Research by the University of Nairobi and FHI in Kenya shows that a simple checklist can be an effective tool in ruling out pregnancy, thereby increasing women's access to contraceptives and reducing the likelihood of an unplanned pregnancy.
At clinics where laboratory testing for pregnancy is not available, new clients who are not menstruating are often asked to return when they are menstruating, in order to assure they are not pregnant. In addition to risking an unintended pregnancy, the practice may discourage some women from returning.
The recent study in Kenya surveyed 1,852 non-menstruating women at seven family planning clinics located throughout the country. Health workers used the checklist when counseling new, non-menstruating clients. The checklist indicated 88 percent of the women were not pregnant, most of whom ordinarily would have been sent home to await the onset of menses. For the remaining 12 percent, the checklist indicated pregnancy was possible.1
[Photo caption: Nurses in Nyeri Provincial Hospital, Kenya, learn how to use pregnancy checklist.]
All 1,852 women in the study were given a pregnancy test (urine dipstick) to determine whether pregnancy had actually occurred. Among the 223 who could be pregnant according to the checklist, 14 were actually pregnant. Among the 1,629 for whom pregnancy was ruled out by the checklist, eight were pregnant.
"The checklist was found to be user-friendly, effective, economical and acceptable to providers," says John Stanback of FHI, the study's principal investigator. "The checklist can thus reduce a serious barrier to family planning access."
The checklist asks six questions:
- 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 you had your child? (These are the criteria necessary to use the Lactational Amenorrhea Method or LAM.)
- 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 one question and is free from signs or symptoms of pregnancy, providers can reasonably assume she is not pregnant and provide a contraceptive choice, Stanback says.
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If she answers no to all questions, providers should offer only barrier methods, such as condoms or spermicides, until a pregnancy test has been performed or the woman's menstrual cycle begins. The checklist was developed from guidelines prepared by the U.S. Agency for International Development's Technical Guidance Working Group and the World Health Organization.2
FHI studies in Africa and Latin America have shown that providers frequently restrict contraceptive access for non-menstruating clients.3 In a previous study in Kenya among 760 women seeking services at health clinics and hospitals, nearly half were not menstruating. More than one-third were sent home without a method.4 Providers may be reluctant to give a non-menstruating woman a hormonal method of family planning, such as pills, insert an intrauterine device (IUD), or perform sterilization because these methods are contraindicated for pregnant women.
In the recent study, the checklist was generally found to be acceptable among providers surveyed at the seven clinics and at eight control clinics. However, some providers expressed concerns that some women may not give truthful answers and some were opposed to giving IUDs to new clients who were not menstruating, since IUD use during pregnancy can result in serious health risks.
JHPIEGO Corp., a U.S.-based training organization, will soon conduct a nationwide training for providers in Kenya on how to use the checklist.
-- Barbara Barnett
Note and References:
- Sensitivity 64 percent, specificity 89 percent, positive predictive value 6 percent and negative predictive value greater than 99 percent.
- World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 1996; Technical Guidance Working Group; How to be reasonably sure the woman is not pregnant. In Curtis KM, Bright PL, eds. Recommendations for Updating Selected Practices in Contraceptive Use: Results of a Technical Meeting, Volume I. (Chapel Hill: Technical Guidance Working Group, U.S. Agency for International Development, 1994)97-98.
- Stanback J, Thompson A, Hardee K, et al. Menstruation requirements: a significant barrier to contraceptive access in developing countries. Stud Fam Plann 1997;28(3):245-50.
- Stanback J, Nutley T, Gitonga J, et al. Menstruation requirements as a barrier to contraceptive access in Kenya. Unpublished paper. Family Health International, 1997.
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