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Research gaps identified during the 2014 update of the WHO medical eligibility criteria for contraceptive use and selected practice recommendations for contraceptive use.
Contraception. 2016 Sep; 94(3):195-201.Universal access to safe and effective contraception is an important public health goal. Family planning and prevention of unintended pregnancy are essential to securing the well-being and autonomy of individuals, while supporting the health and development of communities. The World Health Organization (WHO) recently undertook a process to update its global guidance on “who” can use contraception safely and “how” to use contraception safely and effectively to generate the fifth edition of the WHO Medical Eligibility Criteria for Contraceptive Use (MEC) and the third edition of the WHO Selected Practice Recommendations for Contraceptive Use (SPR). Overall, the MEC demonstrates that contraception is remarkably safe for most people; at least one highly effective contraceptive method is assigned a category “1” or “2” across the majority of conditions in the guidance, indicating no restrictions on use or that the advantages of using a particular method generally outweigh the theoretical or proven risks of use. Once a medically appropriate method is identified, the SPR offers critical guidance on safe and effective use, important for contraceptive management and service delivery. The major goal for producing these evidence-based recommendations is to help improve access to and strengthen the quality of family planning services worldwide. While these recommendations reflect a rigorous synthesis and interpretation of the best evidence to date and contribute significantly to medical and public health knowledge around the world, a number of recommendations in both the MEC and SPR are grounded in limited to no direct evidence. In the absence of direct evidence, indirect evidence and expert opinion inform assessments. Each revision of the MEC and SPR offers an opportunity to identify current knowledge gaps and promote research necessary to continually strengthen the guidelines. As part of the most recent revision of these guidelines, a Guideline Development Group convened in March and September 2014 to generate updated recommendations. During these meetings, we identified a number of key research questions for a variety of topics discussed during the technical consultations. The full list of research gaps is included in Table 1, not further prioritized. However, we present three important topics of global relevance to national programs and policies in greater detail: (a) intrauterine device (IUD) initiation among women at high risk for sexually transmitted infections (STIs); (b) bidirectional drug-drug interactions with use of hormonal contraception (HC) and antiretroviral therapy (ART); and (c) initiation of progestogen-containing contraception following use of ulipristal acetate (UPA) emergency contraception. Each section presents some background on the public health importance of the topic and discusses the limitations of existing data and considerations for future rigorous research. [Excerpts].
Training and reference guide for a screening checklist to initiate use of the copper IUD. Second edition.
Research Triangle Park, North Carolina, Family Health International [FHI], 2009. 79 p. (USAID Cooperative Agreement No. GPO-A-00-05-00022-00)This training and reference guide was developed for family planning service providers interested in using the Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, commonly referred to as the "IUD Checklist." Designed to serve as both a training and reference tool, the guide is composed of two parts: a training module and a collection of essential, up-to-date reference materials on the copper intrauterine device (IUD). This guide is part of a series to train on other checklists. The IUD Checklist was developed to assist service providers in screening clients who have already been counseled about contraceptive options and who have made an informed decision to use the copper IUD. This simple job aid is based on the technical guidance provided by the World Health Organization (WHO) in its Medical Eligibility Criteria for Contraceptive Use (2004, updated 2008). The checklist supports the application of these guidelines -- known as the WHO MEC -- into service delivery practice. (Excerpts)
Contraception Report. 1998 Sep; 9(4): p..In 1995, the World Health Organization (WHO) released revised medical eligibility criteria guidelines to assist family planning agencies and clinicians prescribe contraceptives. By eliminating overly restrictive barriers to use, WHO hopes to increase access to and use of birth control methods. This article briefly reviews some of the important WHO guidelines concerning intrauterine devices. Introduction WHO researchers evaluated the benefits and risks of using IUDs in healthy women and in women with certain medical conditions or individual characteristics, such as parity and exposure or susceptibility to sexually transmitted diseases. A previous article describes WHO's methods for devising the criteria in detail. Briefly, the eligibility criteria were developed by international experts from many organizations. WHO experts reviewed the medical literature from the past 10 years and devised recommended medical eligibility criteria for different contraceptive methods. One main concern was to address outdated contraindications. WHO notes that "The contraindications for many contraceptives tend to become very rigid, resulting in denial of contraceptive access to many women. Relative contraindications tend to become absolute." (excerpt)
