Opinions, Attitudes, and Prescribing Practices of Oral Contraceptive Pills of General Practitioners and Gynecologists in India

Introduction

India was one of the first countries to have launched the National Family Welfare Program (NFWP) in 1952, which aimed to reduce birth rates as a part of the First Five Year Plan (1951–56). The NFWP has since grown and undergone significant transitions especially in terms of financial investment, geographic reach and access, quality of services, and the range of contraceptive methods offered. Consequently, the national total fertility rate, which used to be as high as 3.2 in 2000 decreased to 2.3 in 2016. However, contraceptive choice remains limited, thereby restricting last mile coverage of the unmet need for family planning.

The family planning program currently offers seven contraceptive methods: six methods for spacing—condoms (for both males and females), oral contraceptive pills and emergency contraceptive pills (OCPs and ECPs), intra-uterine contraceptive device, injectable contraceptives, lactational amenorrhea method, and the standard days method, and permanent method for limiting—sterilization (vasectomy/tubectomy). However, female sterilization remains the most preferred method of contraception by and large, with male sterilization being the lowest. In fact, female sterilization has remained the choice method of contraception for women, in general, and specifically among poorly educated and illiterate women from lower socio-economic strata.¹ Family planning for the vast majority of Indians, therefore, remains female-centric and terminal method centric. Poor utilization of spacing methods leads to health complications resulting in poor maternal and child health.² OCPs contain low doses of two hormones; progestin and estrogen like the natural hormones progesterone and estrogen in a woman's body. Their mechanism of action for contraception is primarily by preventing ovulation. Combined oral contraceptives are also called “the pill,” low-dose combined pills, OCPs, and OCs. Their failure rate is less than one pregnancy per 100 women using OCPs over the first year (3 per 1,000 women), and there is no delay in return of fertility after OCPs are stopped.³ Therefore, OCPs are expected to be a more popular contraceptive, but in India, only 3.1% of married women in reproductive age (15–49 years) use this method.⁴

A systematic view of the factors that influence access to and uptake of various methods of contraception necessitates the understanding of both client and provider perspectives. Although providers are essential partners in service programs, their perspectives have received remarkably little attention. Client–providers interactions have been found to be a major factor in clients' subsequent uptake of contraception. Not only do the providers' technical skills and knowledge affect service, but their opinions, attitudes, and advice strongly influence what services clients receive and their clients' subsequent behavior.⁵ As the literature about the provider's perspective is sparse and both gynecologists and general practitioners have unique opportunities to provide family planning, there is a strong need to study their opinions, attitudes, and prescribing behavior for OCPs. Therefore, this study was planned with objectives:

• to study OCP prescription behavior among gynecologists, general medical practitioners (GMPs), and alternative medicine practitioners (AMPs) of a large capital city Lucknow (population 4 million), and

• to develop strategies of popularizing the use of OCP in India both from provider's and end user's perspectives by provider's cross-sectional survey of availability, unmet needs of the users, perceived barriers, qualitative research, and focus group interviews of providers, married, and unmarried users.

Materials and Methods

• Study design: This was a cross-sectional survey.

• Settings and study participants: Gynecologists, general practitioners, and practitioners of other systems of medicine, practicing in Lucknow city were included in the study.

• Study period: The duration of the study was from September 2012 to April 2014.

• Sampling and sample size: Stratified sampling procedure was adopted to include gynecologists, general practitioners, and practitioners of other systems of medicine. The sample size was estimated for descriptive studies. As there were no data available, a proportion of 50% providers was assumed to have greater than 75% score (third quartile median score) toward prescribing OCP. Accepting the type I error equal to 0.05 and expecting the absolute precision equal to 5%, a sample size of 384 was calculated. Approximately, 400 providers from each group of gynecologists, general practitioners, and AMPs were considered the appropriate number of subjects for the study.

• Data collection instrument: The study used a questionnaire as a tool to record opinion, attitude, and practices of the prescriber. A questionnaire with a total of 25 close-ended questions and five open-ended questions was finalized after pilot testing on 20 subjects. Test–retest reliability and inter-observer reliability displayed more than 85% agreement.

