Evaluation of an intervention to improve quality of care in family planning programme in the Philippines

Strengthening contraceptive counselling services to empower clients and meet their needs: protocol for a two-stage, multiphase complex intervention in Pakistan and Nigeria

BACKGROUND

High-quality contraceptive counselling can accelerate global efforts to reduce the unmet need for and suboptimal use of modern contraceptives. This study aims to identify a package of interventions designed to strengthen in Pakistan and Nigeria and determine their effectiveness in increasing client-level decision-making, autonomy and meeting of contraceptive needs.

METHODS

A multisite, two-stage and five-phase intervention design will start with a pre-formative, formative, design, experimental and reflective phase. The pre-formative phase will map potential study sites and establish the sampling frame. The two-part formative phase will first use participatory approaches to identify clients' perspectives, including young couples and providers, to ensure research contextualisation and address each interest group's needs and priorities followed by clinical observations of client-provider encounters to document routine care. The design workshop in the third phase will result in the development of a package of contraceptive counselling interventions. In the fourth experimental phase, a multi-intervention, three-arm, single-blinded, parallel cluster randomised-controlled trial will compare routine care (arm 1) with the contraceptive counselling package (arm 2) and the same package combined with wider methods availability (arm 3). The study aims to enrol a total of 7920 participants. The reflective phase aims to identify implementation barriers and enablers. The outcomes are clients' level of decision-making autonomy and use of modern contraceptives.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (Protocol ID Pakistan: ERC 006232 and Nigeria ERC: 006523). Each study site is required and has obtained the necessary ethical and regulatory approvals that are required in each specific country. Findings will be presented at local, national and international conferences and disseminated by peer-review publications.

TRIAL REGISTRATION NUMBER

NCT06081842.

Quality of family planning services and associated factors among reproductive age women attending family planning unit at public health facilities in Dire Dawa, Eastern Ethiopia, 2021

INTRODUCTION

Improving the quality of care has been a necessary goal for family planning programs worldwide. Even though extensive work has been done, the contraceptive prevalence rate is still low (41% in Ethiopia, 30.5% in Dire Dawa) and the unmet need for contraception is high (26%) in Ethiopia. Moreover, quality of care in family planning services has an important role in increasing coverage of services and program sustainability. Therefore, the objective of this study was to assess quality of family planning services and associated factors among reproductive age women attending family planning unit in public health facilities in Dire Dawa, Eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among reproductive-age women attending a family planning unit in Dire Dawa, Eastern Ethiopia, from September 1-30/2021. A total of 576 clients were selected by systematic random sampling and interviewed using a pre-tested structured questionnaire. SPSS version 24 was used to analyze the data, which included descriptive statistics, bi-variable and multivariable logistic regression analyses. To determine the presence of an association between dependent and independent variables, AOR, P-value 0.05, and 95% CI were used.

RESULTS

A total of 576 clients participated in the study and provided a response rate of 99%. The overall satisfaction of clients with FP services was 79%[95% CI:75.2%, 82.9%]. Having primary education (AOR = 2.11, 95% CI(1.11-4.24), convenient facility opening hours (AOR = 3.13, 95% CI (2.12-5.75), maintaining privacy (AOR = 4.1, 95% CI(2.50-8.12), demonstrating how to use F/P method (AOR = 1.98, 95% CI (1.01-5.20), and discussing F/P issues with husbands (AOR = 5.05, 95% CI: 3.33-7.64) were positively significantly associated with client satisfaction.

CONCLUSION AND RECOMMENDATION

This study revealed that about four-fifth of the clients was satisfied with the service they received. Clients' education, facility opening hour, maintained privacy, discussion with husband, and demonstration of how to use the methods were associated with client satisfaction. Therefore, health facility heads should improve facility opening hour. Health care providers should maintain client privacy every time, and should consistently utilize information, education, and communication materials during consultation sessions by giving more attention to client who has no education. Partner's discussion on family planning issues should also be encouraged.

Community perspectives on family planning service quality among users and non-users: a qualitative study from two cities in Burkina Faso

BACKGROUND

Most studies that focus on quality of family planning (FP) services collect data from facilities. These studies miss the perspectives of quality from women who do not visit a facility and for whom perceived quality may be a barrier to service utilization.

METHODS

This qualitative study from two cities in Burkina Faso examines perceived quality of FP services from women who were recruited at the community level to avoid potential biases based on recruiting women at facilities. Twenty focus group discussions were undertaken with varying groups of women of different ages (15-19; 20-24; 25+), marital statuses (unmarried; married), and current modern contraceptive use experiences (current non-users; current users). All focus group discussions were undertaken in the local language and transcribed and translated into French for coding and analysis.

RESULTS

Women discuss FP service quality in a variety of locations, depending on their age group. Perspectives on service quality for younger women are often informed by others' experiences whereas for the older women, they are formed by their own and others' experiences. Two important aspects of service delivery emerge from the discussions including interactions with providers and selected system-level aspects of service provision. Important components of provider interactions relate to (a) the initial reception from the provider, (b) the quality of counseling received, (c) stigma and bias from providers, and d) privacy and confidentiality. At the health system level, discussions revolved around (a) wait time; (b) stockouts of methods; (c) costs of services/methods; (d) the expectation for tests as part of service provision; and (e) difficulties with method removal.

CONCLUSIONS

To increase contraceptive use among women, it is crucial to address the components of service quality they identify as related to higher quality services. This means supporting providers to offer services in a more friendly and respectful manner. In addition, it is important to ensure that full information is provided to clients on what to expect during a visit to avoid false expectations that lead to poor perceived quality. These types of client-focused activities can improve perceptions of service quality and ideally support use of FP to meet women's needs.

Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling

INTRODUCTION

High-quality contraceptive counseling is critical for supporting full, free, and informed contraceptive decision-making. However, the quality of family planning counseling remains poor globally and is too often not tailored to the individual client. The Counseling for Choice (C4C) approach comprises provider tools and training to structure counseling to center clients' self-identified priorities and to provide relevant information and anticipatory side effects counseling.

METHODS

Providers at 25 public and 20 private facilities in Malawi were trained in the C4C approach. Between October and December 2018, we enrolled women seeking contraceptive services in intervention facilities and in matched comparison clinics in a quasi-experimental study. We collected data immediately before and after contraceptive services were received. We used multilevel logistic regression to compare dimensions of women's counseling experience.

RESULTS

Of 1,179 participants, women counseled by C4C-trained providers rated their providers higher on several quality dimensions, including enabling informed decision-making (11.1% of the comparison group rated their provider as excellent versus 34.4% in intervention), respectful care (35.0% comparison versus 51.3% intervention), and information given about side effects (38.1% comparison versus 72.5% intervention).

