Competency assessment of the medical interns and nurses and documenting prevailing practices to provide family planning services in teaching hospitals in three states of India

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 [1]. 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 [2]. 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 [3]. 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 [4,5]. 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 [6].
FP 2020 is a global partnership between 69 countries to empower women and girls by investing in rights-based FP [7]. India committed to FP 2020 in 2012 with an aim to provide choice, access, and quality of family planning services [8]. 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 [9]. 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 [10]. 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 [11,12]. 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.

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 [14]. 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 [18]. 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 [27,28].

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 [29], 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 [30]. 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 [31]. 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 (S1 File); and the second study tool was used to assess the prevailing FP practices in the department of obstetrics and gynecology. (S2 File). 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. (S1 File). 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. (S2 File).
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 (S3 File) for the nurses as per the World Health Organisation's translation methodology. [20] 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. (S4 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).

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) [12,18]. 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. 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. 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 380mm 2 of copper, making it very effective with very low failure rate [32]. 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.
Overall, the assessment of knowledge in terms of correct, partial, and wrong is presented in Table 5.
Gender wise assessment was done to analyse differences in knowledge between male and female participants, including interns and nurses, and presented in S1 Table. 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 (S2 Table). However, married participants depicted better knowledge (statistically significant with p value <0.05) in certain areas pertaining to reproductive rights (41% and 35% for married. versus 6% and 6% for unmarried participants.) and legality of contraceptives to be given to unmarried people (39% versus 4%;p-value: 0.000). It was observed that this association significantly (p = 0.049) improved with age among nurses, as 65% of the nurses between 30-34 years have answered it correctly as compared to 32.7% and 28.6% among 25-29 years and 20-24 years age group, respectively. (S3 Table) Skills of nurses and interns regarding the use of contraceptive methods (objective structured clinical examination) About 19.8% interns and 64.6% nurses refused to demonstrate the use of MEC wheel for choosing the best contraceptives for hypothetical cases, as shown in Table 6. Further, 43.2% Competency assessment of the medical interns and nurses to provide family planning services

Status of training of interns and nurses on family planning methods and services
Almost 90% of interns received training on FP methods and services. (Table 7). About 76.5% of interns reported that they were ever posted in FP clinic (for 15 days) during training. Although 63% of interns and nurses have seen the insertion of IUCD, more nurses (17.1%) reported performing IUCD insertion than interns (12.3%) at least once. A very small proportion of interns and nurses reported having seen implantable contraceptives (12.3%) and spermicides (17.3%).
All the medical colleges reported that they provide adequate training to their students pertaining to the FP methods and services. The teaching practices were assessed in all the medical colleges (n = 6) that involved infrastructure appraisal, teaching aid and material. It was observed that department of Community Medicine (n = 3) and department of Obstetrics and Gynaecology (n = 3) were jointly involved in teaching family planning services to the students. (S4 Table). Dedicated family planning rooms were available in four medical colleges. Only two colleges had FP skill labs and dummies for demonstrations, while only two medical college had models for family planning courses. However, samples of most of the contraceptives in provided under the government supply (Oral pills, Condoms, Injectable, Emergency contraceptives and Cu T 380 A/375) were available in majority of the medical colleges (N = 5). Only one college had a medical eligibility checklist (MEC) wheel for training purposes. Only two colleges were using the updated national guidelines issued by the government of India for teaching purposes, while others preferred only the standard textbooks. All the colleges stated that they provided hands on trainings to their students.

Status of prevailing family planning practices
Family planning clinics in all the medical colleges (n = 6) were assessed for the prevailing practices (S5 Table). It involved observation of the family planning services that included counselling of clients, assessment of clients eligibility for various family planning methods opted by them. It was observed that auditory privacy was available in only four medical colleges, while MEC wheel was being used only in one medical college. None of the college had MEC wheels in sufficient numbers. Records of these clinics were assessed for stock position of contraceptives and the number of person who were provided FP services in last month. Adequate stock of FP methods (contraceptives, pregnancy test, CuT, etc.) was available in almost all the colleges. However, only two medical colleges were offering vasectomy services, while two colleges had injectables and emergency contraceptives in their stocks. Three medical colleges reported to have an established FP logistic management information system.

