The birth of this training curriculum is an important component of a pilot project entitled "Mainstreaming Emergency Contraception into the Public Sector." It is the result of collaboration among the Ethiopian Society of Obstetricians and Gynecologists (ESOG), the Family Health Department (FHD), Ministry of Health, Population Council, ECAfrique, Family Guidance Association of Ethiopia (FGAE), Marie Stopes International Ethiopia (MSI-E), and five regional Health Bureaus. Implementation activities will be conducted in identified pilot health facilities in Addis Ababa City Administration, Amhara, Oromia, Southern Peoples Region and Tigray.

This training curriculum is designed for trainers of mid-level health workers, and could be also useful for training doctors. It is a one-day course and aims at equipping trainers from the identified pilot project sites from the five regions. This curriculum does not address emergency contraception (EC) using an intra-uterine device as a method. The trainers will be expected to acquaint themselves with the training materials in the given time frame, and they will have the knowledge and skills necessary to conduct training of trainers (TOT) for other service providers on ECPs.

This will also give an opportunity to those who would like to provide EC services at the community level. It can also be used to strengthen the Health Extension Package (HEP), which is a current government priority that delivers health services to the doorsteps of communities and individuals. The health extension workers (HEWs, who provide those services under the HEP can be trained by trainers who are familiar with this curriculum.

This training curriculum is divided into four units. Unit I discusses the status, role and need for EC in Ethiopia. Unit II defines EC and gives details when and how ECPs should be taken. Unit III addresses information, education and communication and behavioral change communication (IEC/BCC) and counseling for ECPs, which is an essential part of EC service provision. The final section of this curriculum covers managing the quality of ECPs services. Under this unit, checklists are provided to assess quality of care in terms of client-provider interaction and provider-competency.

This training curriculum was produced by the Ethiopian Society of Obstetricians and Gynecologists (ESOG) in collaboration with the Family Health Department, Ministry of Health (MOH), and the Population Council through its ECAfrique project. These organizations as well as the Family Guidance Association of Ethiopia, and Marie Stopes International Ethiopia initiated a pilot project to mainstream emergency contraception into the public sector thereby improving the quality of family planning services in the country.

The following governmental and non-governmental organizations participated in the development of this training curriculum:

·         Ministry of Health (Family Health and Training Departments)

·         ESOG (organizer of the workshop)

·         The Population Council

·         Department of Ob/Gyn, Faculty of Medicine, Addis Ababa University

·         Department of Community Health, Faculty of Medicine, Addis Ababa University

·         The Addis Ababa Nursing School

·         FGAE

·         MSI-E

This curriculum is designed for TOTs, and participants will include: doctors, health officers, and nurses of different categories, who will then train other service providers.

The objectives of this training curriculum include:

·         Review and update mid-level health workers' knowledge about the status of Emergency Contraception in Ethiopia, and the need for emergency contraception in ensuring access to family planning services

·         Review and update mid-level health workers' knowledge about methods of EC, ECPs Regimen, their function, eligibility criteria, safety and effectiveness, side effects and their management, and follow up and referral

·         Refresh mid-level health workers' capacity to provide effective IEC/BCC and counseling to family planning clients in general, and to ECPs clients in particular

·         Update mid-level health workers' about the management of ECPs services

This training course is designed for one day, and therefore, the following points are important to remember:

·         IEC/BCC and Counseling are grouped together by incorporating specific counseling skills for ECPs

·         Handouts for trainees should be prepared by photocopying the content notes

·         Primary focus is given to the management of ECPs rather than the broad management information system (MIS) and contraceptive logistics

This course is to be conducted using the principles of adult education/learning, which are based on the assumption that people know what they want to gain from the course and actively participating in acquiring knowledge, attitude and skills.

The trainer is also expected to create a comfortable environment and promote those activities that assist the trainee in updating knowledge, attitude and skills.

Curriculum Organization

The curriculum is designed for mid-level health workers to update their knowledge, attitude and skills. Each unit session is divided into introduction, unit training objectives, specific learning objectives, unit training/learning methodology, resource requirements, evaluation methods, materials for trainers to prepare in advance, time required, major references, unit implementation, content note, and pre/post tests. The specifics of each session is outllined below:

Introduction: Provides the rationale of the unit session and describes some of the characteristics of the issue addressed.

Unit Training Objective: Ensures that mid-level health workers will increase their competence and hence improve the quality of service they provide.

Specific Training/ Learning Objectives: States what trainees should achieve by the end of the unit session. Trainers should review this section with trainees at the beginning of every unit session.

Unit Training/Learning Methodology: It uses the following methods to achieve the Training/Learning Objectives: Lectures - to review existing knowledge and introduce new information, and Discussion - to facilitate interaction between trainees and provide an opportunity to share ideas and experiences.

