Workforce interventions to improve access to emergency contraception pills: a systematic review of current evidence in low- and middle-income countries and recommendations for improving performance

Abstract

BackgroundEmergency contraceptive pills (ECP) are one of the 13 essential commodities addressed by the UN Commission on Life-Saving Commodities for Women and Children. Although ECP have been available for 20 years, a number of barriers still limit women’s access ECP in low and middle-income countries (LMIC). The workforce who prescribe or dispense ECP are diverse reflecting the varied contexts where ECP are available across the health, commercial and justice sectors and in the community. No reviews currently exist that examine the roles and experiences of the workforce that provide ECP in LMIC.MethodWe present a narrative synthesis of research to: identify provider factors that facilitate and constraint access to ECP; assess the effectiveness of associated interventions and; explore associated health system issues in LMIC. A search of bibliographic databases, meta-indexes and websites was undertaken to retrieve peer reviewed and grey literature. Literature was screened and identified documents examined to appraise quality.ResultsThirty-seven documents were included in the review. Studies focused on formal health workers revealing knowledge gaps concerning the role of private sector and non-health providers who increasingly provide ECP. Data from the findings section in the documents were coded under 4 themes: provider knowledge; provider attitudes and beliefs; provider practice and provider training. The analysis revealed provider knowledge gaps, less than favourable attitudes and practice issues. The findings provide limited insight into products prescribed and/or dispensed, the frequency of provision, and information and advice offered to consumers. Pre and in-service training needs were noted.ConclusionAs the provision of ECPs shifts from the clinic-based health sector to increasing provision by the private sector, the limited understanding of provider performance and the practice gaps revealed in this review highlight the need to further examine provider performance to inform the development of appropriate workforce interventions. A standardized approach to assessing performance using agreed outcomes measures may serve to ensure a systematic way forward that is inclusive of the diverse workforce that deliver ECP. Recommendations are outlined to enhance the performance of providers to improve access to ECP. A framework is offered to help guide this process with indicators.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception

“…Even though the results point toward an underestimation of the number of current EC users, they also support the notion that in many geographies, EC use remains extremely low (Dawson et al. 2015; Westley et al. 2013).…”

“…Even in countries where there are no government-or provider-imposed obstacles to procurement, stock outs are common (Dawson et al 2015). The issue is further exacerbated by lack of guidance on how to improve commodity security and logistics for this important contraceptive method (Dawson et al 2014).…”

The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study

“…Consistent with the findings of this study, previous research has found that young women generally find ECPs an acceptable and convenient option that fill the need of a post-coital contraception that can be taken as needed [4, 5, 7, 25]. However, our results also contribute to the growing evidence on barriers to ECP access and use, including myths and misconceptions about risks of ECPs [5, 25, 34, 35, 40], poor knowledge of correct usage [13, 34, 39], and restrictive distribution practices of pharmacists and health care providers [41–44].…”

Provider Bias in Family Planning Services: A Review of Its Meaning and Manifestations

“…Some of the bias around it overlaps strongly with the bias around provision to youth, for example, believing that it leads to promiscuity. A 2015 review of improving access to emergency contraception through workforce interventions found widespread misconceptions among providers, including the belief that it was an abortifacient or that access to it would increase sexual activity among adolescents 25 . Using survey data in Kenya and Ethiopia to explore bias around emergency contraception, Judge et al 26 found that counseling on and provision of emergency contraception was positively associated with providers' greater level of knowledge of the method, indicating that increasing provider knowledge can potentially contribute to offsetting some of the bias and improving access.…”