Family planning refers to utilisation of various types of fertility control methods to prevent unwanted pregnancies. It helps individuals or couples to have children in order to assure the well-being of children and parents (FDRE, 2007; Central Statistical Agency [Ethiopia] and ICF International, 2016). Family planning is a part of basic human rights and was endorsed by the International Conference on Population and Development in Cairo in 1994 (United Nations Population Fund [UNFPA], 2014; Asrade et al, 2018). The modern family planning service in Ethiopia was started by the Family Guidance Association of Ethiopia which was established in 1966 (FDRE, 2014).
Family planning is very important for women in the postpartum and post-abortion periods as fertility can return quickly after giving birth if not breastfeeding (USAID, 2005). Family planning helps women and their families to preserve their health and improve the overall quality of their lives. Family planning contributes in improving children's health and ensuring that they have access to adequate food, clothing, housing and educational opportunities. Additionally, it allows families, especially women, to adequately participate in development activities (USAID, 2005; FDRE, 2014; Asrade et al, 2018).
Provision of family planning with quality improves the health and quality of life very effectively compared with investments in most other health and social interventions. Additionally, committing human and financial resources to improve family planning services does not only improve the health and well-being of women and children but it also supports the implementation of the national and international policies (USAID, 2005; UNFPA, 2014; FDRE, 2014; Assefa et al, 2017; Alemayehu et al, 2018; Asrade et al, 2018).
In many developing countries where resources are scarce, community health workers are widely used to promote access to primary healthcare and improve health outcome. The use of community health workers to increase the access of health services has been a part of various health programmes. In Ethiopia, health measures that could reduce these problems are not accessible to all women. To increase the accessibility of health services, the government of Ethiopia introduced an innovative community based intervention, the Health Extension Program. The Health Extension Program aims to improve access to essential health services through community based health extension workers. Health extension workers are providing promotive, preventive and basic curative health services (USAID, 2005; FDRE, 2014; Assefa et al, 2017; Asrade et al, 2018).
In sub-Saharan Africa, a probability of death from pregnancy or childbirth-related causes is one in 22 which might be due to lack of quality family planning services. Quality of family planning services include provision of contraception to help women for plan and space births, prevention of unintended pregnancies to reduce the number of abortions; offering pregnancy testing and counselling; helping clients who want to conceive; providing preconception health services to improve infant and maternal health.
Access to quality services will determine the uptake and continuous utilisation of services (Fantahun, 2005; USAID, 2005; World Health Organization, 2005; Enabor and Oluwasola, 2013; Fikru et al, 2013; Gebremeskel et al, 2017; Alemayehu, 2018; Asrat, 2018; Assefa et al, 2019). There is limited information on the quality of family planning services in the study area. Therefore, this study aimed to assess quality of family planning services and associated factors at health posts in the Jimma zone, southwest Ethiopia.
Methods
Study design and area
Cross-sectional study design was employed using quantitative study supported by qualitative methods in the Jimma zone from 13 March to 13 April 2018 (Gregorian calendar). The Jimma zone is located at 350 km from Addis Ababa. Based on the 2007 population and housing census, the zonal population is estimated to be 3 261 374 with 548 618 women in childbearing ages. The Jimma zone has 21 districts with 515 rural and 51 urban kebeles. The zone has currently 685 health institutions; out of this, eight are hospitals, 122 are health centres and the remaining 555 are health posts. There are 1 141 health extension workers (HEWs)(1 104 rural and 37 urban) in the Jimma zone.
Study populations
Reproductive age group women (15–49) who came to a health post during the data collection period and health extension workers who lived in the selected area at least for six months were the study population.
Sample size and sampling procedure
The required sample size was determined using single population proportion formula with assumption of 50% expected prevalence of quality of family planning, 5% level of significance and 10% non-response rate. By considering design effect of 1.5 and non-response rate of 10%, a total of 508 sample size was calculated. Additionally, a total of 18 in-depth interviews were conducted. By using simple random sampling technique, six districts namely Dedo, Gomma, Sokoru, Sekachekorsa, Shabe Sombo and Tiro-Afata were selected from the Jimma zone. Then, from each district, 30% of health posts were selected using simple random sampling technique. The sample size was proportionately allocated to the selected health posts. Participants were selected consecutively until the required sample size was fulfilled. HEWs were purposely selected for an interview. Inventory assessment was conducted in all selected health posts.
Data collection procedure and instruments
Client exit interviews were conducted using pre-tested structured questionnaire. Data were collected by 12 BSc holders and supervised by six master of health holders. Qualitative data was collected using in-depth interview guides, direct observation and an inventory checklist. In this study, quality was measured in terms of client satisfaction, availability of facilities, supplies, providers and instruments for family planning service delivery.
