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• An article published in Le Sahel on 21 July 1999, about REDIPOP, a new network that will advocate for population and reproductive health.

• Press release, Afrique-Santé, 12 August 1999, "Reproductive health at the center of a MAQ conference in Dakar."

• Press release, Afrique-Santé, 5 September 1999, Interview with M. Souleymane Mariko (Nigerian delegate at the MAQ conference in Dakar). "Policies, norms and protocols are a tool for improving interactions between clients and service providers."

• Article published in Le Sahel on 7 September 1999, "Maximizing access and quality of family planning services initiative: An Answer to Clients’ Demands."

• Article published in Le Sahel on 16 September 1999, "Access and quality of services in reproductive health: Where does Niger Stand?"

Contributed by the National Population and Development Network, Republic of Niger

Pregnancy Checklist Can Improve Access to Family Planning

Medical Barriers

One of the key concepts of the Maximizing Access and Quality (MAQ) initiative is that of medical barriers. Medical barriers have been defined as service provider biases and practices that have no scientific justification and that deny clients their right to obtain contraceptive services.^{1, 2} Although the MAQ initiative has helped identify and reduce these barriers to contraceptive access, many still exist. And, they still have an impact on many family planning programs.³

Menstruation Requirements: Barriers to Contraception

One common medical barrier that persists in some countries is the requirement that women must be menstruating in order to receive hormonal contraceptives or IUDs.⁴ Studies in Ghana, Kenya, Cameroon, Jamaica and Senegal have described menstruation requirements and examined their rationales. In some cases, a woman may even be refused family planning counseling simply because she is not menstruating.²

Menstruation requirements may be significant barriers to contraceptive access in many parts of the world. In locations where reliable pregnancy tests are not available and healthcare providers fear possible harm to fetuses, many women are asked to wait until the return of their menses before being given a contraceptive method. For example, in a sample of nine clinics and hospitals in Kenya, an estimated 35% of all new family planning clients were denied services because they were not menstruating. Non-menstruating women who are denied contraception run the risk of unwanted pregnancy. And, disappointed or dissatisfied potential clients may not return to the clinic for the family planning services they need.⁵

Pregnancy Checklist

To help reduce menstruation requirement barriers to contraception, a simple, 6-item checklist has been developed from guidelines prepared by the United States Agency for International Development’s Technical Guidance Working Group and the World Health Organization. This checklist enables family planning providers to rule out pregnancy. (See Figure 1.) If a woman answers "yes" to any question and is free from signs or symptoms of pregnancy, she can receive her desired contraceptive method.^{4, 5, 6}

A Synergy of Interventions

One effective approach to reducing medical barriers is the revision of a country’s clinical guidelines. This approach has been taken in Kenya where the country’s newly revised reproductive health and family planning guidelines describe the criteria for ruling out pregnancy.⁴

But revised guidelines alone are not enough. They must be accompanied by plans to disseminate and implement new practices. One practical means of dissemination at the clinic level is the creation of job aids (i.e., tools that service providers can use on the job to help them provide high quality services). In Kenya the pregnancy checklist has been produced as a job aid. It has been reproduced in English and Kiswahili, laminated and distributed to clinics nationwide.⁴

 

Figure 1. Pregnancy Checklist Have you given birth in the past 4 weeks? Are you less than 6 months postpartum and fully breastfeeding and free from menstrual bleeding since you had your child? Did your last menstrual period start within the past 7 days? Have you had a miscarriage or abortion in the past 7 days? Have you abstained from sexual intercourse since your last menses? Have you been using a reliable contraceptive method consistently and correctly? If the client answered NO to all of the questions, pregnancy cannot be ruled out. Client should await menses or use pregnancy test. If the client answered YES to any of the questions, and is free of signs or symptoms of pregnancy, provide her with desired method.

But revised guidelines and job aids are still not enough. Training is also needed. With this in mind, family planning workers throughout Kenya have been trained to use the pregnancy checklist.⁴ The Kenya model is a good example of the synergy of interventions that is central to the MAQ initiative.³ In this case, research, revised guidelines, job aids and training are all combining forces to reduce menstruation requirement barriers to contraceptive access.

Results

In a recent study that surveyed 1,852 non-menstruating women at seven family planning clinics in Kenya, healthcare workers used the checklist when counseling new, non-menstruating clients. The checklist was found to be user-friendly, effective, economical and acceptable to providers. During this pilot test phase, the checklist helped increase the volume of new clients in the seven study clinics by about 30%, compared to no change in the control group of clinics.⁴

Next Steps

A new study is under way in more than 70 clinics in Kenya to evaluate the impact of wide scale use of the checklist on client volume and other outcomes.⁴ Are there menstruation requirements that are barriers to family planning access in your country? If so, what can your country do to reduce these barriers to contraception?

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1. Shelton JD, MA Angle and RA Jacobstein. 1992. Medical barriers to access to family planning. Lancet 340: 1334-1335.

2. Stanback J et al. 1997. Menstruation requirements: A significant barrier to contraceptive access in developing countries. Studies in Family Planning 28(3): 245-250.

3. United States Agency for International Development (USAID). 2000. MAQ Key Concepts. MAQ Exchange. USAID: Washington, DC.

4. Family Health International (FHI). 2000. Better Practices in Reproductive and Child Health: Improving Access to Family Planning. Fact Sheet. FHI: Research Triangle Park, North Carolina.

5. Stanback J et al. 1999. Checklist for ruling out pregnancy among family planning clients in primary care. Lancet 354: 566.

6. Technical Guidance Working Group. 1994. Recommendations for Updating Selected Practices in Contraceptive Use: Results of a Technical Meeting. Volume I. USAID: Washington, DC.

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