An Introduction to the Postpartum Family Planning Compendium Sarita Sonalkar, MD, MPH Assistant Professor, Obstetrics and Gynecology University of Pennsylvania, Philadelphia, PA Mary Lyn Gaffield, PhD Scientist, WHO Department of Reproductive Health and Research Svetlin Kolev Information Officer, World Health Organization

Background: Gates Grant Workstream 1: Ensuring WHO evidence based guidelines and tools are adaptable and appropriate for use in family planning/contraceptive programmes Workstream 2: Strengthening normative standards for monitoring, evaluation and accountability at country, regional and global levels Workstream 3: Strengthening and supporting mechanisms for regional and country leadership in adaptation and implementation of WHO contraceptive guideline recommendations for improving contraceptive programmes

Current Postpartum Family Planning Guidance WHO has multiple documents issuing guidance on postpartum family planning Medical Eligibility Criteria for Contraceptive Use Selected Practice Recommendations for Contraceptive Use Postnatal care of the Mother and Newborn Programming strategies for Postpartum Family Planning

Goals of the Postpartum Family Planning Compendium Working Group Will take guidance from the 2015 MEC, SPR, and other relevant WHO guidelines and resources CREATE A WEB-BASED COMPENDIUM Will design a protocol to field test the appropriateness and usability of the tool. FIELD TEST THE COMPENDIUM Use of the compendium will offer easier access to current WHO recommendations that are relevant to postpartum family planning. INFORM POLICY MAKERS AND PROGRAM MANAGERS

PPFP Compendium: A Work in Progress Guideline implementation consultant developed Power Point mockups Media designer transformed prototype into sample internet images Stakeholders to feed back regarding content and presentation

Agenda Propose a consolidated set of recommendations for contraception in the postpartum period Present a mockup of a web-based compendium Request guidance from our stakeholders to optimize the tool

Topics to consider while viewing the mockup Target audience? Clinicians Community health workers Contraceptive users Program managers Policy makers Medical comorbidities to include? Not possible to include all comorbidities from the MEC Internet search terms? Modality of the information? Internet-based Mobile apps Computer programs, USB drives Paper pamphlets

Development Phase 1: Power point mockups

Home: Presentation of methods Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period First mockup illustrates presentation of all methods, selection options for breastfeeding status, comorbid medical conditions, and timing after delivery 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

Choosing filters Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

MEC Category Display 3 D 3 2 1 Narrow results by: Breastfeeding status Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 If conditions have different criteria numbers, then need to use the highest number for the checked categories. 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

Hover function: Define categories 3 D 3 2 1 Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 Hover 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

Hover function: Define categories 3 D 3 2 1 Medical  eligibility criteria (MEC) categories for contraceptive use   Category 1: A condition for which there is no restriction for the use of the contraceptive method Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method Category 4: A condition which represents an unacceptable health risk if the contraceptive method is used. Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 Illustrates hover functions to describe the MEC categories 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

Selecting a method 3 D 3 2 1 Narrow results by: Breastfeeding status Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 Hover 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

LNG/ETG implant Clickable links to condition details Condition Category BREASTFEEDING a) <6 weeks postpartum 2 b) ≥6 weeks to < 6 months postpartum (primarily breastfeeding) 1 c)≥6 months postpartum HIGH RISK OF HIV Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) Severe or advanced HIV clinical disease (WHO stage 3 or 4) Links to clarifications and evidence are active in presentation view

LNG/ETG implant: Breastfeeding Clarifications/evidence Clarification: There is theoretical concern about the potential exposure of the neonate to DMPA/NET-EN during the first 6 weeks postpartum. In many settings, however, pregnancy-related morbidity and mortality risks are high, and access to services is limited. In such settings, DMPA/NET-EN may be among the few methods widely available and accessible to breastfeeding women immediately postpartum.   Evidence: Direct evidence demonstrates no harmful effect of POCs on breastfeeding performance (61-109) and generally demonstrates no harmful effects on infant growth, health or development (74, 76, 89, 99); however, these studies have been inadequately designed to determine whether a risk of long-term effects exists. Animal data suggest an effect of progesterone on the developing brain; whether similar effects occur following progestogen exposure in humans is unclear (110-112).

