Ways to Improve Reproductive Health Services Explored -- January 8, 2002

Throughout the world, many women are denied contraceptive methods due to health concerns that — in fact — have no scientific basis. Youth continue to face various reproductive health dangers, many of which are tied to behaviors related to sexuality. Meanwhile, reproductive health programs in developing countries struggle to provide quality care with limited resources.

However, various initiatives, tools and research are addressing these ongoing problems, according to the current issue of Network, an international quarterly health bulletin published by Family Health International (FHI).

Unnecessary medical barriers to the use of contraception are associated with nearly every contraceptive method, and 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 Service delivery guidelines that shape provider practices may be outdated and not strictly reflect the latest scientific knowledge or even be available in some settings.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 or is not menstruating, 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. However, as admirable as this goal of protecting clients is, exaggerating the dangers of contraceptive use may cause more harm than good."

Unnecessary medical barriers to the use of contraception can limit women's method choice, decreasing the chance that women will like their selected method and continue using it correctly and consistently.

Key ways of reducing such barriers include: giving more attention to the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use, which are internationally accepted norms based on the latest scientific evidence, when writing service delivery guidelines; disseminating these guidelines widely; taking care to identify elements of national regulations, program policies, and service protocols that include "medical" restrictions motivated by social rather than actual medical concerns; and providing more supervision and training to encourage providers' use of service delivery guidelines.

Youth

Efforts to improve reproductive health services for young people are essential since, as a population, youth are at particular risk for unplanned pregnancy or infection by HIV and other sexually transmitted infections (STIs).

Fortunately, "there is a lot more consciousness about the needs of adolescents," says Dr. Nancy Williamson of FHI, who is director of YouthNet, a new $85 million, five-year program to improve adolescent reproductive health, funded in part by the U.S. Agency for International Development (USAID). "Slowly, over the last decade, barriers are falling. There is more sex education in schools, for example. Policies are changing so that more providers will actually serve unmarried youth, and we are beginning to learn more about which types of services are most effective."

Experts agree that far more evaluation and research is needed to determine how best to involve youth and how to develop services that are both effective and sustainable. Meanwhile, evaluations of specific types of programs offer some helpful data for program planners. For example:

• Multipurpose youth centers most often attract boys, older youth, or young adults, and a low proportion of youth center attendees come for reproductive health information.
• Scouting projects can successfully reach both in-school and out-of-school youth.
• Hotlines and radio call-in programs can be efficient ways to reach many youth.
• Combining mass media, school-based, and community-based approaches can be effective.
• Maintaining the confidentiality of information shared by youth is essential.

Costs

Family planning programs in developing countries face formidable challenges in providing quality care with limited resources. But economic analysis of programs can provide managers with information that can improve both the productivity of programs and the quality of care, says John Bratt, FHI senior associate for health economics.

Among other things, economic analysis can help program managers identify any high revenue-producing services that can subsidize a program's low revenue-producing services; evaluate clients' ability to pay for services; ascertain if certain services or products offered by a program are draining resources and threatening program sustainability; determine if clinics in different regions should charge different prices; and evaluate staff productivity. "Too few organizations routinely use cost data for decision-making in their programs," Bratt says, "although there can be a number of benefits when they do."

FHI is a nonprofit research organization based in the United States that seeks to improve reproductive health worldwide, with an emphasis on developing countries. Network is provided free to family planning providers and others worldwide.

For more information, please contact:

Kim Best, Managing Editor, 919-544-7040