Barrier methods (condoms and spermicides) and oral contraceptives (OCs) are available through many family planning community-based programs. With proper training, community providers can also give injectable contraceptives.
Community-based distribution (CBD) workers can refer individuals to clinics or hospitals, or to mobile teams of medical professionals who provide long-lasting or permanent methods, including intrauterine devices (IUDs), implants, or male and female sterilization.
While offering each client a range of contraceptive choices is ideal, choices may be limited by lack of supplies, poor referral systems or restrictions upon which methods CBD workers are allowed to offer. Restrictions on CBD provision of certain hormonal contraceptive methods are primarily due to safety concerns. For example, community workers who supply OCs must know how to identify contraindications.
Checklists
To address such concerns, checklists for community-based distribution of oral contraceptives and injectables have been distributed by a U.S. Agency for International Development (USAID) working group.1 The checklists indicate whether a CBD worker can safely provide one of the methods or should refer the client to a higher level of care. The checklists were developed by FHI in collaboration with a team of international experts, based on World Health Organization (WHO) eligibility guidelines for contraceptive use.2
There are few medical contraindications to use of oral contraceptives. "Most of the time, CBD workers can safely offer OCs and injectables," says Dr. Roberto Rivera, FHI's director of international medical affairs, who participated in developing WHO eligibility criteria and the USAID checklists. "But the checklists are a preliminary screening tool." When there is doubt, he says, clients should be referred to clinics or other services that have staff who are better prepared to make eligibility decisions.
While useful, checklists do not replace counseling. Counseling is essential to ensure that clients make informed and voluntary choices. Workers must also be able to teach clients how to use methods correctly and consistently, manage side effects, and recognize warning signs of serious complications.
"In particular, CBD workers -- like providers at higher levels of care -- must be prepared to counsel about side effects for which women are often unprepared," says Dr. James Foreit, a Population Council senior associate who has conducted CBD research in Latin America and Asia. For example, the progestin-only injectables, depot-medroxyprogesterone acetate (DMPA) and norethindrone enanthate (NET-EN), tend to produce irregular and prolonged bleeding for the first three to six months of use, and later are associated with amenorrhea.
The checklist to initiate OC use contains 12 questions to identify women who might have contraindications. It screens for cigarette smoking, an important indicator of cardiovascular risk among pill users, especially those older than 35 years. Some older checklists do not ask about smoking habits. By using updated eligibility criteria, the new checklist also reduces the number of women who might be denied the pill unnecessarily. Older checklists often include questions to screen for varicose veins or epilepsy, conditions for which OC use is not contraindicated. Older checklists also often include general questions about headaches. However, WHO criteria contraindicate OC use only when headaches are severe, recurrent and are accompanied by focal neurological symptoms.
Some countries may require a pelvic examination before use. Recommendations by an international panel of experts, however, state that a pelvic examination is not necessary for safe use of OCs.
While blood pressure screening is not necessary for OC use, it may be appropriate in some situations to optimize safe use of OCs. For example, blood pressure screening for women at risk of high blood pressure may be appropriate, since the estrogen component of OCs can have a minor effect (usually insignificant) on blood pressure.3 OC provision by CBD workers is contraindicated for women with moderate or severe hypertension or hypertension with related vascular disease, according to WHO criteria.
WHO and the International Federation of Gynecology and Obstetrics have concluded that many years of experience with OC distribution and use show that pill provision by CBD workers is no more risky than provision at a clinic by a medical practitioner. If CBD workers have backup support from clinics, they can safely deliver oral contraceptives.4
In Matamoros, Mexico, a survey showed that some 100 clients obtaining OCs through CBD were as healthy as 135 clients obtaining OCs through other sources, and that the CBD program did not put women at greater risk of ill health or death than other distribution systems. Researchers noted that "if pills are contraindicated for very few women in the population, elaborate examination procedures are likely to have the overall effect of putting more women at risk of unwanted pregnancy than would be protected from inappropriate pill use."5
The USAID checklist for progestin-only injectables contains eight questions to identify women who might have a condition making them ineligible. Such questions include whether a woman's menstrual period is late and she thinks she might be pregnant; if she has had a stroke or heart attack; or has diabetes, breast cancer or serious liver disease. Answering "yes" to any of these questions suggests a possible or definite contraindication to the method's use. Evaluation by a provider at a higher level of care should be offered.
A survey of some 300 women in Nepal, where DMPA is popular, revealed a very low prevalence of medical conditions that would contraindicate DMPA initiation by CBD workers. Furthermore, such conditions would have been easily identified by the checklist. Only 10 of the women had conditions identified as contraindications to DMPA use (five were pregnant, four could be pregnant, and one woman suffered from abnormal uterine bleeding). Five other women had cardiovascular problems that would contraindicate initiation of DMPA by a CBD worker. Researchers concluded that well-trained CBD workers supplied with checklists could have identified all of these conditions and could have safely delivered DMPA to other clients.6
Lack of supplies
Maintaining adequate contraceptive supplies is often difficult. In 1996, Population Council researchers interviewing CBD workers in seven of Kenya's largest CBD programs found that one-third of the workers reported having run out of supplies within the previous six months. On the day of the interviews, about 25 percent lacked either pills or condoms.7 In Zimbabwe, there were 700 CBD workers in 1993 whose role was to provide a regular supply of OCs, and to monitor blood pressure and side effects. However, more than half of them did not have blood pressure cuffs to monitor pressure.8
Providing DMPA and NET-EN injectables through CBD raises important supply issues. "In an experimental study in a rural area of northern Ghana, for example, provision of DMPA through CBD has been found to be generally successful," says Dr. James Phillips, a Population Council senior associate who has conducted CBD research in Africa and Bangladesh. "Resupplies of contraceptives usually can be purchased at a regional health ministry store, but we have seen local supplies run out. Because CBD workers in the study have a Jeep, they have been very fortunate. This allows them to drive great distances to resupply themselves at other health ministry stores." Many CBD programs, however, are not so well equipped.
