Assessment of family planning services quality from clients'

perspectives in rural areas

Hanan El Gamal
Department of Family Medicine. Faculty of Medicine, Suez Canal
University.
Abstract
Background: Improved quality of care is an increasingly important goal
of international family planning programs, for a variety of compelling
reasons. From a human welfare perspective, all clients, no matter how
poor, deserve courteous treatment, correct information, safe medical
conditions and reliable products. It also has been argued that providing
such quality services will lead to increased services utilization by more
committed users, eventually resulting in higher contraceptive prevalence
and lower fertility.
Aim of the work: This study aims at assessing the quality of family
planning services.
Material and methods: 760 women of child bearing period using family
planning method either from the family planning service or discontinued
using the primary care service of family planning were simply random
selected. They were chosen by simple random sample, 355 discontinuers
clients, 405 continuous service users. Discontinuers were interviewed
through a house hold survey, while an interview questionnaire was used
for continuous users after receiving their service at the primary health
care unit.
Results: Before the CQI program the discontinuation rate was 32.35 %
then changed to 9.62 % after implementing the CQI program. The most
cited causes of discontinuation were; absence of a female doctor, long
waiting time, complications of method, insufficient information,

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unsuitable clinic working hours, inappropriate staff attitude, doctor's care
and finally doctor incompetence.
Conclusion and recommendation: positive changes in continuation rate
of women using family planning method either from the family planning
service or from another family planning services could be achieved by
quality improvement activities, also raised clients expectations, changed
needs, raised awareness about quality, and towards their rights'. So family
planning services should have continuous quality improvement policy to
gain new clients and decrease discontinuation rate.
Key words: quality improvement, family planning services.
introduction
continuous quality improvement is an exciting management approach that
is being introduced in family planning services around the world. Family
planning programs that use CQI can raise staff morals, improve
continuation rate, and client satisfaction. The first goals of high-quality
programs should be to help clients achieve their reproductive goals, not to
reduce aggregate fertility rates. Nevertheless, some express contend that
improving the quality of care will lead to higher contraceptive acceptance
and prevalence rates, higher continuation rates and ultimately, lower
fertility. Moreover, in recognition of declining resources and increasing
demands for contraception, improving the quality of services may also
serve to expand coverage without using up substantial additional
resources1.
"Quality" in terms of reproductive health care is currently defined in a
variety of ways. A consensus exists that good quality requires the
presence of trained personnel in well-equipped clinics where clients are
treated courteously and provided with a variety of appropriate services.
The term, therefore, refers both to the readiness or level of preparedness
of facilities to offer services and the manner in which clients are cared

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for. Diagnostic studies in variety of program settings have identified
constraints to good quality. These include deficiencies in physical
facilities and equipment; disruptions in supplies; insufficient information
provided to clients; and providers' insensitivity to needs of clients2.
Improved quality of care is an increasingly important goal of
international family planning programs, for a variety of compelling
reasons. From a human welfare perspective, all clients, no matter how
poor, deserve courteous treatment, correct information, safe medical
conditions and reliable products. It also has been argued that providing
such quality services will lead to increased services utilization by more
committed users, eventually resulting in higher contraceptive prevalence
and lower fertility3.
Family planning services are often underutilized. This might be an
indication that the problem is not a lack of coverage but satisfaction with
the quality of service being offered(1). Strong programs, such as those in
Thailand or Colombia, lose only 6 % of users evey year because of
dissatisfaction. By contrast, the Paraguay program faces an annual
discontinuation rate of 18 %2. The Egyptian Demographic Health Survey
(EDHS) found a discontinuation rate of 30 % in family planning
services3.
Aim of work:
This study aims to assess quality of family planning services.
Objectives:
1. To assess satisfaction level in continuous service users before and

after the continuous quality improvement (CQI) program at rural

Ismailia Governorate.
2. To define causes of service discontinuation.

