The January 1995 issue of the MAQ Bulletin featured an article on a
classification system developed by a scientific working group at the World Health
Organization (WHO) in Geneva, Switzerland, in March 1994, to provide guidance to
policymakers, family planning program managers and the scientific community in updating
eligibility criteria for the initiation of selected methods of contraception. In May 1995,
a second scientific working group meeting was held and a final report produced.1
The 1995 report includes eligibility criteria for both initiation and
continuation of a wide range of family planning methods: low-dose combined oral
contraceptives (COCs), combined injectable contraceptives (CICs), progestin-only pills
(POPs), depot medroxyprogesterone acetate (DMPA), norethindrone enanthate (NET-EN),
Norplant® implants (NOR), emergency contraception (emergency contraception pills and
emergency use of IUDs), copper intrauterine devices (Copper IUDs), the levonorgestrel IUD
(LNG-IUD), female and male sterilization, natural family planning methods (NFP), calendar
method, coitus interruptus, barrier methods and lactational amenorrhea.
Eligibility criteria tables have been revised and expanded. For example,
criteria for use of low-dose COCs (i.e., those containing <35 µg of ethinyl
estradiol) in clients with hypertension have been revised and more clearly delineated.
Guidelines for Use of COCs in Clients with
Hypertension
The following simplified guidelines, adapted from the WHO report, may be
applied in situations where clinical experience is limited, such as in community-based
services:
Low-dose COCs should not be used if the following conditions are present:
Summary tables have been updated and expanded to include additional family
planning methods. For example, criteria listed in Table 1
apply for STDs.
In a new section on voluntary sterilization, conditions or circumstances
relevant to the timing of the procedure or selection of the facility where the procedure
should be performed have been defined according to four categories, as shown in Table 2.
Table 1. WHO Medical Eligibility Criteria
for STDs
| Condition |
CIC |
COC |
POP |
NET-EN
DMPA |
NOR |
Copper
IUD |
LNG-
IUD |
| STDs |
|
|
|
|
|
|
|
| Current or within 3 months (including purulent cervicitis) |
1 |
1 |
1 |
1 |
1 |
4 |
4 |
| Vaginitis without purulent cervicitis |
1 |
1 |
1 |
1 |
1 |
2a |
2b |
| Increased risk of STDs (e.g., multiple partners or partner who has
had multiple partners) |
1 |
1 |
1 |
1 |
1 |
3 |
3 |
a Where background incidence of STDs is high,
vaginitis may indicate STD.
b Continued use of an IUD depends on the client’s current
risk factors for STDs and PID and her informed choice.
Note: Conditions affecting eligibility for use of each
contraceptive method are ranked according to the following four categories:
1 = No restriction for use of the contraceptive method.
2 = Advantages of using the method generally outweigh the risks.
3 = Risks usually outweigh the advantages of using the method.
4 = Unacceptable health risk associated with using the method.
Table 2. WHO Voluntary Sterilization Categories
| WHO Voluntary
Sterilization Categories |
Definitions |
Examples |
| A(Accept) |
No medical reason to deny sterilization |
Age <35 (Clients of any reproductive age are
eligible for voluntary sterilization) |
| History of deep venous thrombosis/pulmonary embolism |
| C(Caution) |
Conduct procedure in a routine setting, but use extra
preparation and precautions. |
Nonvascular diabetes |
| D(Delay) |
Delay procedure until condition is evaluated and/or
corrected. Provide alternative temporary methods of contraception. |
A current STD (including purulent cervicitis) |
| S(Special) |
Undertake procedure in a setting where an
experiences surgeon and staff, equipment to provide general anesthesia and other backup
medical support are available. For these conditions, the capacity to decide on the most
appropriate procedure and anesthesia regimen are also needed. Provide alternative
temporary methods of contraception, if referral is required or there is otherwise any
delay. |
Coagulation disorders |
| Chronic lung disease (relevant only for female
sterilization) |
WHO Medical Eligibility Criteria:
Summary and Main Conclusions
Many restrictions on the use of high-dose COCs (i.e., those
containing a high dose of estrogen) do not apply to low-dose COCs.
Eligibility criteria for progestin-only methods are different
from those for combined estrogen/progestin methods. For example, use of COCs is more
restrictive than progestin-only contraception for women with the following conditions:
breastfeeding, hypertension, venous thromboembolism, stroke and complicated heart disease.
Risk of STDs is the main factor restricting the use of IUDs. Most
medical conditions are not contraindications for IUD use.
Age alone is not a sufficient criterion for denying a woman any
of the contraceptive methods.
Irregular menstrual bleeding generally does not disqualify a
woman from using any method.
Unexplained vaginal bleeding should be evaluated before deciding
whether or not a woman can use a method.
Unless otherwise described in the WHO document, clinical and
laboratory diagnostic tests are not considered mandatory for the safe use of the
contraceptive methods reviewed as long as the client’s history is taken correctly.
|
1 World Health Organization (WHO). 1995.
Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for
Initiating and Continuing Use of Contraceptive Methods . WHO: Geneva. (The final report,
which contains complete tables and reference citations, is expected to be published and
distributed in early 1996. You may obtain this report from the Unit of Family Planning and
Population, Family and Reproductive Health, World Health Organization, Avenue Appia, 1211,
Geneva 27, Switzerland.)