Discussion
This study highlights the inadequate knowledge and skills of the interns (pre service cadre) and nurses (in-service cadre) regarding family planning services in the medical colleges in Rajasthan, Maharashtra, and Delhi, India. The status of preservice medical education and prevailing practices regarding FP services was also found to be inadequate. These results have many implications not only in providing quality FP services at present but also in terms of producing skilled FP workforce in the future. It may also adversely affect the universal access to quality reproductive and sexual health to the clients, which may lead to a compromise in the reproductive rights of the population, especially of the women, as they are most often not the decision makers in opting for the FP methods. The findings of this study are similar to family planning training assessment studies done in Maharashtra, India and Tanzania [33,34] It is reported that majority of the medical schools were unable to produce competent FP service providers, and the teaching was poorly guided, mainly theoretical with less practical exposure related to FP skill development.
The tool (S1 File) which we used had direct and open ended questions related to choice of contraceptive methods to be offered to the women as per their need, medical history to be ruled out before prescribing certain contraceptive methods like OCPs, DMPA, and questions related to the common side effects. Only the interviewer had the list of the answers as options available with them. We did not specifically asked the categories of the conditions to prescribe OCP/DMPA from the respondents. Options were based on government of India guidelines [18,35,36]. We only asked whether the interns or nurses would like to rule out certain medical conditions or not before prescribing these contraceptives. At their level, we expect them to know about the major conditions which should raise an alarm and they should be able to tell the patient to consult a specialist of obstetrics and gynaecology to advise further.
Our study sample had proportionate representation from the male (54, 33.1%) and female (109,66.9%) groups. A higher proportion of females were because the majority of the nurses were females (84.1%). Significantly higher knowledge of female participants in many questions as observed in this study is similar to Raselekoane NR (2016) study, who reported a non-serious approach of the male students towards contraception and family planning [37]. Gender differences should not be ignored during medical education to avoid compromise with the sexual and reproductive health rights of the clients [38]. Younger participants depicted better knowledge pertaining to various contraceptives. But specifically amongst nurses, improvement in knowledge in specific topics with age may be attributed to change in marital status. Married females tend to gain clarity of certain concepts regarding FP methods as they are free to use and discuss them more often than their unmarried counterparts. It is corroborated by the fact that there is a notable difference in contraceptive usage and family planning practices based upon the women's marital status in developing countries like India [39].
It is recommended to hold in-service refresher training programs as a routine activity in the health system. This can be done under the trainings held under reproductive maternal neonatal, child and adolescent health strategy under National Health Mission in India with p value indicates the statistical significant difference in the proportion of interns and nurses regarding their skills. https://doi.org/10.1371/journal.pone.0211168.t006

