From March 7–11, 1994, a scientific working group of 26 reproductive health
experts from 16 countries met at the World Health Organization (WHO) in Geneva,
Switzerland, to review current clinical and epidemiological data on selected methods of
contraception. As a result, the group has issued a draft report, Improving Access to
Quality Care in Family Planning. Eligibility Criteria for Initiating Use of Selected
Methods of Contraception, to provide guidance to policy makers, family planning
program managers and the scientific community in updating the eligibility criteria for the
initiation of low-dose combined oral contraceptives (COCs), progestin-only oral
contraceptives, DMPA, Norplant implants and copper-containing IUDs. The final draft of
this report will be printed and circulated widely in approximately one to two months.
All available clinical and epidemiological data were carefully reviewed to weigh the
risk-benefit ratio of using each method in the presence of specific
"conditions." "Conditions" were defined as both a woman's
characteristics (e.g., age, history of pregnancy) and known preexisting
medical/pathological conditions (e.g., diabetes, hypertension). The presence of conditions
affecting eligibility for use of a contraceptive method were ranked according to the
following four categories:
- A condition for which there is no restriction for the use of the contraceptive method
- A condition where the advantages of using the method generally outweigh the theoretical
or proven risks
- A condition where the theoretical or proven risks usually outweigh the advantages of
using the method
- A condition which represents an unacceptable health risk associated with the use of the
contraceptive method
Based on this classification system, a three-column table
format was developed which classifies eligibility criteria for initiating use of specific
methods. Column one of the table specifies the condition being considered.
Column two classifies the condition into one of the four categories
described above ranging from one to four. Column three gives a brief rationale for the
classification assigned.
These tables may serve as a guide to the service provider. For example, if a client
presents with hypertension, malaria or sickle cell disease, and the initiation of low-dose
COCs (containing <50 µg of ethinyl estradiol) is being considered, the following table
would apply:
CONDITION |
CATEGORY |
RATIONALE/COMMENTS |
| Essential Hypertension |
- Mild hypertension (<180/105)
|
2 |
COC causes only small
changes in blood pressure among non-hypertensive women. Primary concern is risk of
underlying vascular disease and additional risk of thromboembolism. The health
risk/benefit ratio is dependent upon the severity of the condition. |
- Moderate and severe hypertension
|
3 |
|
|
3/4 |
| Malaria |
1 |
Not relevant for eligibility for
this contraceptive method. No need for restriction of COC use. |
| Sickle Cell Disease |
3 |
Women with sickle cell disease are
at increased risk of thrombosis. |
The working group also developed a table format that classifies eligibility criteria by
condition for all of the methods considered. For example:
CONDITION |
COC1 |
POP2 |
DMPA3 |
NORPLANT |
IUD |
| Age |
| |
<40=1 |
<16=2 |
<16=2 |
<16=2 |
<20=2 |
| |
>40=2 |
>16=1 |
>16=1 |
>16=1 |
>20=1 |
| Parity |
|
|
1 |
1 |
1 |
1 |
2 |
|
|
1 |
1 |
1 |
1 |
1 |
| STDs: current or within three months |
1 |
1 |
1 |
1 |
4 |
| HIV/AIDS |
|
|
1 |
1 |
1 |
1 |
3 |
|
|
1 |
1 |
1 |
1 |
3 |
|
|
1 |
1 |
1 |
1 |
3 |
1 Combined oral contraceptive 2Progestin-only
pill 3Depot-medroxyprogesterone acetate (injectable)
This WHO classification system is intended to be adapted for use at the country-program
level. For example, the four-category classification system, which would be appropriate
for use where the necessary clinical judgment could be provided, may be simplified into a
two-category (yes/no) system for use in situations where clinical judgment is limited,
such as in community-based services.
CLASSIFICATION |
WITH
CLINICAL JUDGMENT |
WITH
LIMITED CLINICAL JUDGMENT |
1 |
Use method in any circumstances. |
Yes |
2 |
Generally use the method. |
Yes |
3 |
Use of method not usually
recommended unless other more appropriate methods are not available or acceptable. |
No |
4 |
Method not to be used. |
No |
For the future, WHO will collaborate with other international agencies
to address medical criteria for both initiation and continuation of all available
contraceptive methods, including levonorgestrel IUDs, NET-EN, combined once-a-month
injectables, barrier methods, female and male sterilization, natural family planning,
withdrawal, and emergency postcoital oral contraceptive regimen.
2 World Health Organization (WHO). Improving
Access to Quality Care in Family Planning. Eligibility Criteria for Initiating Use of
Selected Methods of Contraception: Combined oral contraceptives, Progestin only pills,
DMPA, Norplant implants and Copper IUDs. Draft Report. Geneva, WHO, November 1994.