CONCLUSION

In Malawi, C4C improved the quality of care that clients received and their client experience relative to standard counseling. Counseling approaches that center clients' priorities and provide enhanced anticipatory side effects counseling show promise in improving contraceptive counseling experiences and the quality of care that clients receive.

Misconceptions, Misinformation, and Misperceptions: A Case for Removing the "Mis-" When Discussing Contraceptive Beliefs

Beliefs about contraception are commonly conceptualized as playing an important role in contraceptive decision-making. Interventions designed to address beliefs typically include counseling to dispel any "myths" or "misconceptions." These interventions currently show little evidence for impact in reducing beliefs. This commentary delves into the problems associated with using implicitly negative terminology to refer to contraceptive beliefs, which come laden with assumptions as to their validity. By conceptualizing women as getting it wrong or their beliefs as invalid, it sets the scene for dubious treatment of women's concerns and hampers the design of fruitful interventions to address them. To replace the multitude of terms used, we suggest using "belief" going forward to maintain value-free curiosity and remove any implicit assumptions about the origin or validity of a belief. We provide recommendations for measuring beliefs to help researchers understand the drivers and impacts of the belief they are measuring. Finally, we discuss implications for intervention design once different types of belief are better understood. We argue that tailored interventions by belief type would help address the root causes of beliefs and better meet women's broader contraceptive needs, such as the need for contraceptive autonomy and satisfaction.

The role of job aids in supporting task sharing family planning services to community pharmacists and patent proprietary medicine vendors in Kaduna and Lagos, Nigeria

Background

CPs and PPMVs are an important source of modern contraceptives in Nigeria, yet many lack the requisite knowledge and skills to capably provide these services. This skills gap might be addressed through targeted family planning (FP) training. This study measures family planning knowledge retention of CPs and PPMVs after receiving training in FP counseling and services in Kaduna and Lagos States, in Nigeria.

Methods

In a quasi-experimental longitudinal design without a comparison group, 559 CPs and PPMVs who were enrolled in the IntegratE project between January and December 2019, completed a self-administered questionnaire to assess their knowledge related to the provision of FP counseling, and injectable and implant contraceptive services at three points in time: 1) before the training; 2) immediately after the training; and 3) 9-months after the training in Kaduna and Lagos states, Nigeria. Adjusted multivariate logistic regression analysis was used to assess the effect of provider characteristics and receipt of job aids on FP knowledge retention 9 months after the training. 95% confidence intervals and p-values were used to assess statistical significance.

Results

Majority of study participants were females (60.3%) and between 30 and 49 years old (63.4%). The study revealed the importance of jobs aids as influence on knowledge retention. CPs and PPMVs who reported having the Balanced Counseling Strategy plus (BCS+) counseling cards, were more likely to retain knowledge (AOR: 2.92; 95% CI: 1.01–8.40, p-value = 0.05) at 9 months follow-up. Similarly, in terms of knowledge of injectable contraceptives, CPs and Tier 2 PPMVs who reported receiving the Medical Eligibility Criteria (MEC) Wheel were 2.1 times more likely to retain knowledge of injectable contraceptives 9-months later on (95% CI: 1.14–3.99, p-value = 0.02).

Conclusion

Community Pharmacists and Proprietary Medicine Vendors had good retention of family planning knowledge, especially when combined with job aids. Training and providing them with job aids on FP will therefore support task shifting and task sharing on family planning services provision in Nigeria.

The Know-Do Gap: Understanding and Improving Service Quality Among Pharmacies Providing Injectable Contraceptives Through a Mystery Client Study in Nepal

Private pharmacists in Nepal CRS Company's Sangini network provided quality counseling on injectable contraceptives to mystery clients, suggesting that pharmacists can successfully expand their family planning offerings and equip clients with the information needed to select an appropriate method of their choice.

Nepal is one of the first countries to license pharmacists to administer injectable contraceptives, through Nepal CRS Company's (CRS) Sangini private pharmacy network. There are more than 3,400 Sangini pharmacies in Nepal, including in hard-to-reach mountain areas, where these outlets are a key access point to injectables and other short-acting methods for those who lack access through the public sector or prefer the private sector.

We compared the performance of Sangini pharmacists in (1) CRS-led technical support visits, when providers were aware of being observed, and (2) mystery client visits, when providers were not aware of being observed, to assess any gaps between pharmacists' knowledge and practices. We also assessed how well Sangini providers counseled on injectables and compared counseling on injectables with counseling for oral contraceptives.

We found high levels of adherence to training guidelines on counseling on injectables. However, we identified significant differences between pharmacists' understanding of what they should do and what they actually do in practice, referred to as the know-do gap, in providing privacy, assessing client needs, and determining medical eligibility for hormonal methods. CRS took several steps to narrow the know-do gap through its programming, which may be a useful example for other countries as they expand the role of pharmacies in family planning service provision. Despite highlighting several areas for improvement, the findings show that Sangini providers both know how to and practice appropriate counseling on both injectable and oral contraceptives, suggesting that pharmacists can successfully expand their family planning offerings and equip clients with the information needed to select an appropriate method of their choice.

What Distinguishes Women Who Choose to Self-Inject? A Prospective Cohort Study of Subcutaneous Depot Medroxyprogesterone Acetate Users in Ghana

Depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) is an all-in-one injectable contraceptive administered every 3 months, either by a trained health care provider or community health worker or by training a client to self-inject. Using a prospective cohort of family planning (FP) clients in Ghana, this study explores patterns of DMPA-SC use and mode of injection administration over a 6-month period. This study also examines the predictors of self-injection adoption 6 months after initiating DMPA-SC. Our analysis focuses on 378 women who were using DMPA-SC at the 6-month interview. Adjusted odds ratios accounting for clustering show that clients who were new FP users, never married, or attended high school/attained higher education were significantly more likely to self-inject by the third injection. Results of this study suggest that in Ghana, adding DMPA-SC to the method mix may improve access to FP, especially among new users. Results of this study may inform FP projects and programs aiming to improve access to contraceptive methods and increase contraceptive prevalence by introducing or scaling up DMPA-SC self-injection. The findings also provide a sociodemographic profile of FP clients most likely to adopt DMPA-SC self-injection over time, which could serve as an evidence base for social marketing strategies.

