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In recent years, nearly 50 developing countries have begun developing new or revised
national guidelines on family planning services. Writing guidelines is a collaborative
process, involving providers, government officials, technical experts and others. But
writing them is only the first step.
Disseminating the guidelines, including training providers about how and why to use
them, is essential. Also, guidelines must be updated regularly, since new scientific
findings about contraception or other reproductive health issues may influence procedures
and other policies. Making clients aware of their rights under guidelines is also vital.
"We have to take a comprehensive approach to implementing the guidelines,
involving training, educating, policy-making, empowering clients and addressing cultural
values," says Sandra de Castro Buffington of the U.S. Agency for International
Development (USAID). Previously, when working for JHPIEGO Corp., a U.S.-based technical
assistance organization specializing in reproductive health, Buffington helped develop
guidelines in Brazil, Bolivia, Peru and Guatemala.
"We need to institutionalize the guidelines into the training at schools of
medicine, nursing and pharmacy," she says. "We have to communicate to potential
clients so they will demand that providers answer their questions and respect their right
to make an informed choice. And we have to affect the supervisory and management system,
both from the top down and the bottom up."
These important steps can take years to accomplish. Consequently, evaluating the full
impact of recent family planning guidelines on service practices is not well documented.
"Determining how much national guidelines themselves result in changes in provider
practices is very difficult to determine," says Susan Palmore, who guides policy and
research utilization at FHI. "Many factors affect these practices. Our research at
FHI has sought to sort out the various factors."
International recommendations
In developing guidelines for contraception, many national health officials have relied
extensively on recommendations developed by the World Health Organization (WHO)1 and USAID.2 These recommendations
are designed to make services more accessible, more uniform and of higher quality.
Developing new national guidelines would be more difficult without the USAID and WHO
recommendations, says Dr. Roberto Rivera, FHI's director of international medical affairs,
who was a participant in developing the WHO and USAID documents. The recommendations have
become a primary resource for updating national guidelines. "They represent the
consensus of international experts, based on the latest scientific information
available," says Dr. Rivera, who has advised health officials in Mexico, Paraguay,
Costa Rica, Jamaica and El Salvador as they have developed national family planning
guidelines.
WHO uses a four-tier rating system for how a medical condition or other aspect of a
client's circumstances should affect the use of specific contraceptive methods. If a
condition does not interfere with method use, it is "category 1," while
"category 2" means a person with the condition can generally use the method. For
example, concerning a client's age, any woman from menarche to 40 years old falls into a
category 1 for using low-dose oral contraceptives (OCs), while women 40 or older are a
category 2.
However, if a woman is 35 or older and a light smoker, these conditions make OC use a
category 3: a method not usually recommended unless other more appropriate methods are not
available or not acceptable. If a woman 35 or older is a heavy smoker (20 or more
cigarettes a day), the method should not be used (category 4).
USAID recommendations outline answers to common questions about each method, giving the
scientific rationale involved. They also classify various medical procedures with regard
to contraceptive use. Procedures that are essential, mandatory or important are in one of
four designated categories. Other categories include procedures that are rational in some
circumstances but may not always be appropriate, those that may be good preventive health
measures but are not materially related to contraceptive use, and procedures that are not
only unnecessary but also irrelevant to the safe use of the method.
For example, a pelvic exam, an appropriate medical procedure for some purposes, is not
necessary to ensure safe OC use, placing it in the category of procedures that may be
appropriate for good preventive health, but not related to safe use of the method. Certain
laboratory tests, such as determining cholesterol levels, are in the category of "not
only unnecessary but irrelevant" to safe OC use.
Many national guidelines are incorporating recommendations made by WHO and USAID,
according to a study of guideline revisions in Bolivia, Guatemala, Peru and two states in
Brazil between 1992 and 1996. The study focused on nine key categories with 400 indicators
of program changes that would affect barriers to access and quality services. "We
found a sharp reduction in the number of medical procedures and restrictive medical
eligibility guidelines in the new sets of guidelines," says Jennifer Macías of
JHPIEGO. While most of the guidelines are virtually in agreement with the WHO guidelines
now, she emphasizes that such a desk review of documents does not provide information
about changes in provider practices.3
A recent analysis based on interviews with more than 2,000 providers in five African
countries compared national service guidelines and provider practices. "Providers
impose a considerably different, and much more restrictive, pattern of barriers on clients
than that required by policy," write Kate Miller and her colleagues at the Population
Council.
