Validation of the Interpersonal Quality of Family Planning Scale in a rural Indian setting

Contraceptive counseling, method satisfaction, and planned method continuation among women in the U.S. southeast

OBJECTIVES

We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states.

STUDY DESIGN

We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation.

RESULTS

Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001).

CONCLUSIONS

Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction.

IMPLICATIONS

Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

Contraceptive counseling and choices in pregnancies with maternal cardiac disease

OBJECTIVE

Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy.

METHODS

All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score.

RESULTS

Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options.

CONCLUSION

Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.

A Mixed Methods Study of Contraceptive Counseling and Care at a Federally Qualified Health Center in Maryland

This study examined the experience of contraceptive counseling and care in a Federally Qualified Health Center in Maryland. Patients attending medical visits in 2021 were surveyed using the Interpersonal Quality of Family Planning scale to assess the quality of contraceptive counseling. Medical chart reviews were performed to identify alignment between contraceptive care received, and preferences patients had expressed. Primary care providers, reproductive health providers, and a subgroup of patients were interviewed to further contextualize survey and chart review findings. The average item score for the 94 survey participants was 4.39 (SD: 0.9) out of 5. Factor analysis showed high internal consistency reliability (alpha  =  0.96). Eighty percent of patients received contraceptive care that aligned with their preferences, 4% did not, and 16% lacked clear contraceptive preferences. Qualitative analysis revealed that patients desired more guidance from providers in selecting a contraceptive method, while providers noted logistical and insurance-related barriers to care. While the quality of contraceptive counseling was high, patient experience of care may be improved by implementing team-based care.

Validation and Predictive Utility of a Person-Centered Quality of Contraceptive Counseling (QCC-10) Scale in Sub-Saharan Africa: A Multicountry Study of Family Planning Clients and a New Indicator for Measuring High-Quality, Rights-Based Care

The lack of validated, cross-cultural measures for examining quality of contraceptive counseling compromises progress toward improved services. We tested the validity and reliability of the 10-item Quality of Contraceptive Counseling scale (QCC-10) and its association with continued protection from unintended pregnancy and person-centered outcomes using longitudinal data from women aged 15-49 in Burkina Faso, Kenya, and Nigeria. Psychometric analysis showed moderate-to-strong reliability (alphas: 0.73-0.91) and high convergent validity with greatest service satisfaction. At follow-up, QCC-10 scores were not associated with continued pregnancy protection but were linked to contraceptive informational needs being met among Burkinabe and Kenyan women; the reverse was true in Kano. Higher QCC-10 scores were also associated with care-seeking among Kenyan women experiencing side effects. The QCC-10 is a validated scale for assessing quality of contraceptive counseling across diverse contexts. Future work is needed to improve understanding of how the QCC-10 relates to person-centered measures of reproductive health.

Understanding quality of contraceptive counseling in the CHARM2 gender-equity focused family planning intervention: Findings from a cluster randomized controlled trial among couples in rural India

OBJECTIVES

The CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) intervention engages health care providers to deliver gender-equity and family planning sessions to couples using a person-centered shared decision-making approach for contraception counseling. We previously showed that the intervention improved contraceptive use at 9-month follow-up. We sought to assess whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use.

STUDY DESIGN

This is a planned secondary analysis of the effect of the CHARM2 intervention on 1201 married couples in rural Maharashtra, India in a cluster randomized controlled trial completed between 2018 and 2020. We assessed the effect of CHARM2 on perceived quality of care as measured by the Interpersonal Quality of Family Planning (IQFP) scale using a difference-in-differences linear regression approach including a mixed-effects model with nested random effects to account for clustering. We assessed whether the association between CHARM2 and modern contraceptive use was mediated by quality of family planning care.

RESULTS

Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, SD 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% CI 0.07-0.50).

CONCLUSION

Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve women's perceived quality of care. Effects on quality of care mediate observed effects of the intervention on contraceptive use.

IMPLICATIONS

Contraceptive interventions should focus on improving person-centered outcomes, such as quality of care, rather than contraceptive use targets. By focusing on improving person-centered care, interventions will improve contraceptive use among those who desire a method while meeting the holistic reproductive health needs of clients and couples.