Resource Requirements: Lists resources intended to support the Training/ Learning Objectives described above. Resources include pre/post tests, and audio-visual aids such as overhead projectors, flip charts, transparencies, and marking pens.

Evaluation Methods: Includes various methods of assessment designed to evaluate trainees' achievement of the training/learning objectives. The methods are: pre/post tests to compare the knowledge of trainees before and after learning, and question answer session during discussion.

Materials for Trainers to Prepare in Advance: Guides trainers about preparations that need to be undertaken before the session begins.

Unit Implementation: Contains instructions to the trainer on how to implement the unit session. The approximate time for each set of instructions is also provided.

Content Notes: Contains essential information that would help achieve the learning objectives for the unit session. Content Notes can serve the trainer as resource material and also as handouts for trainees.

Major References: Lists of relevant technical references for each unit to help the trainer and the trainees prepare themselves for each session and for further reading.

Pre and Post-tests: Compares knowledge of trainees and evaluate achievements of the learning objectives. These are to be administered before and after each unit session where applicable. An answer key is provided in Annex 1.

Annexes:  These are materials that may be useful for the trainer and trainees placed at the end of the curriculum. These are: Answers key to the pre/post questionnaire after each unit session, screening checklist, client-provider interaction checklist, provider competency checklist, trainees' course evaluation, and suggested training course schedule.

 

Emergency contraception (EC) as a backup method is new in Ethiopia. Various reports show that there is little knowledge and information available about EC in the country. In the past, EC was not accessible to women, which resulted in high number of unintended pregnancies and unsafe abortions. It is also important to note that there is an enabling policy and legal environment to expand, promote and ensure the availability and accessibility of family planning as well as emergency contractive services in the country.

To provide doctors and mid-level health workers with an overview of the status of emergency contraception, magnitude of unsafe abortion, the role of EC in preventing unintended pregnancy, and enable them to understand the existing policy and legal environment.

By the end of this session, trainees will be able to:

Training/Learning Methodology

Evaluation Methods

Materials for Trainer to prepare in advance

 

 

Training/learning Methods	Time Required
Begin by discussing the objectives and organization of the overall training course, and explain the training-learning methods, and the methods of assessment to be used during the course. Discuss the expectation of the trainees in the training course.	15 minutes
Introduce the EC status in Ethiopia by describing the magnitude of unsafe abortion, complications of pregnancy and childbirth, unprotected sex, and sexual violence. Use a transparency to show some statistics (DHS findings, ESOG's abortion study results, etc.)	20 minutes
Discuss the role of EC in preventing unintended pregnancies in Ethiopia. Ask trainees if they know how to manage rape cases to prevent unwanted pregnancy?	20 minutes
Explain the existing policies and legal issues that create enabling environment for EC services	20 minutes
Summarize the information provided.	5 minutes

 

EMERGENCY CONTRACEPTION AND ITS ROLE IN ADDRESSING REPRODUCTIVE HEALTH NEEDS

Status of Emergency Contraception

The need for emergency contraception (EC) in Ethiopia was identified in the late nineteen nineties, but has not yet been formally introduced into either the public, NGO or private sectors. The 1997 Reproductive Health Needs Assessment revealed that there was lack of knowledge and skill about EC, and recommended the promotion of this back up method and training of service providers in EC. Two years later, the Ethiopian Society of Obstetricians and Gynecologists (ESOG) in its 7^th Annual Conference deliberated on illegal and unsafe abortion in Ethiopia, and strongly recommended that EC promotion and use in the country would reduce incidence of unwanted pregnancies, which otherwise would have ended in unsafe abortion and its complications.

In 2001, the Family Guidance Association of Ethiopia (FGAE) in collaboration with the Population Council initiated for the time a pilot project to introduce EC in selected youth center clinics in the country. In this project EC was provided in a repackaged attractive brand for adolescents and youth by cutting the regular contraceptive pills though the services were limited in scope and coverage. This pilot project demonstrated that EC was popular among young people, served as a learning experience, and showed the need to expand services in the public and NGO sectors.

Although these attempts were encouraging, there was no systematic and organized approach to address the widespread unmet need for family planning in general, and EC in particular, which is needed to bring about national level impact. As a result of this, the Ministry of Health, ESOG, Population Council through its ECAfrique project, FGAE and MSIE launched a new initiative, which focuses on mainstreaming EC into the public and NGO sectors. This curriculum is an important part of this new initiative.

Need and Role for EC in ensuring access to family planning services

Emergency contraceptive pills (ECPs) play a special role in preventing unwanted pregnancies and would serve as a back up to other family planning methods.  Preventing unintended pregnancies by improving the existing family planning services through broadening of the method mix and ensuring access and availability of contraceptives methods, will ultimately contribute to the reduction of the morbidity and mortality of Ethiopian women.

