1. Emergency Contraceptive Pills Session III: Providing LNG Emergency Contraceptive Pills (ECPs)

2. Basic steps of client care
Greet client, introduce yourself,
and ask what he/she needs.
Show a respectful attitude
Explain that your discussion with the client will be kept confidential.
Explain the different ECP options.
Screen the client for ECP use.
Tell client about ECPs; give clear information about use, side effects, and needs for referral or follow-up.
Encourage her to ask questions
Discuss options for regular contraception with client.
Emphasize that just as with any contraceptive method, ECPs should be provided in a manner that is respectful of the client and responsive to her needs for information and counseling.
• Ask participants <What steps should be included in client care>
• List the responses on a flip chart.

3. Counseling ECP clients
When counseling a client about ECP, the provider should:
Actively involve the client in the counseling process
Reassure the client that all information she gives you is kept confidential
Provide a private and supportive environment
Do not make judgmental comments or indicate disapproval through body language
(such as such as crossing your arms
over your chest)
Be responsive to the client’s needs
Be supportive of the clients choices
Be respectful
Ask participants <What are some of the key principles of counseling?>
List the responses on a flip chart.
During counseling providers should:
Reassure all clients, regardless of age or marital status that all information will be kept confidential.
Be supportive of the client's choices and refrain from making judgmental comments or indicating disapproval through body language or facial expressions while discussing ECPs with clients. Supportive attitudes will help set the stage for follow-up counseling about regular contraceptive use and sexually transmitted infection (STI) prevention.
Actively involving the client in the counseling process may be more effective in ensuring compliance rather than simply providing her with information. This active involvement may include:
Asking her what she has heard about ECPs.
Discussing her experience with other contraceptive methods (particularly the incident that led to ECP use).
Validating or correcting her ideas as appropriate.
Whenever possible, ensure that counseling is conducted in a private and supportive environment. In situations where it is difficult to maintain privacy (for example, in pharmacies), give the method to the client with appropriate verbal and printed instructions and advise her to attend a clinic or contact a health care/family planning provider for counseling about regular contraceptive methods.

4. Addressing common concerns, rumors and misconceptions about ECPs
Correct common concerns, rumors or misconceptions by emphasizing:
The availability of ECPs does not increase risky sexual behavior.
ECPs do not prevent implantation
ECPs do not cause abortions
ECPs do not cause deformed babies
ECPs are not dangerous
Before showing the slide, ask participants: What are some common rumors and misconceptions about ECPs?> Write the answers on a flip chart.
Explain that rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:
an issue or information is important to people, but it has not been clearly explained.
there is nobody available who can clarify or correct the incorrect information.
the original source is perceived to be credible.
people are motivated to spread them for moral/political, or religious or reasons (moral/political reasons may be things such as a belief that adolescents should not have sex. Religious reasons may be such things as believing ECPs can cause an abortion).

5. When do rumors occur?
Information given is important to people, but it has not been clearly explained.
There is nobody available who can clarify or correct the incorrect information.
The original source is perceived to be credible.
People are motivated to spread them for moral, religious or political reasons.

6. How to counteract rumors
Listen politely and don’t laugh
Find out where the rumor came from
Explain the facts
Answer questions
Always tell the truth
Clarify information
Use examples
Reassure the client
Discuss methods for counteracting rumors and misinformation
When a client mentions a rumor, always listen politely. Don't laugh.
Define what a rumor or misconception is.
Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.
Explain the facts.
Use strong scientific facts about ECPs to counteract misinformation.
Always tell the truth. Never try to hide side effects or problems that might occur with ECPs.
Clarify information with the use of demonstrations and visual aids.
Without giving names or descriptions, use examples of other women you have provided ECPs for.
Refer back to the flipchart and ask participants how they could counteract each rumor or misconception.

