The Centers for Disease Control and Prevention (CDC) recently adapted global guidance on contraceptive use from the World Health Organization (WHO) to create the United States Medical Eligibility Criteria for Contraceptive Use (MEC). This guidance includes recommendations for use of specific contraceptive methods by people with certain characteristics or medical conditions.CDC determined the need and scope for the adaptation, conducted 12 systematic reviews of the scientific evidence and convened a meeting of health professionals to discuss recommendations based on the evidence.The vast majority of the US guidance is the same as the WHO guidance and addresses over 160 characteristics or medical conditions. Modifications were made to WHO recommendations for six medical conditions, and recommendations were developed for six new medical conditions.The US MEC is intended to serve as a source of clinical guidance for providers as they counsel clients about contraceptive method choices.
New recommendations on the safety of contraceptive methods for women with medical conditions: World Health Organization’s Medical eligibility criteria for contraceptive use, fourth edition Mary E Gaffield, PhD Kelly R Culwell, MD, MPH Background The World Health Organization (WHO) publication, Medical eligibility criteria for contraceptive use (MEC), provides evidence-based recommendations on whether a contraceptive method can be safely used according to more than 80 medical conditions and characteristics. The guideline is intended to be a reference during the preparation of national family planning/sexual and reproductive health programmes for delivery of contraceptives. Medical eligibility criteria for contraceptive use was first published in 1996; subsequently in 2000 and 2004. A WHO expert Working Group reviewed in April 2008 the new evidence in the third edition and developed 251 new recommendations for the fourth edition, including recommendations for an additional medical condition, systemic lupus erythematosus (SLE), and 12 new sub-conditions to existing medical conditions. This article highlights the updated recommendations, and describes the development of the new guidance.
Obstetric fistula has been a neglected issue for a long time. With the 2003 launch of an international campaign, co-ordinated by the United Nations Population Fund, management of the issue is set to become a catalyst in the campaign for maternal mortality and morbidity reduction in developing countries
Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. Female genital mutilation violates series of well-established human rights principles norms and standards including the principles of equality and non-discrimination on the basis of sex the right to bodily integrity the right to life if the procedure results in death and the right to the highest attainable standard of physical and mental health. Given the fact that children are subjected to this procedure FGM also violates the rights of the child. The intense pressure many parents and communities exert on girls to accept it means that childs decision to undergo female genital mutilation cannot be called free informed and uncoerced. The Convention on the Rights of the Child makes explicit reference to harmful traditional practices calling upon all countries to take effective and appropriate measures to abolish them. FGM is harmful practice that negates IPPFs vision of a world in which all women men and young people have access to the information and services they need; world in which sexuality is recognized both as natural and precious aspect of life and as fundamental human right. The Federation will continue to uphold this belief through sustained efforts in partnership with other stakeholders to eliminate FGM.
The UN 1994 International Conference on Population and Development has encouraged the provision of services for syndromic treatment for clients with symptoms or signs of infection, laboratory screening and sexually transmitted disease (STD) risk assessment to guide contraceptive counseling. This proposal was raised in the light of the growing HIV and STD global concern and the use of contraceptive methods for STD prevention. Despite recommendations on using barrier methods for STD/HIV prevention, many family planning providers hesitate about endorsing barrier methods because of lesser efficacy in preventing unintended pregnancies. However, several studies have demonstrated the effectiveness of male and female condoms when used consistently and correctly. In addition, accumulated data on condom use and HIV infection revealed that consistent use of male condoms protect against HIV acquisition (protection ranging from 50% to 100%). These findings underscore the effectiveness of condoms in preventing STD/HIV when used consistently and correctly and should be encouraged at every opportunity.
Violence against women can take many forms and is widespread, but incidences are difficult to quantify because women suffer in silence or fail to realize that the violence they experience is unacceptable. In India, a survey of 1842 rural women of reproductive age revealed that both men and women consider wife beating acceptable and that 40% of all wives have been beaten by their husbands. Indian women who have a good education, are married at later ages, and have control over economic resources are less likely to experience domestic violence. Females can suffer from violence throughout their life cycle. Fetuses may be aborted just because they are female; infants may be killed because they are female; girls may be neglected or subject to various other types of abuse; adolescents may be raped; married women may be beaten, raped, or killed by their husbands; and widows may be neglected and abused. The health effects of this violence, thus, range from death to psychological trauma. In response to this situation, women's organizations have focused worldwide attention on violence against women as a human rights violation and are beginning to hold accountable governments that were party to the Convention on the Elimination of All Forms of Discrimination Against Women. Training medical personnel on how to deal with women who are obvious victims of domestic violence will be an important strategy.