Client satisfaction was measured through client exit interviews using 12 items related to satisfaction each ranking on the five-point Likert scale, from strongly disagree (1) to strongly agree (5). The scores were obtained from the 12 items. The mean score of satisfaction for each client was calculated as the average of satisfaction items. A value less than the mean score was taken as an indicator of client's dissatisfaction (Asrat et al, 2018; Gebreyesus, 2019). HEWs are females who are recruited from the community whom they will serve and they are deployed to service after a one-year formal pre-service training on primary healthcare.
Data analysis
The collected data was checked for its completeness and then entered into the Epi-Data version 3.1 and exported to SPSS version 21.0 software for analysis. Descriptive statistics was performed and presented by text, tables and graphs. Logistic regression analyses were used to identify the predictors of client satisfaction on the family planning services obtained at health posts.
In binary logistic regression, those variables which were found to have an association with the outcome variable at P<0.25 were selected as a candidate variable for multivariate logistic regression analysis to identify the predictors of clients' satisfaction in quality of family planning services at health posts. P-values below 0.05 were used to declare a statistical association. Qualitative data were analysed manually which involved coding, examining, comparing and categorising data and writing the findings. Finally, qualitative data were presented by triangulating with quantitative findings.
Results
From 633 study participants, 95.5% of participants gave complete responses. The mean age of study participants was 27.45+5.34 with the range of 16–43 years. Majority of study participants were married (93.7%) and more than one-third (36.5%) of them cannot read or write (Table 1).
Table 1. Socio-demographic characteristics of study participants from the Jimma zone, 2018
| Variables | Frequency (n) | Percent (%) |
|---|---|---|
| Age of women | ||
| 15−19 | 33 | 5.5 |
| 20−24 | 146 | 24.1 |
| 25−29 | 218 | 36 |
| 30−34 | 126 | 20.8 |
| >35 | 82 | 13.6 |
| Marital status | ||
| Married | 567 | 93.7 |
| Divorced | 19 | 3.1 |
| Number of children | ||
| One | 82 | 14.6 |
| Two | 114 | 20.2 |
| Three | 105 | 18.7 |
| Four | 113 | 20.1 |
| Five | 62 | 10.2 |
| >Six | 85 | 15.1 |
| Educational status of women | ||
| Unable to read and write | 221 | 36.5 |
| Primary school (1−8) | 209 | 34.5 |
| Write and read only | 122 | 20.2 |
| Secondary school (9−12) | 47 | 7.8 |
| Ethnicity | ||
| Oromo | 478 | 79 |
| Yem | 79 | 13.1 |
| Amahara | 34 | 5.6 |
| Religion | ||
| Muslim | 468 | 77.4 |
| Orthodox | 78 | 12.9 |
| Protestant | 47 | 7.8 |
| Wealth quintile | ||
| Lowest | 118 | 19.9 |
| Second | 115 | 19.4 |
| Middle | 125 | 21.1 |
| Fourth | 120 | 20.2 |
| Highest | 115 | 19.4 |
The major source of information about family planning was healthcare professionals (46.1%). A large number of clients (70.4%) reported that the communication or interaction with healthcare providers were easy to understand. Large number of clients (42.8%) reported that most of the time they received family planning services from health posts (Table 2). Similarly, an in-depth interview held with HEWs showed that clients were obtaining family planning services from health posts. A 25-year-old HEW said:
Table 2. Service-related characteristics of participants at health posts in the Jimma zone, 2018
| Variables | Frequency (n) | Percent (%) |
|---|---|---|
| Source information about family planning | ||
| Health profession | 279 | 46.1 |
| Neighbour | 156 | 25.8 |
| Husband | 153 | 25.3 |
| Distance of health facilities | ||
| Less than half hour | 515 | 85.1 |
| Half hour to one hour | 90 | 14.9 |
| Adequacy of information | ||
| Received sufficient information | 464 | 76.7 |
| Not received sufficient information | 131 | 21.7 |
| Feeling about adequacy of consultation hour | ||
| Adequate time | 375 | 62 |
| Too short | 85 | 14 |
| Perception on communication with provider | ||
| Easy to understand | 426 | 70.4 |
| Difficult to understand | 39 | 6.4 |
| Place of receiving contraceptives service | ||
| Health post | 259 | 42.8 |
| Health centres | 247 | 40.8 |
| Private | 36 | 6 |
| Hospital | 11 | 1.8 |
| Preference of contraceptive methods | ||
| Injectable | 293 | 52.6 |
| Pills | 160 | 28.9 |
| Implanon | 98 | 17.7 |
| Others | 5 | 0.83 |
‘At health posts, there are services like family planning, antenatal care and child vaccinations. There is also a session for delivering a message on child feeding practices and post-natal care for all reproductive age women.’