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Methodology:
Site of study: Rural areas in Ismailia Governorate.
Sample type: simple random sample
Sample size; 2 groups were chosen, 355 discontinuers clients, 405
continous service users. Discontinuers were interviewed through a house
hold survey, while an interview questionnaire were used for contionuous
users after receiving their service at the primary health care unit.
This questionnaire is designed to measure satisfaction about service
elements before client exit and after receiving their service.
Target population: women of child bearing period using family planning
method either from the family planning service or shifted to another
family planning service.
Exclusion criteria:
Women who receive family planning service other than primary care
service.
Study design: the first discontinuer group was interviewed by a
household survey by the researcher, the 2nd continuous group was
interviewed at the primary health care unit after receiving the service and
before existing from the center, through March 2003 to September 2003.
Points of improvements gathered from the continuous group were
analyzed by the "Pareto" diagram to define the "vital few" factors to work
on to give the best result from the CQI program, also causes of
discontinuation gathered from the discontinuers were analyzed using the
"Pareto" diagram to define the most important items to work on by using
the CQI program. The discontinuation rate was tracked against time to
demonstrate the trend after using a follow-up system for discontinuers.

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Results:
Table 1 represents discontinuous users group and continuous users group
characteristics
characteristics Discontinuers Continuous users
No. % No. %
Age Below 20 5 1.5 % 8 1.98 %
20-29 181 51.04 % 199 49.14 %
30-39 122 34.32 % 171 42.2 %
40-45 47 13.14 % 27 6.66 %
Education Illiterate 153 42.94 % 181 44.78 %
Primary & preparatory 56 15.82 % 37 9.23 %
Commercial & secondary 124 34.94 % 159 39.24 %
High education 22 6.3 % 28 6.75 %
Number of One child 67 18.87% 67 16.54 %
children 2-3 child 150 42.26% 183 49.19 %
>4 child 138 38.87 % 155 38.27 %
Contraceptive IUD 202 57.02 % 236 58.25 %
method use Inject able 76 21.5 % 109 26.97 %
Pills 61 17.01 % 54 13.31 %
Barrier methods 9 2.4 % 4 0.97 %
implants 7 2.7% 2 0.5 %
Level of Completely unaware 43 12.1% 15 3.7 %
awareness Low awareness 259 73 % 316 78.03 %
with High awareness 53 14.9 % 74 18.27 %
contraceptive
methods

Table 2 shows reasons of discontinuation from discontinuers' view represents that

absence of a female doctor, long waiting time, method complications, insufficient
information, unsuitable working hours, inappropriate staff attitude, are 81.53 % of
total responses that is 758, and it represents the " vital few " factors to work on to
decrease the discontinuation rate

Reasons of discontinuation Number of percentage Cumulative

responses percent
Absence of a female doctor 194 25.59% 25.59%
Long waiting time 110 14.51% 40.1%
Complications of a method 101 13.32% 53.42%
Insufficient information 75 9.89 % 63.31%
Unsuitable working hours 69 9.11% 72.42%
Staff attitude inappropriate 69 9.11% 81.53 %
Doctor isn't caring 68 8.97% 90.50%
Incompetent doctor 51 6.73% 97. %
Social causes 8 1.06% 98.29%
Expensive cost 7 0.92% 99.21 %
Long distance to service 6 0.79% 100 %

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Table 3 shows points of improvement from continuous user's view pre CQI program
represents that waiting time , more time with physician, more information, more
physician care are 88.52% of total responses(612 responses) and it represents the
"vital few" factors to work on to improve client satisfaction
points of improvement pre CQI Number of percentage Cumulative
program responses percent
Waiting time 265 43.28% 43.28%
More time with physician 107 17.49% 60.77%
More information 88 14.38% 75.15%
More physician care 82 13.37 % 88.52%
Staff attitude 36 5.89 % 94.41%
Method availability 35 5.59 % 100%
Table 4 shows points of improvement from continuous user's view post CQI program
represents that waiting time, information giving, more time with physician are still the
most mentioned items of improvement with lesser intensity, and waiting place and
privacy has appeared, this means elevated client's expectations from the health service
Points of improvements post Number of Percentage Cumulative
CQI program responses percent
Waiting time 30 32.61 % 32.61%
More time with physician 30 32.61 % 65.22%
More information 11 11.95 % 77.17%
Waiting place 8 8.7 % 85.87%
Staff attitude 6 6.52 92.38%
More physician care 5 5.43 % 97.80%
Method availability 1 1.1 % 98.9%
privacy 1 1.1 % 100%

Graph (1) change in the discontinuation rate by follow-up system

35

30

25

20

15

10

march April may june july august september

1. Discontinuation rate before CQI program was 32.35 % changed to

9.62 % post CQI program and the change is statistically significant
The change is due to follow-up system

