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Original Article
58 (
1
); 27-37
doi:
10.1055/s-0041-1740924

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

Department of Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
Department of Surgery, King George's Medical College, Lucknow, Uttar Pradesh, India
Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
Department of Community Medicine, All India Institute of Medical SciencesA, Bhopal, Madhya Pradesh, India
Department of Statistics, Lucknow University, Uttar Pradesh, India
Department of Pharmacology, King George's Medical University, Lucknow, Uttar Pradesh, India
Community Empowerment Lab, Lucknow, Uttar Pradesh, India
Address for correspondence Sandeep Kumar, MS, FRCS, PhD, MMSc, Department of Surgery, King George's Medical University, B 52, J Park, Mandir Marg, Mahanagar, Lucknow, 226 006 Uttar Pradesh, India (e-mail: profsandeepsurgeon@gmail.com).
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This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Disclaimer:
This article was originally published by Thieme Medical and Scientific Publishers Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Background

To study the prescription behavior of oral contraceptive pills (OCPs) by physicians, gynecologists, and alternative medicine practitioners (AMPs).

Materials and Methods

Close-ended questionnaire-based cross-section study was performed between 1st September 2012 and 28th February 2014 in three groups of responders, i.e., AMP, general medical practitioners (GMPs), and obstetricians and gynecologists (ObGy). A stratified random cluster sample was used. Data of 400 subjects in all three groups were obtained using both univariate and multi-variate sophisticated statistical analyses for analyzing attitude and practices and were recorded on an ordinal scale using appropriate non-parametric test.

Results

Of the 1,237 subjects surveyed, 400 completed questionnaires were received from each of the three groups viz; AMPs, GMPs, and ObGy. Remaining 37 incomplete questionnaires were not included in the final analysis.

Conclusion

There are equal misconceptions regarding OCPs among users and prescribing physicians. Preference for OCPs in married and unmarried women is also equally low. OCP usage and their prescription practices can be improved by removing potential barriers, developing public–private partnership, and training promoters.

Keywords

oral contraceptive pills
birth rates prescribing behavior
general practitioners
gynecologists

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.

Table 1 Opinions and attitude about OCP utility and readiness for prescription
Variable Alternative medical practitioners General medical practitioners Obstetrics and gynecologist p-Value
n % n % n %
Impact on maternal and infant mortality rates by spreading the knowledge of OCP
MMR and IMR will increase 14 3.50 11 2.80 7 1.80 <0.001
Hardly any change 23 5.80 29 7.30 22 5.50
Some decrement in MMR but not on IMR 69 17.30 49 12.30 21 5.30
Definitely MMR and IMR will decrease but not only with OCPs 129 32.30 136 34.00 95 23.80
OCP will play a major role in decreasing MMR and IMR 165 41.30 175 43.80 255 63.80
Liberal prescription of OCP will help in the reduction of abortion-related morbidity
No effect 21 5.30 22 5.50 7 1.80 <0.001
Reduction in urban clients 46 11.50 30 7.50 9 2.30
Reduction in literate clients 75 18.80 72 18.00 22 5.50
Reduction in all women 90 22.50 105 26.30 32 8.00
Yes, significant reduction in abortion-related morbidity and its complication in women 168 42.00 171 42.80 330 82.50
Liberal prescription of OCP will support liberal sexual activity
Yes, definitely in women of every age group 73 18.30 63 15.80 55 13.80 <0.001
Yes, significantly in literate women 39 9.80 74 18.50 32 8.00
Partially in literates 97 24.30 96 24.00 33 8.30
Partially in adolescents 68 17.00 85 21.30 36 9.00
No effect. It is happening any way with or without OCP 123 30.80 82 20.50 244 61.00
Availability of OCP in rural and urban areas
Poor availability 65 16.30 54 13.50 23 5.80 <0.001
Available at chemist shop only 110 27.50 104 26.00 31 7.80
Available free of cost at urban health setup with limited supply but not available in rural areas 52 13.00 78 19.50 49 12.30
Readily available in urban health setup but not in rural and remote areas 56 14.00 57 14.30 92 23.00
Readily available free of cost both in urban, rural, and remote areas 117 29.30 107 26.80 205 51.30
Agreeing to accessibility of contraceptive methods to all women
Not so readily 55 13.75 26 6.50 15 3.80 <0.001
Only if they demand 183 45.75 128 32.10 39 9.80
Only to married women 47 11.75 24 18.50 34 8.50
All types to contraception readily available 79 19.75 107 26.80 146 36.50
All contraception should be actively promoted 36 9.00 64 16.00 166 41.50