How Much Do Side Effects Contribute to Discontinuation? A Longitudinal Study of IUD and Implant Users in Senegal

Introduction

In Senegal, discontinuation due to sides effects of long-acting, reversible contraceptives (LARCs) is relatively low; 5% of new implant acceptors and 11% of new IUD acceptors stop using in their first year because of health or side effect concerns. This study investigated factors associated with LARC discontinuation in the first 12 months of use in Senegal and explored how LARC users cope with side effects.

Methods

This mixed-method study involved quantitative interviews at five time points with LARC acceptors recruited from three service channels between February 2018 and March 2019. Qualitative interviews were conducted in August 2018 with a subset of those who experienced side effects. Logistic regression models identified factors associated with discontinuation due to side effects and discontinuation for any reason. Twelve-month discontinuation rates due to side effects were also estimated using a cumulative incidence function (CIF) approach to account for time to discontinuation.

Results

In logistic models, method choice (IUD or implant) [OR = 3.15 (95% CI: 1.91–5.22)] and parity [OR = 0.81 (95% CI: 0.7–0.94)] were associated with discontinuation due to side effects; IUD users and women with fewer children were more likely to discontinue. Results for all-cause discontinuation were similar: method choice [OR = 2.39 (95% CI: 1.6–3.58)] and parity [OR = 0.86 (95% CI: 0.77–0.96)] were significant predictors. The 12-month side effect CIF discontinuation rate was 11.2% (95% CI: 7.9–15.0%) for IUDs and 4.9% (95% CI: 3.5–6.6%) for implants. Side effect experiences varied, but most women considered menstrual changes the least acceptable. No statistically significant differences across services channels were observed.

Conclusions

In this study in Senegal, the choice between implants and IUDs had a significant impact on continuation, and women with more children continued LARC methods longer, despite side effects.

Leveraging the Client-Provider Interaction to Address Contraceptive Discontinuation: A Scoping Review of the Evidence That Links Them

Despite considerable investment and effort, unmet need for contraception remains an obstacle to improved family planning outcomes. One influencing factor is the frequency of contraceptive discontinuation among users who desire to prevent pregnancy, often due to method-related concerns and side effects. Contraceptive users have the right to be supported during counseling to voluntarily choose methods that align with their individual needs and preferences. Contraceptive counseling, as a key component of quality of care, is particularly important for providers to reduce unmet need among their clients. This scoping review examined the state of the evidence on contraceptive counseling and its impact on discontinuation. The review first examines the association between quality of care and contraceptive discontinuation, then looks to what the current body of evidence suggests are women's contraceptive counseling priorities, and lastly, explores whether specific counseling tools and approaches have been evaluated with discontinuation as an outcome. The results identified general principles and priorities for good counseling including person-centeredness, client-tailored information exchange, clear and concise information on side effects and bleeding changes, reducing providers' implicit and explicit biases, and trust and respect between the client and provider. The review of the literature also found that evidence to support the use of specific counseling tools and approaches to reduce contraceptive discontinuation is insufficient; research should be designed to determine which specific elements of the client-provider interaction can be improved to significantly impact contraceptive discontinuation. This evidence could inform how the global community of practice might improve and leverage specific counseling approaches and tools to address the most common predictors of discontinuation.

Assessment of segmentation and targeted counseling on family planning quality of care and client satisfaction: a facility-based survey of clients in Niger

BACKGROUND

Niger demonstrates high fertility and low contraceptive use that are typical in much of the West and Central African region. The government of Niger has committed to increasing modern contraceptive use as part of its health strategy. Designing and testing strategies to improve quality of care and satisfaction of family planning clients is important for addressing low contraceptive use in contexts like Niger.

METHODS

This study uses recently collected client exit interview data from 2720 clients surveyed in the Dosso region of Niger to examine whether implementation of segmentation-based counseling leads to improved quality of services and client satisfaction. We compare three scenarios: a) facilities where segmentation counseling was implemented since 2017; b) facilities where segmentation counseling began in late 2019; and c) facilities without segmentation counseling. Bivariate and multivariate analyses are undertaken to determine if there are differences in quality of services and client satisfaction between the facility groups and between clients that were segmented and those who were not segmented in the first two scenarios.

RESULTS

Results demonstrate that clients in facilities with segmentation generally received better quality services than clients in facilities without segmentation. Clients in facilities implementing segmentation longer reported higher quality services than the recent segmentation facilities. Clients who were segmented compared to those who were not segmented also reported better quality services. New clients reported higher quality services than returning clients and among new clients, those who were segmented also reported higher quality services. No differences were found in client satisfaction between facility scenarios or between segmented and non-segmented clients.

CONCLUSIONS

These findings demonstrate that segmentation or another targeted counseling strategy could be useful to the government of Niger to improve the quality of services offered. As part of the scale up process, the government needs to consider strategies that ensure that all new clients are segmented and design an approach that is sustainable and does not risk failing should there be stock-out of segmentation sheets or loss of counseling cards. This type of targeted counseling could improve the quality of services offered and ideally lead to increased contraceptive use in Niger.

Advancing Rights-Based Family Planning from 2020 to 2030

Introduction

An assessment in 2019 by Family Planning 2020 of progress on rights-based family planning since 2012 highlighted the development of tools and guidelines that identify and explain rights in relation to family planning, promotion of rights-based approaches to programing, strengthened accountability, and measurement of rights-focused outcomes. The assessment was also forward-looking, asking what aspects of rights-based family planning still need attention moving from 2020 to 2030.

Methods

This paper draws on interviews with 23 key informants from governments, civil society, and youth focused organizations, implementing partners, and bi-lateral and multilateral organizations from Africa, Asia and the Pacific, Europe and North America, all working on family planning and engaged in various roles with the FP2020 partnership at global and national levels, along with documentation of FP2030 partnership plans. The interviews were conducted as part of the assessment and included questions to respondents for their recommendations on rights-based family planning moving towards 2030.

Results

Respondents agreed that rights should be at the center of the vision for family planning, with attention to rights literacy, accountability and equity, including adolescent and youth leadership. They noted the need for consistent political and financial support, and incorporating rights into result-based financing programming. While respondents noted the need for development and dissemination of practical tools and training materials, along with rights metrics and implementation research, they stressed the importance of focusing work on rights at the country level. Respondents also acknowledged that institutionalizing rights-based family planning will require enhanced commitment and funding from both donors and countries to ensure programming – and success – over the long term. Amplifying civil society and particularly adolescent and youth voices will be key to engaging governments to support both rights-based programming and provide funding. Review of initial planning under FP2030 related to each of the recommendations suggests that the new partnership is seeking to addressing each of them.

Discussion

As the family planning field looks beyond 2020 to 2030, this paper provides a roadmap for building on the gains made over the past decade to effectively tackle the challenges remaining to ensure that programming to achieve the vision of the FP2030 Partnership is rights-based.

