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Contraception Editorial October 2009

Keeping Evidence-Based Recommendations Up to Date: The World Health Organization's Global Guidance for Family Planning

By: Kathryn M. Curtis, Herbert B. Peterson, and Catherine d'Arcangues

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Since the mid 1990s, the World Health Organization's (WHO) Department of Reproductive Health and Research, in collaboration with international partners, has been creating and updating global guidance for family planning, based on the best scientific evidence. In April 2008, WHO held its most recent expert meeting to update this guidance and create the fourth edition of the Medical Eligibility Criteria for Contraceptive Use1 and the third edition of the Selected Practice Recommendations for Contraceptive Use.2 The Medical Eligibility Criteria for Contraceptive Use gives recommendations regarding whether women with specific characteristics and medical conditions can use various methods of contraception. The Selected Practice Recommendations for Contraceptive Use addresses 33 contraceptive management issues, including contraceptive method initiation and continuation, management of side effects, and screening tests needed prior to contraceptive initiation. WHO has also created two companion documents that incorporate all of the guidance of the Medical Eligibility Criteria for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use into tools for family planning providers. The first is the Decision Making Tool for Family Planning Clients and Providers,3 which is a flip chart used to facilitate provider–client interaction in choosing a method of contraception. The second is Family Planning: A Global Handbook for Providers,4 created in collaboration with major family planning organizations around the world. These WHO Four Cornerstones for Evidence-based Guidance for Family Planning have had an impact on family planning practice globally. For example, the third edition of the Medical Eligibility Criteria for Contraceptive Use has been incorporated into guidelines in over 50 countries and is available in 13 languages.

Keeping evidence-based guidance up to date is one of the most challenging aspects of guidelines development. Guidelines can become out of date quickly as new evidence becomes available, and many guidelines do not have formal plans for updating recommendations.5,6 However, WHO has a strong commitment to evidence-based guidelines and has issued “guidelines for guidelines" to steer this work. To keep its family planning guidance up to date, WHO has set up both a formal process that takes place every 3 to 4 years and a system of identification and appraisal of literature as it is published that allows for the determination of interim guidance as needed. This system, known as the Continuous Identification of Research Evidence or CIRE, facilitates the ongoing identification of new evidence relevant to the existing WHO guidance, critical appraisal and synthesis of the evidence through the conduct of systematic reviews, and peer review of the systematic reviews by international family planning experts.7 Peer reviewers are asked to comment on the quality of the systematic review and on whether the new evidence, in the context of the previous evidence, implies any need for change in the guidance. The systematic reviews are conducted according to standard guidelines, such as MOOSE and QUORUM.8,9 The United States Preventive Service Task Force grading system is used to grade the quality of the individual articles, as well as the body of evidence, included in each systematic review.10 This quality system includes a rating for study design, as well as separate ratings for internal validity of the studies. That the Medical Eligibility Criteria for Contraceptive Use is now in its fourth edition (first edition published in 1996) and the Selected Practice Recommendations for Contraceptive Use is in its third edition (first edition published in 2002) is a testament to WHO's commitment to keeping this guidance up to date and based on the best available evidence.

In April 2008, WHO gathered 43 participants from 23 countries to serve as the expert working group to revise and update the current family planning guidance. This group included international family planning experts (clinicians, epidemiologists, policymakers and program managers), experts in evidence identification and synthesis, experts in pharmacology and users of the guidance. At the meeting, the WHO expert working group developed 86 new recommendations and revised 165 existing recommendations for the fourth edition of the Medical Eligibility Criteria for Contraceptive Use. A new medical condition, systemic lupus erythematosus, was added to the guidance, along with 12 new subconditions for existing medical conditions: obesity (<18 years of age); deep venous thrombosis/pulmonary embolism (established on anticoagulant therapy); viral hepatitis (acute or flare); focal nodular hyperplasia of the liver; three classes of antiretroviral therapies (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, ritonavir-boosted protease inhibitors); lamotrigine (an anticonvulsant); and four classes of antimicrobials (broad-spectrum antibiotics, antifungals, antiparasitics and rifabutin/rifampicin). Some of the revisions to existing recommendations contained in the third edition include modifications to the guidance regarding postpartum IUD use, cirrhosis and drug interactions.

