Checklists for Screening Clients Who Want to Initiate COCs, DMPA or IUD

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Screening Checklists to Initiate Use of
ContraceptivesTools for Service Providers
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Objectives

• Rationale and purpose of the screening checklists
• Intended users of the checklists
• Current evidence on the validity and
  effectiveness of checklists
• Recommendations for adapting checklists to the
  local context

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Introducing the Screening Checklists
Checklist for Screening Clients Who Want to
Initiate Combined Oral Contraceptives (COCs)
Checklist for Screening Clients Who Want to
Initiate DMPA (or NET-EN)
Checklist for Screening Clients Who Want to
Initiate Use of the Copper IUD
How to be Reasonably Sure a Client is Not
Pregnant
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Why Screen for Medical Conditions

• Most women can use most contraceptives.
• Some women need evaluation or treatment before
  starting to use certain contraceptives.
• A few women should not use certain contraceptives
  (unless cured).

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Why Rule Out Pregnancy?

• Women who are currently pregnant do not require
  contraception.
• IUD insertion should NOT be initiated in pregnant
  women because it could result in a septic
  miscarriage.
• Sterilization should never be performed during
  pregnancy.

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Basis for the Screening Checklists

• Checklists consist of questions based on
• WHO Medical Eligibility Criteria used to screen
  for medical conditions and to determine if a
  woman
• is a good candidate for a specific contraceptive
• will need further evaluation, or
• should choose another method
• Six conditions/situations to rule out pregnancy
  among nonmenstruating women

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Medical Eligibility for Contraceptives

• Evidence-based recommendations for contraceptive
  provision
• Updated through periodic expert reviews
• Guidance on 19 contraceptive methods
• List individual characteristics or health
  conditions that may or may not affect clients
  eligibility for a particular method

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Medical Eligibility Criteria
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Medical Eligibility Criteria (continued)
Source WHO, 2004.
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Situations/Conditions for Ruling Out Pregnancy

• Gave birth less than 6 months ago, is fully or
  nearly-fully breastfeeding, and has had no
  menstrual period since her delivery.
• Has abstained from sexual intercourse since her
  last menstrual period or delivery.
• Delivered a baby in the last 4 weeks.
• Started her last menstrual period within the past
  7 days (or within the past 12 days if she plans
  to use an IUD).
• Had a miscarriage or abortion in the past 7 days
  (or within the past 12 days if she plans to use
  an IUD).
• Has been using a reliable contraceptive method
  consistently and correctly.

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Purpose of the Checklists
Checklists facilitate a providers screening or
decision-making process as they

• determine if a woman
• is a good candidate for a specific contraceptive
• will need further evaluation, or
• should choose another method
• rule out pregnancy in nonmenstruating women

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Purpose of the Checklists (continued)

• Checklists are not
• Diagnostic tests
• Cannot be used to decide if a woman has a new
  condition which may preclude use of contraceptive
  method
• Counseling tools
• Should only be used once an informed decision has
  been made

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Intended Users of the Checklists

• Facility-based family planning counselors and
  service providers
• Community-based health workers
• Pharmacists/dispensers
• Health care providers who offer integrated family
  planning and HIV/AIDS services
• Health care providers in resource-constrained
  settings, such as refugee camps

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Advantages of Using the Checklists

• Improves quality of care by ensuring
• safety while providing family planning
• that screening is conducted in an efficient and
  reliable manner
• Assists in efficient uses of resources by
• saving time for nonmenstruating clients
• facilitating application of simple,
  evidence-based practices during the screening
  process
• Reduces medical barriers to contraception

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Menstruation Requirements A Barrier to Family
Planning Provision

• Kenya an estimated 1/3 of all new clients sent
  home without method due to menstruation
  requirement
• Ghana 76 of health providers said they would
  send client home
• Cameroon only 1/3 of nonmenstruating clients
  received hormonal methods
• Jamaica 82 of clients were required to be
  menstruating or have a negative pregnancy test at
  a time contraceptives were provided

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Validity of the Pregnancy Checklist
Extensively tested in Egypt, Guatemala, Kenya,
Mali and Senegal.

• Does the checklist accurately predict that a
  woman is not pregnant?
• Yes Researchers compared the checklist results
  with a pregnancy test and found the checklist
  correct in ruling out pregnancy more than 99
  percent of the time.
• Does the checklist accurately predict that a
  woman is pregnant?
• No Most women who are identified as possibly
  pregnant are, in fact, not pregnant.

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Effectiveness of the Pregnancy Checklist

• Percentage of all new family planning clients
  denied their desired method as a result of
  menstrual status, before and after the checklist
  intervention, 2001-03

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Adapting the Checklist to Local Context

• Adapting the checklist to the local language and
  style
• Adapting for local culture
• Adapting the checklist for comprehension

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Example of a Poorly Adapted Question

• Original Question Did you have a baby less than
  6 months ago, are you fully or nearly fully
  breastfeeding, and have you had no menstrual
  period since then?
• Poor Adapted Question Are you fully or nearly
  fully breastfeeding and have you had no menstrual
  period since you gave birth?

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Summary

• Improve quality of care
• Reduce medical barriers to safe and effective
  contraception
• Easy-to-use tools to facilitate screening process
• May require some training and/or practice for
  providers to become comfortable using checklists