Quality of family planning services in northwest Ethiopia

Background: The unmet need for family planning services in Ethiopia is believed to be high (36%) while the already available services do not appear to be optimally used by potential clients. It is thus expected that an assessment and improvement of the quality of family planning services could enhance family planning services utilization. Objectives: The aim of this study is to assess the quality of family planning services provision in terms of clients’ perspectives, technical competence and interpersonal relations of providers and resources for the provision of effective family planning services. Methods: A cross sectional study that employed exit interviews with clients, service provider interviews, observations of clientprovider interactions and an assessment of the availability of the necessary resources was conducted in one hospital, two health centers, two health stations, and one non-governmental clinic operating in north west Ethiopia. Results: Two hundred seventy clients and 14 service providers were interviewed while another 86 clientprovider interactions observations also made. The majority of the clients (66.3%) responded that there was no adequate privacy in service provision sessions. About 18% said that it was difficult to understand the service provider or that she or he did not hold any discussions at all. Communication and privacy was worse in government institutions compared to the NGO clinic included in this study (P<0.05). About 98.5% of the clients were not asked about STD risk and only 3.0% of the respondents were advised to use condoms. The providers mentioned several unjustified restrictions (like menstruation, age, marital status, husband’s consent) in which cases, they did not provide family planning methods. Deficiencies were also noted in the provision of information and communication with clients, infection prevention procedures, and adequacy and cleanliness of service giving facilities. Conclusions: Several aspects of the quality of services observed by this study need to be improved and measures should also be taken to improve the provision of family planning services through training and maintaining adequate resources. [Ethiop.J.Health Dev. 2005;19(3):195-202] Introduction Quality of care in family planning encompasses a wide range of issues including technical competence, choice of methods, information given to clients, interpersonal relationships and appropriate constellation of services (1). Several studies have shown that quality of care greatly influences the uptake and continuation of use of family planning services (1 -5). In Ethiopia only two studies were identified on quality of care in family planning, both of which were conducted in Addis Ababa about a decade ago (6, 7). While one dealt with the clients’ perspective in an NGO clinic, the other one included several health institutions. On the other hand, the Ethiopian population is growing at 2.9% per annum (8) and the unmet need for family planning is high, about 36% (9). The last Demographic and Health Survey reported that while the current use of family planning methods (contraceptive prevalence rate) among married women was estimated to be 8%, 17% have used a method of family planning at some time, indicating a high discontinuation (9). Thus an assessment of the quality of family planning services will make possible the identification of problems that exist in the care of clients, enhance the attraction of clients for family planning and ensure the continued use of the services. The objectives of this study are to assess the perceptions, attitudes and experiences of family planning clients towards the services, investigate the technical competence, interpersonal relations, mechanisms to ensure follow up and examine the facilities and resources useful for the provision of effective family planning services. Methods This study is a cross sectional study and has utilised several methods of data collection. The different methods either assessed the same aspects of the services in order to improve the validity of the conclusions or appraised different aspects of the services. The study was conducted in North Gondar administrative zone, northwest Ethiopia, which has a population of 2.8 million. The study facilities included one hospital, two health centers, two health stations, and one non-governmental clinic that were randomly selected at each level. The number of health facilities selected at each level was based on the total number of health facilities available in 196 Ethiop.J.Health Dev. ______________________________________________________________________________________ Ethiop.J.Health Dev. 2005;19(3) the zone and the number of clients served by the facilities. All women of the reproductive age group 15 49 years and who visited the selected health facilities over a three week period for family planning purposes were deemed eligible for inclusion in the study. The women included in the study sample were selected by the systematic random sampling method by setting a target, on the average, of five women per day. The sampling interval depended on the number of clients visiting the selected health facility on each day. Exit interviews were conducted by experienced and trained nurses drawn from other health institutions. A total of 14 family planning service providers were interviewed including one from the hospital, five from the health centers, six from the health stations and two from the NGO clinic. The number of providers selected for the study was determined by the number of health workers providing family planning services in the health institutions. Such providers numbered about 20 in the selected health institutions. Out of the total of 15 family planning providers selected for the study, one provider from one of the health stations refused to participate. Clinic staff providing FP services at the selected study sites were observed by experienced and trained nurses from other health facilities. Client provider observations were conducted using a checklist that included the approach of the health worker, communication between the provider and the client and the interventions made by the provider. Finally the availability and functionality of facilities for the provision of family planning and related services was assessed using a checklist. Data were entered by experienced clerks and analyzed using EPI INFO version 6. Odds Ratio, 95 % Confidence Intervals and Chi square tests were used to assess the strength and significance of the observed associations. Permission for conducting the study was secured from the Amhara National Regional State Health Bureau and the North Gondar Zonal Health Office. Consent was also obtained from all the study participants after they were briefed about the objectives and the procedures of the research. The questionnaires were anonymous and confidentiality was strictly maintained.