Medical Barriers Often Unnecessary

Barriers with no scientific basis can limit choice and endanger health.

Network: 2002, Vol. 21, No. 3

Copyright Family Health International, 2002. 
Network is reprinted with permission from Family Health International.

Throughout the world, many women are denied contraceptive methods due to health concerns that – in fact – have no scientific basis. These unnecessary medical barriers can limit women’s method choice, decreasing the chance that women will like their selected method and continue using it correctly and consistently. Furthermore, such barriers can be dangerous if they result in a woman not being able to use a highly effective family planning method and then experiencing an unplanned pregnancy. Under most circumstances, a woman’s risk of dying from pregnancy is many times greater than dying from use of a contraceptive method. And some women with unplanned pregnancies opt for abortions, which are all too often performed illegally under unsafe conditions.

Unnecessary medical barriers arise for various reasons. Service delivery guidelines that shape provider practices may be outdated and not strictly reflect the latest scientific knowledge or even be available in some settings. In addition, some providers may misinterpret or ignore service delivery guidelines, and impose their own barriers to contraceptive use. They may deny contraceptive methods by identifying inappropriate contraindications. They may inappropriately restrict use of a method on the basis of parity or age. Also, a woman may be denied a method if she has not had a physical exam or lab tests (see Safe Use of Contraception Seldom Requires Medical Exams) or is not menstruating (see Contraception should be Available to Non-menstruating Women), even though such practices may be medically unnecessary.

This is not to say that providers who deny women contraceptive methods for medically unjustifiable reasons are ill-intentioned. For example, in an FHI study in Ghana, many of those family planning providers who placed unnecessary medical restrictions on specific methods "appear to have imposed these restrictions with the best of intentions," says Dr. John Stanback, an FHI senior research associate who specializes in service delivery issues. "Most providers seemed to feel that by doing so, they were protecting both the client and society. Providers believed they were protecting their clients by denying them access to methods that they thought caused infertility or other health problems. However, as admirable as this goal of protecting clients is, exaggerating the dangers of contraceptive use may cause more harm than good."

How, then, can unnecessary medical barriers to the use of contraception be reduced?

• First, in writing service delivery guidelines, more attention should be given to the World Health Organization (WHO) medical eligibility criteria for contraceptive use, which are internationally accepted norms based on the latest scientific evidence (see FHI’s Quick Reference Chart – PDF 44K – for the criteria). "Many existing service delivery guidelines generally follow, but do not specifically highlight, aspects of the eligibility criteria," says Dr. Barbara Janowitz, an FHI senior economist and director of FHI’s division of health services research. "They may not state, for example, that certain exams and tests should be the exception rather than the rule for contraceptive use. They may also fail to emphasize that providers not use age and parity criteria to prescribe particular methods."

  A training workshop participant in Lima, Peru. Thorough training can increase use of service delivery guidelines.

  Such problems are being addressed by the U.S. Agency for International Development (USAID) and its cooperating agencies as part of an initiative to maximize access to, and the quality of, contraceptive services. And recently, a multi-partner initiative has been launched to encourage countries to adopt sound guidelines that support scientifically justified best practices in reproductive health care.

• Second, once written, those guidelines should be disseminated widely, since they may be unknown in some settings.

• Third, guidelines are designed to be adapted by programs to reflect local needs, concerns, and resources. But care must be taken to identify elements of national regulations, program policies, and service protocols that include "medical" restrictions motivated by social rather than actual medical concerns. Also, individual providers must be encouraged to follow the WHO criteria that are incorporated into regulations, policies, and protocols, rather than imposing their own unnecessary medical barriers to contraceptive use.

• Fourth, thorough training in the use of guidelines, and supervision to reinforce training and guideline messages, can increase the use of guidelines.¹

Provider-imposed barriers

A 1998 review of recent studies on staff-imposed contraceptive restrictions in Botswana, Burkina Faso, Kenya, Senegal, and the Tanzanian archipelago of Zanzibar found that providers on average imposed twice as many eligibility criteria as were required or encouraged by national guidelines.² In Tanzania, national guidelines state that everyone of reproductive age has the right to family planning information, education, and services. Nevertheless, another study conducted in that country in 2000 noted important medical barriers at government family planning service delivery points, where 74 percent of women who use modern family planning obtain their contraceptive methods.³

Many providers who placed unnecessary medical restrictions appear to have imposed these restrictions with the best of intentions.

