Sexual and reproductive health and family planning in primary care

Most people who come for contraception can leave the same day with a method they chose. Your job is to give accurate, unbiased information, check that the method is safe for her (lesson 2), and start it now if she wants. The client decides; you do not choose for her.

Rights you protect in every consultation

• No discrimination: welcome every client, married or not, of any age, with or without children, with or without disability or HIV.
• No one else's permission: do not ask for a husband's, partner's or parent's consent to provide a method.
• Full information: know the methods your facility can provide, do not hold back information, and do not rule out a method because of your own opinion.
• Privacy and confidentiality: counsel where you cannot be seen or overheard, and keep records confidential.
• Quality: keep your skills up to date and help keep supplies in stock.

A simple counselling sequence

1. Ask what she wants: a child soon, later, or no more children? Does she have a method in mind?
2. Ask what matters to her: not having to remember, privacy from partner or family, bleeding changes, quick return of fertility, protection from STIs.
3. Ask about health and medicines that affect eligibility (lesson 2), and about STI and HIV risk (lesson 7).
4. Present the methods that suit her, most effective first, with the main side effects, especially bleeding changes.
5. Check her understanding, give the method, explain what to do if something goes wrong, and agree when to return.

Can she start today? The pregnancy checklist

You can be reasonably sure a woman is not pregnant if she has no signs of pregnancy and answers YES to any one of these:

1. Did your last monthly bleeding start within the past 7 days? (12 days if she wants a copper IUD.)
2. Have you had no sex since your last monthly bleeding, delivery, abortion or miscarriage?
3. Have you used a reliable method consistently and correctly since then?
4. Did you have a baby in the last 4 weeks?
5. Did you have a baby less than 6 months ago, are you fully or nearly fully breastfeeding, and have you had no monthly bleeding since?
6. Have you had a miscarriage or abortion in the past 7 days? (12 days for a copper IUD.)

If she answers NO to all six, pregnancy cannot be ruled out with the checklist: use a pregnancy test, or give condoms and ask her to come back. Do not send her away to wait for her period when the checklist or a test makes you reasonably sure.

There are several good methods. Some last for years and you don't need to remember anything. Others you take or use yourself. Tell me what matters most to you, and I will help you choose.

Source: WHO and Johns Hopkins CCP. Family Planning: A Global Handbook for Providers, 2022 edition (human rights principles; Appendix A; pregnancy checklist job aid).

WHO publishes two linked guidelines. The Medical eligibility criteria for contraceptive use (MEC) says who can safely use which method. The Selected practice recommendations (SPR) says how to use each method. Both were updated in 2025 (MEC sixth edition, SPR fourth edition). Most categories did not change from 2015; the main changes concern breastfeeding, HIV and PrEP.

What you need to check

• For pills, injectables and implants: a history (questions about the conditions below) and, where possible, a blood pressure. No pelvic examination or blood test is needed.
• For an IUD: a history and a pelvic examination (to assess the uterus and look for cervicitis).
• In settings where pregnancy carries high risk and few methods are available, WHO advises that women should not be refused hormonal methods simply because blood pressure cannot be measured.

Common conditions: combined methods versus progestogen-only methods

Conditions that stop you inserting an IUD today

• Current pelvic inflammatory disease (PID), or current purulent cervicitis, chlamydia or gonorrhoea: category 4 to start. Treat first. If PID develops in a woman who already has an IUD, treat it; the IUD usually does not need to come out.
• Unexplained vaginal bleeding that could mean a serious condition, before it is assessed; cervical cancer awaiting treatment: category 4 to start.
• Puerperal sepsis: category 4. Between 48 hours and 4 weeks after birth: category 3 (wait until 4 weeks).
• Severe or advanced HIV disease (WHO stage 3 or 4): category 3 to start; category 2 to continue.

HIV, ART and PrEP (MEC 2025)

• Women at high risk of HIV can use all methods, including progestogen-only injectables and IUDs (category 1). Encourage condoms as well.
• Oral PrEP, the dapivirine ring and injectable cabotegravir do not limit any contraceptive method (category 1).
• Efavirenz may make implants and combined methods less effective (category 2). DMPA is not affected (category 1). Offer condoms in addition, or another method.

Source: WHO. Medical eligibility criteria for contraceptive use, sixth edition, and executive summary, 2025. WHO. Medical eligibility criteria for contraceptive use, fifth edition, 2015. Global Handbook (2022), Appendix D.

Short-acting methods depend on the user: taking a pill every day, returning on time for an injection, or using a condom every time. Clear instructions and a plan for mistakes make them work better.

When to start and when a backup method is needed

Combined pills

• About 7 pregnancies per 100 women in a year as commonly used; fewer than 1 when no pills are missed.
• Common early effects: irregular bleeding, headache, nausea, breast tenderness. These usually settle within a few months.
• Fertility returns without delay when she stops.

