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R E S E A R C H A R T I C L E Open Access
Choice of contraceptive methods in public
and private facilities in rural India
, Vandana Gautam
, Abhishek Gautam
, Arnab Dey
, Ruhi Saith
, Abhishek Kumar
, Kumudha Aruldas
, Amit Chakraverty
, Dinesh Agarwal
, Ravi Verma
, Suneeta Krishnan
and Niranjan Saggurti
Background: Client-centric quality of care (QoC) in family planning (FP) services are imperative for contraceptive
method adoption and continuation. Less is known about the choice of contraceptive method in India beyond
responses to the three common questions regarding method information, asked in demographic and health
surveys. This study argues for appropriate measurement of method choice and assesses its levels and correlates in
Methods: A cross-sectional study was conducted with new acceptors of family planning method (N= 454)
recruited from public and private health facilities in rural Bihar and Uttar Pradesh, the two most populous states in
India. The key quality of care indicator ‘method choice’was assessed using four key questions from client-provider
interactions that help in making a choice about a particular method: (1) whether the provider asked the client
about their preferred method, (2) whether the provider told the client about at least one additional method, (3)
whether the client received information without any single method being promoted by the provider, and (4)
client’s perception about receipt of method choice. The definition of method choice in this study included women
who responded “yes”to all four questions in the survey. The relationship between contraceptive communication
and receipt of method choice was assessed using logistic regression analyses, after adjusting for socio-demographic
characteristics of the respondents.
Results: Although 62% of clients responded to a global question and reported that they received the method of
their choice, only 28% received it based on responses about client-provider interactions. Receipt of the information
on side-effects of the selected method (Adjusted Odds Ratio [AOR]: 7.4, 95% Confidence Interval [CI]: 3.96–13.86)
and facility readiness to provide a range of contraceptive choice (AOR: 2.67, 95% CI: 1.48–4.83) were significantly
associated with receipt of method choice.
Conclusions: Findings demonstrated that women’s choice of contraceptive could be improved in rural India if
providers give full information prior to and during the acceptance of a method and if facilities are equipped to
provide a range of choice of contraceptive methods.
Keywords: Quality of care, Method choice, Family planning, India
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* Correspondence: firstname.lastname@example.org
Population Council, New Delhi, India
Full list of author information is available at the end of the article
Mozumdar et al. BMC Health Services Research (2019) 19:421
With India’s FP2020 commitment to provide 48 million
additional women with modern contraceptives  and
the anticipated increase in the number of people receiv-
ing contraceptive services, maintaining quality of care
(QoC) is critical both for contraceptive uptake and
continuation [2–6]. Family planning impact studies from
Bangladesh, Senegal, and Tanzania showed that women’s
contraceptive use was higher in areas where clients felt
that they were receiving good care [7–13].
Earlier studies on QoC from India mostly focused on
three indicators of method information index (MII),
which includes whether the provider informed the client
about the side-effects of selected methods; whether the
provider explained how to manage the side-effects of the
selected method, if experienced; and whether the pro-
vider provided information about other FP methods
. Recent evidence from India showed that 47% of the
women were told about the side-effects of the selected
method; 39% of women were told how to manage side-
effects, if experienced; and 54% of women were ever told
about other FP methods that could be used .
In the absence of any medical contraindication, the
selection of an FP method by women was often concep-
tualized as an autonomous decision . The studies
from low- and middle-income countries on decision-
making were conducted through different research on
methodologies [17,18], including randomized controlled
trial  and evaluation of counseling tools . The
findings of all these studies suggested that giving women
the information and choice increases their adoption of
contraceptives. Cross-sectional studies in India also
demonstrated a positive association between the use of
contraceptives with receipt of FP advice from health
workers . However, the literature from India mostly
described the QoC related to the method that the client
already selected and was using but lacks studies on the
decision- making process on contraceptive and QoC in
FP from the clients’perspective.
The receipt of the method-choice is one of the indica-
tors of client satisfaction for QoC studies of FP services.
In low- and middle-income countries like India, how-
ever, poor and uneducated women often report that they
received their FP method choice, but the selection of the
method was often not their decision [22,23]. RamaRao
et al.  assessed method choice based on a set of four
indicators of quality of FP services: (1) whether the pro-
vider asked which method the client preferred, (2)
whether the provider told about at least one additional
method besides the method adopted, (3) whether the
client received information without any single method
being promoted by the provider, and (4) whether the
provider gave the client their method choice. If the
answer to all four questions is “yes,”the client’s choice
of method could be considered a result of her decision–
free of any provider bias–and therefore, could be a
better indicator of client satisfaction with FP service.