Abbreviations: IMR, infant mortality rate; MMR, maternal mortality rate; OCP, oral contraceptive pills.

Table 2 OCP prescription practices and opinions about correct practices
Variable Alternative medical practitioners General medical practitioners Obstetrics and gynecologist p-Value
n % n % n %
Is history taking and internal pelvic examination important before prescribing oral contraceptive pill?
No, not necessary 129 32.30 119 29.80 10 2.50 <0.001
Yes, if patient have some complaint 106 26.50 91 22.80 13 3.30
Yes, only history taking is good enough 30 7.50 63 15.80 21 5.30
Yes, both history taking and pelvic examination in high-risk patient only 52 13.00 57 14.30 91 23.80
Yes, both are mandatory 83 20.80 70 17.50 261 65.30
Is pill counseling essential before prescribing OCP?
Not essential 50 12.50 39 9.80 4 1.00 <0.001
Only when patient insists 64 16.00 32 8.00 7 1.80
It is optional 67 16.80 51 12.80 24 6.00
Only in high-risk patient 26 6.50 24 6.00 23 5.80
Always essential 193 48.30 254 63.50 342 85.50
Prescribing oral contraceptive pill
Not so readily 65 16.30 121 30.30 7 1.80 <0.001
Avoid due to side effect 96 24.00 65 16.30 14 3.50
Depends on the type of client 184 46.00 132 33.00 188 47.00
Most of times 43 10.80 63 15.80 112 28.00
Easily prescribe 12 3.00 19 4.80 79 19.80
Pill counseling practice
Never 19 4.80 51 12.80 5 1.30 <0.001
If client demands 116 29.00 85 21.30 21 5.30
Occasionally 91 22.80 59 14.80 12 3.00
Most of times 100 25.00 131 32.80 137 34.30
Never prescribe OCP without counseling 74 18.50 74 18.50 225 56.30
Providing information for missed pills
No 57 14.30 53 13.30 4 1.00 <0.001
In missed pills only 76 19.00 48 12.00 22 5.50
If client demand 97 24.30 68 17.00 10 2.50
Educating client 9 12.30 75 18.80 31 7.80
To all with pill counseling 121 30.30 156 39.00 333 83.30
How do you prescribe OCP
Casually do 129 32.30 119 29.80 10 2.50 <0.001
Verbalize and take a commercial name 106 26.50 91 22.80 13 13.30
Write it and ask assistance to explain its use 30 7.50 63 15.80 21 5.30
Write it and thoroughly explain its use 52 13.00 57 14.30 95 23.80
Carry out check-up and do counseling with written prescription 83 20.80 70 17.50 261 65.30
Advice of side effect of OCP to user
Simply mention SE 133 33.30 90 22.50 22 5.50 <0.001
Hand over written information of SE in vernacular 34 8.50 29 7.30 11 2.80
Exclude high-risk clients and explain SE without over-emphasizing 25 6.30 27 6.80 34 8.50
Emphasize SE to all clients 123 30.80 125 31.30 67 16.80
Emphasize SE to OCP prescription user 85 21.30 129 32.30 266 66.50
Impact of OCP on family planning after explaining its side effect
Negative impact 20 5.00 10 2.50 12 3.00 <0.001
Negative impact in illiterates and less educated 72 18.00 57 14.30 25 6.30
No impact 73 18.30 67 16.80 34 8.50
Insignificant impact 40 10.00 62 15.50 31 7.80
Positive impact 195 48.80 204 51.00 298 74.50
Follow-up of patients after prescribing oral contraceptive pill
Do not call patient for follow-up 72 18.00 91 22.80 1 0.30 <0.001
Seldom call if patient have problem 189 47.30 133 33.30 48 12.00
Regularly at 6 months 41 10.30 50 12.50 31 7.80
Regularly at 3 months 36 9.00 77 19.30 75 18.80
First in third month, second at sixth month, and then annual follow-up 62 15.00 49 12.30 245 61.30
Usual follow-up practice in OCP user client
History of side effect only 255 63.80 277 69.30 46 11.50 <0.001
History and IPE 8 2.00 5 1.30 12 3.00
History, IPE, and BP 52 13.00 46 11.50 31 7.80
History, BP, IPE, and breast examination 42 10.50 28 7.00 103 25.80
History, BP, IPE, breast examination, and PAP smear 43 10.80 44 11.00 208 52.00
In gynecological consultation other than contraception practice, what do you do if the patient is using OCP?
Consider OCP 70 17.50 43 10.80 2 0.50 <0.001
Casually listen and do not take interest 28 7.00 21 5.30 11 2.80
Thorough history of OCP usage 146 36.50 167 41.80 42 10.50
Thorough history of OCP usage and do physical examination 72 18.00 100 25.00 108 27.00
Thorough history, do physical examination, PAP smear, IPE, and reinforce continue usage of OCP 84 21.00 69 17.30 237 59.30

