1. Progestin-Only Pills (POPs)
Session II: Who Can and Cannot Use POPs?
Illustration credit: Salim Khalaf/FHI

2. POPs Are Safe for Nearly All Women
Almost all women can use POPs safely, including women who:
Are breastfeeding (starting immediately after birth)
Have or have not had children
Are not married
Are of any age, including adolescents and women over 40 years old
Have just had an abortion, miscarriage, or ectopic pregnancy
Smoke (no matter their age or the number of cigarettes)
Have anemia now or had it in the past
Have varicose veins
Have an STI or HIV, whether or not they are on antiretroviral therapy
Most health conditions do not affect safe and effective use of POPs
Use slide to show women who can safely use POPs:
Nearly all women can use POPs safely and effectively. This includes breastfeeding women, no matter when they delivered.
Most health conditions do not affect safe and effective use of POPs and only few conditions or situations may affect a woman’s eligibility to use POPs.
The WHO medical eligibility criteria were developed to reassure providers about conditions that do not interfere with safe use of contraceptives and highlight all the conditions that affect a woman’s eligibility to use any given contraceptive method.

3. Who Should Not Use POPs (part 1)
5/25/2012
Are
pregnant
Have or had breast cancer
Take certain types of pills for TB or seizures (fits)
My period is late…
Illustration credit: Ambrose Hoona-Kab.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Explain that most women can safely use the as mentioned in the previous slide. Use slides to show who should not use POPs. In special circumstances, when other methods are not available or acceptable to her, a qualified provider who can carefully assess the woman’s situation and condition may decide that she can use POPs.
Currently have blood clots in legs or lungs
Have serious
liver disease
Think they may be pregnant
Have rheumatic disease, such as lupus
Source: WHO, 2015

4. Medical Eligibility Criteria
5/25/2012
Medical Eligibility Criteria
What are medical eligibility criteria? Define the categories. Review the job aid.
Use slide 4 to introduce the concept of medical eligibility and determine whether participants have an adequate foundation.

5. When clinical judgment is available
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 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
Explain the 4 categories:
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.
Source: WHO, 2015.

6. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
When clinical judgment is available 1
Use the method 2 3
Do not use the method 4
In settings where clinical judgment is limited, Category 3 conditions are treated in the same manner as Category 4 conditions. This means that women with Category 3 or Category 4 conditions should not use POPs. Categories 1 and 2 are combined to mean Use the method.
Explain that POPs are safe for the overwhelming majority of women. Use slides 7-9 to provide an overview of the medical eligibility criteria for POPs.
Source: WHO, 2015.

7. Conditions (selected examples)
Category 1 and 2 Examples (not inclusive): Who Can Use POPs
WHO Category
Conditions (selected examples)
Category 1
menarche to >45 yrs; nulliparous; breastfeeding ≥6 weeks to ≥6 months postpartum; postpartum non-breastfeeding <21 days; post-abortion (any trimester); smoking (any age or number of cigarettes; obesity; headaches including migraines; varicose veins; cervical cancer; endometriosis; hepatitis; thyroid disease; anemia; sickle cell disease; elevated BP
Category 2
breastfeeding <6 weeks postpartum; past ectopic pregnancy; migraines with aura; history of DVT/PE; unexplained vaginal bleeding; gall bladder disease; diabetes; elevated BP systolic ≥ 160 or diastolic ≥ 100 mm Hg; some HIV meds
Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions.
Source: WHO, 2015.

8. Conditions (selected examples)
Category 3 Examples (not inclusive): Who Should Generally Not Use POPs
WHO Category
Conditions (selected examples)
Category 3
Rheumatic Diseases:
Lupus with positive or unknown antiphospholipid antibodies
Vascular conditions:
Acute DVT/PE
Gastrointestinal conditions:
Severe cirrhosis
Liver tumors
Drug interactions:
Use of rifampicin, rifabutin, anticonvulsants
Although progestin-only injectables are safe for most women, there are some exceptions.
According to the WHO MEC, progestin-only injectables are not generally recommended for women with category 3 conditions. In these situations, the risks of using this method usually outweigh the advantages. Category 3 conditions include:
The rheumatic disease lupus with positive or unknown antiphospholipid antibodies, acute blood clot in deep veins of legs or lungs, severe liver disease and most liver tumors, use of some drugs used to treat tuberculosis (rifampicin and rifabutin) and seizures. The materials in this training package reflect the WHO classification, with room for discussion of the various options. 
Source: WHO, 2015; White, 2012

