1. WHO’s Family Planning Guidance Documents and Job Aids
Suggested script:
This presentation provides an introduction to the World Health Organization’s evidence-based guidance documents related to family planning including the Medical Eligibility Criteria for Contraceptive Use, Selected Practice Recommendations for Contraceptive Use, and Family Planning: A Global Handbook for Providers. Also introduced are several job aids that providers can use to determine whether a client is medically eligible to use the method she has chosen.
Although providers like yourselves are not the typical audience for the guidance included in the Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use, it is helpful for you to be aware of how eligibility criteria and practice recommendations evolve—on both a global and national level—so that you can be assured that what you learn during this training, and the services you in turn provide to your clients, are based on scientific evidence available to family planning experts and policy-makers

2. Objectives At the end of this session, participants will be able to:
Explain the purpose and intended use of WHO’s guidelines and job aids:
Medical Eligibility Criteria for Contraceptive Use (MEC) including job aids
Selected Practice Recommendations for Contraceptive Use (SPR)
Family Planning: A Global Handbook for Providers
Instructions for facilitator:
Read the objective on the slide.
Note to facilitator:
This presentation is designed to address this core knowledge objective:
Explain the purpose of WHO’s global guidance and how it has been used to guide the clinical practices described in the training materials and job aids, including:
the Medical Eligibility Criteria for Contraceptive Use, or MEC, and the categories defined in that document which classify conditions and client characteristics in relation to each contraceptive method; especially how the criteria are used in these job aids to help determine a client’s medical eligibility
Medical Eligibility Criteria Wheel for Contraceptive Use
Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use
the Selected Practice Recommendations for Contraceptive Use, or SPR, which describes how to safely and effectively use contraceptive methods once they are deemed medically appropriate for an individual; and
the manual, Family Planning: A Global Handbook for Providers which translates the research evidence presented in the MEC and SPR into practical guidance for family planning providers and program managers.

3. Medical Eligibility Criteria for Contraceptive Use
Evidence-based recommendations
Use by policy-makers and program managers to improve access to, and quality of, family planning services
19 contraceptive methods
Variety of medical conditions and client characteristics
Periodic reviews and updates
Suggested script:
Since 1994, WHO has convened a body of international experts in family planning including clinicians, program managers, and scientists to review the available evidence on safe use of contraceptive methods and organize the findings in a manner that could be used to determine a client’s medical eligibility for a particular method. The recommendations of the expert review team are presented in the document Medical Eligibility Criteria for Contraceptive Use, or MEC.
The MEC guidance is intended to be used by policy-makers, program managers, and the scientific community to provide guidance to national family planning and reproductive health programs in the preparation of guidelines for service delivery of contraceptives. Many countries use the guidance in this document as the foundation for their national service delivery guidelines to help ensure safe, high quality services while avoiding medical barriers that limit access to contraception.
The MEC document provides guidance on the safety of 19 contraceptive methods for women and men with specific individual characteristics or known pre-existing medical conditions. These characteristics and conditions range from age, smoking habits, and parity to cardiovascular disease, cancer, and infections. In all, the MEC makes over 1700 recommendations on who can use various contraceptive methods.
The team of experts meets every four to five years to review new research findings and update their recommendations. WHO introduced updates to the MEC in August 2015 and published an update on the postpartum use of combined hormonal contraceptives in 2010.

