Ruling out pregnancy is recommended before starting a hormonal contraceptive and before IUD insertion. Family planning providers have 3 tools available for this routine task:

1. Medical history (often collected using the Pregnancy Checklist)

2. Pregnancy tests

3. Delaying the start of the method until the client’s next monthly bleeding.

Which tool should a provider use first, and when?

The job aid, How and When to Use the Pregnancy Checklist and Pregnancy Tests, offers guidance based on the client’s chosen method and on whether she has been having bleeding each month or she is not having monthly bleedings due to recent childbirth or other reasons. This job aid also addresses the situation for a woman who has been having monthly bleedings but now has missed her expected monthly bleeding.

Important points to note

• Unless the client has missed her monthly bleeding, ruling out pregnancy starts with the Pregnancy Checklist. This checklist can provide reasonable certainty that a woman is not pregnant.
• Pregnancy tests are not likely to work before the first day of missed monthly bleeding. Using a test earlier is pointless and wasteful.
• The only contraceptive method known to pose a health risk if started during pregnancy is the IUD (either copper or hormonal). If the Pregnancy Checklist cannot rule out pregnancy, a provider should use another tool to rule out pregnancy before inserting an IUD.
• All hormonal methods except the LNG-IUD can be provided without delay even when uncertainty about pregnancy exists. Follow-up is required in some cases (see job aid on next page).
• Delaying the start of the method is the worst choice among the 3 tools for assessing pregnancy. She may become pregnant before her next monthly bleeding. The other tools should be used first whenever possible.
• Both the Pregnancy Checklist and a pregnancy test are highly accurate for ruling out pregnancy when used appropriately. When the checklist can be used, there is no reason to prefer a test.