According to the Ethiopia Demographic and Health Survey (DHS 2000), about 25,000 women die every year due to pregnancy and childbirth complications, and abortion is estimated to account for about 32 percent of these deaths. According to a national survey on abortion conducted by ESOG, abortion related mortality was 1,209 per 100,000 abortions.

The low status of women, poor access to family planning services, lack of information about available reproductive health services and RH rights are the major factors that aggravate the prevailing unacceptable situation. However, in Ethiopia, the status of women is expected to improve, because of an enabling environment with regard to policies and laws that are targeting women. The health, population and women policies and the recently revised penal code on abortion, abduction, rape, etc, ensure the rights of women to access family planning services. 

1. Central Statistical Authority (CSA) and ORC Macro. 2001. Ethiopia demographic and Health Survey. Central Statistical Authority, Addis Ababa and ORC Macro, Calverton, Maryland.

2. Transitional Government of Ethiopia. Office of the Prime Minister. 1993. National Population Policy of Ethiopia. Addis Ababa.

3. Transitional Government of Ethiopia. Health Policy. Addis Ababa, September 1993.

4. The transitional Government of Ethiopia. National Policy on Ethiopian Women, Office of the Prime Minister, September 1993, Addis Ababa.

5. Tekle-Ab Mekbib, Yirgu G/Hiwot, Misganaw Fantahun 2002. Survey of unsafe abortion in selected health facilities in Ethiopia. Ethiopian Society of Obstetricians and Gynecologists (ESOG). May 2002, Addis Ababa.

 

ECPs is a form of contraception that can be used immediately after unprotected sexual intercourse, but before pregnancy is established. Although safe and effective, ECPs did not receive significant attention in Ethiopia until recently. ECPs play a crucial role in family planning programs as a backup method to avoid unwanted and unplanned pregnancy as well as serve as a bridge to continuing use of family planning methods.

To enable mid-level health workers to provide EC services and comprehensive, clear and appropriate information for eligible women.

By the end of this session, trainees would be able to:

Training/Learning Methodology

Evaluation Methods

Materials for Trainer to prepare in advance

 

 

Training/learning Methods	Time Required
Introduce the learning objectives of the session, and administer pre-test to determine areas needing particular attention.	15 minutes
Give the definition of ECPs, describe the different methods of ECPs, and discuss how ECPs work. If you have a dedicated ECP product, use it for demonstration.	25 minutes
Explain eligibility for ECPs. Use the screening checklist (Annex 2) in the discussion.	15 minutes
Describe the safety and effectiveness of ECPs.	15 minutes
Discuss the regimen of ECPs	15 minutes
Explain the side effects of ECPs and their management	20 minutes
Conduct the post test	15 minutes

 

Definition of EC

Emergency Contraception refers to contraception methods that can be used by women following unprotected intercourse or if the woman had a contraceptive accident such as leakage or slippage of condom to prevent an unwanted pregnancy. EC should not be used as a regular family planning method but should be used in an emergency as a back up. 

Methods of EC

The following are emergency contraceptives that are currently in use:

1. Combined Oral Contraceptive Pills (COCPs): An increased dose of combined oral contraceptives containing ethinyl estradiol and levonorgestrel (Yuzpe’s regimen)

2. Progesterone Only Pills (POPs): High dose Progesterone Only Pills containing levonorgestrel.

3. Intrauterine Contraceptive Devices (Copper Releasing Intrauterine Contraceptive Devices)

4. Mefipristone (Ru486): anti progesterone.

This training curriculum will focus on Emergency Contraceptive Pills (ECPs). ECPs are hormonal methods that can be used up to three days after unprotected intercourse. They are also called “morning after” or “post coital" pills. However, these terms do not necessary convey the correct timing of use nor do these terms convey the important fact that EC pills are not regular family planning method and are intended for “emergency “ use only. As a result, the most appropriate term for this method is ECPs.

ECPs Regimen

As mentioned above, there are two types of ECP regimen in use. Treatment with both regimens should not be delayed unnecessarily as efficacy declines over time.

1. Combined oral contraceptive pills: Contain ethinyl estradiol and levonorgestrel or comparable formulations. This regimen is known as the Yuzpe’s method, and it has been used since the 70s. 

• When high dose pills containing 50mcg of ethinyl estradiol and 0.25mg of levonorgestrel are available, two pills should be taken as the first dose as soon as convenient, but not later than 3 days (72 hours) after unprotected intercourse. The second two pills should follow 12 hours later.

• When low dose pills containing 30 mcg ethinyl estradiol and 0.15 mg of levonorgestrel are available, four pills should be taken as the first dose as soon as convenient but not later than 3 days (72 hours) after unprotected intercourse to be followed by another four pills 12 hours later.