4. Selected Practice Recommendations for Contraceptive Use
Evidence-based recommendations on safe and effective use
33 questions related to contraceptive methods
Range of issues including initiation, continuation, incorrect use, treatment of side effects, and some programmatic issues
Use by policy-makers and program managers
Periodic reviews and updates
Suggested script:
Similar to the process used to develop the medical eligibility criteria, WHO assembled a team of experts to review existing evidence and make recommendations about how to use contraceptive methods safely and effectively when clients are determined to be medically eligible.
The recommendations are conveyed in the answers to thirty-three questions included in the Selected Practice Recommendations for Contraceptive Use. The questions were selected based on 1) important controversies or inconsistencies in existing guidance, 2) the likelihood that relevant evidence was available, and 3) proposals from expert working group participants and family planning organizations or agencies.
The SPR provides guidance on the use of hormonal contraceptives, IUDs, emergency contraception, fertility awareness-based methods, and sterilization on a range of issues including: initiation and continuation, adjustments for incorrect use such as missed pills or other problems during use such as vomiting or diarrhea, treatment of menstrual abnormalities, and what to do if an IUD user is diagnosed with pelvic inflammatory disease or becomes pregnant. The document also includes recommendations on several programmatic issues such as, which examinations or tests should be done routinely before providing a method of contraception, advice on how many packs of oral contraceptive pills should be given at initial and return visits, what type of follow-up is appropriate for combined oral contraceptive (COC), progestin-only pill (POP), implant and IUD users; and guidance that providers can use to be reasonably sure that a woman is not pregnant.
The SPR guidance is intended to be used by policy-makers, program managers, and the scientific community to provide guidance to national family planning and reproductive health programs in the preparation of guidelines for service delivery of contraceptives. Much like the MEC, many countries have incorporated the guidance in this document into their national service delivery guidelines.
The team of experts meets every four to five years to review new research findings and update their recommendations. The most recent update was in In the past, the WHO has introduced minor updates to the SPR and has issued a short documents to be inserted into to the book.  These updates are reflected in the technical information included in this training resource package.

5. Family Planning: A Global Handbook for Providers
Essentials needed to provide family planning clients with good-quality care
Latest guidance for delivering 19 contraceptive methods appropriately and effectively
Use by clinical providers
Periodic reviews and updates; latest update 2018
Suggested script:
As the title suggests, Family Planning: A Global Handbook for Providers, translates scientific evidence on family planning into practical guidance for health providers. The handbook reflects the consensus of experts from leading health organizations and is based on the guidance from the Medical Eligibility Criteria for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use.
The Global Handbook provides guidance on the provision of 19 contraceptive methods and other key reproductive health issues. Each of the method chapters describe the characteristics of the method, explain who can and cannot use the method, give instructions on providing the method, provide information on how to assist continuing users, and include a collection of frequently asked questions and answers. The handbook also includes recommendations on other programmatic and reproductive health issues, such as guidance on serving diverse client groups and an overview of sexually transmitted infections. There are also several useful job aids and tools such as instructions for using condoms and a description of the menstrual cycle that can be used when counseling clients.
The Global Handbook is intended to be used by facility-based clinicians although the guidance can be used by any cadre of provider authorized to provide the services described.
Similar to WHO’s MEC and SPR guidelines, the Global Handbook is periodically reviewed and updated to ensure that it reflects the most current practice recommendations. WHO introduced an updated version of the Global Handbook in 2018 based on the latest recommendations from the MEC and SPR. These updates are reflected in the technical information included in this training resource package.
Note to facilitator:
The Global Handbook is an excellent reference manual and job aid for providers. It is available in multiple languages in both print and electronic form. Available from: .

6. Categories for IUDs, Hormonal and Barrier Methods
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
Description
When clinical judgment is available 1
No restriction for use
Use the method under any circumstances 2
Benefits generally outweigh risks
Generally use the method
Suggested script:
For each contraceptive method, the MEC classifies medical conditions and client characteristics into categories based on the risks and benefits associated with use of the method among clients with those conditions or characteristics. Some conditions fall into multiple categories depending on the severity of the condition.
For IUDs, hormonal contraceptive methods and barrier methods, the MEC uses four categories to classify medical conditions or client characteristics. These categories are defined as follows:
Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions.
Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required.
Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required.
Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used.
In some cases, a particular condition or characteristic is assigned to one category for initiation and another for continuation of the method. In other words, the category may depend on whether a woman with the condition wishes to initiate the contraceptive method or was already using that method when she developed the condition. . 3
Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable 4
Unacceptable health risk
Method not to be used
Source: WHO, 2010.

7. When clinical judgment is limited
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
When clinical judgment is limited
Category 2
Use the method 1
Suggested script:
In situations where clinical judgment is limited, such as community-based distribution programs, the four-category classification framework can be simplified into two categories.
When simplified for these situations, categories 1 and 2 indicate that the method can be used, while categories 3 and 4 indicate that the woman is not medically eligible to use the method.
The next slide provides some examples from these four categories of WHO recommendations. 4
Do not use the method 3
Source: WHO, 2010.

