1 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Madhur Verma
1 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kiranjit Kaur
1 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kirti Iyengar
2 United Nations Population Fund, New Delhi, India
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Tarundeep Singh
1 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Anju Singh
3 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Charles A. Ameh, Editor
Disclaimer
1 Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 United Nations Population Fund, New Delhi, India
3 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Liverpool School of Tropical Medicine, UNITED KINGDOM
Competing Interests: The authors have declared that no competing interests exist.
¤Current address: Department of Community & Family Medicine, All India Institute of Medical Sciences, Bathinda, Punjab, India.
* E-mail: moc.liamg@12atpuguhdam
Received 2019 Jan 7; Accepted 2019 Oct 21.
Copyright © 2019 Gupta et al
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Associated Data
S1 File: Study tool on assessing the knowledge and skills of the interns and nurses and training status regarding family planning methods. [DOCX]
pone.0211168.s001.docx [36K]
GUID: C49DBE53-8D21-45E9-B1B0-35B3747CBC43
S2 File: Study tool on assessing the practices of family planning [FP] and reproductive health [RH] services in the medical colleges. [DOCX]
pone.0211168.s002.docx [20K]
GUID: 6B1BB9DA-1464-4A6B-A1C9-1B8CA5D900D3
S3 File: Hindi Version of Study tool on assessing the knowledge and skills of the interns and nurses and training status regarding family planning methods. [DOCX]
pone.0211168.s003.docx [38K]
GUID: 1B4F6D4A-FB44-47CB-A783-05448EE68341
S4 File: Data analysis plan regarding the categorization of responses as correct, partially correct and wrong responses. [DOCX]
pone.0211168.s004.docx [26K]
GUID: 9F955D24-B876-4236-9BF0-C76D7A00F0A7
S1 Table: Gender based assessment of knowledge regarding various contraceptive methods in each provider category. [DOCX]
pone.0211168.s005.docx [25K]
GUID: 11A0CADE-D30C-47C3-82A8-9F4F950CE768
S2 Table: Age wise assessment of knowledge regarding various contraceptive methods of the study participants. [DOCX]
pone.0211168.s006.docx [21K]
GUID: AA84DC6D-04CF-4CE8-983A-C7312E969C21
S3 Table: Assessment of knowledge regarding various contraceptive methods as per the marital status of the study participants. [DOCX]
pone.0211168.s007.docx [26K]
GUID: 1B1E9E76-7EB4-4B73-92E2-2AEE656298E8
S4 Table: Teaching practices of faculty of Community Medicine and Gynaecology and Obstetrics in the medical colleges related to family planning services. [DOCX]
pone.0211168.s008.docx [19K]
GUID: 52FD7ACC-432B-46BA-980B-F6B40560F03B
S5 Table: Record review and observation of family planning clinics under department of obstetrics and gynaecology or community medicine in the medical colleges. [DOCX]
pone.0211168.s009.docx [19K]
GUID: D8E9A864-1A8F-4757-8E29-DB51F7361789
There are ethical restrictions on sharing the de-identified data set as data contain potentially identifying or sensitive patient information; and PGIMER’s ethics committee has imposed these restrictions. Data access request can be sent to the Convener Ethics Committee, IEC, PGIMER, Chandigarh at moc.liamg@igpcei and corresponding author moc.liamg@12atpuguhdam.
Abstract
Objectives
The objectives of the study were to assess the knowledge and skills of medical interns and nurses regarding family planning [FP] services, and document the prevailing FP practices in the teaching hospitals in India.
Study design
A cross-sectional study was conducted in three states [Delhi, Rajasthan, and Maharashtra] of India, among randomly selected 163 participants, including medical interns [n = 81] and in-service nurses [n = 82], during 2017. The semi-structured, pre-tested interview schedule, was used to assess the knowledge and status of training received; and objective structured clinical examination [OSCE] based checklist was used to evaluate the skills.
Results
About 60% of the interns and 48% of the nurses knew more than five contraceptives that could be offered to the clients. About 22% [11.1% interns and 33.3% nurses] respondents believed that contraceptives should not be given to a married woman coming alone, and 31.9% [17.3% interns and 46.3% nurses] respondents reported that it was illegal to provide contraceptives to unmarried people. Nearly 43.3% interns and 69.5% nurses refused to demonstrate intrauterine contraceptive device [IUCD] insertion in the dummy uterus as per OSCE, and among those who did, 12.3% interns and 18.3% nurses had failed. About 63% interns and 63.4% of nurses had observed IUCD insertion, and 12.3% interns and 17.1% had performed IUCD insertion, during their training.
Conclusions
Knowledge and skills of interns and nurses regarding FP services were inadequate. The medical training during graduation or internship, and during the job, was found to be inadequate to provide quality FP services as per guidelines of nursing/medical council of India and Government of India on FP.
Introduction
Family planning is one of the most critical components of a health service to ascertain effective sexual, reproductive and maternal health outcomes. Global estimates have shown that effective usage of contraception, can prevent 90% of maternal deaths related to unsafe abortions and 20% of overall obstetrics causes of mortality []. This would contribute in achieving the sustainable development goal of reducing the maternal mortality ratio to 70 per 100,000 live births by 2030, and goal 3.7 of ensuring universal access to sexual and reproductive health including family planning services []. However, providing universal access to family planning services requires that family planning workforce [specialist doctors, non-specialist doctors, registered and practitioner nurses, auxiliary nurse midwives, pharmacists, community health workers, etc.] are competent and possess necessary skills to deliver quality family planning services []. It has been documented that family planning services remained a neglected area in many countries, especially in the low and middle-income countries with high unmet need for family planning [,]. For instance, even though the family planning [FP] program was the first national program in India that started in the year 1952, it is the second most populous country in the world [].
