A guide to effective and efficient provision of combined oral contraceptives (COCs) - Quick start and advance provision

Oct 6, 2026

A practical job aid for health workers in Nigeria describes evidence-based strategies to increase uptake and continuation of combined oral contraceptives (COCs). It covers quick start steps for initiating COCs after pregnancy screening, preparing pill packs by discarding elapsed days, counseling on daily pill use, and guidance for missed pills. The guide also explains advance provision at menstruation, providing up to three packs, management of side effects and rare complications using ACHES, and the lack of STI protection—recommending condoms and role-play counseling.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Quick start

Steps to initiate COCs

Missed reminder pills and missed active pills

Side effects and rare complications (ACHES)

No STI protection and condom counseling

Advance provision of COCs

Providing multiple packs of COCs

Facts clients should know about using COCs

How to use the pill

• If you missed these pills in the ﬁrst week of a new pack and had unprotected sex, consider using emergency contraception. If you miss any reminder pills: Throw away the missed pills and continue taking pills, 1 each day. Side effects • Some COC users experience side effects. • Side effects are not harmful or signs of illness, and they often go away after about three months. • The most common side effects are headaches, dizziness, nausea, breakthrough bleeding or spotting, breast tenderness, mood changes, weight change, amenorrhea. Complications Complications are rare. Counsel the client to return immediately if she experiences the following symptoms (ACHES): Abdominal pain (sharp) Chest pain (severe) Headache (severe) Eye problems (blurred vision, brief loss of vision) Sharp leg pain Instruct the client to stop taking pills, use a backup method, and return to the clinic immediately. No Protection from Sexually Transmitted Infections (STIs) COCs do not offer protection from STIs including HIV. Clients at risk of STIs should be counseled to use condoms. Allow clients to practice putting a condom on a modeland role play negotiating condom use with a reluctant partner. Copyright: Federal Ministry of Health Nigeria, 2009, with support of FHI-Nigeria A guide to e ective and e􀀞cient provision of combined oral contraceptives (COCs) This job aid is designed to assist health workers of all levels in the implementation of the following evidence-based strategies to increase uptake and continuation of COCs. This tool is to be used in combination with the Ministry of Health-approved checklist for screening clients who want to initiate use ofCOCs. Quick start To initiate a quick start for clients who have made an informed choice to use COCs, follow these instructions: | 1. Use the COC checklist to rule out pregnancy and screen for other conditions to determine if the client is eligible to initiate COCs. If the client is eligible now, proceed to step 2; if not, consider advance provision (see next panel or see next section) . | | --- | | 2. If pill packs are pre-printed with the days of the week, prepare a pack of pills for the client by discarding the pills from the days of the week that have already passed (e.g., if quick-starting on a Wednesday, discard the Sunday through Tuesday pills from the ﬁrst week of the pill pack) . | | 3. Give the client the pill pack; ask her to take her ﬁrst pill. Observe the pill being taken. | | 4. Instruct the client how to follow the directions or arrows on the pack to take the rest of the pills. | | 5. For packs with 28 pills, instruct the client to start the next pack the day after she ﬁnishes her current pack. For packs with 21 pills, instruct the client to wait 7 days after she takes the last pill from her current pack and then start the next pack. | | 6. If the client is switching from injectables and is at or near the due date for re-injection (not more than 4 weeks past her scheduled re-injection), she can begin taking her pills now. No back-up method is needed. | | 7. If the client began her last menstrual period more than 5 days ago or if the client is unsure when she started her last menses, instruct her that she must use condoms or abstain from sex for the next 7 days. Give her condoms to use for the next
7 days.* | | * Clients should also be provided with and instructed how to use emergency contraceptive pills (ECPs), when they are available, in case a condom fails or is not used during the ﬁrst 7 days of COC use. | Advance provision ofCOCs Women in whom pregnancy has not been ruled out but who are medically eligible to initiate COCs may receive one or more packs of pills from their provider in advance to start pill-taking at the time of menstruation. This eliminates the need for clients to return at menstruation to receive pills. Providing multiple packs of COCs Clients receive up to 3 packs of COCs during their visit rather than one pac

FAQs

What should clients do if they miss reminder pills during a COC pack?

Throw away the missed reminder pills and continue taking pills, one each day.

What guidance is given for missed active pills or starting a pack late?

If active pills are missed for 1–2 days or the pack is started 1–2 days late, take a pill as soon as remembered and continue daily. If 3 or more active pills are missed or the pack is started 3+ days late, take a pill as soon as possible, continue daily, and use condoms or avoid sex for the next 7 days; if missed in week 3, finish active pills and start a new pack.

Do COCs protect against sexually transmitted infections (STIs)?

COCs do not protect against STIs, including HIV. Clients at risk should be counseled to use condoms and may be role-played to practice condom negotiation and use.

Oct 6, 2026

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