Jul 11, 2022
Reducing Family Planning Discontinuation Through Improved Quality of Programs
By Jay Gribble
Just as good counseling can have a positive effect on the uptake of modern contraception, poor counseling and quality of services can contribute to their discontinuation. One key reason people discontinue a contraceptive method is because of side effects and health concerns — issues that should be addressed in counseling, service delivery, and follow-up. Data from the 23 most recent Demographic and Health Surveys (DHS) in sub-Saharan Africa indicate that in general, 25–30 percent of women discontinue use of modern methods within 12 months of starting, but as many as 46.4 percent in Liberia and 42.6 percent in Sierra Leone discontinue. The impact of counseling and services can affect whether a person sustains or discontinues contraceptive use in a variety of ways. Improving these aspects of family planning programming not only contributes to a more robust rights-based effort that helps women and couples achieve their reproductive goals but can help programs yield a better return on their investment to attract and maintain clients.
The quality of family planning services relies on a combination of elements that, when functioning in tandem, bring together best practices and enable clients to make empowered choices about which method to use. In their 2018 revision of Bruce’s 1990 quality of care framework, Jain and Hardee update some of the concepts so that they reflect a more rights-based focus of family planning programming. Three of their recommendations provide a solid basis for thinking about how the quality of services can prevent discontinuation while also reinforcing the importance of a rights-based approach: how providers and clients should exchange information, how client follow-up should be provided, and how clients are treated by the systems providing these services.
Information Exchange
Given the importance of side effects and health concerns as a cause of discontinuation, information exchange is critical to improve the quality of services, ensuring that new users of methods have the chance to ask all their questions, understand what the possible side effects are, and establish two-way communication with their provider. In their report on discontinuation, Askew and Castle (2015) cite research about what can happen when poor information exchange happens. While it is not unusual for providers to treat women’s concerns about side effects as unimportant, from the client’s perspective, side effects such as amenorrhea or prolonged bleeding can have a profoundly negative psychosocial and economic impact on their lives, resulting in discontinuing the method. Without quality information exchange, clients may be frightened or concerned about changes in mood, menstruation, or weight — also contributing factors to discontinuation. A positive exchange of information between a client and provider should acknowledge the client’s concerns, avoid paternalistic attitudes and behaviors, and serve as an opportunity for quality engagement. Providers need to allow clients to explain their reproductive intentions to help identify appropriate methods; their previous use of and experiences with family planning — good and bad; and contextual issues, such as clients’ relationships and family circumstances that may influence successful method use.
Client Follow-Up
Building on quality information exchange is the opportunity to extend that engagement through appropriate follow-up. Often, follow-up is based on telling the client when to return to the provider to ensure side effects are under control or to obtain more cycles of pills or the next injection. With follow-up, the responsibility is placed on the client to return to the provider, and if the client doesn’t perceive the provider-client interaction to be supportive, they are less likely to return. DHS data indicate that key reasons for discontinuation are that clients become pregnant or want to become pregnant (i.e., changes in reproductive intention) or that they switch to a different method for unstated reasons. Jain and Hardee suggest expanding the focus of follow-up visits to include guidance on the possibility of switching method, provider, or service outlet. Along with this expanded vision for follow-up visits, women can use them to either help find a short-acting method (so that if she wants to become pregnant soon, she will be able to) or as an opportunity for antenatal counseling if she has decided to get pregnant. Some women will not be happy with their method, and framing follow-up as a way to help women switch to another more appropriate method rather than abandon family planning completely can help them better achieve their reproductive goals. Broadening the focus of follow-up visits can also create opportunities for clients to provide feedback about strengths and weaknesses of the health system. For example, in Guatemala, reproductive health observatories have been established to help the public provide feedback and hold the health system accountable for following through on policy commitments to provide quality family planning services. An external organization charged with giving citizens a vehicle to provide feedback on the provider or the outlet can effectively improve quality of services without placing the onus for that change solely on an individual client.
Client Treatment by the Health System
Health systems are composed of many moving parts across levels of government, different types of facilities and providers, and across the public and private sectors. As efforts are made to strengthen health systems, staff working in the health system need to ensure that care is always provided in a respectful way. Efforts to introduce respectful maternity care are taking hold and changing how antenatal, labor, delivery, and postpartum care are being provided. Jain and Hardee suggest that efforts to promote dignity, respect, privacy, and confidentiality need to be prioritized by health systems to ensure that women’s rights are upheld. One way of advancing this principle is by addressing provider bias, which occurs when providers think they are better positioned to decide on the best method for a client. While related to information exchange, the issue of provider bias needs to be addressed by the health system. Bias can take place because of poor provider training or by providers relying on their own beliefs and values without regard for what the client wants. Askew and Castle mention studies in which unnecessary medical barriers, financial incentives, and client treatment can contribute to women’s discontinuation of their family planning methods. How they are treated — regardless of the technical quality of the service or information exchange — may be what clients remember most about the experience. A negative experience can lead women to discontinue their method if the experience was negative, shameful, or embarrassing as they may want to avoid any future interactions (e.g., for resupply of pills or counseling on side effects) with the provider or health system. Conversely, a positive experience may provide needed support and open doors for continued follow-up with providers.
Quality is a goal in itself — the health sector needs to prioritize quality services so that women can achieve their reproductive goals. When quality is poor, it can undermine clients’ efforts to deal with side effects, to follow up for additional supplies, and to reflect on how they were treated by the health system. Each of these negative factors can be addressed through straightforward interventions. As discussed above, efforts that focus on improving the quality of information exchange, on expanding how follow-up sessions are structured and carried out, and on more responsive ways for the health system to treat clients and improve access to family planning can all contribute to reducing high levels of discontinuation.
Jay Gribble is a senior director with Palladium and deputy director of family planning and reproductive health on the USAID-funded Health Policy Plus (HP+) project.