Choosing another method 1 3 D 3 2 Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 If conditions have different criteria numbers, then need to use the highest number for the checked categories. 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

Choosing the hormonal IUD 1 3 D 3 2 Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 4 4 3 4 1 1 1 1 Hover 1 D 3 1 48 hours 4 weeks 6 months 12 months and beyond 1 3 weeks 6 weeks

LNG-IUD Clickable links to condition details Timing Medical eligibility category POSTPARTUM a) <48 hours including insertion immediately after delivery of the placenta Breastfeeding 2 ii) non-breastfeeding 1 b) ≥ 48 hours to <4 weeks 3 c) ≥ 4 weeks d) Puerperal sepsis 4 HIGH RISK OF HIV I C Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) Severe or advanced HIV clinical disease (WHO stage 3 or 4) Timing Medical eligibility category <10 minutes after delivery of placenta 2 10 minutes after delivery to <4 weeks Greater than or equal to 4 weeks 1 Puerperal sepsis 4 Links to clarification/evidence

Evidence: LNG-IUD postpartum recommendations: breastfeeding women Evidence: Immediate postpartum Cu-IUD insertion, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates than delayed postpartum insertion. Additionally, post-placental placement at the time of caesarean section has lower expulsion rates than post-placental vaginal insertions. Insertion complications of perforation and infection are not increased by IUD placement at any time during the postpartum period (16-29). One randomized controlled trial found that immediate insertion of the LNG-IUD was associated with decreased breastfeeding duration compared with delayed insertion (30). Two other randomized controlled trials assessing early vs delayed initiation of progestogen-only contraceptives failed to show a difference in breastfeeding outcomes (31, 32). In other studies, initiation of LNG-IUD at 4 weeks postpartum or later demonstrated no detrimental effect on breastfeeding outcomes (33-35).

Home: Presentation of methods Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

Choosing new filters Narrow results by: Breastfeeding status Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

Choosing new filters 1 1 A 1 1 Narrow results by: Breastfeeding status Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 1 1 1 1 1 1 1 1 1 1 A 1 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

Choosing another method 1 1 A 1 1 Narrow results by: Breastfeeding status Breastfeeding Not breastfeeding Medical conditions Hypertension Venous thromboembolism HIV Smoking, age 35 or older Migraine headaches Tuberculosis Obesity Timing in the postpartum period 1 1 1 1 1 1 1 1 1 1 1 1 A 1 48 hours 4 weeks 6 months 12 months and beyond 3 weeks 6 weeks

Combined hormonal contraceptives: non-breastfeeding women Clickable links, Practice Recommendations Combined hormonal contraceptives: non-breastfeeding women COC= combined oral contraceptive, P=combined contraceptive patch, CVR=combined contraceptive vaginal ring, CIC=combined injectable contraceptive Condition Category I=initiation, C=continuation COC P CVR CIC a) <21 days i) Without other risk factors for VTE 3 ii) With other risk factors for VTE 4 b) > 21 days to 42 days i) without other risk factors for VTE 2 ii) with other risk factors for VTE c) > 42 days 1 Links to clarification and evidence Links to Practice recommendations, incorporating SPR Practice Recommendation: When can a woman start combined oral contraceptives?

When can a woman start combined oral contraceptives? Postpartum (non-breastfeeding) If her menstrual cycles have not returned and she is 21 or more days postpartum, she can start COCs immediately if it is reasonably certain that she is not pregnant. She will need to abstain from sex or use additional contraceptive protection for the next 7 days. If her menstrual cycles have returned, she can start COCs as advised for other women having menstrual cycles.

Contraceptive method eligibility: The first year postpartum Presentation of methods by timing postpartum Contraceptive method eligibility: The first year postpartum 48 hours 4 weeks 12 months and beyond 6 months 3 weeks 6 weeks Progestogen-only implants All women IUD insertion (Copper or hormonal) Female sterilization Male sterilization Add more re: nonbreastfeeding women?: Nonbreastfeeding women: 0-21 days: COC is category 3, POC is category 1 >=21 days-42 days: COCs are category 2 POC are category 1 <48 hours CuIUD and LNG IUD is category 1 48h-4 weeks: IUDs are category 3 Progestogen-only pills Condoms/spermicides Diaphragm/cervical cap Lactational amenorrhea method Breastfeeding Progestogen-only injection Combined hormonal methods Non-breastfeeding Progestogen-only injection Combined hormonal methods