Interviews in 1994 with 367 Jamaican private physicians offering family planning services revealed how particular health concerns and sociocultural factors influence provider practices. Researchers noted that the high incidence of hypertension and diabetes in Jamaica may lead to overly conservative restrictions on hormonal methods for some clients. Furthermore, the practices of Jamaican private physicians, who provide 36 percent of family planning services in that country, were probably influenced by the fact that Jamaican women highly value their fertility and view menstruation (which can be disturbed by certain contraceptive methods) as an indicator of their general health.⁴

Providers need training and support if they are to be expected to adhere to guideline recommendations, and provider attitudes must be carefully considered for training to be effective.⁵ To that end, USAID and other organizations, including FHI, are providing contraceptive update training programs, in which scientific evidence that refutes such practices is emphasized.

Illustrating the need for provider support, a study of service delivery barriers in Malawi (based on a provider survey, clinic inventories, and reports by women pretending for study purposes to be clients) showed that providers may still be uncertain about the goals of their work, even when new guidelines that better reflect WHO eligibility criteria are available.⁶ "As health professionals, the providers’ overarching credo is ‘first, do no harm,’" says Dr. Paula Tavrow, who conducted the research and is now deputy research director for the Quality Assurance Project, managed by the Center for Human Services, Bethesda, MD, USA. "For those providers who fear that the widespread use of contraceptives – especially by unmarried women – could increase promiscuity and HIV/AIDS, the new guidelines seem at variance with their basic credo. By merely disseminating new guidelines without addressing these deep-seated anxieties, ministries of health generally have not put ‘teeth’ into the guidelines."

An FHI study of low use of the intrauterine device (IUD) in El Salvador found that some providers believed myths associated with the IUD, such as that it causes cancer. Also, some providers lacked the training or skills necessary to provide the method, which likely discouraged them from inserting IUDs and could lead to unnecessary restrictions on use of the method.⁷ In contrast, Tanzanian providers who participated between 1992 and 1996 in a family planning and reproductive health training course designed to increase compliance with national policy guidelines were more likely to insert IUDs than providers who had not received this training (85 percent versus 55 percent).⁸

Concerns, by method

When the WHO eligibility criteria were revised in 2000, the most important changes occurred in the area of cardiovascular disease and hormonal contraceptive use. Medical restrictions increased in this area, recognizing that hormonal contraception raises the risk of an adverse cardiovascular event among women with existing cardiovascular disease. The vast majority of healthy women, however, can safely use hormonal contraception. (The restriction against combined oral contraceptive [COC] use by women 35 years or older who smoke 15 or more cigarettes daily is an exception.)

Yet, unnecessary and persistent provider concerns about the health effects of hormonal contraception have been demonstrated throughout the world.

Injectable contraceptives, in particular, tend to raise concerns unrelated to medical contraindications identified in the WHO eligibility criteria. In non-clinic settings (that is, settings where providers may lack extensive training or experience), the criteria restrict use of the most common injectable in the world – depot-medroxyprogesterone acetate (DMPA) – by women with:

• elevated blood pressure of systolic >160 mm Hg or diastolic >100 mm Hg, current deep venous thrombosis/pulmonary embolism, high blood pressure or diabetes with vascular disease, current or past ischemic heart disease or stroke, or multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and high blood pressure);
• current or past breast cancer, unexplained vaginal bleeding; or
• active viral hepatitis, severe cirrhosis, or liver tumors.

Click on thumbnail to view larger image.

FHI checklist (partially shown) to help non-clinic-based providers determine women's eligibility for DMPA use.

(An FHI checklist to help non-clinic-based providers determine women’s eligibility for DMPA use, based on the WHO medical eligibility criteria, is partially shown at left and is available with instructions in English, Spanish, and French.)

In clinic settings (that is, where providers tend to be well-trained and experienced), use of this progestin-only injectable is restricted only for women with current breast cancer.

