CDC created U.S. Medical Eligibility Criteria for Contraceptive Use 2010 from guidance developed by the World Health Organization (WHO) and finalized the recommendations after consultation with a group of health professionals who met in Atlanta Georgia during February 2009. This guidance comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. The majority of the U.S. guidance does not differ from the WHO guidance and covers >60 characteristics or medical conditions. However some WHO recommendations were modified for use in the United States including recommendations about contraceptive use for women with venous thromboembolism valvular heart disease ovarian cancer and uterine fibroids and for postpartum and breastfeeding women. Recommendations were added to the U.S. guidance for women with rheumatoid arthritis history of bariatric surgery peripartum cardiomyopathy endometrial hyperplasia inflammatory bowel disease and solid organ transplantation. The recommendations in this document are intended to assist health-care providers when they counsel women men and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.

U S. Medical Eligibility Criteria for Contraceptive Use 2010: adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use 4th edition.

The evidence in the demographic and family planning literature of the range and diversity of the barriers to fertility regulation in many developing countries is reviewed in this article from a consumer perspective. Barriers are defined as the constraining factors standing between women and the realistic availability of the technologies and correct information they need in order to decide whether and when to have a child. The barriers include limited method choice, financial costs, the status of women, medical and legal restrictions, provider bias, and misinformation. The presence or absence of barriers to fertility regulation is likely an important determinant of the pace of fertility decline or its delay in many countries. At the same time, barriers inhibit women's ability to avoid unintended pregnancy. Problems of quantifying barriers limit understanding of their importance. New ways to quantify them and to identify misinformation, which is often concealed in survey data, are needed for future research.

http://bixby.berkeley.edu/wp-content/uploads/2015/03/Barriers-Fertility-Regulation.pdf

Barriers to fertility regulation: a review of the literature.

This article offers a conceptual scheme that clarifies the confusion and overlap existing among the definitions of "access" "quality of care" and "medical barriers" as these terms apply to family planning (FP) programs. After an introduction the article explains that these concepts are characteristics of the supply environment and apply to any type of service delivery point. The article also bases its framework on a distinction between what happens "inside" and "outside" of the service delivery point. The article then defines the terms and discusses related issues and concerns. The next sections explore the linkages among the terms and set forth the following research priorities: 1) developing methods of "scoring" various elements of quality 2) improving methods of measuring clients perspectives of access and quality 3) verifying the population-based effects of variations among the components of the concepts and 4) validating the presumed linkages among these concepts. Finally the article enumerates the policy implications of its attempt to clarify these concepts as follows: 1) access involves more than simply geographic availability of services points 2) access and quality must be enhanced concurrently 3) quality promotion should employ a humanitarian and a demographic rationale 4) expansion of FP services to include reproductive health services will require careful consideration of medical barriers as well as monitoring of levels of quality of care and 5) that it is important to have a balanced approach.

http://www.jstor.org/stable/pdfplus/2133525.pdf

Access quality of care and medical barriers in family planning programs.

unintended pregnancy may worsen the condition and carry even greater risk of adverse pregnancy outcomes, including maternal and perinatal death. Although safe and highly effective contraceptive methods are available to prevent unintended pregnancy, there may be concerns about the safety of contraceptive methods among women with medical conditions. The Centers for Disease Control and Prevention (CDC) has recently developed the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, which provides evidence-based recommendations for the safety of contraceptive use among women with medical conditions. Most women, even those with medical conditions, can safely use most methods of contraception.

U.S. medical eligibility criteria for contraceptive use, 2010.

http://bixby.berkeley.edu/wp-content/uploads/2015/03/Sex-and-the-Birth-rate-03.99.pdf

Sex and the Birth Rate: Human Biology, Demographic Change, and Access to Fertility-Regulation Methods

Medical barriers to access to family planning.

Diphyllobothrium latum infection in a North Carolina couple.

