James Kiarie

Background: Prolonging the use of the etonogestrel (ENG) implant beyond the currently approved duration of 3 years could offer substantial benefits including improved accessibility, reduced need for replacements and overall lower healthcare costs. The purpose of this systematic review is to examine the current evidence regarding the effectiveness, safety and acceptability of the use of the ENG implant for up to 5 years. Methods: We searched PubMed, Embase, Scopus, Global Health, CINAHL, ClinicalTrials.gov, Global Index Medicus, Cochrane Central Register of Controlled Trials and International Clinical Trials Registry Platform from 1996 to 2024. Our study population included reproductive-aged women using the 68 mg single-rod ENG contraceptive implant. We included randomised controlled trials, retrospective and prospective cohort studies, case-control studies and conference presentations. Outcomes included those related to efficacy, safety and acceptability. The primary contraceptive efficacy outcome was Pearl Index between the third and fifth years of placement compared to that within 3 years. Results: We identified seven relevant studies. No pregnancies were noted among 860 participants within years 3–4 or among 306 participants within years 4–5. No important safety events were identified. Discontinuation of the implant due to bleeding was higher in the first 3 years of use (20.6%), compared with years 3–5 (5.4%). Due to the non-comparative nature of the studies and the overall low sample sizes of the studies, evidence certainty was deemed to be low or very low using the GRADE criteria. Conclusions: Current evidence, despite its low certainty, does not carry signals of potential concerns with regard to extended use, with potential for benefit.

Background: To evaluate the contraceptive effectiveness, safety and acceptability of continuous or extended-cycle combined oral contraceptives (COCs) compared with conventional cyclic regimens (21/7 or 24/4). Methods: A systematic search was conducted in Medline, Embase, Web of Science, trials registries and other databases from 1 January 1970 to 21 October 2024. Complementary searches were conducted in grey literature sources and reference lists. Results: A total of 9531 records were identified, from which 18 randomised controlled trials and 10 studies of other designs were included. Overall, findings indicated that: (1) continuous or extended-cycle COCs had contraceptive effectiveness similar to cyclic COCs (unintended pregnancies over 1 year: OR 0.79, 95% CI 0.41 to 1.52; Pearl Index mean difference −0.20, 95% CI −1.31 to 0.92); (2) bleeding outcomes varied, with either no significant difference or fewer total bleeding and/or spotting days with continuous or extended-cycle COC use, but more unscheduled bleeding; (3) no significant difference was observed in the odds of experiencing at least one adverse event (OR 1.20, 95% CI 1.03 to 1.41); (4) the relative risk of deep vein thrombosis or venous thromboembolism was low (OR 1.05, 95% CI 0.16 to 6.79), with a small absolute increase (approximately 0.7 additional cases per 1000 users); and (5) satisfaction was generally high in both groups. Conclusions: Continuous or extended-cycle COC use demonstrates comparable contraceptive effectiveness, safety and overall acceptability to conventional cyclic COC regimens. However, interpretation of acceptability and bleeding-related outcomes should consider higher discontinuation rates and missing outcome data.

Objective: To evaluate the efficacy, safety and acceptability of quinestrol combined with quingestanol (Quin-QUIN), quinestrol combined with levonorgestrel (Quin-LNG) and quinestrol combined with norgestrel (Quin-NG) as contraceptives. Methods: PubMed, Web of Science Core Collection, Embase, CENTRAL, CINAHL, CNKI, Wanfang, SinoMed and selected supplementary sources were systematically searched to identify randomised controlled trials (RCTs) and non-randomised studies of interventions related to Quin-QUIN, Quin-LNG and Quin-NG. Two investigators independently performed data extraction and risk-of-bias assessment. A random-effects model was used for the meta-analysis and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Twelve studies (1 RCT and 11 case series) involving 5355 participants were included. Most studies were published in the 1970s. The only included RCT showed no significant difference in the risk of pregnancy (risk ratio (RR)=0.70, 95% confidence interval (CI) 0.31 to 1.55 for Quin-LNG compared with Quin-NG). Quin-LNG was associated with a lower risk of discontinuation and fewer side effects than Quin-NG. Proportion meta-analyses of the case series, all evaluating Quin-QUIN, found a pooled proportion of pregnancy of 3.6% (95% CI 2.5% to 5.0%) and a pooled discontinuation rate of 47.9% (95% CI 17.4% to 79.4%). Nausea, vomiting, dizziness and headache were the most common side effects. The certainty of evidence for most outcomes was low or very low. Conclusions: Available evidence is limited; the risk–benefit profile of quinestrol-based once-monthly oral contraceptives remains uncertain. Their clinical use should be cautious, and high-quality studies are needed to clarify their safety and efficacy.