The road from ICPD to SDGs: Health returns of reducing the unmet need for family planning in India

OBJECTIVE

This study attempts to estimate the impact of reducing the unmet need for family planning on the key maternal and child health indicators in India from 1993 to 2016, and projecting this for the period from 2016 to 2030.

DATA AND METHODS

The data have been compiled from various sources such as the United Nations' World Population prospects, national family health surveys and the sample registration system. The family planning and demographic projection modules of 'Spectrum', a modular computer simulation program, were used to estimate the impact of family planning programmes on reproductive, maternal and child health outcomes in India from 1993 to 2030.

RESULTS

Reduction of the unmet need for family planning averted approximately 56 million unintended pregnancies, 7 million unsafe abortions and 167,000 maternal deaths between 1993 and 2016. It is expected that an additional 41 million unintended pregnancies, 5 million unsafe abortions and 124,000 maternal deaths can be avoided by reducing the unmet need for family planning to 5% by 2030. Similarly, the declining unmet need for family planning between 1993 and 2016 led to a reduction in the pregnancy rate, abortion rate, and risk-adjusted infant and under-five mortality rates by 27 per 1000 married women, 1.8 per million married women, 10 per 1000 live births and 15 per 1000 live births, respectively. It is expected that approximately 24 pregnancies per 1000 married women, 1.6 abortions per million married women, 10 risk adjusted infant deaths per 1000 live births, and 14 under-five deaths per 1000 live births can be avoided by reducing the unmet need for family planning to 5% by 2030.

CONCLUSIONS

The findings of this study advocate that family planning is one of the best return on-investment strategies for India to achieve several targets under the reproductive, maternal and child health-related sustainable development goals.

Understanding factors associated with continuation of intrauterine device use in Gujarat and Rajasthan, India: a cross-sectional household study

The Government of India has promoted the expansion of access to and uptake of intrauterine devices (IUDs), during both the interval (IIUD) and postpartum (PPIUD) periods, as part of its Family Planning 2020 initiative. This study, conducted by EngenderHealth as part of the Expanding Access to IUD Services in India project, examines IIUD and PPIUD continuation rates over time and investigates factors associated with IUD continuation. We recruited respondents (N = 5024) through a repeated cross-sectional household study between February and December 2019. We identified respondents using IUD client data from public health facility registers in 20 districts of Gujarat and Rajasthan. We compared continuation rates for IIUD and PPIUD adopters and used regression analyses to measure the association between continuation and demographic, quality of care, and counselling variables. IIUD continuation rates decreased from 85.6% to 78.3% and PPIUD rates decreased from 78.5% to 70.7% between month 3 and month 12. Clients experiencing side effects or other problems were 15 times more likely to discontinue IUD use than clients who did not. Clients who received IUD counselling prior to insertion were more likely to continue than those who did not. IUD continuation increased significantly in cases where both partners jointly selected the method compared to situations where women decided alone. Several sociodemographic factors were associated with continuation. Our study demonstrates the value and benefits of programmes offering IUD services emphasising quality counselling and client-centred care to increase access, uptake, and continuation.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial

BACKGROUND

Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH.

METHODS

We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169).

RESULTS

A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001).

CONCLUSION

We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings.

TRIAL REGISTRATION

NCT02964169.

'I haven't heard much about other methods': quality of care and person-centredness in a programme to promote the postpartum intrauterine device in Tanzania

BACKGROUND

Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method's high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South.

METHODS

Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics. Using a modified version of the contraceptive counselling quality framework elaborated by Holt and colleagues, we blend deductive analysis with an inductive approach based on open coding and thematic analysis.

RESULTS

Interpersonal aspects of relationship building during counselling were strong, but a mix of PPIUD intervention-related factors and structural issues rendered most other aspects of counselling quality low. The intervention led providers to emphasise the advantages of the IUD through biased counselling, and to de-emphasise the suitability of other contraceptive methods. Respondents reported being counselled only about the IUD and no other methods, while other respondents reported that other methods were mentioned but disparaged by providers in relation to the IUD. A lack of trained providers meant that most counselling took place in large groups, resulting in providers' inability to conduct needs assessments or tailor information to women's individual situations.

DISCUSSION

As implemented, LARC-centric programmes like this PPIUD intervention may decrease access to person-centred contraceptive counselling and to accurate information about a broad range of contraceptive methods. A shift away from emphasising LARC methods to more comprehensive, person-centred contraceptive counselling is critical to promote contraceptive autonomy.

Lot quality assurance sampling: Information provided to female users of contraceptive methods regarding side effects

Women need to receive accurate information on the proper use of contraceptive methods (CM). The objective of our analysis was to evaluate the quality of CM counseling in health institutions of the public sector using the Lot Quality Assurance Sampling (LQAS) technique. We specifically analyzed whether health-service providers informed CM users of all the side effects they might experience, as specified under the Mexican health-care regulations. Our results demonstrated that, among the four CM analyzed -the intrauterine device, hormonal injection, condom and subdermal implant- only the users of the subdermal implant received complete information on side effects. Our findings thus indicate that the quality of family planning services in the institutions analyzed is deficient. We recommend that service providers be regularly trained in order to improve their performance and that LQAS methodology be adopted as an effective means of regularly monitoring the quality of health services in Mexico.

A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't?

AIM

The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages.

METHODS

Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered.

RESULTS

A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types.

CONCLUSIONS

The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

H, P. A, K. P. K, J. B. Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC

Background

Kinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation.

Methodology

This community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation.

Results

A total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3.

Conclusion

In addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision-makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost-effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision-makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

Improving Voluntary, Rights-Based Family Planning: Experience From Nigeria And Uganda

BACKGROUND

Growing focus on the need for voluntary, rights-based family planning (VRBFP) has drawn attention to the lack of programs that adhere to the range of rights principles. This paper describes two first-of-their-kind interventions in Kaduna State, Nigeria and in Uganda in 2016-2017, accompanied by implementation research based on a conceptual framework that translates internationally agreed rights into family planning programming.

METHODS

This paper describes the interventions, and profiles lessons learned about VRBFP implementation from both countries, as well as measured outcomes of VRBFP programming from Nigeria.