FP 2020 is a global partnership between 69 countries to empower women and girls by investing in rights-based FP []. India committed to FP 2020 in 2012 with an aim to provide choice, access, and quality of family planning services []. Since then India has expanded the range and reach of contraceptive options by introducing modern and more effective contraceptive methods and ensuring the availability at all levels of health care delivery system. Currently, FP has been integrated with Reproductive, Maternal, Newborn, Child, and Adolescent Health [RMNCH+A] strategy under the National Health Mission []. FP services are being provided free of cost at over 180000 primary level facilities, more than 6000 secondary level facilities, and over 750 tertiary level facilities, supported by a large pool of accredited private health facilities []. In addition to this, the country’s pool of community health workers like accredited social health activists [ASHAs, n = 900,000] are acting as depot holders for contraceptives, urine pregnancy kits at the village level and ensure adequate spacing between two births. Nurses working in the hospitals and certified auxiliary nurse midwives working at the peripheral health centers are allowed to prescribe the spacing methods like intra-uterine contraceptive devices [IUCDs], injectable contraceptives, oral contraceptive pills [OCPs], condoms and emergency contraceptive pills in addition to the counselling and consenting services. Doctors are trained to prescribe all these spacing methods of contraception as well as perform Minilap, Laparoscopic Sterilization and No-Scalpel Vasectomy [NSV] procedures for permanent sterilization [,].
Despite the concerted efforts, only a minimal improvement has been observed in the family planning [FP] indicators in India. The birth rate had declined from 23.8/1000 mid-year population in 2005 to 20.2/1000 mid-year population in 2017, total fertility rate from 2.7 to 2.2, contraception use rate declined from 56.3% to 53.5%, and unmet need of FP decreased from 13.9 to 12.9[,]. One will observe state wise disparities regarding various FP indicators. The total fertility rate varies from 3.41% in Bihar state to 1.17% in Sikkim state. Similarly, contraceptive use rate ranges from 25.0% in Manipur state to 89.5% in Chandigarh [Union Territory]. Unmet need for contraception also varied from 22.3% in Nagaland to 4.6% in Andhra Pradesh []. Numerous reasons have been cited to explain the slow pace of progress in improvement of FP indicators in India, like the unmet need for contraception, unplanned pregnancy, early marriage and childbearing, low health providers to population ratio, untrained providers, poor quality of available services, irregular supplies, cultural or religious opposition, gender-based barriers and users and providers bias [,,]. There is evidence that the cafeteria approach of providing FP services, where all the available contraceptive methods are offered to the clients with the list of side effects, benefits, and failure rate of each method so as to enable the clients to choose from the menu as per their need and preferences, is not being implemented effectively [,]. This is corroborated by the national family health survey data, round 4 [2015–16], that depicts female sterilization as the commonest contraceptive method used in India []. It may be the case that the service providers are fixed in their minds to provide only certain contraceptive methods to a set of clients [like offering only female sterilization for a woman who has completed her family with 2/3 living children], rather than offering her full basket of choices []. It may also be due to linkage of the financial incentives to the service providers if the permanent methods or long acting reversible contraceptives are chosen []. Uninformed choices lead to unintended pregnancies, lower contraceptive acceptance, and sterilization regrets, which is also a breach of reproductive rights of women []. Barriers that impede access to adequate contraceptives are insufficient number of service providers including the doctors and nurses, inadequate knowledge and skills of the service providers about the family planning services and reproductive rights of the women, poor quality of in-service trainings, and less emphasis on competency and skill-based learning during preservice medical education []. Improved quality of care has a positive correlation with sustained contraceptive usage by the women and meeting the unmet need []. It is, therefore, pertinent for the service providers to have adequate knowledge and skills about the services that they are offering and the reproductive rights of the women[].
As per the Medical Council of India, it is necessary for the medical graduates to undergo a compulsory one-year rotatory internship after the final year to acquire the essential skills required as a doctor that includes delivering FP services and ensuring reproductive rights of the clients. Similarly, Indian Nursing Council ensures uniform standards of training for nurses, including general midwifery and nursing [GNM], auxiliary midwifery, and nursing [ANM] and Bachelor of Science in Nursing [BSc]. They are trained for various FP services skills like counseling of the patients, consent taking, contraceptive prescription and usage techniques including IUCD insertion, condom usage, use of oral contraceptive pills, depot medroxy progesterone acetate [DMPA] injections etc. However, it has been observed that teaching practices in medical and nursing colleges in India are often not evidence-based, and may not align with ever-evolving standard protocols, the national guidelines concerning FP services, or web based Family Planning Training Resources [–]. There is a national training family planning plan for India, however, this is mainly implemented in the public health care delivery system, and medical colleges are generally left out []. The faculty in the medical colleges mostly teach from the standard textbooks and rarely use national level guidelines for teaching. As a result, there is a gap in the quality of FP services delivered by the service providers from the supply side of the chain and meeting the need of these services by the clients from the demand side. Unless we know the extent of this gap and its domains, it will be difficult to intervene effectively. With this background, this study was conducted with the objectives to assess the knowledge and skills of medical interns and nurses regarding FP services and reproductive rights of the women; and to document the prevailing FP practices in the teaching medical facilities in India, so that medical education could be strengthened, and family planning services could be improved.
Methodology
Study area
A cross-sectional study was conducted in three purposively selected states of India, including Delhi, Rajasthan, and Maharashtra, between November and December 2017. As per the census of India 2011, Maharashtra and Rajasthan are amongst the top 10 most populous states of India. As per the fourth round of the National Family Health Survey [2015–16], Rajasthan had low sex ratio at birth [females per 1,000 males] of 887, the infant mortality rate of 41 per 1,000 live births. The quality of FP services being offered is assessed by the facts that the contraceptive usage was 59.7% and an unmet need for FP amongst the currently married women aged between 15–49 years was 12.3% [spacing methods 5.7%]. About 17.5% non-users of contraceptive methods reported that health workers had ever spoken to them about contraceptives. One of the job responsibilities of Auxiliary Nurse Midwives/female accredited social health activists workers in their field area is to counsel the couples who are not using any contraceptives, and thus motivating them to use/adopt any of the available contraceptive methods. The service providers are supposed to counsel the clients of family planning services about the possible side effects of the contraceptive methods except standard days method/lactational amenorrhoea. Nearly 56.5% of current users reported that they were never told about the side effects of the current method[]. In Maharashtra, the sex ratio at birth [females per 1,000 males] was 924, the infant mortality rate of 24 per 1,000 live births. The contraceptive usage was 64.8% and an unmet need for FP amongst the currently married women aged between 15–49 years was 9.7% [spacing methods 5.3%]. Only 18.5% non-users of contraceptive methods reported that health workers ever talked about family planning to them. About 36.3% of current users said that they were told about the side effects of the current method []. While in Delhi, the sex ratio at birth [females per 1,000 males] was 812, the infant mortality rate of 31 per 1,000 live births. The contraceptive usage was 54.9% and an unmet need for FP amongst the currently married women aged between 15–49 years was 15.0% [spacing methods 3.1%]. Only 12% of non-users of contraceptive methods reported that health workers ever talked about family planning to them. Nearly 59.2% of current users reported that they were never told about the side effects of the current method[,].