The WHO expert working group also examined new evidence related to the Selected Practice Recommendations for Contraceptive Use that led to modifications of the existing guidance. The most notable update was the extension of the grace period for DMPA repeat injection from 2 weeks to 4 weeks after the scheduled time for repeat injection. Other modifications were made to the recommendations regarding missed oral contraceptive pills, and treatment options for bleeding problems while using progestogen-only injectables.

Nine of the systematic reviews used for the April 2008 meeting to review the WHO guidance are contained in this issue of Contraception. In addition, WHO held a technical consultation on hormonal contraception and liver disease in January 2008, in preparation for the April 2008 meeting; a summary of that consultation is also included here as a WHO Provider Brief. The full WHO guidance can be found at http://www.who.int/reproductive-health/family_planning/guidelines.htm.

Acknowledgment 

We have had the great privilege of working with numerous individuals and agencies in the creation of WHO's Four Cornerstones of Evidence-based Guidance for Family Planning and the CIRE system to support them. There are too many to recognize here but this work would not have been possible without the leadership of WHO's Dr. Paul A. Van Look (Director, Department of Reproductive Health and Research) and the members of his Team for Promoting Family Planning who worked on the latest editions — Dr. Kelly Culwell, Dr. Mary Lyn Gaffield, Ms. Sarah Johnson, Dr. Nathalie Kapp, Dr. Ian Tilley and Mrs. Gloria Lamptey — as well as Ms. Melissa Paulen, an ASPH fellow working at CDC. This effort would also not have been possible without strong support from CDC's Division of Reproductive Health, NICHD and USAID. USAID supported some of the key agencies and programs that contributed, including Family Health International (Dr. Kavita Nanda).

Kathryn M. Curtis
Division of Reproductive Health
Centers for Disease Control and Prevention
Atlanta, GA

Herbert B. Peterson
Department of Maternal and Child Health, School of Public Health
Department of Obstetrics and Gynecology, School of Medicine
The University of North Carolina at Chapel Hill
Chapel Hill, NC

Catherine d'Arcangues
Department of Reproductive Health and Research
World Health Organization
Geneva, Switzerland

References

  1. World Health Organization. Medical Eligibility Criteria for Contraceptive Use: 2008 update. http://www.who.int/reproductive-health/publications/mec/mec_update_2008.pdf [cited 2009 Mar 17].
  2. World Health Organization. Selected Practice Recommendations for Contraceptive Use: 2008 update. http://www.who.int/reproductive-health/publications/spr/spr_2008_update.pdf [cited 2009 Mar 17].
  3. World Health Organization (WHO) and Johns Hopkins Bloomberg School of Public Health, Decision-Making Tool for Family Planning Clients and Providers. Baltimore, (Md), INFO and Geneva: WHO; 2005.
  4. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP) IP, Family Planning: A Global Handbook for Providers. Baltimore and Geneva: CCP and WHO; 2007.
  5. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. 2009; 301 : 868–869.
  6. Shekelle PG, Ortiz E, Rhodes S, et al.   Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated?. JAMA. 2001; 286 : 1461–1467.
  7. Mohllajee AP, Curtis KM, Flanagan RG, Rinehart W, Gaffield ML, Peterson HB. Keeping up with evidence—a new system for WHO's evidence-based family planning guidance. Am J Prev Med. 2005; 28 : 483–490.
  8. Stroup DF, Berlin JA, Morton SC, et al.   Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000; 283 : 2008–2012.
  9. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999; 354 : 1896–1900.
  10. Harris RP, Helfand M, Woolf SH, et al.   Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001; 20 : 21–35.

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Used with permission from Elsevier, Inc.