Research gaps identified during the 2014 update of the WHO medical eligibility criteria for contraceptive use and selected practice recommendations for contraceptive use

Abstract

Universal access to safe and effective contraception is an important public health goal. Family planning and prevention of unintended pregnancy are essential to securing the well-being and autonomy of individuals while supporting the health and development of communities. The World Health Organization (WHO) recently undertook a process to update its global guidance on “who” can use contraception safely and “how” to use contraception safely and effectively to generate the fifth edition of the WHO Medical Eligibility Criteria for Contraceptive Use (MEC) and the third edition of the WHO Selected Practice Recommendations for Contraceptive Use (SPR). Overall the MEC demonstrates that contraception is remarkably safe for most people; at least one highly effective contraceptive method is assigned a category “1” or “2” across the majority of conditions in the guidance indicating no restrictions on use or that the advantages of using a particular method generally outweigh the theoretical or proven risks of use. Once a medically appropriate method is identified the SPR offers critical guidance on safe and effective use important for contraceptive management and service delivery. The major goal for producing these evidence-based recommendations is to help improve access to and strengthen the quality of family planning services worldwide. While these recommendations reflect a rigorous synthesis and interpretation of the best evidence to date and contribute significantly to medical and public health knowledge around the world a number of recommendations in both the MEC and SPR are grounded in limited to no direct evidence. In the absence of direct evidence indirect evidence and expert opinion inform assessments. Each revision of the MEC and SPR offers an opportunity to identify current knowledge gaps and promote research necessary to continually strengthen the guidelines. As part of the most recent revision of these guidelines a Guideline Development Group convened in March and September 2014 to generate updated recommendations. During these meetings we identified a number of key research questions for a variety of topics discussed during the technical consultations. The full list of research gaps is included in Table 1 not further prioritized. However we present three important topics of global relevance to national programs and policies in greater detail: (a) intrauterine device (IUD) initiation among women at high risk for sexually transmitted infections (STIs); (b) bidirectional drug-drug interactions with use of hormonal contraception (HC) and antiretroviral therapy (ART); and (c) initiation of progestogen-containing contraception following use of ulipristal acetate (UPA) emergency contraception. Each section presents some background on the public health importance of the topic and discusses the limitations of existing data and considerations for future rigorous research. [Excerpts].