IUD use does not cause infertility. If a woman with an IUD becomes pregnant (very rare), the IUD should be removed if possible, but IUD use itself does not cause infertility or ectopic pregnancy (in fact, IUDs prevent ectopic pregnancy better than no method). - **How to address it**: "IUDs are safe. They stay in the uterus and do not get lost inside your body. After the IUD is removed, you can become pregnant. Many women have had IUDs and later had healthy pregnancies." **Myth: "The implant can move around under your skin or migrate to other parts of the body"** - **Fact**: The implant is a solid rod that stays under the skin of the upper arm where it is inserted. It does not migrate. Removal is straightforward - a small incision, and the implant is slid out. - **How to address it**: "The implant stays exactly where it is placed, under the skin of your upper arm. You can feel it if you touch your arm. It does not move around. When you want it out, we make a small cut and slide it out - it is a very quick procedure." **Myth: "Once you start a hormonal method, you will become dependent on it and won't be able to stop"** - **Fact**: There is no addiction or dependence on hormonal methods. The body quickly adjusts after stopping. A woman can start and stop a method whenever she wishes. - **How to address it**: "You can stop this method anytime you want. There is no dependence. If you want to try to get pregnant, you just stop the pill or the injection, and your fertility comes back quickly." **Myth: "Condoms always break or don't work"** - **Fact**: Modern condoms are tested for quality and integrity. They break only if misused (not stored properly, expired, or applied incorrectly) or very rarely due to manufacturing defect. With perfect use, condom effectiveness is 98%; typical use is 82% because of inconsistent use and inconsistent protection. - **How to address it**: "Condoms are reliable if used correctly. Store them in a cool, dry place, check the expiration date, and apply them before any contact. The most common reason condoms seem to fail is they are not used every time or are not applied correctly from the start." ### **7.4 Supporting Clients Through the First 3-6 Months** Many side effects settle within the first 3-6 months as the body adjusts to the hormones. The midwife's strategy for retention is to: 1. **Counsel prospectively**: Before the client starts a method, explicitly mention the most common side effects and reassure her that they are usually temporary. 2. **Offer a return visit at 3 months**: Schedule a brief check-in 3 months after starting the method (in addition to the longer-term return date for resupply). Use this visit to ask about side effects, reassure the client that spotting or amenorrhea is normal, and address any concerns. 3. **Offer to switch rather than stop**: If a client is bothered by side effects, do not simply tell her to live with it. Offer to switch her to another method: "If spotting is bothering you, we have other options. We could try the implant, which some women find has less spotting, or we could try an IUD." Giving the client an option to switch (rather than simply stopping and risking pregnancy) keeps her in the FP program. 4. **Build a supportive relationship**: The midwife who listens, believes the client's concerns, and offers solutions is the one whose clients stay on methods. ### **7.5 Discontinuation and Switching** If a client wants to discontinue a method, the midwife should: 1. **Ask why**: Is it side effects, desire to get pregnant, partner preference, access problems, or something else? Understanding the reason helps the midwife decide if the client can be supported to stay on the method or if switching is the best option. 2. **Ensure continuity**: If the client is stopping to become pregnant, that is planned discontinuation and is fine. But if she is stopping because of side effects or access problems, help her **transition immediately to another method** so she does not have an unprotected interval and risk an unintended pregnancy. "I understand you want to stop the pills because of headaches. Before we do that, let me tell you about other options so you can start something else right away." 3. **Avoid judgment**: The midwife never shames a client for discontinuing a method. "Some women find this method is not right for them, and that is okay. Let us find something that works better for you." 4. **Record the discontinuation**: Document in the FP record why the client discontinued (side effects, pregnancy, switched method, lost to follow-up, etc.). This data help the facility understand dropout patterns and identify if certain methods or side effects are causing problems.