Contraceptive delivery tool for humanitarian settings

Publication date: 2018

CONTRACEPTIVE DELIVERY TOOL FOR HUMANITARIAN SETTINGS About this tool This tool is comprised of a wheel and jacket to be used by front-line providers to help women initiate contraception. The wheel provides guidance regarding “who” can use contraceptive methods and the jacket provides guidance regarding “how” to use these methods safely and effectively. The information on the wheel and jacket is adapted from Medical eligibility criteria for contraceptive use (MEC) 5th edition (2015) and Selected practice recommendations for contraceptive use: 3rd edition (2016), respectively, two of WHO’s evidence-based guidelines. These documents contain in-depth recommendations about other contraceptive methods, conditions and medically-relevant characteristics that are not included in this tool. How to use this tool The wheel matches up the contraceptive methods, shown on the inner disk, with specific medical conditions or characteristics shown around the outer rim. The numbers 1, 2, 3, 4 shown in the viewing slots correspond to recommendations, telling you whether the individual who has this known condition or characteristic is eligible to initiate this contraceptive method. The recommendations are explained on the front of the wheel. Number 1 means: “Use method in any circumstance”, number 2 means: “Generally use method. Benefits outweigh risks”. Both 1 and 2 are coloured green to show that the method can be used. Number 3 means: “Use of method not generally recommended unless other more appropriate methods are not available or not acceptable”. Number 4 means: ”Method not to be used”. Both 3 and 4 are coloured red to show that the method should not be used. If a recommendation is 2-3, greater clinical judgement will be needed and careful follow-up may be required. Recommendations that have caveats are annotated with a letter superscript corresponding to additional explanations provided on the back of the wheel. Once contraceptive method eligibility has been established, the jacket may be reviewed regarding other considerations, such as counseling, possible medical tests required, and timing for initiating the method. The back of the jacket has a chart comparing effectiveness of a broad range of contraceptive methods, including methods described in the MEC document but not on the wheel. More effective Less than 1 pregnancy per 100 women in 1 year Less effective About 30 pregnancies per 100 women in 1 year How to make your method more effective Implants, IUD, female sterilization: After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months Injectables: Get repeat injections on time Lactational amenorrhea method, LAM (for 6 months): The baby is fully or near fully breastfed Pills: Take a pill each day Patch, ring: Keep in place, change on time Condoms, diaphragm: Use correctly every time you have sex Fertility awareness methods: Abstain from sex or use condoms on fertile days. The Standard Days Method or TwoDay Method can also be used. Withdrawal, spermicides: Use correctly every time you have sex Comparing Effectiveness of Family Planning Methods Abbreviations BMI: body mass index, calculated weight (kilograms) divided by height (meters squared) COC: combined oral contraceptive (pill) Cu-IUD: copper-bearing intrauterine device DMPA (IM): depot medroxyprogesterone acetate-intramuscular DMPA (SQ): depot medroxyprogesterone acetate-subcutaneous ECP: emergency contraceptive pill ETG: etonogestrel LNG: levonorgestrel MEC: Medical eligibility criteria for contraceptive use document NET-EN: norethisterone enanthate PEP: post-exposure prophylaxis SPR: Selected practice recommendations for contraceptive use document STI: sexually transmitted infection UPA: ulipristal acetate (UPA) CONTRACEPTIVE DELIVERY TOOL FOR HUMANITARIAN SETTINGS WHO/RHR/18.27 © World Health Organization 2018 Some rights reserved. 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Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Contraceptive delivery tool for humanitarian settings. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at Sales, rights and licensing. To purchase WHO publications, see To submit requests for commercial use and queries on rights and licensing, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland Implants (0.05) Female sterilization (0.5) Injectables (6) Patch (9) Male condoms (18) Female condoms (21) Withdrawal (22) Numbers in parentheses indicate % of women experiencing an unintended pregnancy during the first year of typical use of contraception. Source: Trussell J., 2011 IUD (0.8) Vasectomy (0.15) LAM (2) Vaginal ring (9) Diaphragm (12) Fertility awareness methods (24) Spermicides (28) Pills (9) Emergency contraception Repeated ECP use is an indication that the woman requires further counselling on other contraceptive options. Repeated ECP use may be harmful for women with medical conditions or characteristics classified as 2, 3 or 4 for contraceptives