Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016.

BACKGROUND: Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies. METHODS: Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05). RESULTS: Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts. CONCLUSIONS: Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality.

Using practical quality improvement approaches and tools in reproductive health services in east Africa.

BACKGROUND: A nonprofit, nongovernment organization, AVSC International provides technical assistance worldwide, including a range of reproductive health services and quality improvement (QI) approaches and tools. Current activities in East Africa involve several hundred sites, including referral hospitals, district-level hospitals, and individual family planning clinics. THE QI PACKAGE: AVSC and its local partners developed Client-Oriented, Provider-Efficient Services (COPE), a problem-solving process and set of tools to involve all levels of site staff members in assessing and improving the services. The COPE tools--self-assessment guides, client interview guides, client flow analyses, and action plans--promote involvement, ownership, and commitment to the QI process. Facilitative supervision and whole-site training complemented AVSC's traditional approaches of medical monitoring and informed choice. Facilitative supervision encourages supervisors and managers to consider staff members as internal customers, whose needs they must meet for staff to be able to meet the needs of external customers (clients). Whole-site training was developed to meet the needs of staff members and providers, who needed to function as a team responsible for providing high-quality services. CASE STUDY: A government hospital that has adopted the entire package of QI approaches, has used the Quality Improvement Quotient self-assessment surveys to track its progress in several elements of high-quality care, including management and supervision, safety, and information and client--provider interactions. For example, maternity ward staff learned how to pass on to their clients information about clients' rights and family planning methods through posters, pamphlets, sample contraceptives, and health talks. LESSONS LEARNED: AVSC's work with local organizations suggests a number of lessons learned, including the following: easy-to-use tools that promote staff involvement and ownership are essential in the QI process, QI requires considerable staff development and capacity building at all levels, and although the QI approaches were initially introduced for a relatively narrow field of services, they are applicable to and have increasingly been used in other departments and wards. (It is difficult, may be impossible, and certainly undesirable, to limit QI activities to one ward or service.) CONCLUSION: Activities in East Africa have shown that QI is possible even in very resource-poor settings. The same principles have guided the process in all the different programs, with some adaptation of the tools used. AVSC program activities are to continue to disseminate the experiences of sites implementing the package of tools and approaches, to advocate for investment in supervision and management capacity building as a means to support continuous quality improvement, and to further study the impact of the QI approaches on service quality.