Perceptions of Women regarding the Quality of Family Planning Services for Low-Income Urban Areas of Karachi

doi:10.21203/rs.3.rs-4618494/v1

Download PDF

Research Article

Perceptions of Women regarding the Quality of Family Planning Services for Low-Income Urban Areas of Karachi

https://doi.org/10.21203/rs.3.rs-4618494/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background:

Family planning (FP) is one of the most important family planning services in Pakistan. The purpose of this study is to comprehensively investigate and understand women's perceptions of family planning service quality in the low-income urban areas of Karachi, Pakistan. This study aims to explore the multifaceted dimensions of FP service quality, including individual experiences, attitudes, and beliefs, through the lens of the Judith Bruce framework. Data was collected using semi-structured interview guides for focus group discussions (FGDs) and in-depth interviews (IDIs).

Methods:

This is an exploratory qualitative study, 4 focus group discussions and 13 interviews were conducted with married women in the age group of 25-45 years, who were either current users or ever-users of modern contraceptives, living in underserved areas of three Union Councils of Malir Town (Saudabad, Khokhrapar and Kala Board), Karachi. Data were thematically analyzed.

Results:

Family planning quality of care was defined by participants as the quality of healthcare provider communication and counseling skills (i.e. information exchange), and the outcomes of contraceptive use among women with satisfaction to pave the way for continued use of family planning methods. The data showed that women have limited autonomy in their choice of methods and inadequate information on side effects were identified as reasons for discontinuation. Participants emphasized the importance of respectful interactions with providers and clear explanations about methods.

Conclusion:

Utilizing Judith Bruce's frameworkusing a qualitative approach provided fundamental insights into perceptions and barriers to the quality of care for family planning. Recognizing which elements are particular to family planning is essential for advancing contraceptive consequences. Specifically, women's autonomy in choice of contraceptive method, and robust healthcare systems can enhance service delivery, strengthen women-provider relationships, and ultimately contribute to improved reproductive health outcomes for individuals and communities. By prevailing the importance of dignified behavior with the community members, enhancing technical skills, and fostering women's satisfaction, healthcare systems can strive towards providing equitable access to high-quality family planning for women.

Quality of Care

family planning

reproductive health

perceptions of women

The quality of family planning services is examined through various dimensions, particularly utilizing Judith Bruce's framework. She defines the quality of care (QoC) for family planning as "The way individual couples/womens are treated by the health system provided services," encompassing six integral components: choice of methods, information provision, technical competence, interpersonal relations, continuity and follow-up, and an appropriate constellation of services (1). The International Conference on Population and Development (ICPD) emphasizes the provision of quality reproductive health services to "Ensure universal access for all women to a full range of high-quality and affordable health care, including sexual and reproductive health services" (3).

The sluggish increase in the contraceptive prevalence rate (CPR), coupled with high discontinuation rates and unwanted pregnancies, underscores compromised family planning care quality (6). Global commitments, exemplified by the Sustainable Development Goals (SDGs) introduced in 2015, emphasize achieving significant reproductive health milestones. The UNFPA aims for a 50% increase by 2025, and the SDGs target universal access to sexual and reproductive health services, including family planning, by 2030. A specific objective is to satisfy 75% of women of reproductive age with modern family planning methods (9). The literature demonstrates that family planning programs have reduced births by 40% in Low- and Middle-Income Countries (LMICs) between 1995 and 2000 (8). LMICs, including Pakistan, grapple with common family planning service challenges, particularly compromised care quality recognized as a significant barrier to contraceptive uptake (14). This challenge aligns with Karachi's low-income urban areas, marked by inadequate resources, insufficient healthcare infrastructure, and limited awareness about family planning. Studies in various LMICs, such as Pakistan, Nepal, and Bangladesh, identify gaps requiring attention, emphasizing quality care through accessible products, affordability, and information (7).

Ensuring quality in family planning involves diverse contraceptive options, comprehensive information provision, skilled healthcare providers, respectful interactions, continuous support, integration into broader reproductive health programs, privacy, minimal waiting times, affordability, and community awareness programs. These measures aim to meet individual needs, enhance service quality, and promote positive reproductive health outcomes. However, critical gaps persist in understanding women's perceptions of family planning service quality in low-income urban areas. Despite global successes in reducing births, unique challenges persist at the country level, including issues of poor service quality, lack of information, and socioeconomic constraints impacting utilization (Fig. 1) (16).