2. Progesterone only Pills:

• When pills containing 0.75 mg of levonorgestrel are available, one pill should be taken as the first dose as soon as convenient, but not later than 3 days (72 hours) after unprotected intercourse to be followed by another one pill 12 hours later.

• When pills containing 0.03 mg of levonorgestrel are available, twenty (20) pills should be taken as the first dose as soon as convenient but not later than 3 days (72 hours) after unprotected intercourse to be followed by another 20 pills 12 hours later.

How do ECPs work?

The precise mechanism is not known, and studies have suggested that EC pills can:

• Delay or inhibit ovulation

• Prevent implantation by making the inner lining of the uterus (endometrium) unsuitable for implantation

• Prevent transport of the sperm and ovum

The mechanism that is active in a particular case depends on the time of the menstrual cycle when emergency contraceptives are used. ECPs do not interrupt or abort an established pregnancy. They can only help in preventing unwanted pregnancy. Once implantation (pregnancy) has occurred, ECPs are not effective. ECPs, thus, do not cause any form of abortion or bring about menstrual bleeding.

Eligible women for ECPs

Three types of clients are eligible for ECPs:

• Regular family planning clients, particularly those using barrier methods (condoms), oral contraceptive pills (OCPs), injections or traditional methods such as withdrawal and safe period

• Potential contraception users (those who are not currently using any method of contraception)

• Clients who have requested ECPs

• Clients who are not eligible for ECPs:

• Client already pregnant

• When an emergency contraceptive option other than ECPs should be considered (e.g. clients seeking care later than 3 days)

Upon arrival clients have to be screened to determine eligibility. However, ECPs should not be delayed or withheld in order to carry out screening procedures such as pelvic exam.

Indications for the use of ECPs:

• When no contraceptive has been used

• When there is a contraceptive accident or misuse

• Condom rupture, slippage or misuse, and IUCD expulsion

• Two OCPs missed consecutively, and late for DMPA injection by two weeks or more

• Failure of a spermicidal tablet or film to melt before intercourse

• Failed coitus interruptus (withdrawal)

• Failure to abstain on a fertile day of the cycle in a woman who uses the calendar method

• In case of sexual assault

 

Safety and effectiveness of ECP

 

ECPs are considered very safe:

• In more than 20 years no deaths or serious medical complications have been reported.

• The COCs used as EC pills have not been associated with fetal malformations or congenital defects in the event if EC fails to prevent pregnancy.

• Available data suggest the ECPs do not increase the possibility that a pregnancy    following use will be ectopic

ECPs are fairly effective in preventing pregnancy from unprotected sexual intercourse. It is estimated that if 100 women have unprotected sexual intercourse during the second or third week of their menstrual cycle, 8 would become pregnant.

These estimates suggest that the use of ECPs could reduce the probability of becoming pregnant from unprotected sexual intercourse by roughly 75 percent in the case of combined OCPs, and 85 percent in the case of POPs.

Side effects of ECPs and their management

The following are common side effects of ECPs:

Nausea: It is the most common in ECPs, but COC user experience more nausea than POP users. It usually does not last more than 24 hours.

Management of nausea: Take the pill with food or at bedtime to reduce nausea. A woman who has previously experienced nausea while using hormonal methods including ECPs could need prophylactic anti-emetic.

Vomiting: Occurs in 20% of women using COCs and 5% of women using POPs as ECPs

Management of vomiting: If vomiting occurs within 2 hours, the dose should be repeated.

Irregular vaginal bleeding or spotting: Some women may experience irregular vaginal bleeding or spotting following ECPs use.  

Management: Inform women that ECPs do not bring menses immediately a common misconception among ECP users. If the menstrual period is delayed for more than two weeks from the expected date, the possibility of pregnancy should be considered and a pregnancy test should be done. If you cannot provide the test, refer to facilities where the service can be provided.

Other problems: Breast tenderness, headache, dizziness and fatigue, do not generally last more than 24 hours.

Management: Aspirin or another non-prescription pain reliever can be used to reduce the discomfort of headaches and breast tenderness.

In many situations, it is important to provide follow-up care, and evaluation after providing ECPs. The following situations represent possibilities for follow-up and referrals:

• If the client reports no menses within 4 weeks of ECP use, she may be pregnant. Counsel client, and the final decision will be made by the client herself.