8. Medical Condition/ Characteristic
Categories for IUDs, Hormonal and Barrier Methods
Medical Eligibility Criteria: Examples
Medical Condition/ Characteristic
Contraceptive Method
Category
Uterine fibroids
COCs 1
Anemia
Copper IUD 2
Suggested script:
This table includes a few examples from the WHO medical eligibility recommendations for hormonal contraceptive methods and IUDs to demonstrate how methods and medical conditions are categorized. For instance, the recommendations state that:
Women with uterine fibroids who wish to use COCs can use them without restrictions, as this method presents no risk to women with this condition.
Women with anemia who wish to use a copper IUD can generally use the method because the benefits of using the IUD generally outweigh the theoretical or proven risks associated with the effect that IUD use may have on increased blood loss and anemia. Careful follow-up by the provider may be required in some cases.
Women who have blood pressure equal to or higher than 160/100 usually should not use Depo-Provera, also known as DMPA, because of a concern about increased risk of thrombotic complications.
Among women with current breast cancer, the use of hormonal implants is unacceptable and should be avoided. This is because breast cancer is a hormone-sensitive tumor, and hormonal use may accelerate growth.
Blood pressure ≥160/100 mm Hg
DMPA 3
Current breast cancer
Hormonal implants 4
Source: WHO, 2010.

9. Category Definition Accept Caution Delay Special
WHO’s Medical Eligibility Criteria
Categories for Male and Female Sterilization
Category
Definition
Accept
No medical reason to deny method
Caution
Provide with extra precautions
Suggested script:
Has anyone screened a client for sterilization? <ask for a show of hands and call on one person who has raised their hand> Could you describe what categories you generally use to screen clients for sterilization? <allow participant to answer> How would you define these categories? <allow participant to answer; call on another participant, as needed, to gather more information; use the answers to begin discussion of categories for permanent methods>
The WHO MEC categories 1–4 do not apply to female sterilization or vasectomy. For male and female sterilization, the WHO MEC use the categories Accept, Caution, Delay and Special. These categories are defined as follows:
Accept indicates there is no medical reason to deny sterilization to a person with this condition or in this circumstance.
Caution indicates that the method is normally provided in a routine setting, but with extra preparation and precautions.
Delay indicates that use of the method should be delayed until the condition is evaluated and/or corrected. Alternative, temporary methods of contraception should be provided.
Special indicates that the procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anesthesia and other backup medical support. The capacity to decide on the most appropriate procedure and anesthesia support also is needed. Alternative, temporary methods should be provided if referral is required or if there is otherwise any delay.
As shown later in the presentation, the categories of accept, caution and delay also apply to conditions or circumstances related to the use of fertility awareness methods. <discuss and clarify any points as needed>
Delay
Delay until condition is evaluated
Special
Requires specialized equipment, experienced surgeon and staff
Source: WHO, 2010.

10. Medical Eligibility Criteria for Male or Female Sterilization: Examples
Category
Conditions
Accept
Have few or no children
Caution
Diabetes
Suggested script:
While male and female sterilization procedures are safe for the majority of men and women, there are a few circumstances that require special precautions or arrangements or a delay in the procedure.
The WHO MEC clarifies these circumstances using these categories, accept, caution, delay, and special.
The table demonstrates some examples of how these categories are used for sterilization.
There are no medical reasons to deny sterilization to men or women who have few or no children whether they are married or not.
Sterilization may be provided to men and women with diabetes but extra preparations and precautions are recommended.
Sterilization should be delayed for men and women with active sexually transmitted infections, such as chlamydia or gonorrhea, until the condition is treated and resolved.
Sterilization for men and women with coagulation disorders requires a specialized setting with experienced surgeons, special equipment, and backup medical support.
Delay
Active STIs (e.g., chlamydia or gonorrhea)
Special
Coagulation disorders
Source: WHO, 2010.

