Level of Client Satisfaction with Contraceptive Counseling and Associated Factors Among Women Attending Family Planning Services in Public Hospitals of Addis Ababa 2022

Background: Contraceptive counselling is a type of client-provider interaction that involves two-way communication between a health care staff member and a client for the purpose of confirming or facilitating informed decision by the client, or helping the client address problems or concerns. Effective contraceptive counselling is one of the cornerstones for increasing family planning acceptance. The best decisions about family planning are those that people make for themselves based on accurate information and a range of contraceptive options. Otherwise, they can either deny the service or discontinue the method if they are not properly counselled on minor side effects and myths related to the method. It empowers people to exercise their right to good quality family planning care.

Objectives: To assess the level of client’s satisfaction with contraceptive counselling and associated factors among reproductive age women in Addis Ababa Ethiopia 2022.

Methods: Institutional based cross-sectional study was used and multi-stage sampling technique was employed to recruit 592 participants. Structured and pretested questionnaire was used to collect data. Data was analysed using SPSS version 26. Descriptive statistic was used to summarize Socio-demographic and health related factors. Odds ratio was used to identify factor associated with the outcome variable and statically significant was declared at p-value 0.05. 

Result: The study includes 579 participants making the response rate 97.8%. most (57.2%) of the participants were between the age group 25-34 years. Most (90.7%) of the respondents were married More than half of the study participants are housewives. This study showed nearly three fourth (71.1%) of the respondents were satisfied with counselling given. Clients who were being acknowledged and responded to their concern, being showed how to use and having income greater than or equal to 5000 positively associated with satisfaction with contraceptive counseling.

Conclusion and recommendation: Present study showed that 71% of clients who came for f/p services were satisfied with contraceptive counselling. Acknowledge and respond to client’s concern, demonstrate how to use and income were significantly associated with client satisfaction with contraceptive counseling. Strengthening and maintaining   regular supervision on how clients are counselled is recommended.

Background

World Health Organization (WHO) defines family planning as “the ability of individuals or couples to determine the number of children and realize their predetermined number of children and spacing of their children and timing of their births. This could be accomplished through the use of effective contraceptive methods and the management of involuntary infertility [1]. Family planning (FP) saves lives of women and children and improves the quality of life for all. It is one of the best investments that can be made to ensure the health and well-being of women, children, and communities [2] by decreasing maternal mortality and improves women's health through preventing unwanted and high-risk pregnancies and reducing the need for unsafe abortions. Some contraceptives also improve women's health by reducing the likelihood of disease transmission and protecting against certain cancers and health problems [3]. One principal determinant of uptake and continued utilization of family planning services is overall client satisfaction with those services [4]. It is one of the factors that influences the use of FP and other reproductive health services [5]. Women who reported having received contraceptive counselling were more satisfied with their method [6]. World Health Organization (WHO) recommend to offer evidence-based, comprehensive contraceptive information, education and counselling to ensure informed choice for all women who need the services [7].  According to Turkish Demographic health survey (DHS) 2013, 33% of all women use a modern contraceptive method [8]. United nation population fund agency (UNFPA) DHS analysis from 24 countries in 2016, showed contraceptive prevalence was 64% in Honduras, 22% Senegal, 53% in Kenya and 27% in Ethiopia [9].

Contraceptive counseling is a type of client-provider interaction that involves two-way communication between a health care staff member and a client for the purpose of confirming or facilitating informed decision by the client, or helping the client address problems or concerns [10]. It also helps clients to obtain the information they need to use contraceptive methods correctly [11] and thereby decreases the likelihood that they will discontinue use of the method [12] and decrease unmet need of family planning. Effective contraceptive counseling is one of the cornerstones for increasing family planning acceptance. The best decisions about family planning are those that people make for themselves based on accurate information and a range of contraceptive options. Otherwise, they can either deny the service or discontinue the method if they are not properly counseled on minor side effects and myths related to the method. It empowers people to exercise their right to good quality family planning care [12].

Providing quality education, counseling and medical services related to family planning can lead to improved reproductive health outcomes [2]. Counseling clients properly during family planning services was found to improve both long term outcomes, such as increased birth spacing and continued use of modern contraception methods, as well as short term outcomes such as increased knowledge and satisfaction with family planning services [7]. These all facts suggest the need to reorient and refocus the contraceptive counseling to offer a tailored approach to meet individual needs of clients. Therefore, the study intended to examine client satisfaction with contraceptive counseling and client provider -interactions as related to family planning services and bring into focus the relevance of counseling and effective human relations to family planning in public health facilities in Addis Ababa city. Clients’ satisfaction has long been acknowledged as the primary determinant of uptake and continuation of contraceptive methods, and other reproductive health services [13].

Study area and period

This study was carried out in Addis Ababa the capital city of Ethiopia. The city has a subtropical highland climate. According to 2017 estimation, Addis Ababa has a population of 6.6 million people [44].  There are 13 governmental hospitals with full ANC clinic of these hospitals three hospital namely Ras Desta Damtew, Zewditu Memorial and St. Peter Specialized hospitals were selected by lottery method as study areas. The study was conducted from June to August 2022.