RESULTS

The intervention components in both projects were similar. Both programs built provider and supervisor capacity in VRBFP using comparable curricula; developed facility-level action plans and supported action plan implementation; aimed to increase clients' rights literacy at the facility using posters and handouts; and established or strengthened health committee structures to support VRBFP. Through the interventions, rights literacy increased, and providers were able to see the benefits of taking a VRBFP approach to serving clients. The importance of ensuring a client focus and supporting clients to make their own family planning choices was reinforced. Providers recognized the importance of treating all clients, regardless of age or marital status, for example, with dignity. Privacy and confidentiality were enhanced. Recognition of what violations of rights are and the need to report and address them through strong accountability systems grew. Many lessons were shared across the two countries, including the need for rights literacy; attention to health systems issues; strong and supportive supervision; and the importance of working at multiple levels. Additionally, some unique lessons emanated from each country experience.

CONCLUSION

The assessed feasibility and benefits of using VRBFP programming and outcome measures in both countries bode well for adoption of this approach in other geographies.

Do Indian women receive adequate information about contraception?

This study analysed the recent changes and patterns of information received about contraceptive methods by contraceptive users in India - an important indicator of quality of care in family planning services. Data were taken from the third and fourth rounds of National Family and Health Surveys (NFHS) conducted in India during 2005-06 and 2015-16. The Method Information Index (MII) was used to capture the information received by respondents on three aspects of contraceptive method use: information about the side-effects of the method, what to do if they experienced any complication from using the method and information received about other methods of contraception. A separate analysis of information received by users about the permanency of sterilization was also carried out. Logistic regression models were applied to assess the independent effects of users' background characteristics and their states and union territories of residence on method information received by them. The value of the MII nearly doubled from about 16% in 2004-05 to 31% in 2015-16, indicating a marked increase in the information received by contraceptive users in India over the period between 2005-06 and 2015-16. In addition, the percentage of sterilized women who received information about the permanency of the method also increased, from 67% to 80%, over the period. While considerable progress has been made in the last decade, there is still plenty of scope for improvement in the information received by contraceptive users to advance a voluntary approach to family planning.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services

Rights principles should be prioritized and more clearly stated in performance-based financing (PBF) guidance and operational documents. Additional research, including development of validated measurement metrics, is needed to help PBF programs systematically align with rights-based approaches to health care including family planning.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.

Choice of contraceptive methods in public and private facilities in rural India

Background

Client-centric quality of care (QoC) in family planning (FP) services are imperative for contraceptive method adoption and continuation. Less is known about the choice of contraceptive method in India beyond responses to the three common questions regarding method information, asked in demographic and health surveys. This study argues for appropriate measurement of method choice and assesses its levels and correlates in rural India.

Methods

A cross-sectional study was conducted with new acceptors of family planning method (N = 454) recruited from public and private health facilities in rural Bihar and Uttar Pradesh, the two most populous states in India. The key quality of care indicator ‘method choice’ was assessed using four key questions from client-provider interactions that help in making a choice about a particular method: (1) whether the provider asked the client about their preferred method, (2) whether the provider told the client about at least one additional method, (3) whether the client received information without any single method being promoted by the provider, and (4) client’s perception about receipt of method choice. The definition of method choice in this study included women who responded “yes” to all four questions in the survey. The relationship between contraceptive communication and receipt of method choice was assessed using logistic regression analyses, after adjusting for socio-demographic characteristics of the respondents.

Results

Although 62% of clients responded to a global question and reported that they received the method of their choice, only 28% received it based on responses about client-provider interactions. Receipt of the information on side-effects of the selected method (Adjusted Odds Ratio [AOR]: 7.4, 95% Confidence Interval [CI]: 3.96–13.86) and facility readiness to provide a range of contraceptive choice (AOR: 2.67, 95% CI: 1.48–4.83) were significantly associated with receipt of method choice.

Conclusions

Findings demonstrated that women’s choice of contraceptive could be improved in rural India if providers give full information prior to and during the acceptance of a method and if facilities are equipped to provide a range of choice of contraceptive methods.

Development and Validation of the Client-Reported Quality of Contraceptive Counseling Scale to Measure Quality and Fulfillment of Rights in Family Planning Programs

We developed the Quality of Contraceptive Counseling (QCC) Scale to improve measurement of client experiences with providers in the era of rights‐based service delivery. We generated scale items drawing on the previously published QCC Framework and qualitative research on women's preferences for counseling in Mexico, and refined them through cognitive interviews (n = 29) in two Mexican states. The item pool was reduced from 35 to 22 items after pilot testing using exit interviews in San Luis Potosí (n = 257). Exploratory Factor Analysis revealed three underlying dimensions (Information Exchange, Interpersonal Relationship, Disrespect and Abuse); this dimensionality was reproduced in Mexico City (n = 242) using Confirmatory Factor Analysis. Item Response Theory analyses confirmed acceptable item properties in both states, and correlation analyses established convergent, predictive, and divergent validity. The QCC Scale and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and should be evaluated and adapted in other contexts.

Validation of Two Quality of Care Measures: Results from a Longitudinal Study of Reversible Contraceptive Users in India

Bruce's quality of care framework, developed nearly three decades ago, brought needed international attention to family planning services. Various data collection efforts exist to measure the quality of contraceptive services. Our study validates two process quality measures and tests their predictive validity related to contraceptive continuation among 2,699 married women who started to use a reversible contraceptive method in India. We assessed four process quality domains with 22 items, which were reduced to 10 items using exploratory factor analysis. Weighted additive indices were calculated for the 22- and 10-item measures. Scores were trichotomized into high, medium, and low process quality received. The predictive validity of the two measures was assessed related to modern contraceptive continuation three months later. The adjusted odds of continuing a modern contraceptive three months later was nearly three times greater (AOR: 2.78; 95% CI: 1.83-4.03) for women who received high process quality at enrollment compared with low quality with the 22-item measure, and 2.2 times greater (95% CI: 1.46-3.26) with the 10-item measure. Results suggest that the 22- and 10-item measures are valid, and while the larger 22-item measure can be used in special studies, the 10-item measure is more suited for routine data collection and monitoring.

Association Between the Quality of Contraceptive Counseling and Method Continuation: Findings From a Prospective Cohort Study in Social Franchise Clinics in Pakistan and Uganda

Higher scores on the 3-question Method Information Index (MII)—measuring client-reported receipt of contraceptive information—was associated with continued use of family planning over 12 months. We recommend incorporating use of the MII in routine assessments of family planning service quality.