9. Conditions (selected examples)
Category 3 Examples (not inclusive): Who Should Generally Not Use POPs
WHO Category
Conditions (selected examples)
Category 4
Breast cancer: current or within 5 yrs
Women with category 4 conditions should not use implants. Current or within the last 5 years breast cancer is the only category 4 condition.
Source: WHO, 2015, White, 2012

10. POP Use by Women with HIV
WHO Eligibility Criteria
Condition
Category
At high risk of HIV 1
Asymptomatic or mild HIV clinical disease
Severe or advanced HIV clinical disease
ARV therapy with NRTIs
ARV therapy with NNRTIs- Etravirine and Rilpivirine)
ARV therapy with NNRTIs- Efavirenz and Nevirapine 2
ARV therapy with protease inhibitors (PIs)
Women with HIV can use without restrictions
Women on all ARVs can use POPs safely
Condom use should be encouraged in addition to POPs
Ask participants: Let us take a closer look at the conditions and categories pertaining to clients with HIV or AIDS.
Use slides to present the following:
Women with HIV can use POPs without any restrictions, regardless of how advanced their disease is—category 1.
According to WHO, women with HIV who are on antiretroviral (ARV) therapy can also use POPs, regardless of exact type of ARV therapy. ARV therapy includes a variety of different treatments, but all regimens contain either NNRTI (non-nucleoside reverse transcriptase inhibitors) or PI (protease inhibitor). Research shows that these ARVs interact with progestin in a way that slightly reduces the blood concentration of progestin—but not to a degree that impairs contraceptive effectiveness. For more information, consult the WHO document, Medical Eligibility Criteria for Contraceptive Use.
Regardless of the method chosen, counseling on condom use should be an integral part of contraceptive counseling for women with HIV. Condoms provide both additional protection from pregnancy and protection from STI/HIV transmission between partners.
Source: WHO, 2015

11. POP Use by Postpartum Women
WHO Eligibility Criteria
Condition
Category
Non-breastfeeding <21 days 1
Non-breastfeeding ≥ 21 days
Breastfeeding <6 weeks postpartum 2
Breastfeeding >6 weeks and < 6 months
Breastfeeding ≥6 months
Breastfeeding and non-breastfeeding women may initiate POPs at any time postpartum
Ask participants: Let us take a closer look at the conditions and categories pertaining to postpartum clients.
Use slides to present the following: non-breastfeeding can begin using POPs at any time postpartum
Breastfeeding women can also begin using POPs anytime, because POPs not affect the quality or quantity of breastmilk, or the infant’s health or growth. It is safe for both the mother and the infant for a breastfeeding woman to take POPs at any time postpartum.
Women who are not Refer participants to the 2015 WHO document, Medical Eligibility Criteria for Contraceptive Use, 5th Edition, for the latest WHO update on medical eligibility issues for POPs during postpartum.  Does not reflect the new MEC – this and all supporting materials need to be updated to do that as well as make sure the learner fully understands.
 Updated
Source: WHO, 2015.

12. Read questions 1–5 in the checklist.
Group Activity Understanding the Checklist
Read questions 1–5 in the checklist.
How have you determined medical eligibility in the past?
The checklist also gives instructions about initiating POPs.
This set of questions identifies women who should not use POPs.
This set of questions identifies women who are not pregnant.
Distribute POPs checklist to each participant. When introducing the checklist, mention that it should be used by providers to determine whether a client is medically eligible to use the method that she selected during an informed decision-making process.
The questions on the checklist identify women who have health conditions—WHO Category 3 or 4—that make it unsafe for them to POPs. The checklist also incorporates questions that allow a provider to determine with reasonable certainty that a client is not pregnant. To use the checklist, providers ask the questions on the checklist and follow the instructions based on the client’s responses. Explain that the medical eligibility questions, questions 1–5, are at the top of the checklist. Ask participants to pair themselves with the person sitting next to them and take turns reading questions 1–5 on the checklist and finding the condition on the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use. Ask the pairs to verify that all the category 3 and 4 conditions for POPs on the MEC chart are represented in the questions on the checklist. Allow participants about three to four minutes to examine the checklist questions and compare them with the MEC chart.
Ask participants:
After examining the checklist and the MEC chart, are you confident that the checklist questions address the conditions that prohibit safe use of POPs? Explain why.
How have you determined a client’s medical eligibility for progestin-only injectables in the past and how might the checklist facilitate that process?
Accept responses from several participants and discuss any concerns that participants may raise. Draw attention to questions and emphasize that providers should follow the instructions for this set of questions to identify women who are not pregnant or those who might be pregnant and require a pregnancy test to rule out pregnancy.
Tell providers that the final set of instructions provides details about initiating the method, especially whether the client will need to use a backup method initially.