Actores directos

A total of eight studies were identified that describe the quality of family planning services in North Africa and the Middle East (Al-Qutob and Nasir, 2008; Brown et al., 1995; Mohammad-Alizadeh et al., 2009a; Mohammad-Alizadeh et al., 2007; Mohammad-Alizadeh et al., 2009b; Nakhaee and Mirahmadizadeh, 2005; Swar-Eldahab, 1993; Khademloo et al., 2008). The majority of these were conducted in Iran but three studies also took place in Jordan, Morocco, and Sudan. Only two of these studies, conducted in Morocco and Iran, used some or all of the standard data collection instruments included in the situation analysis approach to measure quality of care as defined by the Bruce framework. Two other studies in Sudan and Iran employed quantitative techniques such as household interviews or exit interviews but failed to tie their results to any established framework of quality. The remaining three studies, in Iran and Jordan, used focus group discussions to assess quality according to both providers and clients. A final study considered the role of side effects in discontinuation of the copper IUD among women in Iran.

A situation analysis was conducted in Morocco in 1992–1993 in 49 facilities using all four standard data collection instruments: facility audits (n=49), observations of client-

provider interactions (n=47), and interviews with both exiting clients (n=293) and service providers (n=165) (Brown et al., 1995). Data was collected on all six aspects of quality in the Bruce framework, as well as facility readiness. Results indicated several strengths including mechanisms to encourage continuity, well trained staff, and availability of basic equipment, as well as weaknesses including little choice of methods and lack of educational materials for counseling. Notably, there were large discrepancies between exit interviews and observations

for data pertaining to whether the client is treated politely, whether all appropriate methods were offered, and whether the client received her method of choice. For each of these three indicators, the mean score for family planning service quality was much higher when reported by an observer as compared to the exiting client. A more recent situation analysis was conducted in Iran in 2005, using observations (n=469) and exit interviews (n=416) at 34 facilities (Mohammad-Alizadeh et al., 2007). Data was collected on elements of quality including choice of methods, client-provider interaction, information given, and provider competence, as well as client satisfaction and knowledge. Results showed quality was low in several areas, including choice of methods (new clients frequently not offered their preferred method due to false interpretation of medical guidelines), information given (especially with respect to information on side effects), and client-provider interaction. In addition, clients were not satisfied with the level of privacy or the ability of providers to address problems, indicating problems with facility readiness and provider competence. On average, clients were treated with respect. A facility audit and provider interviews may have provided additional information about the service infrastructure for the Iranian situation analysis.

Among quantitative studies lacking standard definitions and measures of quality, a study using data collected in 1991 in Sudan investigated barriers to contraceptive use with household interviews of 305 married women (Swar-Eldahab, 1993). Of those women who did not want to become pregnant and were not using contraception (n=91), nearly half reported fear of side effects as their main reason for not using a method. In a more recent study in 2003 in Iran, approximately 900 women exiting 15 health centers consented to participate in a study of client satisfaction (Nakhaee & Mirahmadizadeh, 2005). Clients were least often dissatisfied with aspects of the client-provider relationship including treating the

client politely, answering client questions, and listening carefully to clients. Concerns about method choice, privacy, and information given to clients rated the highest in terms of client dissatisfaction. In both of these studies additional data collection instruments may have provided more complete information about the quality of services provided.

Three studies used qualitative methods to assess quality of care, the first of which was conducted in Jordan in 2004 using focus group discussions with physicians, nurses, and midwives from 50 healthcare facilities (Al-Qutob & Nasir, 2008). Providers reported poor supervision, unequal treatment of providers with respect to educational opportunties, inadequate basic equipment and supplies, and client overload as major barriers to providing optimal services. A subsequent study using focus group discussions with providers in Iran in 2005 found similar results—providers were frustrated by poor supervision, lack of continuing education opportunities, and a dearth of educational and counseling materials (Mohammad- Alizadeh et al., 2009a). Discussions with providers may help highlight ways in which facilities are unprepared to offer high-quality services. A third qualitative study used focus group discussions with 54 current or ever contraceptive users at public facilities in Iran in 2006 and noted sup-optimal quality of care in terms of choice of methods and information given, as well as inadequate privacy (Mohammad-Alizadeh et al., 2009b).

Finally, a randomly selected cohort of 400 TCu380A intra-uterine device (IUD) users in Iran were followed for five years, beginning in 1999, to calculate discontinuation rates and document reasons for discontinuation (Khademloo et al., 2008). Approximately 20% of women had discontinued by the end of two years and more than 80% discontinued by the end of five years. The most commonly cited reason for discontinuation was occurrence of side effects, suggesting the need for improved counseling.