Quality of family planning counseling is likely associated with whether or not women continue to use the same contraceptive method over time. The Method Information Index (MII) is a widely available measure of contraceptive counseling quality but little is known about its association with rates of method continuation. The index ranges from 0 to 3 based on a client's answer to whether she was told about other methods, potential side effects with her chosen method, and what to do if she experienced side effects. Using data from a prospective cohort study of 1,998 social franchise clients in Pakistan and Uganda, we investigated the relationship between reported baseline MII and the risk of method continuation over 12 months using survival analysis and Cox proportional hazard models. At baseline, about 65% of women in Pakistan and 73% of women in Uganda reported receiving information about all 3 MII aspects. In Pakistan, 59.4% of the 165 women who stopped using their modern method did so while still in need of contraception. In Uganda, of the 77 women who stopped modern method use, 64.9% discontinued while in need. Despite important differences in the demographics and method mix between the 2 countries, we found similar associations between baseline MII and discontinuation: in both countries as the MII score increased, the risk of discontinuation while in need decreased. In Pakistan, the risk of contraceptive discontinuation was 64% lower (crude hazard ratio [HR_crude]=0.36; P=.03), and 72% lower (HR_crude=0.28; P=.007), among women who were told about any 2, or any 3 aspects of MII, respectively. After adjusting for additional covariates, only the difference in the risk of contraceptive discontinuation between MII=3 and MII=0 remained statistically significant (HR_adj=0.35; P=0.04). In Uganda, women who reported being informed about all aspects of MII were 80% less likely to discontinue while in need (HR_adj=0.20; P<.001), women informed about any 2 aspects of MII were 90% less likely (HR_adj=0.10; P<.001), and women who were informed about any 1 aspect of MII were 68% less likely (HR_adj=0.32; P<.02) to discontinue contraceptive use while in need as compared to women who reported not being informed about any aspect of MII. Baseline MII scores were positively associated with method continuation rates in our sample of clients from social franchises in both Pakistan and Uganda and could potentially be used as an indicator of contraceptive counseling quality.

Interventions to improve the person-centered quality of family planning services: a narrative review

Person-centered care, a key component of quality of care, is receiving increased attention for maternal and reproductive health. While many interventions have aimed to improve person-centered care for family planning, there is no known narrative review of person-centered-focused interventions in family planning and the outcomes of these interventions. This narrative review fills this gap by conducting a rigorous analysis of interventions that address person-centered care and measure family planning related outcomes, including quality, knowledge and use/continuation. The search of the published and grey literature, from 1990 to 2015 identified 5530 papers, of which 25 were ultimately included in the analysis (after exclusion criteria was applied). We grouped these interventions under seven domains of person-centered care: dignity, autonomy, privacy/confidentiality, communication, social support, supportive care, and trust. We find that person-centered interventions had high success in improving perceptions of quality and knowledge of family planning among clients; however, results were less consistent in improving family planning uptake and continuation. These findings will help program and policy makers develop interventions that incorporate person-centered components to have the highest likelihood for success in improving clients' experiences and family planning use.

Women's preferences for contraceptive counseling in Mexico: Results from a focus group study

BACKGROUND

Client-centered contraceptive counseling is critical to meeting demand for contraception and protecting human rights. However, despite various efforts to optimize counseling, little is known outside of the United States about what individuals themselves value in counseling. In the present study we investigate women's preferences for contraceptive counseling in Mexico to inform efforts to improve service quality.

METHODS

We conducted applied qualitative research, using six focus group discussions with 43 women in two cities in Mexico with distinct sizes and sociocultural contexts (Mexico City and Tepeji del Río, Hidalgo) to assess contraceptive counseling preferences. We used a framework approach to thematically code and analyze the transcriptions from focus groups.

RESULTS

Consistent with quality of care and human rights frameworks for family planning service delivery, participants expressed a desire for privacy, confidentiality, informed choice, and respectful treatment. They expanded on usual concepts of respectful care within family planning to include avoidance of sexual assault or harassment-in line with definitions of respectful care in maternal health. In contrast to counseling approaches with method effectiveness as the organizing principle, participants preferred counseling centered on personalized assessments of needs and preferences. Many, particularly older, less educated women, highly valued hearing provider opinions about what method they should use, based on those personalized assessments. Participants highlighted the necessity of clinical assessments or physical exams to inform provider recommendations for appropriate methods. This desire was largely due to beliefs that more exhaustive medical exams could help prevent negative contraceptive outcomes perceived to be common, in particular expulsion of intra-uterine devices (IUDs), by identifying methods compatible with a woman's body. Trust in provider, built in various ways, was seen as essential to women's contraceptive needs being met.

CONCLUSIONS

Findings shed light on under-represented perspectives of clients related to counseling preferences. They highlight specific avenues for service delivery improvement in Mexico to ensure clients experience privacy, confidentiality, informed choice, respectful treatment, and personalized counseling-including around reasons for higher IUD expulsion rates postpartum-during contraceptive visits. Findings suggest interventions to improve provider counseling should prioritize a focus on relationship-building to foster trust, and needs assessment skills to facilitate personalization of decision-making support without imposition of a provider's personal opinions. Trust is particularly important to address in family planning given historical abuses against women's autonomy that may still influence perspectives on contraceptive programs. Findings can also be used to improve quantitative client experience measures.

Predictors of DMPA-SC continuation among urban Nigerian women: the influence of counseling quality and side effects

Objectives

In 2015, private healthcare providers in Nigeria introduced DMPA-SC (depot medroxyprogesterone acetate administered subcutaneously) into the method mix. We aimed to [1] examine the sociodemographic predictors of continued DMPA-SC use after 3 months, and [2] characterize the additional influences of contraceptive counseling quality and experiences of side effects on continuation.

Study design

From March to August, 2016, we conducted phone interviews with a convenience sample of women obtaining DMPA-SC from selected providers to survey them about their experience obtaining an initial dose of DMPA-SC. Study coordinators contacted women again about 3 months later after when they were due for reinjection. We used logistic regressions to examine the likelihood of having obtained a subsequent dose of DMPA-SC at follow-up as predicted by sociodemographic characteristics, a quality of counseling indicator based on responses to a 14-item scale, and reports of side effects experienced.

Results

Of the 541 DMPA-SC users who completed the first survey, 311 were reached again via phone after 3 months to conduct a second survey. Multivariate results for sociodemographic predictors of continued DMPA-SC use show that those with some college education or more (OR=2.79; 95% CI: 1.09–7.14), and those with four or more children (OR=2.89; 95% CI: 1.09 0 7.67) were more likely to obtain another dose. Our summary quality measure showed that women overall rated the quality of their initial counseling session high. Logistic regressions indicated that higher quality during the initial counseling session is related to the likelihood of getting another dose of DMPA-SC (OR=2.04; 95% CI: 1.12–3.47) whereas experiencing more bleeding reduced the likelihood of continuation after 3 months (OR=0.15; 95% CI: 0.07–0.34).