For example, while none of the guidelines in the five countries requires a spouse's
consent except for sterilization, a substantial percentage of providers in all countries
did require spousal consent for most methods. For OCs, almost a third of providers in
Burkina Faso and nearly 10 percent in Kenya required spousal consent. In Botswana, 12
percent of providers required consent for injectables, and 25 percent of providers in
Senegal required it for intrauterine devices (IUDs).
The study compared restrictions in service practices regarding marital status, spousal
consent, parity requirements, and age requirements with what each country's guidelines say
about these issues for six methods (OCs, condoms, IUDs, injectables, Norplant and female
sterilization). "In all cases, providers are vastly overapplying restrictions to
contraceptives above those required by protocol," the authors concluded.4
Anecdotal evidence indicates that some new guidelines have improved services. The
injectable depot-medroxyprogesterone acetate (DMPA) was once kept locked at regional
district medical offices in Tanzania, and providers would not give DMPA to a woman unless
she had several children. "DMPA was thought to be a dangerous drug that should be
prescribed by doctors only," says Dr. Catherine Sanga, deputy family planning program
manager for Tanzania's Ministry of Health. Working with INTRAH, the ministry convened a
group in Tanzania to draft new guidelines, followed by a year-long dissemination process.
On the DMPA issue, the new document agreed with WHO and USAID recommendations that a woman
with no children can use the method and any trained service provider can offer it.
"Officials have now taken the locks off the DMPA supply and made the method
available to more women," says Dr. Sanga. The percentage of women of reproductive age
in Tanzania using injectables went from 0.3 percent in 1991, before the new guidelines, to
3.7 percent in 1996, after the change, according to Demographic and Health Surveys data.
Dissemination of the new guidelines was critical to the change. "In 1993, we held
workshops in all 101 districts and went through the guidelines page by page to be sure
everyone knew what they were saying," says Dr. Sanga.
Provider practices
Studies also indicate that guidelines affect provider practices. In a review of
published evaluations of clinical guidelines, 55 of 59 studies found "significant
improvement in the process of care after the introduction of guidelines." The
reviewed guidelines covered such medical issues as antenatal care, tetanus vaccinations
and cesarean deliveries. "The successful introduction of clinical guidelines is
dependent on many factors, including the methods of developing, disseminating and
implementing these guidelines," the study concluded.5
At a recent meeting in Washington, USAID assembled more than 100 experts to assess the
role of guidelines in affecting service quality in the international family planning
field. The meeting described the process of developing and disseminating guidelines as a
"road to maximizing access and quality." The overall goal is for providers to
use the guidelines. Said Pauline Muhuhu of INTRAH, who has worked with developing
guidelines in Africa for a decade: "The guidelines must come off the shelf. All of us
in the reproductive health field have a responsibility for keeping the guidelines lively
so they are used."
Establishing the need for guidelines and ensuring the commitment of government
officials to the process is essential. Pre-testing an early draft with local providers
helps assure that guidelines make sense to those who will actually be using them.
Well-organized dissemination and promotion efforts must follow. The guidelines must
also be updated and, ideally, their use be evaluated. Each step can influence the success
of the overall effort.
An FHI review of recent changes in family planning guidelines emphasizes the importance
of appropriate strategies at each step in the process. "Adequate dissemination of new
or revised guidelines is necessary, as well as training, close supervision and monitoring
to ensure that practices actually change," conclude the authors. The authors also
called for more research on how guidelines affect provider practices and service quality.6
A study in Cameroon, conducted by the Pan-African Association of Anthropologists and
FHI, found that new national guidelines distributed in training workshops appeared to have
little impact on changing provider practice regarding barriers to service. While the
guidelines say that all women of reproductive age should have access to OCs and all,
except adolescents, to injectables, they do not specifically say that providers should not
use age and parity criteria to prescribe particular methods. Similarly, the guidelines do
not say specifically that pelvic exams and blood or urine tests, known as "process
hurdles," should be the exception rather than the rule. "The material referring
to eligibility criteria and process hurdles is difficult to find," the study noted.7
Preliminary results from a 1998 follow-up study provided mixed results, says John
Stanback, an FHI health services researcher who is coordinating the study. There were few
changes in most types of barriers to services. For example, even though the guidelines say
that age and parity in general are not reasons to deny contraceptives, the proportion of
clients younger than age 20 years old and without any children did not increase after the
dissemination workshops in 1994.
