Evidence-Based Medicine for Family Planning in Jordan

Nadia Al-Alawi
Shirin Aladwan
Minki Chatterji
Soon Kyu Choi
Marianne El-Khoury
Fieldwork by:
Amman and Zarqa regions of Jordan
267 medical doctors
2011 - 2013
Target group:
  • Health care providers
Outcome of interest:
  • Provider Performance
Intervention type:
  • Information
  • Training
AEA RCT registration number:

As Jordan seeks to control its rapid population growth, researchers partnered with USAID to study the impact of Evidence-Based Medicine programs on changing family planning providers’ biases against injectable contraceptives. The randomized evaluation found no significant impacts on providers’ knowledge of injectable contraceptives and their side effects, improvement in provider attitudes, or confidence in discussing the method. Overall, researchers found no change in provider practices and self-reported prescriptions.

Policy issue

Quasi-experimental studies from several countries suggest that family planning providers’ misconceptions and biases about contraceptive methods are major barriers to access for women. One approach to impact family planning in low- and middle-income countries is Evidence Based Medicine (EBM), where the providers are given the most up-to-date scientific evidence about contraceptive methods.  The idea is that this information improves knowledge of family planning methods which in turn mitigates provider reliance on existing beliefs regarding a particular method. However, researchers hypothesize that few of these programs have been rigorously evaluated. To fill this gap, researchers tested the impact of EBM regarding injectable contraceptives, such as Depot Medroxy Progesterone Acetate (DMPA), on the knowledge, attitudes, and reported clinical practices of private family planning providers in Jordan.

Context of the evaluation

Jordan is a middle-income country seeking to contain its growing population but has low rates of use of modern family planning methods likely related to pervasive provider and consumer biases and misconceptions towards these methods. Between 2002 and 2012, the prevalence of modern contraception stagnated at 42 percent. Hormonal methods are even less popular and the least popular are injectable contraceptives, such as DMPA. Since, DMPA has already been available in Jordan and there are no market shortages or health systems constraints, Jordan makes an appropriate setting to the study the effectiveness of EBM in reducing biases and misconceptions towards this method.

Details of the intervention

Researchers partnered with a USAID-funded project entitled, “Strengthening Health Outcomes through the Private Sector (SHOPS)” to provide an EBM program on the use of DMPA contraceptives over a six-month period between January and June 2012. Researchers measured the impact of the program on family planning providers’ knowledge of DMPA and its side effects; their attitudes towards and willingness to recommend DMPA; their self-perceived confidence in discussing DMPA with clients; and their self-reported prescription or discussion of DMPA with clients.

Researchers randomly assigned 267 private providers in two urban areas, Amman and Zarqa, to an EBM group or to a comparison group. Participants assigned to the EBM group were invited to attend a two-hour roundtable seminar on DMPA led by peer providers and offered two 15-minute educational visits by trained health workers at their clinics. Using an interactive approach that responds to the providers’ conceptions and biases, the program aimed to address concerns about DMPA’s side effects and perceived delays in returns to fertility, and convey information on its benefits and possible protective effects against cancer. Comparison group participants were offered two educational visits related to a different contraceptive method.

Results and policy lessons

The evaluation concluded that there was low compliance with the EBM program and no significant change in any of the measured outcomes.

Participation in the EBM DMPA program

Overall only 38 percent of invited providers completed the entire program. About 45 percent of invited providers attended the roundtable seminars and about 76 percent received both educational visits. These low take-up rates, mostly due to busy schedules, indicate the already disadvantaged position of DMPA among providers, compared to other contraceptive methods.

Knowledge, attitudes and confidence in discussing DMPA

The randomized evaluation did not detect significant impacts of the EBM program on providers’ knowledge of DMPA their attitudes, or confidence. Researchers suggest this could be due to the low take-up rates.

Practice by prescribing or discussing DMPA with clients

Since there was no significant change in knowledge and  attitudes, the providers’ level of stocking, discussing, and prescribing DMPA to the clients measured by a practice score was also the same whether they participated in the EBM program or not.

Researchers hypothesize that since EBM encourages providers to take patient values and preferences into high consideration, the lack of detectable change in practices of discussing and prescribing DMPA could also be a result of persistent consumer biases.

The evaluation concludes that while the small sample size and low take up might explain the lack of detectable impact on knowledge and practice researchers suggest that an EBM program on unpopular contraceptive methods would benefit from adding an intervention working on the consumers’ behavior as well.