• A client should be encouraged to return to the health care provider if she has concerns or problems

• Assess STI risk and manage or refer the client as appropriate

• If client has been sexually assaulted or raped, referral to the appropriate facility for the necessary care

Unit II: Pre/Post Test

Choose the Correct Answer Below 

1.   Emergency Contraceptive Pills (ECPs) may be used

a.  Up to 24 hours after unprotected sex

b.  Up to 48 hours after unprotected sex

c.  Up to 72 hours after unprotected sex

d.  Up to one week after unprotected sex

2.   The most common side effect of ECPs is

 a.   nausea

 b.   blurry vision

 c.   weight gain

 d.   none of the above

3.      If using low dose COCPs, the correct formulation for ECPs would be:

 a.  Two pills immediately followed by two pills 12 hours later

 b.  Four pills immediately followed by four pills 12 hours later

 c.  Twenty pills immediately followed by twenty pills 12 hours later

d.      One pill immediately

4.   ECPs are appropriate for use in the following situations

 a.  in cases of contraceptive failure

 b.  in cases of sexual assault

 c. in cases of contraceptive non use

d.      all of the above

5.     Which of the following statements describes the purpose of ECPs?

a.     ECPs are used before unprotected intercourse to avoid unwanted pregnancy

b.     ECPs are used after unprotected intercourse to avoid unwanted pregnancy

6.     What is the interval between doses of ECPs?

a.          6 hours

b.          24 hours

c.          12 hours

d.           48 hours

e.          None of the above

Mark “True" or "False" in the space provided

1____________ECPs cannot cause abortion

2. ___________All clients should undergo full pelvic exams before receiving ECPs

3. ___________ECPs can cause nausea in approximately 20% of the users

4. ___________Only pills containing estrogen and progestin may be used for EC

5. ___________ECPs can be effective when used as a regular contraceptive method

   

1. World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Initiating and Continuing Use of Contraceptive Methods, 2000.

2. Bellagio Conference on Emergency Contraception. 1995. Consensus statement on emergency contraception. Contraception. 1995;52:211-213.

3. Pathfinder International. Emergency Contraceptive Pills (ECPs): Service Delivery Guidelines. February 1996. 

4. Pathfinder International. Comprehensive Family Planning Training Manual. Emergency Contraceptive Pills ( ECPs), April 1996

5. International Planned Parenthood Federation. Statement on Emergency contraception London. IPPF,  2000.

6. Trussel J and C. Ellestron. Efficacy of emergency contraception. Fertility Control Reviews. 1995, 4(2)16-18.

 

Awareness creation in family planning services is crucial because it improves utilization and enables individuals to make informed decisions. In-depth counseling is required to facilitate better understanding and appropriate usage of EC as a back up method.

To equip mid-level health workers with the necessary IEC/BCC knowledge and counseling skills to enable them provide quality family planning services.

By the end of this session, trainees will be able to:

Training/Learning Methodology

Evaluation Methods

Materials for Trainer to prepare in advance

 

Training/learning Methods	Time Required
Begin the session by introducing the learning objectives. Display the learning objectives use a transparency. Discuss each objective and later on administer the pre-test to determine areas needing particular attention.	10 minutes
Introduce the concepts of IEC/BCC using transparencies and flip charts.	20 minutes
Discuss the basic principles of counseling in family planning services with particular emphasis on EC.	20 minutes
Discuss some of the frequently asked questions about ECPs, and summarize the information provided in brief.	15 minutes
Identify three trainees (one supervisor, one client and one provider) for role- pay to demonstrate proper use of client-provider interaction checklist.	20 minutes
Identify two trainees (one supervisor and one provider) for role-play to demonstrate proper use of the provider competency checklist.	10 minutes
Administer post-test	5 minutes

 

IEC/BCC

In Ethiopia, one of the greatest barriers to the use of EC is lack of awareness. This is evidenced by scarcity of information about EC not only among the general population, but also among service providers. Without knowledge EC, clients are unable to make informed, timely and appropriate contraceptive choice. There is a need to develop IEC materials that are targeted to different segments of the population. The intervention modalities of IEC activities include: information sharing through one-to-one communication, group discussion forum, community conversation, and distribution of printed and audio-visual materials through appropriate channels.

COUNSELING ON ECPs

Counseling is an integral and essential part of family planning service delivery. Family planning counseling is a face-to-face communication in which one person helps another to make decisions and act upon them by providing relevant information. Any family planning provider, at any level and any time, can help a client to make these decisions. Counseling on ECPs is no different from counseling on other family planning methods. As it is a relatively new backup method, and most clients do not know much about it, it is important that potential clients are properly informed.

All clients may not need counseling on every method at the time of a contraceptive consultation. Information must be tailored to suit the client’s needs. It is essential that clients are provided information and services (i.e., supply of pills) on this method during counseling on other contraceptive methods. Clients who are interested in learning about other methods when they visit for counseling on ECPs should be given information on these methods as well. Three types of clients need to be educated on ECPs: potential contraceptive users (those who are not using any method of family planning), regular family planning clients, particularly those who use barrier methods, OCPs, DMPA injections and traditional methods, and clients who ask for ECPs.

Potential contraceptive users

It is essential that all potential clients for contraception are informed about the benefits of family planning and provided options for contraceptive methods. While talking about all contraceptive methods, there is a great opportunity for providers to inform clients about ECPs. Non-users of family planning methods should be informed about the methods available for contraception, details about various family planning methods, and the scope of ECPs as a backup support.

