U.S. Selected Practice Recommendations for Contraceptive Use,2013

Abstract

Unintended pregnancy rates remain high in the United States and these pregnancies may carry increased risks for negative health outcomes. Lack of contraceptive use and inconsistent use are important contributors to the high rate of unintended pregnancies. Women may face certain barriers to starting contraception and using it effectively. The Centers for Disease Control and Prevention has recently developed the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, which provides guidance for common yet sometimes complex issues in contraceptive management. This guidance aims to reduce barriers to contraceptive use by providing clear recommendations for providers to assist women in initiating and using contraceptive methods to maximize effectiveness and decrease risk of unintended pregnancy.

Introduction

Approximately half of all pregnancies in the United States are unintended, and these pregnancies are at higher risk for negative health consequences.^1,2 Lack of contraceptive use and imperfect use are important contributors to the high rate of unintended pregnancies. About half of unintended pregnancies occur among women not using contraception, while the other half occur among women who reported using contraception in the month of conception³; presumably, many of these contraceptive failures were due to incorrect or inconsistent use of contraceptive methods. Therefore, efforts to increase and improve use of contraception are critical to reduce unintended pregnancy rates. Many potential barriers may hamper women's attempts to initiate and use contraception correctly and consistently; for example, women may be required to have several visits or unnecessary examinations and tests before starting a contraceptive method or may discontinue their method if side effects occur. The Centers for Disease Control and Prevention (CDC) has recently adapted global family planning guidance from the World Health Organization (WHO) to help reduce such barriers. The U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (US SPR) provides evidence-based guidance on contraceptive management for health care providers. Recommendations are given for common yet sometimes complex issues in contraceptive management, such as when a woman can initiate contraceptive methods, what examinations or tests are needed prior to initiation of contraceptive methods, and how to manage side effects or usage errors. The intent of the US SPR is to serve as a source of clinical guidance and to decrease barriers to contraceptive initiation and increase effective use. Health care providers should always consider the individual clinical circumstances of each person seeking family planning services. The purpose of this article is to describe the process of adapting the SPR for the US and to provide an overview of how providers can use the SPR in clinical practice.

Development of the US SPR

WHO evidence-based contraceptive guidance

Since the 1990s, WHO has developed and disseminated evidence-based global guidance for contraceptive use. The Medical Eligibility Criteria for Contraceptive Use (MEC) was developed by WHO to provide evidence-based recommendations for the safety of contraceptive use among women with certain characteristics or medical conditions (e.g., age, smoking, hypertension, and diabetes). The WHO MEC includes recommendations for 18 contraceptive methods and 160 medical conditions and is currently in its fourth edition.⁴

As a companion document to the MEC, WHO developed the Selected Practice Recommendations for Contraceptive Use (SPR). While the MEC provides guidance on who can safely use contraceptive methods, the SPR provides guidance on how to use contraceptive methods.⁵ The SPR gives recommendations for health care providers as they help their patients to initiate contraception and use it effectively. For example, the SPR addresses when during a woman's cycle she can begin contraception, what examinations or tests are needed before a woman begins contraception, and what to do if a woman misses pills. The WHO SPR is currently in its second edition with an update in 2008.

Adaptation of the WHO SPR for the United States

WHO recognized that the context of family planning provision may differ in different countries and regions and therefore intended that its guidance be adapted for use at the local level. CDC previously adapted the WHO MEC for use in the United States, with the US MEC published in 2010, and updates in 2011 and 2012.^6
–8 CDC recently undertook an adaptation of the WHO SPR for the United States. During a meeting with U.S. family planning experts, it was determined that many of the WHO SPR recommendations should be reviewed for best implementation in the United States and that several new topics should be considered for addition to the guidance. Suggestions were also made regarding changes in overall format to enhance usability of the document for the United States, such as organization by contraceptive method, simplification of recommendations, and addition of tables and figures.