HEWs also further elaborated that they were disseminating information about family planning for their clients:
‘After delivery, women should come to health institutions for vaccinations and family planning utilisation. At health posts, when women come for the services, we are providing education on the utilisation of family planning methods. And also, we are giving them family planning services like pills and implants.’
Majority of respondents (94.4%) reported that they have received the contraceptive method they preferred and a large number of the clients preferred the injectable one (52.6%) (Table 2). Information obtained from HEWs also supports this finding:
‘Most of the time, women preferred the injectable type of family planning methods. After 45 days of childbirth, the child will be vaccinated and a mother starts to use the family planning methods. Most of the time, women prefer injections.’
Regarding the expectation of clients before utilisation of family planning services, 60.7% of clients had bad expectations. Out of 156 clients who had problems with utilisation of family planning, 8.1% of them discontinued the utilisation (Table 3). More than half of respondents (57.2%) considered the healthcare provider's greeting as good and in a friendly way. A large proportion of clients (59.8%) agreed with the healthcare provider's performance procedure on cleanliness and sanitation (Table 4).
Table 3. Clients' expectation before and after utilisation of family planning methods in the Jimma zone, 2018
| Variables | Frequency (n) | Percent (%) |
|---|---|---|
| Previous expectation of family planning | ||
| Bad expectation | 367 | 60.7 |
| Good expectation | 237 | 39.2 |
| Causes of bad expectation | ||
| Lack of knowledge | 286 | 78.2 |
| Religion | 81 | 21 |
| Health problem due to utilisation family planning | ||
| Yes | 449 | 74.2 |
| No | 156 | 25.8 |
| Discontinued family planning due to health problem | ||
| Yes | 107 | 91.9 |
| No | 49 | 8.1 |
Table 4. Clients satisfaction on family planning services at health posts in the Jimma zone, 2018
| Variables | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| Provider greeting was good and in friendly way | 227 (37.5) | 346 (57.2) | 27 (4.5) | 5 (0.8) | - |
| Performed the procedure with cleanliness | 119 (19.7) | 362 (59.8) | 114 (18.8) | 10 (1.7) | - |
| Provider had good knowledge and skill | 86 (14.2) | 367 (60.7) | 130 (21.5) | 22 (3.6) | - |
| Sufficient methods were available | 71 (11.7) | 398 (65.8) | 93 (15.4) | 43 (7.1) | - |
| Sufficient information was given about method | 71 (11.7) | 327 (54.0) | 173 (28.6) | 34 (5.6) | - |
| Privacy was maintained | 91 (15) | 318 (52.6) | 161 (26.6) | 33 (5.5) | - |
| Waiting time was adequate | 74 (12.2) | 343 (56.7) | 96 (15.9) | 90 (14.9) | 2 (0.3) |
| Waiting place had latrine and water supply | 53 (8.8) | 214 (35.4) | 185 (30.6) | 149 (24.6) | 4 (0.7) |
| Health provider was always available | 61 (10.1) | 212 (35.0) | 149 (24.6) | 178 (29.4) | 5 (0.8) |
| Time of service was convenient | 76 (12.6) | 331 (54.7) | 160 (26.4) | 37 (6.1) | - |
| Closeness of health facility to clients | 78 (12.9) | 334 (55.2) | 178 (29.4) | 15 (2.5) | - |
| Appointment was given | 98 (16.2) | 333 (55.0) | 162 (26.8) | 12 (2) | - |
More than half of health posts (54.4%) had functional blood pressure apparatus and 70.4% had family planning guidelines. Most of the health posts had shortages of the combined oral pill (65.5%) and injectable methods (70.4%) (Table 5).
Table 5. Facility observation (inventory) on logistics and supplies at health posts of the Jimma zone, 2018
| Variables | Frequency (n) | Percent (%) |
|---|---|---|
| Logistics and supplies | ||
| Private examination room | 41 | 67.2 |
| Functional blood pressure apparatus | 33 | 54.09 |
| Family planning guideline | 43 | 70.4 |
| Had electricity service | 38 | 62.2 |
| Progestin-only oral pill shortages | 10 | 19.2 |
| Combined oral pill | 40 | 65.5 |
| Injectable pills | 43 | 70.4 |
| Implanon | 42 | 68.8 |
| Safety box | 51 | 83.6 |
| Examination bed | 47 | 77.04 |
| Weight scale | 41 | 67.2 |
| Registration book | 45 | 73.7 |
| Disposable glove | 46 | 75.4 |
In this study, 42.8% of clients were satisfied with family planning services at health posts at the Jimma zone. Bivariate logistic regression models showed that age of participant, residence, religion, husband occupation, attending family planning education, source of information about family planning, preference of client and economic status were significantly associated with client satisfaction on family planning utilisation (Table 6).