This forms the basis of this article, which examines the
receipt of method choice of those attending public and
private health clinics in rural areas of two large north
The study was conducted in selected health facilities in
Bihar and Uttar Pradesh (UP), the two most populous
states of India, with a total population of more than 300
million. Both states are also high-focus states areas for
FP because of prevailing high unmet need (21% in Bihar
and 18% in UP), high fertility (total fertility rate of 3.4 in
Bihar and 2.7 in UP), and low use of modern contracep-
tive methods (23% in Bihar and 32% in UP) . Histor-
ically, the use of modern contraceptive use has remained
low in these two states [15,25]. The method-mix in
these two states are different; the percentage of female
sterilization among users of any modern method in
Bihar is 89% and in UP is 55%. The public sector
remains the main source of modern contraceptives (63%
for Bihar and 54% for UP) .
The study used baseline data conducted as part of a
comprehensive QoC study for FP services in public
health facilities in Bihar, and public and private health
facilities in UP. The facilities were selected using three
stratified random sampling strategies for three types of
health facilities: public health facilities in Bihar, public
health facilities in UP, and private health facilities in UP.
The public health facilities that were classified to receive
an intervention or not in Bihar were divided into three
strata: district hospitals (DH), community health centers
(CHC), and primary health centers (PHC). The number
of facilities selected in each stratum was determined by
the relative proportion of each type of facility from the
list of intervention and non-intervention facilities.
Finally, from each of the strata, facilities were selected
using probability proportionate to size (PPS) sampling
based on numbers of Mini-Lap sterilization (chosen as a
proxy to the volume of client load) procedures con-
ducted during the year preceding the survey. However,
all the study facilities had short-acting and/or long-
acting reversible contraceptive methods on the day of
For public health facilities in UP, within each district,
the health facilities were stratified into two groups: DH
and CHC. Of the total sample of facilities, 50% were taken
from the program high priority districts (HPDs), and the
other 50% were taken from the non-high-priority districts.
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 2 of 10
Health facilities (DH and CHC) within each district were
selected using systematic PPS sampling based on numbers
of sterilization procedures conducted during the year pre-
ceding the survey. The sterilization procedures numbers
were chosen to get to enough numbers of new acceptors
of family planning. Similar to the public health facilities in
Bihar, all selected study facilities in UP had short-acting
and/or long-acting reversible contraceptive methods on
the day of data collection.
The private health facilities of UP were selected from
the list of all private facilities participating in social
franchises of Population Services International (PSI) and
Hindustan Latex Family Planning Promotion Trust
(HLFPPT). Social franchises of PSI are present in 10
districts, and of HLFPPT in 17 districts of UP. The dis-
tricts were arranged by their modern contraceptive
prevalence rate as estimated in Annual Health Survey
2012–13 . Fourteen districts, i.e., seven districts for
each of the social franchise networks were selected as
study sites using systematic random sampling. Within
each district, all clinics under social franchise with a load
of 20 or more FP clients per month were included in the
Clients of all three types of facilities (irrespective of
the type of contraceptive method they received) were
interviewed at the point of exit. The clients were asked
about their experiences with FP services in the facility.
Specifically, each client was asked a set of questions
about the information received about contraceptive
methods, respectful care, and their willingness to follow
up or return to the facility as a measure of the level of
satisfaction with the FP services received in the overall
quality of care study. Data chosen for this study included
only the clients who answered all the questions across
three types of facilities. In total, 454 clients were
interviewed from 187 health facilities. The sector-wise
break-up of the clients was 158 clients from 61 public
health facilities of Bihar, 221 clients of 88 public health
facilities of UP, and 75 clients of 38 private health facil-
ities of UP. Of the 158 clients from Bihar public health
facilities, 94% were sterilization acceptors, and remaining
were acceptors of long-acting reversible methods, or
short-acting methods. Of the clients from UP public
health facilities, 48% were sterilization acceptors, 30%
were acceptors of long-acting reversible methods, and
22% were acceptors of short-acting methods. Of the 75
clients from UP private health facilities, 8% were
sterilization acceptors, 91% were acceptors of long-
acting reversible contraceptive method, and 1% were
acceptors of short-acting methods. The youngest partici-
pant was 19 years old.
Three separate research organizations collected the
data for this study under a partnership, and standardized
and comparable questions were used in data-collection
tools. Except for female sterilization clients, all those
coming to the facility for FP services on a typical day
who agreed to participate in the study were interviewed
at the point of exit from the facility. The sterilization
clients were interviewed at home, 15 to 30 days after the
procedure, because they left the facility on the same day
and it was difficult to conduct an exit interview after the
sterilization procedure. Information from the sterilized
clients was collected through face-to-face interviews in
UP and through telephone in Bihar.
