April 1997 Insights Issue #22

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Family planning quality and contraceptive method choice

Interest in improving the quality of care in family planning programmes has intensified since the ICPD, with its new focus on reproductive health care rather than population control. An international research effort is underway to define key indicators of quality of care which, many people would agree, should include a choice of methods on offer to clients.

People’s use of contraceptives is dynamic and variable because contraceptives differ in their attributes and because individuals and couples vary according to their sexual life-style, their health status and their stage of the life-cycle. Research in developing countries with moderate to high levels of contraceptive prevalence has shown that about 30% of users will switch methods or stop completely within one year and 50% will do so within two years. One study has also shown a higher discontinuation rate among women who were not provided with the method they knew they wanted before coming to the clinic. For all these reasons, it is not surprising that research has suggested a link between an increase in the range of methods used and a rise in the overall level of contraceptive prevalence.

Method choice availability is not in itself an indication of family planning quality of care because the fundamental issue is the appropriate client-method match. On the other hand, looking at the range of methods used will capture not just the quality of service delivery but also medical biases (such as complicated procedural requirements) and other access barriers (such as legal or regulatory restrictions) which are also aspects of quality, in its broadest sense.

Some observers think medical and access barriers to method choice over- shadow the best efforts of particular providers to meet the needs of their clients. National method-use data suggest that this may be true. In the average country, 50% of modern contraceptive use is accounted for by one method category usually oral contraceptives or sterilisation. The extent to which a single method category dominates use in a country ranges from 30% to 87%. Every region in the world has some countries with a very high dependence on a single method and others with a more even distribution of method use. This is true for both developed and developing regions and is not correlated with the contraceptive prevalence rate.

There are some problems with using these data for evaluation: data are required in narrower categories so that, for example, different types of pill are not grouped. In addition, the dominance of one method category could reflect age structure and socio- economic effects. Nevertheless, it seems unlikely that extreme dominance by a single method category would be associated with a high-service-quality and low-barriers-to- access family planning programme. Policy-makers concerned with improving family planning quality of care could usefully focus on reducing medical and access barriers at the national level in order to increase the range of methods used.

Maia Ambegaokar,
Centre for Population Studies,
London School of Hygiene and Tropical Medicine

T: +44 (0) 171 388 3071
F: +44 (0) 171 388 3076

E: maia.ambegaokar@lshtm.ac.uk