Background

Strengthening family planning services is crucial to improving health, human rights, economic development, and slowing population growth [1]. Yet, globally more than 289,000 maternal deaths occurred in 2013 of which nearly 99% (286,000) women died in developing countries, of which a larger proportion were African countries [2]. Studies have showed that up to 40% of maternal deaths could have been averted through use of family planning services [3,4]. In 2015, 64% of married or in-union women of reproductive age were using some form of contraception in the world but the use was much lower in Africa (33%) [5]. It is estimated that globally, 225 million women who want to avoid pregnancy are not using safe and effective family planning methods [6,7]. Most of the women with an unmet need for contraceptives live in 69 of the poorest countries [8]. This unmet need is due to both rapidly growing populations and shortage of family planning services [6,7].

In response to this, increasing access to family planning services has become a globally recognized public health priority. A number of global partnerships such as the International conference on Population and development (ICPD) in 1994 [9], the Millennium Development Goal (MDG) summit in 2000 [10], and the London Summit on Family Planning in 2012 endorsed a global partnership known as Family Planning 2020 (FP2020). This partnership aims to enable 120 million more women and girls to use contraceptives by 2020 in 69 of the world’s poorest countries [11].

Improving the quality of care in family planning services is key to improve use of family planning services in developing countries, both by attracting new contraceptive users and by maintaining existing users (i.e. ensuring continued engagement with services) [12–19]. Providing decision makers in developing countries, including in Africa, with the best available evidence on the factors that determine the quality of care in family planning services, from the perspective of clients and health care providers, is important to inform the design and implementation of the most effective, efficient and acceptable measures.

The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility” [20]. A report developed by Center for Disease control (CDC) and the Office of Population Affairs (OPA) of the United States Department of Health and Human Services articulates family planning services broadly in terms of infertility treatment and sexually transmitted disease (STD) screening and treatment, pregnancy testing and counseling services, helping clients who want to conceive; providing preconception health services besides services related to contraceptive provision and counseling [21]. However, previous studies conducted to assess the quality of care in family planning services viewed family planning services narrowly, as the provision or prescription of contraceptive methods after women receive counseling on contraception to help them delay or prevent pregnancies [22–24].

Literature relating to quality of care in family planning services found that a number of approaches have been used to define and measure quality of care in family planning services and its determinants, and these vary with the stakeholders’ priorities and perspectives [25]. The Donabedian [26,27] and Bruce Frameworks [28] are the two conceptual frameworks that have been used most frequently since the early 1990s to inform empirical work assessing the quality of family planning services and factors that determine quality of care in family planning services. The latter framework was developed specifically for family planning services.

Donabedian [27]p5 defined quality of care as “the application of medical science and technology in a manner that maximizes the benefits to health without correspondingly increasing the risk”. This model, developed in 1988, was intended to assess quality of care in various health services, including family planning. He described quality of care in a linear model comprising the three components—structure, process, and outcome [26]. This model has continued as a dominant paradigm for assessing quality of care in health services although it has been critiqued for failing to incorporate precursors to quality care such as patient characteristics and broader environmental factors (including the patient’s cultural, social and political context), as well as factors related to the health profession itself [29].

Underpinned by the work of Donabedian, Bruce and Jain [28,30] identified six elements of quality of care in family planning programs that “reflect the six aspects of services that clients experience as critical” [28]p63. These six elements were: choice of methods; information given to clients; technical competency of providers; interpersonal relations; follow-up mechanisms; and appropriate constellation of services [28]. The ‘choice of methods’ refers to having a range of contraceptive methods offered to the clients considering their diverse needs such as clients age, gender, contraceptive intention and lactation status. ‘Information given to clients’ refers to the information provided to clients during service interactions that enables clients to choose and use contraception with competence and satisfaction. This includes information about a range of available contraceptive methods, method contraindications, method advantages and disadvantages, how to use selected method, potential side effects, and continuing care from service providers. The ‘technical competence’ aspect involves providers’ clinical techniques, use of protocols, and implementing aseptic procedures in performing clinical conditions. ‘Interpersonal relations’ refer to the degree of empathy, trust, assurance of confidentiality, and sensitivity of providers to meet the client’s needs and expectations. The ‘follow-up mechanism’ considers how service providers encourage clients on the continuity of use through well-informed mechanisms such as community mass media, client-based follow-up mechanisms (return appointments), or home visits. The last component, ‘appropriate constellation of services’, is suitability of family planning services in terms of their location being at convenient place and time and the level of integration with other reproductive and maternal health services. Since its development, this framework has been widely used to inform studies measuring quality of care in family planning services [31–34].