Conclusions

Among urban Nigerian women, both counseling quality and experiencing side effects were important factors in predicting continued use of DMPA-SC after 3 months. These findings are consistent with previous studies of DMPA and injectable contraception continuation.

Implications

New contraceptive methods that are designed for increased access and ease of use, combined with high quality provision, have potential to increase contraceptive use in settings with low levels of contraceptive prevalence. Higher quality counseling can help encourage women's continuation of a new injectable contraceptive method at 3 months.

Estimates of Side Effects Counseling in Family Planning Using Three Data Sources: Implications for Monitoring and Survey Design

With growing attention to monitoring and improving quality of care, it is critical to have evidence-based recommendations to measure quality of care indicators and guidelines to interpret estimates from different data sources. This study facilitates methodological discussion regarding measurement of counseling for side effects in family planning, a critical component of quality. The study assesses and compares estimates of side effects counseling based on three data sources. Data came from nationally representative facility and household surveys, Service Provision Assessments, and Demographic and Health Surveys in four countries. The level of side effects counseling was unacceptably low and varied systematically by data source. Compared to observation data in the facility survey, exit interview data from the survey overestimated the level substantially, and its reporting had poor predictive value. Estimates from household surveys were comparable with the observation-based estimates applying the minimum definition of counseling. In monitoring quality of care, data sources should be carefully reviewed, and estimates may need to be adjusted if the sources are inconsistent.

Measuring Access to Family Planning: Conceptual Frameworks and DHS Data

Expanding access to family planning (FP) is a driving aim of global and national FP efforts. The definition and measurement of access, however, remain nebulous, largely due to complexity. This article aims to bring clarity to the measurement of FP access. First, we synthesize key access elements for measurement by reviewing three well-known frameworks. We then assess the extent to which the Demographic and Health Surveys (DHS)-a widely used data source for FP programs and research-has information to measure these elements. We finally examine barriers to access by element, using the latest DHS data from four countries in sub-Saharan Africa. We discuss opportunities and limitations in the measurement of access, the importance of careful interpretation of data from population-based surveys, and recommendations for collecting and using data to better measure access.

INFORMATION ABOUT METHODS RECEIVED BY CONTRACEPTIVE USERS IN INDIA

Very little is known, at national and state levels, about how much information women in India are receiving about the method of contraception they are using. The purpose of this study was to fill this gap in knowledge. A Method Information Index (MII) was calculated from the responses of women who started using a modern contraceptive method five years prior to interview, and who were still using it at the time of interview, in the third National Family Health Survey conducted in India in 2005–06. The women were asked whether at the time they initiated contraceptive use they were told about other methods they could use, the side-effects of their selected method and what to do if they experienced these side-effects. The MII values (percentages of women who responded ‘yes’ to all three questions) were calculated for each category of women’s characteristics to show the relationship between MII and each characteristic. Mixed-effect logistic regression models were used to assess the independent effect of each variable after controlling for the effects of other variables on MII. The results indicate that contraceptive users in India in 2005–06 were receiving very little information about the method they were using: only 15.6% of contraceptive users reported receiving information on all three items. This low level was prevalent across different socioeconomic strata and across all the major states. There were a few exceptions, but the level was still quite low. Clearly, there is plenty of scope to improve the content of information exchanged between service providers and clients in order to ensure the rights of women to receive services of good quality, as well as improve informed choice and continuity of contraceptive use. Such a focus on improving quality of services is likely to help the Ministry of Health and Family Welfare in making its stated transition from a ‘population control centric’ to a ‘reproductive rights based’ approach to family planning in India.

Evaluating the impact of social franchising on family planning use in Kenya

BACKGROUND

In Kenya, as in many low-income countries, the private sector is an important component of health service delivery and of providing access to preventive and curative health services. The Tunza Social Franchise Network, operated by Population Services Kenya, is Kenya's largest network of private providers, comprising 329 clinics. Franchised clinics are only one source of family planning (FP), and this study seeks to understand whether access to a franchise increases the overall use or provides another alternative for women who would have found FP services in the public sector.

METHODS

A quasi-experimental study compared 50 catchment areas where there is a Tunza franchise and no other franchised provider with 50 purposively matched control areas within 20 km of each selected Tunza area, with a health facility, but no franchised facility. Data from 5609 women of reproductive age were collected on demographic and socioeconomic status, FP use, and care-seeking behavior. Multivariate logistic regression, with intervention and control respondents matched using coarsened exact matching, was conducted.

RESULTS

Overall modern contraceptive use in this population was 53 %, with 24.8 % of women using a long-acting or permanent method (LAPM). There was no significant difference in odds of current or new FP use by group, adjusted for age. However, respondents in Tunza catchment areas are significantly more likely to be LAPM users (adj. OR = 1.49, p = 0.015). Further, women aged 18-24 and 41-49 in Tunza catchment areas have a significantly higher marginal probability of LAPM use than those in control areas.

CONCLUSIONS

This study indicates that access to a franchise is correlated with access to and increased use of LAPMs, which are more effective, and cost-effective, methods of FP. While franchised facilities may provide additional points of access for FP and other services, the presence of the franchise does not, in and of itself, increase the use of FP in Kenya.

Measuring and monitoring quality of care in family planning: are we ignoring negative experiences?

Despite decades of emphasis on quality of care, qualitative research continues to describe incidents of poor quality client–provider interactions in family planning provision. Using an emerging framework on disrespect and abuse (D and A) in maternal health services, we reviewed the global published literature for quantitative tools that could be used to measure the prevalence of negative client experiences in family planning programs. The search returned over 7,000 articles, but only 12 quantitative tools included measures related to four types of D and A (non-confidential care, non-dignified care, non-consented care, or discrimination). We mapped individual measurement items to D and A constructs from the maternal health field to identify measurement gaps for family planning. We found significant gaps; current tools are not adequate for determining the prevalence or impact of negative client experiences in family planning programs. Programs need to invest in tools that describe all aspects of client experiences, including negative experiences, to increase accountability and maximize the impact of current investments in family planning programs.

Taking stock: protocol for evaluating a family planning supply chain intervention in Senegal

BACKGROUND

In Senegal, only 12% of women of reproductive age in union (WRAU) were using contraceptives and another 29% had an unmet need for contraceptives in 2010-11. One potential barrier to accessing contraceptives is the lack of stock availability in health facilities where women seek them. Multiple supply chain interventions have been piloted in low- and middle-income countries with the aim of improving contraceptive availability in health facilities. However, there is limited evidence on the effect of these interventions on contraceptive availability in facilities, and in turn on family planning use in the population. This evaluation protocol pertains to a supply chain intervention using performance-based contracting for contraceptive distribution that was introduced throughout Senegal between 2012 and 2015.

