Barriers to Access to Quality: An Evidence Based look to Contraceptive Prescription

1. Barriers to Access to Quality: An Evidence Based look to Contraceptive Prescription Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Faculty of medicine

2. In February 2002, A Big event occurred in Cairo…

3. The Problem… “There is lack of a mechanism to facilitate the exchange of MAQ principles and evidence-based lessons learned which can result in inadequate coordination, design and implementation of FP/RH programs.”

5. MAQ Attributes: • Practical and realistic • Client-centered • Evidence-based • Impact-oriented • Field relevant • Drawing on international consensus • Prioritized (“first things first”) • Collaborative

6. What is… QUALITY?

7. Quality = Goodness

8. WHY ??

9. Good Access and Quality Increases Contraceptive Prevalence Rates Pakistan 6 CBD Pilot Projects CPR Percentages (All Methods) Months of Follow-up Source: Shelton et al, 1999.

10. Safety Interpersonal Relations Dimensions Of Quality Access To Service Efficiency Continuity Technical Competence Effectiveness Amenities

11. Barriers to Access and Quality Physical Medical • Access to services • Contraceptive choice • Quality services provided Location Knowledge Cost Appropriate eligibility criteria Process Gender Regulatory Socio-cultural norms Time Legal Provider bias Poor CPI

12. Medical Barriers • Medical barriers are “… practices derived at least partly from a medical rationale, that result in a scientifically unjustifiable impediment to, or denial of, contraception.” • These include : • eligibility restrictions, • process barriers, • contraindications and • provider limitations/bias. Shelton, Angle, Jacobstein, The Lancet, Volume 340, November 28, 1992.

13. Anecdotes • Intermediate Outcomes “The Winds of Change”

14. EBM

15. Validity Best Evidence Relevant Patient Centered Life Long learner Provider Expertise Effectiveness

16. Improving Knowledge Setting Medical Eligibility Criteria Correction of Provider Bias Improving CPI Implementing Best Practices Continuity

17. Current Policies And Health Care Practices Are Based On: • Scientific studies of contraceptive products that NO longer exist. • OR on long-standing theoretical concerns that have NEVER been substantiated. • OR on the provider PERSONAL preferences. • OR on BIAS of service providers.

18. How did they proceed…? • 1994~1996: • The objective was : Improving the Access to quality care in family planning through breaking the medical barriers set against quality. • The method was: An in-depth review of the epidemiological and clinical evidence relevant to the medical eligibility criteria of various contraceptive methods.

19. How did they proceed…? • 2000: • New evidence from systematic reviews women of the literature for contraceptive use among women with certain pre-existing conditions .

20. Efficacy Safety Convenience

21. Pills Have Changed Over Time • New pills are safer due to reduced hormonal dose • Typical dosages by year (approximate) - 1960s~1970s: 50 mcg of ethinyl estradiol - 1980s~ 1990s: 30 mcg of ethinyl estradiol - Present: 20 mcg of ethinyl estradiol (becoming available)

22. And… COCs Have Non-Contraceptive Benefits • Reduce the risk of: - benign breast disease - ovarian and endometrial cancer - functional ovarian cysts - ectopic pregnancy - symptomatic PID • Menstrual improvements

23. COCs … Ovarian Cancer Protection • COCs reduce risk by more than 50% • Protection develops after 12 months of use and lasts for at least 15 years Lifetime risk of acquiring ovarian cancer Number per 100 women 100 2.0 1.7 1.5 1.0 0.7 0.6 0.6 0.5 0.2 0.2 0 Costa Rica China United States Non COC users COC users (8+ years of use) Source: Petitti and Porterfield, 1992.

24. COCs… Endometrial Cancer Protection Lifetime risk of acquiring endometrial cancer • COCs reduce risk by more than 50% • Protection develops after 12 months of use and lasts for at least 15 years Number per 100 women 100 4 3.1 Non COC users 3 COC users (8+ years of use) 2 1.2 1 0.7 0.4 0.3 0.1 0 Costa Rica China United States Source: Petitti and Porterfield, 1992; CASH Study, 1987.

