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CM10.6-7 | CM10.6-7 | Family Planning and Family Welfare Programme — SDL Guide (Part 3)
Counselling for Family Planning and Applying Method Choice
Effective family planning counselling is the mechanism by which a client moves from vague reproductive intent to an active, informed choice. The GATHER framework — Greet, Ask, Tell, Help, Explain, Return — provides the operational structure. In family planning, the critical GATHER steps are: Ask (elicit the client's reproductive intentions, current method if any, previous method experience including side effects or expulsion, partner's attitude, medical history for contraindication screening) and Tell (present all suitable methods with honest information on effectiveness, side effects, non-contraceptive benefits, and contraindications — not a single recommended method, but a range). WHO Medical Eligibility Criteria (WHO MEC) provides the contraindication framework: Category 1 = no restriction; Category 2 = benefits generally outweigh risks; Category 3 = risks generally outweigh advantages (use only when no alternative); Category 4 = absolute contraindication (do not use). For the PPIUCD candidate in the hook scenario: the woman is breastfeeding (WHO MEC 1 for IUCD postpartum), has a previous IUCD expulsion history (explore: was it postpartum or interval? interval expulsion is less predictive of postpartum expulsion risk), and wants 3 years of spacing — PPIUCD is the strongest match if she is still within 48 hours, with careful counselling that postpartum insertion has a different expulsion pattern than interval. If she declines IUCD, DMPA is WHO MEC 2 while breastfeeding (progestogen-only, no milk suppression) and provides 3-month coverage with high effectiveness. The male condom (her husband's preference for non-hormonal methods) is a valid backup but requires consistent use and provides no LARC-level assurance. The counselling ends with a clear follow-up plan: date for next injectable dose, or 6-week IUCD check, or return if any problem.
SELF-CHECK
A 35-year-old woman who smokes 20 cigarettes a day asks for the combined oral contraceptive pill for spacing. She has no history of thrombosis and her BP is 130/82 mmHg. What is the correct WHO MEC classification for COC use in her case?
A. WHO MEC Category 1 — no restriction; smoking is not a contraindication to COC
B. WHO MEC Category 2 — advantages outweigh risks; she can use COC with monitoring
C. WHO MEC Category 4 — absolute contraindication; COC is never appropriate for a smoker
D. WHO MEC Category 4 — the combination of age ≥35 and smoking ≥15 cigarettes/day is an absolute contraindication to COC
Reveal Answer
Answer: D. WHO MEC Category 4 — the combination of age ≥35 and smoking ≥15 cigarettes/day is an absolute contraindication to COC
WHO MEC Category 4 (absolute contraindication): combined oral contraceptive use in a woman aged ≥35 years who smokes ≥15 cigarettes per day. This combination carries significantly elevated risk of arterial thromboembolism (myocardial infarction, stroke) because estrogen potentiates the prothrombotic effects of smoking, and the risk increases sharply after age 35. Category 4 means the COC should not be prescribed regardless of other factors. The appropriate alternative for this woman is a progestogen-only method (POP, DMPA) or a non-hormonal method (IUCD, condom). Note: smoking in women under 35 is WHO MEC 2 for COC (advantages generally outweigh risks).