Study participants
The study participants were medical interns who had passed the final exam of bachelor of medicine and surgery [MBBS], and completed compulsory rotatory training in the department of obstetrics and gynecology; nurses, who were already in the job, with less than 5 years' of experience in the medical college or health posts attached with the medical colleges; and faculty or medical officer-in-charge of FP centre in the department of obstetrics and gynaecology or community medicine.
Sample size and sampling technique
Since no previous information regarding prevalence was available, therefore as a thumb rule [], correct knowledge percentage score of medical interns and nurses regarding FP services was assumed to be 50%, absolute precision as 10% and a design effect of 1.5, the sample size was calculated to be 145 using OpenEpi, version 3, open source calculator []. Assuming a 10% non-response rate, the final sample size is estimated to be 160 [80 interns and 80 nurses]. Multistage simple random sampling technique was used to first select two districts within each study states, and then two medical colleges from the selected districts in the second stage. Private medical colleges were excluded, as it was difficult to get permission from these colleges. Since Delhi did not have districts, two medical colleges were selected randomly within it. However, the approval to conduct the study in one of the medical colleges could not be obtained. Hence, the additional medical college from Maharashtra was selected. In total six medical colleges [one medical college in Delhi, two in Rajasthan and three in Maharashtra] were included in the study. Interns who had fulfilled the inclusion criteria were enlisted, and proportionate number [19, 31 and 31 interns from Delhi, Rajasthan, and Maharashtra] were randomly selected. As per MCI guidelines an intern must have dedicated 15 days posting in family planning clinic[]. Permission to interview nurses could not be obtained from the selected medical college in Delhi. Thirty two nurses from Rajasthan and 50 from Maharashtra were randomly selected.
Prior permission from the respective Dean of the selected medical colleges was obtained who liaised with the project team [a faculty and two postgraduate doctors] and with the faculty coordinating the duties of the interns and nursing superintendent in the respective medical college. The team obtained the list of the interns and nurses as per the eligibility criteria of the study. From this list, the required number of interns and nurses were randomly selected. The list of chosen nurses and interns were given appointments for the interview in a designated place as provided by the coordinating faculty/nursing superintendent of the medical college. After ensuring anonymity, written informed consent was obtained from the participants before the start of the interview.
Study tools and data collection methods
The study tools were semi-structured and pretested. These were of two types, one dealt with assessing the knowledge and skills of the interns and nurses regarding family planning methods; and also about the training they have received during their graduation []; and the second study tool was used to assess the prevailing FP practices in the department of obstetrics and gynecology. []. The first tool had three parts including, a] background information of the participants and knowledge-based questions on contraceptive methods; b] skill assessment using an observation checklist based upon Objective Structured Clinical Examination [OSCE] for demonstration of steps of the intrauterine contraceptive device [e.g., CuT] insertion in a model, condom use on the thumb and use of Medical Eligibility Criteria [MEC] Wheel; and c] FP teaching and observation of training facilities. Information on part a] and b] of the first study tool was obtained from the interns and nurses, and information on part c] was obtained from the faculty of either obstetrics and gynecology or community medicine by face to face interview. []. The information in the second tool was obtained by observing the family planning clinic regarding privacy [visual and auditory] of the clients, record review and stock position of contraceptive methods, and interview of the faculty/medical officer in charge of the FP clinics regarding FP practices. [].
The study tools were developed in consultation with family planning experts from the United Nations Population Fund [UNFPA], faculty from the department of obstetrics and gynecology, department of community medicine and school of public health in Postgraduate Institute of Medical Education and Research [PGIMER], Chandigarh. The content validity was further established by another group of experts from the department of obstetrics and gynecology, PGIMER, Chandigarh. The tools were pretested in the government multi-specialty hospital, sector 16, Chandigarh, among 10% of the total sample size [n = 17] including interns [n = 7] and nurses [n = 10]. It was realized during pretesting of the tool that nurses understand the questions better if they were interviewed in Hindi as compared to the English language, while there was no such issue with the interns, as English was the primary language of teaching in the medical colleges for the interns. Hence, the tool was translated into Hindi [] for the nurses as per the World Health Organisation's translation methodology.[]
Two postgraduate doctors [Doctor of Medicine in Community Medicine and Masters in Public Health] were specially recruited, and trained by the experts [faculty] from obstetrics and gynecology and community medicine department to collect the data. The training of these doctors was done for 15 days, and it aimed at refreshing their knowledge and skills about the various family planning methods, the latest government of India guidelines on contraceptive methods and how to assess the skills as per OSCE. They were also sensitized about the differences in the FP services delivered by different FP workforce [nurses and doctors]. Data collection was regularly supervised by the experts in the study states to ensure data quality.
Data analysis
The responses obtained in different questions were assessed by assigning marks to each part of the question. The marking strategy for individual question is available as supplementary file. []. Full and partial marks were given to the participant on the basis of answers provided by them. Full marks depicted that the participant was able to answer all the points of the answer, partial means that they answered only some parts of an answer, and wrong means that they did not give correct response. Data thus obtained was categorised into ordinal variables. Data was entered and analyzed in Statistical Package for Social Sciences, version 16.0. Proportions were estimated, and differences in proportions between interns and nurses regarding knowledge and skills in respect to use of various contraceptive methods, FP training received were considered significant at a 95% confidence interval. Since we did not estimate the sample size to compare the knowledge and skills of interns/nurses among the three states, hence we did not perform the state wise comparison.