Abbreviations: BP, blood pressure; IPE, internal pelvic examination; OCP, oral contraceptive pills; PAP smear, Papanicolaou smear; SE, side effect.

Table 3 Attitude and practices for OCP promotion
Variable Alternative medical practitioners General medical practitioners Obstetrics and gynecologist p-Value
n % n % n %
Update oneself with recent guidelines for OCP prescription
Do not require 41 10.30 32 8.00 4 1.00 <0.001
MRs 132 33.00 82 20.50 27 6.80
Colleagues and peers 30 7.50 46 11.50 13 3.30
News, publications, print media, and conferences 89 22.30 86 21.50 66 16.50
CMEs, MRs, colleagues, peers, news, etc. 108 27.00 154 38.50 290 75.50
Use of posters of OCP for promotion
Not take care, let it languish 18 4.50 9 2.30 0 0.00 <0.001
Casually put it 92 23.00 90 22.50 18 4.50
Put in my chamber 94 23.50 90 22.50 28 7.00
Put it both in my chamber and patient waiting lounge 75 18.80 91 22.80 161 40.30
Choose the most important one for display 121 30.30 120 30.00 193 48.30
Methods to spread knowledge of OCP usage
Newspaper, booklets 33 8.30 19 4.80 5 1.30 <0.001
TV advertisement and radio 54 13.50 36 9.00 14 3.50
Group discussion 35 8.80 43 10.80 19 4.80
One-to-one counseling 32 8.00 15 3.80 11 3.50
All of above 246 61.50 287 71.80 351 87.80
No, waste of money 70 17.50 45 11.30 12 3.00 <0.001
Not significantly 110 27.50 114 28.50 47 11.80
Improved continuation at a higher cost of dispensing 58 14.50 87 21.80 36 9.00
Reduce drop outs without affecting cost of dispensing 54 13.50 69 17.30 74 18.50
Improved continuation with lower cost of dispensing 108 27.00 85 21.30 231 57.80
Decrease OCP usage 17 4.30 29 7.30 8 2.00 <0.001
Cannot say 168 42.00 123 30.80 73 18.30
No significant effect 78 19.50 120 30.00 81 20.30
Significant effect on increasing OCP usage 51 12.80 67 16.80 96 24.00
OCP should be available in camouflage packets 86 21.50 61 15.30 142 35.50
Not necessary 8 2.00 9 2.30 3 0.80 <0.001
Only if they are interested 48 12.00 29 7.30 10 2.50
Only female health workers 70 17.50 44 11.00 19 4.80
Compulsory to female and optional to male workers 89 22.30 97 24.30 53 13.30
All health workers 185 46.30 221 55.30 315 78.80
No, OCP have nothing to do with sex education 38 9.50 9 2.30 3 8.00 <0.001
Yes, only as method of contraception 66 16.50 47 11.80 41 10.30
Yes and would emphasize on other methods of contraception too 60 15.00 58 14.50 26 6.50
Definitely and will verbally provide information on OCP usage 122 30.50 178 44.50 95 23.80
Educate about OCP usage by written information 114 28.50 108 27.00 235 58.80