The Donabedian and Bruce/Jain Frameworks have identified a range of outcomes for quality of care including client satisfaction, change in behaviour and contraceptive knowledge, reduction in fertility and mortality [26,28]. However, measuring some of these outcomes are complex, time consuming, and expensive. To address this challenge, client satisfaction, a simple and more practical outcome measure, can serve as a good indicator and outcome measure in resource limited countries [35]. Client satisfaction has been found as a key determinant of uptake and continued use of family planning services [12,36]. Measuring client satisfaction not only evaluates certain aspects of quality of care but also indicates better prospects for sustainability in terms of recruiting new users and maintaining those clients who are already in the service [12,36,37]. Evidence has also showed that good quality of healthcare positively correlates with patient satisfaction [38]. As a result, client satisfaction is widely used for measuring quality of care in family planning and other health services and has been used in a number of previous studies in low and middle income country settings aimed at determining the factors associated with quality of care in family planning services [22,24,39–41]. Therefore, client satisfaction was used as an outcome of interest in the quantitative part of this review.

A preliminary search of databases found no existing systematic review, or systematic review protocol, with the objective of identifying factors determining the quality of care in Africa or in any one or group of African countries. The objective of this systematic review was to identify and synthesise quantitative and qualitative evidence to understand factors determining the quality of care in family planning services in Africa.

Methods

This review followed best practice guidelines for systematic review of quantitative and qualitative evidence [42]. The review was based on published protocol [43] and followed established Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA reporting guidelines (S1 Table) [44].

Results

Description of studies

In total, 4334 potentially relevant records were identified, of which 3780 remained after removing duplicates. Title and abstract screening led to an additional 3682 exclusions. A total of 98 articles were deemed eligible for full text analysis, of which 87 articles were excluded for not meeting the inclusion criteria. (S1 Text lists the articles excluded on full text examination with the reasons for exclusion). A total of 11 studies [22,41,47–55], eight quantitative [22,41,47–50,54,55] and three qualitative [51–53], met the inclusion criteria.

Of the eight quantitative studies [22,41,47–50,54,55] reporting the factors associated with quality of care in family planning services, four [22,41,49,50] undertook secondary data analysis, with two studies [22,50] undertaking analysis in three different countries (three countries each). Two studies [22,50] identified the factors for higher level (Hospital/health centre) and lower level (clinics/others) facilities separately. Two studies were conducted in Egypt, three in Kenya, two in Senegal, two in Ethiopia, one in Ghana, one in Tanzania, and one in Namibia (Table 1). Two studies [22,49] employed the same database from Senegal but used a different study population and data analysis techniques. In total, 3219 health facilities and 7676 clients were included in the eight quantitative studies.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Characteristics of the quantitative studies included in the review.

https://doi.org/10.1371/journal.pone.0165627.t001

Three qualitative studies [51–53], two conducted in Kenya [51,52] and one in Uganda [53] met the eligibility criteria of the qualitative review component. One [52] included client and provider participants, one [51] had only client participants, and one [53] had provider participants. In total, there were 122 client and 65 health provider participants in the three qualitative studies (Table 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Key characteristics of qualitative studies included in the review.

https://doi.org/10.1371/journal.pone.0165627.t002

Of the eight quantitative cross-sectional studies [22,41,47–50,54,55], seven were rated as moderate quality and one was rated high quality. Two [48,55] out of eight studies undertook systematic random sampling in selecting their study participants. The samples taken for the study were representative and outcomes were measured using reliable methods. Most (7/8) of the studies assessed their outcome using objective measures through proxy questions. Most (7/8) studies controlled confounding factors using multivariate regression analysis. Most (7/8) studies did not describe those participants who withdraw or refused to participant in the study. This would affect the studies generalizability when they had a high rate of non-response and eventually influence generalization in the present review.