However, "new clients were more likely to have continued with their methods for
both six months and a year, and continuation was even better in the clinics where
providers said they had recently referred to guidelines," says Stanback. Also, after
1994, new clients were more likely to be unmarried, especially in clinics where at least
half of the staff had been to the workshops and referred to the protocols. The study
reviewed records on more than 5,000 women from 1992 to 1996 (300 clients in each of 18
clinics).
Stanback is currently studying the impact of guidelines and dissemination workshops in
Senegal. "The new Senegalese guidelines are very user-friendly, and the pattern of
dissemination should make the impact on service practices easier to determine," he
says.
Encouraging adherence
In 1996 and 1997, the Ministry of Health in Paraguay developed new national family
planning guidelines and service delivery protocols. The guidelines address topics not yet
widely contained in national documents, including emergency contraception, male
sterilization and the lactational amenorrhea method (LAM). Following field testing, the
new guidelines were revised. In 1998, the ministry held three dissemination workshops and
follow-up training workshops, with FHI providing technical assistance.
FHI plans to study the effectiveness of three dissemination approaches: attending
dissemination workshop only; attending the workshop and having a supervisor reinforce the
central messages during site visits; and attending the workshop and receiving printed
reminders of guidelines highlights.
Many potential obstacles exist to ensuring that providers actually follow the new
guidelines. In areas with scarce resources, the full vision of developing, disseminating,
and using new guidelines is ambitious, says Dr. Robert Leke of the University of Yaoundé
in Cameroon. "How do we get the guidelines where they have to go at local sites? We
do not even have the necessary logistics to put them into practice. At each step, it is a
question of cost. How are we going to ensure there are resources for dissemination and for
sustaining the new practices?"
National guidelines must be revised periodically to reflect new scientific information,
which is also expensive. Informing clients about new national policies, and how these
affect services, is a difficult task. Still another concern is the scope of guidelines.
Many of them are more than 200 pages long, making them cumbersome and intimidating to
providers.
Despite such challenges, progress has been made in standardizing national policies that
have the potential to improve access and quality. Still more progress can be made if
dissemination focuses on the guidelines' most essential elements. "The three biggest
service limitations on access and quality are age, parity and when to start different
methods," says Dr. Rivera. "If you want to change provider practices, start with
the most important. That way, you are more likely to have the highest impact."
-- William R. Finger
References
- Improving Access to Quality Care in Family Planning: Medical
Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 1996.
- Recommendations for Updating Selected Practices in Contraceptive Use:
Results of a Technical Meeting, Volume I. Washington: U.S. Agency for International
Development, 1994; Recommendations for Updating Selected Practices in Contraceptive
Use, Volume II. Washington: U.S. Agency for International Development, 1997.
- Macías J. Documenting the reduction of medical barriers in reproductive
health service guidelines: Bolivia, Brazil, Guatemala and Peru. Presented at MAQ: From
Guidelines to Action Conference, Washington, May 12-13, 1998.
- Miller K, Miller R, Fassihian G, et al. How do providers restrict access
to family planning methods? Results from five African countries. Unpublished paper.
Population Council, 1998.
- Grimshaw JM, Russel IT. Effect of clinical guidelines on medical
practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317-22.
- Hardee K, Janowitz B, Stanback J, et al. What have we learned from
studying changes in service guidelines and practices? Int Fam Plann Perspect
1998;24(2):84-90.
- Nkwi P, Thompson A, Janowitz B, et al. Cameroon: Measuring Adherence
of Service Providers to the National Maternal and Child Health/Family Planning Service
Guidelines, Final Report. (Research Triangle Park, NC: Family Health International,
1995)16.
For more information, visit Family Health International's Website at www.fhi.org
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