Ethical considerations
Ethical approval was obtained from the primary institute i.e. PGIMER, Chandigarh, India, to conduct the study in all the medical colleges. [PGI/IEC/2017/578]. In addition, ethical approval was obtained individually from ethics committee/institutional review board of two other medical colleges including Grant Medical Colleges, Mumbai and Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune. In the remaining four medical colleges, prior approval of the Head of institution was obtained.
Results
A total of 81 interns and 82 nurses were enrolled in the study from Rajasthan [31 interns, 32 nurses], Maharashtra [31 interns, 50 nurses] and Delhi [19 interns]. All the interns who were interviewed had completed their clinical postings in the department of Obstetrics and Gynaecology. At the time of interview, 74 [91.4%] interns were posted in community medicine department, 3 [3.7%] in surgery and 4 [4.9%] in paediatrics department in their respective medical colleges; and 55 [67%] nurses were posted in the obstetrics and gynaecology department, 24 [29.2%] in surgery [n = 24, 29.2%] and one [1.2%] in intensive care unit. All the nurses had a Bachelor level of qualification i.e. BSc Nursing [n = 30] or GNM [n = 52]. Mean [standard deviation] age of interns were 23.8 [±1.2], and nurses 29.2 [±1.2] years. Males [50.6%] and females [49.3%] were equally represented among interns, while females [66.8%] were more among nurses. [Table 1].
Table 1
Background characteristics of study participants.
CharacteristicsInterns
n = 81 [%; 95% CI]Nurses
n = 82 [%; 95% CI]Total
n = 163 [%; 95% CI]P valueSexMale41 [50.6; 45.0–56.2]13 [15.8;12.2–19.4]54 [33.1;29.4–36.8]0.593Female40 [49.3; 43.7–54.9]69 [84.1; 78.3–89.9]109 [66.8;63.1–70.5]Mean Age [standard deviation]23.8[1.2]29.2[3.3]26.4[3.7]Age group20–2466 [81.5; 77.2–85.8]4 [4.9; 3.1–6.7]70 [42.9;39.0–46.8]0.00024–2915[18.5; 14.2–22.8]45 [54.9; 48.4–61.4]60[36.8;33.0–46.8]30–34030 [36.6; 30.6–42.6]30[18.4;15.4–21.4]> = 3503 [3.6; 1.5–5.7]3[1.8;0.8–2.8]Years of experience< = 1 year81 [100; 100–100]2 [2.4; 1.2–3.6]83[50.9;47.0–54.8]0.0002 years022 [26.8;21.5–32.1]22[13.5;10.8–16.2]3 years016 [19.5;14.9–24.1]16[9.8;7.5–12.1]4 years024 [29.3;23.8–34.8]24[14.7;11.9–17.5]> = 5 years018 [22.0;17.1–26.9]18[11.0;8.5–13.5]Marital statusMarried7 [8.6;5.5–11.7]70 [85.4]77 [47.2;43.3–51.1]0.000Unmarried74 [91.4;88.3–94.5]12 [14.6]86 [52.8;48.9–56.7]StateDelhi* MC119 [23.5;18.8–28.2]019 [11.7;9.2–14.2]RajasthanMC 216 [19.8; 15.4–24.2]16 [19.8; 15.4–24.2]32 [19.6;16.5–22.7]MC 315 [18.5;14.2–22.8]16 [19.8;15.4–24.2]31 [19.0;15.9–22.1]MaharashtraMC 411 [13.6;9.8–17.4]19 [23.5;18.8–28.2]30 [18.4;15.4–21.4]MC 517 [21.0;16.5–25.5]23 [28.4;23.4–33.4]40 [24.5;21.1–27.9]MC 63 [3.7;1.6–5.8]8[9.9; 6.6–13.2]11 [6.7;4.7–8.7]
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* MC: Medical College; p value indicate the statistical significant difference in the proportion of interns and nurses
Knowledge of interns and nurses regarding contraceptive methods
About 60% of the interns and 48% of the nurses could enumerate more than 5 contraceptives from a total of nine methods that are being offered by the government of India through the cafeteria approach including the Spacing Methods; IUCD 380 A and Cu IUCD 375, Injectable Contraceptive Depot Medroxy Progesterone Acetate [Antara Programme], Combined Oral Contraceptive Pill [Mala-N], Centchroman non-steroidal pill [Chhaya], Progesterone-Only Pill [POP], Condoms [Nirodh], Emergency Contraceptive pills; and permanent sterilization methods including female Sterilization [tubectomy/tubal ligation: laparoscopic, Minilap] and male sterilization [no-scalpel vasectomy] [,]. Majority of the respondents thought that condoms [88.3%] and oral contraceptive pills [OCPs] [77.9%] were the best contraceptives for newly married couples. [Table 2]. For a woman with one child, intrauterine contraceptive device [IUCD] [93.4%], and a woman with three children, sterilization [95.8%] was the most common response. About one-fifth of the participants [22%] responded that the contraceptives should not be given to a married woman who was coming alone. Nearly 31.9% [17.3% interns and 46.3% nurses] respondents told that it was illegal to provide the contraceptives to unmarried people.
Table 2
Knowledge of interns and nurses regarding various contraceptive methods and reproductive rights of the clients.