Apart from the regular offering, the public health
system of Bihar and Uttar Pradesh often offer “fixed-
day-services”for family planning. The number of clients
served on those “fixed-days”are higher than on a typical
day. We expected that the quality of care in those
“fixed-days”would be worse than a typical day due to
higher client-load, therefore, we conducted the client
exit interviews on a typical day, also we kept a similar
setting of data collection in public facilities compared to
the setting of private facilities. Interviews were con-
ducted by trained female investigators using a structured
set of questions in the Hindi language–the local
language of these two states. The study design for this
analysis used a common set of questions prepared by
researchers of all three organizations that collected the
Outcome indicator: method choice
The outcome indicator in this study was the receipt of
method choice among FP clients. This indicator was cal-
culated using responses to four questions from the client
exit interview: whether the provider asked about method
preference, whether the client was told about at least
one additional method, whether the client was not
promoted to adopt any one FP method by the provider,
and whether the client reported that she received her
method choice. Women who answered “yes”to all four
questions were considered to have received their method
As existing literature suggests that one element of QoC
may affect the other element, a set of QoC process
indicators were considered as the predictor variables.
These indicators were adopted using the situation ana-
lysis approach proposed by Miller et al. . The categor-
ies of the predictor variables selected are given below.
Facility readiness to provide a method Both public
and private health facilities were assessed for their
readiness, on the day of the survey, to provide each of
the FP methods, available in the public health system of
the state, such as, female sterilization using both laparos-
copy and mini-lap procedure, intra-uterine contraceptive
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 3 of 10
device (IUCD), condoms, and oral contraceptive pills. No
other contraceptive methods were available in the public
sector in India at the time of this study. Each of the se-
lected facilities was assessed using a facility audit checklist
that collected data on the basic infrastructure (e.g., avail-
ability of water and electricity); the presence of trained
staff; availability of drugs, equipment, and supplies re-
quired to provide clinical FP services; and availability of
commodities of nonclinical FP methods.
Based on the facility readiness of the type of methods,
each facility was categorized into one of the four groups:
facilities ready to provide only short-acting methods
(condoms and pills); facilities ready to provide short-
acting methods and the long-acting reversible method
(IUCD); facilities ready to provide permanent methods
(female sterilization) and either the long-acting revers-
ible method or short-acting methods; and facilities ready
to provide all three types of FP methods: permanent,
long-acting reversible, and short-acting.
Client-provider interaction The indicators for informa-
tion given to clients included the variables related to the
discussions or information exchange, that the client had,
with the family planning service provider. Apart from
the four indicators mentioned as a part of method
choice, five additional indicators on client-provider
interaction were considered: provider told client about
the side-effects of the method, provider told client how
to manage side-effects if experienced, provider told
client the results of tests and examinations, provider
encouraged the client to ask questions, and client felt
respected by the provider’s behavior.
Background characteristics of the clients
Background characteristics of the clients were also
considered as predictors. Categories are: age groups of
clients (less than 25 years, 25–29 years, 30–34 years, and
35 years and above), client belongs to social group
(scheduled castes or scheduled tribes, other backward
classes, and general caste), client’s education status (no
education or completed less than 5th standard, com-
pleted 5th to 9th standard, and completed 10th standard
or higher), education status of client’s husband (no edu-
cation or completed less than 5th standard, completed
5th to 9th standard, and completed 10th standard or
higher), and number of living children the woman has
(no child, one child, two children, three children, four or
Univariate analyses were used to understand the back-
ground characteristics of the clients. The differences in
QoC indicators by receipt of method choice, or not,
were compared using chi-square tests. Multivariate
regression analyses were used to identify the factors
associated with the method choice.
To identify the factors associated with the receipt of
method choice, binary logistic regressions were per-
formed. In these analyses, the dependent variables were
binary variables, where the receipt of method choice was
coded as “1,”and “0”otherwise.
Two sets of logistic regressions were used: Model 1a-e
using each of the QoC indicators and facility readiness
as factors, and Model 2 using all QoC indicators and fa-
cility readiness together. Since receipt of information
about side effects for the selected method and receipt of
the information on how to manage side-effects were
highly correlated, the second variable was dropped from
the regression analyses. Both the models were adjusted
for clients’background characteristics as confounders.
Results obtained from the regression analyses were
presented as adjusted odds ratios (AORs) along with the
95% confidence interval (95% CI). All these analyses
were done using Stata (version 13) statistical software.
Background characteristics of the clients
About half of the clients (52%) aged 25–29 years (Table 1).
More than half of the clients (57%) belonged to other
backward classes and 27% of the clients belonged to
scheduled caste or scheduled tribe families. About half of
the clients (46%) had no education or completed less than
5th standard of schooling. About three-fifths (57%) of the
clients had three or more children.