Progestogen-only injectables

• About 4 pregnancies per 100 women in a year as commonly used; fewer than 1 when injections are on time.
• A DMPA injection can be given up to 4 weeks late, and NET-EN up to 2 weeks late, with no test or backup needed. Either can be given up to 2 weeks early. Tell her to come back however late she is.
• Subcutaneous DMPA can be self-injected. Offer to teach her and give doses to take home where your programme allows.
• Bleeding is irregular at first and often stops altogether: this is not harmful. Average weight gain is 1 to 2 kg a year.
• Fertility returns more slowly: on average about 4 months longer after DMPA (1 month after NET-EN) than after other methods. Mention this if she wants a pregnancy soon after stopping.

Condoms and dual protection

• Male condoms: about 13 pregnancies per 100 women a year as commonly used, 2 with correct use every time.
• Used consistently and correctly, condoms prevent 80% to 95% of the HIV transmission that would otherwise occur, and protect against other STIs.
• Dual protection means protection from both pregnancy and STIs: a condom every time, or a condom with another method. Give condoms to anyone with STI risk, whatever their main method.

If you miss pills, take one as soon as you remember. If you miss three or more, take one, use condoms for seven days, and come to the clinic if you had sex in the last five days.

Source: Global Handbook (2022), chapters 1, 2, 4 and 13. WHO. Selected practice recommendations for contraceptive use, fourth edition, 2025.

Implants and IUDs are the most effective reversible methods: fewer than 1 pregnancy per 100 women in a year. Once in place, the user has nothing to remember. Fertility returns without delay after removal. WHO recommends that nurses and midwives insert and remove both, and that auxiliary nurses and auxiliary nurse midwives insert and remove implants, with targeted monitoring.

When to insert

• Implant: any time she is reasonably sure not to be pregnant. Within 7 days of the start of bleeding: no backup; later: backup for 7 days. Breastfeeding women can have one inserted any time after birth.
• Copper IUD: within 12 days of the start of bleeding (no backup needed, ever). After birth: within 48 hours, otherwise wait until 4 weeks. After a first- or second-trimester abortion: at the same visit, unless the abortion was septic.
• Levonorgestrel IUD: within 7 days of the start of bleeding without backup; later, backup for 7 days.

Before an IUD

• Ask about STI symptoms and risk, and do a speculum and bimanual examination. Do not insert if there is current PID, purulent cervicitis, chlamydia or gonorrhoea (lesson 2). Treat using the STI syndromic protocol and insert when treated, offering another method meanwhile.
• Follow strict infection prevention: a no-touch technique with high-level disinfected or sterile instruments.
• Pain relief (SPR 2025): where available, an NSAID, a paracervical block or topical lidocaine may be offered routinely. Do not withhold an IUD because these are not available.

Medicines that interact

Efavirenz may make implants less effective, roughly as effective as pills as commonly used. Women on efavirenz can still choose an implant, with condoms as well, or choose DMPA or an IUD, which are not affected.

Source: Global Handbook (2022), chapters 9 to 11. WHO. Selected practice recommendations for contraceptive use, fourth edition, 2025. WHO. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (OptimizeMNH), 2012.

Emergency contraception (EC) prevents pregnancy after unprotected sex, contraceptive failure (a torn condom, missed pills, a late injection) or sexual violence. It does not cause abortion, does not harm an existing pregnancy and does not affect future fertility. There is no medical condition that makes emergency contraceptive pills unsafe, and they can be used more than once in a cycle.

• No tests or examinations are needed before EC pills, except that a woman whose last period is late should have a pregnancy test before UPA.
• Vomiting within 2 hours of LNG or combined pills, or within 3 hours of UPA: take another dose as soon as possible.
• Routine anti-nausea medicine is not needed with LNG or UPA.
• Give an advance supply where allowed, especially to young women and users of pills and condoms. It does not increase risky sex and means EC is taken sooner.

Starting ongoing contraception afterwards

Source: WHO. Selected practice recommendations for contraceptive use, fourth edition, 2025, section 5.5. Global Handbook (2022), chapter 3. WHO MEC, sixth edition, 2025.

Women often leave care after birth or abortion without a method, and fertility can return before they expect it. Discuss contraception during pregnancy, at birth and at every postnatal contact (day 3, days 7 to 14 and week 6; see the postnatal care protocol). Advise waiting at least 2 years after a birth, and at least 6 months after a miscarriage, before trying for another pregnancy.

Earliest start after childbirth

The lactational amenorrhoea method

LAM is effective (about 2 pregnancies per 100 women in 6 months as commonly used) only while all three conditions are met:

1. Her monthly bleeding has not returned.
2. The baby is fully or nearly fully breastfed, often, day and night.
3. The baby is less than 6 months old.

As soon as any one condition stops, she needs another method. Plan the next method at the start.

After abortion or miscarriage

• Ovulation can return as early as 8 to 10 days after an abortion or miscarriage, and usually within a month. Offer counselling and a method before she leaves.
• Almost all methods can start immediately after a first- or second-trimester abortion, including implants, injectables and pills. After medical abortion, hormonal methods can start with the first pill of the regimen.
• An IUD can be inserted once the abortion is complete, but not after a septic abortion. After a second-trimester abortion it needs a specially trained provider and has a higher risk of expulsion.
• Sterilisation must be decided in advance, never while she is in pain, sedated or under stress.
• Pill users can be given up to a year's supply. Offer self-injection of DMPA as an option.
• Ask privately about sexual violence and STI risk.

