Academic journal article International Perspectives on Sexual and Reproductive Health

Quality of Care and Contraceptive Use in Urban Kenya

Academic journal article International Perspectives on Sexual and Reproductive Health

Quality of Care and Contraceptive Use in Urban Kenya

Article excerpt

Family planning plays an important role in reproductive rights and the protection of maternal health, yet is underutilized in many parts of Sub-Saharan Africa. In the region, approximately 20% of married women currently use a modern method of contraception, and an average of one in four married women want to space or limit pregnancy, but are not using a modern method. (1) Family planning programs in developing countries have worked to increase the number of service delivery points and expand into remote areas; (2) however, to be effective, they must also address issues of service quality. Many family planning experts hypothesize that low-quality family planning services are a barrier to high contraceptive prevalence. (3-6)

Substantial increases in contraceptive use and corresponding declines in fertility have been consistently observed throughout the developing world, although such changes have been more limited in Sub-Saharan Africa than in other developing regions. (7) In Kenya, the prevalence of contraceptive use has increased since the 1970s: At that time, only 7% of married women of reproductive age used a family planning method, but that figure grew to nearly 40% by 19988 At the same time, the total fertility rate (TFR) dropped, from more than eight children per woman in the early 1970s to approximately five by the late 1990s. Since then, however, progress has slowed: In 2013, Kenya's contraceptive prevalence among married women was 46%, and the TFR was 4-5 children. (8,9)

Motivated by the hypothesis that improvements in service quality may facilitate greater contraceptive use, two prior large-scale, facility-level, quantitative studies have assessed the quality of family planning service delivery in health care facilities in Kenya. Kenya's first nationwide assessment of family planning quality, conducted in 1989 among 99 randomly selected public facilities, found several deficiencies in service quality, including restricted choice of methods, little information on management of side effects, failure on the part of providers to ascertain the client's reproductive goals and a dearth of mechanisms in place to ensure follow-up. (10) A subsequent study that focused on public facilities in Nairobi was conducted in 1993; (11) its results did not differ markedly from those of the national study.

Other studies have described the quality of family planning service delivery in Kenya, but have been unable to assess the relationship between quality of care and current contraceptive use. (10,12-17) Such an assessment typically requires both facility- and individual-level data, as well as the ability to link women to the facility where they reported receiving or are assumed to have received services. A few studies have taken this type of multilevel approach to assessing the relationship between family planning service quality and contraceptive prevalence or continuation, with mixed results. Studies conducted in Peru, Egypt and Morocco in the late 1980s and early 1990s found little to no effect of quality on method use or continuation; (18-20) however, studies conducted between 1991 and 2003 in Tanzania, Egypt, the Philippines and Nepal found moderate to strong associations between service quality and use. (21-24) The conflicting results in these studies may be explained by variations in how quality was defined and measured. A 1988 study in Egypt that found no relationship between quality and continued method use measured quality solely through interviews with staff and defined quality by the number of trained personnel, number of available methods and presence of female doctors;18 in contrast, a 2003 study in Egypt that found an association between the two measured quality with a variety of tools, including provider and client interviews and observations, and created a quality of care index. (23)

Studies that fail to find a notable link between quality and use may accurately reflect the absence of a strong relationship between the two. …

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