• Data collection process: A list of gynecologists, private practitioners, and practitioners of other systems of medicine were obtained from various hospitals including King George Medical University (KGMU) Hospital, Lucknow, Indian Medical Association, Associations of Private Gynaecologists, Lucknow, Nursing Home Association, and practitioners working in Lucknow and nearby areas. Gynecologist and private practitioners, women practitioners, qualified practitioners of Unani, Homeopathy, and Ayurveda (AYUSH) in government hospitals, clinics, and private practice both in urban and rural Lucknow were included. Subjects and responders were mostly busy doctors and had to be visited several times. Block filling of the questionnaire was also used at a time of conferences and meetings of the above associations. Several visits were made to the clinics of doctors after prior appointments, and, in some cases, impromptu drop-ins at their clinics were also employed for collecting data. Thus, overall, this data collection was a sampling of convenience; however, the objectives and study outcomes are unlikely to be biased by this method of sampling.

• Statistical analysis: Descriptive statistics are presented as counts and percentages for categorical variables. The chi-square test was used to test differences among different groups. IBM-SPSS-21 Software was used for statistical analysis. For open-ended questions, themes were identified, categorized, and presented as counts and percentages.

• Ethics issues: The study protocol was approved by the Institutional Human Ethics Committee of KGMU Lucknow. All data collection was done after obtaining written informed consent from the participant.

Results

A total of 1,500 participants were contacted of which 1,237 responded, therefore giving a response rate of 82.46%. Out of these, 1,200 filled the questionnaires fully and were included in analysis. This included 400 respondents from each of the three groups, viz obstetrics and gynecologists (ObGy) (group-1), GMPs (group-2), and AMPs (group-3). This was intentionally done, to keep the numbers same across the groups and achieve the minimum sample size. All group-1 respondents were at least MBBS and Masters or Diploma holders in Gynecology and Obstetrics. In group-2, 144 of the respondents were MD or had completed some other postgraduate qualification. All group-3 respondents were qualified practitioners who had received a bachelor's degree in one of the branches of AYUSH, viz, Bachelor of Homeopathic Medicine and Surgery, Bachelor of Ayurvedic Medicine and Surgery, or Bachelor of Unani Medicine and Surgery.

Distribution of females among three groups was 10.7, 0.5, and 12.1%.

Table 1 summarizes respondents' opinions and attitudes about OCP utility and their readiness for its prescription to their clients. ►Table 2 shows OCP prescription practices and opinions regarding correct practices. ►Fig. 1 depicts respondents' first preference of contraception for married and unmarried women. ►Table 3 summarizes attitudes and practices of respondents toward OCP promotion. ►Table 4 highlights themes about perceived OCP prescription barriers among respondents.

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Fig. 1

(A, B) First preference contraceptives for married and unmarried women.

Export to PPT

OCPs or contraceptive methods directly or indirectly reduce unwanted pregnancies and, thereby, reduce the risk of abortion and birth-related morbidity and mortality.² Overall, AMPs and GMPs had less favorable opinions toward advantages of OCPs in comparison to gynecologists. Most of the AMPs, GMPs, and some of the gynecologists also opined that the liberal use of OCPs would lead to increased sexual activity. More than two-thirds of AMPs and GMPs were unaware of the availability of OCPs in urban and rural areas. Only one-thirds of AMPs and GMPs advocated for easy accessibility of OCPs, while most of the gynecologists favored easy accessibility (►Table 2).

World Health Organization (WHO) and various national guidelines have advocated contraceptive counseling using the “GATHER” approach and after thorough history taking and examination.³ However, AMPs and GMPs seem to be hesitant in doing so since more than half of them thought that thorough examination and history taking are not necessary for all women being considered for OCPs and they do not usually counsel to everybody. A less favorable attitude of AMPs and GMPs is also reflected in their OCP prescription practices, wherein more than one-third of them do not readily prescribe OCPs and their prescription is casual or even only verbal (mentioning the brand name) (►Table 3).

All three groups of respondents majorly chose to go with barrier contraception and did not prefer OCPs for either married or unmarried women (►Fig. 1).

Information regarding missed pills and side effects is given during counseling by only one-third of AMPs and GMPs and by most of the gynecologists. More than half of the respondents opined about the positive impact of information about side effects on OCP usage. Proper follow-up and thorough history taking and examination of OCP users are expected for the long-term continuation of OCPs. However, about two-thirds of AMPs and GMPs did not call clients for follow-up visits. Overall, gynecologists were found to be more alert about pill counseling, history taking, examination, explaining side effects, asking for follow-up, and in opportunistic scrutiny for the usage of OCPs and their examination (►Table 3).