ParametersInterns
n = 81 [%; 95% CI]Nurses
n = 82 [%; 95% CI]Total
n = 163 [%; 95% CI]p-valueContraceptive choices for newly married couple* • Condom74 [91.3; 88.2–94.4]70 [85.3; 81.4–89.2]144 [88.3; 85.8–90.8]0.992 • OCP68 [83.9; 79.8–88.0]59 [71.9; 66.9–76.9]127 [77.9; 74.7–81.1] • POP6 [7.3; 4.4–10.2]6 [7.4;4.5–10.3]11 [6.8;4.8–8.8] • IUCD30 [36.5; 31.2–41.8]30 [36.5; 31.2–41.8]60 [36.8;33.0–40.6] • All1 [1.2; 0–2.4]1 [1.2; 0.0–2.4]2 [1.2;0.3–2.1]Contraceptive choices for the woman with one child • Condom38 [46.9; 41.4–52.3]44 [53.7; 48.2–59.2]82 [50.3; 46.4–54.2]0.460 • OCP44 [54.3; 48.8–59.8]47 [57.3; 51.8–62.8]91 [55.8;51.9–59.7] • POP3 [3.7; 1.6–5.8]9 [11.0; 7.5–14.5]12 [7.4;5.3–9.5] • IUCD75 [92.6; 89.7–95.5]77 [93.9; 91.3–96.5]152 [93.4;91.5–95.3] • All01 [1.2;0.0–2.4]1 [0.6; 0.0–1.2]Contraceptive choices for the woman with 3 children • Condom16 [19.8; 15.4–24.2]21 [25.6;20.8–30.4]37 [22.7; 19.4–26.0]0.907 • OCP15 [18.5; 14.2–22.8]13 [15.8; 11.8–19.8]28 [17.2; 14.2–20.2] • POP1 [1.2; 0.0–2.4]2 [2.4; 0.7–4.1]3 [1.8; 0.8–2.8] • IUCD48 [59.3; 53.8–64.8]50 [61.0; 55.6–66.4]98 [60.1; 56.3–63.9] • Sterilization77 [95.1; 92.7–97.5]79 [96.3; 94.2–98.4]156 [95.8; 94.2–97.4]Can contraceptives be given to a married woman coming alone? • Yes64 [79.0; 74.5–83.4]35 [43.2; 37.7–48.7]99 [61.1; 57.3–64.9]0.000 • Yes, but after asking the family members8 [4.9;2.5–7.3]19 [11.7; 8.2–15.2]27 [16.7; 13.8–19.6] • No9 [11.1;7.6–14.6]27 [33.3; 28.1–38.5]36 [22.2;18.9–25.5]Can contraceptives be given to unmarried women coming alone? • Yes60 [37.0; 31.6–42.4]29 [17.9;13.7–22.1]89 [54.9; 51.0–58.8]0.000 • Yes but after asking the family members7 [8.6;5.5–11.7]11 [13.6; 9.8–17.4]18 [11.1;8.6–13.6] • No10 [12.4;8.7–16.1]42 [51.9; 46.4–57.4]52 [32.1; 28.4–35.8]Is it legal to provide contraceptives to unmarried people • Yes52 [64.2; 58.9–69.5]33 [40.2; 34.8–45.6]85 [52.1; 48.2–56.0]0.000 • No14 [17.3; 13.1–21.5]38 [46.3;40.8–51.8]52 [31.9; 28.2–35.6] • Don’t know15 [18.5;14.2–22.8]11 [13.4; 9.6–17.2]26 [16;13.1–18.9]
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*OCP: Oral Contraceptive Pill; POP: Progesterone Pills; IUCD: Intrauterine contraceptive devices; p value indicates the statistical significant difference in the proportion of interns and nurses regarding their knowledge.
Knowledge of interns and nurses regarding oral contraceptive pills, condoms, and emergency contraceptives is presented in Table 3. Respondents knew the common medical conditions like cardiovascular diseases [41.7%], breast diseases [30%], headache/migraine [25.7%] and thromboembolic disorders [22.1%] to rule out before prescribing OCPs.
Table 3
Knowledge of interns and nurses regarding oral contraceptive pills, condoms, and emergency contraceptives.
ContraceptivesInterns
n = 81 [%; 95% CI]Nurses
n = 82 [%; 95% CI]Total
n = 163 [%; 95% CI]p-valueOral contraceptives Pills [OCPs]Conditions to rule out from history before prescribing OCPs • Smoking10 [12.4; 8.7–16.1]5 [6.1; 3.5–8.7]15 [9.2; 6.9–11.5]0.060 • Diabetes10 [12.4;8.7–16.1]15 [18.3; 14.0–22.6]25 [15.3; 12.5–18.1] • Headaches24 [29.6; 24.5–34.7]18 [21.95; 17.3–26.5]42 [25.7; 22.3–29.1] • Cardiovascular diseases45 [55.6; 50.1–61.1]23 [28.1; 23.1–33.1]68 [41.7; 37.8–45.6] • Thromboembolic disorders29 [35.8; 30.5–41.1]7 [8.5;5.4–11.6]36 [22.1; 18.9–25.3] • Post-partum haemorrhage7 [8.6; 5.5–11.7]2 [2.4; 0.7–4.1]9 [5.5; 3.7–7.3] • liver disease28 [34.6; 29.3–39.9]11 [13.4;9.6–17.2]39 [24.0; 20.7–27.3] • Breast disease33 [40.7; 35.2–46.2]16 [19.8; 15.4–24.2]49 [30.6; 27.0–34.2]Instructions to be given while prescribing OCPs should include • When to start OCP64 [79.0;74.5–83.5]62 [76.6; 71.9–81.3]126 [77.8; 74.5–81.1]0.471 • Daily intake without fail71 [87.7;84.1–91.3]67 [82.7; 78.5–86.9]138 [85.2; 82.4–88.0] • What to do if misses a pill56 [69.5; 64.4–74.6]41 [50.6; 45.1–56.1]97 [59.9;56.1–63.7] • Possible side effects22 [27.5;22.5–32.5]13 [16.1; 12.0–20.2]35 [21.6; 18.4–24.8]What to do if the client misses 2 pills? • To take 2 