11. Category Definition Accept Caution Delay NA
WHO’s Medical Eligibility Criteria
Categories for Fertility Awareness-based Methods
Category
Definition
Accept
No medical reason to deny method
Caution
Provide with extra precautions (e.g., special counseling)
Suggested script:
Has anyone screened clients for fertility awareness-based, or FAB, methods? <ask for a show of hands and call on one person who has raised their hand> Could you describe the categories used to classify conditions or characteristics when screening clients for FAB methods? <allow participant to answer> How would you define these categories? <allow participant to answer; call on another participant, as needed, to gather more information; use the answers to begin discussion of categories for FAB methods>
The WHO MEC categories for classifying conditions or characteristics for FAB method eligibility are similar to those used for male and female sterilization. For FAB methods, the WHO MEC use the categories Accept, Caution, Delay and NA. These categories are defined as follows:
Accept indicates there is no medical reason to deny the method to a woman with this condition or in this circumstance.
Caution indicates that the method is normally provided in a routine setting, but with extra preparation and precautions. For FAB methods, this usually means that special counseling may be needed to ensure correct use of the method by a woman in this circumstance.
Delay indicates that use of the method should be delayed until the condition is evaluated and/or corrected. Alternative, temporary methods of contraception should be provided.
NA indicates not applicable.
Delay
Delay until condition is evaluated NA
Not applicable
Source: WHO, 2010.

12. Medical Eligibility Criteria for FAB Methods: Examples
Category
Conditions
Accept
Non-breastfeeding ≥ 4 weeks post-partum can use symptoms method
Caution
Life stages (post-menarche and peri-menopause)
Suggested script:
This table includes a few examples from the WHO MEC to demonstrate how conditions and circumstances are categorized for FAB methods. For instance, the recommendations state that:
Non-breastfeeding women four or more weeks postpartum may use symptoms-based methods. Prior to four weeks women are not likely to have sufficient ovarian function to either require a fertility awareness-based method or have detectable fertility signs or hormonal changes.
Women post-menarche and peri-menopause often experience menstrual irregularities during these life stages which may complicate the use of fertility awareness-based methods.
Postpartum women who are primarily breastfeeding and are amenorrheic are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes. Fertility awareness-based methods during breastfeeding may be less effective than when not breastfeeding.
Fertility awareness-based methods are not relevant, or NA, during pregnancy.
Delay
Breastfeeding < 6 weeks postpartum NA
Pregnancy
Source: WHO, 2010.

13. MEC Wheel Includes COCs, POPs, DMPA, NET-EN, implants, and copper IUDs
Suggested script:
The Medical Eligibility Criteria Wheel for Contraceptive Use, available from WHO, provides an easy reference for most of the conditions and characteristics that may affect a client’s medical eligibility to initiate use of six methods.
The wheel can be used by providers to determine whether a woman presenting with a known medical or physical condition is able to initiate COCs, POPs, DMPA, NET-EN, implants, or copper IUDs safely. In addition to the information on the face of the wheel, the back side of the wheel includes supplementary notes to explain eligibility for some conditions and characteristics. <distribute copies of the wheel to participants>
Note to facilitator:
The wheel can be adapted to match the national service delivery guidelines. Alternatively, printed copies of the standard wheel can be purchased from WHO. An instruction manual and an animated file are available from WHO to facilitate the explanation of how to use the MEC wheel. Available:

14. MEC Quick Reference Chart
Includes all category 3 & 4 conditions for COCs, DMPA, IUDs, and implants
Suggested script:
The Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use is included with the training resource package materials. It provides an easy reference to conditions and characteristics that may affect a client’s medical eligibility for four commonly-used methods. We will refer to it as the MEC Quick Reference Chart. The MEC Quick Reference Chart is a comprehensive listing of all the category 3 and 4 conditions for COCs, DMPA, implants, and copper IUDs and can be used as a job aid to identify women who cannot safely use one of these four methods. <distribute copies of the quick reference chart to participants>
Note to facilitator:
The quick reference chart is available in English, French, and Spanish. It has been adapted for use by ministries of health in several countries to match the national service delivery guidelines.