containing hormones. An advance supply of ECPs may be given to ensure that she will have them available when needed and can take them as soon as possible after unprotected intercourse. Intimate partner violence can interfere with a woman’s use of family planning Suspect violence if she has repeated unwanted pregnancies or medical terminations, or difficulties adhering to correct use of contraception, or repeated STIs. In this case, ensuring privacy, ask in a non judgemental way (see reference below on how to ask). If a client is experiencing violence provide first-line support using LIVES: L isten empathetically and without judgement I nquire about her needs and concerns and respect her choices V alidate. Show her that you understand and believe her E nhance Safety. Identify her risks and help her develop a plan to protect herself/her children. S upport. Connect her to information, services and social support as needed. Help her choose a method of contraception that would be harder for her partner to interfere with, e.g. injectables/depo, implants, copper-hormonal IUDs. For detailed information see : Family Planning: A global handbook for providers (2018 edition) pp. 360-364. Management of missed pills Considerations for initiating contraception If already using contraception and switching to one of these methods below, refer to SPR document to determine if contraceptive protection is needed before new method becomes effective. Cu-IUD LNG/ETGIMPLANTS DMPA NET-EN COC POP Examinations or tests before initiation STI risk assessment*; Pelvic/genital examination Blood pressure screening, if available** Blood pressure screening, if available** Blood pressure screening, if available** Blood pressure screening, if available** When to start if the provider is reasonably certain that the woman is not pregnant (see previous page for explanation) Anytime Anytime Anytime Anytime Anytime Number of days to use barrier contraception or abstain from sex if initiating method >5 days after menses started 0 days 7 days 7 days 7 days 2 days When to start after levonorgestrel emergency contraception Immediately Immediately Immediately Immediately Immediately When to start after ulipristal emergency contraception Immediately 6 days 6 days 6 days 6 days When to start postpartum (after a vaginal or cesarean birth) See Wheel See Wheel See Wheel See Wheel See Wheel When to start after abortion Immediately (except if septic abortion) Immediately Immediately Immediately Immediately Counsel regarding inconsistent use or dosing errors Examinations or tests before initiation Examinations or tests before initiation If late for re-injection, injection can be given if reasonably certain she is not pregnant, with additional protection for 7 days Examinations or tests before initiation Yes, see Management of Missed Pills Counsel about common changes in menstrual bleeding Irregular or increased amount or duration of bleeding in first 3-6 months Irregular or increased amount or duration of bleeding in first year; amenorrhoea Irregular or increased amount or duration of bleeding in first injection cycle; amenorrhoea Irregular bleeding first few months common, then bleeding lighter or more regular Irregular bleeding first few months, then regular bleeding or continued irregular bleeding Delay in return to fertility No No Yes. On average: 10 months after last DMPA injection, 6 months after last NET-EN injection No No Information regarding when the method needs to be removed or next injection due Yes, depending on device type Removal at 3 years for Implanon; 4 years for Levoplant; 5 years for Jadelle (4 years if >80 kg) Next injection: 3 months for DMPA, 2 months for NET-EN. Can be given up to 2 weeks early for both, up to 2 weeks late for NET-EN, 4 weeks late for DMPA Not applicable Not applicable Follow-up after method initiation 1st menses or 3-6 weeks following insertion; when due for removal When due for removal When due for next dose Consider follow-up in 3 months, then annually Consider follow-up in 3 months Cu-IUD for EC LNG-ECPs Combined ECPs UPA-ECPs Dose Single dose 1.50 mg LNG (or two 0.75 mg LNG tablets) 100 μg ethinyl estradiol + 0.5 mg LNG. Repeat 12 hours later 30 mg UPA Timing / Effectiveness Up to 120 hours (5 days) after unprotected intercourse As early as possible, within 120 hours after unprotected intercourse. The longer the delay in taking the ECPs, the lower the effectiveness. Combined ECPs are less effective and have more side-effects than LNG-ECPs and UPA-ECPs General eligibility Same as for general Cu-IUD insertion All women. Category 2 for history of severe cardiovascular disease, migraine, and severe liver disease Post rape Do not use when high risk of STI Use and consider adding HIV PEP for women presenting within 72 hours of sexual assault Breastfeeding Continue Continue Continue Express your milk and discard it for 1 week after taking pill * STI risk assessment may entail medical history and physical examination. Risk of STIs varies