Of the three qualitative studies, two [51,53] were assessed as high quality, receiving scores of 7/10 and one [52] was assessed moderate quality (6/10). All three of these studies lacked description of the congruency between the philosophical perspectives and research methodology used. Failure to describe how the researchers’ perspectives may have influenced the analysis and interpretation of findings was identified as the main weakness in the three qualitative studies, potentially undermining credibility (S4 Table).

Factors associated with quality of care in family planning services identified by the quantitative evidence

Eight quantitative studies [22,41,47–50,54,55] identified various factors determining quality of care in family planning services in seven African countries. Table 2 shows the factors that the studies have found to be statistically significantly associated with quality of care, categorized into factors related to the client, provider, facility, structure, and process. These factors were related to the demographics of clients, the provider involved in the provision of family planning clients, and the general characteristics of the health facilities in terms of locations, ownership. In addition, those factors related to the infrastructure, equipment, and provider-client interaction were classified as structural and process related factors.

Client, provider, and facility factors.

Two studies [41,47] showed that the age of the client was associated with client satisfaction. However, the effect of age was inconsistent in that Abdel-Tawab et al. [47] found young clients were less likely to be satisfied with family planning services while Agha et al. [41] revealed young clients as more likely to be satisfied than their older counterparts. Another three studies [22,49,55] showed no statistically significant association between age of clients and client satisfaction.

A significant association between client’s educational status and quality of care in family planning services was found in three studies [41,50,55]. Clients with higher educational levels were identified as more likely to be satisfied with quality in two studies [50,55], while, one study showed less educated women as more likely to be satisfied [41]. One study revealed that repeat family planning clients were more likely to be satisfied with the service than first time clients [48] (Table 2).

With respect to the provider variables, provider’s years of education and number of years of experience were significantly associated with client’s satisfaction in family planning services [41,49]. One study also showed that clients were less satisfied with family planning services provided by young physician than when they received services from older physicians [47] (Table 2).

Regarding the health facility characteristics [22,41,49,50], firstly, client satisfaction was reported in three studies as greater for private than publicly owned health facilities [22,41,50]. Secondly, client satisfaction was found in two studies as being associated with geographic location of health facilities [41,49].

Structural factors.

Health facility’s structural factors such as staffing levels, management, availability of materials and equipment were found to be associated with the quality of care in family planning services [22,41,48,50,54]. There was a positive but weak association between number of staff in facilities and client’s satisfaction in that clients were more likely to be satisfied in facilities possessing higher staff numbers [41]. Greater numbers of days in a week for family planning service, facilities closer to the client’s residence, and with what client perceived to be convenient opening hours were positively associated with client’s satisfaction in family planning provision [48,50]. In contrast, Wang et al. [22] found that greater number of days in the week for family planning services provision did not result in client satisfaction In addition, two studies showed facility cleanliness as a factor associated with client’s satisfaction [48,54] (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Summary of the statistically significant factors affecting quality of care in family planning services in Africa.

https://doi.org/10.1371/journal.pone.0165627.t003

The presence of supervision of health facilities in the past six months before the survey from higher officials including from the district federal officials was identified by two studies [20, 38] as a factor determining quality of care in family planning services. However, the two studies presented inconsistent findings with regard to how supervision affected quality of care. Wang et al. [22] showed health facility supervision was positively associated with client satisfaction in two countries, whereas Hutchinson et al. [50] found a negative association between presence of facility’s supervision and client satisfaction. Infrastructure in the form of availability of electricity, water, toilets, and waiting areas were associated with client satisfaction in some levels of health facilities in Kenya and Tanzania [50]. Other structural factors associated with client satisfaction were availability of trained providers, and use of incentives and promotions for health providers [41,50]. While following family planning protocol was positively associated with client’s satisfaction in Tanzania, having client cards/ records was negatively associated with client satisfaction [50]. Costs of family planning services were associated with client satisfaction in two studies [41,54] (Table 2).