Table 6. Factors associated with client satisfaction of family planning utilisations at health posts in the Jimma zone, 2018
| Variables | COR (95% CI) | AOR (95% CI) | P-value |
|---|---|---|---|
| Age of the patient | |||
| 15−19 | 4.85 (1.81, 12.99) | 6.12 (1.63, 22.8)* | 0.007 |
| 20−24 | 2.25 (1.29, 3.92) | 2.40 (1.25, 4.60)* | 0.008 |
| 24−29 | 1.20 (.72, 2.00) | 1.21 (0.67, 2.18) | 0.521 |
| 30−34 | 1.17 (0.67, 2.04) | 1.32 (0.69, 2.49) | 0.390 |
| >35 | 1 | 1 | |
| Religion | |||
| Orthodox Christian | 0.57 (0.35, 0.93) | 0.49 (0.28, 1.86) | 0.053 |
| Catholic | 0.76 (0.23, 2.54) | 2.08 (0.46, 9.40) | 0.340 |
| Protestant | 0.33 (0.17, 0.62) | 0.24(0.12, 0.49)* | 0.001 |
| Muslim | 1 | 1 | |
| Husband occupation | |||
| Farmer | 3.08 (0.89, 10.69) | 1.62 (0.39, 6.63) | 0.50 |
| Government employer | 1.57 (0.39, 6.23) | 1.46 (0.32, 6.73) | 0.620 |
| Trader/merchant | 1.81 (0.49, 6.76) | 0.99 (0.23, 4.34) | 0.980 |
| Daily labour | 0.21 (0.04, 1.06) | 0.17 (0.03, 1.02) | 0.051 |
| Others | 1 | 1 | |
| Source of information | |||
| Husband | 1.22 (0.44, 3.37) | 0.65 (0.19, 2.29) | 0.52 |
| Neighbours | 1.88 (0.68, 5.19) | 0.67 (0.19, 2.47) | 0.55 |
| Health professional | 2.58 (0.95, 6.99) | 1.31 (0.37, 4.58) | 0.67 |
| Others | 1 | 1 | |
| Residence | |||
| Rural | 2.99 (1.12, 7.97) | 1.03 (0.32, 3.29) | 0.97 |
| Semi-urban | 1 | ||
| Attended family planning education | |||
| Yes | 2.96 (2.00.4.37) | 1.87 (1.09, 3.17) | 0.021 |
| No | 1 | 1 | |
| Preference of client | |||
| Yes | 2.09 (1.48, 2.96) | 1.96 (1.24, 3.09) | 0.004 |
| No | 1 | 1 | |
| Wealth quintile | |||
| Lowest | 0.25 (0.141, 0.43) | 0.33 (0.17, 0.66)* | 0.002 |
| Second | 0.35 (0.202, 0.61) | 0.51 (0.27, 0.95)* | 0.033 |
| Middle | 0.49 (0.29, 0.87) | 0.43 (0.23, 079)* | 0.007 |
| Fourth | 0.63 (0.36, 1.10) | 0.59 (0.32, 1.08) | 0.089 |
| Highest | 1 | 1 | |
Significant at p<0.05 (information gathered from other sources such as media and friends)
Findings of multivariable logistic regression analysis showed that women aged from 15–19 were six times more likely (adjusted odds ratio [AOR]=6.12 [1.63, 22.8], P=0.007) satisfied with family planning services than women aged 35 years and above. Similarly, clients who attended family planning education were 87% more satisfied (AOR=1.87 [1.09, 3.17], P=0.021) than women who did not attend family planning education classes. Clients those who got their preferred family planning were 96% more satisfied (AOR=1.96 [1.24, 3.09], P=0.004) than clients who did not get their preference. Similarly, clients at the lowest economic status were 67% (AOR=0.33 [0.17, 0.66], P=0.002) less satisfied than clients with the highest economic status.
Discussion
This study tried to assess the quality of family planning services offered at health posts among women in the reproductive age in the Jimma zone. Client satisfaction with family planning services is an important indicator of quality of care that represents the needs, preferences and subjective experience of clients from the clients' point of view. This study showed that 42.8% of clients were satisfied with the overall aspects of the family planning service. This is relatively low compared to a study done in Ethiopia and northern Nigeria where 59% and 85% of clients were satisfied with family planning services (Enabor and Oluwasola, 2013). This might be due to inclusion of higher-level facilities, including hospitals and private clinics, whereas this study includes only health posts, a lower-level health service delivery point.