In addition to the drug itself, adequate supplies of syringes and needles are necessary. "The tendency to develop logistics systems for injectables alone without thinking about needles and syringes can be a big problem," says Dr. Phillips. If both DMPA and NET-EN are offered, two different needle sizes must be maintained because of different viscosities.
As is true with giving any injection, CBD workers must ensure that their needles are sterile. A sterile needle and a sterile syringe must be used only for one injection, since nonsterile or contaminated needles and syringes can transmit disease. Reusable metal needles and glass syringes should be sterilized in a steam sterilizer for 20 minutes at 121° C, or in boiling water in a container with a lid for 20 minutes. Required boiling time increases, however, with increasing altitude, and boiling may not kill infectious organisms at high altitudes.9 Single-use (disposable) syringes and needles must be discarded safely, especially in areas with high prevalence of HIV/AIDS.
Referral systems
There are several obstacles to successful referrals by CBD workers. "First there may not be a clinic to refer a client to," says Dr. Foreit of the Population Council, "or distance may make referral prohibitive. For lack of time or money, the client may not want to go to a clinic that offers other methods, or the CBD worker may lack the motivation or ability to make an effective referral."
In Saradidi, Kenya, for example, volunteer health workers began providing family planning information and services in 1980 and contraceptive use rose in just three years from less than 1 percent to 17 percent of some 180 currently married women of reproductive age who were interviewed. Yet, nearly two-thirds of clients referred by helpers to a clinic for examination and supplies did not go to the clinic.10
Paying CBD workers referral fees when they send clients to clinics for long-term methods, such as the IUD and sterilization, might strengthen the referral system but could be abused. Clients could be coerced into choosing a long-term method. However, a study in 1989 of two family planning agencies with posts in the outskirts of Lima, Peru, where more than 2,500 women receive IUDs each year, found no evidence of coercion or abuse in IUD referrals made by CBD workers who received small referral fees. Interviews with approximately 250 women who obtained IUDs in this way also revealed that most users thought they had received adequate counseling about the method before and after insertion.11
"If you pay CBD workers for referrals for methods they themselves cannot provide, the number of referrals does increase," says Dr. Foreit, who helped conduct the study in Lima. "This financial compensation could pose an ethical problem. But if a CBD worker is already earning a commission for distributing OCs, the incentive for making a referral for a different method is not very compelling. In fact, it might be more profitable for a CBD worker not to make the referral."
When referrals are not possible or effective, mobile outreach teams or camps may allow clients of CBD workers access to contraceptive methods usually available only at clinics or hospitals. While concerns have been raised about service quality and lack of method choice, outreach camps play a significant role in expanding accessibility.
In Nepal, outreach camps are an important way to meet couples' demand for sterilization services in rural areas where hospital- or clinic-based services are not available throughout the year. In 1996, 42 percent of all sterilization clients received services from such camps. A study that compared the experiences of 445 women who had been sterilized in public hospitals and 372 women who underwent the procedure in temporary camps found no evidence that the camp approach led to the sterilization of women for whom the procedure was inappropriate. The percentage of women who regretted having been sterilized was similar for hospital and camp patients.12
Furthermore, quality of care did not appear to be compromised in the camps. Quality of care included the degree to which clients' decisions to accept sterilization were based on informed choice, as measured by clients' awareness of various family planning methods. More than 90 percent of both hospital and camp patients knew about at least one of four temporary methods (pills, injectables, implants and IUDs).
-- Kim Best
References
- U.S. Agency for International Development. Recommendations for Updating Selected Practices in Contraceptive Use: Volume II. (Washington: U.S. Agency for International Development, 1997)177-84.
- World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 1996.
- U.S. Agency for International Development. Recommendations for Updating Selected Practices in Contraceptive Use: Volume I. (Washington: U.S. Agency for International Development, 1994)21.
- World Health Organization, International Federation of Gynecology and Obstetrics. Community-based services for family planning: the role of the medical profession. Int J Gynecol Obstet 1995:49(1):85.
- Zavala AS, Pérez-Gonzáles M, Miller P, et al. Reproductive risks in a community-based distribution program of oral contraceptives, Matamoros, Mexico. Stud Fam Plann 1987;18(5):284-90.
- Rai C, Thapa S, Bhattarai L, et al. Prevalence of conditions in Nepal for which DMPA initiation is not recommended: implications for community based service delivery of DMPA. Unpublished paper. Family Health International, 1998.
- Assessing the impact of community-based distribution (CBD) programs in Kenya. Update 1996;(7):1-2.
- Manjanja S. Zimbabwe: a family planning profile. Malawi Med J 1993;9(1):37.
- World Health Organization. Injectable Contraceptives. (Geneva: World Health Organization, 1990)33.
- Kaseje DC, Sempebwa EK, Spencer HC. Community-based distribution of family planning services in Saradidi, Kenya. Ann Trop Med Parasitol 1987;81(Suppl 1):135-47.
- Garate MR, Mostajo P, Rosen JE, et al. CBD promoter incentives for IUD insertion referral: can they lead to client coercion and abuse? Findings from Peru. Presentation at the American Public Health Association annual meeting, Atlanta, GA, November 11-14, 1991.
- Thapa S, Friedman M. Female sterilization in Nepal: a comparison of two types of service delivery. Int Fam Plann Perspect 1998;24(2):78-83.
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