AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 29 GUIDELINES CLINICAL ASSESSMENT AND ELIGIBILITY Due to potentially serious side-effects, patients need to be screened for eligibility. The World Health Organisation (WHO) Medical Eligibility Criteria (MEC) publications use evidence regarding the safety of contraceptives in specific medical conditions and patient characteristics to categorise the safety of methods per condition. Summarised versions of the 5th edition (2015), the WHO MEC wheel and the WHO application for smartphones are also available. Four safety categories are specified for use with clinical judgement and when clinical judgement is not available. (5) MODERN CONTRACEPTIVE METHODS Contraceptive classes are briefly discussed, more or less in order of long term efficacy with typical use, starting with the LARCs, which are the most desirable group of contraceptives. (6) Permanent contraception Permanent contraception involves either tubal ligation (TL) in women or vasectomy in men. Neither female, nor male sterilisation is an emergency procedure or reliably reversible. It must be well thought through and well- motivated, as numerous alternative highly effective forms of reversible contraception are available. SASOG has developed patient information and pro forma consent for female sterilisation to ensure careful counselling and to limit medico-legal risk. Tubal ligation at the time of caesarean section or immediately postpartum (mini-laparotomy) is convenient and has a very low morbidity; as an interval procedure it is done via laparoscopy. Failure rates are low, provided the patient is not pregnant at the time, an effective method is used and both tubes are visualised and interrupted. Histology confirmation is a good option when the method allows. Informed consent should preferably be done during the antenatal period, as informed consent in the emergency setting is not ideal. Vasectomy is done by surgically interrupting the vas deferens and is not immediately effective. After a number SASOG | BETTERGYN TM Contraception: SASOG BetterGyn TM Clinical Guideline Aims: This guideline is not intended as a comprehensive textbook about contraceptives. It aims to summarise pivotal clinical issues, modern contraceptive product groups that are available and widely used in South Africa, and gives guidance on patient counselling and method selection. Contraception is one of the most effective and cost-effective interventions to prevent maternal mortality and improve women’s well-being and health. It should be freely available to all women and should logically be funded by all public and private health care providers and funders. Definitions: Contraception is an important aspect of fertility and family planning. It allows individuals and couples to decide when to start a family, spacing of children, and the size of the family, resulting in numerous social and economic benefits and especially enables empowerment of women. In addition, there are many non-contraceptive medical benefits. Modern contraceptives employ a product or procedure which interferes with reproduction resulting from sexual intercourse and include permanent methods (male and female sterilisation), mechanical methods (male and female condoms, diaphragm and cervical cap), medical or chemical methods (sponge, spermicides), intra-uterine methods (copper and progestogen containing) and systemic hormonal methods (progestogen-only methods and combined estrogen-progestogen methods). Traditional methods do not fulfil the criteria above, and include fertility awareness methods, withdrawal, lactational amenorrhoea and abstinence. (1) Long Acting Reversible Contraception (LARC’s) typically require administration less that once per month and are less user dependant. This group includes injectables, intrauterine devices/systems and subdermal contraceptive implants. There is a growing trend towards LARCs as first line in view of high efficacy and good continuation rates. Effectiveness: The Pearl Index (PI) is the most used method of measuring contraceptive efficacy and is the percentage of women with unintended pregnancy during the first year of use; it needs to be compared to the PI of using no method, which is 85%. For most methods typical use is less effective than perfect use. Spermicides and sponges are the least effective methods and should not be used on their own as typical use leads to pregnancy in 24+%, perfect use in 10-20%. The difference between typical and perfect use is larger for methods that are more user dependant like fertility awareness methods and withdrawal (24% vs ~4%), female condoms (21% vs 5%), male condoms (18% vs. 2%), and diaphragm (12% vs.6%). Another factor that determines effectiveness is the continuation rate, which ranges from 40 to 57% for these methods at one year. (2) Combined and progestin oral, transdermal (patch) and vaginal (ring) contraceptives have similar reported PI of 9% for typical use, 0.3% for perfect use and reported continuation rates of 67%. The PI of most of the LARCs are almost the same for typical and perfect use, and are reported to range from 0.05% for Implanon ® , 0.2% for Mirena ® and Depo-Provera (which has typical use PI of 6%) to 0.6% for Copper containing IUCDs. Male and female sterilisation has effectiveness of 0.15% and 0.5% respectively. (2) While all classes should be available, methods which do not depend on perfect use or motivation and which have high continuation rates should be prioritised. (3) Interestingly, the reported Pearl index of newer products appears to be increasing, called “creeping pearl index”. This trend is most likely caused by more frequent pregnancy testing, more sensitive pregnancy tests, and less compliant study populations. (4) Patel M 1 , Nene Z 2 , Dreyer G 2 , BetterGyn team 2023 3 1 Department of Obstetrics and Gynaecology, University of Cape Town, Grootte Schuur Hospital 2 Department of Obstetrics and Gynaecology, University of Pretoria and Steve Biko Academic Hospital 3 All members of the BetterGyn team 2023 reviewed and contributed to the final document