Quality of care
Quality of FP services as reported by the clients in the
study area is presented in Table 2. More than three-
fifths (62%) of clients reported that they received their
method choice. However, only about half the clients re-
ported that they were told about the side-effects (56%),
how to manage side-effects if experienced (55%), the
results of tests and examinations done (48%), and were
encouraged to ask questions (54%). About three-fourths
(73%) of clients reported that the provider asked them
about their method preference, 75% of clients reported
that the provider gave information without strongly
encouraging the client to adopt any one method, and
65% of clients reported that the provider told them
about other FP methods than the selected method.
To examine how many clients were informed about
different methods without provider bias, and could
therefore be considered as having received free (of pres-
sure) and informed “method choice,”we examined the
percentage of clients who were asked about their
method preference before they chose a method, told
about methods other than the selected method, and not
coerced to accept a particular method.
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 4 of 10
FP method choice
Figure 1shows the proportion of clients who received
method choice, as defined in this study, and comparison
of clients’reporting receipt of the method of choice in
response to a global question. The results show that 73%
of clients were asked about their method preference
during counseling. About 57% of clients were asked
about their method preference and were also informed
about different FP methods. About two-fifths (39%) of
clients who were asked about method preference were
also informed about other FP methods without the
provider encouraging a particularmethod.Inall,28%
of clients reported receipt of method choice by an-
swering “yes”to all four questions. This is a consider-
able drop from the proportion of clients (62%) who
reported that they received method choice by answer-
ing just one question on method choice in the ques-
tionnaire. If we consider method choice as a score by
adding the number of “yes”responses, the score
ranges from 0 to 4 and the mean ± SD of the score
was 2.7 ± 1.0.
Association between receipt of method choice and other
Table 3presents a comparison of receipt of the infor-
mation on side-effects among clients who did or did
not receive the method choice. The findings show the
clients who did not receive method choice also re-
ceived significantly less information about side-effects.
For example, 87% of the clients who received method
choice by the study definition also received informa-
tion about the side-effects. However, only 44% of the
clients, who did not receive method choice, received
information about side-effects. Similarly, among the
clients who were not informed about FP methods, a
significantly smaller proportion received other ele-
ments of care than the clients who received method
choice. Those other elements of care in contraceptive
services provision were receipt of the information on
how to manage side-effects, receipt of information
about test results and examinations, encouragement
from providers to ask questions, and feeling of being
Determinants of receipt of method choice
Table 4shows the results of logistic regressions examin-
ing the correlates of receipt of method choice. The
results of multivariate logistic regression suggest that
clients of facilities that were ready to provide both long-
Table 1 Distribution of the clients across selected
Background characteristics (N= 454) %
Age of the client
Less than 25 years 18.2
25–29 years 51.7
30–34 years 22.2
35 years or above 8.0
Scheduled castes/tribes 26.9
Other backward classes 57.3
Client’s education status
No education/lower than 5th standard 46.0
5th–9th standard 33.0
10th standard and higher 20.9
Client’s husband’s education status
No education/lower than 5th standard 30.7
5th–9th standard 25.8
10th standard and higher 43.5
No child 0.7
1 child 9.9
2 children 32.2
3 children 29.1
4 children or more 28.2
Table 2 Percentage of clients reported receipt of quality of care in family planning services
Quality of care indicators (N= 454) n %
Provider asked about preferences of client 331 72.9
Provider told client about other methods 295 65.0
Provider gave information without promoting any single method 342 75.3
Provider told client about side-effects of the method 254 56.0
Provider told client how to manage side-effects, if experienced 248 54.6
Client was told the results of tests and examinations 219 48.2
Provider encouraged client to ask questions 245 54.0
Client reported receiving method of her choice 279 61.5
Client felt respected 395 87.0
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 5 of 10
acting reversible and short-acting methods have more
than two and half times higher odds of receiving method
choice (AOR = 2.67, 95% CI 1.48–4.83) than the clients
of facilities having only short-acting methods. Similarly,
clients who received services from the facilities ready to
provide all three methods (permanent methods, long-
acting reversible methods, and short-acting methods)
also have higher odds of receiving method choice
(AOR = 1.45, 95% CI 0.62–3.42) than the clients of facil-
ities having only short-acting methods. Women’s receipt
of method choice is also higher if they were given infor-
mation about the side-effects of the selected method
(AOR = 7.40, 95% CI 3.96–13.86) than if they were not
given information about side-effects.
Study findings highlight that there is a huge difference
between those reporting receipt of method choice via a
single question versus when it is examined in combin-
ation with the extent of information exchange during
the selection of method choice. The receipt of method
choice with complete information is far from universal.