No medical reason exists to restrict DMPA based on parity (the number of children a woman has), since DMPA does not cause infertility. Young and childless women should simply be advised that, on average, it takes a woman four months longer to become pregnant after discontinuing DMPA than after discontinuing COCs, IUDs, or barrier methods.⁹

However, many providers impose parity requirements (that women have a minimum number of children) because they fear that DMPA use will cause infertility. One-quarter to one-third of providers in studies conducted in Tanzania and Senegal imposed parity requirements for DMPA use. In Tanzania, the mean number of children required before a woman could use the method was 2.5; in Senegal, 3.4.¹⁰ In Nigeria, half of 245 providers who reported in a Population Council study restricting use of injectables did so on the basis of parity.¹¹

Unwarranted concerns that DMPA delays fertility or causes infertility also lead to unnecessary age requirements for use. In an FHI study in Ghana in which 97 providers deemed likely to impose restrictive barriers to services were interviewed, more than half of the providers said they enforced both minimum and maximum age requirements for various methods, with injectables most stringently restricted. Some providers also erroneously believed that younger women faced a greater risk of complications from hormonal methods than older women. Three providers established the age of 35 years as a minimum for injectable use, explaining that "at age 35, clients have children and are nearing menopause, so if they become infertile from injectables, it won’t worry them."¹²

COCs

Medical restrictions for both COCs and combined injectable contraceptives (CICs) are generally the same.¹³ In non-clinic settings, neither method should be used by women 35 years or older who smoke 15 or more cigarettes daily. They also should not be used by women with:

• elevated blood pressure of systolic >140 mm Hg or diastolic >90 mm Hg, current or past deep venous thrombosis/pulmonary embolism, major surgery with prolonged immobilization, multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and high blood pressure), high blood pressure or diabetes with vascular disease, current or past ischemic heart disease or stroke, or complicated valvular heart disease;
• current or past breast cancer, active viral hepatitis, severe cirrhosis, or liver tumors;
• women 35 years or older suffering migraines, or women of any age suffering migraines with focal neurological symptoms; or
• women taking certain antibiotics or anticonvulsants that affect liver enzymes.

Click on thumbnail to view larger image.

FHI checklist (partially shown) to help non-clinic-based providers determine women's eligibility for COC use.

(An FHI checklist to help non-clinic-based providers determine women’s eligibility for COC use, based on the WHO medical eligibility criteria, is partially shown at left and is available with instructions in English, Spanish, and French.)

Women with these medical conditions face many of the same medical restrictions even in clinical settings.

However, healthy nonsmokers can safely use low-dose COCs or CICs. As long as they are free of cardiovascular disease, even older women can safely use these methods until menopause.

Nevertheless, providers often express concern that COCs or CICs themselves will put older clients at risk of cardiovascular diseases.

In Tanzania, an analysis of the 1996 Service Availability Survey found that 80 percent of some 850 family planning service providers imposed either minimum or maximum age requirements on COC use. The analysis also showed that young or old age, parity, marital status, and menstrual status cumulatively affect the barriers a Tanzanian woman will face in getting oral contraceptives. Providers in more than half of all government facilities would restrict COC use by a 15-year-old, unmarried adolescent with no children or for a 40-year-old woman with four children. In contrast, a 20-year-old, married woman with one child who wanted to use the pill could obtain it at 80 percent of facilities. A 35-year-old, married woman with four children could do so at about 95 percent of facilities.¹⁴

Another unnecessary medical barrier to COC use is provider reluctance to supply clients with several cycles of pills. USAID recommends giving as many as 13 cycles of pills at the first visit and each follow-up visit in order to guarantee continuous, ready access for a year.¹⁵ Yet, a recent FHI study of the impact of guidelines dissemination in Paraguay showed that new pill clients at 36 health centers and four district hospitals usually received only one cycle of oral contraceptives after counseling. Continuing users rarely received more than two cycles during a resupply visit.¹⁶ In a recent FHI study, only one of every five new pill users seen at 72 clinics in Kenya received three or more cycles of pills.¹⁷

Although requiring resupply visits within the first year of COC is not medically necessary, it may be beneficial for other reasons. Whether requiring a resupply visit after a month of COC use affects such factors as client satisfaction, pill continuation, and reports of side effects will soon be examined by FHI in Jamaica.

IUDs

A provider counsels a client about family planning at a clinic just outside of Kathmandu, Nepal.

In a clinic setting, medical restrictions for initiating either copper IUD or levonorgestrel intrauterine system (LNg-IUS) use include unexplained vaginal bleeding, cervical or endometrial cancer, uterine fibroids with distortion of the uterine cavity, pelvic tuberculosis, current pelvic inflammatory disease (PID) or sexually transmitted infection (STI), or PID or STI within the last three months. Use of an LNg-IUS is also restricted for women with breast cancer.

Women wanting to use an IUD may face unnecessary requirements for follow-up visits.

