September 18, 2015
Written by Martha Carlough and Roy Jacobstein, IntraHealth International
This post originally appeared on the K4Health blog.
Unmet need for family planning has decreased only moderately in recent decades, and the demand for family planning is on the rise due to population growth, longer life expectancies, and the increasing desire for smaller families.
We must address this gap if we hope to increase the health, social, and economic well-being of women and their families around the world.
Health workers do not walk into their client interactions as blank slates.
Integration of family planning into maternal, newborn, and child health helps connect more women with the family planning methods they need to protect their health and plan their futures. Addressing provider bias with evidence-based, supportive, and health systems-based solutions is critical to success, yet often ignored.
Health workers do not walk into their client interactions as blank slates. They bring with them their personalities, cultural and socioeconomic backgrounds, understandings of “how the world works,” and biases. These biases may be against a particular method, a client characteristic or situation, or both, and they may not be immediately evident to the providers themselves.
Provider bias in family planning is multidimensional, but important factors to consider especially during integration include the following:
Lack of evidence-based, current knowledge and experience in providing modern contraceptivesExaggerated fear of doing harmPersonal bias against particular family planning methods (e.g., IUD)Personal bias against the use of family planning in specific situations or populations (e.g., unmarried adolescents)Personal (and program) bias toward the non-family planning technical area (e.g., providers of immunizations or postabortion care programs may fear deleterious effects of integrating family planning into the program)Being asked to do more without being supported to do more or having other tasks removed 1. Provide regular evidence-based, accurate information.
Change in medical settings typically takes a great deal of time. Particularly in pre-service education, outdated and incorrect family planning information may sow misunderstandings that are hard to prevent or dispel.
Frank deficits in knowledge—such as how to manage side effects of hormonal contraception or how to optimize lactational amenorrhea—affect clients directly. Accurate, evidence-based information about contraception needs to be provided to future health workers by experienced educators with opportunities for regular updates for students and practicing health workers.
2. Identify and use early adopters.
Medicine is both art and science. Even in the face of the latest evidence, health workers often do not change the way they provide services.
For changes to take root, health workers usually need to understand the practicalities of how to apply the new information or skill in their own environments.
This takes early adopters and champions—those individuals who are willing to work out the kinks in providing a new service or method (or have already done so). For example, a health facility may at first use one or two “dedicated providers” to offer clients a new method like an IUD. These providers may then mentor their colleagues to provide the same method or service.
3. Promote doing good, not just avoiding harm.
“Medical barriers” is the term often applied to inappropriate practices or standards based on medical rationale that prevents clients from receiving contraceptives. Much of the time, these barriers stem from a fear of harm winning out over doing good.
For example, the WHO Medical Eligibility Criteria lists four categories of clients to guide clinical decision-making. For providers defined as having “limited clinical judgment,” these categories are collapsed into two. If a client falls into Category 1 (yes) or 2 (benefits outweigh the risks), the guidelines state that the family planning method can be provided. If a client falls into Category 3 or 4, the health worker should not provide the method.
However, in practice, some providers may only provide a method to clients in Category 1, wrongly denying it to Category 2 clients because of the misunderstanding or exaggerated fear of associated risks. Combatting this tendency with accurate data, such as the absolute vs. relative risk of complications and the very real risks of pregnancy and pregnancy-related complications, is critical.
4. Promote justice for all clients.
An underpinning principle of professional integrity in medicine is the expectation that the same intellectual and moral standards of care should be provided to clients regardless of the social situation of the client being cared for.
A focus on improving access to family planning has significantly addressed barriers of physical distance from health facilities by diversifying outlets through community-based or mobile providers and social franchises, but a lack of “psychosocial access” often persists. For example, health workers may not provide IUDs to clients who they perceive, often erroneously, to be at high risk of STDs. Or emergency contraception may be provided only to those clients who are educated and responsible as determined by the provider. Studies with simulated clients which capture provider perspectives and misinformation with the intent to use this data in short cycle self-improvement may be valuable.
Addressing provider bias does not mean blaming the health workers, especially where the health systems in which they work fall short.
5. Support rather than blame health workers.
Addressing provider bias does not mean blaming the health workers, especially where the health systems in which they work fall short. Health workers do not provide evidence-based, respectful family planning services in a vacuum.
It is important to understand the health worker’s perspective and his or her own life situation. In addition, programs must factor in the reality that providing longer acting methods of family planning, such as IUDs and implants, take more time and resources. Not addressing this reality could exacerbate working conditions that may reinforce provider bias.
When there are gaps in the health care system—such as frequent unavailability of supplies and needed protocols and guidelines for decision-making, accurate assessments of workload and time commitments, and a lack of supportive colleagues and supervision—these impediments and system shortcomings also need to be addressed.
Health workers—especially those working in difficult conditions—need and deserve our support, particularly when asked to take on even more.
Since integration of family planning into maternal and child health services is a vast area with many intersections, considering how to address provider bias is an important element for family planning success.