Amr Nadim, MDProfessor of Obstetrics & Gynecology

Ain Shams Faculty of medicine

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

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

In February 2002, A Big event occurred in Cairo…

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.”

MAQ Attributes:

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

What is…What is…

QUALITYQUALITY?

Quality =

Goodness

Quality =

Goodness

Good Access and Quality Increases Contraceptive Prevalence Rates

05

1015202530354045

0 2 4 6 8 10 12

Quetta

Falsalabad

Korangi

Orangi

Swabi

Lyari

Months of Follow-up

CPR Percentages

(All Methods)

Source: Shelton et al, 1999.

Pakistan 6 CBD Pilot Projects

Dimensions Of QualityDimensions Of Quality

EffectivenessEffectiveness

Interpersonal Relations

Interpersonal Relations

AccessTo

Service

AccessTo

Service

EfficiencyEfficiency

Technical Competence

Technical Competence

AmenitiesAmenities

ContinuityContinuity

SafetySafety

Access to services

Contraceptive choice

Quality services provided

Legal

Time

Socio-cultural norms

Medical

Cost

Regulatory

Gender

Process

Physical

Appropriate eligibility criteria

Poor CPIProvider

bias

KnowledgeLocation

Barriers to Access and Quality

Medical BarriersMedical 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.

•Anecdotes

•Intermediate Outcomes

“The Winds of Change”

Expertise

Client values& concerns

Best Evidence

EffectivenessEffectiveness

Best EvidenceBest Evidence RelevantRelevant

Patient Centered

Patient Centered

Provider ExpertiseProvider Expertise

Life Long learnerLife Long

learner

ValidityValidity

Improving CPIImproving CPI

Improving Knowledge

Improving Knowledge Setting Medical

Eligibility CriteriaSetting Medical

Eligibility Criteria

Correction of Provider BiasCorrection of Provider Bias

ImplementingBest PracticesImplementingBest PracticesContinuityContinuity

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.

Current Policies And Health Care Practices Are Based On:

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.

How did they proceed?…

2000: New evidence from systematic

reviews women of the literature for contraceptive use among women with certain pre-existing conditions .

Efficacy

Safety Convenience

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)

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

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

COC users (8+ years of use)

Costa Rica China

1.7

0.7 0.6

0.2

0.6

0.2

Non COC users

United States

Lifetime risk of acquiring ovarian cancerNumber per 100 women

0

0.5

1.0

1.5

2.0

100

Source: Petitti and Porterfield, 1992.

COCs…Endometrial Cancer Protection

Lifetime risk of acquiring endometrial cancerNumber per 100 women

COC users (8+ years of use)

Costa Rica

3.1

0.70.3 0.4

0.1

United States China

Non COC users

2

0

1

3

4

100

Source: Petitti and Porterfield, 1992; CASH Study, 1987.

• COCs reduce risk by more than 50%

•Protection develops after 12 months of use and lasts for at least 15 years

1.2

Relative Risk with95% Confidence Intervals

0.1

1.0

10.0

Significantlyelevated RR

Nonsignificantlyelevated RR

Significantlydecreased RR

Increasedrisk

Equal risk

Decreasedrisk

RelativeRisk (RR)

95%Confidence Interval

Relative Risk = Medical condition in exposed population

Medical condition in non-exposed population

Risk of Breast Cancer,By Duration of COC

Use

Source: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception, Contraception 1998.

0.1

0.5

1.0

5.0

10.0

1.0 1.07 1.091.05 1.16

Increasedrisk

Equal risk

Decreasedrisk

Relative Risk

1.08 1.07

Nonusers < 1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15 yrs Ever

Risk of CVD and Use of Hormonal Contraceptives

Source: WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception, Contraception 1998; 57: 315-324

0.1

0.5

1.0

5.0

10.0

1.0

Non-users

Oralcombined

Progestin-onlyinjectable

Combinedinjectable

1.14 0.951.02

Increasedrisk

Equal risk

Decreasedrisk

Relative Risk

Return to Fertility AfterStopping DMPA Use

Source : Tieng, 1982.

0

20

40

60

80

100

0 4 8 12 16 20 24

Oral Contraceptives (0=last pill taken)

IUD (0=device removed)

DMPA (0=15 weeks after last injection)

Months After Stopping Contraceptive

Percent of Women Having Conceived

Eligibility Criteria WHO (1996 Classifications)

(known conditions)Classification of known Conditions

Definitions

1 No restriction of use

2 Benefits generally outweighs the risk

3 Risks generally outweighs the benefits

4 Unacceptable health risks

Women Who Can Use COCs Without Restriction

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.

(Selected examples)

Women Who Should Not Use COCs

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*.

Source: WHO, Medical Eligibility Criteria for Contraceptive Use. Second Edition, 2000.

*No proven effects on the fetus, if taken accidentally during pregnancy

(Selected examples)

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

Clinical Procedures to Be Done Before Providing a Method of

Contraception

Class A essential and mandatory in all circumstances for safe and effective use of the contraceptive method

Class B Contributes substantially to safe and effective use, but implementation may be considered within the public health and/or service context. The risk of not performing an examination or test should be balanced against the benefits of making the contraceptive method available

Class C does not contribute substantially to safe and effective use of the contraceptive method.

How Can You Be Reasonably Sure A Woman is Not

Pregnant

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.

You can be reasonably sure if she has no symptoms or signs of pregnancy, and:

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.

Clinical Procedures Before Providing

A Non-hormonal Method The only clinical procedures considered essential

and mandatory in all circumstances are

a. Pelvic and genital examination before

providing IUDs, diaphragm/cervical cap,

female and male sterilization

b. STI assessment before providing IUDs

c. Blood pressure screening before female

sterilization

Source: Selected Practice Recommendations for Contraceptive Use

WHO Eligibility Criteria

USAID Recommendations for

Updating Selected Practices

in Contraceptive Use

JHPIEGO Infection

Prevention reference manual

CPI guidance documents

Evidence Based and Updated Guidelines

Thank you