Observational/Multivariate Studies

Egypt and Morocco contributed four studies investigating the association between quality of service delivery or service environment and contraceptive behavior (Ali, 2001; Hong et al., 2006; Magnani et al., 1999; Steele et al., 1999). In two of the studies the outcome of interest is contraceptive use of one or more methods; the other two focus on continuation or both adoption and continuation of available methods. A fifth study, in Iran, looks at factors potentially supporting or inhibiting the provision of high-quality services (Shahidzadeh-Mahani et al., 2008).

Two studies of quality from this region focus on the outcome of contraceptive use. In the first, conducted in Morocco in 1992–1995 among a sample of 910 women, researchers investigated the association between the supply environment and use of all available methods (Magnani et al., 1999). Aspects of quality included in this analysis include number of nearby facilities, number of trained staff, method availability, and infrastructure, including presence

of water, electricity, and an examination table. Training (p≤0.01) and availability of methods

(p≤0.05) were significantly, but weakly, associated with contraceptive use. A more recent study in Egypt used individual-level data on 8,445 women from the 2003 DHS and linked these women to a family planning facility (n=602) within 10 kilometers to determine the role of quality in adoption of the IUD (Hong et al., 2006). Four elements of quality were

measured: counseling, examination room, choice of methods, and training and supervision. Women linked to public facilities that scored high on an index of quality combining these four elements were 1.36 (p < 0.01) times as likely to use an IUD as those linked to facilities that scored low. There was no association between distance to the nearest facility and IUD use. Considered individually, counseling and a well-supplied examination room appeared to

have the strongest association with IUD use at public facilities. This association was not seen at private facilities.

An analysis using Egypt 1988 DHS individual-level data linked to facility-level data by cluster measured quality of care by the percentage of family planning doctors who were female, competence and training of family planning staff, and range of methods. This study found that women linked to facilities with a “below average” number of available methods had a decreased risk of discontinuing pill use at 24 months (adjusted risk ratio = 0.70, 95% CI (0.54, 0.91), after controlling for demographic characteristics and fertility motivations (Ali, 2001). No association was found between the other quality measures and use. A study using DHS panel data from 1992–1995 measured contraceptive adoption and pill

continuation among a sample of 3,324 Moroccan women (696 of whom were pill users) and

found that a public health center within 10 kilometers (p≤0.05) or the availability of three or

more methods at the nearest facility (p≤0.05) were significantly associated with modern- method adoption (Steele et al., 1999). In addition, among women who discontinued for reasons including spousal disapproval, inconvenience, ineffectiveness, cost, and access, there was a weak but significant association between obtaining pills from a non-governmental source and continuation.

Last, a 2006 study in Iran sought to understand reasons for low-quality services among a sample of 25 facilities, 396 family planning clients, and 83 providers (Shahidzadeh- Mahani et al., 2008). Quality was measured using client exit interviews and personnel files to complete a checklist of 27 items that fell into four categories: history taking, physical

examination, choice of methods, and counseling. Factors contributing significantly to the delivery of high quality services included provider experience (odds ratio=1.9, CI=1.2, 3.0),

low caseload (OR=3.7, CI=2.0, 6.7), and being a new client (OR=4.2, CI=2.6, 6.7).

Ironically, providers without college degrees had significantly greater odds of offering high quality service (OR=6.7, CI=4.0, 10.8) compared to those with a college degree.

Observations, interviews with providers, and/or facility audits may have provided additional information or validated some information collected from clients.

Evaluation studies

Two studies in Egypt and Turkey were conducted to assess the impact of efforts to improve the quality of family planning services (Hong et al., 2011; Ozek et al., 1998). On- the-job trainings conducted at 16 clinics with 130 service providers in Turkey between 1995 and 1998 were assessed using observations of the client-provider interaction (Ozek et al., 1998). Training was provided over a course of five visits during the three-year period and included staff meetings, self-assessment, role plays, demonstration, coaching, and feedback. Measures of quality included national standards for counseling, IUD insertion, privacy, and infection prevention. Although the percentage of providers adhering to national standards increased throughout the five visits, it is impossible to know from the information provided by the authors whether or not the noted improvements were significant or attributable to the trainings. In the second study, a national quality improvement program was implemented in Egypt from 1995 to 2000, focusing on improved training and supervision (Hong et al., 2011). Facility audits, provider interviews, and observations in the 2004 Egypt SPA survey were used to compare the quality of services provided at intervention and non-intervention facilities (n=637) four years after the end of the program. Measurements of quality included method choice, counseling, supplies and privacy of examination room, and supportive management. Even after controlling for facility type and location, the facilities successfully

targeted by the government program significantly outperformed other facilities across all measures of quality. Unfortunately, neither of these assessments considered the effect of quality improvements on contraceptive outcomes.

Summary of quality in North Africa, the Middle East, & Eastern Europe