Standards › Standard 12 › Policies
Policy · GYN-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.12
At a glance
- Each woman is offered information on contraceptive methods, their risks, their effectiveness and their eligibility.
- The information is given in a form the woman understands.
- Her choice, or her decision not to choose, is recorded on GYN-FRM-002.
- Eligibility is checked against the WHO criteria before a method is given.
- Stop and get help straight away if: a method is given without eligibility checked, or a woman leaves without the information offered.
1. Purpose
To offer contraception and reproductive choice with full information (12.12).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A woman has the right to decide whether and when to have children. Information on each method, and a recorded choice, supports that right and reduces unplanned pregnancy.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician or gynaecologist | Owns the policy | Clinician |
| Midwife or nurse | Gives the information and records the choice | Nurse |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Inform.
- Explain the methods, their risks and effectiveness, in a form the woman understands.
Key point: Understood.
Step 2. Check eligibility.
- Check eligibility against the WHO criteria before giving any method.
Key point: Eligibility first.
Step 3. Record.
- Record the choice on GYN-FRM-002.
Key point: Choice recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Women offered contraception information with a recorded choice | 95% | Monthly | Lead obstetrician or gynaecologist | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| GYN-FRM-002 | Contraception choice record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Medical eligibility criteria for contraceptive use (5th edition, 2015). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)