by individual behaviour (number of partners, use of condoms) and local STI prevalence. Therefore, while many women at increased risk of STIs can generally have an IUD inserted, some women at increased risk (very high individual likelihood) of STIs should generally not have an IUD inserted until appropriate testing and treatment occur. ** It is desirable to have blood pressure measurements taken before initiation. However, in some settings, blood pressure measurements are unavailable. In many of these settings, pre- gnancy morbidity and mortality risks are high, and hormonal methods are among the few methods widely available. In such settings, women should not be denied use of hormonal methods simply because their blood pressure cannot be measured. Considerations for follow-up after contraception initiation Follow-up visits or contacts should include, at a minimum, counselling to address issues such as side-effects or other problems, correct and consistent use of the method, and protection against STIs. Additional assessment may be appropriate. How to be reasonably certain that a woman is not pregnant NO YES 1. Do you have monthly menses AND have you abstained from intercourse since your last period? 2. Did your last period start within the last 7 days? 3. Have you been using a modern contraceptive method consistently and correctly? 4. Have you had a baby in the last 4 weeks? 5. Have you had a miscarriage or abortion within the past 7 days? 6. Did you have a baby less than six months ago AND you are fully or nearly fully breastfeeding AND you have had no period since then? As soon as the woman answers “YES” to any of these questions, you can be reasonably sure she is not pregnant and she is eligible to begin any contraceptive method. Highly reliable urine or blood pregnancy tests are often extremely useful, if available. Pelvic examination, where feasible, is reliable 8-10 weeks since the first day of the last menstrual period. In situations in which the healthcare provider is uncertain whether the woman might be pregnant, the benefits of initiating ENG or LNG implant, DMPA or NET-EN injection and COC likely exceed any risk; therefore, starting the method should be considered at any time, with a follow-up pregnancy test in 2-4 weeks. For IUD insertion, in situations in which the healthcare provider is not reasonably certain that the woman is not pregnant, the woman should be provided with another contraceptive method to use until the healthcare provider can be reasonably certain that she is not pregnant. Missed pills Action Additional protection Note Combined oral contraceptives - COC Missed 1 active (hormonal) pill, or starts a pack 1 day late Take an active (hormonal) pill as soon as possible, then continue taking pills daily, 1 each day No additional contraceptive protection needed Missed 2 active (hormonal) pills in a row, or starts a pack 2 days late Take 2 hormonal pills together – the missed pill and the dose for the current day No additional contraceptive protection needed Missed 3 or more active (hormonal) pills in a row, or starts a pack 3 or more days late Take an active (hormonal) pill as soon as possible, then continue taking pills daily, 1 each day Use condoms or abstain from sex until she has taken active (hormonal) pills for 7 days in a row. If pills missed in the 1st week and unprotected sex takes place, consider use of emergency contraception. If pills missed in the 3rd week, finish active (hormonal) pills in current pack and start new pack the next day. Do not take the seven inactive pills. Missed any inactive (nonhormonal) pill Discard the missed inactive pill. Keep taking the pill once a day. Start new pack as usual Progestogen-only pills - POP Having menstrual cycles (including those who are breastfeeding) AND missed 1 or more pills by more than 3 hours Take 1 pill as soon as possible, then continue taking pills daily, 1 each day Use condoms or abstain from sex for the next 2 days. Consider the use of emergency contraception, if appropriate In case of the 75μg desogestrel-containing pill, same guidance once pills have been missed for 12 hours Breastfeeding and amenorrhoeic AND missed 1 or more pills by more than 3 hours Take 1 pill as soon as possible, then continue taking pills daily, 1 each day If she is less than 6 months postpartum, no additional contraceptive protection is needed In case of the 75μg desogestrel-containing pill, same guidance once pills have been missed for 12 hours C hla my dia o r g eni tal or <4 weeks <6 weeks <6 months <4 weeks <6 weeks com plications, to age abnorm al treatment elevated, 90-99 or 30 kg/m2 mig rai no us w ith ou t w ith au raO an tic on vu l- ri fa m pi ci n/ o r f la re o r c ar rie r an tir et ro vir al sta ge o r p uru len t in fec tion sB postab ortion no sepsis < 18 years pap/biopsy unable to adequately au raO s an ts rif ab ut in t he ra py 3 or 4 G on orr ho ea / O the r S TIs P ast Cu rrent Postpa rtum < 48 hours 48 hours to 4 weeks to 6 weeks to <48 