Conceptual framework

Different conceptual frameworks have been proposed for evaluating FP service quality. In 1990, Bruce and Jain [26, 29–31] recommended a user perspective to evaluate the quality of FP services and CM supply based on the following criteria: (1) choice of method, (2) information provided, (3) technical competency, (4) interpersonal relations, (5) follow-up and continuity mechanisms, and (6) an adequate constellation of services. Evidence has shown that improving these dimensions redounds to greater use of services and, in turn, to improved outcomes [26, 29–31]. These criteria can be framed within the three classical quality dimensions proposed by Donabedian: program structure, service processes and outcome of care in terms of user knowledge, behavior and satisfaction [29,32,33]. While Bruce-Jain and Donabedian converge in their focus on user satisfaction, the former consider different FP dimensions and highlight the importance of establishing mechanisms to ensure follow-up and continuity in care.

In 1996, Creel et al. proposed a different conceptual framework for evaluating the quality of FP services. They considered ten dimensions of quality based on demand: (1) availability of CMs and possibility of choice; (2) absence of medical-bureaucratic hurdles; (3) an appealing physical setting that inspires confidence; (4) continuity in care; (5) assorted service offerings; (6) competent staff; (7) adequate schedules and waiting times; (8) affordability; (9) effective counseling; and (10) friendly interpersonal relations. While Creel et al. shared numerous elements with Bruce and Jain, the first added two new components: service accessibility and acceptability [26].

S1 Fig offers a full picture of the three models proposed by Bruce-Jain, Donabedian and Creel for evaluating the dimensions of quality in reproductive health services. Based on this conceptual framework, analyzing the quality of services from the perspective of those who demand service sheds light on the opinions of users as influenced by their personal values, experiences and concepts regarding the role of health services.

It is important to bear in mind that the components of quality are interrelated; for instance, free choice is related to the availability and variety of CMs. In other words, the capacity of a user to make an appropriate decision can be transferred to the possibility of choosing a CM of his or her preference [34]. CM availability at health facilities has been identified as a factor with one of the highest predictive values for user satisfaction—higher than that of other components, or dimensions, of quality [34]. The interpersonal relations expressed in user-provider interactions also play a decisive role in perceived quality. Studies have demonstrated that women seeking free or subsidized services from the public sector have experienced mistreatment, disrespect and even physical abuse [34]. These situations limit the capacity of users to demand quality health services and are often related to a differential treatment from health providers based on age, social class and economic/cultural status [34]. A study in Uganda [35] demonstrated that the perceptions of providers on the payment capacity of users influenced the care they offered, even determining the type of CM they prescribed. Finally, correct information provided to users as part of their FP services is relevant in that it affects their capacity and disposition to use certain methods [34].

While valuable contributions have been made to knowledge on these dimensions by previous studies [6] these analyses have largely been quantitative. Strategies aspiring to upgrade the quality of FP care would achieve more targeted efforts by complementing actions aimed at improving the behavior and infrastructure of service providers with qualitative evidence. The experience of users and the perspective of service demand play a highly relevant role in the quest for better care. Weight needs to be accorded to the opinions and necessities of users, particularly as regards the selection of contraceptives, the availability of preferred methods and the establishment of a respectful and private environment [26].

In light of the foregoing, this study used a qualitative approach to ascertaining the opinions of FP service users regarding four quality-related elements: (a) the presence and identification of barriers to accessing services; (b) the availability of CMs, with special emphasis on those preferred by users; (c) provider-user interpersonal relations; and (d) the type and quality of the information provided.

Study design

Based on a descriptive, qualitative design, our study was conducted in public health facilities belonging to the MoH. We analyzed service quality specifically with regard to access, availability, interpersonal relations and information provided to clients, as perceived by users throughout their experience in the FP care process.

Sample selection

Field staff

Our field staff was comprised of two female coordinators and five interviewers (four female and one male). The interviewers were knowledgeable about FP matters, educated in social sciences and public health and widely experienced in the use of qualitative tools such as interviews. The field staff had sustained no previous relations with the interviewees and were not personnel from the clinics, but rather independent interviewers hired to assist the research team. They introduced themselves to the patients as researchers from the National Institute of Public Health. Prior to kickoff, the field staff received one week of training sessions on themes related to the research questions, the interview guide, effective interviewing and ethical behavior during fieldwork.