Nairobi, Kenya, Ministry of Health, 2004 Jun.  p. (IUCD Method Briefs Update)The World Health Organization (WHO) recently revised the guidelines for IUCD use as part of an update of its Medical Eligibility Criteria for Contraceptive Use (MEC). These revisions will improve quality of care and reduce medical barriers for women who are considering an IUCD as a contraceptive method. Based on the latest clinical and epidemiological research, the revisions are particularly significant for women at risk of sexually transmitted infections (STIs), including HIV, and women living with HIV or AIDS. Research has shown that while some conditions restrict IUCD initiation, they do not necessarily affect the safety of continued use. Under the new guidelines, for example, a client who has gonorrhea or chlamydial infection is considered a Category 4 for IUCD initiation and should be advised to choose another method. However, if an IUCD user develops an STI, she can be treated with antibiotics without the IUCD being removed (Category 2). In addition, the client should be counseled about partner notification and treatment, and condom use. (excerpt)
Geneva, World Health Organization, 1966. (Technical Report Series NO. 332).The value and possible hazards of IUDs are discussed. Grafenberg developed a metal ring IUD in 1928. There was initial enthusiasm about the device, but it became discredited and interest was not revived in the method until 1959. Today, various shapes, sizes, and materials are employed in making IUD'S. No single cause or mechanism of action of an IUD has so far come to light. In sub-human primates the IUD causes accelerated passage of ova through the tube and the rest of the reproductive tract appears to be the major, but not necessarily the only, mechanism, of action. In ruminants, the contraceptive action of the IUD is exerted, at least in part, at the ovarian level. In rats, mice, rabbits, and ferrets, the main effect of the IUD is suppression of the implantation. It is concluded that the action of the IUDs in the human species is exerted before the stage of implantation. The most effective devices are associated with an incidence of 1.8 to 2.9 pregnancies per 100 insertions during the first year of use. The frequency of spontaneous expulsion ranges from about 5% to over 20% depending on the type of device. About one half of all expulsions occur in the first 3 months and comparatively few after the first year. The incidence of removal for medical reasons ranges from approximately 10% to 25% of first insertions during the first year. The method can be used successfully by almost 3 out of every 4 women who adopt it. Side effect and complications include bleeding and pain and less frequently pelvic inflammatory disease and perforation. The only absolute contraindications to the use of IUDs are: (1) active pelvic inflammatory disease, and (2) pregnancy, proven or suspected. Research needs are noted.
BRITISH MEDICAL BULLETIN. 1993 Jan; 49(1):245-51.Currently, more than 50% of married women of childbearing age are using a form of contraception. Between 1960-65 and 1985-90, the number of contraceptive users in all developing countries increased from 31 to 381 million, in East Asia from 18 to 217 million, in Latin America from 4 to 44 million, in South Asia from 8 to 94 million, and in Africa from 2 to 18 million. WHO has recently estimated that over 500,000 women die each year from causes related to pregnancy and childbirth. With a worldwide estimate of 36-53 million induced abortions performed each year, between 125,000 and 170,000 women die each year because of unsafe abortions. According to data from the World Fertility Survey, short spacing between births raises the average chances of offspring dying in infancy by 60-70% and the chances of dying before the age of 5 years by about 50%. WHO's minimal estimate for yearly incidence of bacterial and viral STDs (excluding HIV infection) is 130 million. Most STDs have more serious sequelae in women than in men and lead to pelvic inflammatory disease (PID), permanent infertility, and the risk of ectopic pregnancy. African countries with high incidence of STDs have the lowest prevalences of contraceptive use. A recent examination of the WHO international data base of 22,908 IUD insertions and 51,399 woman-years of follow-up indicates that the occurrence of PID in IUD users is most strongly related to the insertion process and to background STD risk and suggests that PID is an infrequent occurrence after the insertion period. A WHO Scientific Working Group review confirmed the beneficial effects of oral contraceptives in reducing the risk of ovarian cancer, endometrial cancer, and biopsy-proven benign breast diseases. A WHO collaborative study in 5 centers in Kenya, Mexico, and Thailand provided assurance that women who used DMPA for a long time and who initiated use many years previously are not at increased risk of breast cancer.
