Checklist for ruling out pregnancy among family-planning clients in primary care

doi:10.1016/S0140-6736(99)01578-0

The Lancet

Volume 354, Issue 9178, 14 August 1999, Page 566

https://doi.org/10.1016/S0140-6736(99)01578-0 Get rights and content

Summary

Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to non-menstruating 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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There are more references available in the full text version of this article.

Cited by (43)

Young Women's Experiences With Subcutaneous Depot Medroxyprogesterone Acetate: A Secondary Analysis of a One-Year Randomized Trial in Malawi
2020, Journal of Adolescent Health
Citation Excerpt :
Task sharing from clinic-based staff to CHWs reduces clinic-based staff's workloads—allowing more time to provide higher-level care and curative services—while also increasing access to contraception for women living in hard-to-reach places, thereby helping to address their unmet family planning needs [21]. Eligible participants were aged 18–40 years, in self-reported good general health, able to understand and willing to sign an informed consent document, willing to give contact information for follow-up, willing to have follow-up visits or interviews, willing to be randomized to the self-injection arm or provider-administered injection group, not pregnant according to the WHO guidelines, and able to meet eligibility criteria for receiving DMPA per WHO medical eligibility criteria [22–24]. Women in the self-injection group who successfully self-injected at enrollment (assessed by the provider) received three doses of DMPA-SC to take home for subsequent self-injections, whereas women in the provider-administered injection group were asked to return to the provider for injections at 3, 6, and 9 months post enrollment.
The purpose of this study was to compare the effectiveness, safety, and experiences with side effects of self-injected and provider-administered injectable contraception between young (18–24 years) versus older (≥25 years) women.
We conducted secondary analysis of data from a 12-month randomized controlled trial in Malawi, where a total of 731 women were randomized to receive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) administered by a provider or be trained to self-inject subcutaneous depot medroxyprogesterone acetate. Data collectors contacted women after the reinjection window at 3, 6, and 9 months to collect data on discontinuation and women’s experiences, including adverse events. Twelve months after enrollment or at early discontinuation, women had their final interview, including pregnancy testing. We compared continuation, pregnancy, safety, and side effects among young women versus older women.
Among self-injectors, there were no significant differences found in continuation by age (p = .345) with continuation rates at 12 months of 79% for young women and 69% for older women. Continuation rates were lower for both age groups with provider-administered injections. In the provider-administered group, continuation rates among young women (39%) were lower than among older women (49%) (p = .047). The distribution of reasons for discontinuation did not differ significantly by age for those receiving provider injections (p = .698). However, younger self-injectors were less likely to miss the reinjection window than older self-injectors (p = .011). Age did not significantly influence pregnancy or safety.
With evidence of potential higher impact on continuation and no safety concerns, we recommend self-injection be added to the contraception options available to young women in low-resource settings.
Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial
2018, The Lancet Global Health
Injectable contraceptives are popular in sub-Saharan Africa but have high discontinuation rates due partly to the need for provider-administered re-injection. We compared continuation rates of women who self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and women who received DMPA-SC from a health-care provider, including community health workers (CHWs).
We did an open-label randomised controlled trial based at six Ministry of Health clinics in rural Mangochi District, Malawi. Health-care providers recruited adult women who presented at the six clinics or to CHWs in rural communities in the clinic catchment areas. Participants received DMPA-SC and were randomised (1:1) to receive provider-administered injections or training in how to self-inject DMPA-SC. Randomisation was done via a computer-generated block randomisation schedule with block sizes of four, six, and eight and stratified by study site, generated by an independent statistician. Self-injectors administered the first injection under observation and were sent home with three doses, written instructions, and a calendar. The provider-administered group received a DMPA-SC injection and a calendar, and were asked to return for subsequent injections. Data collectors contacted participants after the 14-week re-injection window at 3, 6, and 9 months to collect continuation data. At 12 months after enrolment or early discontinuation, women had their final interview, which included pregnancy testing. The primary outcome was discontinuation of DMPA-SC, as assessed in the intention-to-treat population. We used Kaplan-Meier methods to estimate the probabilities of continuation and a log-rank test to compare groups. Safety was assessed in the as-treated population, which consisted only of participants who successfully received at least one DMPA-SC injection after randomisation. This trial is registered with ClinicalTrials.gov, number NCT02293694.