The results further indicate that method choice linked
to provider-client interaction is more likely to happen if
the facilities are equipped to provide various contracep-
tive methods. This finding is relevant given findings
from previous research  that have highlighted the
likelihood of providers giving information about the
methods that are available in the facilities. Further, the
Fig. 1 Information cascade for receipt of method choice, compared with reporting of receipt of method of choice using single-question response
Table 3 Comparison of quality of care in family planning services between clients who received and who did not receive method
Quality of care indicators Did not receive method choice Received method choice
N= 328 N= 126
Provider told client about the side-effects of the method* 43.9 87.3
Provider told client how to manage side-effects, if experienced* 43.9 82.5
Provider told results of tests and examinations 47.3 50.8
Provider encouraged client to ask questions* 48.5 68.3
Client felt respected* 84.5 93.7
* Significant difference between the two groups of clients p< 0.05, Chi-square test
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 6 of 10
Table 4 Odds ratio obtained from binary logistic regression analysis showing the determinants of receipt of method choice
(a) (b) (c) (d) (e)
AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)
Facility readiness for type of methods
Only for short-acting methods Ref. Ref.
Long-acting reversible and short- acting methods 3.63 (2.10–6.24) 2.67 (1.48–4.83)
Permanent method and any other method 0.62 (0.27–1.41) 0.55 (0.23–1.35)
Permanent, long-acting reversible and short-acting methods 2.45 (1.08–5.55) 1.45 (0.62–3.42)
Provider told client about the side-effects of the method 9.52 (5.30–17.11) 7.40 (3.96–13.86)
Provider told results of tests and examinations 1.22 (0.80–1.87) 0.94 (0.57–1.54)
Provider encouraged client to ask questions 2.41 (1.54–3.79) 1.20 (0.71–2.01)
Client felt respected 2.58 (1.17–5.66) 1.78 (0.75–4.18)
Less than 25 years 2.01 (0.66–6.12) 1.97 (0.60–6.45) 1.95 (0.67–5.70) 2.37 (0.79–7.12) 1.93 (0.66–5.64) 1.87 (0.54–6.44)
25–29 years 1.67 (0.65–4.33) 2.32 (0.85–6.30) 2.02 (0.80–5.06) 2.52 (0.98–6.48) 2.04 (0.82–5.13) 1.94 (0.69–5.48)
30–34 years 1.73 (0.65–4.64) 1.75 (0.63–4.89) 1.93 (0.75–5.01) 2.13 (0.81–5.59) 1.88 (0.73–4.87) 1.46 (0.50–4.26)
35 years or above Ref. Ref. Ref. Ref. Ref. Ref.
Scheduled castes/tribes 0.70 (0.33–1.49) 1.09 (0.50–2.39) 0.71 (0.34–1.47) 0.84 (0.40–1.75) 0.73 (0.35–1.51) 0.99 (0.44–2.26)
Other backward classes 1.05 (0.54–2.02) 1.36 (0.68–2.70) 1.15 (0.61–2.15) 1.24 (0.65–2.35) 1.14 (0.60–2.14) 1.17 (0.57–2.38)
General Ref. Ref. Ref. Ref. Ref. Ref.
Client’s education status
No education/lower than 5th standard Ref. Ref. Ref. Ref. Ref. Ref.
5th–9th standard 1.17 (0.71–1.94) 1.14 (0.67–1.93) 1.26 (0.78–2.03) 1.19 (0.73–1.94) 1.19 (0.74–1.91) 1.11 (0.64–1.94)
10th standard and higher 0.39 (0.19–0.80) 0.55 (0.28–1.10) 0.55 (0.29–1.04) 0.56 (0.29–1.07) 0.54 (0.28–1.02) 0.42 (0.20–0.89)
No child/1 child 0.94 (0.36–2.48) 0.92 (0.33–2.55) 1.24 (0.50–3.07) 1.12 (0.44–2.84) 1.26 (0.51–3.14) 0.78 (0.27–2.27)
2 children 0.83 (0.44–1.57) 0.67 (0.34–1.33) 0.90 (0.49–1.64) 0.79 (0.43–1.46) 0.88 (0.48–1.60) 0.63 (0.31–1.30)
3 children 0.80 (0.44–1.47) 0.63 (0.33–1.19) 0.80 (0.45–1.43) 0.70 (0.39–1.28) 0.80 (0.45–1.42) 0.62 (0.31–1.21)
4 children or more Ref. Ref. Ref. Ref. Ref. Ref.
Note: AOR Adjusted Odds Ratio, CI Confidence Interval, Ref. Reference category, AORs in bold are significant at p< 0.05
Model 1a-e: Effect of each of the factors was estimated separately for (a) facility readiness for type of methods, (b) provider told client about the side-effects of the method, (c) provider told results of
tests and examinations, (d) provider encouraged client to ask questions, and (e) client felt respected. All models were adjusted for client’s age, parity, education, and social group
Model 2: Effect of all factors were estimated together and adjusted for client’s age, parity, education, and social group
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 7 of 10
number of women reporting receipt of method choice is
likely to be high if they are informed about the side-
effects of the method.