Contraceptive method eligibility: The first year postpartum Choosing filters Contraceptive method eligibility: The first year postpartum 48 hours 4 weeks 12 months and beyond 6 months 3 weeks 6 weeks Progestogen-only implants All women IUD insertion (Copper or hormonal) Female sterilization Male sterilization Add more re: nonbreastfeeding women?: Nonbreastfeeding women: 0-21 days: COC is category 3, POC is category 1 >=21 days-42 days: COCs are category 2 POC are category 1 <48 hours CuIUD and LNG IUD is category 1 48h-4 weeks: IUDs are category 3 Progestogen-only pills Condoms/spermicides Diaphragm/cervical cap Lactational amenorrhea method Breastfeeding Progestogen-only injection Combined hormonal methods Non-breastfeeding Progestogen-only injection Combined hormonal methods

Contraceptive method eligibility: The first year postpartum 48 hours 4 weeks 12 months and beyond 6 months 3 weeks 6 weeks Progestogen-only implants All women IUD insertion (Copper or hormonal) Female sterilization Male sterilization Add more re: nonbreastfeeding women?: Nonbreastfeeding women: 0-21 days: COC is category 3, POC is category 1 >=21 days-42 days: COCs are category 2 POC are category 1 <48 hours CuIUD and LNG IUD is category 1 48h-4 weeks: IUDs are category 3 Progestogen-only pills Condoms/spermicides Diaphragm/cervical cap Lactational amenorrhea method Breastfeeding Progestogen-only injection Combined hormonal methods

Contraceptive method eligibility: The first year postpartum Choosing a method Contraceptive method eligibility: The first year postpartum 48 hours 4 weeks 12 months and beyond 6 months 3 weeks 6 weeks Progestogen-only implants All women Female sterilization Male sterilization May incorporate images by hovering over text Progestogen-only pills Condoms/spermicides Diaphragm/cervical cap Lactational amenorrhea method Breastfeeding Progestogen-only injection Combined hormonal methods

LNG-IUD postpartum recommendations: breastfeeding women Guidance and evidence LNG-IUD postpartum recommendations: breastfeeding women Timing Medical eligibility category <48 hours including insertion immediately after delivery of the placenta 2 ≥ 48 hours to <4 weeks 3 ≥ 4 weeks 1 Puerperal sepsis 4 Evidence For recommendations based on medical comorbidities, please visit the full Medical Eligibility Criteria at: http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/

LNG-IUD postpartum recommendations: breastfeeding women Guidance and evidence LNG-IUD postpartum recommendations: breastfeeding women Timing Medical eligibility category <10 minutes after delivery of placenta 2 10 minutes after delivery to <4 weeks Greater than or equal to 4 weeks 1 Puerperal sepsis 4 Timing Medical eligibility category <48 hours including insertion immediately after delivery of the placenta 2 ≥ 48 hours to <4 weeks 3 ≥ 4 weeks 1 Puerperal sepsis 4 Evidence For recommendations based on medical comorbidities, please visit the full Medical Eligibility Criteria at: http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/

Evidence: LNG-IUD postpartum recommendations: breastfeeding women Guidance and evidence Evidence: LNG-IUD postpartum recommendations: breastfeeding women Immediate postpartum IUD insertion, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates than delayed postpartum insertion. Additionally, post-placental placement at the time of caesarean section has lower expulsion rates than post-placental vaginal insertions. Insertion complications of perforation and infection are not increased by IUD placement at any time during the postpartum period (link to references).

Phase 2: Web development

WEB MOCKUPS METHOD VIEW

WEB MOCKUPS TIMELINE VIEW

WEB MOCKUPS RECOMMENDATION TABLE

WEB MOCKUPS EVIDENCE PAGE

Returning to your feedback Target audience? Medical comorbidities to include? Internet search terms? Modality of the information? Please take 5 minutes to complete the survey: Go to http://www.familyplanning2020.org/ppfp and click on “Postpartum contraception compendium survey” in the Agenda section

THANK YOU! Questions/comments?