This study delves into the nuanced landscape of family planning service quality in Karachi's low-income urban areas exploring women's perspectives through Judith Bruce's framework, it sheds light on critical challenges, providing insights to enhance service quality, improve reproductive health outcomes, and empower women in making informed family planning decisions. Drawing from Judith Bruce's six dimensions framework, the research emphasizes family planning quality as the delivery of services that are safe, effective, and responsive to womens' needs and desires. This women-centered approach underscores the importance of tailored services, recognizing that experiences, satisfaction levels, and opinions significantly influence the overall quality of family planning care (Fig. 1) (14).

The purpose of this study is to comprehensively explore and understand women's perceptions of family planning service quality in the low-income urban areas of Karachi. The study aims to explore the multifaceted dimensions of FP service quality, including individual experiences, attitudes, and beliefs, through the lens of the Judith Bruce framework. By examining the quality of care (QoC) provided in family planning services, the research seeks to identify challenges, gaps, and potential areas for improvement. Ultimately, the study aims to contribute insights that can inform policymaking, enhance service quality, and promote positive reproductive health outcomes in these communities.The study targets non-users and current family planning users to understand adoption factors. It emphasizes tailored interventions for each group, facilitating comparative analysis to identify differences.

Study Design and Setting

This study aimed to understand the concept of quality as perceived by women of reproductive age through the phenomenon of “why” and “how” and used a “qualitative exploratory” study design (12) because the study focuses on the knowledge, attitudes, and practices allowing for a holistic and contextually rich exploration, providing valuable insights using the conceptual framework outlined by J. Bruce for quality of care in family planning services was followed (1).

This study was carried out at the low socio-economic area, where married women of reproductive age (15 to 49 years), who were either current users or ever-users of modern contraceptives, living in underserved areas of three Union Councils of Malir Town (Saudabad, Khokhrapar and Kala Board), Karachi, Pakistan. This area was selected because FP indicators were poor, and uptake of modern contraceptives was low. The contraceptive service in this population is mainly provided through NGOs, the public and private sectors. A local NGO working in the area for Family planning provided us with the list of users and ever user from their record.

Inclusion and Exclusion Criteria:

In this study, women were selected through purposive sampling based on the women who fulfilled the criteria and agreed to give an interview. The inclusion criteria of this study were; 1. married women of reproductive age (15–49), 2. residents of three selected union councils of Malir town, 3. using any modern contraceptive method or have not used any modern contraceptive method in the last six months because of low quality. 4. Women who refused to participate and or had tubal ligation were excluded from the study.

Four FGDs (FP current users:2, and FP ever-users:2) and twelve IDIs (FP current users:9, FP ever-users: 3) were conducted from July 2016 to September 2016 in privacy either in participants’ homes or at a clinic in a separate room. From the list of family planning users, and ever user were randomly selected, and this information was provided by the Saudabad, Khokhrapar, and Kala Board Union Council Office. First, we conducted the FGDs and each FGD had 5–7 participants. The principal investigator facilitated the discussions and interviews which were audiotaped. During interviews, notes were taken by note keepers.

When the overlapping of the data was evident, the data collection continued till the point of saturation is reached. Each FGD discussion lasted approximately 80–120 minutes. Similarly, IDIs were carried out with current users and ever-users. Each IDI discussion lasted approximately between 30 and 45 min. All the participants gave consent to tape recording of the interviews. Ethical approval for this study was obtained from the Aga Khan University Ethical Review Committee (AKU-ERC– 4162-CHS-ERC- 16).

Data Collection Methods and Study Participants:

Both Focus Group Discussions and In-depth Interviews were used to inquire about the research questions. Data was collected using semi-structured interview guides for focus group discussions (FGDs) and in-depth interviews (IDIs). According to J.B framework guidelines were prepared to understand the general perception of women about quality, perception related to healthcare quality, and lastly experiences of women, particularly for the quality of family planning services.

