Client Assessment

&
MEC FOR FP USE
Solomon A.

1 Solomon A 4/28/2025
 Objectives
At the end of this session, you will be able to:
Discuss why client assessment needed?

Describe specific information that need to be extracted

from the client.
Describe how a provider be reasonable sure a client is not
pregnant?
Identify the four categories of MECs.

2 Solomon A. 4/28/2025
 Introduction
Client assessment:
➢ It creates an environment where client-provider communication
is established and confidence is built.

➢ It helps to ensure the client receives safe and effective

contraception.

➢ Previously undiagnosed medical and surgical conditions may

also be uncovered during the assessment.

3 Solomon A. 4/28/2025
 Client assessment:
➢ Most contraceptive methods does not require performing a
physical, pelvic or laboratory examination.

➢ Few physical and laboratory examinations are mandatory

before providing contraceptive methods like IUCDs and VSC.

4 Solomon A. 4/28/2025
 History
❖Information shall be sought in clients that request FP
services to ensure safety and effectiveness before providing
contraceptives.
Age
Parity, last delivery, last abortion, history of ectopic
pregnancy
Breastfeeding
Smoking
Sexual behavior: self, partner

5 Solomon A. 4/28/2025
 History…
❖ Present and past medical conditions

 STIs/HIV status

 Pelvic surgery and infection

 Tuberculosis, HTN and DM

 CVS risk factors (smoking, obesity, hypertension, previous

thrombo-embolic phenomena)
 Migraine(increased risk of ischemic stroke)

 Viral hepatitis

6 Solomon A. 4/28/2025
 History…
❖ Medications the client is taking:

Antiretroviral drugs (Ritonavir Rx)

Antibiotics (Rifampin, Rifabutin, and Rifapentine)

Antidepressants (Carbamazepine)

Anticonvulsants (Phenobarbital, phenytoin, and

carbamazepine)

❖ Family history of cancers, cardiovascular diseases and

cerebro-vascular accidents

7 Solomon A. 4/28/2025
 Physical examination
Blood pressure measurement – note systolic and diastolic
measurements
Obesity – height and weight

Pelvic examination
Pelvic examination is seldom necessary, except to rule out
pregnancy in women who are amenorrheic for more than 6
weeks from LMP and before the use of IUCD and female
sterilization..
8 Solomon A. 4/28/2025
 Laboratory examination
❖Only when indicated

 Hemoglobin

 Screening for STIs/HIV –VDRL, HIV test

9 Solomon A. 4/28/2025
How to be reasonably sure that a woman is
not pregnant
NO YES
Have you abstained from sexual intercourse since your last
monthly bleeding or delivery?
Have you been using a reliable contraceptive method correctly
and consistently?
Did your last monthly bleeding start within the past 7 days (or
within 12 days if the client is planning to use an IUCD)?
Have you had a baby in the last 4 weeks?

Have you had a miscarriage or abortion in the last 7 days (or

within 12 days if the client is planning to use an IUCD)?
Did you have a baby less than 6 months ago, if so, are you fully or
nearly fully breastfeeding, and had no monthly bleeding since
then?
 How to be reasonably sure that a
woman is not pregnant…
If the client answered ’yes’ to at least one of the

questions, and she has no symptoms or signs of pregnancy,

she can start the method she has chosen

If the client answered ‘No’ to all questions, pregnancy

cannot be ruled out. The client should wait for her next
monthly bleeding or use a pregnancy test.

11 Solomon A. 4/28/2025
12 Solomon A. 4/28/2025
How to be reasonably sure that a woman is
not pregnant…
❖ Pregnancy test is not essential most of the time.

❖ It may be required in certain circumstances where:

▪ It is difficult to confirm an early pregnancy (6 weeks or less from the LMP); or

▪ The results of pelvic examination are doubtful (e.g., obese client).

❖ In these conditions, urine pregnancy test or ultrasound scan may be helpful, if

readily available and affordable.

❖ If pregnancy test is not available counsel the client to:

▪ Abstain from sexual intercourse or

▪ To use barrier methods until her menses return or pregnancy is confirmed.

13 Solomon A. 4/28/2025
 Procedures and tests for providing FP
methods
 Class A: Essential and mandatory in all circumstances for safe and effective use

of the contraceptive method.

 Eg. PV for IUCD and female sterilization, STI risk assessment for IUCD

 Class B: Contributes substantially to safe and effective use.

 If the test or examination cannot be done, the risk of not performing it should

be weighed against the benefits of making the contraceptive method available.