Regular Family Planning Clients

Users of barrier methods, DMPA injections and traditional methods must be told:

·        How to use barrier methods, DMPA injections and traditional methods correctly

·        When and how to use ECPs

·        What the side effects of ECPs are and how they are managed

·        What contraceptive options are available after using ECPs

·        What should be done if a woman misses her expected menses more than 7 days after having used ECPs.

Users of oral contraceptive pills must be told in particular:

·        What to do if they miss three pills consecutively

·        When and how ECPs should be used

·        What should be done with the rest of the pills in the packet

·        Why condoms should be used for any further intercourse

·        What should be done if the menstrual cycle is delayed more than 7 days

·        How to resume using oral contraceptive pills regularly once the next menstrual cycle starts

Clients who have asked for ECPs

Five steps should be followed in counseling clients who have requested for ECPs after unprotected intercourse:  1) ask and assess, 2) inform, 3) explain, 4) remind, and 5) return.

Ask and assess:

·         Ask screening questions to assess whether a woman has had unprotected sex within the past 72 hours.

·         If the client visits within 72 hours, she should be informed about the correct use of ECPs, how ECPs work, efficacy and failure, and when ECPs are most effective.

Explain:

·         Clients should be told not to take any extra pill (s) as this will not make them work better, and may result in more side-effects.

·         Many clients mistakenly believe that ECPs result in immediate menstruation.

·         Clients should be told that ECPs do not result in immediate menses but will come at the expected time or few days earlier or later.

Remind:

• Clients should be reminded about the side effects of ECPs and how this should be managed.

• If the client is counseled before she takes the pills, she will find it easier to cope with the side effects.

• Clients need to be told and reminded that ECPs are not 100 percent effective, and can result in failure.

• Clients also should be reminded that ECPs should be used only in emergencies and not as a regular method of contraception, as they are not effective as regular contraceptives.

• Clients should also be reminded that ECPs have a higher failure rate and more side-effects than regular contraceptives.

Return

• Although users of ECPs do not require routine follow up, clients should be asked to come back to the clinic if their menses is delayed by more than a week, or if the menses is to light in terms of color.

• Clients who would like to discuss ECPs in detail, or would like to talk about future contraception, or have any other concern, should also be asked to come back.

• It is crucial that the client should not rely totally on ECPs for their contraceptive needs. Service providers should try and encourage the client to return to a regular method or to her previous method rather than continue to use ECPs.

In the provision of ECPs there are frequently asked questions that merit appropriate responses. In this conversation, issues of safety, method failure, frequency of use, the time interval to switch to regular family planning methods, associated risks, etc. should be well addressed. Unit II of this curriculum addresses in detail the above-mentioned concerns and issues to which the trainer should pay special attention.

A client provider interaction checklist (Annex 3) should be used to help whether this Unit is well understood by trainees. Moreover, in order to assess provider competency and knowledge base, the trainer can use a checklist designed for the purpose (Annex 4).

Choose the Correct Answer Below (More than One Correct Answer is Possible)

1.     Which of the following women are eligible for ECP use?

a.      Potential contraceptive users

b.      Regular family planning clients

c.      Clients who have asked for ECPs

d.      Post-menopausal women

2.     What should a family planning counselor tell a client about ECP use?

a.        Different EC methods available

b.        How EC methods are used

c.        When EC is used

d.        Side effects of EC methods

 Mark “True” or False in the space provided

___________   1. Counseling is important to provide EC services. 

___________   2.  Special skills are needed to provide EC services.

___________   3. Counseling on all contraceptive methods should focus on the client's need.

___________  4.  EC is a well-known practice in Ethiopia.

___________  5.  Regular family planning users may still need EC.

___________  6.  There is no need to talk about side effects of ECPs because they are used only for a brief period.

___________  7.  EC can be followed by regular family planning methods

___________  8. EC services should be given to all women who ask for it without any screening questions.

___________  9.  It is important for counselors to help clients understand the mechanism of action of ECPs.

___________10. Increasing the recommended dose of ECPs changes the effectiveness of ECPs.

___________ 11. Taking ECPs result in immediate menstrual bleeding.

___________ 12. ECP users do need follow up care.

 

ECPs: A Training Manual. Directorate of Family Planning, Ministry of Health and Family Welfare, Bangladesh, and the Population Council. Bangladesh. May 2003.

Contraceptive Technology Update. 1998. Emergency Contraceptive Pills. Family Health International.

 

ECPs can be provided safely and effectively by a variety of trained personnel. To ensure that quality ECPs services are provided, providers should follow clear service delivery guidelines.

