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By Kathleen Henry Shears, Senior Science Writer, Family Health International, Research Triangle Park, NC, USA Studies show that a checklist developed and tested by Family Health International (FHI) is highly effective in ruling out pregnancy and can be used with confidence when laboratory tests are not available. The checklist was originally designed as a screening tool for women seeking family planning services, and research has found that its use increases access to such services. But the checklist also can be useful for ruling out pregnancy in other situations. For example, providers can use the pregnancy checklist before prescribing medications that should be avoided during pregnancy, including certain antibiotics or anti-seizure drugs. No need to wait When a woman says she wants to begin using a contraceptive method, her physician or other healthcare 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. 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 sterilisation procedure, because of concerns about possible harm to an unrecognised pregnancy and because pregnant women do not need contraception. But if a client is not having her period when she visits a clinic, she may be sent home empty handed. FHI studies in Kenya, Senegal, Mali, Egypt, and Guatemala found that from 17% to 47% 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. But the evidence from several FHI studies to validate the pregnancy checklist shows that a woman need not wait until she is menstruating to receive her contraceptive method of choice. The checklist consists of six questions a provider can ask a woman while taking her medical history. These questions are based on criteria established by 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 1852 new family planning clients at seven clinics in three regions of Kenya in 1999. The study was repeated among 1000 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% of the time. Overall, only 1% to 2% of the study participants 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 study revealed that without the checklist, many women who were not pregnant would have been unjustifiably denied essential family planning services. Improving access to services From 2001 to 2003, FHI conducted 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 contraceptive 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. The proportion of women denied their desired method because of their menstrual status declined significantly, from 16% to 2% of new clients in Guatemala and from 11% to 6% of new clients in Senegal. In Mali, where the denial rate was only 5% 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 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. 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 Provider resources). FHI has worked with ministries of health and nongovernmental organisations in a number of countries to incorporate these checklists into practice. In Kenya, for example, the MOH's Department of Reproductive Health worked with FHI to adapt the checklists, and it is training providers to use the new versions. The Ugandan MOH also adapted the provider checklists and incorporated them into various training courses. The pregnancy checklist has been translated into Kiswahili and many other languages. Its inclusion in a new global handbook for family planning providers (see Global family planning handbook) will encourage its use in other countries throughout the world.
FHI's pregnancy checklist is one of four screening tools FHI has developed and tested. Three additional checklists help providers screen clients who want to initiate use of combined oral contraceptives, injectable contraceptives, or the copper IUD. These checklists are available with a reference guide for using and adapting them. The World Health Organization's Four Cornerstones of Family Planning Guidance support the safe and effective provision and use of family planning methods. They include Medical Eligibility Criteria for Contraceptive Use, Selected Practice Recommendations for Contraceptive Use, the Decision-Making Tool for Family Planning Clients, and Family Planning: A Global Handbook for Providers. Printed copies of Family Planning: A Global Handbook for Providers are available free of charge to readers in developing countries. Copies may be ordered by mail from: Orders, INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA; by telephone at 1.410.659.6315; by fax at 1.410.659.6266; or by e-mail at orders@jhuccp.org. The entire handbook or individual chapters can also be downloaded.
This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk). |
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