More than 106 million women worldwide take "the pill" to prevent pregnancy. Pills containing a combination of the hormones estrogen and progestin have an annual failure rate of less than 1% if taken perfectly, that is, one pill each and every day without interruption. However, life is not perfect and pill users are no exception. Typical failure rates among pill users are as high as 12% to 20% in some surveys. The importance of helping women take the pill correctly is clear. Reducing the number of oral contraceptive (OC) failures by only 1% would mean about a million fewer accidental pregnancies each year.
Correct and consistent use is essential to the effectiveness of oral contraceptives. Incorrect OC use (often called "poor compliance") is not always due to a woman's conscious decision to skip pills or forgetfulness. It may be due to confusing, incorrect, or incomplete information about how to take the pill, or how to handle missed pills. It may be due to a desire to reduce side effects, lack of supplies, or the belief that it is not necessary to take OCs if no intercourse is anticipated for a week or two.
The four most common pill-taking errors are:
starting a pack late, without using a back-up contraceptive method;
taking the pills in the wrong order, out of sequence;
interrupting use for any reason;
not using additional, back-up contraception when two or more pills are missed.
Increasing the Likelihood of Correct Use
Appropriate counseling and education are crucial to correct and continued use, especially for women just beginning to use OCs. Women need to know how OCs work, how to take them correctly, what to do in case of missed pills, warning signs for complications, and common side effects and how to manage them.
Stressing the safety of OCs and their protective effects against anemia and endometrial and ovarian cancer is also important to reassure women who may believe OCs are dangerous.
Service providers can take these steps to encourage effective use of pills:
Ensure that providers have accurate, understandable information about the pill. This is essential for correct OC use. Providers need thorough training about OCs, with regular review of informational materials to stay up-to-date.
Counsel clients about all types of contraceptive methods and let them know they have a choice of methods. If the woman chooses OCs, counsel her specifically about the benefits and side effects of this method and its correct use. If she has trouble taking the pill regularly, help her switch to another method.
Emphasize to women that pills must be taken every day (except during the pill-free week for women using 21-day packs), preferably at the same time each day.
Urge users to wait no more than seven days between packs of 21 days pills and to start each 28 day pack immediately after finishing the last one. This is because ovulation and conception are most likely to occur if the hormone-free week is extended beyond seven days.
Emphasize that when two or more pills are missed in a row a woman should use a back-up contraceptive method until she has been taking active, hormonal pills again for at least seven days.
Keep records on individual users. This allows follow-up of those who have problems with OC use or who do not return regularly for supplies.
Provide multiple packs of pills at a time, as well as a back-up contraceptive method such as condoms or foam. This can help to compensate if clients experience periodic difficulties in obtaining supplies and can help women be prepared if they miss pills.
New OC users can be counseled alone or in groups but should be provided with printed materials to take home. Illiterate women should have someone read the materials to them. During subsequent client visits, providers should question clients to determine their understanding of OC use, to assess the problems they have experienced, and to correct misunderstandings about how to take the pill.
Recommended OC Instructions
Simple, effective instructions were pilot tested by Family Health International in Mexico. Following are instructions that providers can give to clients, based on that pilot testing and USAID's guidelines:
Starting the pill
Start the first pack of pills within seven days of starting your menstrual cycle or at any other time your provider is reasonably sure that you are not pregnant. If you do not start your pills within seven days of starting your period, you will also need a back-up method of birth control for the first 7 days you actually take the pill. Condoms, foaming tablets or abstinence are all methods that can protect against pregnancy during the first week of use.
Managing missed pills
If you miss one active pill, take that pill as soon as you remember, then continue taking your pills as usual.
The active pills are the 21 [specify COLOR] pills that contain the birth control hormones. The inactive pills are the 7 [specify COLOR] pills that do not contain hormones. The 7 inactive pills, found only in 28-day packs, often contain iron for your blood. However, missing an inactive pill does not increase your risk of pregnancy.
If you miss two or more active pills, in a row:
continue taking the remaining pills in the current pack, one each day, until the pack is empty.
use another, back-up method of contraception (eg, condoms or abstinence) until you have taken active pills again for 7 days in a row. These may be from the next pack.
Conclusion
No drug can work well if it is used improperly. To be effective, oral contraceptives require daily use. As part of a broad effort to ensure good quality of care, providers should offer clear instructions on how and when to take pills. Counseling and education can help women take the pills correctly and avoid an unplanned pregnancy.