In order to determine the demand for hormonal male contraceptive agents, a survey was undertaken of the attitudes of 450 men in four centers of a Contraceptive Development Network: Edinburgh, Scotland; Cape Town, South Africa; Hong Kong; and Shanghai, China. In Edinburgh and Cape Town, 66-68% of the men indicated that they would definitely or probably use a male daily pill, but this percentage dropped to 48-50% in Hong Kong and Shanghai. Except in Cape Town, there was little support for a monthly injection, and the idea of implants was universally unpopular. To determine the attitudes of women about a male contraceptive pill, a survey was made of over 400 women attending family planning clinics in Edinburgh and Shanghai. In each case, most of the women were positive about the possibility and indicated that they would adopt such a method. There was also almost universal agreement that women bear too much of the responsibility for contraception. Currently, one of the greatest challenges facing development of an acceptable male hormonal contraceptive is discovering a satisfactory formulation to replace testosterone at physiological doses while inhibiting sperm production. Two World Health Organization trials have revealed that incomplete suppression of spermatogenesis remains a problem, and research is focusing on development of a long-lasting testosterone injection with administration of an oral gestagen. Development of a safe and reliable male oral contraceptive may require another 5-10 years.
Reports of IUD transmigration with complications have for many years caused concern among both clients and service providers. The incidence of transmigration is, however, rare, but the unusual nature of the complications has attracted more attention than warranted to the issue. While the mechanism of IUD transmigration is uncertain, total or partial perforation of the uterus at the time of insertion is thought to be the main reason for the phenomenon. The incidence of uterine perforation due to the use of modern IUDs is estimated to be only one in 3000 insertions. This paper summarizes what is known about transmigration, and includes some examples from the author's own experience which shows that, in most cases, transmigration produces few or no symptoms. Sites of translocation and complications, case studies, mechanism of transmigration, and clinical management are discussed.
This paper reviews the quality of family planning services offered by the International Plan Parenthood Federation (IPPF) and examines the challenges faced by IPPF in the 1990s. The goal of IPPF is to maintain a good quality of family planning services for the following important reasons: to secure the safety and effectiveness of the methods provided; to secure the satisfaction of the clients with the services; to secure the acceptability and sustained practice of family planning; and to secure confidence among the public and the supporters of family planning programs. Moreover, IPPF utilizes three principles when planning strategies and activities for the quality care and these principles are stated in the paper. Furthermore, the Central Council of the IPPF at its November 1990 meeting passed a resolution emphasizing quality of care as the top priority. The paper also presents the highlights of the IPPF meeting that was held in London on August 30-31, 1994.
Although women with sickle cell disease have been found to have a delay in puberty of 2.3 years, there is no evidence that they are less fertile than women without hemoglobinopathy. Women with sickle cell disease therefore need adequate family planning advice to prevent unwanted pregnancy. The need for good and comprehensive advice is particularly important given the association among these women between pregnancy and increased maternal and fetal mortality and morbidity rates. Moreover, unwanted pregnancy rates among women with sickle cell disease have been reported as being in the range of 38-64%, and one study found that only 33% of a group of women with sickle cell disease used any form of contraception compared to 66% in a control group. Sickle cell disease is listed in the manufacturers' data sheets in the UK as a contraindication to the use of the majority of combined oral contraceptive pills, but there is little good evidence to support this restriction. In fact, women with the sickle cell trait have no particular added risks and can be offered the usual range of contraceptive methods. Evidence that the use of injectable progestagens may reduce the risk of crises, however, suggests that they should be recommended as a first option of contraception for these women. Good evidence exists that the injectables are safe and effective for women with sickle cell disease despite the adverse publicity which they have received. The IUD appears to be safe as are the common barrier methods, while the combined oral contraceptive pill is a convenient, effective, and reliable form of contraception which should continue to be prescribed for these women, albeit with caution.
