CC BY-NC-ND 4.0 · Ann Natl Acad Med Sci 2022; 58(01): 027-037
DOI: 10.1055/s-0041-1740924
Original Article

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

Sandeep Kumar
1   Department of Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2   All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
,
Varsha Dwivedi
3   Department of Surgery, King George's Medical College, Lucknow, Uttar Pradesh, India
,
Yashodhara Pradeep
4   Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
,
Abhijeet Pakhare
5   Department of Community Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
,
Girdhar Gopal Agrawal
6   Department of Statistics, Lucknow University, Uttar Pradesh, India
,
Anil Kumar Saksena
7   Department of Pharmacology, King George's Medical University, Lucknow, Uttar Pradesh, India
,
Vishwajeet Kumar
8   Community Empowerment Lab, Lucknow, Uttar Pradesh, India
› Author Affiliations
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.
 

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.


#

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.


Zoom Image
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.


#
#

Conflict of Interest

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

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.


  • References

  • 1 Singh P, Singh KK, Singh P. Factors explaining the dominion status of female sterilization in India over the past two decades (1992-2016): a multilevel study. PLoS One 2021; 16 (03) e0246530
  • 2 Family Health International. India Brief 1- the status of family planning in India: an introduction. Accessed June 10, 2021 at: https://www.fhi360.org/sites/default/files/media/documents/india1-family-planning-status.pdf
  • 3 WHO. | Family planning - a global handbook for providers. WHO. Accessed August 23, 2021 at: http://www.who.int/reproductivehealth/publications/fp-global-handbook/en/
  • 4 International Institute for Population Sciences (IIPS) and Macro International. NFHS-3 Fact Sheet. 2009 . Accessed June 10, 2021 at: http://rchiips.org/nfhs/pdf/India.pdf
  • 5 Calhoun LM, Speizer IS, Rimal R. et al. Provider imposed restrictions to clients' access to family planning in urban Uttar Pradesh, India: a mixed methods study. BMC Health Serv Res 2013; 13 (01) 532
  • 6 Sulak PJ, Buckley T, Kuehl TJ. Attitudes and prescribing preferences of health care professionals in the United States regarding use of extended-cycle oral contraceptives. Contraception 2006; 73 (01) 41-45
  • 7 Seval DL, Buckley T, Kuehl TJ, Sulak PJ. Attitudes and prescribing patterns of extended-cycle oral contraceptives. Contraception 2011; 84 (01) 71-75
  • 8 Wiegratz I, Galiläer K, Sänger N, Rody A, Kuhl H, Schleussner E. Prescribing preferences and personal experience of female gynaecologists in Germany and Austria regarding use of extended-cycle oral contraceptives. Eur J Contracept Reprod Health Care 2010; 15 (06) 405-412
  • 9 Yang X, Li X, Wang Y, He X, Zhao Y. Practices and knowledge of female gynecologists regarding contraceptive use: a real-world Chinese survey. Reprod Health 2018; 15 (01) 115
  • 10 Hamani Y, Sciaki-Tamir Y, Deri-Hasid R, Miller-Pogrund T, Milwidsky A, Haimov-Kochman R. Misconceptions about oral contraception pills among adolescents and physicians. Hum Reprod 2007; 22 (12) 3078-3083
  • 11 Choi A, Dempsey A. Strategies to improve compliance among oral contraceptive pill users: a review of the literature. Open Access J Contracept 2014; 5: 17-22
  • 12 Judge-Golden CP, Smith KJ, Mor MK, Borrero S. Financial implications of 12-month dispensing of oral contraceptive pills in the veterans affairs health care system. JAMA Intern Med 2019; 179 (09) 1201-1208
  • 13 Ghule M, Raj A, Palaye P. et al. Barriers to use contraceptive methods among rural young married couples in Maharashtra, India: qualitative findings. Asian J Res Soc Sci Humanit 2015; 5 (06) 18-33

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   

Publication History

Article published online:
30 December 2021

© 2021. National Academy of Medical Sciences (India). 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/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Singh P, Singh KK, Singh P. Factors explaining the dominion status of female sterilization in India over the past two decades (1992-2016): a multilevel study. PLoS One 2021; 16 (03) e0246530
  • 2 Family Health International. India Brief 1- the status of family planning in India: an introduction. Accessed June 10, 2021 at: https://www.fhi360.org/sites/default/files/media/documents/india1-family-planning-status.pdf
  • 3 WHO. | Family planning - a global handbook for providers. WHO. Accessed August 23, 2021 at: http://www.who.int/reproductivehealth/publications/fp-global-handbook/en/
  • 4 International Institute for Population Sciences (IIPS) and Macro International. NFHS-3 Fact Sheet. 2009 . Accessed June 10, 2021 at: http://rchiips.org/nfhs/pdf/India.pdf
  • 5 Calhoun LM, Speizer IS, Rimal R. et al. Provider imposed restrictions to clients' access to family planning in urban Uttar Pradesh, India: a mixed methods study. BMC Health Serv Res 2013; 13 (01) 532
  • 6 Sulak PJ, Buckley T, Kuehl TJ. Attitudes and prescribing preferences of health care professionals in the United States regarding use of extended-cycle oral contraceptives. Contraception 2006; 73 (01) 41-45
  • 7 Seval DL, Buckley T, Kuehl TJ, Sulak PJ. Attitudes and prescribing patterns of extended-cycle oral contraceptives. Contraception 2011; 84 (01) 71-75
  • 8 Wiegratz I, Galiläer K, Sänger N, Rody A, Kuhl H, Schleussner E. Prescribing preferences and personal experience of female gynaecologists in Germany and Austria regarding use of extended-cycle oral contraceptives. Eur J Contracept Reprod Health Care 2010; 15 (06) 405-412
  • 9 Yang X, Li X, Wang Y, He X, Zhao Y. Practices and knowledge of female gynecologists regarding contraceptive use: a real-world Chinese survey. Reprod Health 2018; 15 (01) 115
  • 10 Hamani Y, Sciaki-Tamir Y, Deri-Hasid R, Miller-Pogrund T, Milwidsky A, Haimov-Kochman R. Misconceptions about oral contraception pills among adolescents and physicians. Hum Reprod 2007; 22 (12) 3078-3083
  • 11 Choi A, Dempsey A. Strategies to improve compliance among oral contraceptive pill users: a review of the literature. Open Access J Contracept 2014; 5: 17-22
  • 12 Judge-Golden CP, Smith KJ, Mor MK, Borrero S. Financial implications of 12-month dispensing of oral contraceptive pills in the veterans affairs health care system. JAMA Intern Med 2019; 179 (09) 1201-1208
  • 13 Ghule M, Raj A, Palaye P. et al. Barriers to use contraceptive methods among rural young married couples in Maharashtra, India: qualitative findings. Asian J Res Soc Sci Humanit 2015; 5 (06) 18-33

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