Source: Global Handbook (2022), chapters 20, 24 and 25. WHO MEC sixth edition, 2025. WHO recommendations on maternal and newborn care for a positive postnatal experience, 2022.

Every contraception visit is also an STI and HIV prevention visit. Ask about partners and symptoms in private, offer HIV and syphilis testing, treat STIs syndromically where there is no laboratory (see the STI syndromic care protocol), and link anyone who tests HIV-positive to treatment the same day where possible (see HIV: testing and starting ART).

Who needs extra prevention

• Anyone with an STI now or recently, a partner with HIV who is not virally suppressed or of unknown status, several or new partners, transactional or sex work, men who have sex with men, transgender people, and people who inject drugs.
• WHO first defined substantial risk as a setting with HIV incidence above 3 per 100 person-years, but individual risk matters more than group. Anyone who asks for PrEP is likely to be at risk and should be offered it.

PrEP options recommended by WHO

• PrEP prevents HIV only. It does not prevent pregnancy or other STIs: add contraception and condoms.
• PrEP and hormonal contraception do not interact: every method is MEC category 1 with PrEP (2025).

Contraception for women with HIV

Women with HIV can use almost every method. Those with WHO stage 3 or 4 disease should not start an IUD until they are well on treatment (category 3). Check for interactions with efavirenz (lesson 4). Offer pregnancy planning: on effective ART with a suppressed viral load, the risk of passing HIV to a partner or baby is very low.

PrEP is a tablet, ring or injection that stops you getting HIV if you are exposed. It does not stop pregnancy or other infections, so we will also talk about condoms and contraception.

Source: WHO. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring, 2021. WHO. Guidelines on long-acting injectable cabotegravir for HIV prevention, 2022. WHO. Guidelines for HIV post-exposure prophylaxis, 2024. WHO recommendation on injectable lenacapavir for HIV prevention, 2025. WHO MEC sixth edition, 2025. Global Handbook (2022), chapters 22 and 23.

Adolescents

Young people may come for contraception, for advice about their bodies and relationships, after unprotected sex, or with an STI. Some are married and some already have children. Criticism keeps them away; services do not encourage sex, they protect health.

• Do not require a parent's or guardian's permission to provide contraception. Counsel privately and assure confidentiality, within your national law on child protection.
• Age alone is not a medical reason to refuse any method. MEC classes DMPA under 18 years and IUDs under 20 years as category 2 (generally use).
• Implants and IUDs suit many young women: very effective, private and nothing to remember. IUDs are more likely to come out in women who have not given birth.
• Give emergency contraceptive pills in advance, and condoms for dual protection. Practise condom use and how to say no to unwanted or unprotected sex.
• Ask, privately and gently, whether sex is wanted. Young age, an older partner or signs of coercion or abuse need safeguarding action according to national law.

Infertility: what it is

• Infertility is failure to achieve a pregnancy after 12 months or more of regular unprotected sex. About 85% of women would be pregnant by then.
• It is common. Secondary infertility (after a previous pregnancy) is more common than primary infertility in many settings.
• The cause can be in the man, the woman or both. In more than 40% of couples with fertility problems a male factor contributes, and in about 20% both partners have a cause.
• Infertility can bring stigma, divorce, violence and depression, especially for women. Ask about mood and safety.

First steps in primary care

1. See both partners, together if possible. Explain that a man is just as likely as a woman to have a fertility problem.
2. History: how long trying, menstrual pattern, previous pregnancies, abortions or deliveries with infection, STI or pelvic pain, TB, mumps after puberty in the man, surgery, cancer treatment, medicines, smoking, alcohol, weight.
3. Treat what you find: STIs in both partners, and support stopping smoking and reaching a healthy weight.
4. Teach the fertile window: the most fertile days are the few days before and at ovulation. Fertility awareness methods can help couples find them.
5. Reassure that past contraception does not cause infertility (DMPA can delay return of fertility by several months).

Prevention is primary care's main job

Untreated gonorrhoea and chlamydia can block the fallopian tubes and the male ducts, often without symptoms. Prompt STI treatment with partner treatment, infection prevention during IUD insertion and other procedures, and good care of postpartum and post-abortion infections all prevent infertility. WHO's first global infertility guideline (2025) also calls for fertility education in primary care and for psychosocial support throughout care.

Source: Global Handbook (2022), chapters 21 and 25. WHO MEC sixth edition, 2025. WHO. Guideline for the prevention, diagnosis and treatment of infertility, 2025.

Answer all 15 questions, then press Mark. You need 12 or more to pass. You can look back at the lessons: the aim is learning. A pass gives a printable certificate of completion for 5 hours of self-directed learning; you need a free account, signed in, to issue it.