Objective: To systematically review the contraceptive safety and effectiveness of ormeloxifene, a non-hormonal selective oestrogen receptor modulator, among reproductive-age women. Methods: A comprehensive search was performed across MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar. No restrictions were applied regarding language, geography or publication year. Eligible studies included interventional and observational designs that evaluated the contraceptive effectiveness and/or safety of ormeloxifene. Two reviewers independently extracted data using a standardised form, assessed the risk of bias for individual studies, and graded the certainty of evidence using design-appropriate tools. Results: The review included 14 studies on contraceptive use of ormeloxifene and 41 studies assessing its safety in non-contraceptive contexts. Twelve contraceptive studies reported Pearl Indices ranging from 0.48 to 4.2 per 100 woman-years, with failure rates between 0.8% and 10.1%. No serious adverse events such as thromboembolism or hepatotoxicity were reported. Two cases of benign endometrial hyperplasia were reported, and transient reductions in lactation were noted among 5.7% of women at 1 month, decreasing to 2% at 6 months among women using ormeloxifene as contraception. Infant exposure during breastfeeding remained below 10% of the maternal dose. The most common side effects were menstrual irregularities, leading to discontinuation in up to 31.5% of users. Continuation rates were high at 3–6 months (>85–100%), declining to 27–91% in larger cohorts involving longer follow-up extending beyond 12 months. Method satisfaction was consistently high (75–95%). All 14 studies on contraceptive use were conducted in India, had a high risk of bias, and only four were multicentre studies. Conclusions: Ormeloxifene shows promise as a moderately effective, safe and user-acceptable contraceptive option. The current evidence is limited by methodological weaknesses and geographic concentration. High-quality, large-scale studies in diverse populations are essential to establish ormeloxifene’s comparative effectiveness and safety with greater certainty and support its inclusion in global contraceptive guidelines. PROSPERO registration number: CRD42024622516.

Objective: To identify client and provider perspectives on contraceptive counselling in Pakistan and inform the development of an effective, rights-based counselling intervention package. Design: A formative, multimethod qualitative study was conducted using in-depth interviews, non-participant observations of counselling encounters and thematic analysis. The study was embedded within a WHO-led multiphase complex intervention. Setting: Primary care-level family planning facilities (public and private) in the urban and peri-urban districts of Islamabad and Rawalpindi. Participants: The analysis reported in this paper includes 72 married family planning clients (36 women and 36 men), 15 frontline healthcare providers and 72 observed counselling sessions across three facilities. Broader stakeholder interviews with programme managers, public-sector officials and donor/development partners were collected for the wider multiphase study but are not analysed in this paper. Results: Three overarching themes were identified: (1) counselling was often understood as basic method-related information rather than a structured, rights-based decision-making process; (2) public and private facilities differed in counselling depth, method choice, privacy and use of visual/couple-centred approaches; and (3) system constraints, including time pressure, commodity limitations, limited follow-up mechanisms, weak privacy arrangements and inconsistent training, shaped the quality of counselling. Observation data supported interview findings by showing variation in privacy, side-effect discussion, client engagement and follow-up advice across facilities. Conclusions: Findings from participating facilities suggest that the current counselling model in these settings inadequately supports informed, autonomous reproductive choices. A redesigned, context-sensitive counselling package is needed to address these gaps. This should be supported by improved training, supportive supervision, inclusive tools, systemic reforms and enhanced follow-up mechanisms that are essential to increase decision-making autonomy and contraceptive continuation. Trial registration number: NCT06081842 .

Among 1.64 billion women of reproductive age (15–49 years) living in low- and middle-income countries (LMICs), 923 million wish to avoid pregnancy, yet 24% face an unmet need for family planning (FP), endangering their health and well-being and impacting their families. 1 49% of pregnancies in LMICs—equivalent to 111 million annually—are unintended.2 Addressing this unmet need and providing care to all women at the standards recommended by the WHO could reduce unintended pregnancies by 68%, unsafe abortions by 72% and maternal deaths by 62%, as advised by the Guttmacher Institute.1