hours 48 hours to 4 weeks to ≥6 weeks No M enarche VIA+ or Before Current Previously 140-159/ ≥160/≥100 J BMI≥ Age <35 Ag e ≥ 35 N on - M igr ain e M igr ain e O n O n No n- pe lv ic A cu te C hr on ic On W HO 1 1 1 1 1 3 3 3 1 1 1 1 1 1 1 2 2 D 1 1 2 2 4 G 3 W 2 2 3 1K 2M 1 1 1 2 2H 1V 1- 2Q 1 1 1 1- 2 T 1 1 1 1 1 1 4 4 4 3 3 3 2 1 1 1 1 1 1 1-2 F 2 2 4 G 4 3 3 4 2 2M 2 3-4N 1 2 -3H ,P 4 3 3 1 3 /4 A ,R 1 1- 2 T 1 4 A 2 1- 2 C 4 A 4 1 3 1 1 1 3 1 1 1 2 2 1-2 D 1 E 2 1 4 A 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 2 /3 S 3A 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1 2 D 1 1 2 2 4 G 2 H 2 1 2 1 2 1 1 1 2 2 H 2U 2 1 1 1 1 -2 T 1 IN FE CT ION S DI SEA SE REL ATED S EPSIS ABORTION BIRTH PROLONGED FIBROIDS PRE-CANCER CANCER CANCER HEART SE XU AL LY TR AN SM ITT ED PE LVI C IN FLA MM ATOR Y PREGNA NCY POSTPARTUM AND BREASTFEEDING POSTPARTUM AND NOT BREASTFEEDING POST- NO PRIOR ADOLESCENT IRREGULAR, UTERINE ANAEM IA CERVICAL CERVICAL BREAST ISCHAEMIC ELEVATED BLOOD PRESSURE OBESITY DIAB ETESL SM OKI NG HE AD AC HE S EP IL EP SY T UB ER CU LO SI S V IR AL H EP AT IT IS HI V OR HEAVY DISEASE VAGINAL STROKE, d isc ha rge of VTE measure I controlled J th er ap y BLEEDING VTE Hx 1 1- 2 T 1 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 4 G 2 H 2 1 2 1 2 1 1 1 2 2 H 3U 3 1 1 Women with these additional conditions are eligible for all methods of contraception Reproductive Conditions: Benign breast disease or undiagnosed mass • Benign ovarian tumours, including cysts • Cervical ectopy (ectropion) • Dysmenorrhoea • Endometriosis • History of gestational diabetes • History of pelvic surgery, including caesarean delivery • Past ectopic pregnancy • Postpartum ≥ 6 months Medical Conditions: Depression • HIV asymptomatic or mild clinical disease (WHO stage 1 or 2) • High cholesterol • Malaria • Mild cirrhosis • Schistosomiasis (bilharzia) • Superficial venous disorders, including varicose veins • Surgery without prolonged immobilization • Taking antibiotics (excluding rifampicin/rifabutin) • Thyroid disorders • Uncomplicated valvular heart disease Other: Age ≥40 years • Breast cancer family history • Venous thromboembolism family history • High risk for HIV Refer to the full MEC document for other conditions that are not listed above or on the front of this tool that may pose risks for women considering female methods of contraception “Combined” as in combined hormonal contraception, refers to a combination of ethinyl estradiol and a progestogen BMI: Body mass index; weight (kg) divided by height (m2) DMPA (IM, SC): depot medroxyprogesterone acetate ETG: etonogestrel MEC: Medical eligibility criteria for contraceptive use document SPR: Selected practice recommendations for contraceptive use document VIA: visual inspection with acetic acid (for cervical cancer screening) VTE: venous thrombo-embolism WHO stage 3 or 4: severe or advanced HIV clinical disease Explanations A If condition develops while using method, can continue using it during treatment B For women, genital infections refer to trichomonas vaginalis and bacterial vaginosis. For men, genital infections refer to internal (testes) and external (penis, scrotal skin) infections C If had pregnancy after pelvic inflammatory disease, IUD =1, if no pregnancy after, IUD =2 D If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected and has not been evaluated, IUD=4 (if already using IUD, may continue to use); implants and DMPA/NET-EN =3 E If uterine cavity distorted preventing IUD insertion, IUD =4 F If sickle cell disease =2 G If disease in the past and no evidence of disease for 5 years, hormonal method =3 H If ischemic condition developed while on this method, consider switching to non-hormonal method; for acute VTE=3 I If history of high blood pressure only during pregnancy and current blood pressure is measured and normal, COC =2 and all other methods =1 J When blood pressure is measured. Either systolic or diastolic blood pressure may be elevated K If age <18 years and obese, DMPA=2 L Insulin-dependent and non-insulin dependent. If history of diabetes in pregnancy only (gestational diabetes) =1 for all methods M If complicated (kidney, eye or nerve disease) or >20 years duration, DMPA/NET- EN =3 and COC =3/4 N If <15 cigarettes/day, COC =3. If ≥15 cigarettes/day, COC =4 O Aura refers to reversible, temporary visual or sensory neurological symptoms, (seeing flickering lights, tingling or numbness on one side of the face or one limb) P If age <35, COC =2. If age ≥ 35, COC =3 Q DMPA =1 R The category recommendation should be assessed according to the severity of the condition S If clinically well =2. If not clinically well =3 T If antiretroviral therapy with EFV, NVP, ATV/r, LPV/r, DRV/r, RTV: Implants, NET-ET, COC, =2; DMPA =1. For all NRTIs, ETR, RPV, RAL each method =1. See full MEC document for antiretroviral drug abbreviations U exception: lamotrigine=1 V NET-EN=2 W For history of VTE, DMPA/NET-EN=2

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