For the first time in India, this study explored multiple
aspects of receipt of method choice controlling for facil-
ity readiness and other elements of service provision,
therefore, findings from this study could not be com-
pared with other studies because of the dearth of litera-
ture on receipt of method choice within the country.
RamaRao et al.  reported a higher mean score of
method choice (3.5) in the Philippines than this study
(2.7), however, RamaRao et al.  did not report how
many clients scored “4”in method choice score, i.e. who
answered “yes”to all four questions. Therefore, the find-
ings of this study could serve as the benchmark for
measurement on the method choice for future studies in
similar settings. Overall, the study revealed that when
women were asked about their method preference, and
received information about other available methods,
side-effects of the chosen method, and the test and
examination results, they were more likely to report that
they chose the FP method by themselves.
Although less than one-third of the clients reported
they received method choice, most clients (87%), regard-
less of whether they received method choice or not, felt
respected during FP services, and most clients (more
than 75%) also reported that the provider did not en-
courage any one method. This reflects the Government
of India’s commitment to expand and give choice to
women for contraception . The findings in this study
also highlight the utility of comprehensively measuring
the information exchange between provider and client
for understanding the receipt of method choice, which is
one of the critical indicators of quality of care.
Although the findings have several implications to
measurement and utility of assessing client’s method
choice as part of the quality of care studies, the results
may be interpreted in the light of certain limitations.
Firstly, most women included in this study were younger
than 30 years of age, belonged to other backward classes
and the scheduled castes and scheduled tribes, therefore,
these findings reflect the contraceptive service-related
care for young women from marginalized sections of the
society seeking services from public (mostly) and private
health sectors in the study geographies. Secondly, the
number of women that could be recruited from each site
was limited due to the low uptake of family planning
services by people and the type of methodology adopted
in the study. We have carried out clients’exit interview
on a typical day leading to lower numbers, resulting
from very low uptake of reversible contraceptive
methods. Future prospective research is needed to exam-
ine the effects of method choice on the continuation of
reversible methods or switching to other methods.
Thirdly, the data represents reporting from clients, the
reporting may have some personal biases. Some may
argue that it would be better to observe the information
exchange between the providers and clients with a struc-
tured checklist for appropriate assessment of quality in
the provision of contraceptive services. On the other
hand, the observation data of the provider-client inter-
action may have some Hawthorne effect (alternation of
the natural behavior of the subject of a study due to
their awareness of being observed) and that may
overestimate the level of quality of care. Alternatively, a
“mystery client”methodology for quality of care in
reversible contraceptive methods provision may provide
realities of provider-client interaction.
While the client-centric contraceptive services continue
to be the focus of the FP program, study results also high-
light the differences in usual response about the receipt of
method choice and whether women received information
while making a mention of receipt of method choice or
not. It poses both programmatic and rights-based ques-
coming to a facility for a particular method, and given that
context, how relevant it is for the providers to talk about
other methods. The rights-based approach recommends
that women should have the right to information from pro-
viders at the facility and to make an autonomous and fully
informed decision about their preferred method of contra-
ception, irrespective of their preparedness before coming
to a facility. Autonomy and full information require that
any counseling, advice, or information provided to the
using language and methods that can be easily understood
by the client. Therefore, health-care providers have the
responsibility to convey accurate information and noncoer-
cive counseling, and to facilitate fully informed decision-
making [28,29]. The rights-based approach is critical given
that most of the women in rural India and other develop-
ing countries are illiterate and belong to poor economic
households, therefore, women should get complete infor-
irrespective of the method they may ask for at the begin-
ning of their consultation. This has implications to change
thinking in program efforts to promote the continuation of
method use, because improved method choice leads to
higher continuation rate of contraceptive use .
Historically, a skewed method mix indicates either
provider bias in the system or user preferences, or both
[30,31]. The method-mix of the two states under study,
especially Bihar, are heavily skewed toward female
sterilization. Given that clients in these two states are
predominantly adopting only one method, it is necessary
to study in-depth how provider bias could influence the
contraceptive decision-making of the women and there-
fore their contraceptive use.
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 8 of 10
Quality of care in FP reinforces the client’s rights to
information, choice, and the quality of interaction with the
provider. Quality FP services lead to client satisfaction and
that increases the chance of continuing contraceptive use
if not continuing the same method. QoC also enhances the
job satisfaction of the provider and motivates the provider
to deliver better services . But, encouraging the
providers to provide sufficient information irrespective of
clients’prior knowledge on methods may need emphasis
in the current family planning program.