The interview guides were prepared and pre-tested in a similar community not included in the main study. The pilot focus group discussion (FGD) helped women grasp the collective perspectives of both users and ever-users regarding the concept of quality. To address this, we incorporated practical examples from real-life situations into the discussion guide. The pretest results underscored a significant knowledge gap among women, specifically concerning the notion of quality in the context of family planning. It became evident that participants encountered difficulties in comprehending the posed questions, highlighting a fundamental lack of basic knowledge about quality within the domain of family planning.

To address this gap, an educational intervention was implemented during the pretest. The approach involved providing women with basic, relatable examples from everyday life to illustrate the concept of quality. By connecting the idea of quality to familiar scenarios, participants were empowered to comprehend and respond to questions related to quality in general, quality in healthcare, and specifically, quality in family planning. This educational strategy proved effective as it facilitated a clearer understanding among the participants. Once equipped with relatable examples, the women were able to articulate their thoughts and provide meaningful responses regarding quality in the context of family planning. This intervention not only bridged the knowledge gap but also empowered the participants to actively participate in discussions about the quality of family planning services. The success of this educational approach underscores the importance of employing accessible and relatable methods to convey complex concepts, especially in settings where there might be a lack of basic understanding. This finding also emphasizes the need for targeted and community-specific educational initiatives to enhance awareness and empower individuals to meaningfully participate in discussions related to critical aspects of healthcare, such as family planning quality.

Data Analysis

Data was thematically analyzed according to the six thematic areas identified by the J.B model of FP Quality of Care. As the themes were pre-defined, following Braun and Clarke’s guidelines (12), a deductive analysis approach was employed (a way of coding the data without preconceptions of the themes). Furthermore, it provides a structured and focused way to analyze data in alignment with existing theoretical frameworks or research objectives. Additionally, it can enhance the rigor and reliability of the analysis, as it ensures that findings are grounded in established concepts or theories.

The interviews scheduled comprised open-ended questions concerning perceptions/understanding of perceptions about the Quality of Family Planning Services. Hence data was analyzed at the semantic level as it focuses on the explicit surface meanings of words, particularly useful in this study as it focuses on exploring participants' perceptions, attitudes, and beliefs and is valuable as it allows researchers to gain a clear, contextually rich understanding.

The study audio recordings from the FGDs and IDIs were transcribed into Urdu and then translated into the English language. Transcripts were read several times by three research investigators to reach an understanding of the content related to identified themes about the women's perspectives/experiences about family planning services quality. This is an iterative process where data were coded, linked, compared, and refined to create emerging themes.

The transcribed verbatim was divided into ‘meaning units’ which were later shortened and labeled with a ‘code’ without losing the study context. Codes were then analyzed and grouped into similar categories. In the final step, similar categories were assembled under sub-themes and main themes. Two independent investigators (NA and FA) performed the coding and category creation, and discrepancies were resolved through discussion until a consensus was reached. Supplementary Tables depict the theme, categories, and codes on the Excel sheet.

Profile of respondents

We conducted 4 FGDs with married women in the age group of 25–45 years who were current or ever-users of modern contraceptives. All the participants were housewives and residents of the selected underserved areas. (Table 1).

This study has explored the perception of women continuously using any modern contraceptive method without disruption and the ones who have not used any modern contraceptive in the last six months but have used these before.

3.1 Choice of methods

Findings from this study revealed that the choice of contraceptive method is often constrained by limited access to a variety of options. However, many participants cited adverse effects as a common reason for discontinuing contraceptive use within the first year. The availability of modern contraceptive methods from reliable sources is influenced by factors such as age, gender, contraceptive intention, lactation status, and health profile. Current users expressed their reasons for using a particular family planning (FP) method, while ever-users shared why they had discontinued its use.

Notably, there is a dearth of data from low- and middle-income countries (LMICs) examining women's experiences with individual contraceptive methods due to the restricted range of choices available to meet user needs. Ever-users reported that they had not received their desired modern contraceptive method and subsequently discontinued its use.

Ever-Users perceptions on the modern contraceptive discontinuation due to side effects were using including injection, implant, intrauterine device but discontinued due to their side effects.

Injection:

The ever users had their concerns among ever-users regarding the injectable contraceptive method. Participants expressed apprehensions about its potential to disrupt the menstrual cycle, leading to irregularities. Additionally, there were concerns that the injectable method could increase bleeding.

One of the IDI ever-user said,

“From the word of mouth, I have heard someone had a frightening experience that woman got herself injected, and for a whole month she bled and became weak as a result (Ever-user, injection, age 30, married).

