As part of your role as a health practitioner you need to know how to help clients use their contraceptive method(s) of choice. In Box 5.2, you will find a summary of the procedure for using COCs.

Box 5.2 Procedure for using COCs

Give your female client at least one packet of the same pills that she will use, even if she will be getting her pills elsewhere later.

Show her:
- which kind of pill packet you are giving her (21 pills or 28 pills). If the pack has 28 pills, point out that the last seven 'remainder' pills are a different colour and do not contain hormones.
- how to follow the direction of the arrows on the packet to take the rest of the pills, one each day (including the remainder pills).
Give her instructions on starting the first packet, starting the next packet, and what to do if she misses a pill.
Ask her to repeat the most important instructions, and show you how she will take her pills, using the pill packet.
Ask her if she has any questions, fears or concerns, and answer her concerns clearly and respectfully.

Starting COCs

There are several ways to begin taking the pill. One common way is to start on the first day of menstruation (or period), or the first day after an abortion.

Continuing COCs

The client has to take her pill on a daily basis, one pill every day until she finishes an entire pack. In order to remember this, she needs to link taking the pill with a regular activity that she does at the same time every day, like eating a meal or brushing her teeth.

Women who cannot take the pill

Some women may not be able to take the pill because of the risk of serious health problems. If they display any of the following symptoms, which could be due to a blood clot, they must see a health officer or doctor straight away:

Severe headache
Bad pains in the chest
Leg swelling
Breathing difficulty
Coughing up blood
Sudden problems with sight or speech
Weakness or numbness in an arm or leg
Collapse.

Women who are under 35 years and have migraines, gall bladder disease, hypertension, diabetes, epilepsy, sickle cell disease, and/or have had elective surgery, have a history of blood clots, or liver or heart disease, may not be able to take the pill.

Women who are over 35 years and have a history of heart attacks, or strokes, blood clots, unexplained vaginal bleeding, known or suspected cancer, known or suspected pregnancy or liver disease, should not take the pill at all.

Instructions for missed pills

You will need to instruct women on how to continue taking pills after they have missed one or more pills from the pack. See Box 5.3 for some useful rules for missed pills.

Box 5.3 Rules for missed pills

ALWAYS:

Take a pill as soon as you remember.
Take the next pill at the usual time. This may mean taking two pills on the same day or even at the same time.
Continue taking active pills (see Figure 5.1) as usual, one each day.

You should also advise your clients to follow the steps in Table 5.1 when they have missed a pill or started the pack late.

Table 5.1 Instructions for missed pills.

When pills are missed	How pills are missed	Follow the three rules in Box 5.3 and instructions below
In the first seven days	Started the pack two or more days late, OR Missed any two to four pills	Avoid sex, or use additional contraception for the next seven days.
Days 8–14	Missed any two to four pills	Follow the three 'Always' rules in Box 5.3.
Days 15–21	Missed any two to four pills	Go straight to the next pack. Throw away inactive pills from 28-day pack (days 22–28); don't wait seven days before starting a 21-pill pack.
In the first three weeks (days 1–21)	Missed five or more days in a row	Avoid sex, or use additional contraception for the next seven days. Go straight to the next pack. Throw away inactive pills from a 28-day pack (days 22‒28); don't wait seven days before starting a 21-pill pack.