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Bangladesh: High Quality of Care During Outreach Linked to Contraceptive Use
OR Summary no. 41

Over the past decade, family planning programs have focused on improving the quality of interactions between providers and clients. However, clear evidence on the impact of this element of quality on contraceptive use has been limited, in part due to limitations in the techniques used for research. 

In 2001 FRONTIERS supported a project by the Johns Hopkins School of Public Health to evaluate the relative impact of service quality and client characteristics on contraceptive adoption and continuation in rural Bangladesh. Researchers conducted a secondary analysis of data collected from 1989 to 1993 as part of a long-term surveillance project by the International Center for Diarrhoeal Disease Research. 

The researchers analyzed data from a large representative sample of reproductive-aged women served by 11 clinics and 65 female outreach workers in communities within the clinical catchment areas. For the study of contraceptive adoption, the researchers analyzed data for the sample of 4,610 women who were not using modern contraception at baseline. For the study of method continuation, the study population consisted of 3,611 use segments, or observations from women who either were using a temporary method at baseline or who adopted a temporary method during the subsequent 36-month observation period. Researchers used proportional hazards analysis to take into account how long survey participants remained in the sample.

The measure of service quality was based on the direct perceptions of survey respondents, specifically those related to the interpersonal aspects of client-provider interaction and overall service quality. Data were analyzed in relation to four programmatic factors: (1) perceived quality of care provided by female outreach workers; (2) contact, or frequency of visitation, by outreach workers; (3) perceived quality of care provided by clinics in the catchment areas; and (4) access to clinical care (distance from participating households to the clinic). The study also analyzed the effects of client characteristics, such as age, desire for more children, income, and educational level.

Findings

All four programmatic aspects of service—especially that provided by the outreach workers—were significantly associated with either contraceptive acceptance or continuation. However, the degree of association varied by the specific outcome of interest and was modified by client characteristics, as follows:

Contraceptive adoption

• Quality of care provided by outreach workers was significantly associated with the adoption of contraception. Relative to respondents in the 10th percentile of outreach quality of care, respondents in the 50th and 90th percentiles of service quality were 38 percent and 77 percent, respectively, more likely to adopt a method. More frequent outreach worker visitation and residence closer to clinic facilities were also significantly associated with method adoption.

Discontinuation of the first method chosen

• Frequent visits by outreach workers were significantly related to lower discontinuation of the first method chosen. Respondents who were visited at least once during a six-month period were significantly less likely to discontinue use of their initial method. Neither quality of care from outreach workers or clinics had an effect on first method discontinuation.

Discontinuation of all methods

• In contrast to first method discontinuation, higher quality of care provided by outreach workers was significantly related to lower discontinuation of any method, along with frequency of outreach worker visits. Relative to respondents in the 10th percentile of outreach quality of care, respondents in the 50th and 90th percentiles of service quality were 24 percent and 38 percent, respectively, less likely to discontinue overall modern method use.

Client characteristics and method adoption

• The quality of services from female outreach workers played a significant role in the adoption and continuation of a modern method by less educated women. Women with no education or only some primary school education were significantly more likely to adopt contraception when they received high quality care from outreach workers. In contrast, this quality of services was not significantly associated with method adoption among women with secondary school education (see Figure).

Policy Implications

• Outreach worker services are an important determinant of contraceptive use in this rural setting, especially for less educated women. Policymakers should ensure that outreach workers receive adequate training, refresher courses, and an uninterrupted supply of contraceptives to support effective use.  
   
• The aggregated approach to data analysis is a potentially useful method for obtaining methodologically rigorous measurements of the quality of interaction between clients and providers and of the effect of these interactions on contraceptive use dynamics.

May 2004

Sources: Koenig, Michael A., Saifuddin Ahmed, and Mian Bazle Hossain. 2004. “Quality of care and contraceptive behavior: Further evidence from longitudinal data from rural Bangladesh.” Unpublished manuscript.

 ———. 2003. “The impact of quality of care on contraceptive use: Evidence from longitudinal data from rural Bangladesh,” FRONTIERS Final Report. Washington, DC: Population Council. (PDF, 551 KB)

This project was conducted with support from the U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT under Cooperative Agreement Number HRN-A-00-98-00012-00.

For more information contact:
Frontiers in Reproductive Health (FRONTIERS)
Population Council
4301 Connecticut Ave. N.W., Suite 280
Washington, DC 20008 USA
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: frontiers@popcouncil.org

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This page updated 1 May 2006

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