Advances in Contraception. 1986 Mar; 2(1):55-63.Based on data from case control and cohort studies, the relationships between current and past IUD use, duration of IUD use, and the type of IUD were evaluated to determine the risk of ectopic pregnancy among users. 3 studies are evaluated in this article: 1) the Women's Health Study (WHS), 2) the Oxford Family Planning Association study in the UK, and 3) a multiclinic, international study by the World Health Organization (WHO). Data from the WHS shows that women who were using IUDs at the time of their last menstrual period, and who had used their IUDs for less then 2 years, had a significantly lower risk of ectopic pregnancy compared to women who had never used IUDs; this relative risk increased to 1.7 for women who used their IUDs for 4 or more years. In 1965, there were 4 reported ectopic pregnancies among 23 women who became pregnant with a Lippes Loop in situ. Regardless of the duration of IUD use, overall IUD users were not found to be at any increased risk of ectopic pregnancy. The WHO study also indicates that IUD use does not increase the risk of ectopic pregnancy. Data from the Oxford Family Planning Association study found that while the rate of ectopic pregnancy was fairly constant over time, the proportion of all pregnancies that were ectopic increased over time. Considered collectively, the studies reviewed do not indicate that past IUD use, regardless of the type of IUD used, increases a woman's risk of ectopic pregnancy. Based on the various studies and data evaluated the following may be concluded: 1) neither current nor past use of an IUD is associated with any increased risk of ectopic pregnancy, 2) the incidence of ectopic pregnancy is similar for current users of all types of IUD, except for the Progestasert, and 3) the duration of IUD use does not increase the risk of ectopic pregnancy.
In: Intrauterine contraception: advances and future prospects, edited by Gerald I. Zatuchni, Alfredo Goldsmith, and John J. Sciarra. Philadelphia, Pennsylvania, Harper and Row, 1985. 354-64. (PARFR Series on Fertility Regulation)Little data is available from developing countries on the incidence of ectopic pregnancy and the associated risk factors: pelvic inflammatory disease (PID), sexually transmitted diseases (STDs), intrauterine devices (IUDs), and abortion. To address this problem, the World Health Organization conducted a multinational case-control study between 1978 and 1980 of factors associated with ectopic pregnancy in 12 centers, 8 in developing countries and 4 in developed countries. Results suggest that risk factors are similar in women from developing and developed countries. The only exceptions were increased risks of ectopic pregnancy associated with spontaneous abortion or smoking in developing but not developed country centers. This may reflect misreporting of illegal induced abortion or postabortion complications, and behavioral differences between smoking and nonsmoking women in developing countries. All methods of contraception prevent pregnancy and so provide protection against ectopic pregnancy. This protective effect is least with the IUD, however, and accidental conceptions during IUD use or after sterilization carry an increased risk of ectopic pregnancy. With the IUD, this probably reflects both differential protection against intrauterine and extrauterine pregnancy and an increased risk of IUD-related PID resulting in tubal damage. The risk of ectopic pregnancy is also increased in women with a previous history of PID or a prior pregnancy. However, cesarean section was found to reduce the risk of ectopic gestations in all comparison groups.
Populi. 1983; 10(1):78-81.The World Health Organization's (WHO) aim is to achieve a level of health that will allow all the world's citizens to lead a socially and economically productive life by the year 2000. Peter D. O'Neill's book, "Health Crisis 2000," is based on WHO's European regional strategy for attaining "health for all" by the year 2000. Its goal is to enable a large audience to participate in a dialogue on the real issues. An analysis of trends in health and disease, made over the past 3 years by representatives of the medical profession, has produced ominous signs that current health policies have set a dangerous course. If "health for all" is to be realized by the year 2000, it will be necessary to implement a new strategy with 3 inseparable themes, i.e., health as a way of life, the prevention of ill health, and community care for all. While the book analyzes the 1st stage of work which the WHO European Region has drawn up for itself, it interprets the official strategy document and offers ample detail to draw ministers, parliamentarians, industrialists, and the media into the debate. Fakhruddin Iqbal reports that a recent study suggests that the Bangladesh family planning program neglected to consider age old social and cultural values. The study identifies 2 distinct cultural values that present obstacles to the program: the traditional preferences for age old treatment as opposed to modern medical practices and the persistent tradition of relegating women to the lowest rung of mass education; and the traditional family size perceptions of the people. Andrew Hamilton writes that the Jamaica Family Planning Association has employed 7 people to spread knowledge of family life education and family planning among youth. These 18-23 year old youth associates are part of a major national drive to keep Jamaica's population below 3 million by the year 2000. About traditional midwives Jan Steele writes that they deliver between 60-80% of babies in the developing world each year and provide support and care in environments commonly shunned by the medical profession. The IPS reports that according to the 1980 census the population of Brazil is 120 million. If the current demographic trends continue, the population will double by 2014. With the present unemployment level, there will be 41.5 million people underemployed and 15 million unemployed in 2014. Meena Panday writes that Nepal cannot seem to get its population program going. The Population Council reports that no evidence exists as yet that use of the copper bearing or nonmedicated IUD increases the risk of ectopic pregnancy.