Process factors.

The study conducted in Egypt [47], identified client-provider interaction in the form of positive talk by the provider, as positively associated with client satisfaction. Similarly, client centered family planning services, client’s choosing on the type of contraceptive method to use were more likely to result in client satisfaction [47]. Confidentiality assurance and maintaining privacy were also shown to be positively associated with client’s satisfaction in four studies [41,48,50,54].

Three studies found that information given to the client during the counseling such as information about how to use the method was associated with for client satisfaction [48,50,55]. The studies have presented mixed findings about information provision about side effects as a factor determining quality of care in family planning services [49,50]. The provider’s technical competency was associated with client’s satisfaction in two of the studies [41,50]. In this regard, clients who were asked more reproductive health related questions and underwent physical examination were more likely to be satisfied with the services [41,50]. Hutchnison et al. study [50] measuring the quality of family planning services in three different countries and the study by Wang et al. [22] conducted in for Kenya, showed that injectable method provisions/prescriptions were more likely to bring higher levels of client satisfaction. Counseling on when to return/follow up dates was identified as a factor in two studies [41,49].

Finally, with respect to the results from the quantitative studies, the overwhelming majority of studies (6/8), identified waiting time as a factor determining quality of care in family planning services [22,41,49,50,54,55].

Synthesized findings on perceptions of factors associated with the quality of care in family planning services from qualitative findings

Client perceptions.

The limited findings from the two existing qualitative studies [51,52] that have explored how African clients perceive the factors determining quality of care in family planning services, were summarized in three synthesized findings (Table 4).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 4. Synthesis of qualitative findings on how clients perceive factors determining the quality of care in family planning services.

https://doi.org/10.1371/journal.pone.0165627.t004

Synthesized finding one: Accessibility of services was important to clients. Proximity to clients’ residing areas, costs incurred to get to services, convenience of facility’s opening hours, availability of clients preferred contraceptive methods, and pre-requisites for getting contraceptive methods were identified by clients as factors that influence service accessibility and in turn quality of care. Five categories of findings informed this synthesized finding (see Table 4). Category one included findings that spoke about physical proximity of the facilities [52]; category two included findings that were about costs incurred to receive the services [52]. The third category related that convenience, and more specifically opening hours, made services easily accessible [51]. For example, one client said: “I can go [to the private hospital] at any time” [51]p3. The fourth category spoke about clients’ preference for facilities possessing their preferred contraceptive methods [51].

The fifth category included findings which related that pre-requisites expected to be fulfilled by the clients [51,52] affected access. The following client voices illustrate how client’s perceived pre-requisites to be fulfilled such as the requirement of being on menses to take contraceptive methods

When my periods came [at 4 weeks], I felt like it was an emergency, and I didn’t want to waste more time because, like I mentioned, these men are unpredictable and they might demand for it [sex] at any time. I had planned on going for the [public] clinic, but when my menses came I asked a friend if they will allow me to take up family planning at the clinic [early] and she told me that they cannot accept. That is why I went for the method at a private health facility. (Age 27, 3 children, page 4)[51]p4.

Synthesized finding two: The way care was provided in family planning services was central to clients’ notions of quality care in family planning services. Clients identified six characteristics of the way care was provided as central to their notions of quality of care in family planning services. Positive service delivery qualities, that clients related they valued, and as influencing quality of care included: 1) responsiveness of providers to clients’ self-perceived needs and freedom to choose the contraceptive method; 2) length of waiting time; 3) behavior of providers towards clients; 4) provision of information and support in making decision during consultation; 5) privacy and confidentiality; and 6) range of services. Six categories of findings informed this synthesized finding. Each identified a different attribute of the way care was provided from clients’ perspectives influenced the quality of care. Category one related that clients valued facilities in which providers listened to clients’ needs and allowed them to choose their preferred method [51,52]. Category two included findings related to the time spent before receiving family planning services. Clients indicated that they valued facilities with short waiting time [51,52]. The third category included findings in which clients spoke about provider behavior. Clients said that respectful behaviour of providers was important to them [51,52]. In this regard, a client said that “"…the last time I found a Kisii lady. her advice was good, she was polite like a fellow woman. She showed some signs of respect to me…” [52]p42. The fourth category included findings [51,52] that were about information provision as a factor determining quality of care. Clients said that they valued being provided with information about the side effects of contraception and having their questions adequately responded [51]. The importance of privacy and confidentiality was identified by the findings in category five. One client said that she perceived confidentiality to be facilitated by one to one counseling [51,52]. In the sixth category informing this synthesized finding, clients indicated that a wide range of services, including eligibility screening, blood tests and physical examinations were factors influencing quality of care in family planning services [51,52].