Recruiting and data collection

Users were contacted at the selected primary-care facilities. The field team reviewed the appointment lists daily and identified users requiring FP services and/or follow-up care for puerperium or CPOE purposes; they had no access to their medical records. Every day during the fieldwork period, the field staff invited all the FP users on the facilities’ waiting lists to participate in the study. Listed individuals were approached in the waiting room without offering any participation incentive whatsoever. Those who agreed to participate were taken to a private area where their oral informed consent and permission to tape record the interviews were obtained. Very few users declined our invitation, all of them adducing lack of time. The interview length time averaged 30 minutes and ranged from 16 to 58 minutes. All the interviews were conducted in Spanish and were listened to only by the researchers.

Instruments

We used a guide for semi-structured interviews (S1 and S2 Files). The questions explored general socio-demographic data (age, sex, marital status, educational level and occupation) but focused on the research themes: (a) reasons for seeking FP services; (b) experiences while accessing FP services; (c) experiences related to CMs—specifically access, availability, free choice, and previous as well as current use—whether at the primary-care facility where the interview took place or at another MoH facility; and (d) perceived treatment and interpersonal relations at the facility. The guide was first piloted among subjects with characteristics similar to those of the target population with the objective of testing the questions and enhancing the internal validity of the instrument. Notes taken during each interview were registered in a field journal.

Analysis

Data collected were emptied into a response matrix. The response matrix is a table containing two or more cross-classified dimensions, variables or concepts [41,42]. We transcribed the discourses of our interviewees verbatim in the results matrix and captured the data using a line for each respondent and a column for each code or analytical category. To build the matrix, we used the elements explored during the semi-structured interviews as a-priori codes and added emerging codes as needed. Verbatim fragments of the discourses of users were keyed in and brief analytical notes annexed; the socio-demographic characteristics used to analyze the data were also entered. We used cross coding to ensure that the matrix included standardized codes; that is, all the members of the research team coded the same interview and incorporated the data from that interview into the matrix. Comparing and contrasting among team members allowed for standardizing the data captured under each code, thus optimizing the quality of data capture and ensuring reliability.

We then performed thematic analysis [43,44] by searching the analytical categories, or codes, for themes that could assist in understanding the phenomenon under study. We specifically sought categories that contained detailed explanations related to our research questions. Two parallel rounds of data readings were carried out by two members of the research team. A triangulation exercise was then undertaken to identify findings; these were examined in the light of our research questions and defined as themes that co-occurred in the analyses of both researchers. The credibility of our findings was thus ensured through the systematic and rigorous process of interpretive triangulation [45]. Our theoretical findings were based on detailed and sound information; they captured the experiences of respondents and provided an understanding of their thought patterns and interactions. These findings can therefore be transfered to other subjects presenting equivalent characteristics and seeking CPOE services at facilities similar to those analyzed. [46].

Our results are presented below in the form of verbatim fragments from the interviews recorded at the participating FP service facilities. In order to contextualize the voices in the users’ testimonies, the following labels were established: (1) state (Nuevo Leon, Coahuila, Mexico State, Morelos, Campeche and Veracruz); (2) sex (female and male); (3) age at the time of the interview (e.g., 42 years old); (4) marital status (married, single, free union, divorced, and widowed); (5) completed educational level (none, elementary school, middle school, high school, bachelor’s degree, and beyond); (6) occupation (housewife, employee, student and other); (7) CM being used (e.g., condom, hormonal, IUD, and bilateral tubal ligation-BTL); and (8) ID number ascribed to the interview (e.g., E14). All data were analyzed in Spanish; the English translation of this article was performed by a professional translator specializing in public health and sexual and reproductive health.