7. ECP information for the client should include:
How to use ECPs
ECP information for the
client should include:
How and when to take the pills.
What to expect once the pills are taken. Including possible side effects and what the woman should do.
Effectiveness/failure rates.
Importance of using regular contraception.
Ask participants <What points are important when counseling women on how to use ECPs>
Write responses on a flip chart
Explain that there are a number of key points to cover when counseling a client about how to use ECPs.
Make certain that the client does not want to become pregnant, but that she understands that there is still a chance of pregnancy even after treatment with ECPs. Explain that ECPs will not harm the fetus should they fail to prevent pregnancy.
Explain how to take ECPs correctly.
1. The woman should swallow the ECP as soon as possible after unprotected sex. Encourage the woman to take the ECP while she is still with you, before leaving the treatment room or facility.
A WHO-led study in 10 countries established that a single dose of 1.5 mg LNG is as effective as two doses of 0.75 mg. Some providers give 2 tablets of 0.75mg at the same time. Labels on some 2-dose ECP packages suggest that the woman should take the second dose 12 hours after the first dose. However, these labels do not reflect current scientific information.
2. Advise the client not to take any extra ECPs, as these will likely increase the possibility of nausea or vomiting, but will not increase effectiveness.
3. Describe common side effects.
4. Explain that the dosage needs to be repeated if the client vomits within 2-3 hours of taking ECPs.
Make sure that the client understands that ECPs will not protect her from pregnancy if she engages in unprotected intercourse in the days or weeks following treatment. Advise the client to use a barrier method, such as the condom, for the remainder of her cycle. A different contraceptive method may be initiated at the beginning of her next cycle if desired. For some women, initiating or continuing combined oral contraceptives (COCs) or progestin-only injectables the day after using ECPs may be an option, as long as you are fairly sure that she is not pregnant
5, Explain that ECPs typically do not cause the client's menses to come immediately. The client should understand that her period might come a few days earlier or later than normal. Explain that if her period is more than a week late, she may be pregnant. She should seek evaluation and care for possible pregnancy.
6. Advise the client to come back or visit a referral clinic (as appropriate):
If there is a delay in her menstruation of more than one week past the expected date.
If she has any reason for concern.
As soon as possible after the onset of the menstrual period for contraceptive counseling, if desired.
7. Use simple written or pictorial instructions to help reinforce important messages about correct use of ECPs.

8. Possible side effects of ECPs
Some women experience:
Changes in bleeding patterns (not serious and will
resolve without treatment)
Slight irregular bleeding for 1-2 days or
Monthly bleeding that starts earlier or later than
expected
Within the week after taking ECPs (these side effects are
not serious, require no treatment and usually resolve within 24 hours)
Nausea
Vomiting (rare with LNG-only ECPs)
Abdominal pain
Fatigue
Headaches or dizziness
Explain that when clients are given ECPs, they need to know what to expect. Explain to your client that:
Most women have their next menses up to a week early or late. Some women have irregular bleeding or spotting after taking ECPs. Changes in bleeding patterns are not dangerous and will resolve without treatment. If your menses is more than one week later than you expect it, you may be pregnant. You should have a pregnancy test and appropriate care.
Nausea, rarely accompanied by vomiting occurs in less than 20% of women using LNG ECPs.
Some women may feel dizzy or have headaches, abdominal pain, fatigue or breast tenderness. These side effects are not serious and usually do not occur more than a few days after treatment and usually stop within 24 hours. If you become pregnant before or after using ECPs, the pregnancy will not be harmed in any way. ECPs will not cause an abortion or birth defects.
Distribute Handout #6 ECP Competency Based Checklist.
Review each item on the checklist.
Divide participants into groups of 3. Explain that in each group one participant will play the role of the client, another will play the role of the provider and the third will play the role of the observer. The groups will change roles with each new roleplay. The observer will use the competency based checklist and the observer checklist (on the same page as the roleplay scenarios) as they observe the roleplay and give feedback to the participant playing the role of the provider.
Give each group the 3 roleplay scenarios. (Handout # 5)

9. Need continuing protection?
Ask your client:
Could unprotected intercourse happen again?
Do you need dual protection from pregnancy and STIs/HIV/AIDS?
Can you always choose when you have sex?
Have you been using an regular method of contraception? Are you satisfied with it?
Following ECP use, clients will need continuing protection against pregnancy and may need protection against STIs and possibly sexual abuse.

