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Quality of family planning counseling is likely associated with whether or not women continue to use the same contraceptive method over time. The Method Information Index (MII) is a widely available measure of contraceptive counseling quality but little is known about its association with rates of method continuation. The index ranges from 0 to 3 based on a client’s answer to whether she was told about other methods, potential side effects with her chosen method, and what to do if she experienced side effects. Using data from a prospective cohort study of 1,998 social franchise clients in Pakistan and Uganda, we investigated the relationship between reported baseline MII and the risk of method continuation over 12 months using survival analysis and Cox proportional hazard models. At baseline, about 65% of women in Pakistan and 73% of women in Uganda reported receiving information about all 3 MII aspects. In Pakistan, 59.4% of the 165 women who stopped using their modern method did so while still in need of contraception. In Uganda, of the 77 women who stopped modern method use, 64.9% discontinued while in need. Despite important differences in the demographics and method mix between the 2 countries, we found similar associations between baseline MII and discontinuation: in both countries as the MII score increased, the risk of discontinuation while in need decreased. In Pakistan, the risk of contraceptive discontinuation was 64% lower (crude hazard ratio [HR crude ]=0.36; P=.03), and 72% lower (HR crude =0.28; P=.007), among women who were told about any 2, or any 3 aspects of MII, respectively. After adjusting for additional covariates, only the difference in the risk of contraceptive discontinuation between MII=3 and MII=0 remained statistically significant (HR adj =0.35; P=0.04). In Uganda, women who reported being informed about all aspects of MII were 80% less likely to discontinue while in need (HR adj =0.20; P<.001), women informed about any 2 aspects of MII were 90% less likely (HR adj =0.10; P<.001), and women who were informed about any 1 aspect of MII were 68% less likely (HR adj =0.32; P<.02) to discontinue contraceptive use while in need as compared to women who reported not being informed about any aspect of MII. Baseline MII scores were positively associated with method continuation rates in our sample of clients from social franchises in both Pakistan and Uganda and could potentially be used as an indicator of contraceptive counseling quality.
All data from this study were collected over 12 months in Pakistan and Uganda using similar methodologies. Pakistan and Uganda were selected due to the presence of strong partners and due to the fact that both countries have high rates of unmet need for family planning. In both countries, the partners delivered services through social franchises—networks of private health care providers, linked through a common brand. Typically, in such arrangements, the franchisor provides training, commodities, and quality assurance while the franchisees agree to provide franchised services, be audited, and adhere to price ceilings.22 Working with franchises allowed the study to leverage existing administrative and quality assurance systems and to work with a large number of service delivery sites. This study was conducted in collaboration with Population Services International's (PSI's) Ugandan partner Program for Accessible Health Communication Education (PACE)-Uganda, which operates the ProFam franchise of health clinics throughout the country, and Marie Stopes Society in Pakistan, which operates the Suraj franchise. The ProFam franchise is a network of privately owned health clinics that are located across the country and offer a range of health services, including family planning, HIV, malaria, cervical cancer screening, and maternal health. Clinics are mostly owned by practicing or retired midwives, nurses, nursing assistants, and, in a few cases, medical doctors. The Suraj fractional franchise is focused on family planning services, and the health care providers are primarily midwives. The study was conducted in social franchise clinics in Pakistan and Uganda. Uganda has one of the highest fertility rates in the world (total fertility rate=5.4), and 41% of all births in Uganda are mistimed or unwanted.23 Ugandan women have a high need for limiting or spacing pregnancies (67% of married women of reproductive age), but only 35% of married Ugandan women use a modern method of contraception.23 According to the 2016 Uganda DHS, Uganda's method mix predominantly consists of short-acting methods, with injectables accounting for more than half of the method mix. The next most frequently used method is implants (18% of modern method mix) while intrauterine devices (IUDs) account for only 4%. However, the situation in Uganda is changing rapidly; data from Performance Monitoring and Accountability 2020 (PMA2020) suggest that the rates of use of implants almost doubled from 15.5% in 2016 to 26.7% in 2018.24 In Pakistan, 16% of births in the 5 years preceding the 2012–2013 DHS survey were mistimed or unwanted, and the total fertility rate is 3.8.25 Over one-quarter (26.1%) of