Recommendations for Contraceptive Use
		Introduction

A. Purpose of this Document

These recommendations are part of United States Agency for International Development's (USAID) broader efforts to improve quality and access in family planning (FP) programs under the Maximizing Access and Quality (MAQ) Initiative. They have been developed by the Technical Guidance/Competence Working Group (TG/CWG) in collaboration with World Health Organization (WHO) to help update service delivery guidelines and to make them consistent with current clinical and epidemiological evidence. The intention of this document is to improve both access to and quality of men's and women's FP and related RH services through better use of resources. To help achieve this goal, this document also provides the underlying scientific rationale for each recommendation.

This document should not be viewed as constituting actual service delivery guidelines; it is intended to provide guidance for the administration of selected FP methods and related RH issues for anyone who is developing, updating, or revising FP and other RH service guidelines.

This online version combines the already published Recommendations for Updating Selected Practices in Contraceptive Use: Volumes I and II in order to allow for their wider distribution.

B. Content

This document provides four types of information:

• Contraceptive Methods
• Checklists
• Reproductive Health Issues
• Information about this document

Contraceptive Methods. This section contains information on select contraceptive methods organized in a question/answer format. The topics discussed include:

• combined oral contraceptives (COCs)
• oral contraceptives as emergency contraceptive pills (ECPs)
• combined (estrogen-progestin) injectable contraceptives (CICs)
• progestin-only pills (POPs) during breastfeeding
• progestin-only injectables (DMPA and NET-EN)
• NORPLANT^® implants
• non-hormonal intrauterine devices (IUDs)
• levonorgestrel-releasing IUDs (LNg IUDs)
• female sterilization
• vasectomy
• natural family planning (NFP)
• withdrawal
• barrier methods
• lactational amenorrhea method (LAM)

For each question posed, the document includes:

1. recommendations, and
2. the basic scientific rationale justifying the recommendations, with citations of the most relevant (preferably primary) literature.

In addition to the information included in the question/answer portion, each section includes a table that addresses the relative necessity of selected procedures prior to the initiation of the contraceptive method. The information in the tables indicates which of the procedures fall into thefollowing classes, and provides a rationale and citations for the classification.

The following four classes were established to differentiate the relative necessity of various procedures.

Class A = essential and mandatory or otherwise important in all circumstances for safe and effective use of the contraceptive method

Class B = medically/epidemiologically rational in some circumstances to optimize the safe and effective use of the contraceptive method, but may not be appropriate for all clients in all settings

Class C = may be appropriate for good preventive health care, but not materially related to safe and effective use of the contraceptive method

Class D = not materially related to either good routine preventive health care or safe and effective use of the contraceptive method

The following procedures are addressed for each contraceptive method since these procedures are the most commonly used in programs to screen clients before providing contraceptive methods:

1. Pelvic examination
2. Blood pressure
3. Breast examination
4. STD screening by lab tests
5. Cervical cancer screening
6. Routine, mandatory lab tests
7. Proper infection prevention procedures
8. Counseling

Checklists. The combined oral contraceptive (COC) and DMPA (or NET-EN) checklists are designed to determine whether clients can safely initiate use of these methods. The checklists are intended for use by health care workers in community-based service (CBS) settings. The checklists are followed by guides that provide information to program managers, policymakers, administrators and trainers about adapting and using the checklists.

Reproductive Health Issues. Information on a variety of reproductive health issues is also provided, including:  

• client-provider interaction (CPI)
• informed choice
• contraceptive method efficacy
• sexually transmitted disease (STD) risk assessment
• prevention of STDs in the context of FP services
• dual method use
• FP methods and protection against STDs
• cervical cancer prevention

Guidelines for determining with reasonable certainty that a woman is not pregnant are also included as is a summary of the WHO 1996 medical eligibility criteria for initiating use of contraceptives.¹

World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva, WHO, March 1996.

Two Related Quality of Care Concepts

It is important to note two related quality of care concepts which should also be addressed,but are not the focus of the guidance given in this document:

1. Appropriate medical eligibility criteria for use of each contraceptive method should be followed. The Recommendations for Updating Selected Practices in Contraceptive Use do not address all of the questions that deal with medical eligibility for initiation and re-administration of these methods. Therefore, it is recommended that the medical eligibility criteria compiled by the World Health Organization (WHO) be consulted for this information.* (Please note the WHO 1996 medical eligibility recommendations have been summarized.)
2. Service providers should be appropriately trained, adequately equipped, and properly supervised in order to competently deliver specific contraceptive methods, according to relevant national or institutional standards and the performance requirements for each cadre of service provider.

Information about this document. In addition to the information provided below, there is information about the people responsible for the creation of this document:

• lists of: participants' and reviewers' organizations, participants in the November 24, 1992 and May 23, 1996 meetings, and reviewers
• acknowledgments, including the list of volunteer resource persons-persons who helped substantially with the chapters (e.g. drafting the initial version of a chapter)

Limitations of the Scope of This Document

The goal of this document is NOT to produce a set of "generic" guidelines, but rather to produce a reference for service providers involved in developing and updating FP service delivery guidelines.

The participants of the November 1992 and May 1996 meetings, members of the USAID TG/CWG and other FP/RH experts, did not attempt to comprehensively cover aspects of policy, program, social, economic, and other types of barriers to FP and related RH service access and quality. Participants also did not address certain quality issues and other technical aspects of contraceptive methods not covered in this document. Such issues merit attention by policymakers, program directors, and client groups, but this document does not attempt to deal comprehensively with these concerns. Other USAID-supported activities address training, communication research, policy and service delivery initiatives necessary to improve the quality of and access to FP and RH care.

Background and Contributors

The TG/CWG of the MAQ Initiative was established with USAID support in August 1992 to provide leadership and guidance on updating selected procedures and practices in FP and other selected RH service guidelines. Since 1992, the TG/CWG has addressed the challenge of maximizing FP/RH service quality and access, through the improvement of FP/RH guidelines. As described below, this online document, Recommendations for Updating Selected Practices in Contraceptive Use combines the two products of the TG/CWG.

In November 1992, the USAID MAQ Initiative's TG/CWG convened a meeting of representativesof many of the Cooperating Agencies (CAs) of USAID. From that meeting, Volume I of Recommendations for Updating Selected Practices in Contraceptive Use was initiated. It was published in 1994 and supplied information on four contraceptive methods: COCs, progestin-only injectables, NORPLANT^® Implants and IUDs. In 1995, plans for the second volume were implemented. Published in 1997, Volume II complemented Volume I by including those FP methods not previously covered. It also includes some additional recommendations for methods that were included in Volume I as well as information on other RH issues that the working group thought would be of interest to the users of these documents. In an attempt to make the information widely available, this online version has been developed to complement the printed documents.

*To view the file, you need to download and install the free Adobe^® Acrobat^® Reader software. For the latest version of the Reader software for a variety of platforms, see the Adobe website.

Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.