METHODS

This multi-disciplinary research project will include quantitative, qualitative and economic evaluations. Trained researchers in the different disciplines will implement the studies separately but alongside each other, sharing findings throughout the project to inform each other's data collection. A non-randomised study with stepped-wedge design will be used to estimate the effect of the intervention on contraceptive stock availability in health facilities, and on the modern contraceptive prevalence rate among women in Senegal, compared to the current pull-based distribution model used for other commodities. Secondary data from annual Service Provision Assessments and Demographic and Health Surveys will be used for this study. Data on stock availability and monthly family planning consultations over a 4-year period will be collected from 200 health facilities in five regions to perform time series analyses. A process evaluation will be conducted to understand the extent to which the intervention was implemented as originally designed, the acceptability of third-party logisticians within the health system and potential unintended consequences. These will be assessed using monthly indicator data from the implementer and multiple ethnographic methods, including in-depth interviews with key informants and stakeholders at all levels of the distribution system, observations of third-party logisticians and clinic diaries. An economic evaluation will estimate the cost of the intervention, as well as its cost-effectiveness compared to the current supply chain model.

DISCUSSION

Given the very limited evidence base, there is an important need for a comprehensive standardised approach to evaluating supply chain management, and distribution specifically. This evaluation will help address this evidence gap by providing rigorous evidence on whether private performance-based contracting for distribution of contraceptives can contribute to improving access to family planning in low- and middle-income countries.

Comparison of family-planning service quality reported by adolescents and young adult women in Mexico

Objective

Associations between age and patient-reported quality of family planning services were examined among young women in Mexico.

Methods

A repeated cross-sectional analysis of survey data collected in 2006, 2009, and 2014 was performed. Data from women aged 15–29 years who had not undergone sterilization and were currently using a modern contraceptive method were included. The primary outcome was high-quality care, defined as positive responses to all five quality items regarding contraceptive services included in the survey. Multivariable logistic regression and marginal probabilities were used to compare adolescents and women aged 20–29 years. The responses of respondents using different contraceptive methods were compared.

Results

Data were included from 15 835 individuals. The multivariable analysis demonstrated lower odds of reporting high-quality care among women aged 15–19 years (odds ratio 0.73; 95% confidence interval 0.60–0.88) and 20–24 years (odds ratio 0.85; 95% confidence interval 0.75–0.96) compared with women aged 25–29 years. Adolescents using hormonal and long-acting reversible contraception had significantly lower odds of reporting high-quality care compared with women aged 25–29.

Conclusions

Adolescents in Mexico reported a lower quality of family planning services compared with young adult women. Continued research and policies are needed to improve the quality of contraceptive services.

Advancing sexual and reproductive health and rights in low- and middle-income countries: implications for the post-2015 global development agenda

The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the International Conference on Population and Development in Cairo in 1994. The PoA presents a path-breaking sexual and reproductive health and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the United Nations post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to sexual and reproductive health (SRH) information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda.

Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya

Background

Nearly 40 % of women in developing countries seek contraceptives services from the private sector. However, the reasons that contraceptive clients choose private or public providers are not well studied.

Methods

We conducted six focus groups discussions and 51 in-depth interviews with postpartum women (n = 61) to explore decision-making about contraceptive use after delivery, including facility choice.

Results

When seeking contraceptive services, women in this study preferred private over public facilities due to convenience and timeliness of services. Women avoided public facilities due to long waits and disrespectful providers. Study participants reported, however, that they felt more confident about the technical medical quality in public facilities than in private, and believed that private providers prioritized profit over safe medical practice. Women reported that public facilities offered comprehensive counseling and chose these facilities when they needed contraceptive decision-support. Provision of comprehensive counseling and screening, including side effects counseling and management, determined perception of quality.

Conclusion

Women believed private providers offered the advantages of convenience, efficiency and privacy, though they did not consistently offer high-quality care. Quality-improvement of contraceptive care at private facilities could include technical standardization and accreditation. Development of support and training for side effect management may be an important intervention to improve perceived quality of care.

Reducing unmet need and unwanted childbearing: evidence from a panel survey in Pakistan

Pakistan's high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country's expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time.

Voluntary, human rights-based family planning: a conceptual framework

At the 2012 Family Planning Summit in London, world leaders committed to providing effective family planning information and services to 120 million additional women and girls by the year 2020. Amid positive response, some expressed concern that the numeric goal could signal a retreat from the human rights-centered approach that underpinned the 1994 International Conference on Population and Development. Achieving the FP2020 goal will take concerted and coordinated efforts among diverse stakeholders and a new programmatic approach supported by the public health and human rights communities. This article presents a new conceptual framework designed to serve as a path toward fulfilling the FP2020 goal. This new unifying framework, which incorporates human rights laws and principles within family-planning-program and quality-of-care frameworks, brings what have been parallel lines of thought together in one construct to make human rights issues related to family planning practical.

Does human resource management improve family planning service quality? Analysis from the Kenya Service Provision Assessment 2010

INTRODUCTION

Human resource (HR) management is a priority for health systems strengthening in developing countries, yet few studies have empirically examined associations with service quality. The purpose of this study was to assess the relationship between HR management and family planning (FP) service quality.

METHODS

Data came from the 2010 Kenya Service Provision Assessment, a nationally representative health facility assessment. In total, 912 FP consultations from 301 facilities were analysed. Four indices were created to measure quality on reproductive history taking, physical examination, sexually transmitted infections prevention and pill/injectable specific counselling. HR management variables included training in the past year, any and supportive (i.e. with feedback, technical updates and discussion) in-person supervision in the past 6 months and having a written job description. Multivariate linear regression analyses were conducted to estimate coefficients of HR management variables on each of the four quality indices, adjusting for background characteristics of clients, provider and facilities.

RESULTS

The level of service quality ranged from 16 to 53 out of a maximum score of 100 across the indices. Fifty-two per cent of consultations were done by providers who received supportive in-person supervision in the previous 6 months. In 23% and 38% of consultations, the provider was trained in the past year and had a written job description, respectively. Multivariate analyses indicated that having a written job description was associated with higher service quality in history taking, physical examination and the pill/injectable specific counselling. Other HR management variables were not significantly associated with service quality.

CONCLUSION

Having a written job description was significantly associated with higher service quality and may be a useful tool for strengthening management practices. The details of such job descriptions and the quality of other management indicators should be explored to better understand the relationship between HR management and FP service quality.