Mechanisms for ensuring validity and rigor

The credibility and consistency of our data were ensured through interpretive triangulation, which involves the participation of several researchers in the analysis and interpretation of data [47]. The purpose of this analytical strategy was to achieve transferability of our findings based on theoretical saturation sampling [39]. Confirmability and validity of our data were established by comparing and contrasting the themes of our findings and concepts analyzed against the literature. We also held critical reflection sessions among team members in order to ensure agreement on the research problem, theory and methodology [48].

Ethical aspects

In conformity with the ethical principles of the Helsinki Declaration for medical research involving human subjects, we provided an oral informed consent form to all potential interviewees. Those who agreed to participate were asked for their authorization to tape record their interviews. The study was approved by the Ethics and Research Committees of the National Institute of Public Health in Mexico.

Access

Access to health services is the gateway to FP. Participants had generalized access to FP services and CMs. While they classified their access as easy, barriers clearly existed—albeit systematically indicated and normalized as part of the health care process. Only a few respondents defined their access as difficult. The testimonies compiled from participants revealed that, once access was obtained, differences existed in the type of CM offered and the form of interpersonal relations developed with the FP promoters, depending on whether they were attending a regular FP or CPOE consultation.

Availability of contraceptives and free choice

In general, the accounts of the users revealed a shortage in the availability and a reduced variety of preferred methods (e.g., the implant, the patch and the injection) coupled with the availability of the methods least desired (e.g., the IUD, condoms, and daily hormones).

Interpersonal relations

Service quality was also explored from the standpoint of interpersonal relations, an important aspect of care. Users in the study have defined adequate interpersonal relations as a warm and respectful attitude coupled with the provision of satisfactory information, for instance, about HIV/AIDS and CMs including permanent alternatives.

Information provided to clients

The case of BTL: Reports ranging from lack of information to the violation of human rights.

Finally, we explored the information provided to users in relation to BTL. It should be noted that the majority of interviewees (N = 66) were under 30 years of age, which may have contributed to the failure of providers to offer information concerning permanent methods. However, those over 30 who had at least one child (N = 20) also reported not having received information on definitive methods. This is significant, as the likelihood of reported information on these methods would be expected to be highest among this group of women.

With regard to the BTL method, our findings revealed a lack of information compounded, in some exceptional cases, with interpersonal relations denoting outright user dependency towards staff. Some women who had undergone BTL reported that they had been informed only about the permanence of the method. In one case—coincidentally a woman attending puerperium consultation—BTL was performed against her will and without her being offered any information about the method. This case demonstrated unacceptable treatment of users and their families by the health care system.

The following testimonies bring to light the lack of information available to users prior to undergoing BTL:

This case features a 45-year-old woman. She had undergone BTL, with the medical staff warning her only about the possibility of experiencing acute anxiety and “nervousness” following the operation:

“When I told him [the health professional] to go ahead and operate, he told me not to get scared, because sometimes one could feel like desperate and get really nervous. And I told him I didn’t think that would happen because I did want to have the operation. That was all [the information he gave me].” (Nuevo León, woman, 45 years old, free union, middle school, housewife, BTL, CPOE, E01)

The case of insufficient information described above pales in comparison to the event experienced by the following user. In this exceptional case, the medical staff decided to operate on a woman in puerperium despite her expressed wish not to have the operation, this on the grounds that she had already signed a consent form:

“When they operated [BTL] on me they asked me to sign the consent form. I regretted it afterwards, but since I had already signed there was nothing they could do […] I hadn’t even had the operation when I started to regret it […] but I had already signed the form and my husband had given his authorization, so there was nothing I could do.” (Morelos, woman, 31 years old, married, fourth grade of elementary school, employed, BTL, CPOE, E55)

This testimony depicts an unacceptable combination of events: a lack of information on the scope of informed consent, a violation of human rights and a breach of the freedom of reproductive choice within the framework of FP service delivery.

Table 2 summarizes the findings of our study on user perceptions regarding the quality of FP services in Mexico. It was elaborated according to the types of users and quality components analyzed.

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Table 2. FP quality components.

