Step 5. Provide or refer for the contraceptive method
Provide or refer for the contraceptive method, along with instructions about correct and consistent use; using the selected method; and confirm patient understanding.
Once a patient has selected a method, it should be provided without delay. Providers can refer to the U.S. Selected Practice Recommendations (U.S. SPR) to guide method initiation and management. A broad range of Food and Drug Administration (FDA)-approved or FDA-cleared contraceptive products should be available on-site, with strong referral networks for contraceptive methods or products not available on-site. Patients selecting natural family planning methods should be offered counseling and education on the different natural family planning methods (FDA-cleared app, calendar calculation, basal body temperature charting, cervical mucus monitoring, lactational amenorrhea). If STI screening or other preventive services are indicated, these should be offered that day if feasible. Requiring that the patient accept the offer of screening before prescribing contraception, however, has no medical justification and is coercive.94
Providers should offer same-day initiation (or “quick start”) of all methods, including implants and IUDs, whenever possible as a patient-centered best practice to increase timeliness of contraceptive care. Prior to placement, providers can be reasonably certain that a person is not pregnant if they have no signs or symptoms of pregnancy, and they meet any one of the following criteria:94
- Is ≤ seven days after the start of normal menses
- Has not had penis-in-vagina sex since the start of last normal menses
- Has been correctly and consistently using a reliable method of contraception
- Is ≤ seven days after spontaneous or induced abortion
- Is within four weeks postpartum
- Is fully or nearly fully breast(chest)feeding (≥ 85 percent of feeds), amenorrheic, and < six months postpartum
The following tools and algorithms can help providers determine whether there is reasonable certainty that a patient is not pregnant, the appropriateness of quick starting a particular method, and the need for back-up contraception:
A urine pregnancy test can be used alongside these criteria. However, a negative urine pregnancy test alone is insufficient to establish reasonable certainty that a person is not pregnant. Early in pregnancy, a person may have a low level of bHCG present in their urine, and this may result in a false-negative result on a standard urine pregnancy test. High-sensitivity pregnancy tests should be recommended for better accuracy early in pregnancy. Routine urine pregnancy testing is not always required and is often unnecessary.94
In situations in which a provider cannot be reasonably certain that a person is not pregnant, the benefits of starting most methods likely exceed risks.94 Providers can advise patients that, if they desire, they can start the implant, pill, patch, ring, or shot at any time, with follow-up pregnancy testing in two to four weeks. If the patient’s preferred method is an IUD, they should be offered a contraceptive method other than an IUD to use until the provider can be reasonably certain that they are not pregnant and can place the Cu-IUD or LNG-IUD. Although the Cu-IUD is not FDAapproved as emergency contraception, it may be considered for such use by a provider based on a determination that it is appropriate for a particular patient.94
Emergency contraception (EC) should be offered to all patients as appropriate. For more information on EC, please refer to the section on strategies to increase access to care, where there are detailed instructions about provision of EC pills (ECP).
Working with a patient interactively to establish a plan helps ensure people access and use their preferred method and switch or discontinue their method when desired. This includes discussing issues surrounding access (for example, getting to a pharmacy for refills), use (for example, having condoms and ECPs available when needed), and discontinuation (for example, getting an IUD or implant removed without delay) as well as what to expect and how to manage side effects. Providers should also recognize preferences can change over time and that discontinuation or switching of a method is normal and expected. Providers should also counsel around and ensure same-day removal of contraceptive implants and IUDs when patients request it. Side effects are one of the most common reasons for discontinuation, so addressing them in a person-centered and timely way is critical. If a patient is initiating a new method, providers can share information and support to optimize the patient’s correct use of the method in the context of their unique life circumstances. For example, providers can work with patients to develop a personal technique to remember to take a pill every day. Making a plan can also involve anticipating problems, like what to do if a dose of the shot is late or missed.