AOR: Adjusted odds ratio; CHC: Community health center; CI: Confidence
interval; DH: District hospital; FP: Family planning; HLFPPT: Hindustan Latex
Family Planning Promotion Trust; HPD: High priority district; IUCD: Intra-
uterine contraceptive device; MII: Method information index; PHC: Primary
health center; PPS: Probability proportionate to size; PSI: Population Services
International; QoC: Quality of care; SD: Standard deviation; UP: Uttar Pradesh
The authors would also like to extend our appreciation to all participants and
data collectors. We appreciate the hard work of Tamal Reja and Binit Jha from
ICRW; Dr. Nayan Kumar, Dr. Nisha Gupta, Vipul Kumar, and Dilip Parida from
OPM; and Navin Kumar, Suchita Mathur, and Ruchira Chaudhury from
Sambodhi in pretesting of tools, conducting trainings for research investigators,
organizing training of medical professionals, managing, and monitoring the
entire fieldwork and data management for their respective sectors. We thank
Joyce Altman of the Population Council to copyedit the manuscript.
NS, PA, and KA conceptualized and designed the study. AM and AK analyzed
the data. AM, AK, and KA wrote the draft manuscript. RS, VG, and NS reviewed
and edited the final manuscript. AG, AD, RS, UT, PA, VG, DA, AC, RV, PN and SK
provided intellectual input to the manuscript. All authors read and approved
the final manuscript.
The Bill and Melinda Gates Foundation (BMGF) funded the study through
separate grants to Oxford Policy Management (Grant # OPP1142884), Sambodhi
Research and Communications Private Limited (Grant # OPP1083531),
International Center for Research on Women (Grant # OPP142874), and
Population Council (Grant # OPP1142878). The funding organization had no
role in study design, data collection, data analysis, data interpretation or in
writing the manuscript. The views expressed are those of the authors and do
not necessarily represent those of the authors’organizations or funding agency.
Availability of data and materials
Data would be made available from the corresponding author on reasonable
Ethics approval and consent to participate
The study used combined data sets from three specific sectors, collected by
three different organizations. All organizations obtained approval from their
Institutional Review Board (IRB) for their respective survey. Additionally, in
Bihar public sector, Oxford Policy Management obtained ethical approval for
the data collection from the IRB of Sigma Research and Consulting. In UP
public sector, this study was conducted in partnership with the National
Health Mission of Uttar Pradesh. IRB approval for this study was granted from
Public Health Service–Ethical Review Board and from the Health Ministry
Screening Committee, facilitated by the Indian Council for Medical Research.
These protocols were also registered with the Clinical Trial Registry—India
(CTRI/2015/09/006219). In UP private sector, study protocol received approval
from IRB of the International Center for Research on Women, Washington
DC, and local approval from the IRB of Sigma Research and Consulting. In all
three studies, participants provided a written, informed consent confirming
their voluntary participation in the study. Confidentiality and privacy of
medical information were maintained during the study.
Consent for publication
The authors declare that they have no competing interests.
Population Council, New Delhi, India.
Oxford Policy Management, New
International Center for Research on Women, New Delhi, India.
Sambodhi Research and Communications Private Limited, Noida, Uttar
IPE Global, New Delhi, India.
Bill and Melinda Gates
Foundation, New Delhi, India.
Received: 1 August 2018 Accepted: 12 June 2019
1. Government of India. India’s vision FP 2020. New Delhi: Ministry of Health
and Family Welfare (MOHFW); 2014.
2. Jain AK, Winfrey W. Contribution of contraceptive discontinuation to
unintended births in 36 developing countries. Stud Fam Plan. 2017;48:269–78.
3. Arends-Kuenning M, Kessy FL. The impact of demand factors, quality of care
and access to facilities on contraceptive use in Tanzania. J Biosoc Sci. 2007;
4. Blanc AK, Curtis SL, Croft TN. Monitoring contraceptive continuation: links to
fertility outcomes and quality of care. Stud Fam Plan. 2002;33:127–40.
5. Mariko M. Quality of care and the demand for health services in Bamako,
Mali: the specific roles of structural, process, and outcome components. Soc
Sci Med. 2003;56:1183–96.
6. Sanogo D, RamaRao S, Jones H, N'Diaye P, M'Bow B, Diop CB. Improving
quality of care and use of contraceptives in Senegal. Afr J Reprod Health.
7. Koenig MA, Hossain MB, Whittaker M. The influence of quality of care upon
contraceptive use in rural Bangladesh. Stud Fam Plan. 1997;28:278–89.
8. Miller R, Askew I, Horn MC, Ndhlovu L. Clinic-based family planning and
reproductive health services in Africa: findings from situation analysis
studies. New York: Population Council; 1998.