2. Satisfaction level before CQI program was 90.37 % and changed to

97.5 % post CQI program and the change is statistically non significant but
clinically significant

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Discussion:
Results revealed that discontinuation rate before the CQI program was
32.35 % then changed to 9.62 % after implementing the CQI program.
This differ from a study done by the Cairo Demographic Center (CDC)
which revealed that the service discontinuation rate was 83 %. The
difference between the two studies could be due to the quality
improvement activities focusing on causes of discontinuation and items
of dissatisfaction mentioned by the discontinuers and the continuous
users groups in the present study 4.
- Cause of discontinuation; the most cited cause of discontinuation was
absence of a female doctor. This coincidence with a study conducted by
Mohamed Ali in Egypt 1989, that showed the facilities without a female
doctor is associated with high risk of discontinuation5.
- Long waiting time is also considered a cause of discontinuation in
14.51% of responses. This finding differs from the IPPF study which was
done in eight Latin American and Caribbean clinics on 15000 clients
from 1993 through 1996. Waiting time was mentioned by 70 % of
surveyed clients. The difference may be due to different social norms
against complaining in our community6.
- Complications of method were mention as a cause of discontinuation in
13.32 % of responses. This finding differs from a study in Bangladesh.
Where 40 % admit they experienced method complications. The
difference could be due to different settings of the study (rural in the
present study Vs urban in Bangladesh study)7.
- Insufficient information was experienced in 9.89 % of responses. This
finding differs from a study done in Peru that showed, 34 % discontinue
because they didn't receive sufficient information. The difference could
be due to lack of orientation towards patient rights in our clients where
42.94 % of them are illiterate 8 .

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- Unsuitable clinic working hours also cited as a cause of discontinuation
in 9.11% of responses because it was the same working hours of working
clients, as 40.97 % of clients' educational level are secondary,
commercial and high education.
- Inappropriate staff attitude was experienced as a cause of
discontinuation in 9.11% of responses. This finding differs from a
nationwide study conducted in Nigeria. Where nearly all clients staff
were friendly and easily to understand9.
- Doctor isn't caring was mentioned during the study by the clients as a
cause of discontinuation in 8.97 % of responses. This coincidence with
Ndhlovu Lewis study 1995, which revealed clients give weight to
provider attitude10.
- A percentage of 6.73 % of respondents mentioned that doctor
incompetence was the cause of their discontinuation. This finding differs
from the IPPF study, where clients didn't mention incompetence at all.
This could be due to difference in doctor training and qualification or
client's perception6.
Results showed that the satisfaction level before CQI program was
90.37% had changed to 97.5 % after the CQI program. This differs from
the study conducted at Central and East Java as more than three-fourths
of the 900 women interviewed were satisfied with family planning11.
However the results are in coincidence with a study carried out by
RIMCU in the Philippines, with technical assistance for the population
council. It found that 91 % of family planning clients reported to be
satisfied with their visit to the clinic6.
From these results, we conclude that there are positive changes in
continuation rate of women using family planning method either from the
family planning service or discontinued family planning service. These
changes might return to quality improvement activities, while others are

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negative due to raised clients expectations, changed needs, raised
awareness about quality, and towards their rights'.
References:
1. Hull, Valerie J." Improving Quality of care in Family
Planning: How Far Have we come? Regional working paper No.5
Jakarta: The Population Council.1996
2. Judith Bruce, Anrudh Jain,. " A new Family Planning
Ethos". Population Council, New York. (2001).
3. El-Zanaty.F., Ways AA, Egypt Demographic and Health
Survey 2000. Ministry of Health and Population, National
population Council. Ch.(7), p 96.
4. Makhlouf, Hisham, and Saad Zagloul Amin.." Continuation
and discontinuation of contraceptive use by method and reasons for
drop out in CSI project", Cairo: Cairo Demographic Center and
the Council. May (1995).
5. Ali M." Quality of care and pill discontinuation in rural
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(1994).
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Makhlisur Rahman, and J. Chakraborty. " The Demographic
impact of the family planning health services project in Matlab,
Bangladesh ." Studies in Family planning.13, 5: 131-140. (1982).

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8. Mauldin, W.P." Experience with contraceptive methods in
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population Council (1979).
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