IPPF Medical Bulletin. 1981 Dec; 15(6):1-3.These policy statements and guidelines from the International Planned Parenthood Federation's (IPPF) International Medical Advisory Panel (IMAP) concern IUDs. The following contraindications to IUD use are recognized: 1) pelvic inflaminatory disease, 2) known or suspected pregnancy, 3) history of previous ectopic pregnancy, 4) gynecological bleeding disorders, 5) suspected malignancy of the genital tract, 6) congenital uterine abnormalities or fibroids distorting the cavity, and 7) anemia, blood coagulation, severe cervical stenosis, copper allergy, Wilson's disease, and others. Generalities regarding appropriate IUDs are: 1) non-medicated devices (e.g. Lippes Loop) are studied for women who may not return for regular check-ups, 2) smaller medicated devices usually cause less menstrual blood loss than the non-medicated devices, 3) smaller devices are better for a smaller uterus and larger devices for the larger uterus, and 4) when a smaller device is expelled it is advisable to try a larger one and vice versa. Dalkon Shields should not be used by the IPPF system and all women using them should have the device removed. Correct insertion of IUDs is important and should be done by properly trained personnel. The timing of insertion is best during the menstrual period. Withdrawal of the applicator while leaving the device in place is the recommended insertion technique. Sterilization of IUDs should follow instructions on bulk-packaged IUDs. Complications include perforation, bleeding and pain, infection, and ectopic pregnancy. IUD removal should be done during menstruation. Good clinical management and follow-up care are recommended.
IPPF Medical Bulletin. 1980 Dec; 14(6):3.The Dalkon Shield IUD was introduced to the list of contraceptives being distributed to developing countries by IPPF (International Planned Parenthood Federation) in 1973. By 1974, doubts had arisen about the safety of the Dalkon Shield and several cases of maternal mortality and sepsis in Dalkon Shield users had been reported. In 1974, IPPF stopped supplying Dalkon Shields to its affiliates. During the 1973-74 period of distribution, IPPF had distributed approximately 300,000 of the Shields in 41 countries. Almost 1/2 that amount had already been inserted. The position of IPPF's IMAP (International Medical Advisory Panel) on any relationship existing between use of IUDs and pelvic inflammatory disease is as follows as of 1980: 1) infection with actinomycosis makes up only a small component of all the incidents of pelvic inflammatory disease connected with IUDs; 2) the occurrence of pelvic inflammatory disease is not related to the length of use of an IUD; 3) data do not now support the recommendation that inert devices free from major side effects should be removed; and 4) any woman still wearing a Dalkon Shield should have it removed.
HRP Task Force evaluation. Summary of conclusions regarding intrauterine devices and female sterilization.
In: Assessment of the WHO Special Programme of Research, Development and Research Training in Human Reproduction [HRP]. II. Task Force reports. Country reports, [compiled by] Sweden. Swedish Agency for Research Cooperation with Developing Countries [SAREC]. Stockholm, Sweden, SAREC, 1983 Apr. 4 p.The promotion of contraceptive methods is a high priority in developing countries. IUDs are effective, but the misfortune with the Lippes Loop in the 1960s has detrimentally impacted the use of IUDs in South East Asian countries. Complications can include bleeding, uterine cramps, perforations, expulsions, infections, and the risk of intrauterine and ectopic pregnancy. These can be alleviated by modifying the shape of the devices, by professional evaluation and fitting of IUDs on the part of maternal-child health (MCH) services, and by an assessment of psycho- social implications of IUD use. Unipurpose crash family planning programs have failed. The WHO's IUD research program is concerned with the reduction of side effects and contraceptive safety. Research on female sterilization has the objective of reducing maternal and child morbidity and mortality in grand multiparity. On the other hand, sterilization has been misused in several developing countries. It is imperative to ensure informed and voluntary consent to minimize misuse and to secure adequate health care for the living children of the sterilized client (immunization and infectious disease control). Economic reasons for promoting sterilization are unacceptable. Sterilization infrastructure development is indispensable (trained staff, equipment, and anesthesia). Simple but safe sterilization procedures need further development, and adverse psychological effects require further research. Attitudinal studies are needed on providers and acceptors, targets, incentives, and disincentives. Sterilized couples have to have access to MCH services, and the WHO research program on human reproduction should incorporate sterilization and its ramifications.