Almost 62% of clients felt their hour-long consultation with their healthcare providers were adequate in providing family planning services and this figure was relatively low compared to the study done in northern Nigeria and the Jimma zone, where 74% and 93% of clients were satisfied with the waiting time, respectively (Enabor and Oluwasola, 2013; Fikru et al, 2013). This difference might be due to the fact that the number of healthcare providers at health posts was not proportional with the flow of clients they were serving. The majority of clients (70.4%) also reported that it was easy for them to understand what the healthcare provider said to them. This study was consistent with the findings from north Gondar zone and northwest Ethiopia were 82%, and 85.7% of the women could easily understand what the health provider said to them (Fantahun, 2005; Asrat et al, 2018). This might be due to the selection of HEWs from the local communities as they share similar culture and language with their clients.
This study showed that most of family planning users (52.6%) preferred injectable kinds of family planning methods which was relatively low compared to findings from Bahirdar (61.8%) and Boditi town (84.3%) (Gebremeskel et al, 2017; Asrat et al, 2018). An in-depth interview with a health provider also indicated majority of clients preferred family planning which was an injectable. This might be due to the fact that injectable type of family planning does not require daily base remembrance.
This study showed that more than one-fifth (21.7%) of clients did not get the service and information they expected from healthcare providers which is relatively high compared to study from Jjigjiga, where 6.5% of the study participants did not get the service and information they expected from healthcare providers (Gebreyesus, 2019). This might be due to lack of motivation or workload to give services by healthcare providers. According to this study, the major source of information for clients were health professionals (46.1%) which was relatively low compared to study done in northwest Ethiopia were 89.6% clients got information from health professionals. This might be due to the fact that the rural residents are less accessible to get information from other sources such as from media, internet and the others (Asrat et al, 2018).
Findings from observations at health facilities indicated that only less than half of healthcare providers took the client's blood pressure, checked their weight and asked questions about chronic illnesses. More than half of healthcare providers have informed clients about the possible side effects of the contraceptive methods contrary to findings from the Dembia district in northwest Ethiopia (Kebede, 2007). However, the study from Hosanna indicated that more than three-fourths of clients were informed of the possible side effects of the contraceptive methods (Argago et al, 2015). This might be due to inclusion of higher-level facilities, including hospitals and private clinics, in the study conducted at Hosanna.
Findings of this study indicated that young women were more satisfied with the family planning services they obtained at health posts than older women which is similar with the study done in Hosanna town (Argago et al, 2015). This might be due to the fact that young age groups were more accessible to information from different sources and had different educational statuses.
Furthermore, wealth status was associated with a level of client satisfaction. Accordingly, clients at the lowest wealth status were less likely satisfied with family planning services they obtained at health posts as opposed to their counterparts. Although family planning services are free of charge, women can be dissatisfied due to an exposure to indirect costs such as payment for transportation.
Attending family planning education classes were significantly associated with client satisfaction on family planning utilisation. Findings from in-depth interviews also showed that there was family planning education and improvement of family planning utilisation over a period of time. The study done in Hosanna also indicated significant association between family planning education and client satisfaction (Argago et al, 2015).
According to this study, those who received their preferred family planning service were more satisfied than clients who did not get their preferred methods. Clients need family planning services that meet their individual fertility goals and so providing a range of methods will satisfy them. Studies also showed that accessibility to various contraceptive methods is the key to client satisfaction and to use family planning methods (Kebede, 2007; Medhanyie et al, 2017; Gebreyesus, 2019).
This study was not without limitation. Despite attempts to get a reliable picture of client satisfaction, there were several potential threats to the validity of this study. For example, staff reports of their own behaviour can be inaccurate, client interviews may suffer from courtesy bias and normal activities may be affected by presence of research teams. Additionally, this study did not consider the advantage of family planning in prevention of sexually transmitted diseases; only the quality of family planning services was assessed.
Conclusion
In conclusion, less than half (42.8%) of clients were satisfied with the overall aspects of family planning services. Health professionals were a major source of information for clients about family planning utilisation. Majority of clients reported that they had an adequate consultation with health providers. Clients' satisfactions in utilisation of family planning methods were significantly associated with clients' preference of family planning methods, age of clients, their attendance at family planning education classes and wealth status. Therefore, there is a need to increase the availability of different contraceptive methods and enhancing family planning education to improve quality of family planning services. Religious affiliation of an individual was significantly associated with client satisfaction which can be better explored by using qualitative method from client perspectives.