Systematic reviews of published scientific evidence were conducted and the reviews were peer-reviewed by U.S. family planning experts. A meeting was held in 2011, comprised of U.S. family planning providers and other experts in contraception, during which the evidence and recommendations were discussed. The first edition of the US SPR was released in 2013.⁹ The SPR and other associated resources can be found at www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm

Using the US SPR

Format

The US SPR is designed for health care providers as they counsel women, men, and couples about their chosen contraceptive method. The US SPR comprises recommendations for most reversible and permanent methods of contraception, including intrauterine devices (IUDs), implants, injectables, combined hormonal contraceptives (CHCs), progestin-only pills (POPs), fertility-awareness based methods, emergency contraception, and female and male sterilization. The US SPR does not provide comprehensive information about each method, but rather includes guidance for key issues in contraceptive management that may be common yet complicated. The US SPR is arranged by contraceptive method, and for each method there is generally information about initiation of the method, regular follow-up, and management of problems with use. While much of the guidance is the same or similar to the WHO SPR, several new topics were added to the US SPR, including guidance for use of the combined contraceptive patch and vaginal ring, how to start regular contraception after taking emergency contraceptive pills, management of bleeding irregularities among women using extended or continuous CHCs, when a woman can rely on female sterilization for contraception, and when a woman can stop using contraceptives and not be at risk for unintended pregnancy. Adaptations to the WHO SPR recommendations include changes in the length of the grace period for repeat injectables, differences in some of the examinations and tests recommended before contraceptive method initiation, differences in some of the recommendations for management of bleeding irregularities, and modifications to the missed pill guidelines. Summary tables and clinical algorithms have been added to enhance understanding and usability of the guidelines where appropriate.

Removal of barriers to contraceptive use

Women may face barriers to initiating contraception, including needing to wait for menses to start a method, undergo unnecessary examinations or tests prior to starting, or return for additional visits before starting. Women may also face barriers to continuing use of their contraceptive method or using the method correctly and consistently. Difficulties obtaining contraceptive supplies may arise if the woman is required to return for specific follow-up visits or required to obtain repeat prescriptions at frequent intervals. Side effects, such as bleeding irregularities, are the most common reason women discontinue oral contraceptives.¹⁰ Errors in usage, such as missing pills, are common and contribute to decreased contraceptive effectiveness.^11,12

To address these barriers, the US SPR aims to present clear and usable guidelines for health care providers as they help their patients manage contraceptive issues. With respect to initiation, the US SPR states that all methods of contraception can be started at any time, if the provider is reasonably certain that the woman is not pregnant (Table 1), and the US SPR lists criteria to assist providers in determining whether the woman may be pregnant. Depending on the timing of her last menses, back-up contraception may be needed for a certain amount of time until the method becomes effective (Table 1). In practical terms, most women can begin a contraceptive method on the day of the visit, also known as “Quick Start,” which decreases the time during which they are at risk for unintended pregnancy and improves short-term method continuation.¹³ The US SPR also provides guidelines for which examinations or tests are needed before starting contraception (Table 1). While certain examinations and tests may be important in the context of routine preventive health care, most are not necessary for the safe initiation of contraception. For most women, no or very few examinations or tests are recommended before starting contraception. For example, neither breast examination nor cervical cancer screening (Pap smear) are necessary before starting any method of contraception. Pelvic examination is not necessary before starting most methods, with the exception of IUDs and diaphragms.

Table 1.

When to Start Using Specific Contraceptive Methods

Contraceptive method	When to start (if the provider is reasonably certain that the woman is not pregnant)	Additional contraception (i.e., back-up) needed	Examinations or tests needed before initiation ^a
Copper-containing IUD	Anytime	Not needed	Bimanual examination and cervical inspection^b
Levonorgestrel-releasing IUD	Anytime	If >7 days after menses started, use back-up method or abstain for 7 days.	Bimanual examination and cervical inspection^b
Implant	Anytime	If >5 days after menses started, use back-up method or abstain for 7 days.	None
Injectable	Anytime	If >7 days after menses started, use back-up method or abstain for 7 days.	None
Combined hormonal contraceptive	Anytime	If >5 days after menses started, use back-up method or abstain for 7 days.	Blood pressure measurement
Progestin-only pill	Anytime	If >5 days after menses started, use back-up method or abstain for 2 days.	None

Adapted from Centers for Disease Control and Prevention.⁹

Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (US MEC 1) or generally can be used (US MEC 2) among obese women. However, measuring weight and calculating BMI (weight [kg]/height [m]²) at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.