Summary of user perceptions by type of user.

https://doi.org/10.1371/journal.pone.0210319.t002

Internalized access barriers to family planning services

In general, service users felt that access was “easy” but rarely considered the levels of access that would be required to ensure an effective provision of services. They were satisfied with simply being able to utilize the services, notwithstanding the bureaucratic, organizational, economic and interpersonal hurdles experienced. Normalization of these barriers probably accounts for the high levels of satisfaction usually reported in quantitative analyses [6] despite the access barriers revealed in user testimonies. This is consistent with findings from a study in Peru by Vicuna in 2002 [49].

With respect to internalized barriers, it is important to mention the socio-demographic profile of FP users in public health facilities. They are normally women exhibiting high structural and social vulnerability–low educational and socioeconomic levels, as well as a lack of formal employment and Health Care protection–which may limit their ability to demand respect for their rights and undermine their empowerment when seeking and receiving health services. This is in line with the findings of previous studies that have indicated a lack of user objectivity in perceiving concrete service conditions within contexts exposed to amalgamated cultural and social influences [50,51].

Other barriers to access identified by our research concern the fact that those in need of FP services must pay fees unless they are affiliated with the Seguro Popular or PROSPERA. Our findings match those of a study conducted in Canada in 2015, where it was observed that the need to pay fees was one of the principal barriers to FP care. People lacking the capacity to pay were unable to undergo FP processes, and thus faced a greater risk of unwanted pregnancies. This was especially the case among adolescents, young adults no longer eligible to receive services at youth clinics, immigrants, and the working poor [52]. Economic barriers to FP access represent a limitation in receiving quality care.

Organizational and managerial limitations identified in the participating health facilities also require immediate attention. Institutional and administrative barriers resulting from limited service hours, excessive paperwork and long waiting time for obtaining services were evident from the testimonies presented and must be considered a major issue in the provision of FP services [53–55]. Our results are consistent with the international literature in demonstrating that bureaucratic barriers are crucial in determining whether or not users are able to benefit from health services [53–55].

Inverse availability of contraceptive methods at family planning facilities

The discourses of the interviewees reveal that users must confront the scarcity of preferred birth control methods such as the implant, the patch and injections, and make decisions under conditions of inverse availability, that is, being forced to choose what is available rather than what they prefer. While the patch and the implant are the methods most preferred and requested by users, they are the ones least available in FP facilities. The inverse relationship between preferences and availability identified in our study undermines freedom of choice. A study by Hutchinson et al. in 2011 supports our findings that the frequent scarcity of supply and inadequacy of information on different methods can inhibit their continued use over the long term [56]. Misalignment of the contraceptive methods (CMs) available at FP facilities with those preferred by users has been previously identified in the literature [57]. In a study of Burundi, Ndayizigiye et al. (2017) reported that women preferred long-term CMs which were, however, the least available at health centers. Comparable to our results in Mexico, the implant, the method most preferred by women in Burundi, was available for only 40% of the study sample. Referring to the long-term effect of this method, the arguments of users highlighted the covenience of utilizing a contraceptive that did not require them to return to the provider for three years [57]. The Burundi study also identified what the authors designated as a “climate of fear” among users, who were afraid of being seen by others while seeking FP services. This emerged as one of the factors behind the limited use and coverage of FP services.

The issue of CM availability at FP facilities also calls for a discussion regarding the purchase and distribution mechanisms for the supply of CMs in the Mexican public health sector. Further analysis of the determinants of supply deficiencies is warranted, particularly in view of the sustained increase in public investment that maternal health and FP have enjoyed in recent years [20]. Unwanted effects ensuing from a lack of strategic planning in the acquisition of CMs (often guided by previous budgets and patterns of consumption), irregularities in the supply chain and an inefficient use of resources could be causing a problem as visible and tangible as the lack of supply in the facilities [58–60]. A reliable and responsive supply chain, providing an adequate inventory of the right contraceptives, under appropriate conditions, when and where they are needed, is key to overcoming these challenges [58–60]. Other studies have documented the importance of streamlining and standardizing the supply process as a sine qua non for achieving FP goals. Our results highlight deficiencies in the supply chain at the point of delivery and, consequently, in the provision of FP services to users.