Dr. Li Shunqiang of the Chongqing Family Planning Scientific Research Institute in Sichuan province, China, developed the no-scalpel vasectomy (NSV) in 1974. Before NSV, few men had undergone vasectomy. Since its introduction, more than 9 million men in Sichuan province have accepted NSV. Today in Sichuan province, 5 NSVs are performed for every 1 tubal occlusion. NSV was introduced outside of China in 1985. During 1990-1992, 50,000 men received NSVs from programs supported by the Association for Voluntary Surgical Contraception (AVSC) in 19 countries. A vasal nerve block anesthetizes the area. Two instruments have been designed exclusively for NSV: the extracutaneous vas deferens ringed clamp and the vas deferens, dissecting forceps (also a modified hemostat). Surgeons should undergo hands-on training in the NSV technique, especially since they need to be able to identify the vas through the scrotal skin and subdermal fat. AVSC provides assistance to NSV training programs in 30 countries outside of North America. AVSC's publication No-Scalpel Vasectomy: An Illustrated Guide for Surgeons is a great resource for NSV workshops and hands-on training. Surgeons puncture the scrotal skin to deliver the vas. No stitches are required. They can cover the puncture with an adhesive dressing or a sterile gauze dressing. A scrotal support should be worn for a few days. Sexual intercourse with temporary contraceptive protection can resume within 2-3 days. The recently vasectomized man should provide a semen sample for sperm analysis either 12 weeks after the operation or after 20 ejaculations. NSV takes less time to do and causes fewer complications than dos the traditional incisional technique. For example, during the King's birthday vasectomy festival in Thailand, men undergoing traditional vasectomy had an immediate complication rate of 3.1% compared to 0.4% for those undergoing NSV. Since it is also less invasive than the traditional technique, it is more acceptable to men.
Depot medroxyprogesterone acetate (DMPA, Depo-Provera) is used for contraception by 8-9 million women in more than 90 countries, including the US, as of January 1993. Pharmacologically active levels of DMPA persist for 3-4 months following injection. A 150 mg dose is used most often for high contraceptive efficacy every 3 months. Norethindrone enanthate (NET-EN, Noristerat) is somewhat less widely used and is not marketed in the US. Injectables act primarily by inhibiting ovulation, lowering the levels of follicle-stimulating hormone and luteinizing hormone. Approximately 50% of women using DMPA for 1 year report amenorrhea whose occurrence is less frequent with NET-EN. Menstrual changes are the most frequent causes of discontinuation of injectables. In cases of heavy bleeding it is appropriate to undergo gynecological examination to rule out unrelated conditions, such as vaginitis, cervicitis, or cervical lesions. The use of conjugated estrogen (12.5-2.5 mg daily) for 10-21 days will minimize bleeding. Some women using injectables experience headache, dizziness, bloating of the abdomen or breast, and mood changes. Long-term use of DMPA or NET-EN can often result in 1-3 kg weight gain. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives was launched in 1979 to examine cancer risks with the use of DMPA in Thailand, Mexico, and Kenya. The relative risk of breast cancer was 1.21, which was statistically not significant. In women diagnosed with breast cancer under age 35, short-term exposure to DMPA was associated with a slightly increased breast cancer risk, which, however, was not associated with duration of use. DMPA dramatically lowers the risk of endometrial cancer for at least eight years following discontinuation of its use. DMPA did not alter the risk of cervical cancer. Fertility returns in 70% of former users within 12 months; it is suitable for postpartum and lactating women, and provides other noncontraceptive benefits.
"This article will deal with the family planning situation in Benin, more precisely [with] the level of knowledge, attitudes and practice (KAP) concerning modern contraceptive methods, and the hope for a successful family planning programme in Benin. We will look at studies which have already been done and we will also present some promising results of an experimental study which we carried out [in 1990]...." The period studied is from 1979 to 1991.
The most pressing challenges in reproductive health and family planning in the 1990s are enumerated: doubling of contraceptive users, improving consistent use of pills and IUDs, providing condoms for AIDS prevention, allocating funds, expanding social marketing, sterilizing those in need, quality assurance and finally, dealing with demand for abortion if contraceptive needs are not met. New contraceptive users will be found in the Soviet Union and Eastern Europe who currently have no access, as well as a 33% increase in numbers of young couples. Much can be done with packaging and counseling to improve on the 5-20% failure rates of pill users in developing countries. Similarly, improvement in IUD technology in China and elsewhere will save on costs of failures and removals. Funds provided by donors for contraceptive supplies alone will almost double, despite social marketing, because of the higher numbers of users. A much higher proportion of the program costs will be direct expenditures on supplies. New rapid and less invasive methods of sterilization will be needed to meet the needs of vast numbers of couples desiring to limit births, especially in the Soviet bloc nations. If these challenges are met, millions of mothers and infant lives will be saved, yet the world population will stabilize at closer to 10 rather than 15 billion by the end of the next century.
