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 Family Planning Guidance

Guidance

for

guides

Guidance

for

providers

WHO Medical Eligibility Criteria (MEC)

Purpose:

who can use

contraceptive

methods

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

Adaptation of the WHO Guidance

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 Guidelines

Adaptation of the WHO MEC:

Example from the United States

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

5. Publication

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

8. Address research gaps

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

The findings and conclusions in this

presentation have not been formally

disseminated by the Centers for

Disease Control and Prevention

and should not be construed to

represent any agency determination

or policy.