Missed-Pill Instructions

FHI research leads to clearer guidance for oral contraceptive users.

Family Health Research: 2007, Vol. 1, Issue 3

Inconsistent use and other incorrect uses of oral contraceptive pills are a major cause of unintended pregnancy. Research suggests that many clients and even some family planning providers are not sure what a woman should do when she fails to take her pills regularly.

Users of the World Health Organization's (WHO's) instructions on what to do after missing one or more pills in a cycle reported that the instructions were difficult to follow and to explain to clients. Published in Selected Practice Recommendations for Contraceptive Use, the instructions were scientifically accurate but complicated.

The WHO and other organizations have worked together to simplify their missed-pill instructions. Some of these simplified versions were field tested with providers, but until recently, no one had examined how well they were understood by oral contraceptive users.

FHI assessed comprehension of four different types of missed-pill instructions among 864 current and past users of oral contraception in Kingston, Jamaica. The study's participants were asked to use one of four sets of instructions to determine what should be done in eight to 10 different scenarios. In each scenario, a woman had forgotten to take one or more pills in either a 21-day or 28-day cycle.

Results
More than 60 percent of the respondents knew what to do when one pill was missed, but most did not give the correct answer for missing two or more pills on consecutive days, no matter which instructions they used. The women found the three instructions that used graphics easier to understand than the text-only version. Of those three, the two that had been simplified proved easier for the women to comprehend.

Impact on service delivery
"The FHI study provided valuable evidence for the need to simplify the rules and to provide easy-to-follow instructions to pill takers," said Sarah Johnson of WHO's Department of Reproductive Health and Research.

Experts convened by the WHO in 2004 to make recommendations for the second edition of Selected Practice Recommendations used the study results to develop a simpler version of the missed-pill instructions with graphics. It focuses on the mistakes most likely to lead to unintended pregnancy — missing three or more pills, particularly in the third week.

The new missed-pill instructions were first published in the 2004 edition of Selected Practice Recommendations, which has been used in countries throughout the world to update service delivery guidelines and training curricula. They also appear on the inside back cover of the new global handbook for family planning providers (see Global Family Planning Handbook article).

If You Miss Pills

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