married women use a modern contraceptive method while 20.1% of married women have an unmet need for family planning. Recent data (2012) from Pakistan indicates that Pakistani women using modern methods are predominantly using female sterilization or condoms (each comprising 35% of modern contraceptive use), with 7% to 11% of contraceptive users using the IUD, pill, or injectable.25 Implant availability is increasing, but the method has been available in Pakistan only since 2010; recent data on implant prevalence is not available.26 Method discontinuation is an issue both Uganda and Pakistan. In Uganda, 45% of contraceptive users will discontinue within 12 months. Discontinuation rates are highest for pills (67%) and injectables (52%). The most common reason for discontinuation is side effects or health concerns, with more than 1 in 3 users discontinuing for this reason. Of those who discontinued any method and stated wanting another method, just 5% switched to another method within 2 months.23 In Pakistan, 37% of women discontinue within 12 months, and the majority of those women discontinue while still in need of contraception (26%). Similar to Uganda, the most common reason for discontinuation in the first year of use is side effects or health concerns, and the rate of switching is relatively low, with 7.6% of contraceptors switching within the first 12 months.25 In both countries, more than one-third of current family planning users obtained their method from the private medical sector (35% in Pakistan, 39% in Uganda).23,25 This study was conducted in the private-sector facilities that are affiliated with our study partners. In Uganda, we recruited women for this study from high-volume ProFam franchise clinics that provided a full range of modern contraceptive methods. As of July 2016, there were 193 active ProFam clinics operating in Uganda. Of these, we deemed for inclusion 163 clinics (84%) that provided at least 1 of 3 reversible forms of contraceptives (IUDs, implants, or injectables) in the first 6 months of 2016. We restricted the sample to clinics that had at least 28 new family planning clients per month (which was approximately the 50th percentile in the full sample of ProFam clinics) in order to be able to recruit at least 1 new patient per day per clinic. We also limited our sample to clinics in the Central, Southwest, and East regions to minimize data collection costs. However, the excluded regions tended to also have lower patient flows, so this geographic restriction did not reduce the number of high-volume clinics in our sample by very much. We randomly selected 32 clinics from the remaining list of 69 facilities in our sample. Among those selected, 2 clinics were in the process of leaving the ProFam network, so we excluded them from our study, leaving us with 30 clinics in our final sample. In Pakistan, we used multi-stage sampling to first select 12 districts in 3 provinces of Pakistan (Sindh, Punjab, and Khyber Pakhtoon Khwa). We chose these districts in consideration of project budget and ease of monitoring. Second, all providers who belonged to another project that was closing were dropped from the sampling frame. Finally, 75 Suraj social franchise centers were randomly selected from a total of 81 centers in those provinces in late 2016. The total number of study facilities was chosen based upon a desire to have sufficient heterogeneity in quality while being mindful of feasibility. All Suraj franchises provide condoms, pills, injectables, and IUDs. In Uganda and Pakistan, PACE-Uganda and Marie Stopes Society, respectively, notified selected facilities about the study and sought their consent to participate in the study. All selected facilities agreed to participate in the study. Women were eligible to participate in this study if they had received a modern contraceptive method (male or female condom, pill, injectable, implant, IUD, or emergency contraceptive) during the visit in which they were recruited and were either first-time users (reported using contraception for the first time in their life), switching to a different modern method, or lapsed users returning to use (reported not using any contraceptive method in the 3 months prior to the baseline interview). Additionally, to be eligible in Uganda, women must also have provided at least 1 phone number at baseline where they could be reached for follow-up interviews. Women who obtained a resupply of an existing method, received sterilization, or were using non-modern methods, such as withdrawal, were not eligible. All eligible women were asked to provide written informed consent to participate in the study. Exit interviews were conducted in a private setting to ask about their visit and demographics immediately after adopting a modern method during a visit to a social franchise site. First-time users, method switchers, and lapsed users of reversible contraception were eligible for inclusion in the study. Study recruitment took place in Pakistan from December 2016 to February 2017, and in Uganda, between February and April 2017. To recruit women, in both countries women exiting a study clinic were screened for eligibility, and if eligible, asked to take an exit survey and