Implant:

However, findings from both the focus group discussions (FGDs) and in-depth interviews (IDIs) with ever-users of the implant revealed a common experience: participants reported that “their periods had increased and become heavier since adopting the method.”

This contrasts with existing literature, where prolonged or heavy bleeding is frequently cited as the primary reason for discontinuing the implant. These divergent experiences underscore the complexity of individual responses to contraceptive methods and highlight the importance of further investigation into user perspectives and experiences with the implant.

Intrauterine Device (IUD ):

According to all the FGD & IDI barriers include participants expressed fear associated with the insertion process, along with concerns regarding changes in sexual experiences following insertion.

One of the IDI ever-user said,

“I got married at an early age i.e., 15 years of age, at that time there was no concept to discuss FP within the family, she further added, “My sister did family planning and after that, she could not have children. She used the modern contraceptive method of IUD for spacing between children. But suddenly her elder son died and after that, she could not get pregnant, resultantly, her in-law's attitude was changed and they labeled her infertile” (Ever-user, IUD, age 22, married).

3.2 Information given to clients

To determine women’s family planning service quality experiences, we assigned elements involved in the unit of services received to the framework for assessing quality according to J. Bruce. However, in this study unexplained or poorly explained information given on modern contraceptives like IUDs, and implants became the reason for ever-users to discontinue.

In most of the IDIs women who ever used a modern method of contraception and were currently not using any modern contraceptive method mentioned that their trustworthy source of information is mostly based on word of mouth from friends, relatives, or close household members.

As we are busy with household chores if anybody within the family finds out any information related to modern contraception useful, they share it with us. We have heard about different modern contraceptive methods from other women (mainly mother-in-law/maternal/paternal aunt, or a friend) around us who have used or are using any method.

Another aspect of giving information is related to providing counseling in selecting a method that fulfills women's intimate sexual and social needs. Moreover, they also considered the methods as low-quality methods which according to them include the harmful ones and as side effects (Fig. 2).

One of the IDI current users said,

“I came to know about pills and injection methods from my sister-in-law and based on her experience I started using pills after the birth of my second child, but I kept missing the pills and had a third unplanned child. Now I have shifted to the injection method as I have to go for an injection every three months. The Community Health worker of the area serves as a reminder for me, she comes on my due date and accompanies me on my request to the center as my husband won’t allow me to go alone.” (Current user, injection, age 25, married).

The last aspect of information provision, particularly regarding potential challenges associated with selected contraceptive methods, significantly influences women's willingness to return to FP service providers. Ever-users expressed a need for their questions to be addressed to provide reassurance and ensure their comfort with the chosen method. However, participants raised concerns about the completeness of information, lack of trust, and non-supportive behavior exhibited by government service providers. These findings underscore the importance of addressing gaps in information provision and improving the quality of interactions between healthcare providers and women seeking contraceptive services.

3.3 Technical Competence:

According to J. Bruce framework clinical competency principally includes factors such as expertise in the clinical technique of providers for IUD, implants, and sterilization methods. But the literature shows medical proficiency is not often reported. However, this study has explored the perception of current users and ever users on the quality of FP clinical procedures. However, women considered inadequate training of FP service providers with contraceptive method that results into women facing needless agony, infection, adverse effects, and in some situations, death.

“During our first visit, we were told that the modern contraceptive FP methods do not have any adverse effects but after using a particular method we all realized that we all were misguided at the FP clinic, the FP method we opted 'were harmful” (FGD and IDI ever-users).

“Most of us do not practice FP primarily because we do not have the knowledge about the side effects, and what to do if we get any side effects.

(Ever-user, implant, age 38, married, Ever-user, IUD, age 22, married, Ever-user, injection, age 30, married).

On the other hand, women in this study do talk about how much time provider has given to them during their visit, with compassionate perspective as quality.

3.4 Interpersonal Relations

Based on the interactive associations between users and providers, the emotional ease is explained by J. Bruce. However, there is a dearth of qualitative studies on women/provider interactions. Apart from that this has also explored the perception of FP modern contraceptives both current and ever users, during their FP facility visit, their experience, and interaction based on the emotional content and behavior. It also includes desired attributes i.e. understanding, respect, honesty, women were asked to be seated, ability to participate in a two-way communication, and asking queries.