Contraception for married adolescents (15-19 years) in India: insights from the National Family Health Survey-4 (NFHS-4)

Purpose

Despite the fact that marriage below the age of 18 years is illegal in India, a considerable number of females get married and start childbearing during their adolescent years. There is low prevalence of contraceptive methods and high unmet need for family planning (FP). Realizing this, new government programs have been launched to increase the uptake of sexual and reproductive health services among adolescents. However, evidence specific to this age group remains scarce.

Aim and objectives

The present study was conducted to assess the prevalence of modern contraceptives among married adolescents, and to determine its association with sociodemographic variables, health worker outreach, and media exposure to FP messages in India.

Methods

Data for this analysis was drawn from the fourth round of the National Family Health Survey (NFHS-4) conducted in India during 2015–16. The sample size is restricted to 13,232 currently married adolescent girls aged 15–19 years, who were not pregnant at the time of the survey. Bivariate and multivariate analysis were conducted to assess the levels of contraceptive use and its predictors among married adolescents.

Results

The use of modern contraceptives among married adolescents increased from 4 to 10% between 1992–93 and 2015–16. The uptake of modern contraceptives was found to be low among the uneducated, those residing in rural areas, among backward classes, those practising Hindu religion, women in the poorest wealth quintile, women without children, and those with no exposure to FP messages via media or health care workers. Among those who met health care workers and discussed FP issues with them, 34.11% were using modern contraceptives as compared to 11.53% of those who did not have discussions with health care workers.

Conclusions

The evidence suggests that contact with health care workers significantly influences the use of modern contraceptives. Further focus on increasing contact between married adolescents’ and health care workers, and improving the quality of counselling will protect adolescents from early marriage and pregnancy.

Complications related to early pregnancies and childbirth are a leading cause of death among adolescent girls. Still, a considerable number of young girls in India get married and start childbearing in adolescence. Data shows that 9% of the girls aged 15–19 years in rural areas and 5% in urban areas have already begun childbearing. The World Health Organisation (WHO) recommends access to high-quality sexual and reproductive health information and services as a fundamental right of adolescents. In recent years, the Indian government has also taken several initiatives to cater to the needs of adolescents.

The present study focuses on the levels of contraceptive use and the influence of health care workers and media outreach on the uptake of modern contraceptives among married adolescents in India.

Findings from the present study suggest that though there has been an increase in the use of modern contraceptives among married adolescents over time, overall the level of contraceptive use is very low. There is visible variation in the use of modern contraceptives depending on the educational status, residence, religion, caste, and household wealth of adolescent girls. Contact of married adolescents with health care workers positively influences the uptake of modern contraceptives. However, the proportion of married adolescents who had contact with health care workers is very low.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception

OBJECTIVE

To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program.

STUDY DESIGN

In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type.

RESULTS

Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use).

CONCLUSIONS

In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods.

IMPLICATIONS

State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.

Family Welfare Expenditure, Contraceptive Use, Sources and Method-Mix in India

Making universal access to sexual and reproductive health care a reality, and thus building momentum for comprehensive family planning by 2030, is key for achieving sustainable development goals. However, in the last decade, India has been retreating from progress achieved in access to family planning. Family planning progress for a large country such as India is critical for achieving sustainable developmental goals. Against this backdrop, the paper investigated the question of how far family welfare expenditure affects contraceptive use, sources of contraceptive methods, and method-mix using triangulation of micro and macro data analyses. Our findings suggest that, except for female sterilizations, modern methods of contraception do not show a positive relationship with family welfare expenditure. Notwithstanding a rise in overall family welfare expenditure, spending on core family planning programs stagnates. State-wise and socio-economic heterogeneity in source-mix and method-mix continued to influence contraceptive access in India. Method-mix continued to skew towards female sterilization. Public sector access is helpful only for promoting female sterilization. Thus, the source-mix for modern contraceptives presents a clear public-private divide. Over time, access to all contraceptive methods by public sources declined while the private sector has failed to fill the gap. In conclusion, this study identified a need for revitalizing family planning programs to promote spacing methods in relatively lower-performing states and socio-economic groups to increase overall contraceptive access and use in India through the rise in core family planning expenditure.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis

BACKGROUND

Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently.

METHODS

We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling.

RESULTS

The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected.

CONCLUSIONS

High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care.

TRIAL REGISTRATION

CTRI/2015/09/006219. Registered 28 September 2015.