also to consent to follow-up at 3, 6, and 12 months after the visit. In Uganda, the women consented for follow-up at 9 months, too. Eligible women who consented to participate were given a short exit survey at the time of recruitment that covered demographics, patient experience, method use, subjective measures of quality and satisfaction, including the 3 items from the MII index, and provider trust (Uganda only). The baseline questionnaire was administered by trained enumerators either inside the clinic or immediately outside of the clinic, depending on the clinic's setup. In both cases, special areas were set aside to conduct the interviews to provide privacy to the women. In Pakistan, baseline and follow-up data were collected on paper surveys via in-person interviews. Data were double-entered into an EpiData database, and exported to Stata 13 for analysis.27,28 Surveys were conducted in Urdu. Women were requested to provide specific contact details including a phone number, where available, in order to schedule in-person follow-up interviews. At the baseline interview, enumerators discussed how participants wanted to be contacted for follow-up, including if they wished to meet in their homes or at a neutral location if they preferred other household members not be present during interviews, and how the enumerator should identify themselves if they tried to contact the participant by phone. All participants elected to be interviewed at follow-up visits in their homes. Data collectors introduced themselves as field workers who were raising awareness about maternal and child health, in order to further protect study participants. In both countries, follow-up interviews were conducted with a 2-week delay (e.g., 3.5 months, 6.5 months) in order to allow a buffer for women who needed subsequent doses of injectables. In Uganda, all baseline survey data were collected using tablets, and questionnaires were available in English and locally spoken languages (Luganda, Lumasaba, Runyankole, Runyoro, Lusoga, and Lugwere). Enumerators were typically fluent in English and at least 1 other language and were assigned to health facilities where the second language was more likely to be used by survey respondents. Follow-up interviews were conducted by mobile phone. Women who did not own a phone at baseline were asked to provide alternate contact phone numbers (e.g., a friend's phone number or the number of a village phone vendor). All women were asked to provide primary, secondary, and alternative phone contacts to be used in case they could not be reached at the primary phone number as well as preferred days and times to be reached. All women who completed the survey were given a small gift of mobile phone airtime, worth 5,000 Ugandan shillings (approximately US$1.40), transferred to the first phone number provided, to compensate her for her participation with the survey. Women received a similar gift upon completion of the follow-up interviews. To follow-up, enumerators attempted to contact the women at the preferred times. If the phone line was busy, women were re-contacted. Excluding busy responses, at least 3 attempts were made to reach each woman via phone. After 3 non-busy attempts, women were considered lost to follow-up. Following baseline data collection, the government of Uganda implemented a new policy requiring all SIM cards be registered using an individual's national identification card. Non-registered phones were to shut off during the summer of 2017, greatly affecting our ability to follow-up with a potentially large number of women at 3 months. In the 3-month follow-up, all women whose phone line had been switched off or was continuously busy at the first follow-up were sought in person by ProFam agents to see if they were willing to continue to be engaged in the study. If women were identified, agents did not conduct the survey immediately but provided a mobile phone to allow the trained enumerator to collect the 3-month follow-up survey. At the end of the survey, women were asked to provide new phone numbers to be reached for subsequent follow-up surveys. In both countries, sample size calculations were based upon a hypothesized rate of discontinuation in each setting, with a 95% confidence interval, precision of 0.07, and 80% power. Loss to follow-up, given the 12-month duration of follow-up in this cohort study, and potentially low mobile phone ownership at baseline were important potential factors that we accounted for in the sample size calculations. We planned to assess correlations between measures of observed structural and process quality, as well as the self-reported MII and discontinuation of family planning over the 12-month period. Given the large number of correlations, the analyses needed to account for the increased probability of a false positive. As an approximation of the sample size required to reach a higher type 1 error threshold, the chosen sample size was based upon α=0.01. Given the 2 different contexts, the design effect and assumed loss to follow-up differed for each sample size calculation. In Uganda, we determined that we needed to have at least 530 women complete our endline survey. We also assumed a design effect of 1.5, which