One of the main concerns was the dissatisfaction with counseling that women brought up repeatedly especially if women had prior information from more experienced friends and family members on a specific method, they felt dissatisfied by the incomplete counseling they received at the FP clinic. As one of the current users, FGD participant states:

“I thought that having an implant will be hurting because the Field Educator, had said that there might be trivial effects that one might feel after having the implant inserted, and they would go away with time, but I have never felt anything, I feel normal, and I am happy that the CFE told me about the implant. To me, it has been a good method, and I am happy, and I didn’t even feel any of the minor side effects that was told to me. Similarly, at least one or two women from each ever user discussion group indicated that they were not told much about their method before obtaining it”.

In this study, a Community Field Educator (CFE) working in an NGO was found to be extremely helpful in reassuring and empathetic toward women, which appeared to influence whether a woman continued using the contraceptive method, after facing the adverse effects that were not available at the facility level.

According to all the current and ever users, “Whenever we experience issues with the current method, they all sought follow-up services from community field educator (CFE) who provided free of cost support through ongoing counseling and on the other hand also teaching them how to manage FP side effects and if in case they face major complication CFE also go along with women to the FP facility.”

However, many participants in this study considered trust and the relationship between a provider and a customer as a measure of Quality. “If you are buying something and quality turns out to be good, you go again and again to the same shop, the owner of the shop recognizes you and he may offer some discount to you, the shopkeeper becomes more welcoming. Such examples can be seen in the case of purchasing jewelry, fruit, vegetable, cloth, medicine, and groceries”.

Some women expressed that quality of service can only be achieved if one has the money to spend, and they are willing to spend it in case of emergency only on getting care from a private health facility.

“Being poor we only have the option to visit government hospitals, as our pocket doesn’t allow us to go to private hospitals” (FGD current and ever user participants).

This generated discussion in the group regarding the attitude of providers in public sectors health facilities, below given quote summarizes the discussion well,

‘In FP government hospital physicians and paramedic staff are more knowledgeable and skillful, the difference between them and us is that we are poor, and the only thing we need from them is to provide our treatment with respect. Free-of-cost service does not mean paying less attention and misbehaving if a poor illiterate woman asks many questions to understand the message, whereas in the private FP clinic you pay a hefty fee and find good treatment with respect. FGD & IDI current users & ever users).

The results presented in this study provide an important update on the state of QoC delivered in perceptions of women in low-income urban areas in Karachi. Hence, this study's perceptions of current users and ever users on how to improve the Quality FP services have been asked. Judith Bruce's original six themes of quality in family planning services provide a framework for understanding the different aspects that contribute to the quality-of-service delivery. While her framework doesn't explicitly mention respect, technical skills, and women satisfaction as separate categories, these factors can be inferred from the broader themes she identified. Here's how these three factors may originate from Bruce's original themes:

Respect:

Respect can be seen as encompassing aspects of Bruce's themes of Accessibility and Attitude. Accessibility refers to the ease with which individuals can access family planning services, including factors such as proximity, affordability, and convenience. Attitude pertains to the demeanor and behavior of healthcare providers towards womens, emphasizing the importance of respectful and non-judgmental interactions. Respect for womens' autonomy, privacy, and dignity aligns with Bruce's emphasis on the human rights-based approach to family planning.

Technical Skills:

Technical skills correspond to Bruce's themes of technical competence and information exchange. Technical Competence refers to the proficiency and expertise of healthcare providers in delivering family planning services, including the accurate provision of contraceptive methods and counseling on their use. Information Exchange underscores the importance of clear communication between providers and womens, ensuring that womens receive accurate information about contraceptive options, side effects, and follow-up care. Effective information exchange requires healthcare providers to possess adequate technical skills to address womens' needs and concerns competently.

Women Satisfaction:

Women satisfaction can be linked to Bruce's themes of counseling and choice. Counseling involves the provision of comprehensive information and support to help womens make informed decisions about family planning. (Fig. 2) Womens' satisfaction with the counseling process reflects their perceived value of the information provided, the clarity of communication, and the extent to which their individual needs and preferences are addressed. Choice emphasizes the importance of offering a range of contraceptive methods and empowering womens to select the method that best suits their reproductive goals and lifestyle. Women satisfaction is enhanced when individuals feel empowered and supported in making contraceptive choices that align with their preferences and circumstances. The perceived quality of family planning services is essential because it directly affects a women’s decision to use and continue using those services. When womens perceive high-quality care, they are more likely to be satisfied and return for future services or recommend them to others.

