To identify bottlenecks in the delivery of comprehensive reproductive health care in Bulawayo, Zimbabwe's second city, a study was performed utilising volunteers pretending to be in need of emergency contraception. A total of 55 private, Zimbabwe National Family Planning Council, municipal and government health facilities were visited. These consultations resulted in 9 (16%) correct, 1 possiblycorrect and 15 wrong prescriptions for the morning-after pill (MAP); no treatment was prescribed in 30 instances. Public sector health personnel were very judgemental in their attitude toward sexually active teenagers. Although the Essential Drug List of Zimbabwe is quite clear about the MAP, many health providers are not aware of this, and others do not even have/use this book

Rutgers, R A K

Verkuyl, D A A

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SAMJArt c I e sSpecial Article MethodsTable I. Attitude of the provider reported by the clientsResultsAttitudesAs Table I shows, the women were treated politely and withenough privacy in most private surgeries. Somereceptionists were very keen to know the reason for the visit.One proved to be an unsurmountable barrier. One doctorwas so pleasant that she gave her home telephone numberto use, even at night, for instant support. At one surgery,there was such a long wait before the doctor could escapefrom his government duties that the woman gave up.Six women, aged 16 - 26 years, were trained with the helpof role-plays to present themselves convincingly with a fakeproblem to pharmacies, general practitioners' surgeries andclinics (municipality, central hospitals, Zimbabwe NationalFamily Planning Council (ZNFPC) and one private motherand child health clinic). Twenty-two of the 23 pharmacies, 1doctor at most surgeries, 6 of 17 municipal clinics and theoutpatient departments of both government hospitals werevisited as well as the 3 ZNFPC clinic, including the YouthAdvisory Service. The study was terminated after no newinsights had emerged for some time and detection of the'fraud' through health networks seemed imminent. The twoyoungest fake clients made nearly all their visits together formoral support.The women pretended to have been involved in anincident where a condom had torn the previous night. Theywould stress that they were not keen to be pregnant. Theywould reveal, if asked, that their last period had been afortnight before and that they had a cycle of 4 weeks. If nosolution were offered, they would say that they had heardabout 'the morning-after pill'. After their visits they weredebriefed with a checklist.4431243221332116Staff in clinicsGPs Pharmacies and hospitalsCondescending/condemning/angry/too much lecturingAsked advice of others!unsure what to doTotalConcerned/friendly/helpful/(very) nice/seriousIn a hurry/not interestedAmused/shocked/nervousA report on visits of fake clients,pretending to be in need of emergencycontraception, to health facilities inBulawayo, ZimbabweS Afr Med J 1998; 88: 143-145.The morning-after pill (MAP) has been called the best-keptcontraceptive secret. The public does not know about it andmany pharmacists, nurses and doctors have forgotten whatexactly it is and which reference book to check. Rape isreported to be on the increase, and the use of condoms(which can tear and slip) should be. We see patients whorefuse any contraceptive other than the condom, becausethey fear that concurrent use of, for example, the pill mightundermine their reso"lve to use the former, even if exclusivelyfor HIV prevention. These women need emergencycontraception (EC) if they have an accident with this barriermethod. Knowledge of and access to EC especially amongteenagers, who often have unplanned sexual intercourse,could substantially reduce the numbers of (clandestine)abortions' and/or ruined lives! Contact with the healthservices for EC should then be used as an opportunity fordiscussion of more structured use of contraception andprotection against sexually transmitted infections (STls).This study was performed in Bulawayo in December 1995to assess attitudes and practices with regard to EC in orderto plan appropriate educational interventions.To identify bottlenecks in the delivery of comprehensivereproductive health care in Bulawayo, Zimbabwe's secondcity, a study was performed utilising volunteers pretendingto be in need of emergency contraception. A total of 55private, Zimbabwe National Family Planning Council,municipal and government health facilities were visited.These consultations resulted in 9 (16%) correct, 1 possiblycorrect and 15 wrong prescriptions for the morning-afterpill (MAP); no treatment was prescribed in 30 instances.Public sector health personnel were very judgemental intheir attitude toward sexually active teenagers. Althoughthe Essential Drug List of Zimbabwe is quite clear aboutthe MAP, many health providers are not aware of this, andothers do not even have/use this book.R A K Rutgers, 0 A A VerkuylPlease help, our condomtore last night9 Chancellor Avenue, Kumalo, Bulawayo, ZimbabweR A K Rutgers. MD. MPHo A A Verkuyl. MRCOGMost pharmacists were kind and