 

At the end of this session, trainees would be able to:

Training/Learning Methodology

Evaluation Methods

Materials for Trainer to prepare in advance

 

 

Training/learning Methods	Time Required
Introduce the idea of ECP management of services.	10 minutes
Discuss the need for appropriately trained ECPs service providers.	10 minutes
Explain the ECPs supply management relationship.	15 minutes
Give a definition for M & E, and discuss some M & E indicators for EC services.	15 minutes
Describe the monitoring and evaluation mechanism as well as supportive supervision in ECPs services.	15 minutes

 

In order to run an effective EC program, there is a need to deploy a well-trained provider, ensure an adequate supply of contraceptive commodities, and establish an effective monitoring and evaluation mechanism that is coupled with a facilitative supervision.

Human resources for EC services

ECPs can be distributed safely by a variety of trained personnel and through clinical and non-clinical service delivery systems.  Doctors, nurses, midwives, pharmacists, and other clinically trained personnel and as well as community health workers and health extension workers can provide ECPs. All ECP providers should receive adequate training to ensure provision of quality EC services and receive regular and supportive supervision

Ensure continuous supply of EC commodities

In order to assure a continuous supply of EC commodities the following activities need to be undertaken:

1. keep appropriate records throughout the system for ECP

2. periodically crosscheck commodity data against service statistics

3. design ECP procurement plans to take into account the stock level, rate of use, and other administrative issues that affect speed of procurement

4. secure storage capacity large enough to meet current needs and those in the foreseeable future.

5. conduct inventories of storage sites at least once a year

Staff should have adequate logistics management skills to perform their jobs.  They should also be prepared to see incoming clients in order to serve women requiring immediate care, as pills must be taken as soon as possible- and no later than 72 hours- after unprotected sexual intercourse or rape.

As an important element of providing quality EC services, clinics must ensure that sufficient EC supplies are present and that comprehensive written instructions are available to the client.

Establish good monitoring and evaluation system

Definition of M & E: Monitoring is a continuous process used to determine the extent to which an intervention or a project has been implemented at different levels, in time and at what cost. Its main purpose is to improve efficiency, adjust work plan, and keep track of the essential activities that lead to the achievement of the pre-set objectives.

Evaluation is a collection of activities designed to determine the value or worth of a specific program, intervention or project, i.e., to link a particular output or outcome directly to a particular intervention. It also entails detailed analysis of the effectiveness of the program by calculating the extent to which the pre-set objectives and targets are achieved.

The following are some M & E for EC services:

·        Number of providers trained in EC

·        Number of EC users in a month/year by age, place of residence, marital status, etc.

·        Number of EC users by type (family planning users, non-users, etc.

·        Available IEC materials

·        IEC sessions on EC

·        Number/percent who become regular family planning users

·        ECPs available in the institution by number, type, etc.

·        Clients coming back for follow-up with side effects

·        Clients referred

The EC program needs to be continuously monitored using returns from service statistics. Reporting should be done using Ministry of Health reporting formats for MCH activities. Ensure completeness of record keeping so that appropriate usage of data and timely decision-making is facilitated.

Undertake supportive and facilitative supervision

Facilitative supervision is part of an objective and systematic process of evaluating the quality of a particular program, particularly using a quality of care framework.  The EC program needs to be checked with respect to the following 6 elements of a quality family planning program. These are: 

• Choice of methods

• Information given to clients

• Client provider interaction

• Competence of providers

• Continuity of care and

• Appropriate constellation of services

Sources of information needed to assess EC programs

• Clinical records

• Interview with clients

• Client-provider interaction check list

• Meetings with staff members

 

 

 

	Question Number	Multiple Choice	True or False
Unit II	1.	C	True
	2.	A	False
	3.	B	True
	4.	D	False
	5.	B	False
	6.	C
	7	-
Unit III	1.		True
	2.		True
	3.		True
	4.		False
	5.		True
	6.		False
	7		True
	8.		False
	9.		True
	10.		False
	11.		False
	12		True

 

 

1.  Do you want to prevent pregnancy?	Yes	No
2.   Have you had unprotected sex during the last 3 days (72 hours)?       If “Yes” then client may be eligible for ECPs.	Yes	No
3.   Was the last menstrual period less than 4 weeks ago?	Yes	No
4.  Was this period normal in both its length and timing?       If “Yes” to the previous two questions, ECPs may be provided.	Yes	No
5.   Is there reason to believe you may be pregnant?	Yes	No
NB: If the client is not pregnant ECPs may be given. If the client’s pregnancy status is unclear ECPs may still be given with the explanation that the method will not work if she is already pregnant and will not harm the fetus.