generated a minimum number of 796 women completing the survey at 12 months. After inflating this up to account for loss to follow-up (30%), we needed to enroll at least 1,140 eligible women to complete the baseline interview. In Pakistan, a sample of 514 women needed was adjusted by a design effect of 1.3, and 20% potential loss to follow-up, for an effective sample of 800. All women who were enrolled in the study had complete baseline information. In Pakistan, none of the dates of discontinuation were missing. In Uganda, 12% of women who discontinued while in need had a date of discontinuation which was missing or set to missing due to the fact that the reported date did not fall between 2 adjacent rounds of data collection. These dates were imputed by taking a random date in between the 2 adjacent rounds of data collection for the woman. Women who reported method discontinuation but did not report a reason for discontinuation were assumed to have discontinued while in need. Women were considered lost to follow-up if they could not be located at the address or phone number(s) given, or if they were not available after 3 attempts to contact them. The MII was calculated by summing the binary responses to the following 3 questions: The Method Information Index sums a client's binary responses to 3 questions on whether the client was told about other methods, side effects, and what to do if she experienced side effects. The index, ranging from 0 to 3, was used as an ordinal variable as well as a binary variable (3 or less than 3) in the analyses. Age was categorized into 3 groups (15–24, 25–34, 35+), and a woman's primary baseline method was categorized as short- or long-acting (implant or IUD). The household's relative wealth was assessed using an asset index, benchmarked to the most recent DHS survey from each country (2012–2013 in Pakistan, 2016 in Uganda). The asset index was generated from the EquityTool, a shortened list of country-specific assets that are highly correlated with the full list of assets used to generate the wealth index employed by DHS.29 Time to discontinuation was treated as a continuous variable, measured in days, with a maximum allowable time of 360 days in Pakistan and 300 days in Uganda. Time in Uganda was truncated due to violation of model assumptions at the end of the reporting period. No events took place in the final 60 days of the reporting period. The event of interest was defined as discontinuation of a modern method while in need. The event occurred if the self-reported reason for discontinuation of any modern method (not necessarily the method obtained at baseline) was method-related (side effects, health concerns, method failure); related to access to resupply (cost, travel time); or social (disapproval of a family member). Women who discontinued for other reasons without switching to another modern method were censored. This study used survival analysis and Cox proportional hazard models with robust standard errors to account for clustering by facility to assess the degree of correlation between MII and discontinuation. Log-rank tests and Kaplan-Meier survival curves assessed the unadjusted effect of MII. Discontinuation rates were estimated from survival curves. Explanatory variables tested in each country were age, wealth group, parity, education, method type at baseline (short- or long-acting), and user type at baseline (first-time user, returning to contraception after a lapse in use, method switcher). Assumptions of proportionality for each covariate were tested numerically and graphically. We tested correlation between the potential covariates and dropped parity due to a high correlation with age. Variables were considered for the final adjusted model if they were significant at P≤.10 when included with MII in a Cox proportional hazard model. We tested each significant variable to see if it was time-dependent and assessed model fit using parameters available in Stata 13.30(pp164-194) In Uganda, a model curtailed at 300 days was compared to one for the full available time, and the curtailed model had better fit without changing model parameters. Finally, we tested the significance of the joint effect of method selected at baseline and MII on discontinuation. The parsimonious Cox proportional hazard model is thus presented for both contexts, adjusted for covariates that met significance criteria (P≤.10) in at least 1 country. The results are presented in the form of crude and adjusted hazard ratios; the adjustment accounts for women's age category, prior contraceptive use (new user, switcher, lapsed user), and whether a short- or long-acting method was adopted at baseline. Approval for the study arm in Pakistan was obtained from Ethical Review Committee (ERC) Marie Stopes International (MSI), UK (022-16), and the National Bioethics Committee (NBC) at Pakistan Medical Research Council (PMRC), Islamabad (4-87/17/NBC-227/RDC/2308). Approval for the study arm in Uganda was obtained from the Makerere University School of Public Health Higher Degrees Research and Ethics Committee (451) and the Uganda National Council of Science and Technology (UNCST), Kampala (SS4215).
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