supportive, but somewould communicate loudly to a colleague so that otherclients could hear: 'This girl comes for the morning-afterpill'. In the municipal clinics the young teenagers werelectured extensively by the sisters, sometimes in a roomSAMJ Volume 88 No.2 February 1998 __Table 11. Feelings of the clients during the consultationwithout much privacy. At one clinic the other patientslaughed loudly when an unaccompanied 16-year-old left thebuilding, without drugs but after a loud angry lecture. Shewas crying when she entered the car collecting her.An 18-year-old girl was told at the municipal clinics thatshe was old enough and that it was about time she had ababy, anyway. ZNFPC clinic staff showed no concern andwere not helpful. Table 11 shows the feelings of the clientsduring consultations.In the GP's In therooms pharmacies14 (3)5(4)3 (1)1 (1)1111 (6)22 PharmaciesTable IV. Overview of the different prescriptionsType of prescription (correct dosage)Lo-femenal 8 (3)NordetteDemulenMAP'Injection to make the lining ofthe uterus loose' (Z$200)OvretteProveraNorethisteroneTrinovum'Obecalp'PremarinTotal21 GPs24In the clinicsand hospitals512At ease/comfortable/ 17not badNot at ease/not taken 4seriouslyBad to horribleTotal 21522612Table V. Reasons for not providing the MAP/general commentsgivenNo. of responsesManagement of the problemTable III details the questions asked by the different groupsof health workers. No doctor asked to do a vaginalexamination. Some palpated the abdomen and somewanted to do a pregnancy test. Eleven of the 22pharmacists gave drugs, only in 6 cases the correct ones.The corresponding figures for doctors were 14 of 21, correctin 3 cases (Table IV). Some remarks from health providerswere peculiar. They are summarised in Table V. Only onedoctor referred to the Essential Drug List of Zimbabwe,(EDLlZ) but could only find the 1989 edition. The 1994edition has a description of the MAP. Of the 11 doctors whowrote an incorrect prescription, a few had it nearly right. Oneof the doctors prescribed 'MAP 2 stat PO'. The client wouldhave had a 27% chance of visiting a pharmacy with the rightinformation.Table Ill. Questions asked by the providersDo parents know 4about visit?Reasons given for not providing the MAPNot yet available in the countrylBulawayo/ 4still to go through ParliamentIllegal in Zimbabwe/we are not allowed to 3prescribeShould have come in the morning/within 28 hours, it is now too lateVery expensiveVery dangerousThis pill is for nausea in pregnancyThe pill you take when you forget yourregular FP tabsNot efficientMAP is still in experimental phaseGeneral commentsHave the baby/get married 4Don't worry, this is not your fertile 2periodSex is a crime at your age 1He not only gave you a baby, but also AIDS 1You should always shower after sex 1Buy spermicide to kill the remaining sperm 1Go to the UK for an abortion 1Only a hysterectomy can help you now 1One ZNFPC clinic sister told our client that the MAPmeant just that and that since it was now afternoon shecould not be helped. At the municipal clinics the girls wereadvised to marry before the 'stomach showed', or that theywere not only pregnant but must have acquired AIDS also.Municipal clinics had the right EDLlZ and used it, but sisters,often discussing the problem among themselves in thepresence of the fake patient, did not feel authorised todispense EC. A government hospital OPD referred clients tothe ZNFPC clinic on its grounds and vice versa.292Staff in clinics!hospitals(N = 12)10Pharmacystaff(N=22)4338GPs(N = 21)19Last menstrualperiod?Regularity of period? 14Age?Ever used 8contraceptives?Could you be 7pregnant now?Any chance you have 3anSTI?Offered pregnancy testVolume 88 No.2 February 1998 SAMJSAMJArt c I e sSide-effectsFew prescribers explained about possible side-effects andwhat to do. Some prescribed anti-emetics. Few explainedthat the MAP could either cause early or late periods.Future contraceptionEven without the MAP the chance of becoming pregnantafter one act of unprotected intercourse at the time ofovulation is only 20 - 30%; this is reduced to 5 - 7% withthe MAP.' Few clients were counselled about futurecontraceptive options, although private doctors might haveintended to initiate this discussion at a suggested follow-upvisit. Municipal and even ZNFPC clinics did not raise thissubject. The mother and child health clinic sister wanted to,but finally did not, prescribe the pill because our clientrefused vaginal examination.Sexually transmitted infectionsOnly 3 doctors asked if STI treatment could be necessaryafter the condom mishap. Another doctor wanted to give aseries of penicillin injections regardless. HIV screening ofboth partners was never suggested.DiscussionProbably few members of the public know about EC, butapparently the medical, nursing and pharmaceuticalprofessionals are not at all ready for requests for the MAP.An article about condoms in Bulawayo's The Chronicle of1 November 1995 and in the Matabeleland AIDS Councilnewsletter of January 1996 specifically mentioned the MAPin relation to ruptured condoms. This should have promptedsome research