GRADE table 1(Question 1): Among breastfeeding women and their infants, does the use of the progesterone-releasing contraceptive vaginal ring (PVR), compared with non-use of progestogen-only contraceptive (POC) methods, affect maternal health, breastfeeding performance, infant growth and infant health? (Direct evidence)

OutcomeType and number of studies (number of participants)LimitationsInconsistencyImprecisionIndirectnessOther factorsQualityEstimate of effect
Progesterone-releasing vaginal ring (PVR) vs intrauterine device (IUD), Norplant or progesterone-only pill (POP)
Pregnancy7 cohort studies (n=3397)Serious limitations
(5 fair, 2 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLowFew pregnancies and similar pregnancy rates in breastfeeding women using PVR vs IUD (6 studies), Norplant (2 studies), or POP (1 study)
Use of supplementation4 cohort studies (n=1129)Serious limitations
(3 fair, 1 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLowNo difference between PVR and IUD (3 studies), Norplant (2 studies), or POP (1 study) in proportion fully breastfeeding; 1 study found ring associated with fewer supplementation episodes and days than IUD at all follow-up periods (P < 0.001)
Breastfeeding duration4 cohort studies (n=1117)Serious limitations
(2 fair, 2 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLowNo difference between PVR and IUD (4 studies), Norplant (2 studies), or POP (1 study)
Breastfeeding episodes2 cohort studies (n=2083)Serious limitations
(2 fair)		No serious inconsistencyNo serious imprecisionNo directnessNoneLowNo differences between PVR and IUD (2 studies)
Continuation of use5 cohort studies (n=2722)Serious limitations
(3 fair, 2 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLow4 studies found PVR associated with lower continuation/higher discontinuation vs IUD; 1 study found PVR associated with higher continuation/lower discontinuation
Bleeding episodes3 cohort studies (n=2279)Very serious limitations
(1 fair, 2 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLowNo clear differences between PVR vs IUD (3 studies), Norplant (1 study), or POP (1 study)
Infant weight gain7 cohort studies (n=3397)Serious limitations
(5 fair, 2 poor)		No serious inconsistencyNo serious imprecisionNo indirectnessNoneLowNo difference between ring vs IUD (7 studies), Norplant (2 studies), or POP (1 study)

From: I, Development of the Medical eligibility criteria for contraceptive use, fifth edition

Cover of Medical Eligibility Criteria for Contraceptive Use
Medical Eligibility Criteria for Contraceptive Use. 5th edition.
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