Most of the participants were eager to update their knowledge about OCPs through various sources like mainly medical representatives (MRs) for AMPs and GMPs, and MRs as well as continuing medical education for gynecologists. More than half of AMPs and GMPs were reluctant to use posters, while three-fourth of gynecologists displayed them strategically. Most of the participants advocated all kinds of communication modes like print and multimedia for spreading the knowledge of OCPs and also endorsed the need for training of all health workers in OCP use and management. Two-third of gynecologists felt that prescriptions for longer durations such as 3 months instead of 1 month will help in improving compliance and reducing costs. Respondents had a mixed opinion regarding the strategy of distributing OCPs in the unnamed package to increase its acceptability and usage in rural areas, orthodox communities, and sexually active adolescents. Only half of the respondents favored joint sessions of sex education and OCP promotion.

Discussion

Our study shows less favorable attitudes and opinions and sub-optimal practices regarding OCP prescription among AMPs and GMPs. However, gynecologists have more favorable attitudes and most of them adhere to the standards of practice for OCP prescription.

Our study shows that AMPs and GMPs undermine direct and indirect non-contraceptive benefits of OCPs and it gets reflected in their lesser willingness and actual practice of ready prescription of OCPs. There were distinct differences regarding the knowledge of OCP prescription protocols among gynecologists and other practitioners. It is a known fact that knowledge improves attitudes which, in turn, influence practice. Other investigators have also reported that when compared with other specialists, gynecologists are more likely to prescribe OCPs as compared with GMPs.^6,7,8

We have found inconsistencies in practices like not providing counseling to all users, informing about missed pills only on demand, not asking everyone to come to follow-up, not carefully assessing history at follow-up, and not performing opportunistic screening for OCP usage. Using standardized checklists and formats as envisaged in WHO Family Planning Global Handbook for Providers would facilitate the adoption of uniform practices.³

OCPs are cost-effective, reversible, and safe choices both for married and unmarried women. However, it still is not a popular mode among users of contraception, which was reflected in our study. Most of our study participants did not consider it as the first preference for contraception. This could be explained with perceived out-of-proportion apprehensions of providers for side effects, necessity of strict compliance, and regular follow-up. Hamani et al have reported similar misconceptions regarding OCPs among users and prescribing physicians.^9,10 These misconceptions regarding side effects, breakthrough bleeding, compliance, and failure rates might be playing a role in reducing OCP preference in both providers and clients.

Our study respondents particularly gynecologists advocated continuous prescription for 3 months instead of 1 month for improving compliance and reducing cost. Some studies which have explored OCP compliance over a long time suggest that prolonged adherence to OCP regimes is threatened by the same factors which derail other long-term therapeutic medications—demographic factors, costs, and side effects. On the contrary, increased compliance and adherence were seen in women who designated a daily time slot for consuming OCPs.¹¹ However, long-term prescription for OCPs has been found to be more affordable than monthly prescriptions.¹² These studies, however, explore uptake and adherence to OCPs in different (western) socio-cultural and economic contexts. In countries like India where contraception uptake is tied to socio-cultural norms and government facilities provide OCPs almost free of cost, factors that govern poor consumption of OCPs need to be explored.¹³ The strategy to distribute OCPs in unnamed packages elicited mixed responses. Our respondents unanimously agreed on the need to train all health workers on OCP prescription, usage, and management. Currently, medical officers, staff nurses, auxiliary nurse midwives, and accredited social health activists working in government-run health centers are periodically trained in family welfare programs. Private hospitals also employ many paramedics and they can be engaged in counseling, follow-up, and promotion of contraception methods to ease the workload of private practitioners. Therefore, mechanisms for the training of these paramedics from the private sector need to be evolved, which would definitely increase the quality of care in OCP prescription and management.

Conclusion

Opinions and attitudes of AMPs and GMPs are less favorable toward OCP usage, and their prescription practices are suboptimal as well. This is despite the fact that the government of India is trying to promote OCP usage through intensive mass media and national guidelines. This can be improved by developing public–private partnership and imparting targeted training to them, via the use of specific service guidelines, which may lead to increased adherence to standard prescription practices among gynecologists, in turn increasing the preference for OCPs in married and unmarried women.

Compliance with Ethical Standards

The study was conducted as part of the Indian Council of Medical Research project, and complete adherence to prescribed ethical standards was followed including institutional ethical clearance and informed consent of all participants.