Our study sheds light on the state of quality of care (QoC) delivered in low-income urban areas of Karachi, providing valuable insights into the perceptions of women regarding family planning services. Through the lens of Judith Bruce's six themes of quality in family planning services, healthcare providers and policymakers can work towards ensuring that family planning services are accessible, acceptable, and of high quality. This holistic approach emphasizes the importance of women-centered care, informed decision-making, and continuous support throughout the contraceptive process. (1)

The narratives shared by current users and ever-users of family planning methods provided valuable insights into their experiences and perceptions, emphasizing the influence of healthcare provider guidance and information provision on contraceptive decision-making. By addressing the factors of respect, technical skills, and women satisfaction, healthcare systems can enhance service delivery, strengthen women-provider relationships, and ultimately contribute to improved reproductive health outcomes for individuals and communities.

Moving forward, efforts to improve family planning services should prioritize the integration of these findings into policy and practice. By promoting respect, enhancing technical skills, and fostering women satisfaction, healthcare systems can strive towards providing equitable access to high-quality family planning services for all individuals, thereby advancing reproductive rights and health equity.

6. Strengths & Limitations:

The strength of this study is its qualitative approach which provided a depth of understanding not possible with quantitative methods alone. By addressing experiences from women, researchers gained insights into why women choose or discontinue specific contraceptives. This allowed them to explore the social and cultural context surrounding family planning choices. While this study provides valuable insights into family planning services in low-income urban areas of Karachi, one of the limitations of the study is time constraint and its focused on specific underserved areas in Karachi. Extrapolating these findings to other regions or contexts may require caution, as local dynamics can significantly impact perception. Moreover, the study primarily explored the views of current and past family planning users. Including perspectives from non-users could offer additional insights and a more comprehensive picture.

SDG Sustainable Development Goals

LMIC Low- or Middle-Income Country

CPR Contraceptive prevalence rate

QoC Quality of care

ICPD International Conference on Population and Development

UNFPA United Nations Fund for Population Activity

FGD Focused Group Discussion

IDI In Depth Interviews

Declaration-Availability of data and materials

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request. Most of the data generated or analyzed during this study are included as supplementary information files.

Acknowledgments

The authors acknowledge the support of all study participants and the transcriber for the conduct of this research.

Funding: None

Contributions:

Nazia Ahsan: Conception and design, administrative support, provision of study material or patients, collection and assembly of data

Sarah Saleem: Design of the work, drafting the article, manuscript writing, critical revision and final approval of manuscript

Farina Abrejo: Provided administrative support, data interpretation, and final approval of manuscript

Zahid Memon: Final approval of manuscript

Ethical Declaration

This study was approved by Ethics Review Committee of Aga Khan University (ERC Number:4162-CHS-ERC- 16).

Consent for publication: Not applicable.

