Protocol · WHO MEC and Family Planning Handbook
Contraception: choosing and starting a method
Most people can safely use most methods. The job at first-level care is to help the client choose, check the few conditions that make a method unsafe, be reasonably sure she is not pregnant, and start the method on the same visit. Delaying the start until her next period is the worst option: she may become pregnant in the meantime.
- Based on WHO MEC and Family Planning Handbook
- For doctors, clinical officers, nurses, midwives and community health workers
- Reviewed October 2026
1Who / when
- Anyone, including adolescents, who wants to delay, space or limit pregnancy. Offer it at every contact: postnatal care, after abortion or miscarriage, HIV and TB clinics, NCD clinics.
- Women whose health would be at high risk in pregnancy need it most: for example blood pressure 160/100 or higher, complicated valvular heart disease, sickle cell disease, epilepsy, diabetes with complications, HIV, TB, or breast cancer.
Dual protectionCondoms are the only method that also protects against HIV and STIs. Offer them alongside any other method when there is a risk of infection.
2Red flags: refer now
- Signs of pregnancy complications: heavy bleeding, severe lower abdominal pain, or fainting (think ectopic pregnancy).
- Sexual assault: give emergency contraception now and follow your post-rape care protocol (HIV PEP, STI care, support).
- In a method user: sudden severe chest pain or breathlessness, a painful swollen leg, sudden severe headache, weakness or loss of vision (stop combined methods and refer the same day).
3Assess
Ask, then examine only what is needed
- Her goals: how soon she may want a child, breastfeeding, partner, and her own preferences. The choice is hers.
- Medical history for the MEC: blood pressure, smoking and age, migraine with aura, past blood clot, heart or liver disease, diabetes complications, breast cancer, medicines (rifampicin, some anticonvulsants).
- Measure blood pressure before combined methods. A pelvic examination is needed only before an IUD.
Rule out pregnancy
WHO pregnancy checklist: she is reasonably certain not to be pregnant if any one of these is true:
- Gave birth less than 6 months ago, fully or nearly fully breastfeeding and no period since; or
- Has not had sex since her last normal period; or
- Has used a reliable method consistently and correctly; or
- Started her period within the last 7 days (12 days if starting a copper IUD); or
- Gave birth in the last 4 weeks; or had a miscarriage or abortion in the last 7 days (12 days for a copper IUD).
Use the WHO pregnancy checklist first; a pregnancy test does not work before the first missed period. All hormonal methods except the LNG-IUD can be started even when pregnancy cannot yet be ruled out (follow up with a test in 3 to 4 weeks). Do not insert an IUD unless pregnancy is ruled out.
4Classify
| MEC category | Meaning | Action |
|---|---|---|
| 1 | No restriction | Provide |
| 2 | Benefits generally outweigh risks | Provide, with follow-up |
| 3 | Risks usually outweigh benefits | Usually choose another method; use only with clinical judgement and close follow-up |
| 4 | Unacceptable health risk | Do not use this method |
| Condition | Combined pill, patch, ring | Progestogen-only pill, implant | DMPA | Copper IUD |
|---|---|---|---|---|
| BP 160/100 or higher | 4 | 2 | 3 | 1 |
| BP 140 to 159 / 90 to 99 | 3 | 1 | 2 | 1 |
| Age 35 or over, smokes 15 or more a day | 4 | 1 | 1 | 1 |
| Migraine with aura (any age) | 4 | 2 | 2 | 1 |
| Past or current DVT or PE | 4 | 2 | 2 (acute: 3) | 1 |
| Breastfeeding, under 6 weeks after birth | 4 | 2 | 2 | Within 48 h or from 4 weeks |
| Breastfeeding, 6 weeks to 6 months | 3 | 1 | 1 | 1 |
| Rifampicin treatment | 3 | POP 3; implant 2 | 1 | 1 |
5Treat
| Method | When to start (periods regular) | Backup needed |
|---|---|---|
| Combined pill | Within 5 days of period start: no backup. Any other time if not pregnant | 7 days if started after day 5 |
| Progestogen-only pill | Within 5 days: no backup. Any other time if not pregnant | 2 days if started after day 5 |
| DMPA injection (150 mg every 3 months) | Within 7 days: no backup. Any other time if not pregnant | 7 days if started after day 7 |
| Implant (LNG 5 years, ETG 3 years) | Within 7 days: no backup. Any other time if not pregnant | 7 days if inserted after day 7 |
| Copper IUD (up to 12 years) | Within 12 days of period start, or any time if pregnancy is ruled out | None |
Common problems
- Missed combined pills: take one as soon as possible and carry on. Missed 3 or more (or a new pack started 3 or more days late): also use a backup for 7 days and consider emergency pills if she had sex in the last 5 days; if in the third week, skip the inactive pills and start the next pack.
- Late DMPA: she can have the injection up to 4 weeks late with no extra steps. Later than that: give it if reasonably certain she is not pregnant, with backup for 7 days.
- After childbirth: progestogen-only pills and implants any time; copper IUD within 48 hours or from 4 weeks; combined methods not before 6 months if breastfeeding (not before 21 days if not breastfeeding).
Emergency contraceptionLevonorgestrel 1.5 mg as a single dose, or a copper IUD, within 5 days of unprotected sex. The sooner, the better. Ulipristal 30 mg is an alternative. Then start or restart a regular method.
6Follow-up
- Invite her back at any time with problems or if she wants to change method; no routine visit is needed for most methods.
- DMPA: book the next injection at 3 months (13 weeks). Give a full year of pills where supply allows.
- IUD: check after the first period or 3 to 6 weeks after insertion, and teach her to check the strings.
- Recheck BP in combined method users when you see them.
7Counsel
- Effectiveness: implants and IUDs fail in less than 1 in 100 women a year; injections about 4 and pills about 7 in 100 as commonly used, because doses are missed.
- Bleeding changes are common with progestogen-only methods and are not harmful.
- Fertility returns quickly after stopping most methods; after DMPA it may take several months longer.
- Weight gain of 1 to 2 kg a year is common with DMPA.
You can choose the method that suits you. If you have problems or want to change, come back at any time; we will help you switch without a gap.
8When to refer
- Same day: any red flag above, or suspected pregnancy complication.
- A medical condition where every suitable method is MEC 3 or 4, or you are unsure of the category.
- IUD or implant wanted but no trained provider; difficult implant removal or missing IUD strings.
- Request for female sterilisation or vasectomy.
9Sources
- World Health Organization. Medical eligibility criteria for contraceptive use, sixth edition. 2025 (ISBN 9789240115583). MEC categories and the condition rows in the table.
- World Health Organization and Johns Hopkins Bloomberg School of Public Health. Family planning: a global handbook for providers, 4th edition (2022 update). 2022. When to start, backup days, missed pills, late injections, postpartum timing, effectiveness, emergency contraception and the pregnancy checklist.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.