A review of 9 reference protocols for IUD training in the US and in developing countries revealed conflicting instructions on antibiotic prophylaxis postpartum insertion of IUDs management of complications and sterilization and disinfection procedures. The protocols only agreed on the contraindication status of pregnancy and active gynecological or chlamydial infections (all listed as absolute contraindications) which were just 2 of 32 different contraindications. US physicians considered some conditions to be contraindications to IUD use but they usually are not applicable to women in developing countries. In developing countries with maternal mortality rates 2 times greater than those in developed countries 8 contraindications may be inappropriate: prior expulsion of or perforation by an IUD IUD insertion during the postpartum period prior pregnancy with and IUD in place prior ectopic pregnancy copper allergy coagulopathy valvular heart disease and Wilsons disease. The only inappropriate contraindication addressing infection (1 of 8) was a distant history of pelvic inflammatory disease. This history should not exclude IUD use in a woman not at risk of sexually transmitted diseases. Contraindications referring to cancer of the reproductive tract should be consolidated in a statement warning against hormonal contraceptive and IUD use in women especially those over 35 who have recent undiagnosed irregular vaginal bleeding until the cause has been determined. The reviewers also discussed justifications for other contraindications including those related to menstrual blood loss small uterus structural abnormality of the uterus severe vasovagal reactivity or fainting and severe cervical stenosis no access to services and future fertility. THis analysis indicated a need to simplify rationalize and update current IUD protocols as well as make them consistent. This will improve service quality and reduce unnecessary medical obstacles to contraception.

IUD protocols for international training.

Interactions between drugs and oral contraceptives (OCs) may reduce the effectiveness of OCs. These interactions most affect OCs with <50 mcg of estrogen since these OCs only contain the lowest possible effective hormonal dose and indeed a slight reduction in hormonal level can result in reduced OC effectiveness. Providers should be cautious when prescribing many antibiotics since they reduce normal intestinal bacteria growth which in turn affects recirculation of estrogen. The antibiotic Rifampin/rifampicin (treatment for leprosy and tuberculosis and prophylactic for meningococcal meningitis) causes an increase in liver enzymes. Similarly many anticonvulsants and the oral antifungal drug griseofulvin have the same effect. Since increases in liver enzymes bring about a decrease in serum estrogen and progestin levels family planning providers must look out for possible warning symptoms and manage the situation immediately and effectively to prevent pregnancy. OCs especially those with = or + 50 mcg estrogen can change the effects of therapeutic drugs. Since they alter liver enzyme activity and liver enzymes metabolize therapeutic drugs OCs may bring about drug toxicity e.g. phenytoin theophylline and beta blocker. They can also increase the risk of liver toxicity and jaundice in women taking the antibiotic troleandomycin (TAO). Further OC side effects themselves may alter the safety of effectiveness of a therapeutic drug rather the OC itself. For example since estrogens increase coagulation combined OCs with a high dose of estrogen can decrease the efficacy of anticoagulants. Medications used to treat leprosy malaria and schistosomiasis do not appear to interact substantially with OCs. Nevertheless different women respond differently to concurrent use of OCs and drugs so physicians should carefully monitor each woman. This article is targeted to health providers and managers. It is intended to be used as a reference/background document.

Interactions between oral contraceptives and therapeutic drugs.

The benefits of the early diagnosis of pregnancy such as timely initiation of prenatal care and the avoidance of prescribing hormonal contraceptives to pregnant women--are obvious. In many African settings however pregnancy testing reagents are unavailable and the diagnosis is made on the basis of history taking and physical examination. A 1990 survey of maternal child health/family planning service providers in Kenya Tanzania and Kenya revealed that only 5.7% of the 70 facilities included in the study provided pregnancy testing with a reagent. When the physical examination produces inconclusive findings clients are advised to return in 4 weeks for a 2nd examination or--if the client is unwilling to wait this long--given a 6-day course of oral contraceptives containing 50 mcg of estrogen to see if bleeding occurs. Since it is not realistic to expect that reagents will soon become accessible or affordable to clinics in Africa primary care service supervisors and trainers must ensure that personnel are skilled in non-reagent pregnancy diagnosis procedures. Provider skills can be assessed through 3 methods: role play of history taking and management of suspected pregnancy use of pelvic model for demonstration of a speculum and bimanual pelvic examination and actual observation of provider-client interactions.

M.A. Angle

Papers

Medical barriers to access to family planning.

Diphyllobothrium latum infection in a North Carolina couple.

IUD protocols for international training.

Interactions between oral contraceptives and therapeutic drugs.

Pregnancy diagnosis and contraception.