Competing interests: The authors declare that they have no competing interests

Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann. 1990;21(2):61–91.
Pakistan Demographic and Health Survey. 2012–2013.
Caldwell JC, Phillips JF. The future of family planning programs. Stud Fam Plann. 2002;33(1):1–10.
Choi Y, Fabic MS, Hounton S, Koroma D. Meeting demand for family planning within a generation: prospects and implications at country level. Glob. Health Action [Internet]. Taylor & Francis; 2015 [cited 2017 Apr 14];8:29734.
Azmat SK, Mustafa G, Hameed W, Ali M, Ahmed A, Bilgrami M. Barriers and perceptions regarding different contraceptives and family planning practices amongst men and women of reproductive age in rural Pakistan: a qualitative study. Pakistan J Public Health. 2012;2(1):17–23.
Marvi K, Howard N. Objects of temporary contraception: an exploratory study of women's perspectives in Karachi, Pakistan. BMJ open. 2013;3(8):e003279.
Yameen S, Nausheen S, Hussain I, Hackett K, Rizvi A, Ansari U, Lassi ZS, Canning D, Shah I, Soofi SB. The family planning know–do gap among married women of reproductive age in urban Pakistan. Public Health Action. 2021;11(3):132–8.
Osotimehin B. Family planning as a critical component of sustainable global development. Glob. Health Action [Internet]. Volume 8. Taylor & Francis; 2015. p. 29978. [cited 2017 Apr 14];.
Tessema GA, Streak Gomersall J, Mahmood MA, Laurence CO. Factors Determining Quality of Care in Family Planning Services in Africa: A Systematic Review of Mixed Evidence. PLoS ONE. 2016;11(11):e016562.
Severy LJ, McKillop K. Low-income women's perceptions of family planning service alternatives. Fam Plan Perspect. 1990:150–68.
Mustafa G, Azmat SK, Hameed W, Ali S, Ishaque M, Hussain W et al. Family planning knowledge, attitudes, and practices among married men and women in rural areas of Pakistan: Findings from a qualitative need assessment study. Int J reproductive Med. 2015.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.
Mensch B, Arends-Kuenning M, Jain A. The impact of the quality of family planning services on contraceptive use in Peru. Stud Fam Plann. 1996:59–75.
Hakim A, Cleland J, Muh B. Pakistan Fertility and Family Planning Survey 1996–97. Islamabad. Pakistan & London, UK: National Institute of Population Studies, and Centre for Population Studies, London School of Hygeine & Tropical Medicine; 1998.
Mostafa K, Aynul I. Contraceptive use: socioeconomic correlates and method choices in rural Bangladesh. Asia Pac J Pub Health. 2010;22(4):436–50.
Mohammed A, et al. Determinants of modern contraceptive utilization among married women of reproductive age group in North Shoa Zone, Amhara Region, Ethiopia. Reprod Health. 2014;11(13):1–7.
Lwelamira J, Mnyamagola G, Msaki MM. Knowledge, attitude and practice (KAP) towards modern contraceptives among married women of reproductive age in Mpwapwa District, central Tanzania. Curr Res J Soc Sci. 2012;4(3):235–45.
Dehingia N, et al. Family planning counseling and its association with modern contraceptive use, intiiation and continuation in rural Uttar Pradesh, India. Reprod Health. 2019;16(1):178.
Farrokh-Eslamlou H, et al. Impact of the World Health Organization’s decision-making tool for family planning womens and providers on the quality of family planning services in Iran. J Fam Plann Reprod Health Care. 2014;40(2):89–95.
Prabhavathi K, Sheshadri A. Pattern of IUD use: a follow up of acceptors in Mysore. J Family Welf. 1988;35(1):3–16.
Severy LJ, McKillop K. Low-income women's perceptions of family planning service alternatives. Fam Plan Perspect. 1990:150–68.
Cotten N, Stanback J, Maidouka H, Taylor-Thomas JT, Turk T. Early discontinuation of contraceptive use in Niger and the Gambia. Int Fam Plan Perspect. 1992:145–9.
Komasawa M, Yuasa M, Shirayama Y, Sato M, Komasawa Y, Alouri M. (2020). Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: a cross-sectional study. PLoS ONE, 15(3), e0230421.
Imran M, Yasmeen R. Barriers To Family Planning In Pakistan. J Ayub Med Coll Abbottabad 2020 Oct-Dec;32(4):588–91. PMID: 33225672.
Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, Adeyi O, Barker P, Daelmans B, Doubova SV, English M, García-Elorrio E, Guanais F, Gureje O, Hirschhorn LR, Jiang L, Kelley E, Lemango ET, Liljestrand J, Malata A, Pate M. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Global health. 2018;6(11):e1196–252. https://doi.org/10.1016/S2214-109X(18)30386-3.

Table 1: Thematic Analysis Coding Framework -‘Quality’
Codes	Sub-categories	Categories	Theme
(a)Benefit me	Satisfaction for my wellbeing	Should not give harm	Choice of Method
(a)We do not investigate further as we have the information, (b) Individual Self-selection, (c) my heart like, I will recommend it to others	Empowerment when we decide on our own for our self	My own choice and role of Fate/Luck
(a)We can use it for a long, (b) It can cover one or two seasons, (c) one-time use, (d)reliability, (e)only Known & famous brands give this	Sustainability	Long Lasting
(a)Influence of my husband or in laws will recommend/suggest	Social belonging	My husband