by health workers in the city. With 30% ofthe antenatal clinic patients in Bulawayo HIV-positive, onewould expect increased use of condoms and therefore moredemand for the MAP in the future. Any random (un)wantedpregnancy has a 12% chance of ending in a vertically HIV-infected child and an 18% chance of resulting in an orphan-to-be.' It therefore seems quite reasonable to preventunwanted pregnancies.Nobody offered to insert an intra-uterine contraceptivedevice (IUCD), which is more effective and can be appliedlonger after the mishap than the MAP. Combined withantibiotics this would be the best option in countries whereaccess to safe, affordable abortion is restricted, and the veryeffective MAP, RU486 (mifepristone) cannot be usedbecause it is unavailable.The legal situation worried some personnel, but becausethe mechanism of action (delaying ovulation, interfering withthe corpus luteum and preventing implantation") is, at worst,similar to the action of a OegaQ IUCD, this should be of noconcem. Even the Vatican has recently approved the use ofthe MAP in the case of rape.5 One pharmacist, worriedabout the law, prescribed tablets recognisable as Trinovumin the wrong dose and labelled them Obecalp (which can beunderstood if it is read backwards).It was disappointing to see that the EDUZ, a product of thebest medical and pharmaceutical minds in Zimbabwe, wasused so little by everybody apart from the municipal nursingsisters. Local doctors see this book as being 'just for sisters'.Conclusion andrecommendationsThis study found that most health providers know little aboutEC but that municipal nursing sisters can find theinformation. Staff in the public sector tend to be veryunfriendly to sexually active girls, even when speciallyrecruited to advise young people. Private doctors werefound to be friendly and understanding, but should considerreading the EDLlZ or the future South African equivalent.All opportunities should be used to educate healthproviders and the public about the MAP. Posters anddiscussions in health facilities and schools, and inserts in or,still better, printed on the combined oral contraceptivepacket itself (together with instructions about what to dowhen pills are forgotten) should spread the word about theMAP. It could even be argued that condom manufacturersshould legally be obliged to suggest the MAP in case offailure of their product. The MAP should be available withoutprescription as suggested in the UK," so that dinic sistersfeel confident about dispensing it. Police personnel shouldbe informed about the EC option after rape and should beurged to take the victim to a health facility in time. Readersshould ensure that EC is available at their own medicalfacility for, for example, a case of rape, even after hours andon weekends.IUCDs have lost some ground in Zimbabwe since the(re)introduction of injectables and Norplant and since theadvent of HIV, but they still have a place in emergencysituations, particularly while menstruation regulation andinduced abortions are illegal and mifepristone unobtainable.Discussions at the World Health Assembly in May 1995indicate that the message about prevention of teenagepregnancy is at long last getting across. Education aboutand provision of EC should be an integral part of that effort.7Thousands of unwanted pregnancies that end in ruined liveshappen every day because so few teenagers in this part ofthe world protect themselves at the time of first sexualintercourse. EC can give them a second chance.Thanks to Kelly, Nelly, Thembi, Natalie, Varda and Nienke,who were so brave. Thanks also to the health workers whounwittingly provided the data for this study, participated in afriendly feedback meeting after its completion, and agreed thatthe result of these shock tactics was that they were unlikely toforget how to handle EC again.REFERENCES1. Reader Fe. Emergency contraception. A few days rather than a few hours to act.BMJ 1991; 302: 80l.2. ~~ul~~~5Two world religions and family planning (Viewpoint). Lancet 1993;3. Kubba A. Faculty of Family Planning and Reproductive Health Care of the RCOGEmergency Contraception Guidelines for Doctors (Undated; available from 27 .Sussex Place, Regent's Park, London NWI 4 RG, UK).4. Verkuyl OM. Practising obstetrics and gynaecology in areas with a highprevalence of HIV infection. Lancet 1995; 345: 293-296.5. Nation~1 Conference of C~tholic Bishops. Ethical and Religious Directives forCatholic Health Care Services. Washin9ton, DC: United States CatholicConference, 1995.6. Glasier A. Emergency contraception: time for deregUlation? Br J Obstet Gynaecol1993; 100: 611-812.7. ;~~~~~~8~.fter the morning after and the morning after that. Lancet 1995; 345:SAMJ Volume 88 No. 2 February 1998 __

A report on visits of fake clients, pretending to be in need of emergency contraception, to health facilities in Bulawayo, Zimbabwe

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A report on visits of fake clients, pretending to be in need of emergency contraception, to health facilities in Bulawayo, Zimbabwe

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