The World Health Organization’s Family Planning Guidance: Example of a National Adaptation Kathryn M. Curtis, PhD Division of Reproductive Health Centers for Disease Control and Prevention
The World Health Organization’s Family Planning Guidance:
Example of a National Adaptation
Kathryn M. Curtis, PhD
Division of Reproductive Health
Centers for Disease Control and
Prevention
The World Health Organization’s Family Planning Guidance:
Example of a National Adaptation
• WHO Four Cornerstones of Family Planning
Guidance
• New and upcoming from WHO
• National adaptations
• Example of adaptation for United States
Why is evidence-based guidance needed?
• To base family planning practices on the best
available evidence
• To address misconceptions regarding who
can safely use contraception
• To reduce medical barriers
• To improve access and quality of care in
family planning
WHO Medical Eligibility Criteria Categories
1. No restriction for the use of the contraceptive method
2. The advantages of using the method generally outweigh the theoretical or proven risks
3. The theoretical or proven risks usually outweigh the advantages of using the method
4. An unacceptable health risk if the contraceptive method is used
Smoking and Contraceptive Use
SMOKING
a) Age<35
b) Age>35
(i) <15 cigarettes/day
(ii) >15 cigarettes/day
Cu-IUD
1
1
1
1
1 1
POPCONDITION CICCHC LNG-IUD
NET-EN
DMPA
2
1
1
IMP
11
1
1
1
2
3
4
1
1
2
3
WHO Selected Practice Recommendations for Contraceptive Use
• Follow-up to WHO MEC
• First edition, 2002
• Last update, 2008
• Intent: Evidence-based guidance for common, yet
controversial contraceptive management questions
When to start
Missed pills
Bleeding problems
Exams and test
Follow-up
How to be reasonably certain that a woman is not pregnant
CDC Role
Four Steps of Evidence Preparation
• Identification of new evidence
• Systematic review
• Peer review
• Evaluation and action by WHO
WHO Expert Working Group Process
• Systematic reviews sent to experts prior to
the meeting
• Brief narrative presentation of the systematic
reviews
• Discussion focused on evidence
• Consensus process
WHO Technical Meeting to Revise MEC and SPR
• April 2008: 4th edition of MEC and 3rd
edition of SPR
• Updates
Added systemic lupus erythematosus
Changes to postpartum IUD use
Changes to drug interactions
Extended grace period for DMPA
• Systematic reviews published in
Contraception, October 2009
WHO: New and Upcoming
• Combined Hormonal Contraception for
Postpartum Women
Updated guidance, Sept 2010
• 2011 British Medical Association Book Awards:
MEC won First Prize, Obstetrics and
Gynaecology Category
• Hormonal Contraception and HIV
Technical consultation, Jan 2012
Impact of the Guidelines • Translated into 8 languages
French, Spanish, Romanian, Russian,
Arabic, Chinese, Indonesian,Vietnamese
• Influenced family planning practice in
more than 50 countries
• Fully incorporated into family planning
guides around the world
• Reflected in service delivery guidelines,
job aids, posters
WHO Intent for MEC
“…guidance in this document is intended
for interpretation at country and
programme levels in a manner that
reflects the diversity of situations and
settings in which contraceptives are
provided.” WHO MEC, 3rd edition, 2004
National Adaptation
1. Determine stakeholders
2. Define scope and process
3. Conduct systematic reviews of the evidence
4. Adapt guidance
5. Publish guidance document
6. Disseminate, implement, evaluate
7. Keep guidance up to date
8. Address research gaps
1. Determine stakeholders
• Federal partners
• Professional organizations
• Service provider organizations
• Training institutions
• Advocates
• Range of providers
• Researchers
• Others
2. Scope and Process • Current WHO MEC contains > 1800
recommendations
• No need to adapt the majority of recommendations
Science is the same
Recommendations widely used around the world, including US
• CDC accepted majority of WHO recommendations for US
• Exceptions: existing WHO recommendations that may need to be adapted for the US context
2. Scope and Process
• Compared WHO guidance with standard practice
guides in US
• Talked to key family planning providers in US
• Small expert meeting
• Identified
existing WHO recommendations that may
need adaptation for best implementation in US
new medical conditions to consider adding
3. Systematic Reviews
• Conducted for each recommendation
Existing recommendations to adapt
New recommendations to add
• Same methods as for WHO
Comprehensive literature search
Followed standard guidelines for systematic reviews
USPSTF grading system for quality of evidence
• Peer review
4. US Adaptation of MEC
• Expert meeting, Feb 17-19, 2009
~35 FP experts from US
• For each topic:
Systematic review presentation
Expert presentation
Discussion
Draft recommendation
Priority research gaps
• Rationale for adaptation
New evidence
US context
US MEC
Existing WHO guidance
• Breastfeeding and hormonal methods
• Valvular heart disease and IUDs
• Postpartum IUD insertion
• Ovarian cancer and IUDs
• Fibroids and IUDs
• DVT/PE and hormonal methods and IUDs
New Medical Conditions
• Rheumatoid arthritis
• Endometrial
hyperplasia
• Inflammatory bowel
disease
• Bariatric surgery
• Solid organ
transplantation
• Peripartum
cardiomyopathy
6. Disseminate, implement, evaluate
• Dissemination meeting with stakeholders
• Work with partners
• Dissemination and implementation strategy
• Job aids and tools
• Evaluation
US Medical Eligibility Criteria for Contraceptive Use
More to come - PDA version, wheel, speaker
slide sets
Reach out to provider groups
Training curricula
Board exams, Maintenance of
Certification
7. Updating guidance • Updates triggered by
New evidence
Updated recommendations from WHO
• CHC and postpartum period
Triggered by WHO update
US consultation
Reviewed evidence and updated WHO
guidance
Adapted guidance for US
Published as MMWR
• Hormonal contraception and HIV
Resources
• WHO evidence-based family planning
guidance documents:
http://www.who.int/reproductivehealth/publicat
ions/family_planning/en/index.html
• CDC evidence-based family planning
guidance documents:
http://www.cdc.gov/reproductivehealth/UnintendedPre
gnancy/USMEC.htm