Nurses n = 82 (%) p-value
Status of Training � inclusion of nurses working in the medical colleges [40]. As per the guidelines, there is a provision of capacity building of the services providers for family planning services, especially onsite training especially for intrauterine devices by organizations like Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego), Engender Health, International Projects Assistance Services (IPAS) [18]. However, medical colleges may deny to be trained by the external organizations, or may give an excuse of limited funds for such purposes. However, such events could be planned during drafting of the state program implementation plan or medical colleges can plan as part of continued nursing or medical education annually with their own or external expert faculty members. It was observed that participants did not report to provide FP methods as per the cafeteria approach to an eligible woman [15]. Most of them were unaware of the new FP methods [like DMPA (86%)] that have been introduced in India [12]. Rhythm method (87.9%), coitus interrupts (55.4%), LAM (45.2%) were preferred natural methods during counseling. However, these are not promoted in newer family planning programs. Fehring RJ et al. (Milwaukee, 2001), also observed that when a client specifically asked for information on Natural Family Planning methods, 62.3%, 47.7%, 42.8% and 37% of the certified nurse-midwives (CNM) respondents would describe the symptom-thermal method, the ovulation method, the Basal Body Temperature method, and the calendar method, but did not recommend the use of these methods as a means of avoiding pregnancy [41]. In our study, IUCD, condom, and sterilization were preferred contraceptives for newly married women, for women with one child and women with three children. Jain AK et al. (India, 2017), observed 15.6% of contraceptive users receiving information on all four items (IUCDs, condom, sterilization, and pills) [42]. In our study, 32.1% of participants reported that FP services should not be offered to unmarried females coming alone, and 31.9% of participants reported that providing FP services to unmarried people is illegal. Tilhaun et al. study (Ethiopia, 2010) also observed a negative attitude toward providing FP methods to unmarried adolescents [43]. Sociocultural norms of Indian society contribute to having sex-related issues a taboo and hinder young people from seeking counseling regarding sexual health [44]. Though, there is no specific law against or in favour of prescribing contraceptives to unmarried people in India, but it has been reported earlier that that healthcare providers often impose unnecessary barriers in dispensing contraceptives, including denial of a contraceptive method based on age, parity, marital status or lack of parental or spousal authorization [45,46]. There are Family planning guidelines and adolescent reproductive and sexual health guidelines under National Health Mission, Ministry of Health and Family Welfare, Government of India [12] and WHO [47], which states that women in the reproductive age group (15 to 49 years) including adolescent girls irrespective of the marital status (married or unmarried) should be made aware about the contraceptive services; and these should be made accessible to them. There is no legal issue in offering contraceptives to the unmarried people.
Knowledge regarding side effects and contraindications of IUCD use (68.7%) was better than other studies done in the past [48,49]. This may be attributed to improvement in health promotion activities conducted in the last decade. We stress on the fact that the participants were asked to enumerate the conditions that should be ruled out before inserting Copper-T. Though HIV is not a direct contraindication, but the WHO medical eligibility criteria caution against IUD and LNG-IUS use by women at risk of HIV, HIV positive women, and women with AIDS. This is a grade 3 criterion "theoretical or proved risks generally outweigh the advantages" as opposed to grade 4 which is an "unacceptable health risk." There are a number of concerns about IUD use by women with HIV infection relating to contraceptive efficacy, risks of sexual transmission, and acute pelvic inflammatory disease [50,51]. Regarding PPIUCD's insertion, timing of consent taken was asked from the respondents to ascertain their knowledge regarding the reproductive rights of the women. (Table 4). As per the PPIUCD reference manual, counselling for informed consent should take place in the antenatal period, in early labor or immediately postpartum. Counselling for informed consent should not take place during the active phase of labor [36].
Few interns (12%) had adequate knowledge about instructions that should be given to a woman who had missed up to two doses of her OCPs. These findings are in line with a study by Rutter W et al. (Australia 1988) [52]. Adequate knowledge of interns and nurses regarding male condoms (72%) in this study is similar to the observations made by Simbar et al. study (Iran 2005) [53].
More than 60% of participants were unaware about injectable contraceptives, particularly DMPA. Hogmark et al. (India, 2013), reported that despite the positive attitude of medical students towards modern contraceptives, sex education and FP counseling, they still had misconceptions about modern methods of contraception in Maharashtra, which is consistent with the findings of the present study [33]. Knowledge about lactational amenorrhoea was partial, as only 9.9% interns and 12.2% nurses could correctly enumerate its three criteria (Table 4) to be an efficacious method [54]. Singh S et al. (Delhi, 2002) observed high awareness about emergency contraception among doctors who felt that the use of emergency contraceptives could bring down the number of induced abortions [55]. Less than half of the respondents (61% nurses; 30% interns) had ever witnessed tubectomy operation, while 16% had seen eligibility checklist, and 45.5% had seen the consent form for tubectomy. This difference is probably because taking consent from patients is primarily a job responsibility of nurses in India. Few interns and nurses accepted that they did not attend any family planning classes during their degree course. We did not look into the reasons behind low attendance during family planning classes. Anecdotally, it is a general notion amongst the medical students that there is no need to attend family planning classes if you don't want to be a gynaecologist. However, this aspect needs further exploration because of its long term implications. Attendance can be improved with compulsory weightage to family planning during passing exams.
Availability of adequate infrastructure is an essential part of pre-service trainings and helps students to adhere to the standard protocols with the clients. In our study it was observed that only 1 out of 6 medical colleges had a MEC wheel. As these were not used in the routine FP practices in most of the medical colleges, hence students have not observed these during their training period and this is attributed as one of the major reasons behind their refusal to demonstrate the use of MEC wheel during OSCE. A similar study reported difficulties in delivering quality services as per the protocols, which were attributed to improper facility layout and lack of furniture [56]. Inadequate logistics and privacy may also affect the client's satisfaction [57,58].