 Eg. Hemoglobin for female sterilization

 Class C: Does not contribute substantially to safe and effective use of the

contraceptive method.
14 Solomon A. 4/28/2025
 Procedures and tests for providing
FP methods …
This classification apply to people who are presumed to be

healthy

For a person with a known medical condition or other

special condition, refer to the Medical Eligibility Criteria

for Contraceptives

15 Solomon A. 4/28/2025
 Criteria for Contraceptive Use
(MEC)

16 Solomon A. 4/28/2025
 Medical Eligibility Criteria (MEC)
 It used to review who can and cannot safely use a contraceptive method.

 It offers guidance on the safety of using different methods for clients

with specific reproductive and social characteristics or known medical

conditions.

 Improve both the quality of and the access to FP services for clients.

 To address and change misconceptions about who can and cannot safely

use contraception

 The recommendations are based on systematic reviews of available

17 Solomon A. 4/28/2025
clinical and epidemiological research.
 What Is Answered by WHO’s MEC?
▪In the presence of a given individual characteristic or

medical condition,
▪Can a particular contraceptive method be used?

18 Solomon A. 4/28/2025
 MECs Categories
➢ The conditions affecting eligibility for the use of
each method are classified under in to four
categories:
1. A condition for which there is no restriction for the use of
the contraceptive method.
2. A condition where the advantages of using the method
generally outweigh the theoretical or proven risks.
3. A condition where the theoretical or proven risks usually
outweigh the advantages of using the method.
4. A condition which represents an unacceptable health risk if
the contraceptive method is used.
19 Solomon A. 4/28/2025
 MECs Categories…

20 Solomon A. 4/28/2025
 MEC exercise
‘’A 32-year-old woman, in her first 6 weeks postpartum, is
currently breastfeeding while managing multiple health
conditions, including HIV/AIDS, tuberculosis treated with
rifampicin, and severe hypertension, requiring close
monitoring and a multidisciplinary approach to her care’’

 Which type of contraceptive method be used safely?

21 Solomon A. 4/28/2025
 Categories for Sterilization

22 Solomon A. 4/28/2025
 Categories for Fertility awareness methods

23 Solomon A. 4/28/2025
24
 Initiation versus continuation
▪ The MEC addressed the medical evidence for the
initiation and continuation of use of all methods
evaluated.
▪ Continuation criteria is clinically relevant whenever a
woman develops the condition while she is using the
method.
▪ Differences for initiation and continuation are noted as
'I=Initiation' and 'C=Continuation'.

25 Solomon A. 4/28/2025
 What is new in the MEC 2015?
❑Addition of new contraceptive methods (four) to the

fifth edition of MEC

❑ New recommendations regarding some conditions

26 Solomon A. 4/28/2025
 Breast feeding women and POPs
and implants
 Start progestin only pills or implants immediately
after delivery/any time postpartum
o If menstrual bleeding has not returned, she can start
any time between giving birth and 6 months. No
need for a backup method.
o If her monthly bleeding has returned, can start as
advised for women having menstrual cycles.
 The previous recommendation was 6 weeks after
child birth

27 Solomon A. 4/28/2025
New selected practice recommendations
on….

Levoplant (Sino-Implant (II)) DMPA –SC Combined vaginal ring

Combined Patch Ulipristal acetate (UPA) for ECP

 Levoplant (Sino-Implant (II))
Highly effective 2-rod contraceptive
implant
Each rod contain 75 mg levonorgestrel
(a synthetic form of the hormone
progestin).
Effective up to 4 years
Highly effective i.e. < 1 pregnancy for
100 users
DMPA-SC
Progestin-Only
Meant only for subcutaneous injection
(just under the skin).
Available in
o Uniject device
o Prefilled, single-dose, conventional
syringes.
Useful for community-based programs
Women can easily learn to give
themselves
 Combined Patch (xulane or twirla)
 A small, thin, square of flexible plastic worn on the body.

 Choose clean, dry, hairless skin on (Upper outer arm,

Abdomen, Buttocks, Upper back
 Continuously releases progestin and estrogen
 New patch every week for 3 weeks, then no patch for the
fourth week.
 In fourth week, the woman will have monthly bleeding.
 Works primarily by preventing ovulation.
 When no mistakes, less than 1 pregnancy per 100 users

