The thin blue line: Increasing access to pregnancy tests in family planning programs

A version of this post originally appeared on The Lancet Global Health Blog. Reposted with permission.

The thin blue line: Increasing access to pregnancy tests in family planning programs

Photo Credit: Jessica Scranton/FHI 360

What is the true value of a 10-cent (US$) pregnancy test? In many countries, women are routinely denied same-day provision of family planning methods if they arrive at the clinic on a day when they are not menstruating. When it comes to ensuring reliable access to contraception, it turns out that simple, low-cost pregnancy tests can be extremely valuable.

Sonia, a 49-year-old woman in Rwanda, is a long-time user of Depo-Provera, the popular three-month injectable contraceptive. She explains that women who are not menstruating are often turned away for family planning services because health care providers are concerned that these women might be pregnant. Many are told to return during their next menses, leaving them at risk of unintended pregnancy in the meantime. Sonia says, “When you get there, they ask if you are having your period. When it is ‘no,’ they give you another appointment. When it is ‘yes,’ they give you cotton wool and you go somewhere discreet to put some blood [on it] and come back to show it to the provider. It is only then that the provider shows you the methods.”

Research conducted by FHI 360 indicates that nearly half of new family planning clients are not menstruating when they visit the clinic, and that 17 to 35 percent of these women are denied family planning services. Recent studies have demonstrated that the provision of simple, low-cost pregnancy tests can help reduce this medical barrier.

In a study led by FHI 360 in Zambia, women were four times more likely to be turned away from contraceptive services in clinics where pregnancy tests were not available, compared to sites where tests were provided. Another study in Madagascar conducted by Abt Associates found that when community health workers were given pregnancy tests to distribute to clients for free, the number of new users of hormonal contraceptives increased by 24 percent in an average month compared to the control group.

In particular, pregnancy tests can be critical to helping a woman access long-acting, reversible contraceptives (LARCs) such as implants and intrauterine devices (IUDs). Health care providers who administer LARCs are often especially cautious in ruling out pregnancy, so a simple pregnancy test can make all the difference for women who seek the benefits of these highly effective contraceptive methods.

Pregnancy tests are important not only for family planning programs. A study conducted in South Africa demonstrated that the availability of pregnancy tests can lead to earlier confirmation of pregnancy and access to antenatal care services, which can have important health benefits for mothers and children.

Yet too often, affordable pregnancy tests are not accessible to women. Easy-to-use, highly accurate “dip strip” tests can be purchased from manufacturers for less than 10 cents. However, in many countries, pregnancy tests are sold to women at a 2000 percent markup or more, making them prohibitively expensive. For example, a recent study in Burkina Faso revealed that non-menstruating family planning clients are required to buy pregnancy tests, which, at a price of just over US$2, many women there cannot afford.

Efforts to reduce the number of non-menstruating women who are denied family planning services have focused on the distribution of the Pregnancy Checklist, a tool endorsed by the World Health Organization that includes questions health care providers can ask to rule out pregnancy. The checklist is used in dozens of countries and has been shown to effectively increase women’s access to same-day provision of family planning. The checklist, however, does not work in all situations. Therefore, it is recommended that providers first screen a woman using the checklist and administer a pregnancy test when necessary. For example, if a woman has missed her monthly period or if her menses are late, the checklist will not be effective at ruling out pregnancy and a pregnancy test should be used.

Despite the importance of pregnancy tests, they are often not procured for large-scale distribution through family planning programs. In recent years, as part of the Family Planning 2020 (FP2020) effort, national governments and donors have committed to reach an additional 120 million girls and women worldwide with contraceptive services within the next five years. Yet, the lack of access to pregnancy tests is a substantial barrier that is potentially limiting the provision of services to millions of women. With more than $2.6 billion pledged to reach the ambitious FP2020 goal, it is time to recognize the important role that a simple, 10-cent diagnostic test can play in increasing women’s access to family planning.

Names in this blog were changed. The quotation comes from an interview conducted as part of a study in Rwanda examining reasons for non-use of contraception.

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