One of the main strength of our study was the use of reliable and valid method, i.e., OSCE, to assess the skills of the study participants [59][60][61]. Some nurses (45.1%) refused to demonstrate the procedure of using a condom, which could be linked with shyness, or with unawareness of the correct process. This has implications on proper demonstration of condom usage to the clients, which may lead to higher failure rates and inconsistent use of condoms. This may also result in increased use of emergency contraceptives in the population at high risk of unintended pregnancy. Lim MS et al. (China, 2015) has stressed that efforts should be made to sensitize the students to rise above and overcome this social taboo, and emphasis should be given to training in skills for condom/contraception negotiation, as partner refusal to use condoms is common [62]. The use of MEC wheel during pre-service training should be stressed upon as it aims to guide health-care providers in decision making and minimizing errors [63].
There are certain limitations in our study. Although we assessed how medical graduates are provided FP training, by interviewing the faculty of department of community medicine and obstetrics and gynaecology, but we did not assess the knowledge and skills of faculty themselves regarding family planning services, which could have further provided gaps in the medical education pattern. Since this was a cross-sectional study and information was self-reported by face to face interview, there could be a chance of recall and social desirability bias. Though interviews were conducted with one respondent at one time in closed room settings, yet response bias (tendency of the participants to respond falsely to questions) cannot be ruled out [64]. This could be attributed to contamination by prior information to the participants regarding what is being asked during the interviews by the interns/nurses who had already been interviewed. So the participants might already know the correct answers before facing the actual interview, but in reality their knowledge might be less. There could be chances of selection bias due to non-recruitment of nurses from medical college in Delhi.
In-depth cause of poor knowledge and skills of participants could not be explored, and it is suggested that qualitative studies should be planned to further explore these reasons in the future. Exploring client level barriers and enablers for accessing the FP services could have further given more clarity on this issue. While the planned methodology of doing an OSCE is strong, but half of the respondents had refused to demonstrate. This aspect can be strengthened by stating it as a part of the inclusion criteria of the study, included in the consent form, and a proper explanation of what it is in future studies. The reasons for denial for practical demonstrations by medical interns and nurses can also be explored.
To conclude, our study depicted that knowledge and skills of interns and nurses regarding FP services were inadequate. The medical training pertaining to family planning services during graduation or internship, and during the job, was found to be inadequate to provide quality FP services as per guidelines of medical council of India and Government of India. Information provided through our study can be considered edifying as it attempts to provides insights into training needs, barriers and facilitators from different perspectives and hence can be considered as a baseline assessment for designing large-scale research studies and guide the policy makers in taking initiatives to strengthen preservice medical education on FP.
Based on the results of this study, it is recommended that training of interns and nurses on FP services should be given more emphasis during pre-service medical education and in-service training. Quality of in-service training of nurses including continued nursing education on FP related topics should be organized. It is recommended to improve the pre-service medical education pertaining to the FP and reproductive rights by having a consensus on core competencies in FP for medical students, identifying opportunities for building FP skills like giving case studies, conducting role plays, organzing capacity building seminars for medical students, and continued medical education for medical faculty on skill-based FP as suggested by medical council of India regarding competency and skills to be acquired by medical graduates [65]. Skill based reproductive health learning (by simulated training) should be implemented. Practical examinations can be modified by including competency skill-based assessment regarding use of contraceptive methods. Similar modifications suggested in other studies have substantiated the existing curriculum and improved the skills sets of the students [66,67]. Internship duties should include a minimum set of procedures (like IUCD insertion) and minimum number of cases/clients counseled on use of various contraceptive methods in the FP clinic/ OPD. Skills and knowledge acquired during the posting might be assessed by conducting the exit tests.
There is evidence on improvement of skills and knowledge of interns on family planning and reproductive health by improved teaching curriculums. According to Berdzuli et al report 2009, United States Agency for International Development [USAID] has documented the strengthening of preservice medical education on family planning and reproductive health in Europe and Eurasia by addressing the key problems in medical and nursing schools related to FP teaching and training. The specific actions taken included implementation of the evidence based curriculum content and teaching, curricular reforms to include case based teaching and student centred learning of FP, for example use of WHO Medical Eligibility Criteria for contraceptive use and development of core competencies curriculum for the medical graduates [68]. Earlier USAID and JHIEPGO had developed National Integrated Clinical Training system to strengthen FP and reproductive preservice education and inservice training in Turkey, where it has been documented that interns FP/RH knowledge and skills especially of of IUCD insertion especially improved after this change in the training pattern [69]. Linhares et al (2015) had prepared a standardized competency matrix with list of minimum requirements that interns should be able to practice after rotatory training in the department of Obstetrics and Gynaecology [70]. Gebremeskel et al (2018) in an intervention study reported a higher proportion of interns in the intervention arm, trained under integrated FP curriculum with skill based teaching and learning, who rated being competent themselves across all contraceptive procedures as compared to the control arm (p<0.01) [66]. There are evidences from other specialities [medicine and ophthalmology] as well where competency based learning and skill assessment has resulted in better knowledge and skills of interns [71,72].
Enabling the interns and nurses to be competent in providing family planning services would also be dependent on the clients and procedure load of the clinical setting. This should be sufficient enough to meet the training needs of both medical interns and nursing students. If the clients and procedure load is not sufficient then other methods including use of simulation/models, role plays, case studies should be explored for inclusion in the teaching. Recent MCI competency based guidelines on family planning teaching has mentioned the methods of teaching as well to guide the faculty [65]. Faculty members of the medical college should take the responsibility of teaching their students with a more serious approach towards FP services to ensure universal access to sexual and reproductive health care services and rights.