amr nadim, md professor of obstetrics & gynecology ain shams faculty of medicine barriers to...
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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
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In February 2002, A Big event occurred in Cairo…
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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.”
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MAQ Attributes:
Practical and realistic Client-centered Evidence-based Impact-oriented Field relevant Drawing on international consensus Prioritized (“first things first”) Collaborative
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What is…What is…
QUALITYQUALITY?
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Quality =
Goodness
Quality =
Goodness
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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
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Dimensions Of QualityDimensions Of Quality
EffectivenessEffectiveness
Interpersonal Relations
Interpersonal Relations
AccessTo
Service
AccessTo
Service
EfficiencyEfficiency
Technical Competence
Technical Competence
AmenitiesAmenities
ContinuityContinuity
SafetySafety
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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
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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.
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•Anecdotes
•Intermediate Outcomes
“The Winds of Change”
Expertise
Client values& concerns
Best Evidence
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EffectivenessEffectiveness
Best EvidenceBest Evidence RelevantRelevant
Patient Centered
Patient Centered
Provider ExpertiseProvider Expertise
Life Long learnerLife Long
learner
ValidityValidity
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Improving CPIImproving CPI
Improving Knowledge
Improving Knowledge Setting Medical
Eligibility CriteriaSetting Medical
Eligibility Criteria
Correction of Provider BiasCorrection of Provider Bias
ImplementingBest PracticesImplementingBest PracticesContinuityContinuity
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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:
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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.
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How did they proceed?…
2000: New evidence from systematic
reviews women of the literature for contraceptive use among women with certain pre-existing conditions .
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Efficacy
Safety Convenience
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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)
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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
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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.
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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
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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
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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
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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
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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
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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
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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)
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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)
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What Procedures Do You Need To Do Before Prescribing Contraceptive Methods?
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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.
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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:
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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.
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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
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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
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Thank you