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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 references 9

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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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        Improving adherence to family planning guidelines in Kenya: an experiment.

        Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed. Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices. Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement. A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation. Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective. Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa.
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          Menstruation requirements: a significant barrier to contraceptive access in developing countries.

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            Author and article information

            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 ).
            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
            4168583
            GHSP-D-13-00011
            10.9745/GHSP-D-13-00011
            © 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/

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