Pregnancy Checklist for Providers

A simple screening tool improves access to family planning.

Family Health Research: 2007, Vol. 1, Issue 3

When a woman says she wants to begin using a contraceptive method, her family planning provider may ask her if she is having her period. Providers often rely on the presence of menstruation to rule out pregnancy when laboratory tests are unavailable or unaffordable.

Family planning providers are required to determine whether a woman might already be pregnant before giving her a hormonal method, inserting an intrauterine device, or performing a sterilization procedure because of concerns about possible harm to an unrecognized pregnancy and because pregnant women do not need contraception. But if a client is not having her period, she may be sent home empty handed.

FHI studies in Kenya, Senegal, Mali, Egypt, and Guatemala found that from 17 percent to 47 percent of all new, nonmenstruating family planning clients were denied their desired contraceptive methods because of their menstrual status. Most of these clients were sent home without any method, which put them at risk of unintended pregnancy.

Photo credit: Rebecca Callahan/USAID

Family planning service providers at Koibatek District Hospital have posted checklists on the wall for easy reference

But the evidence from several FHI studies shows that a woman need not wait until she is menstruating to receive her contraceptive method of choice. These studies assessed the effectiveness of a simple checklist that FHI designed to help providers rule out pregnancy among clients who wish to initiate contraceptive use.

Part of a series of screening tools that FHI has developed and tested, the pregnancy checklist consists of six questions a provider can ask a woman while taking her medical history. These questions are based on criteria established by the World Health Organization to help providers rule out pregnancy with a reasonable degree of certainty.

The FHI studies found that if a client answers yes to any of the questions and there are no signs or symptoms of pregnancy, then a provider can be reasonably sure the woman is not pregnant.

Ruling out pregnancy

FHI tested the validity of the checklist against a standard pregnancy test among 1,852 new family planning clients at seven clinics in three regions of Kenya in 1999. The study was repeated among 1,000 women in Egypt in 2005 and with 263 women in Nicaragua in 2004 and 2005.

In all three studies, the checklist correctly identified women who were not pregnant 99 percent of the time.

Overall, only 1 percent to 2 percent of the women who sought family planning services had a positive pregnancy test. "Given the low prevalence of pregnancy and the serious health consequences of unintended pregnancy, the real risk was that many women who were not pregnant would have been unjustifiably denied essential family planning services," noted Dr. John Stanback, principal investigator of the study and a senior associate in FHI's Health Services Research Division.

Improving access to services

From 2001 to 2003, FHI conducted operations research among 4,823 women at 16 family planning clinics in Guatemala, Mali, and Senegal to determine whether introducing the pregnancy checklist would improve women's access to contraceptives services. The study found that the checklist was helpful in Guatemala and Senegal, where a substantial number of new clients were denied such services because they were not menstruating.

Among new family planning clients, those who were denied their desired method because of their menstrual status declined significantly, from 16 percent to 2 percent of new clients in Guatemala and from 11 percent to 6 percent of new clients in Senegal. In Mali, where the denial rate was only 5 percent of new clients before the checklist was introduced, it remained essentially unchanged (see figure). Reducing such a low denial rate may not have been feasible.

Impact on service delivery

After the results of the operations research were presented in Senegal, the country's Ministry of Health (MOH) had the pregnancy checklist translated into Wolof and incorporated into the national family planning guidelines and the client cards used in contraceptive counseling. The results also prompted use of the checklist in clinics run by the national family planning association in Guatemala.

Since then, the pregnancy checklist has been used in at least 15 countries, often together with three additional checklists that FHI developed to help providers determine a client's eligibility for contraceptive services (see list below). And FHI has worked with ministries of health and nongovernmental organizations in a number of countries to incorporate these checklists into practice.

• In the Dominican Republic, a 2007 assessment among 61 of the 1,700 MOH employees who had been trained to use the checklists in 2006 found that most of these clinicians were using the materials at least once a week.
• In Kenya, the MOH's Department of Reproductive Health worked with FHI to adapt the checklists and is training providers to use the new versions, with plans to disseminate 5,000 copies in English and Kiswahili.
• In Uganda, where the MOH also adapted the provider checklists and incorporated them into various training courses, the checklists are in widespread use among family planning providers, nurse-midwives, and community-based health workers.

FHI's Provider Checklists How to Be Reasonably Sure a Client is Not Pregnant Checlist for Clients Who Want to Initiate COCs  Checlists for Clients Who Want to Initiate DMPA (or NET-EN) Checklist for Clients Who Want to Initiate use of the Copper IUD The checklists, along with a reference guide to their use and other resources, can be downloaded here.

FHI continues to promote the use of its checklists to improve women's access to contraceptive services. By September 2007, FHI had responded to requests for almost 10,000 copies of the checklists for use in a dozen countries. Inclusion of the pregnancy checklist in the new global handbook for family planning providers (see Global Family Planning Handbook) will encourage its use in other countries throughout the world.