Examples of abuse and disrespect in the interpersonal relations at FP facilities, representing human, sexual and reproductive rights violations

The top-down, paternalistic and intrusive relationship between users and providers is at times so extreme in the provision of CMs that it represents a violation of the human rights of users. This is especially true in the case of women being treated for CPOE and IUD placement, constituting an important barrier to receiving quality care. According to data reported by Hulme et al. in 2015 [52], the beliefs, prejudices and preferences of providers towards certain CMs can influence their prescription. For instance, some prescribe oral CMs indiscriminately, even for women who have difficulty in taking daily pills, while others refrain from prescribing certain methods such as the IUD based on the mistaken belief that they should not be used by nulliparous women. The information analyzed in our study does not allow for proving that induced demand reflects the beliefs of providers; it does however demonstrate that it is linked to the unavailability of certain methods at the facilities. Our findings are also in agreement with those of other studies in highlighting the central role of interpersonal relations in either facilitating or deterring access to health care. Relations that do not convey a friendly attitude and quality care have been identified as a barrier for those who seek FP services [27]. The discourses of our respondents reveal unfortunate–if rare–cases of violation of human rights, preventing women from selecting their own FP methods.

Even though CPOE represents one of the most cost-effective and useful maternal health interventions, the perceptions of users in our study document the frequent lack of dignified and respectful treatment at health facilities during the procedure. Treatment is often violent: in some cases users are told that certain methods are mandatory, that they are required to return to the clinic at a later date if they wish to remove their IUD, and that they must use an IUD against their will despite their physical discomfort following childbirth.These findings suggest that training and sensitivity interventions for maternal health care providers are necessary to ensure that normative and regulated procedures are carried out with utmost respect and under the proper informed consent of users. Disrespectful treatment–at times even violent and in violation of their human rights, for instance, in those cases where women are forced to undergo a BTL procedure against their expressed will–indicates the absence of quality interpersonal care in explicit violation of the sexual and reproductive rights of users.

Provision of inadequate or erroneous information

The function of offering information to users is an opportunity to provide them with FP counseling and accurate, evidence-based facts. This function is intended to open the possibility of dispelling myths and ensuring that users understand the information provided regarding treatment, continuity in care and the onset of side effects. It also allows FP staff to build a relationship with users conducive to sustained interaction [34]. Nonetheless, our findings indicate that providers repeatedly miss this opportnunity. This is evidenced in the accounts of our respondents regarding inaccurate and often erroneous information provided. Studies conducted in other contexts refer to the fact that that providers, acting as guardians of information, frequently prioritize what they communicate to their clients [34] and can selectively avoid subjects that they consider to be potentially embarrassing or to cause uneasiness for either themselves or their clients. This is particularly evident during the provision of sexual and reproductive health services given that sexual problems often prove difficult to broach, especially when they involve behavior regarded as socially inappropriate or taboo [34].

Limitations

Our findings apply only to users of services provided by the Ministry of Health, and thus cannot be generalized to women using Health Care protection services. Since interviews were conducted solely with users encountered in public health facilities, the present study cannot address barriers to access for users of other services. While qualitative findings can be transferable to populations and circumstances similar to those analyzed, they do not have the potential to be generalized.

In spite of our efforts to protect user confidentiality, the fact that interviews took place in health facilities may have contributed to the underreporting of testimony critical of the poor quality of services.

Although the study included rural areas, our field staff spoke no indigenous languages and therefore concentrated on mestizo women. We do not know what additional barriers are confronted by indigenous women in accessing quality services.

Strengths

We employed various mechanisms to ensure the rigor and validity of our qualitative analysis, and hence, the robustness of our findings.

While we sought to obtain a broad panorama by sampling six culturally diverse states including urban and rural areas with different levels of marginalization, we cannot guarantee that all our results are applicable nationally. Nevertheless, specifically with regard to CPOE, given the saturation and density of our data and the fact that the reported conditions were encountered in all of the facilities analyzed, it can be concluded that our findings are transferable [61] to similar situations throughout Mexico.