Contraception

Donna Shoupe

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9781444333510
• eBook ISBN: 9781444342635
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Which method of contraception best suits your patient's needs?

Contraceptive technology has exploded at breakneck speed. The options now available can bewilder patients who need practical advice for family planning.

Contraception provides just that practical advice. Divided into three sections covering selection and cost comparison, individual methods of contraception, and risks and benefits for various patient groups, the editor presents a clear pathway to help your patients decide which method is best for them.

The book covers all available contraceptive methods with WHO Medical Eligibility Criteria of contraceptives and CDC modifications. It gives sound advice on selecting contraceptive methods for women with bleeding problems, previous ectopic pregnancy, mood and depressive disorders, hirsutism and acne, perimenopausal women, women with HIV and other STIs.

Provides an essential guide to all gynecologists, family medicine physicians and health care workers who provide contraceptive advice.

Part of the new practical Gynecology in Practice series.

Section 1: Overview

1

Contraceptive Use: Guidelines and Effectiveness

Kathryn M. Curtis, Naomi K. Tepper, and Polly A. Marchbanks

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, USA

Introduction

Clinicians are now able to rely on evidence-based guidelines to efficiently incorporate scientific evidence into clinical practice regarding appropriate selection and use of specific contraceptive methods.

Contraceptive effectiveness is also an important factor in contraceptive choice; tools are available to assist providers in communicating contraceptive effectiveness to family planning patients.

Evidence-Based Guidelines

As the volume of scientific literature rapidly expands, it has become increasingly difficult for individual clinicians to keep up with finding, reading, and interpreting new evidence to put into practice. A PubMed search using the terms “contraception” and “family planning” yielded an average of 130 new articles per month in 2010. Many clinicians rely on evidence-based guidelines to efficiently use the best scientific evidence when making decisions about patient care.

EVIDENCE AT A GLANCE

• The World Health Organization’s evidence-based guidance on contraceptive use (WHO Medical Eligibility Criteria for Contraceptive Use (MEC)) is used around the world and has been adapted by several countries, including the United States.
• The Centers for Disease Control and Prevention (CDC) has recently adapted the WHO MEC for use in the United States (US MEC). While the vast majority of the CDC recommendations are identical to the WHO recommendations, some adaptations were made to more accurately focus on methods currently available in the USA, and to better reflect the surgical and medical practices of the USA (see also Chapter 21).
• Additional sources of guidance include the National Guidelines Clearinghouse, professional organizations, and international groups.

Clinical practice guidelines have been defined by the Institute of Medicine as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.”

EVIDENCE AT A GLANCE

Guidelines that are based on a critical appraisal of the scientific literature, most often through systematic reviews and meta-analyses, are considered “evidence-based guidelines,” and have the advantage of linking the recommendation to the scientific evidence.

Evidence-based guidelines are intended to be “assistive rather than directive,” and are not meant to replace clinical judgment.

While clinical guidelines can be an efficient way for clinicians to practice evidence-based medicine, these guidelines can be difficult to find; conversely, there may be multiple guidelines on a single topic, perhaps with conflicting recommendations.

Several appraisal systems for clinical guidelines exist, but many of these systems are aimed at organizations that want to undertake a guidelines appraisal process prior to adopting a guideline for their members, rather than at individual clinicians.

Vlayen et al. have proposed 10 dimensions to be considered in any guideline appraisal instrument. We have adapted those 10 dimensions to suggest elements that individual practitioners may want to consider when assessing clinical guidelines for use in their practice (Table 1.1).

Table 1.1 Elements to consider when choosing an evidence-based clinical practice guideline

1	Validity
	a Scientific evidence: Were rigorous systematic reviews of the scientific literature conducted and used as the basis of the recommendations, including systematic search of the literature, critical appraisal and grading of the evidence according to some standard grading system, availability of the references and systematic reviews to the users of the guideline?
	b Decision-making: Are the methods for translating the evidence to recommendations clearly described?
	c Benefits and risks: Are the expected health benefits, potential harms, and alternative interventions described?
2	Reliability/reproducibility: Was the guideline sent to external experts for peer review? Has the guideline been piloted or pretested in a clinical setting? Has the process of the guideline development been documented?
3	Clinical applicability: Do the goals and rationale of the guideline meet your clinical needs? Is the guideline intended for your patient population and your provider type?
4	Clinical flexibility: Does the guideline allow for flexibility in its application? Are patient choices considered?
5	Clarity: Is the guideline clearly worded and easy to use?
6	Scheduled review: Is the date the guideline was issued included, along with a plan for scheduled review?
7	Development team: Did the guideline development team include representatives of all relevant disciplines? Was there consideration of any potential conflicts of interest among the development team, and are the sources of funding clearly documented?
8	Implementation, dissemination, and evaluation: Is there a clear plan for implementation, dissemination, and evaluation of the guideline?

Adapted from Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D. A systematic review of appraisal tools for clinical practice guidelines: multiple similarities and one common deficit. Int J Qual Health Care 2005;17:235–42.

Family planning providers frequently face difficult decisions with their patients in the provision of contraceptive methods and management of their use. Because of these challenges, there is a critical need for the use of evidence-based medicine and decision-making in the field of family planning practice.

Development of WHO Evidence-Based Guidance for Contraceptive Use

In the early 1990s, the Department of Reproductive Health and Research at WHO began addressing the need for evidence-based contraceptive guidance. WHO, the US Agency for International Development (USAID) and others were concerned about unnecessary medical barriers to contraceptive access that were not based on scientific evidence. There was particular concern about medical conditions or other characteristics that were unjustifiably perceived by providers as contraindications to contraceptive use. To address these issues, WHO developed the Medical Eligibility Criteria for Contraceptive Use (WHO MEC), first published in 1996, with the intent of improving access to, and quality of, family planning services. This guidance document is currently in its fourth edition and provides recommendations on whether women and men with specific medical conditions and characteristics can safely use various contraceptive methods; for example, whether a woman with hypertension can use combined oral contraceptives or an adolescent can use depot medroxyprogesterone acetate (DMPA).

Currently, the WHO MEC contains recommendations for 18 contraceptive methods and over 160 medical conditions or characteristics. Each medical condition and contraceptive method combination is given a classification from 1 to 4 (Table 1.2), denoting whether or not the contraceptive method is safe to use for women or men with that medical condition or characteristic.

Table 1.2 US Medical Eligibility Criteria for Contraceptive Use Classifications

Classification	Definition
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

Source: US Medical Eligibility Criteria for Contraceptive Use, 2010.

WHO also publishes the Selected Practice Recommendations for Contraceptive Use (WHO SPR) that addresses common clinical management questions for contraception. The WHO SPR currently contains 33 evidence-based questions and answers, such as when a woman can start a contraceptive method and when she needs to use a back-up method, what a woman can do if she misses oral contraceptive pills, and what tests or examinations need to be done prior to initiating a method of contraception.

In addition to these two evidence-based guidance documents, WHO also developed two documents that are intended for direct use by family planning providers.

• The Decision-Making Tool for Family Planning Clients and Providers is a flip chart meant to assist clients and providers in choosing a method of contraception.
• Family Planning: A G...

Table of contents

• Cover
• Title page
• Copyright page
• Series Foreword
• Preface
• Contributors
• Section 1: Overview
• Section 2: Individual Contraceptive Methods
• Section 3: Guidelines for Use in Selected Populations
• Index