Many women and men have chronic medical conditions
that should be considered when they choose a contraceptive method or decide to have
children. Family planning providers need to be aware of a client's chronic condition and
counsel accordingly.
Because most studies of contraceptives leading to marketing approval are conducted
among healthy people, information about contraception in people with chronic medical
problems is often lacking. As a result, some providers may recommend contraceptive methods
that seem more appropriate for a person with a chronic health problem than other available
choices, but are less safe or effective than other choices. For example, a provider may be
overly cautious by recommending that a couple use barrier methods instead of oral
contraceptives, fearing that the hormones in the pill may worsen the woman's medical
condition when they may not.1
In fact, as is true for healthy women, most contraceptive methods are safer than an
unintended pregnancy for women with chronic medical conditions. Thus, when counseling
clients about their contraceptive choices, providers need to strike a careful balance
between the benefits and risks, safety, acceptability and effectiveness of various methods
versus the risks of pregnancy. A method that is very safe to use but not very effective
could expose some women to a high-risk pregnancy.
The articles in this issue of Network consider major chronic diseases that have
important implications for making contraceptive choices. Chronic conditions commonly found
in many countries worldwide include hypertension, diabetes, epilepsy, serious headaches,
malaria and other tropical diseases. For example, parasitic worms, malaria or hypertension
each affect more than 500 million people worldwide.2 Other
chronic problems, including mental or physical disabilities and risk of transmission of
sexually transmitted diseases, are also addressed.
Providing quality reproductive health services for clients with chronic conditions can
be a complex process involving several important considerations. If a woman with a chronic
medical condition becomes pregnant, the pregnancy itself may worsen her medical problems.
Treatments can harm mother or fetus during a pregnancy. If a woman with a chronic
condition uses contraception, however, some methods may exacerbate her medical condition
or related complications. Finally, a medical condition or its treatment can affect the
efficacy of a contraceptive method.
Other key issues that providers need to consider when serving clients with chronic
diseases or conditions include the following:
Contraceptive options -- As noted, a person with a chronic disease may not be as
free as a healthy person to use a particular method. If a woman with a chronic condition
prefers a hormonal method, providers should keep in mind that not all hormonal methods are
the same. Some contain estrogen, which acts upon many different organ systems and has a
wide range of effects that could be relevant to her condition. Other hormonal methods do
not contain estrogen, or have very low doses, and can be free of such effects on organ
systems.
Counseling -- Given the potential interactions of disease and various
contraceptive methods, people with chronic problems generally require more contraceptive
counseling than do healthy people. In addition to health risks and benefits from each
method, counseling should consider the couple's unique situation, including the woman's
ability to conceive, appropriate timing for a pregnancy if desired, and ability of the
woman or man to comply with a contraceptive regimen.
In-depth counseling is particularly important for women with chronic diseases that pose
serious risks in case of pregnancy. If such women choose to use a barrier method, for
example, counseling should emphasize consistent and correct use of the method in order to
prevent an unintended pregnancy.
Multiple conditions -- Not infrequently, a client has more than one chronic
disease or condition. For example, a diabetic woman may also have vascular conditions such
as hypertension or ischemic heart disease. Providers should remember that each disease or
condition may have different risks posed by pregnancy or contraceptive use, and each must
be considered.
Not only is effective contraception important, but people with chronic diseases may
need the services of other professionals, usually physicians, and sometimes highly
specialized care for a particular disease or condition. Those who specialize in
reproductive health care should help clients with chronic diseases or conditions to obtain
other appropriate medical services.
-- Kim Best
References
- Grimes DA, Mishell DR Jr, Speroff L. Introduction. Am J Obstet
Gynecol 1993;168(6, part 2):1979.
- World Health Organization. The World Health Report 1998. Life in the
21st Century. A Vision for All. (Geneva: World Health Organization, 1998)48.
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