Most women do not require additional STD screening at the time of IUD insertion if they have already been screened according to CDC's STD Treatment Guidelines (available at www.cdc.gov/std/treatment). If a woman has not been screened according to guidelines, screening can be performed at the time of IUD insertion, and insertion should not be delayed. Women with purulent cervicitis or current chlamydial infection or gonorrhea should not undergo IUD insertion (US MEC 4). Women who have a very high individual likelihood of STD exposure (e.g., those with a currently infected partner) generally should not undergo IUD insertion (US MEC 3). For these women, IUD insertion should be delayed until appropriate testing and treatment occurs.BMI, body mass index; HIV, human immunodeficiency virus; IUD, intrauterine device; STD, sexually transmitted disease; US MEC, US Medical Eligibility Criteria for Contraceptive Use, 2010 (available at www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm).

With respect to continuing use, the US SPR provides guidance for follow-up after starting contraception and states that women should be encouraged to return to discuss side effects or other problems with use, or if they want to switch to a different method. While routine follow-up visits are generally not required, some groups of women might benefit from more frequent follow-up, including adolescents and women with certain medical conditions. The US SPR also recommends that women using oral contraceptive pills (combined or progestin-only) should be provided with a 1-year supply at a time, therefore decreasing the need for repeat visits or prescriptions and increasing continuation rates.¹⁴ The US SPR addresses management of bleeding irregularities while using certain contraceptive methods and highlights that anticipatory counseling about bleeding changes is critical to a woman's satisfaction with her method and can improve continuation.^15,16 To help women maximize their contraceptive effectiveness, the US SPR provides clear and simplified clinical algorithms for what to do if they miss pills or experience dosing errors with the patch or the ring.

Next Steps

Dissemination, implementation, and evaluation

Since the release of the US SPR, CDC has been working to disseminate the guidance to US health care providers. In close collaboration with partners in family planning and women's health, CDC is working to ensure that providers are aware of the guidance and understand how to use it in clinical practice, through activities such as presentations at meetings and publications in professional journals. CDC is also working to develop electronic resources and other tools for providers to use. To evaluate impact, CDC is in the process of surveying public and private family planning providers to monitor changes in attitudes and practices that may have resulted from the U.S. family planning guidance.

Research gaps

Although the guidance is based on the best available evidence, gaps in scientific evidence always exist. During the process of guidance development, several important gaps were identified and published, for the purpose of stimulating research and ensuring that the scientific basis for these guidelines continues to advance.¹⁷ For example, instructions for managing dosing errors with pills, patch, and ring are varied and sometimes conflicting, which presents challenges for provider and patient understanding and adherence. Further research is needed to assess patient understanding of these instructions and to identify the most effective approaches to improve patient understanding and adherence.

Updating the guidance

As with any evidence-based guidance, it is important to monitor new scientific evidence and update the guidance as new evidence warrants. For the purpose of keeping family planning guidance up-to-date, WHO and CDC developed and use the Continuous Identification of Evidence (CIRE) system to monitor publication of relevant evidence on a continuous basis.¹⁸ WHO and CDC then critically appraise this evidence and update their guidance as needed. In addition to full updates of the MEC and SPR approximately every 4 years, CDC also issues interim guidance as needed.

Conclusions

In order to reduce the persistently high rates of unintended pregnancy in the United States, efforts should continue to focus on increasing and improving use of contraception. The US SPR provides evidence-based guidance for health care providers as they help their patients to initiate contraception and manage issues during use, although health care providers should always consider the individual clinical circumstances of each person seeking family planning services. Implementation of the US SPR should help reduce barriers to contraceptive use and thereby decrease the risk of unintended pregnancy.

Footnotes

Author Disclosure Statement

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. For all authors, no competing financial interests exist.

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