Introduction Infertility is a major public health concern, and many individuals face substantial barriers to accessing fertility care. Across jurisdictions, regulations, eligibility criteria and funding frameworks for fertility care vary considerably, particularly in relation to lesbian, gay, bisexual, transgender, intersex and queer/questioning people (LGBTIQ+), as well as unpartnered individuals. Moreover, existing definitions and prevalence estimates of infertility are largely derived from studies of heterosexual couples which may underestimate the need for fertility care among other populations. This protocol describes a systematic review designed to synthesise current evidence on the need for and access to fertility care among LGBTIQ+ populations and unpartnered individuals as well as the policies and regulations that govern such care. Methods and analysis This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Systematic searches were conducted in MEDLINE (Ovid), Embase, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Global Health, as well as grey literature sources including ProQuest Dissertations & Theses, ECRI Guidelines Trust, Canadian Medical Association Journal (CMAJ) Guidelines, National Institute for Health and Care Excellence, fertility societies guidelines and Google Scholar. Eligible studies will include quantitative, qualitative, mixed-methods, narrative synthesis and typology mapping designs. Two reviewers will independently perform title/abstract and full-text screening, data extraction and quality assessment. The Critical Appraisal Skills Programme checklist will be used for qualitative studies and the Joanna Briggs Institute tools for quantitative studies. Completeness and credibility assessments will be applied to narrative syntheses and typology mappings. The primary outcomes will include measures of fertility care need, indicators of access and policy frameworks influencing service availability. Ethics and dissemination This study does not involve human participants. The protocol received an exemption from Research Ethics Board review by the McGill University Health Centre Research Ethics Board. Findings will be disseminated through peer-reviewed publications, conference presentations and professional networks and shared with the WHO to inform evidence-based policy. PROSPERO registration number CRD420251126056

UNSTRUCTURED Engaging civil society organizations (CSOs) and community-based organizations (CBOs) in the development of global guidance can improve the relevance, acceptability and implementation of recommendations at the country level. Despite increasing recognition of its importance, involvement of CSOs and CBOs in guideline development remains inconsistently applied, insufficiently documented or limited to a small group of technical experts. Through the IBP network, the World Health Organization (WHO) has engaged with CSOs and CBOs working in family planning and sexual and reproductive health globally. This viewpoint describes the design and implementation of three IBP network-facilitated virtual consultations and how stakeholder inputs contributed to the strengthening of three WHO guidance documents: a step-by-step guide to South-South Learning Exchanges (SSLEs), Scaling up postpregnancy family planning and Social and behaviour change interventions for contraception and family planning. Between December 2022 and June 2024, members of the IBP network were invited to participate in three independent virtual consultations conducted via Zoom. All consultations followed a similar format, with a series of structured questions to guide the discussion. A total of 1,353 stakeholders registered across the three consultations, of whom 555 participated live, representing more than 100 countries. For the SSLE guide, participants emphasized improving practical applicability, clarifying roles and responsibilities, enhancing contextual relevance and inclusivity, and strengthening monitoring and sustainability approaches. For the SBC guidance, participants highlighted the importance of strengthening partnerships, improving SBC content, messaging, and communication strategies, capacity building for SBC implementation, ensuring sustainable financing, and stronger monitoring systems. For the postpregnancy family planning guide, recommendations focused on strengthening policy and governance frameworks, improving community engagement, expanding access to post-abortion FP, strengthening provider capacity and health information systems, engaging community and religious leaders, addressing misconceptions, increasing male involvement, and task sharing. These recommendations informed revisions to all three guides. As virtual platforms become more advanced, they should be leveraged to strengthen WHO’s community engagement efforts in guideline development processes. These virtual consultations enabled direct engagement between participants and WHO experts, while structured discussions generated focused and actionable feedback. Virtual platforms also provided a more inclusive and equitable mechanism for participation by reducing geographic, financial, and logistical barriers that often limit involvement in normative guidance processes.

Introduction Infertility affects millions of people globally. The presence of key indicators of infertility and fertility care is critical to monitoring access and utilisation of services as part of universal health coverage. In the area of infertility, it is important to track both clinical and non-clinical outcomes of care. Previous reviews have examined clinical indicators for infertility and fertility care; however, non-clinical indicators have received limited attention. This systematic scoping review aims to map the literature related to the non-clinical indicators of fertility care and their types and dimensions. Methods and analysis This review will adhere to the established reporting guidelines for systematic scoping reviews and has been registered in the PROSPERO database to avoid duplication. A systematic literature search strategy will be developed and adapted to four electronic bibliographic databases (Medline [PubMed], EMBASE [Embase.com], CINAHL [EBSCOhost] and Web of Science [Clarivate]). Supplemental searches will be performed to obtain relevant grey literature from major health research institutes and international organisations. The search will be limited to literature published from 1990 to date. This review will cover all non-clinical interventions relevant to human infertility and fertility care. Two reviewers will independently screen papers and identify relevant studies for inclusion using predetermined criteria and extract data based on a predefined template. Types and dimensions of non-clinical indicators will be identified and a descriptive narrative synthesis will be used to describe the overall landscape. This review is expected to start on 1 June 2026 and conclude by 15 December 2026. A preliminary search strategy has been developed. Ethics and dissemination As this study is based on a review of publicly available literature, ethical approval is not required. This scoping review will provide a comprehensive overview of the existing non-clinical indicators used to measure, report and monitor infertility and fertility care services. The findings will provide a comprehensive evidence base for developing a set of core indicators to monitor infertility and fertility care that can be adopted globally. Results will be disseminated through peer-reviewed publications, scientific conferences and webinars. PROSPERO registration number CRD420251177901.