pills the next day42 [51.9; 46.3–57.5]43 [53.1; 47.6–58.6]85 [52.8; 48.9–56.7]0.025 • Again 2 pills the second next day16 [19.8; 15.4–24.2]12 [14.9; 11.0–18.8]28 [17.3; 18.4–24.8] • The couple should also use condom for 7 days34 [42.0; 36.5–47.5]12 [14.9; 11.0–18.8]46 [24.4; 21.0–27.8]Can OCPs be given to [yes] • Newly married women68 [84.0; 79.9–88.1]43 [52.5; 47.0–58.0]111 [68.1; 64.4–71.8]0.079 • Illiterate women64 [79.0; 74.5–83.5]60 [73.2; 68.3–78.1]124 [76.1; 72.8–73.6] • Women who do not want any more children53 [65.4; 60.1–70.7]61 [74.4; 69.6–79.2]114 [70.0; 66.4–73.6] • CondomsThe failure rate of Condoms if used correctly • 15%4 [5.0; 2.6–7.4]5 [6.2; 3.5–8.9]9 [5.6; 3.8–7.4] • Other1 [1.2; 0.0–2.4]6 [7.4; 4.5–10.3]7 [4.3; 2.7–5.9] • Do not know3 [3.7; 1.6–5.8]12 [14.8; 10.9–18.7]15 [9.3; 7.0–11.6]Two most common Advantages of condom • Dual protection against pregnancy and STI/HIV^70 [86.4; 91.1–96.5]47 [58.0; 52.5–63.5]117 [72.2; 68.7–75.7]0.016 • No side effects23 [28.4;23.4–33.4]34 [42.0; 36.5–47.5]56 [35.2; 31.5–38.9]Emergency contraceptivesType of contraception used after unprotected intercourse • Emergency contraceptive pills76 [93.8;91.1–96.5]71 [86.6; 82.8–90.4]147 [90.2; 87.9–92.5]0.000 • Intrauterine contraceptive devices45 [55.6; 50.1–61.1]6 [7.3; 4.4–10.2]51 [31.3; 27.7–34.9] • Yuzpe’s method24 [29.6; 24.5–34.7]4 [4.9; 2.5–7.3]28 [17.2; 14.2–20.2]The emergency contraceptive pill is effective if consumed within • 24 hours of unprotected intercourse02 [2.4; 0.7–4.1]2 [1.2; 0.3–2.1]0.177 • 48 hours of unprotected intercourse3 [3.7; 1.6–5.8]6 [7.32; 4.4–10.2]9 [5.5; 3.7–7.3] • 72 hours of unprotected intercourse77 [95.1; 92.7–97.5]68 [82.9; 78.7–87.1]145 [89.0; 86.5–91.5]The frequency for taking centchroman • 1 tablet weekly18 [22.2; 17.6–26.8]2 [2.4; 0.7–4.1]20 [12.3; 9.7–14.9]0.000 • Incorrect response15 [18.5; 10.8–28.7]015 [9.2; 5.2–14.7] • Do not know48 [59.3; 53.8–64.8]80 [97.6; 95.9–99.3]128 [78.5; 75.3–81.7]
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^STI/HIV: Sexually Transmitted Infections/Human Immunodeficiency Virus; p value indicates the statistical significant difference in the proportion of interns and nurses regarding their knowledge.
Knowledge of interns and nurses regarding reversible long-acting contraceptives [IUCDs and hormonal contraceptives] and permanent contraceptives [tubectomy] is shown in Table 4. Duration of protection [10 years] offered by long-acting IUCD, i.e., CuT 380 A was known to 51.9% interns and 35.4% nurses. CuT 380 A is a T shaped intrauterine device which has a surface area of 380mm2 of copper, making it very effective with very low failure rate []. About 38% were aware that depot medroxyprogesterone acetate [DMPA]. It is an injectable hormonal contraceptive that can be injected subcutaneously or in the muscles and is available free of cost in the government supply. About 83% of respondents had seen the eligibility checklist for tubectomy during their training period, but only half of them [43%] had seen tubectomy operation. Lactational amenorrhoea [LAM] means no menstruation among women in the post-partum period when they are breastfeeding [lactating] the baby. It has three essential components to be effective as a contraceptive method, including amenorrhea, exclusive breastfeeding, and six months of the postpartum period. This concept was clear to only 9.9% interns and 12.2% of the nurses.
Table 4
Knowledge of interns and nurses regarding reversible long–acting contraceptives [intrauterine contraceptive devices and hormonal contraceptives, post–partum contraception] and permanent contraceptives [tubectomy].
ParametersInterns
n = 81 [%; 95% CI]Nurses
n = 82 [%; 95% CI]Total