Synthesized finding three: Clients perceive two characteristics of health care providers, provider competency and provider age as influencing the quality of care in family planning services. Two categories informed this synthesized finding. The first was comprised of one finding [52] in which clients related that they preferred older providers because they felt self-conscious about showing their naked body to a young provider. The second category included findings in which clients related they perceived the knowledge and competency of the provider to be a factor determining the quality of care. In this regard, one client said “…the doctor might be qualified, but he could be using his wife to assist him, but the wife is not qualified” [51]p4.

Provider perceptions.

The very limited qualitative evidence identified, on how providers perceive the factors determining quality of care in family planning services, also generated by two studies [52,53] was summarized in two synthesized findings (Table 5).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 5. Synthesis of qualitative findings on how providers perceive factors determining the quality of care in family planning services.

https://doi.org/10.1371/journal.pone.0165627.t005

Synthesized finding four: Providers identified factors related to the availability of resources as influencing the quality of care in family planning services. These included: clients’ low income levels, and inability to pay high fees; inadequate supplies in facilities; and high staff workload. Three categories informed this synthesized findings. The first category related that the high costs of family planning services relative to clients’ income undermined clients’ ability to choose facilities and methods, and affected quality of care [52,53]. Category two informed that lack of family planning supplies often prevented providers from delivering the type of services clients intended to receive [53]. The high workload of providers in the facility influenced the delivery of quality of care for their family planning clients [53] was the third category. The following two illustrations were client’s voices supporting the second and third categories. In the words of one provider: “We had no Depo-Provera, for a long time … over 6 months actually. [Question: So what were you doing by that time?] Those who wanted Depo were not being served because most people here do not like oral contraceptives.” (Manager)[53]p38. The third category included only one finding which identified too few staff relative to clients as a factor affecting quality of care [53]. In the words of a provider: “We are overloaded. We are small doctors [laughter]. There are clients for Voluntary Counselling and Testing (VCT) there … in the labour ward; there are two mothers waiting and then there are clients in antenatal clinic … If these mothers wait for so long, they have to go elsewhere and if they do not get their method they will never come back.” (Bushenyi, FGD) [53]p39.

Synthesized finding five: Behavior of providers towards clients, for example being disrespectful of client’s time, regard for privacy and confidentiality for family planning clients, were perceived by providers as factors affecting the quality of care. Providers also identified the range of services offered by providers to clients as a factor influencing the quality of care. This synthesized finding was informed by three categories of findings. The first described provider behavior as something that affected quality of care [52,53]. The second spoke the importance of privacy and confidentiality of clients affecting quality of care [53]. The third identified the range of services as a factor affecting quality [52]. The following provider voice illustrates that the providers perceptions about clients need about range of services.

"I have seen a client coming from town [to our clinic] and she already was provided with pills but she said she was not examined. She told her friend who told her that one normally is supposed to be examined…So I think they value examinations—general examinations and pelvic" (INDEPTH, Provider 11, Location 2) [52]p44.

Discussion

This systematic review aimed to develop an evidenced based understanding of factors that determine the quality of care in family planning services in Africa, using a systematic review of mixed evidence. A total of 11 moderate to high quality studies, undertaken in seven of the fifty five African countries, were identified and included to inform understanding of the factors determining quality of care in family planning services in Africa.

