High maternal morbidity and mortality rates continue to burden Francophone West Africa, a sub-region characterized by having the highest fertility rates in the world with a low contraceptive prevalence. In Togo, the total modern contraceptive prevalence rate among all women was 23% in 2018 (1). Unmet need for contraceptives in Togo is high at 34% (2), and among the most common reasons for non-use are socio-cultural norms including the belief that male partners make decisions related to women’s reproductive health needs, low levels of knowledge about where to access services, economic constraints, long travel distances and negative experience with health services resulting in contraceptive discontinuation (3). Proper information on the timing of return to fertility after method discontinuation is needed as many contraceptive users in Togo acknowledge method reversibility to be a chief concern (4). Previous research has shown that clients are better able to achieve their reproductive intentions when family planning services meet their needs and they have satisfying client provider interactions (5, 6).
Improving client satisfaction is linked to contraceptive uptake and continuation (6) and can result in new users when existing clients share positive experiences through word of mouth with their family members and peers (7). Measuring client satisfaction helps in understanding their experiences of health care, identifying problems, and evaluating quality service provision (8). Service quality measured through external observations can objectively identify gaps in technical competency and weaknesses in interpersonal communication as compared to recommended clinical practices. Client satisfaction provides a subjective measure of a client’s attitudes and opinions of the care received and can indicate what is perceived to be acceptable care by clients themselves (i.e. waiting an hour or more for services) (7). Measures of client satisfaction are typically constructed from questions pertaining to the client’s perception of provider treatment, information provided, opportunities to ask questions and have them answered, perceptions of privacy and whether the waiting time is considered reasonable.
Several factors influence client satisfaction including ease of access, quality of services and medical barriers such as provider-imposed restrictions (9). Access refers to “the degree to which family planning services and supplies may be obtained at a level that is both acceptable to and within the means of a large majority of the population” (9). There is consensus that good quality of care includes the presence of trained personnel in well-equipped clinics where clients are treated courteously and provided with a variety of appropriate services (6). A systematic review found that factors determining quality of care of family planning in Africa reflected those defined by Donabedian (10) and included structure or inputs to care, and process or content of care (11). The quality of stock inventory was the most identified structural factor (11). Client's waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most frequently identified process factors (11). Several qualitative studies have found that clients may also experience poor quality of care including negative client-provider interactions (12, 13).
Health providers play a critical role in the quality of reproductive health services and client’s access to them (14). Provider behaviors determine who will be permitted to obtain information or medical attention and under what conditions (15). Previous studies have found that client satisfaction was higher among clients who received higher quality family planning counseling (8, 16) particularly when clients felt they were able to ask questions, state opinions and express concerns (17). Compelling evidence has also shown that provider behaviors, attitudes (18) and biases (19) affect the quality of reproductive health services, which, if improved, could more effectively introduce the concept of family planning and address client concerns to promote voluntary contraceptive use (20). Barriers include provider-imposed eligibility restrictions that prohibit the use of contraceptive methods based on a woman’s age, parity, or consent of their partner (9).
There is limited evidence from Togo on the factors influencing contraceptive uptake and use which can be used to inform family planning programs. Among the few family planning related studies conducted in Togo, the majority examined male engagement and the need to address misconceptions surrounding modern methods and the risks of advanced maternal age and high parity pregnancy through appropriate channels such as facility, community and home based counseling in order to increase contraceptive use (4, 21–23). Evidence from facility-based surveys in Togo found high levels of provider restrictions for family planning related to partner consent, age, and marital status but did not find an effect on whether clients were able to obtain their preferred methods as a result (21). Strategies aimed at improving the quality of post abortion care by increasing providers knowledge, attitudes and skills and reducing unnecessary restrictive biases were found effective in increasing access to contraception (24, 25). In addition, several studies from Togo identified multiple service availability and readiness related barriers (26).
The U.S. Agency for International Development (USAID) funded Breakthrough RESEARCH project aims to catalyze social and behavior change (SBC) through research and evaluation and promotes evidence-based solutions to improve health and development programs around the world. In 2018, Breakthrough RESEARCH spearheaded an interactive consultation with USAID and multilateral partners to develop an SBC research and learning agenda to guide investments, research, and program design. An important area that emerged through these consultations was the need for more evidence to inform provider behavior change strategies including: What interventions improve perceptions of service quality and accountability of providers? and How can we best assess/measure the quality of client-provider interactions from client and provider perspectives? (27). Using secondary data, this paper seeks to address these questions by examining factors related to access and quality of care that influence family planning client satisfaction in Lomé, Togo. This analysis further demonstrates how facility surveys similar to the Demographic and Health Survey Service Provision Assessment can be leveraged and adapted to contribute detailed information that will support the adaptation of SBC program strategies with an emphasis on provider-based counseling approaches.