An expert meeting on infection prevention was held in Baltimore on June 8-11, 1991, to establish consensus guidelines on infection control at family planning service delivery sites. Present were representatives of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), the WHO, IPPF, USAID and cooperating agencies. It was decided that instruments that penetrate the blood stream, such as needles, syringes, trocars and scalpels, should be sterile. High level disinfection (HLD), which kills everything except bacterial endospores, is satisfactory when sterilization is not available. HLD is the only way to disinfect a laparoscope, the endoscope of which cannot tolerate heat. The standard conditions for autoclaving instruments were set at 121 degrees Celsius (250 degrees Fahrenheit) of temperature, 15 lb/square inch (106 KPa) pressure, for 20 minutes for unwrapped, of 30 minutes for wrapped items. Sterilization by dry heat means 170 degrees Celsius for 1 hour, or 160 degrees Celsius for 2 hours, with added time for reaching temperature and cooling. Boiling is only acceptable as a method of HLD, not for sterilization. Boiling at a rolling boil for 20 minutes was recommended, with no correction for altitude. In the absence of an autoclave, surgical drapes are best prepared by ironing, since hanging them to dry would contaminate them after boiling.
Maternal-child health care interventions in Pakistan's Faisalabad District have produced dramatic reductions in maternal mortality and are potentially replicable in other developing country settings. In the late-1970s, health personnel became concerned with the high rates of maternal mortality, infant mortality, malnutrition, fertility, and illegal abortion in the district. Since 80% of deliveries in Pakistan are carried out by traditional birth attendants (TBAs), the author initiated a program of refresher courses for TBAs in the district. In the 10 years since 1978, 5500 urban and rural TBas have participated in these annual seminars and been provided with information on detection of high-risk pregnancies for referral, sepsis prevention, prenatal care, neonatal resuscitative measures, and family planning. During this same 10-year period, maternal mortality dropped from 10.1 to 1.86/1000, largely as a result of referral of complicated cases to the District Headquarters Hospital. Another innovation was the Faisalabad FLying Squad service, an emergency ambulance equipped with medicines and trained staff that can rapidly transport women who develop complications during delivery to the hospital. In the 1 year since program inception in January 1989, there have been 73 calls for the emergency service. In 1990, designated The Year of the Mother and Child, lectures on family planning, maternal-child health, and the availability of the obstetric Flying Squad were given throughout the district. The main causes of the 48 maternal deaths in the district in 1989 (maternal mortality rate of 0.86/1000) were insistence on home delivery and reluctance to go to the hospital.
The Safe Motherhood Initiative calls for improved maternity care for all women, essential obstetric services at the nearest place possible, and access to and acceptance of family planning services adapted to the needs of individual couples. Central to this effort is the midwife, who can serve as a link between community health workers and physicians. However, an International Planned Parenthood (IPPF) review of 29 countries that utilize midwives in their health systems found that half had a shortage and that a collective total of 61,000 additional midwives is needed to create a midwife:live birth ratio of 1:200. The regions with the worst ratios are generally those with lowest prenatal coverage and contraceptive prevalence rates and the highest incidence of maternal mortality. This situation could be remedied, in part, by greater utilization of auxiliary nurse midwives or specially trained traditional birth attendants. In countries where trained community health workers are permitted to distribute condoms, barrier methods, and the pill, an intermediate-level health worker should be authorized to provide injectables and IUDs. In many countries, even midwives are not permitted to provide family planning services, and their education does not include family planning content. Experiments in Indonesia, Turkey, Thailand, and the Philippines have demonstrated that midwives can be trained to insert Norplant and IUDs, and even perform sterilizations, as effectively as physicians. In Chile, a core of 300 physicians and midwives were selected for training in family planning methods and education and went on to train others. It is important that midwives themselves take the lead in restructuring and upgrading their profession and form strong partnerships with women's organizations at the grass-roots and policy-making levels.