Abbreviations: CME, continuing medical education; MR, medical representative; OCP, oral contraceptive pills.

Table 4 Themes about OCP prescription barriers—open-ended question analysis
Obstetrics and gynecologist General practitioners Practitioners of alternative medicine
Q26 Barriers in prescribing OCPs Social barriers, high cost.
Compliance and side effects.
Logistic barrier, lack of awareness, and education.
No barriers.
Social, custom, and logistic barriers.
Compliance and
side effects.
Improper counseling and
practice barriers.
No barrier
Compliance and logistic barriers.
Side effect and lack of information.
Custom and practice barriers
Q27 Major drawbacks of present-day OCPs Breakthrough bleeding and side effects.
Missed pill and daily intake.
Improper counseling and lack of education.
High cost.
Not easily accessible.
Poor compliance, side effects, and daily intake.
No drawbacks.
High cost and lack of availability.
Side effects
No drawback.
Lack of education and awareness, high cost, and poor availability.
Q28 Switching from one type of contraception to OCPs Breakthrough bleeding, compliance, and side effects.
Never.
Sometimes if patient demands.
Never.
Poor compliance.
Depends on patients.
Not frequently.
OCP is not a perfect method of contraception.
Never.
If patient demand.
Q29 Fears/doubts in your mind in prescribing OCPs Breakthrough bleeding, compliance, and side effects.
No doubts.
Missed pill, daily intake, and poor follow-up. Interference in the natural process
No fear.
Side effect.
Patient compliance, poor availability, and failure of OCP.
No doubts.
Side effect.
Lack of education and awareness.
Q30 Free and frank opinion on liberal use of OCP Free is usage recommended on medical ground after proper counseling, education, and follow-up to prevent unwanted pregnancy.
Should be made readily available.
Free usage in a monogamous relationship but not helpful in preventing sexually transmitted diseases.
Free usage will help in reducing MMR and IMR.
Apart from OCP other barrier methods should also be used.
Free usage or liberal use of OCP must be encouraged after proper counseling, education, and awareness after medical examination and on medical prescription, which can help in population control.
Free usage can lead to more liberal sex; therefore, free usage is not recommended.
Encouragement of good-quality OCP for liberal use to prevent unwanted pregnancies and control population under strict medical prescription and education.
Liberal usage of OCP can lead to its misuse.

Abbreviations: IMR, infant mortality rate; MMR, maternal mortality rate; OCP, oral contraceptive pills.

Fig. 1
(A, B) First preference contraceptives for married and unmarried women.

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.

Author Contributions

S.K. conceived the study, wrote the research proposal, and was the principal investigator. V.D. with the help of all other authors designed and tested the questionnaire, conducted the survey, and computed the data. Y.P. provided the technical and clinical inputs. G.G. and A.P. did the statistical analyses. A.P. facilitated and provided inputs in content validity and logistics of data collection.

Conflict of Interest

V.D. received a salary as a research officer from the ICMR. The other authors report no conflict of interest.

Funding

The above work was supported by an ad hoc research scheme funded by the Indian Council of Medical Research –ICMR, New Delhi (Ref No.: 5/10/12/2009-RHN). The work of S.K. was funded as a research project by the ICMR.

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