Elsevier

Contraception

Volume 68, Issue 5, November 2003, Pages 327-333
Contraception

Original research article
A consensus process to adapt the World Health Organization selected practice recommendations for UK use

https://doi.org/10.1016/j.contraception.2003.07.007Get rights and content

Abstract

The nominal group technique for consensus development was used to consider the World Health Organization Selected Practice Recommendations for Contraceptive Use for adoption or adaptation in the United Kingdom. The nominal group comprised 11 opinion leaders who agreed that 74% of the WHO recommendations were consistent with current UK practice. Of 63 recommendations considered by the group to be at odds with current practice, 23 were adopted with advice that United Kingdom practice should change in line with WHO. Twenty-five were adopted because, although the group felt that the WHO recommendation differed from practice in the UK, it was unable to reach a consensus on an alternative recommendation. Thirteen WHO recommendations underwent minor revision for UK use. The group rejected two further WHO recommendations [on the timing of starting low-dose progestogen-only contraception (POC) during lactation] but was unable to reach consensus on any alternative guidance. It was agreed clinicians should be left to decide for themselves how to advise breastfeeding women about when to start low-dose POC. A UK version of the WHO Selected Practice Recommendations should help to standardize practice and improve the quality of care for couples using contraception.

Introduction

Contraceptive practice (how to select who should use which method, advise men and women to use contraception safely and effectively and manage common side effects) is a skill that has evolved over time. Current recommendations are often based on the views of so-called opinion leaders who write seminal textbooks [1], [2], [3] and speak at national and international meetings. Contraceptive practice is also strongly influenced by the information that pharmaceutical companies include in their product data sheets (specific product characteristics) or labels. Recently, professional organizations, such as the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) of the UK, have started to produce evidence-based guidance [4], [5] in an attempt to promote good practice and high standards of care.

In 1995, the Human Reproduction Programme (HRP) of the World Health Organization (WHO) convened a group of experts to consider the evidence underpinning the relative and absolute contraindications to all existing methods of contraception in a document [6] entitled “Quality Care in Family Planning, Medical Eligibility Criteria for Contraceptive Use.” The document has been adopted internationally and has been extremely influential in standardizing norms for contraceptive provision. In 2001, HRP underwent a similar exercise to produce a second document (“Selected Practice Recommendations for Contraceptive Use” [7]), which considered the evidence base for a number of recommendations concerning safe and effective use of contraception and the management of common side effects. The document concentrated on areas of controversy or inconsistent practice. However, HRP is concerned primarily with improving contraceptive use in developing countries where high rates of maternal morbidity and mortality result from unwanted and mistimed pregnancies. The Selected Practice Recommendations (SPR) reflect a programmatic stance with the overriding aim of increasing contraceptive prevalence. The programmatic view accepts that relaxing some of the more cautious criteria for contraceptive use might result in a few individual women suffering unwanted side effects, becoming pregnant or even dying from the serious risks of a particular contraceptive method. In return, however, large numbers of women are enabled to use a range of contraceptive methods. In contrast, in developed countries such as the United Kingdom, health professionals who provide contraception are overwhelmingly driven by what is best for the individual couple or even just the female partner. For this reason, a number of the recommendations made in the SPR that slightly relax the accepted rules for safe and effective contraceptive use are potentially at odds with current UK practice.

The nominal group technique is a formal method for synthesizing opinion that has previously been employed in the healthcare field [8] when a lack of sufficient research-based evidence makes it necessary to combine research with the knowledge and opinions of experts in the field. It involves expert facilitation of a structured group discussion of participants' opinions to facilitate the development of consensus. The FFPRHC agreed to adopt this formal consensus process to produce a set of recommendations for clinical practice based on those of WHO but better suited to practice in the UK.

Section snippets

Methods

A group of 11 “opinion leaders” in active clinical practice in the United Kingdom representing general practice, NHS family-planning doctors and academics with an interest in fertility regulation was invited to participate. A copy of the WHO Selected Practice Recommendations was sent to each participant. Participants responded to a questionnaire that asked whether, in their view, each recommendation was at odds with current UK practice and, if so, how they would like to see the recommendation

Results

The WHO Selected Practice Recommendations address 23 “Key Questions” relating to contraceptive use. Two key questions relate to the use of combined injectable contraception and the “standard days method.” Neither method is presently available in the United Kingdom and the group agreed not to consider the questions further. The WHO Selected Practice Recommendations report included 242 individual recommendations relating to the remaining 21 key questions. These were reviewed by the expert panel

Discussion

In the introduction to the Selected Practice Recommendations [7] the HRP clearly states that the set of recommendations should not be regarded as rigid but rather should serve as a starting point for developing or revising national guidelines. It is acknowledged that country situations vary greatly and that the guidelines should be adapted in the light of national health policies, needs, priorities and resources. Perhaps surprisingly, 74% of the WHO recommendations were judged by the consensus

Acknowledgements

Ms. Jacquie Silcott from the FFPRHC and Ms. Julie Foxcroft of the FFPRHC Clinical Effectiveness Unit for secretarial help with the consensus exercise.

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