n = 163 [%; 95% CI]P valueAwareness about types of intrauterine contraceptive devices [IUCDs] • Copper containing IUCDs81 [100; 100–100]78 [95.1; 92.7–97.5]159 [97.6; 96.4–98.8]0.000 • Hormonal IUCDs60 [74.1; 69.2–79.0]12 [14.6; 10.7–18.5]72 [44.2; 40.4–48.2] • First generation /inert IUCDs51 [63.0; 57.6–68.4]23 [28.1; 23.1–33.1]74 [45.4; 41.5–49.3]Duration of protection offered by CuT 380 A • 10 Years42 [51.9; 46.3–57.5]29 [35.4; 30.1–40.7]71 [43.6; 39.7–47.5]0.034Most common conditions to rule out before inserting Copper T • Pregnancy46 [56.8; 51.3–62.3]40 [48.8;43.3–54.3]86 [52.8; 48.9–56.7]0.287 • STI/HIV53 [65.4; 60.1–70.7]36 [43.9; 38.4–49.4]89 [54.6; 50.7–58.5] • Irregular Periods50 [61.7; 56.3–67.1]54 [65.9; 60.7–71.1]104 [63.8; 60.0–67.6] • Adnexal Mass/Ectopic Pregnancy41[50.6; 45.0–56.2]25 [30.5; 25.4–35.6]66 [40.5; 36.7–44.3] • Multiple Sexual Partners1 [1.2; 0.0–2.4]01 [0.6; 0.0–1.2]Most common side effects of Cu-T insertion • Pain/cramps61 [75.3; 70.5–80.1]55 [67.9; 62.7–73.1]116 [71.6; 68.1–75.1]0.004 • Bleeding/menorrhagia/spotting/irregular bleeding61 [75.3; 70.5–80.1]72 [88.9; 85.4–92.4]133 [82.1; 79.1–85.1] • Infections/PID/vaginal discharge51 [63.0; 57.6–68.4]32 [39.5; 34.1–44.9]83 [51.2; 47.3–55.1] • Expulsion29 [34.6; 29.3–39.9]9 [11.1; 8.6–15.8]37 [22.8; 19.5–26.1]When is Post-Partum IUCD [PPIUCD] to be inserted • Within 10 minutes of delivery37 [45.7; 40.2–51.2]30 [36.4; 31.1–41.7]67 [41.1; 37.2–45.0]0.001 • Within 48 hours27 [33.3; 28.1–38.5]10 [12.2; 8.6–15.8]37 [22.7; 19.4–26.0] • During caesarean section10 [12.4; 8.7–16.1]8 [9.8; 6.5–13.1]18 [11.0; 8.5–13.5] • Other26 [32.1; 26.8–37.2]11 [13.4; 9.6–17.2]37 [22.7; 19.4–26.0] • Don’t know2 [2.5; 0.8–4.2]13 [16.0; 12.0–20.0]15 [9.3; 7.0–11.6]Time for taking consent for PPIUCD insertion • Ante-natal period40 [49.4; 43.8–55.0]29 [35.8; 30.5–41.1]69 [42.3; 38.4–46.2]0.001 • Inta-natal period31 [38.3; 32.9–43.7]16 [19.5; 15.1–23.9]45 [28.8; 25.3–32.3] • Post-natal period8 [9.9; 6.6–13.2]25 [30.9; 25.8–36.0]33 [20.4; 17.2–23.6]Questions to ask before inserting Depot Medroxy Progesterone Acetate [DMPA] • Pregnancy14 [17.3;13.1–21.5]12 [14.8; 10.9–18.7]26 [16.0; 13.1–18.9]0.639 • Irregular periods24 [29.6; 24.5–34.7]15 [18.5; 14.2–22.8]39 [24.7; 21.3–28.1] • Breast cancer20 [24.7; 19.9–29.5]12 [14.9; 11.0–18.8]32 [19.8; 16.7–22.9] • Liver diseases9 [11.1; 7.6–14.6]5 [6.2; 3.5–8.9]14 [8.6; 6.4–10.8] • Thromboembolic episodes11 [13.6; 9.8–17.4]7 [8.6; 5.5–11.7]18 [11.1; 8.6–13.6]Topics to be covered while counseling for DMPA • Menstruation related side effects27 [33.3; 28.1–38.5]14 [17.2; 13.0–21.4]41 [25.2; 21.8–28.6]0.668 • Delayed return of fertility14 [17.3; 13.1–21.5]5 [6.1; 3.5–8.7]19 [11.6; 9.1–14.1] • Don’t know19 [23.7; 19.0–28.4]12 [15.0; 11.1–18.9]31 [19.4; 16.3–22.5]Contraceptives that can be advised to breastfeeding mother • Intrauterine contraceptive device45 [55.6; 50.1–61.1]61 [74.4; 69.6–79.2]106 [65.0; 61.3–68.7]0.000 • Injectable contraceptives8 [9.9; 6.6–13.2]9 [11.0; 7.5–14.5]17 [10.4; 8.0–12.8] • Progesterone only Pills31 [38.3; 32.9–43.7]6 [7.3;4.4–10.2]37 [22.7; 19.4–26.0] • Condoms56 [69.1; 64.0–74.2]54 [65.9; 60.7–71.1]110 [67.9; 64.2–71.6]Tubectomy: Have ever seen [yes] • Eligibility checklist for Tubectomy12 [85.2; 81.3–89.1]14 [79.3; 74.8–83.8]26 [82.2; 79.2–85.2]0.259 • Tubectomy operation31 [38.3; 32.9–43.7]39 [47.6; 42.1–53.1]70 [43.0; 39.1–46.9] • Consent form for Tubectomy24 [29.6; 24.5–34.7]50 [61.0; 55.6–66.4]74 [45.4; 41.5–49.3]Prerequisites for lactational amenorrhea to be an effective contraceptive • Amenorrhoea18 [22.2; 17.6–26.8]14 [83.0; 78.9–87.1]32 [80.4; 77.3–83.5]0.024 • Exclusive breast feeding59 [72.8; 67.9–77.7]45 [54.9; 49.4–60.4]104 [63.8; 60.0–67.6] • 6 months post-partum43 [53.1; 47.6–58.6]36 [43.9; 38.4–49.4]79 [48.5; 44.6–52.4] • All15 [18.5; 10.8–28.7]11 [13.4; 6.9–22.7]26 [16.0; 10.7–22.5] • Don’t know11 [13.8; 10.0–17.6]27 [33.3; 1.3–5.3]38 [23.6; 20.3–26.9]
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p value indicates the statistical significant difference in the proportion of interns and nurses regarding their knowledge.
Overall, the assessment of knowledge in terms of correct, partial, and wrong is presented in Table 5.
Table 5
Overall knowledge of interns and nurses regarding various contraceptive methods.