 

 

Did the Provider:		Yes	No
1. Greet the client in a friendly, respectful and helpful way?
2. Ask the clients why she has come to the clinic or what makes her think that she needs ECPs. Ensured confidentiality?
3. Take a brief medical history, which includes information on dates of unprotected intercourse and last menstrual period?
4. Tell the client about ECP?	When and how to use?
	How it works?
	Effectiveness?
	Possible side-effects and management?
5. Allow the client to ask questions?
6. Explain how to manage possible side effects?	Nausea and vomiting? ·         Remind client that nausea/vomiting may occur? ·         Suggest taking pill(s) after having some food? ·         Advise client to repeat the dose if it is vomited within two hours?
	Irregular bleeding or spotting? ·         Inform that it may occur? ·         This is a common side effect? ·         Assure that it should not last long?
7. Tell the client that her menstrual period may be a few days early or late, but most likely will be on time?
8. Remind the client that ECPs are not suitable as a regular method of contraception. Ask client to come back if she would like to discuss about other methods she can use in the future?
9. Explain method failure cases how to come back to the regular methods or method she used?
10. Demonstrate a non-judgmental attitude and respect for client throughout ECP service provision?
11. Ask the client to summarize the instructions or take feedback?

 

The following checklist can be used to rate provider competency.  The questionnaire is to be administered verbally, and correct answers are indicated by bold type.

 

Knowledge Questions on ECP
1a. If a woman has unprotected intercourse, what is the chance of her getting pregnant? Everybody has equal chance of getting pregnancy after an unprotected intercourse               Do not know                       Give incorrect answer 1b. Are you communicating EC to every family planning client?       Yes        No
2. You have been trained and provided ECP. Could you please tell me when you give ECP to a woman what do you say/advice?
a. When (in what situations) can ECP be used?	b. Time limit within which 1st dose must be taken?	c. Number of dose?	d. Number of pills in each dose?	e. Interval between doses?
1   Intercourse without using any FP method 2   Failure to take OCPs for more than 3 days 3   Being late for a contraceptive injection 4   Failed coitus interruptus 5   Miscalculation of the infertile period 6   Condom burst or slip 7   Do not know 8   Gave an incorrect answer	Within 72 hours of unprotected intercourse   Do not know Give an incorrect      answer	2 doses   Do not know   Gave an incorrect answer	1 tablet         Gave an incorrect answer	1 tablet         Gave an incorrect answer
3.  A woman who is using pill misses 2 consecutive days, what should she do? Take two pills when remember, two pills on the next day, then rest pills 1 pill everyday and use condom        Do not know                                  Gave an incorrect answer
4.  A woman who is using pill misses 3 consecutive days, what she should do?      Leave pills as menses could start and use condom until next menses      If period does not come, use ECP, continue 1 pill daily after ECP treatment and use      condom until next menses        Do not know           Gave an incorrect answer
5.  Whose condom has burst or slipped?      Use ECP, continue condom again and use condom from the next cycle       Do not know                                   Gave an incorrect answer
6.   Who has forgot to take due injection?       Use ECP, use condom until next menses and get injection from the next cycle       Do not know                                  Gave an incorrect answer
7.   A woman who has requested for ECP, what should be asked to her?       Date of last menstrual period        Length of women's normal menstrual cycle          Timing of all unprotected intercourse during current cycle         Number of hours since the 1st unprotected intercourse during current cycle        Number of hours since the 1st since the 1st unprotected sex        Do not know          Gave an incorrect answer

Please take a few moments to evaluate this training course so that we can improve future sessions.

Rate each of the following statements as to whether or not you agree with them, using the following key:

5          Strongly agree

4          Somewhat agree

3          Neither agree or disagree

2          Somewhat disagree

1          Strongly disagree

I.          COURSE MATERIAL

1.         The Learning objectives were clearly defined                                 5   4   3   2   1

2.         The training material was clear and well organized                        5   4   3   2   1

3.         The pre/post tests accurately assessed my in-course learning 5   4   3   2   1

4.         New topics that should be included are:

            ____________________________________________________________

5.         Topics that should be excluded are:

            ____________________________________________________________

II.         TRAINING METHODOLOGY

1.         Trainer's presentations were clear and organized                          5   4   3   2   1

2.         Discussions contributed to my learning                                            5   4   3   2   1

3.         Learning models contributed to learning/improving knowledge 5   4   3   2   1

4.         Required reading/references were useful                            5   4   3   2   1

5.         The trainers encouraged my questions and input               5    4   3   2  1

III.        TECHNICAL INFORMATION

1.         What new information did you acquire?

            ____________________________________________________________

2.         What new knowledge did you learn?

            ____________________________________________________________

IV.       ANY OTHER SUGGESTION OR COMMENTS

            ____________________________________________________________

 

TIME	TOPICS
	UNIT I	UNIT II	UNIT III	UNIT IV
9:00-10:30
10:30-11:00                                      TEA       BREAK
11:00-12:30
12:30-1:30                                       LUNCH     BREAK
1:30-3:00
3:00-4:00                                          TEA        BREAK
4:00-5:00