This study lasted from Sept 17, 2015, to Feb 21, 2017. 731 women underwent randomisation, with 364 assigned to the self-administered group and 367 to the provider-administered group. One woman in the self-injection group withdrew at month 0. Treatment was discontinued by 99 women in the self-administered group and 199 women in the provider-administered group. The 12 month continuation rate was 73% in the self-injection group and 45% in the provider-administered group, giving an incidence rate ratio of 0·40 (95% CI 0·31–0·51; p<0·0001). Adverse events deemed to potentially be treatment-related were reported by ten women (20 events) in the self-administered group and 17 women (28 events) in the provider-administered group. Five serious adverse events were reported during the trial by four women; two events related to DMPA-SC (menorrhagia and anaemia requiring hospital admission) were reported by the same woman in the provider-administered group and resolved without sequelae. The other serious adverse events, including one death, were deemed to be unrelated to DMPA-SC.
Women who self-injected DMPA-SC had significantly higher rates of continuation than those receiving provider-injected DMPA-SC. Community-based provision of injectable contraception for self-injection in low-resource settings seems to be safe and feasible. Self-administration of DMPA-SC should be made widely available.
United States Agency for International Development and Children's Investment Fund Foundation.
Highlights From the U.S. Selected Practice Recommendations for Contraceptive Use
2018, Nursing for Women's Health
Citation Excerpt :
Visual inspection of the cervix for signs or symptoms of a sexually transmitted infection (STI), in addition to a bimanual examination, should be performed before IUD placement (Curtis, Jatlaoui, et al., 2016). As reviewed earlier, a urine pregnancy test is not a prerequisite for insertion (Curtis, Jatlaoui, et al., 2016; Stanback et al., 1999). STI cultures should be collected at the time of insertion if not obtained within the past 12 months (Curtis, Jatlaoui, et al., 2016).
The U.S. Centers for Disease Control and Prevention recently updated the U.S. Selected Practice Recommendations for Contraceptive Use to foster a reduction in unplanned pregnancy rates and to provide clinicians an evidence-based guide for contraception management. Nurses play an important role in helping women and families with reproductive life planning. By bridging knowledge gaps and removing access barriers with regard to contraception, nurses can contribute to reducing rates of unintended pregnancy. Nurses and other clinicians are encouraged to use the U.S. Selected Practice Recommendations for Contraceptive Use when counseling women about safe and effective contraception management.
Does using the “pregnancy checklist” delay safe initiation of contraception?
2017, Contraception
Proposed clinical guidance for excluding pregnancy prior to contraceptive initiation
2017, Contraception
Unprotected intercourse in the 2 weeks prior to requesting emergency intrauterine contraception
2016, American Journal of Obstetrics and Gynecology
Previous emergency contraception studies have excluded women who report >1 episode of unprotected or underprotected intercourse. Thus, clinical recommendations are based on exposure to a single episode of underprotected intercourse.
We sought to assess the prevalence and timing of underprotected intercourse episodes among women requesting emergency contraception and to examine the probability of pregnancy following an emergency contraception regimen including placement of either a copper intrauterine device or a levonorgestrel intrauterine device with simultaneous administration of an oral levonorgestrel pill in women reporting multiple underprotected intercourse episodes, including episodes beyond the Food and Drug Administration–approved emergency contraception time frame (6-14 days).
Women seeking emergency contraception who had a negative pregnancy test and desired either a copper intrauterine device or levonorgestrel emergency contraception regimen enrolled in this prospective observational study. At enrollment, participants reported the number and timing of underprotected intercourse episodes in the previous 14 days. Two weeks later, participants reported the results of a self-administered home pregnancy test.
Of the 176 women who presented for emergency contraception and received a same-day intrauterine device, 43% (n = 76) reported multiple underprotected intercourse episodes in the 14 days prior to presenting for emergency contraception. Women with multiple underprotected intercourse episodes reported a median of 3 events (range 2-20). Two-week pregnancy data were available for 172 (98%) participants. Only 1 participant had a positive pregnancy test. Pregnancy occurred in 0 of 97 (0%; 95% confidence interval, 0–3.7%) women with a single underprotected intercourse episode and 1 of 75 (1.3%; 95% confidence interval, 0–7.2%) women reporting multiple underprotected intercourse episodes; this includes 1 of 40 (2.5%; 95% confidence interval, 0–13.2%) women reporting underprotected intercourse 6-14 days prior to intrauterine device insertion.
Women seeking emergency contraception from clinics commonly reported multiple recent underprotected intercourse episodes, including episodes occurring beyond the Food and Drug Administration–approved emergency contraception time frame. However, the probability of pregnancy was low following same-day intrauterine device placement.

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Research LettersChecklist for ruling out pregnancy among family-planning clients in primary care

Summary

Lancet

Menstruation requirements: a significant barrier to contraceptive access in developing countries

Stud Fam Plann

Research Letters
Checklist for ruling out pregnancy among family-planning clients in primary care