Family Planning Including Contraceptive Choice and Quality of Care Print E-mail
Although the proportion of couples in developing regions of the world with access to safe and effective methods of contraception has risen significantly in recent decades, an estimated 120 million couples who want to postpone or avoid childbearing are not using any method to do so.  Similar numbers are in need of a more effective or appropriate method than the one they are currently using. Together with partners such as UNFPA and the International Planned Parenthood Federation (IPPF), WHO works to broaden choices among safe, effective, acceptable and affordable family planning methods and to improve the accessibility and quality of care.

Family Planning Including Contraceptive Choice and Quality of Care

Among other topics, the clinical and behavioral research supported by WHO is aimed at improving the safety and efficacy of existing methods such as hormonal pills and emergency contraception and investigating new methods (especially for men), developing better approaches to ensure dual protection from pregnancy and STIs (such as vaginal microbicides), identifying reasons for improper use and discontinuation of contraceptive methods that result in unintended pregnancies, and promoting culturally sensitive counseling techniques and clinical practices. 

Guidelines for providers

Intended for policy makers, program managers and the scientific community, Medical Eligibility Criteria for Contraceptive Use (2004) is the third edition of this widely distributed resource for standard-setting in family planning. Designed as a guide for providers in national family planning programs and NGOs, the book sets out detailed criteria for determining whether individual clients are medically eligible to use, or continue using, a particular contraceptive method. These criteria are proposed with the understanding that denying clients the method of their choice also poses risks. Tables identify the eligibility criteria of each method for clients with special needs or concerns (e.g., smokers, breastfeeding women, adolescents, clients with multiple partners), including oral and injectable contraceptives, emergency contraceptive pills, intrauterine devices, barrier methods (male and female condoms, diaphragms, etc.), fertility awareness (rhythm), lactational amenorrhea, coitus interruptus (withdrawal), and male and female sterilization.  New evidence and guidance updates are included.

Selected Practice Recommendations for Contraceptive Use (2004) was created as a companion piece to the Medical Eligibility volume for designing service delivery guidelines for national programs. Special attention is paid to issues of service quality and access that affect contraceptive adoption and use.  These two guidelines will be joined by two forthcoming tools for health-care providers: the Decision-Making Tool for Family Planning Clients and Providers (2004) and a Handbook for Family Planning Providers (2004). Together, the guidelines and tools comprise WHO's four cornerstones of evidence-based guidance for family planning.  They may be consulted in conjunction with a basic text, The Essentials of Contraceptive Technology (2001), which explains the fundamentals of how contraceptive methods work and includes advice for providers on assisting clients with method choice and on encouraging continuation or method switching, as appropriate.

The urgent need for family planning providers to address the problem of STIs/RTIs and HIV/AIDS is addressed in at least five key publications. The first three: The Female Condom: A Guide for Planning and Programming (2000) together with a WHO Information Update on Considerations Regarding the Reuse of the Female Condom (2002) and The Male Latex Condom (1998) answer basic questions about the safety, effectiveness and acceptability of condom use. They also offer training tools for providers on how to communicate information on dual protection with diverse clients in a variety of settings. 

Two additional reports, Exploring Common Ground: STI and Family Planning Activities (2001) and Integrating STI Management into Family Planning Services: What are the Benefits? (1999) address issues of promoting dual protection within the health system. They spell out the rationale for integrating STI and family services and note its implications for clients and providers, such as counseling family planning clients on sexual health and STI protection with partners, promoting male or female condom use, and performing gynecological examinations, syndromic diagnosis and STI treatment or referrals. Methods of assessing the impact of integration on both STI and family planning care address topics such as client case load, changes in contraceptive method mix, and the impact of these changes on service quality and client satisfaction.

WHO continues to support research on the efficacy and safety of emergency contraception (EC) (hormonal pills taken within 72 hours of unprotected intercourse) and on appropriate delivery systems for EC. In addition to literature reviews and updates on the RHL and on the RHR website, useful guidelines can be found in the previously mentioned Medical Eligibility Criteria for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use mentioned above. 

The Reproductive Health Database in the RHL contains reviews and commentaries on emergency contraception, intrauterine devices, hormonal contraception and tubal sterilization. Consult the Effectiveness Summaries for conclusions on the efficacy of particular forms of care. For example, under "forms of care with a tradeoff" one finds that "immediate insertion of intrauterine device (IUD) following abortion rather than interval insertion (a few weeks after an abortion) may be associated with higher expulsion rates but ... may be worthwhile considering the low rate of women coming back for IUD insertion after a few weeks." (See also Post-Abortion Family Planning: A Practical Guide for Programme Managers, 1997, on this topic.) Many other useful findings are listed in the RHL.

Policies and strategic plans

Planners interested in improving contraceptive services at the national or district level should consult Making Decisions about Contraceptive Introduction: A Guide for Conducting Assessments to Broaden Contraceptive Choice and Improve Quality of Care (2002). Employing the Strategic Approach (see National Policies and Strategic Plans below) for introducing new contraceptive methods such as hormonal implants or emergency contraception into existing family planning programs, the manual describes three stages of work using a participatory process with stakeholders within a systems framework for assessing family planning needs and resources and introducing changes. An extensive set of appendix topics covers issues such as obtaining technical and financial support for an assessment, writing a background paper, engaging in field work, observing client-provider interactions, and analyzing the data.

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