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Reproductive Health

Provider Rationale for Unnecessary Service Practices

Background

As in other countries, many providers in Ghana require various medical procedures, such as physical exams, pelvic exams, blood pressure measurements and blood and urine tests, before they prescribe certain methods of family planning. For example, data from a 1993 situational analysis in Ghana showed that 59% of current providers said they required pelvic exams before provision of hormonal methods and 87% required blood or urine tests before prescribing hormonal methods or IUDs. Providers' requirements for follow-up and their handling of special clients, such as nonmenstruating and breastfeeding women, can create barriers for the acceptance of family planning.

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Study Design

FHI, in collaboration with the Ghana Statistical Service, surveyed 97 providers in October 1994 to determine why they require various exams and tests; how they use the results in providing family planning; why they use the follow-up schedules that they do for IUDs and oral contraceptives; and how they manage nonmenstruating and breastfeeding clients. In addition, clinic records of the providers were reviewed to document exam and test results. Providers included auxiliary nurses, nurse-midwives and extension workers.

Results

The study showed that providers relied too heavily on various service practices that experts

have determined to be unnecessary. Another common problem was that providers distrusted clients' ability to follow instructions. Of the providers interviewed:

  • Almost 75% indicated that they routinely required laboratory tests of blood and/or urine before provision of family planning. These test requirements were verified through clinic files. Generally, providers demonstrated adequate knowledge of the rationale for the tests and knew the acceptable results or ranges. However, experts agree that systematic laboratory testing is not necessary before prescribing hormonal methods in Africa.
  • 67% recommended that women receiving IUDs return for three or more follow-up visits in the first year to verify that the IUD was in place, check for complications and counsel the women about infection prevention. Current recommendations call for only one fixed follow-up visit for well-counseled IUD clients.
  • 89% gave only one packet of pills at the first visit, and 90% gave three or fewer packets at subsequent visits, though providing more cycles to clients at each visit is considered both safe and convenient. Providers limit the number of cycles because they think that pill clients must be examined and have blood pressure taken periodically to detect possible complications.
  • 75% indicated they sent away clients who were not menstruating, without attempting to rule out pregnancy or provide pills for later initiation. Nearly one-fifth did not provide barrier methods. Pregnancy tests were used by 24% of providers to rule out pregnancy.
  • 90% appropriately recommended progestin-only pills or the IUD to breastfeeding clients. However, fewer than half recommended injectables because they mistakenly thought that injectables reduce the production of breast milk.
  • 99% required blood pressure readings, and all demonstrated adequate knowledge of the reasons for taking blood pressure. However, about one-fourth of the providers gave upper limits for systolic blood pressure lower than 140, which, if enforced, might unnecessarily reduce a woman's choice of methods.

Conclusions

Unnecessary service practices can constitute serious financial and time barriers for family planning clients. In addition, such practices can be costly for clinics and increase the workload for service providers

Most of the unnecessary service practices revealed in this study were due to providers' inadequate knowledge of the contraindications to and side effects of modern contraceptive methods. The providers' goal of protecting their clients was admirable, but in exaggerating the dangers of contraception, providers may have been doing more harm than good.

November 1996

This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development.