Checklist Removes Obstacle for Women Who Want Family Planning -- December 15, 1999

Many women who come to health clinics for family planning leave disappointed. They cannot obtain the contraceptive method they need because of clinic rules, which say they must be menstruating in order to receive pills, injectables, implants or intrauterine devices (IUDs).

However, a new checklist, developed by the U.S.-based research organization Family Health International (FHI), could help eliminate the menstruation requirement. The checklist, which contains six simple questions, is designed to screen women for pregnancy. Health workers can use the checklist instead of expensive laboratory tests to safely rule out pregnancy.

"The requirement that women be menstruating before they receive certain family planning methods is well-intentioned," says John Stanback, an FHI researcher who developed the checklist. "It is designed to make sure women who are already pregnant do not receive a method that, in theory, could endanger their pregnancy.

"Yet, the effect of the menstruation requirement is that many women who could safely use hormonal methods or the IUD are denied these methods. They return home without contraception and risk an unplanned pregnancy. The checklist could help make contraception more accessible to women who want it."

Stanback and colleagues at FHI developed the checklist, based on criteria from the World Health Organization (WHO) and the U.S. Agency for International Development (USAID).

Checklist questions are:

• Have you given birth in the last four weeks?
• Are you less than six months postpartum and fully breastfeeding and free from menstrual bleeding since your last child?
• Did your last menstrual period start within the past seven days?
• Have you had a miscarriage or abortion in the past seven days?
• Have you abstained from sexual intercourse since your last menses?
• Have you been using a reliable contraceptive method consistently and correctly?

If a woman answers yes to any question and she is free from the signs or symptoms of pregnancy, she can receive a contraceptive method. If she answers no to all questions, she should receive only barrier methods, such as condoms or spermicides, until a pregnancy test has been performed or until her next menstrual period begins. A woman who might be pregnant should not use contraceptives containing hormones (pills, implants or injectables) or the IUD since these methods could affect her pregnancy.

FHI research has found that the checklist is a reliable indicator of whether a woman is pregnant. Researchers in Kenya surveyed 1,852 new clients who were not menstruating at seven family planning clinics throughout the country. Health workers used the checklists when interviewing women who wanted family planning methods. The checklist ruled out pregnancy for 88 percent of the women. Ordinarily, most of these women would have been sent home without contraception. For the remaining 12 percent, the checklist indicated that pregnancy was possible.

In this research project, all study participants were given pregnancy tests to verify the validity of the checklist. Among the group for whom the checklist indicated pregnancy was possible, 14 women were actually pregnant. Among the group for whom the checklist indicated that there was no pregnancy, 8 women were actually pregnant.

"Our study showed that the checklist is highly effective. It can eliminate a serious obstacle for women who want to use family planning," said Stanback.

Previous FHI research has found that in many countries, the requirement that women be menstruating poses a serious, unnecessary barrier to contraceptive use. In Kenya, researchers estimated that 78 percent of all women who were not menstruating -- one-third of all new family planning clients -- were sent home without a method. In Ghana, 76 percent of health providers said they would not provide oral contraceptives to non-menstruating women. In Jamaica, 82 percent of women posing as clients were required to be menstruating or to have a negative pregnancy test before they could receive contraception.

FHI is working to make family planning programs around the world aware of its new checklist. In addition to the pregnancy checklist, FHI has developed two other simple checklists, based on WHO and USAID criteria, to help health workers determine if women can safely use oral contraceptives and injectable methods.

FHI is a non-profit organization that conducts biomedical and social science research worldwide on reproductive health, including family planning and AIDS.

Editor's note: For more information about checklists or other FHI research, contact Barbara Barnett, principal research writer, in the United States. Her telephone number is: 1-919-544-7040, Ext. 482. The fax number is: 1-919-544-7261. And her e-mail address is: bbarnett@fhi.org.