The quantitative component of the review pointed to a wide range of factors determining the quality of care in family planning services in Africa. These included client, provider, facility, structural and process factors. Client’s waiting time before receiving the services, provider competency, provision of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors found in the quantitative studies. Quality of stock inventory was the most commonly identified structural factor identified by the quantitative evidence. In addition, the quantitative studies pointed to the type of ownership of facilities as an important factor influencing quality of care in family planning services. More specifically, privately owned facilities were associated with higher levels of client satisfaction than publicly owned facilities. We also found from the quantitative studies, that certain client characteristics, namely age, educational status, and types of clients in terms of being whether new or repeat users were associated with satisfaction with family planning services.

A number of factors that were identified by the quantitative studies as important factors determining the quality of care in family planning services were mirrored in the synthesized findings from the included qualitative studies. These were waiting time, information provided to clients, maintaining client’s privacy and assurance of confidentiality, provider competency, convenient operating hours and cost of family planning services. The qualitative findings pointed towards three additional factors not identified by the quantitative studies. These were pre-requisites to be fulfilled by clients before taking family planning services, workload of providers, and provider behaviour.

The findings from the systematic review corroborate the aspects of quality of care of family planning identified in the Bruce and Jain framework [28,30]. The aspects that the Bruce and Jain Framework suggested, were mostly related to the process of family planning services provision included the contraceptive method mix, the information provided to the clients, provider’s technical competency, the interpersonal relationship between provider and clients, continuity and follow-up, and constellation of services [28,30]. However, the current review highlighted additional factors that were associated with quality of care. Firstly, service accessibility issues including cost of services and the presence of certain pre-requisites such as clients were required to confirm they were on their menses at the time of contraceptive initiation. Secondly, waiting time and client’s preference for older and mature providers were identified as additional factors determining quality of care in family planning services from the qualitative studies. The range of factors identified by this review as influencing the quality of care in family planning services in Africa points to the limitations for the Donabedian model in the sense that it excludes the patient’s own characteristics as important factors determining quality of care [29]. In this regard, the included studies in the current review showed age and educational status of clients as factors associated with quality of care.

Similar to this review, a review of studies conducted in the United States, showed quality of family planning services as depending on a range of factors including the characteristics of the facility, provider, and client [56]. Three studies, one in United States [57] and two [58,59] conducted in Iran, also highlighted access to services as an important factor influencing quality of care in family planning services.

This systematic review has several strengths and shortcomings. The first strength is its inclusion of qualitative and quantitative studies. The inclusion of mixed evidence in systematic review is widely regarded as best practice [60,61] to provide decision makers with information to inform policy making as qualitative evidence can aid understanding, by offering insights into factors that cannot be measured. A second strength of this reviews is the consideration and inclusion of academic (peer reviewed) and grey literature. Inclusion of grey literature addresses the issue such as publication bias [62]. The use of best practice method for systematic review, and in particular the conduct of critical appraisal and formal synthesis of qualitative findings using meta-aggregation is a third strength.

This systematic review also has a number of limitations. Firstly, the included quantitative studies employed different definitions classification and measurement approaches of client satisfaction and hence meta-analysis was not possible. Secondly, the studies were conducted in a small number of Africa’s diverse countries and regions. The findings may reflect health service structures and client/provider perceptions that are specific to these areas and may not be applicable to other African countries and regions. Thirdly, there were relatively few quantitative studies and very few qualitative studies included in our review. These last two limitations may limit the generalizability of the results. However, some factors were found to be significant in all or the majority of the studies, which suggests that these may be applicable to a number of settings. Finally, although client’s perceptions are often mediated through the social and cultural environment [63], the included studies did not consider the cultural aspects of family planning clients.

Conclusion

Overall, the limited, moderate to high quality, quantitative and qualitative studies on factors determining quality of care in family planning services in Africa, pointed to multiple factors, related to client, provider, facility characteristics, as well as structural and process. Hence, improving quality of care in family planning services in Africa requires multiple actions that target these different factors. Further research is required to understand the key factors associated with quality of care in family planning services in African countries.

Supporting Information