PocketGuide: Preface

Reading Room

PocketGuide for Family Planning Service Providers

Preface

The PocketGuide for Family Planning Service Providers was designed to provide clinicians with easily accessible, clinically-oriented information for use in family planning service provision. It was intended to be used by those who need immediate answers to questions about a client's condition or a contraceptive method but cannot wait for an answer until getting to a library or other reference material.

The PocketGuide has been used in this way but clinicians throughout the world have found additional uses as well. For example, the PocketGuide is used in many inservice and preservice training programs as a reference manual. To make this valuable information available to a wider audience, we have created this online version. It contains all of the same information as the print version; the difference is the way in which users can access the information.

How to Use the PocketGuide

The information in the PocketGuide is organized according to two types of clinical situations:

When the clinician is faced with a client with special needs, such as a woman with a medical problem (e.g., diabetes) or who may need emergency contraception. Guidance is provided for commonly encountered clinical conditions as well as rare medical problems.

When information about a specific contraceptive method is required. For each method, information such as the mechanism of action, characteristics and conditions requiring precaution is followed by instructions for management of common side effects and other problems. We have divided method characteristics into benefits and limitations; such divisions are subjective and while our decisions were based on field experience, for some clients our choices may not hold true.

In addition, the user is provided with supplemental information on counseling, client assessment and client instructions which s/he will need when working in the clinic or office.

Finally, essential information has been included for reference when providing services which involve:

procedures requiring use of recommended infection prevention practices; or
STDs, including genital tract infections (GTIs)

Design of the PocketGuide

More information exists on family planning methods, especially combined oral contraceptives (COCs) and IUDs, than for almost any medical subject. Unfortunately, this information is not always easily accessible, nor is it written and arranged in a "user friendly" manner. To correct these problems, the information in the PocketGuide is limited to the essentials. A detailed table of contents makes it easy to find what is needed for a given clinical situation while links guide the user to additional information.

Medical Criteria for Use of Contraceptive Methods

A contraindication is a condition or a disease that makes a drug or treatment unsafe or inadvisable for a client. In the past, to protect the client from contraceptive complications, lists of contraindications had been developed for each contraceptive method. Although such lists were produced with the best interest of the client in mind, potentially serious, but often rare complications were overemphasized.

In addition, while contraindications change over time, the lists tend to become permanent. (The same is true to a certain extent for lists of indications.) Moreover, what may be an appropriate contraindication in one country may not be appropriate when applied to a setting that has different reproductive health characteristics. Finally, in many countries, new information is slow in arriving and the contraindication list remains the standard for many years.

In the PocketGuide, we have chosen to replace contraindications with conditions requiring precaution. Making this change, however, does not solve the problem of "lists" entirely. Therefore, in addition to listing the indications and those conditions requiring precaution, a brief statement is included explaining the rationale for categorizing the condition as such.

World Health Organization Classification System

During 1994-1995, a series of working group meetings was held at the World Health Organization (WHO) to review medical criteria for initiation and continuation of all commonly available methods of contraception including voluntary sterilization (VS). The members of these scientific working groups developed a classification system and applied it to all methods of contraception (a separate system was developed for VS procedures-see the Voluntary Sterilization chapter). In the resulting classification system, the suitability of different contraceptive methods is determined by weighing the health risks and benefits relative to specific "conditions." (A condition is defined to include both a woman's biologic characteristics such as age or reproductive history and any known, pre-existing medical problem(s) such as diabetes or hypertension.)

The presence of a specific condition affecting eligibility for using a contraceptive method falls into one of four categories:

WHO Classification System

WHO CLASS	DEFINITION	EXAMPLE (FOR COCs)
Class 1: Use the method in any circumstance	A condition for which there is no restriction for the use of the contraceptive method.	Varicose veins
Class 2: Generally use the method.	A condition where the benefits of using the method generally outweigh the theoretical or proven risks.	Blood pressure <160/100
Class 3: Use of the method not usually recommended unless other more appropriate methods are not available or acceptable.	A condition where the theoretical or proven risks usually outweigh the benefits of using the method.	Blood pressure >160/100
Class 4: Method should not be used.	A condition which represents an unacceptable health risk associated with the use of the contraceptive method.	Pregnancy

Assessing Unexplained Vaginal Bleeding

Serious pathologic problems (tumors and cancer) are uncommon in women of reproductive age, especially those younger than age 35. For example, unexplained vaginal bleeding in women of this age group is most often due to a pregnancy-related problem (e.g., spontaneous or incomplete abortion or a tubal pregnancy) or a functional disorder such as anovulation. Therefore, only women with unexplained vaginal bleeding that the service provider strongly feels could be caused by a serious problem need to be evaluated before starting a contraceptive method. Women with irregular menstrual bleeding patterns, which are not suspected of being serious, can use any contraceptive method without restriction (WHO Class 1).

Special Note on Combined Injectable Contraceptives (CICs)

With the second edition of the PocketGuide, we have included CICs (Cyclofem and Mesigyna) for the first time. Although CICs, which contain an estrogen and a progestin, are a relatively new contraceptive method, there is little epidemiologic data on their long-term effects. There is, however, no reason to believe that clients will have more problems with CICs than with COCs-only different and perhaps less serious problems. For example, with CICs, unlike COCs, estrogen is only available during the first 8-11 days following an injection and the levels more closely mimic those during the normal menstrual cycle. As a consequence, cycle control is not quite as good (more breakthrough spotting and bleeding days and amenorrhea) as compared with COCs (see Client Assessment Chapter: Women with Acceptable Bleeding Patterns). However, the more physiologic estrogen dose in CICs has been found to cause less change in blood pressure, blood clotting, lipid metabolism and liver function. On the other hand, while COCs can be stopped immediately, the effect of CICs continues for some time after the last injection.

Harmonizing the PocketGuide with International Medical Criteria

Throughout the PocketGuide, every effort has been made to harmonize the existing information in order to provide clear guidance to the service provider on the provision of family planning services and management of side effects and other problems. By providing updated knowledge and consistency among different sources of information, it is hoped that:

the competence and confidence of service providers will improve when assisting clients in making contraceptive choices,
the quality of family planning will improve (e.g., increased client satisfaction), and
access to quality contraceptive services will increase.

The PocketGuide complements the WHO classification system. For example, like the WHO system, the PocketGuide includes a brief rationale for why a particular condition is assigned to one of the four categories. (For the reader's convenience, the WHO classification for each condition is included throughout the PocketGuide.)

The rationales included in this PocketGuide are adapted not only from those presented in the most recent WHO document but also from those provided in the manual, Recommendations for Updating Selected Practices in Contraceptive Use (Volume 1), produced by the USAID Technical Guidance Working Group (November 1994), and selected references from the international literature on contraceptive technology.

Back to PocketGuide for Family Planning Service Providers