Checklists Reduce Medical Barriers to
Contraceptive Use

Contraceptive provision in many settings continues to be based on outdated medical information, unproven theoretical concerns, and provider biases. Studies have found that in some developing countries 25-50% of women seeking contraceptives are refused services until they are menstruating.¹ Coupled with effective training, checklists can be important tools for health care workers at various levels to apply the latest WHO medical eligibility criteria and guidelines for contraceptive use. The pregnancy, combined oral contraceptive (COC), depot-medroxyprogesterone acetate (DMPA), and intrauterine device ( IUD) checklists allow health care workers to avoid medical barriers and better provide methods of contraception.

Pregnancy Checklist. Before prescribing a hormonal contraceptive or IUD, providers should be reasonably certain that a family planning client is not pregnant. Many providers require clients to be menstruating before they will prescribe a method. However, this strict requirement often prevents non-pregnant women from receiving the method they want, thereby increasing their risk of unplanned pregnancies. In settings where pregnancy tests are not available or are expensive, the checklist, “How to be Reasonably Sure a Client is Not Pregnant,” is a simple, inexpensive, and accurate alternative. This pregnancy checklist can be used by clinic or community-based workers, pharmacists, nursing staff, or other health care providers. The checklist is highly effective and has been validated in Kenya, Guatemala, Senegal, Mali, and most recently, Egypt. If used correctly, the checklist is more than 99% accurate in ruling out pregnancy.1 COC and DMPA Checklists. Checklists for oral and injectable contraceptive provision can be used by providers at all levels including community agents and other para-professionals. These checklists are based on the WHO’s Medical Eligibility Criteria for Contraceptive Use and include simple questions to help providers identify health conditions that might preclude a woman from using these hormonal methods of contraception. COC and DMPA checklists

offer providers the most accurate and up-to-date medical eligibility  information on these methods in a simple and clear format that can be understood by both health care worker and client. Evaluation of the DMPA checklist with community health care workers in Nepal concluded that it allowed health care workers to identify candidates who did not meet WHO criteria for safe use of DMPA.2

IUD Checklist. In 2004, after review of new research, the WHO changed its medical eligibility criteria for use of the copper-based IUD. A simple checklist has been developed for IUD provision based on these new criteria. Like the COC and DMPA checklists, the IUD checklist leads providers through a simple set of questions to determine if a woman can safely use an IUD. The IUD checklist can be introduced during clinical training on IUD insertion/removal and also can be used at clinics as a job aid. Program managers and trainers should consider introducing the checklist with a comprehensive explanation and training on WHO Medical Eligibility Criteria, along with other interventions at the clinic (e.g., logistics, supervision) to support IUD provision.

Programmatic Considerations
The pregnancy, COC, DMPA, and IUD checklists have the potential to significantly improve the quality of family planning provision in clinical and non-clinical settings by ensuring that practices follow the most current scientific guidance. In most cases, these checklists will also allow providers to “screen in” a greater number of clients for contraceptive use by reducing some of the traditional medical barriers to their provision. The pregnancy checklist can rule out pregnancy through a simple set of questions, thus allowing providers to safely provide hormonal contraceptives and IUDs to women who wish to use these methods, but who are not pregnant and not currently menstruating. Similarly, the IUD checklist, based on new WHO medical eligibility requirements, indicates that, contrary to previous belief, IUDs can be used by nulliparous women, women at risk for some STIs, and women with HIV infection, thus extending the option of IUD use to women previously thought of as ineligible. Designed to take the place of inaccurate and outdated checklists that often included vague and even irrelevant questions, the DMPA and COC checklists use specific, standardized questions that can more precisely determine whether or not a woman may safely use these hormonal methods and, thus, identify more potential users.

In addition to increasing access to contraceptive options, these checklists also help providers at all levels ensure their clients’ safety by screening for conditions or health problems that might prevent safe use of a specific contraceptive method. Though not intended to enable providers to make a diagnosis about a condition or disease, the COC, DMPA, and IUD checklists can identify women who may need further evaluation before initiating these methods.

Each of these checklists should be introduced into service delivery settings with adequate training on their use and the medical eligibility criteria on which the checklists are based. These checklists should also be adapted, if necessary, to the particular context in which they will be used. However, in order for them to be used effectively, it is important that adaptations maintain the meaning of the questions included in the checklists and that additional questions are not added.

All of the checklists described in this brief are available in English, French, and Spanish. The pregnancy checklist is also available in other languages, including Kiswahili and Arabic. The checklists can be accessed on the Family Health International Web site at http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/index.htm.

¹ J. Stanback, et al. “Checklist for ruling out pregnancy among family planning clients in primary care,” Lancet 354 (1999); 566.

² C. Rai, et al. “Conditions in rural Nepal for which DMPA initiation is not recommended: implications for community-based service delivery,” Contraception 60 (1999); 31-37.

Where to get more information: www.maqweb.org

Last Revised: 04/06/06
Produced in association with The Maximizing Access and Quality Initiative

Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Published with support from the United States Agency for International Development (USAID), Global, GH/POP/PEC, under the terms of Grant No. GPH-A-00-02-00003-00.