10. Follow up and referral for clients
If the client reports no menses within 4 weeks of ECP use, she may be pregnant.
Invite client to tell her story, including the number of sex partners. If her story suggests STI exposure, refer for treatment. Discuss use of condoms if appropriate.
If at risk for STIs, discuss dual protection from pregnancy AND from STIs/HIV/AIDS
If story suggests coercion or violence, provide more help if possible.
Can start another method right away. If client chooses no regular method now, offer ECPs and male or female condoms with instructions for use.
Contraceptive use should never be made a condition for ECP use.
Ask participants <In what instances would it be Important to
follow up with a client after ECP provision?> <In what instances would it be good to refer a client?>
• If the client reports no menses within 4 weeks of ECP use, she may be pregnant. It is normal for a woman’s menses to begin a few days earlier or later than usual after taking
ECPs. If a woman does not have a period within 4 weeks, discuss her next options.
• A client should be encouraged to return if he/she has concerns or problems.
• Assessing STI risk and referring the client for diagnosis and/or treatment is a critical part of EC services. If at risk for STIs, discuss dual protection from pregnancy and from STIs/HIV/AIDS
• Women who have been forced to have sex or have been sexually assaulted and/or raped may seek advice or services. Seeking health services may be a stressful experience after the trauma of a sexual assault. Be supportive and sensitive to the emotional turmoil that women in this situation may be experiencing. Women who have been sexually assaulted are also in need of diagnosis and possible treatment for STIs and should be offered referral for a comprehensive evaluation and possible prophylactic STI treatment.

11. When to begin a regular method of contraception following LNG ECPs
Condom COCs Progestin-only injectable Monthly injectable Implants IUD
Immediately The day after taking ECPs or wait until next menstrual bleeding The same day as the ECPs or within the first 7 days after the start of her next menstruation The same day as the ECPs, but needs back-up method for first 7 days Same day as ECPs or after menstruation has returned, but needs condoms or COCs until then Can be used for emergency contraception, or on the same day if taking ECPs or within the first 7 days after the start of her next menstruation
Show the slide and discuss when it is appropriate to start each method.
Explain that whenever possible, clients requesting ECPs should also be offered information and services for regular contraceptives. But, not all clients want contraceptive counseling at the time of ECP treatment. Contraceptive use should never be made a condition for ECP use. Clients who are interested in learning about other methods should receive information and counseling at the time of the ECP visit, at a follow-up appointment scheduled at a more convenient time, or should be referred to a FP clinic if other FP methods are not available (i.e., pharmacies, etc.). If the reason for requesting ECPs is that a regular contraceptive method was not used, or was used incorrectly, discuss how it can be used consistently and correctly in the future.
Women should be provided at least a temporary method, such as condoms, whenever possible, to use in the immediate future.
Show slides 11 and 12 and discuss when it is appropriate to start each method for both new contraceptive users and continuing users.

12. When to begin a regular method of contraception following UPA ECPs
Condom COCs Progestin-only injectable Monthly injectable Implants IUD All women need to abstain or use a backup method* from the time they take UPA-ECPs until they have been using a hormonal method for 7 days (or 2 days for progestin-only pills).
Immediately On the 6th day after taking UPA ECPs Can be used for emergency contraception, or on the same day if taking ECPs
Show the slide and discuss when it is appropriate to start each method.
Explain that whenever possible, clients requesting ECPs should also be offered information and services for regular contraceptives. But, not all clients want contraceptive counseling at the time of ECP treatment. Contraceptive use should never be made a condition for ECP use. Clients who are interested in learning about other methods should receive information and counseling at the time of the ECP visit, at a follow-up appointment scheduled at a more convenient time, or should be referred to a FP clinic if other FP methods are not available (i.e., pharmacies, etc.). If the reason for requesting ECPs is that a regular contraceptive method was not used, or was used incorrectly, discuss how it can be used consistently and correctly in the future.
Women should be provided at least a temporary method, such as condoms, whenever possible, to use in the immediate future.
Show slides 11 and 12 and discuss when it is appropriate to start each method for both new contraceptive users and continuing users.

13. Resuming contraception after ECP use
Contraceptive
How to resume the method
Condoms COCs Progestin-only injectable Implant and IUD
Use a condom for every sexual encounter Use a condom for the first 7 days. Resume taking COCs as before or continue using condoms until menstruation, then begin a new pack. Use condoms until next menstruation and then begin progestin-only injectable. Need for ECP rare, but If implant or IUD is past expiration and ECP is needed, use a condom until next menstruation. Have a new implant or IUD inserted within first 7 days of menstruation.
Experiential Learning Exercise (30 min)
Explain that all of the participants will be involved in a roleplay of a scientific conference on ECPs.
Ask for 4 volunteers to be the panel of experts.
Distribute the list of frequently asked questions (Handout #8) to the remaining participants who will be the audience.
Instruct the “audience” to ask questions of the panel of experts.
When all questions have been asked, distribute the answers to the frequently asked questions and discuss.
If time permits, encourage participants to make up questions to ask the panel of experts.