9. Mroz TA, Bollen KA, Speizer IS, Mancini DJ. Quality, accessibility, and
contraceptive use in rural Tanzania. Demography. 1999;36:23–40.
10. Speizer IS, Bollen KA. How well do perceptions of family planning service
quality correspond to objective measures? Evidence from Tanzania. Stud
Fam Plan. 2000;31:163–77.
11. Costello M, Lacuesta M, RamaRao S, Jain A. A client-centered approach to
family planning: the Davao project. Stud Fam Plan. 2001;32:302–14.
12. Sathar Z, Jain A, Ramarao S, ul Haque M, Kim J. Introducing client-centered
reproductive health services in a Pakistani setting. Stud Fam Plan. 2005;36:
13. Jain AK, Ramarao S, Kim J, Costello M. Evaluation of an intervention to
improve quality of care in family planning programme in the Philippines. J
Biosoc Sci. 2012;44:27–41.
14. Jain AK. Examining Progress and equity in information received by women
using a modern method in 25 developing countries. Int Perspect Sex
Reprod Health. 2016;42:131–40.
15. International Institute for Population Sciences (IIPS) and ICF. National Family
Health Survey (NFHS-4) 2015–16, India. Mumbai: IIPS; 2017.
16. Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women’s
preferences for contraceptive counseling and decision making.
17. Kim YM, Kols A, Mucheke S. Informed choice and decision-making in family
planning counseling in Kenya. Int Fam Plann Persp. 1998;24:4–11, 42.
18. Abdel-Tawab N, Roter D. The relevance of client-centered communication
to family planning settings in developing countries: lessons from the
Egyptian experience. Soc Sci Med. 2002;54:1357–68.
19. Lazcano Ponce EC, Sloan NL, Winikoff B, Langer A, Coggins C, Heimburger
A, et al. The power of information and contraceptive choice in a family
planning setting in Mexico. Sex Transm Infect. 2000;76:277–81.
20. Kim YM, Kols A, Martin A, Silva D, Rinehart W, Prammawat S, et al.
Promoting informed choice: evaluating a decision-making tool for family
planning clients and providers in Mexico. Int Fam Plan Perspect. 2005;31:
Mozumdar et al. BMC Health Services Research (2019) 19:421 Page 9 of 10
21. Yadav D, Dhillon P. Assessing the impact of family planning advice on
unmet need and contraceptive use among currently married women in
Uttar Pradesh, India. PLoS One. 2015;10:e0118584.
22. Hutchinson PL, Do M, Agha S. Measuring client satisfaction and the quality
of family planning services: a comparative analysis of public and private
health facilities in Tanzania, Kenya and Ghana. BMC Health Serv Res. 2011;
23. Tessema GA, Mahmood MA, Gomersall JS, Assefa Y, Zemedu TG, Kifle M, et al.
Client and facility level determinants of quality of care in family planning
services in Ethiopia: multilevel modelling. PLoS One. 2017;12:e0179167.
24. RamaRao S, Lacuesta M, Costello M, Pangolibay B, Jones H. The link
between quality of care and contraceptive use. Int Fam Plan Perspect. 2003;
25. International Institute for Population Sciences (IIPS) and Macro International.
National Family Health Survey (NFHS-3) 2005–06, India. Mumbai: IIPS 2007.
26. Office of the Registrar General and Census Commissioner (ORGI). Annual
health survey 2012–13, fact sheet: Bihar and Uttar Pradesh. New Delhi: ORGI,
Ministry of Home Affairs, Government of India; 2013.
27. Mugisha JF, Reynolds H. Provider perspectives on barriers to family planning
quality in Uganda: a qualitative study. J Fam Plann Reprod Health Care.
28. Hardee K, Newman K, Bakamjian L, Kumar J, Harris S, Rodriguez M, et al.
Voluntary family planning programs that respect protect and fulfill human
rights: a conceptual framework. Washington, DC: Futures Group; 2013.
29. World Health Organization (WHO). Ensuring human rights in the provision
of contraceptive information and services: guidance and recommendations.
Geneva: WHO; 2014.
30. Sullivan TM, Bertrand JT, Rice J, Shelton JD. Skewed contraceptive method
mix: why it happens, why it matters. J Biosoc Sci. 2006;38:501–21.
31. Bertrand JT, Sullivan TM, Knowles EA, Zeeshan MF, Shelton JD.
Contraceptive method skew and shifts in method mix in low- and middle-
income countries. Int Perspect Sex Reprod Health. 2014;40:144–53.
32. Bruce J. Fundamental elements of the quality of care: a simple framework.
Stud Fam Plan. 1990;21:61–91.
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