Parameters [Choices]*The response of Interns n = 81 [%]The response of Nurses n = 82 [%]p-valueCorrectPartially correctWrongDon’t knowCorrectPartially correctWrongDon’t knowContraceptive choices for newly married couple [Condom, OCP, POP, IUCD, all, few of these]23 [28.3]50 [61.7]8 [9.8]023 [28.0]36 [43.0]31 [37.8]0 [0]0.000Contraceptive choices for a woman with 1 child [Condom, OCP, POP, IUCD, all, few of these]27 [33.3]28 [34.5]26 [32.1]035 [42.3]23 [28]23 [28.0]1[1.2]0.440Contraceptive choices for the woman with 3 children [Condom, OCP, POP, IUCD, sterilization, all, few of these]22 [27.1]27 [33.3]31 [38.2]1 [1.2]26 [31.7]27 [32.1]29 [34.1]0 [0]0.707Can contraceptives be given to a married woman coming alone?68 [83.9]013 [16.0]037 [45.1]045 [54.8]0 [0]0.000Can Contraceptives be given to unmarried women coming alone?61 [75.3]018 [22.2]2 [2.4]32 [39]048 [58.5]2 [2.4]0.000Is it legal to provide contraceptives to unmarried people?52 [64.1]014 [17.2]15 [18.5]33 [40.2]038 [46.3]11 [13.4]0.000Types of IUCDs available [1st generation, Copper, Hormonal]18 [22.2]15 [18.5]48 [59.3]051 [62.2]17 [20.7]9 [11.0]1 [1.2]0.000Common contraindications for IUCDs [pregnancy, STI/HIV, irregular periods/ adnexal mass, ectopic pregnancy, multiple sexual partners]17 [21.0]18 [22.0]42 [51.9]3 [3.7]20 [24.4]27 [32.9]25 [30.5]8 [9.8]0.035Common side effects of IUCDs
[cramps, menstrual problems, infections, RTI/STI, expulsion]12 [14.8]31 [38.3]36 [44.1]1 [1.2]11 [13.4]38 [46.3]26 [32.7]5 [6.1]0.169Types of Cu-T in government supply [CuT375, 380A]24 [29.6]48 [59.3]3 [3.7]6 [7.4]19 [23.2]28 [34.1]6 [7.3]29 [35.4]0.000How long does Cu-T 380A offer protection?42 [51.91]0 [0]34 [42.0]5 [6.2]29 [35.4]0 [0]37 [45.1]16 [19.5]0.016When is PPIUCD inserted?15 [18.5]43 [53.1]11 [13.6]12 [14.8]9 [11.0]36 [43.9]8 [9.8]29 [35.4]0.022When is consent for PPIUCD taken?61 [75.3]0 [0]10 [12.3]10 [12.3]3 [3.7]43 [52.4]17 [20.7]19 [23.2]0.000Medical contraindications for OCPs [Any 4 correct responses]21 [25.9]0 [0]49 [60.5]11 [13.6]15 [17.3]0 [0]35 [42.7]32 [39.0]0.001Yes OCPs can be bought over the counter53 [65.4]0 [0]24 [29.6]4 [4.9]52 [62.3]0 [0]29 [35.4]1 [1.2]0.321Instructions were given before starting OCPs48 [59.3]27 [33.3]4 [4.9]2 [2.5]38 [46.3]32 [39.0]5 [6.1]7 [8.5]0.215Instructions if 2 pills are missed10 [12.3]29 [35.8]20 [24.7]22 [27.2]4 [4.9]25 [30.5]22 [26.8]31 [37.8]0.214Whom can OCPs be given to? [Newly married women, illiterate women, Women who do not want any more children]41 [50.6]26 [32.1]14 [17.3]0 [0]31 [37.8]28 [34.1]22 [26.8]1 [1.2]0.237Which OCPs are available in govt. supply [Mala N, Mala D]^14 [17.3]63 [77.8]3 [3.7]1 [1.2]23 [28.0]39 [47.6]5 [6.1]15 [18.3]0.000What kind of contraceptive is DMPA?59 [72.8]0[0]8 [9.9]14 [17.3]32 [39.0]0[0]3 [3.7]47 [57.3]0.000Medical contraindications for DMPA [Any 3 correct responses out of pregnancy/irregular periods, breast cancer, liver disease, thromboembolic episodes]8 [9.9]21 [25.9]11 [13.6]41 [50.6]5 [6.1]16 [19.5]3 [3.7]58 [70.0]0.031Common side effects of DMPA [menstruation related side effects, delayed return of fertility]9 [11.1]22 [27.2]4 [4.9]46 [56.8]4 [4.9]12 [14.6]2 [2.4]64 [78.0]0.037Yes, injectable contraceptives are available in the government supply36 [44.4]033 [40.7]12 [14.8]28 [34.1]028 [34.1]26 [31.7]0.038Prerequisites for lactational amenorrhea method8 [9.9]44 [54.3]15 [18.5]14 [17.3]10 [12.2]25 [30.5]17 [20.7]30 [36.6]0.010Contraceptives that can be given to breastfeeding women [Condoms, POP, IUCD, Injectable]14 [17.3]45 [55.6]16 [19.8]6 [7.4]14 [17.1]35 [42.7]26 [31.7]7 [8.5]0.296
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*OCP: Oral Contraceptive Device; POP: Progesterone Only Pill; IUCD: Intrauterine Contraceptive Device; DMPA: Depot medroxy progesterone acetate, PPIUCD: Post–Partum Intrauterine Contraceptive Device; STI/HIV: Sexually Transmitted Infections/Human Immunodeficiency Virus;
^ Mala–N is a Low dose OCP with nor–ethisterone acetate and ethinyloestradiol and is available in Government supply, while Mala–D is also Combined OCP with levonorgestrel and ethinyloestradiol and is available at the cost of INR 3 under social marketing; p value indicates the statistical significant difference in the proportion of interns and nurses regarding their knowledge.
Gender wise assessment was done to analyse differences in knowledge between male and female participants, including interns and nurses, and presented in . Though, proportion of females was higher with correct responses, but statistical significance could be seen only for a few questions specifically. Overall, females had better knowledge [statistically significant] pertaining to reproductive rights. However, female interns had significantly better knowledge as compared to male interns regarding the choice of contraceptives for women with one child [47.5% vs. 24.4%; p = 0.036], with three children [45% vs. 17.1%; p = 0.042]; and regarding types of IUCDs [90% vs. 65.9%; p = 0.009]. Older participants [>25 years] had better knowledge regarding common conditions to be ruled out before inserting CuT [52% versus 30%;p-value: 0.016], OCP prescription[20% versus 15%;p-value: 0.001], instructions to be given to patients [63%% versus 44%;p-value: 0.011], emergency contraception [31% versus 10%;p-value: 0.000], frequency of taking centchroman [21% versus 2%; p-value: 0.00], etc. Younger participants [≤ 25 years] responded better to knowledge based questions []. However, married participants depicted better knowledge [statistically significant with p value