In non-clinic settings, LNg-IUS use is further restricted for women with current deep venous thrombosis/pulmonary embolism, past breast cancer, ovarian cancer, active viral hepatitis, severe cirrhosis, liver tumors, high risk of HIV or other STIs, HIV-positive status, or AIDS. In non-clinic settings, initiation of copper IUD use is further restricted for women with ovarian cancer, high risk of HIV or other STIs, HIV-positive status, or AIDS.

Click on thumbnail to view larger image.

FHI's Quick Reference Chart for the Medical Eligibility Criteria of the WHO

However, an FHI study of 30 providers in El Salvador, where IUD use is very low, found that a third of these providers restricted use of the method if a woman had any history of PID or any uterine fibroid. Six of the providers unnecessarily restricted use if a woman had a history of abnormal bleeding. Furthermore, a third of the providers restricted use of the device by childless women.¹⁸ In Ghana, FHI researchers found that one-third of 33 providers who reported imposing parity restrictions for IUD use cited a fear of delaying fertility or causing infertility; another third contended that the cervix or uterus were too tight in women who had not given birth.¹⁹ While IUDs are not a first choice for childless women due to an increased risk of expulsion, WHO criteria state that the benefits of IUD use by such women outweigh its theoretical or proven risks. Recent FHI research in Mexico has shown that IUDs can be safely used by these women without endangering their fertility.²⁰

Women wanting to use an IUD may also face unnecessary requirements for follow-up visits. A 1994 FHI study in Jamaica found that a quarter of some 182 private physicians inserting IUDs required four or more follow-up visits during the first year of IUD use.²¹ Most experts on family planning and IUDs, however, recommend no more than two visits in the first year of use.²²

– Kim Best

References

1. Stanback J, Brechin SG, Lynam P, et al. The Effectiveness of National Dissemination of Updated Reproductive Health/Family Planning Guidelines in Kenya. Research Triangle Park, NC: Family Health International, 2001.
2. Miller K, Miller R, Askew I, et al. eds. Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York: Population Council, 1998.
3. Speizer IS, Hotchkiss DR, Magnani RJ, et al. Do service providers in Tanzania unnecessarily restrict clients’ access to contraceptive methods? Int Fam Plann Perspect 2000;26(1):13-20,42.
4. McDonald OP, Hardee K, Bailey W, et al. Quality of care among Jamaican private physicians offering family planning services. Adv Contracept 1995;11(3):245-54.
5. Hardee K, Stanback J, Roxby A, et al. Changing provider practices to increase access to quality contraceptive and reproductive health services. FHI Technical Advisory Committee Meeting for Contraceptive Technology and Family Planning Research, Research Triangle Park, NC, Family Health International, June 5, 1997.
6. Tavrow P. What prevents family planning clinics in developing countries from adopting a client orientation? An exploratory study from Malawi. Ph.D. dissertation. Ann Arbor, MI: University of Michigan, 1997.
7. Carranza J, Johnson L, Katz K, et al. Determining Reasons for Low IUD Use in El Salvador. Research Triangle Park, NC: Family Health International, 2000.
8. United Republic of Tanzania, Bureau of Statistics, Planning Commission. Tanzania Service Availability Survey 1996. Chapel Hill, NC: The EVALUATION Project, 1997.
9. U.S. Agency for International Development. Recommendations for Updating Selected Practices in Contraceptive Use: Volume I. Washington: U.S. Agency for International Development, 1994.
10. Speizer; Miller.
11. Askew I, Mensch B, Adewuyi A. Indicators for measuring the quality of family planning services in Nigeria. Stud Fam Plann 1994;25(5):268-83.
12. Stanback J, Twum-Baah KA. Why do family planning providers restrict access to services? An examination in Ghana. Int Fam Plann Perspect 2001;27(1):37-41.
13. World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 2000.
14. Speizer.
15. U.S. Agency for International Development.
16. Chin-Quee D. Paraguay: the impact of family planning guidelines dissemination. Unpublished paper. Family Health International, 2001.
17. Stanback, Brechin, Lynam, et al.
18. Carranza.
19. Stanback, Twum-Baah.
20. World Health Organization; Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67.
21. Bailey W, McDonald OP, Hardee K, et al. Family Planning Service Delivery Practices of Private Physicians in Jamaica. Research Triangle Park, NC: Family Health International, 1994.
22. Hubacher D, Fortney J. Follow-up visits after IUD insertion. Are more better? J Reprod Med 1999;44(9):801-6; Stewart GK. Intrauterine devices (IUDs). In Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology, Seventeenth Revised Edition. (New York: Ardent Media, Inc., 1998)511-54.

 

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