Providing community health workers (CHWs) with pregnancy testing kits appears to be an effective way to increase their distribution of hormonal contraceptives, according to an evaluation of a 2013 intervention conducted in rural Madagascar.1 Compared with CHWs in the study's control group, those in the study's intervention group—who received urine pregnancy tests to distribute without charge to women in their communities and training on how to use the tests—provided hormonal contraceptives (i.e., the injectable and the pill) to a greater average number of new clients per month during the four-month study period (3.1 vs. 2.5). In analyses by specific method, the difference by group was seen for distribution of the injectable, but not of the pill.
In Madagascar, CHWs are allowed to sell contraceptives to women living in rural areas, where access to other family planning providers is limited. Before providing a hormonal method, CHWs are supposed to confirm that the client is not pregnant. This is typically done using a six-question checklist; however, the checklist method has a high false-positive rate, which results in many eligible women being denied a hormonal method. To assess whether providing CHWs with free urine pregnancy testing kits increases distribution of hormonal contraceptives, researchers evaluated an intervention implemented in three regions of eastern Madagascar in 2013.
All practicing CHWs in the study regions were eligible to participate; however, the researchers excluded 48 in two hard-to-reach districts, as well as 36 with extremely high client caseloads, which resulted in a sample of 622. Within each region, half of participating CHWs were randomized to the intervention group and half to the control group. Intervention group CHWs each received a free supply of 50 pregnancy tests and training on how to use them, but were not specifically instructed to use the tests for the provision of hormonal contraceptives; all CHWs received training on how to collect family planning service data using a monthly reporting form. Data were collected from CHWs at baseline and for each of the four months following training, and were analyzed using descriptive and ordinary least-squares regression analyses.
At baseline, the majority of CHWs in the intervention and control groups were female (65% and 72%, respectively) and married (86% and 83%); for both groups, the mean age was 43. On average, CHWs lived a two-hour walk from the nearest health center and had to travel nearly 20 kilometers to replenish their supply of health products for resale. The vast majority (94%) reported using the checklist to determine pregnancy status, but fewer than half (46%) believed that it is "very reliable." Intervention group CHWs served a mean of 39 contraceptive clients in a month (24 injectable clients and 15 pill clients), which was not significantly different from the mean numbers served by the control group (41 overall, 27 injectable clients and 14 pill clients). The only baseline differences were that intervention CHWs worked fewer hours per week (17 vs. 20) and control CHWs were more likely to report ever experiencing a shortage of the injectable (35% vs. 22%).
Over the four-month study period, CHWs in the intervention group served an average of 3.1 new hormonal contraceptive clients per month, whereas control CHWs served a monthly average of 2.5 new hormonal contraceptive clients; the difference was statistically significant and represented an intervention impact of 26%. Analyses by contraceptive method found that intervention CHWs served more new injectable clients per month than did control-group CHWs (1.9 vs. 1.5, respectively), but that there was no difference by group in the average monthly number of new pill clients served. In addition, no differences by group were evident in the number of individual family planning sessions held per month or in the frequency with which the pregnancy checklist was used.
The authors conclude that "giving CHWs free pregnancy tests is an effective way to increase distribution of hormonal contraceptives in countries like Madagascar, particularly where health workers are not trained or are hesitant to use the pregnancy checklist." They suggest that "as pregnancy tests—which cost less than 10 cents each—become an increasingly affordable alternative for health-care systems in developing countries, community-based distribution programs should consider using the tests as a low-cost addition to CHWs' services." As a result of this study's findings, the Ministry of Health, with the support of the United States Agency for International Development, is now supporting the distribution of pregnancy test kits country-wide.—J. Rosenberg
1. Comfort AB et al., Providing free pregnancy test kits to community health workers increases distribution of contraceptives: results from an impact evaluation in Madagascar, Contraception, 2016, 93(1):44–51.