31 Solomon A. 4/28/2025
Combined vaginal ring (NuvaRing)
 A flexible ring, placed in her vagina.
 Continuously releases progestin and an
estrogen
 Place the ring for 3 weeks, then removes
it in the fourth week.
 During this fourth week the woman will
have monthly bleeding.
 Works primarily by preventing ovulation.
 When no mistakes, less than 1 pregnancy
per 100 users
Ulipristal acetate(UPA) for ECP
 Sold under brand names like ella® (in the
U.S.) and ellaOne® (in Europe and
elsewhere).
 30 mg stat after unprotected sex.
 Work by blocking or delaying ovulation by 5
to 7 day.
 UPA-ECPs are more effective than other
ECPs between 72-120 hours after
unprotected sex.
 UPA-ECPs are not intended for use as a
continuing oral contraceptive.
 When to start FP after taking ECPs
 In all method chapters:
o Start or restart any method immediately after she takes
the ECPs. No need to wait for next monthly bleeding.
o Abstain from sex or use a backup method for the first
7 days of using method.
o Start any method at any time if it is reasonably certain she is
not pregnant.
 Previous recommendation was almost the same except
for implants
“Give her a backup method and start implant after
return of monthly bleeding.”

34 Solomon A. 4/28/2025
Update on Implants – MEC 2015
Levonorgestrel (LNG) containing implants
• Norplant: 6 rods; 36mg of LNG/rod, no longer in production
• Jadelle: 2 rods, 75mg of LNG/rod
• Sino-implant(II): 2 rods; 75mg/rod - a new entrant in the MEC
Etonogestrel (ETG) containing implants
• Implanon: Single rod; 68mg of ETG/rod; phasing out
• Nexplanon: Single rod; radio-opaque; 68mg of ETG/rod

4th Edition
(2009) 5th Edition (2015)
Condition Category Category

Breast Feeding less than 6 weeks 3 2

ART: NRTI (Abacavir-ABC, Tenofovir-TDF, Ziduvudine-AZT,

2 1
Lamuvudine-3TC)

ART: Integrase Inhibitors (Raltegravir-RAL) 2 1

Update on IUDs – MEC 2015
4th Ed. (2009) 5th Ed. (2015)
LNG-IUD use among breastfeeding women Category Category

< 48 hours postpartum (breastfeeding) 3 2

< 48 hours postpartum (not breastfeeding) 1 1

≥ 48 hours to < 4 weeks postpartum 3 3

≥ 4 weeks postpartum 1 1

Puerperal sepsis 4 4

IUD use for women with increased risk of STIs*

IUD initiation (generally) 2 2

IUD initiation (with very high individual likelihood) 3 3

IUD continuation 2 2
Update on Postpartum Use of Progestogen
containing contraceptives (POP, LNG/ETG implants,
LNG IUD, PVR and EC (UPA) – MEC 2015

5th Edition (2015)

4th Ed.
Category
(2009)
Breastfeeding Category Initiation Continuation

< 6 weeks postpartum breastfeeding for POP,

3 2 2
LNG/ETG Implant

< 48 hours postpartum (including C/S)

immediately after delivery of placenta for 3 2 2
LNG IUD

≤ 4 weeks postpartum for PVR 1 1

Emergency contraceptive:
2
Ulipristal
Update on Postpartum Use of Combined oral
contraceptive, Combined vaginal ring, contraceptive
patch – MEC 2015

5th Edition (2015)

4th Ed. Category
(2009)
Non-Breastfeeding Category Initiation Continuation

Without other risk factor for VTE 3 3 3

< 21days
With other risk factor for VT 3 4 4

Without other risk factor of VT 1 2 2

≥ 21 days to
42 days
With other risk factor of VT 1 3 3

≥ 42 days 1 1
 Major change & Recommendation
❑Breastfeeding women

❑ Women < 6 weeks postpartum- Can generally use

Progesterone only pill, Implants and LNG containing
IUD (Mirena) (cat 2), category 3 in the previous MEC

NB. DMPA (Depo-Provera) remains as category 3 in

the new MEC

39 Solomon A. 4/28/2025
 Summary
 The safe provision of most contraceptive methods does not require
performing a physical, pelvic or laboratory examination.
 Few physical examinations are absolutely necessary and few laboratory
examinations are mandatory before commencing some of the
contraceptive methods, IUCDs and voluntary sterilization.
 Medical eligibility criteria’ that is used to review who can and cannot safely
use a contraceptive method.
 MEC offers guidance on the safety of using different methods for women
and men with specific reproductive and social characteristics or known
medical conditions.
 The recommendations are based on systematic reviews of available clinical
and epidemiological research.

40 Solomon A. 4/28/2025
41 Solomon A. 4/28/2025
 References
1. WHO. Family Planning. A global handbook for providers,

2022.

2. Federal Democratic Republic of Ethiopia Ministry of Health.

National Guideline for Family Planning Services in Ethiopia,

2018.

42 Solomon A. 4/28/2025
 Thank you

43 Solomon A. 4/28/2025