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      Does free pregnancy testing reduce service denial in family planning clinics? A cluster-randomized experiment in Zambia and Ghana

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          Abstract

          Pregnancy tests, which cost very little (∼US$0.10) and are often required for successful family planning service delivery, may reduce service denial, and should be available in all family planning clinics at no or minimal cost to clients.

          Abstract

          Pregnancy tests, which cost very little (∼US$0.10) and are often required for successful family planning service delivery, may reduce service denial, and should be available in all family planning clinics at no or minimal cost to clients.

          ABSTRACT

          Background:

          In many countries, pregnancy tests are not freely available in family planning clinics. As a result, providers sometimes deny services to non-menstruating clients due to uncertainty about pregnancy. Few clients are actually pregnant, yet denied clients run the risk of becoming pregnant, and those sent to pharmacies pay inflated prices for inexpensive tests. To assess the programmatic effect of free pregnancy testing, we conducted cluster-randomized trials in Ghana and Zambia, assessing clients' uptake of contraception in family planning clinics.

          Methods:

          In each country, 5 clinics were randomized to intervention status and 5 to control. Service data from 2,028 new, non-menstruating clients in Zambia and 1,556 in Ghana were collected. Intervention clinics received supplies of pregnancy tests, and staff were instructed to use tests as needed to help exclude pregnancy. Control clinics received no intervention. The primary outcome was the proportion of non-menstruating clients denied an effective contraceptive method. Cost-effectiveness was also evaluated.

          Results:

          In Zambia, clients in intervention and control clinics faced a similar risk of service denial at baseline, 15% and 17%, respectively. At follow-up, denial remained unchanged at 17% in control clinics, but decreased significantly to 4% in intervention sites. Clients in Zambia were 4.4 (95% confidence interval [CI] = 1.3–14.4) times more likely to be denied a method in control sites versus intervention sites ( P<.01). Results from Ghana were inconclusive. Cost of a “denial averted” in Zambia was estimated to be US$0.59.

          Interpretation:

          Zambia results suggest that availability of free pregnancy testing significantly reduced contraceptive service denial, although results from Ghana preclude an unqualified recommendation. Authors conclude that free pregnancy testing in family planning clinics may make strong public health sense in those developing countries where denial to non-menstruating clients remains a problem. Although pregnancy can usually be excluded with a client history, pregnancy tests are often necessary.

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          Most cited references7

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          Barriers to fertility regulation: a review of the literature.

          The evidence in the demographic and family planning literature of the range and diversity of the barriers to fertility regulation in many developing countries is reviewed in this article from a consumer perspective. Barriers are defined as the constraining factors standing between women and the realistic availability of the technologies and correct information they need in order to decide whether and when to have a child. The barriers include limited method choice, financial costs, the status of women, medical and legal restrictions, provider bias, and misinformation. The presence or absence of barriers to fertility regulation is likely an important determinant of the pace of fertility decline or its delay in many countries. At the same time, barriers inhibit women's ability to avoid unintended pregnancy. Problems of quantifying barriers limit understanding of their importance. New ways to quantify them and to identify misinformation, which is often concealed in survey data, are needed for future research.
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            Checklist for ruling out pregnancy among family-planning clients in primary care.

            Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to nonmenstruating clients. In Kenya, a trial of a simple checklist to exclude pregnancy showed a good negative predictive value, which could improve access to service and reduce unwanted pregnancies and their sequelae.
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              Ruling out pregnancy among family planning clients: the impact of a checklist in three countries.

              Women in many countries are often denied vital family planning services if they are not menstruating when they present at clinics, for fear that they might be pregnant. A simple checklist based on criteria approved by the World Health Organization has been developed to help providers rule out pregnancy among such clients, but its use is not yet widespread. Researchers in Guatemala, Mali, and Senegal conducted operations research to determine whether a simple, replicable introduction of this checklist improved access to contraceptive services by reducing the proportion of clients denied services. From 2001 to 2003, sociodemographic and service data were collectedfrom 4,823 women from 16 clinics in three countries. In each clinic, data were collected prior to introduction of the checklist and again three to six weeks after the intervention. Among new family planning clients, denial of the desired method due to menstrual status decreased significantly from 16 percent to 2 percent in Guatemala and from 11 percent to 6 percent in Senegal. Multivariate analyses and bivariate analyses of changes within subgroups of nonmenstruating clients confirmed and reinforced these statistically significant findings. In Mali, denial rates were essentially unchanged, but they were low from the start. Where denial of services to nonmenstruating family planning clients was a problem, introduction of the pregnancy checklist significantly reduced denial rates. This simple, inexpensive job aid improves women's access to essential family planning services.
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                Author and article information

                Journal
                Glob Health Sci Pract
                Glob Health Sci Pract
                ghsp
                ghsp
                Global Health, Science and Practice
                Global Health: Science and Practice
                2169-575X
                November 2013
                24 September 2013
                : 1
                : 3
                : 382-388
                Affiliations
                [a ]FHI 360 , Research Triangle Park, NC, USA
                [b ]Ghana Health Service , Accra, Ghana
                [c ]FHI 360/Zambia , Lusaka, Zambia
                [d ]Ministry of Health, Government of Zambia , Lusaka, Zambia
                Author notes
                Correspondence to John Stanback ( jstanback@ 123456fhi360.org ).
                Article
                GHSP-D-13-00011
                10.9745/GHSP-D-13-00011
                4168583
                25276551
                6a654654-0bdb-4547-a545-537d4c251755
                © Stanback et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of this license, visit http://creativecommons.org/licenses/by/3.0/

                History
                : 5 February 2013
                : 16 August 2013
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