25. Relative Risk with95% Confidence Intervals Medical condition in exposed population Relative Risk = Increasedrisk Medical condition in non-exposed population RelativeRisk (RR) 10.0 95% Confidence Interval 1.0 Equal risk Decreasedrisk 0.1 Significantlydecreased RR Nonsignificantlyelevated RR Significantlyelevated RR

26. Risk of Breast Cancer,By Duration of COC Use Relative Risk Increasedrisk 10.0 5.0 1.0 1.07 1.05 1.09 1.16 1.08 1.07 1.0 Equal risk 0.5 Decreasedrisk Nonusers < 1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15 yrs Ever 0.1 Source: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception, Contraception 1998.

27. Risk of CVD and Use of Hormonal Contraceptives Relative Risk 10.0 Increasedrisk 5.0 1.0 1.14 1.02 0.95 1.0 Equal risk 0.5 Decreasedrisk 0.1 Non- Oralcombined Progestin-only injectable Combinedinjectable users Source: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception, Contraception 1998; 57: 315-324

28. Return to Fertility AfterStopping DMPA Use Percent of Women Having Conceived 100 80 60 Oral Contraceptives (0=last pill taken) 40 IUD (0=device removed) DMPA (0=15 weeks after last injection) 20 0 0 4 8 12 16 20 24 Months After Stopping Contraceptive Source : Tieng, 1982.

29. Medical Barriers

30. Eligibility Criteria WHO (1996 Classifications) (known conditions)

32. Women Who Can Use COCs Without Restriction (Selected examples) • Adolescents • Nulliparous women • Postpartum (3 weeks, if not breastfeeding) • Immediately Postabortion • Women with varicose veins • Any weight (including obese) Source: WHO, Medical Eligibility Criteria for Contraceptive Use. Second Edition, 2000.

33. Women Who Should Not Use COCs (Selected examples) • Breastfeeding (<6 weeks postpartum). • Smoke heavily AND are over age 35. • At increased risk of cardiovascular disease. • Have certain pre-existing conditions (breast cancer, liver tumors or cancer). • Pregnant*. *No proven effects on the fetus, if taken accidentally during pregnancy Source: WHO, Medical Eligibility Criteria for Contraceptive Use. Second Edition, 2000.

34. What Procedures Do You Need To Do Before Prescribing Contraceptive Methods?

35. Clinical Procedures to Be Done Before Providing a Method of Contraception

36. How Can You Be Reasonably Sure A Woman is Not Pregnant You can be reasonably sure if she has no symptoms or signs of pregnancy, and: • has had no intercourse since last normal menses, or • is correctly and consistently using another method, or • is within first 7 days after onset of normal menses, or • is within 4 weeks postpartum (non-lactating women), or • is within first 7 days postabortion, or • is amenorrheic, fully breastfeeding and less than 6 months postpartum Source: Recommendation for Updating Selected Practices in Contraceptive Use, 1994.

37. Clinical Procedures Before Providing A Hormonal Method Of Contraception • No examination or tests are considered essential and mandatory in all circumstances for safe and effective use of any of the hormonal contraceptive methods (excluding LNG-IUD) • It is desirable to have blood pressure measurements taken before initiation. • However, in settings where pregnancy morbidity and mortality are high women should not be denied use of hormonal methods simply because their blood pressure can not be measured. Source: Selected Practice Recommendations for Contraceptive Use.

38. Clinical Procedures Before Providing A Non-hormonal Method • The only clinical procedures considered essential and mandatory in all circumstances are • Pelvic and genital examination before providing IUDs, diaphragm/cervical cap, female and male sterilization • STI assessment before providing IUDs • Blood pressure screening before female sterilization Source: Selected Practice Recommendations for Contraceptive Use

39. Evidence Based and Updated Guidelines • WHO Eligibility Criteria • USAID Recommendations for Updating Selected Practices in Contraceptive Use • JHPIEGO Infection Prevention reference manual • CPI guidance documents

42. Thank you