Table 2: Thematic Analysis Coding Framework - ‘Healthcare Quality’
Codes	Sub-categories	Categories	Theme
Private maternity hospital: (a)Pay more as health is an important preference given to my treatment, (b) attendants don’t need to go here and there for the medicine, (c) charge more fee in a private clinic Public maternity hospital: (a) affordable, (b) free of cost but low quality being poor we have the only option to avail treatment from there	Public maternity hospital has some cost not completely free but affordable Private is costly with high quality	Affordability	Interpersonal Relationship
Private maternity hospital: (a) Complete satisfaction with the treatment, service & HR (b) technical competency during complication, (c) give choice of companion to stay together, (d) assist woman to ambulate during labor, (e) comfort or hasten labor by breathing, (f) encourage woman or companion to stay together, (g) inform about toileting facilities, (h) praise and reassure woman for abiding instructions, (i) listen attentively Public maternity hospital: (a) discriminatory attitude of health professionals, (b) facility staff behavior was non-compassionate (arrogant), (c) poor service provision on the uptake of maternal health services	Experiences-How women are treated during childbirth in public & private health facilities	Lack of supportive care in Public	Interpersonal Relationship

Table 3: Thematic Analysis Coding Framework - ‘Quality of Family Planning’
Codes	Sub-categories	Categories	Theme
Private: (a)Neat, (b)clean drinking water facility, (c)spacious area for patients waiting Public: (a)lack of hygiene, (b)lack of cleanliness.	Public FP Facility Private FP Facility	Physical Environment	Freedom of choice of method
Private: Hefty Fee Public: (a) free of cost is good but at times they ask some amount for biscuits and tea, (b)It is free of cost and within our approach	Public FP Facility has some cost not completely free but affordable Private is costly we can’t compromise on our health and pay a hefty fee	Affordability
Private: (a)Soft, humble behavior, (b)respect my questions, (c) listening to my complaints, (d)doctor availability, (e)good interpersonal relationship, (f)repo building is necessary Public: (a)Dr use bad language and get angry, (b)we feel sorry for ourselves, (c)no privacy, (d)in front of other women, (f)Dr. scared me about the side effect, (g) Dr. is also confused.	As we pay, the Dr shared their cards to visit the private clinic where the same doctor treats us so well In public FP facility doctor scold, we feel insecure in sharing our fears	Unprofessional FP doctor/staff behavior
Pills: Weight gain Injections: Heard from other experiences it causes BP, & heart problem Implant: Causes cancer IUCD: Ring was mal placed, I might lose my life Condoms: Fear of getting pregnant again, it leaks, a chemical may cause harm	Ever Users and current users ware afraid and have concerns about modern contraceptive usage	Side effects of different contraceptive methods
(a)Prefer to seek FP advice from health educator, (b)go to govt. for FP along with a health educator, (c)otherwise, I will never go alone, as FP fulfills women's need for birth spacing (d)not using any FP method but health educator guided, after that, we have started using modern contraceptives	Domiciliary visits must be promoted	FP Health Educator Role
(a)Gives no harm and side effects involved, (b)clean facility environment, (c)gives no pain, (d)freedom of our own choice and selection, (e)doctors treat us well, (f)listen to my all, (g)guide me well, (h)give me respect, (i)gives me protection, (j)immediate care, (k)Dr. must give correct information, (l)recommend us renown and famous company, (m)long expiry of products	Women's contentment with the continuation	Satisfied and Ideal FP method from Women Perspectives

No competing interests reported.

FPQualityStudyFindingsThematicAnalysisTables.docx

Download PDF

Editorial decision: Revision requested
25 Jun, 2024
Editor assigned by journal
23 Jun, 2024
Submission checks completed at journal
23 Jun, 2024
First submitted to journal
21 Jun, 2024

You are reading this latest preprint version

Perceptions of Women regarding the Quality of Family Planning Services for Low-Income Urban Areas of Karachi

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study Design and Setting

Inclusion and Exclusion Criteria:

Data Collection Methods and Study Participants:

Data Analysis

Results

3.1 Choice of methods

Injection:

Implant:

3.2 Information given to clients

3.3 Technical Competence:

3.4 Interpersonal Relations

Discussion

Respect:

Technical Skills:

Women Satisfaction:

Conclusion

6. Strengths & Limitations:

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1