Study Design

Hospital based cross sectional quantitative study design was used. 

Source   Population

All reproductive age group women attending family planning clinics in government hospitals in Addis Ababa

Study population

All reproductive age group women attending family planning clinics in the selected government hospitals in Addis Ababa

Inclusion criteria

All women who came for family planning service during data collection period (volunteer to participate in the study)

Exclusion criterion

Those who were not volunteer to be interviewed 

Sample size and sampling technique

Multistage sampling   technique was used to select the study participants

The sample size was calculated by using single population proportion formula based on the following assumptions: Proportion of client satisfaction with contraceptive counseling was taken to be 62.8% (a study done in Asela town (46) at significant level α= 0.05, 95% confidence interval, Margin of error 5% and 10% non-response rate, the sample size was calculated by the following formula

Where: 

N = the required Sample size 

P = Proportion of client satisfaction with contraceptive counselling 62.8% (30)

Z = the value of the standard normal curve score corresponding to the given confidence interval (1.96) 

d = the permissible Margin of error (the required precision) = 5%

Since the sampling technique was multistage sampling, and considering design effect of 1.5 the sample size was539 and with 10% none response rate the final sample size was 592.

Sampling procedure 

The total sample size wase proportionally allocated based on the number of patients attending contraceptive counseling in each hospital as follows

A total of 20000 women attended the hospitals so 

Sample size for SPH= number of women attending contraceptive counseling in SPH * total sample size

Total number of women attending contraceptive counseling in at the selected hospitals

                                      = 9000*592=266/ 20000

Sample size for RDDH 1= number of women attending contraceptive counseling in RDDH* total sample size

 Total number of women attending contraceptive counseling in at the selected hospitals 

                                      = 6000*592 =178

                                          20000       

Sample size for ZMH= number of women attending contraceptive counseling in RDDH* total sample size

Total number of women attending contraceptive counseling in at the selected hospitals =5000*592=148

  20000

Three government hospitals were selected using multistage sampling technique as follows

Operational Definition

Contraceptive counseling: is a type of client-provider interaction that involves two-way communication between a health care staff member and a client for the purpose of confirming or facilitating informed decision by the client, or helping the client address problems or concerns [9].

Data collection procedure

Interview technique was used to collect data with pretested questionnaire. Three-degree midwives were recruited from other health facility based on their experience of data collection and communication skills with clients for data collection. One day training was given for data collectors concerning the research objective, data collection tools and procedures, and interview methods that are supposed to be applied during data collection based on prepared training manual. In order to measure satisfaction with contraceptive counseling, the five Likert scale questions were categorized in to two. Nine items were computed and the mean was used in order to classify into two. Accordingly: Those who score mean and above were categorized as satisfied with contraceptive counseling Those who scored below mean were dissatisfied with contraceptive counseling. Principal investigator carried out regular supervision, spot-checking and reviewing the completed questionnaire daily to maintain data quality. Pre-test was done on about 5% of the sample at Menillik II hospital to check validity and reliability of questionnaire. After the questionnaire was pretested, it was revised and amended.

Data entry and Analysis procedure

The collected data was checked for completeness and was entered and analysis will be made with Statistical Package for Social Science (SPSS) versions 20. Descriptive summaries were   used to describe the study variables. Significant variables (P less than 0.2) detected at bivariate level and those deemed to be important by the researcher were subsequently entered into Multivariate logistic regression model were used to control for possible confounding variables, to examine association and to produce crude and adjusted odds ratio along with their corresponding confidence limits (95% CI). A P-value less than 0.05 was considered to be statistically significant.

Socio demographic characteristics 

The study includes 579 participants making the response rate 97.8%. most (57.2%) of the participants were between the age group 25-34 years and slightly more than half of the participants (51.1%) were from rural area. Most (90.7%) of the respondents were married and had 90.7% had 1-3 children. More than half of the study participants are housewives and 58.5% of the respondents said it took them 30 minute to reach health facility (Table 1).

Table 1: sociodemographic characteristics of the study participants (n=579).

Response of clients on rapport building of health care provider

Slightly more than half of the study participants (55.5%) reported that the provider didn’t greet her with but introduce self for her. Majority of the respondents reported that the provider did not Offer her a seat and ensures your comfort (61.7%), Address you respectfully (63.3%) and arrange for privacy and confidentiality (62.9%) but nearly all 97.2% reported the provider makes welcoming gesture (Table 2).

Table 2: Response of family planning clients on rapport building of health care provider, Addis Ababa 2022 (n=579).

Response of clients on what they were asked by health care provider 

Among 579 respondents, 563(97.2%) said they were asked about their medical history while only431 (74.4%) reported they were asked whether they plan to have more children by health care provider. Provider asked if clients were concerned about using a modern family planning method in only 124(21.2%) of cases Table 3.

Table 3: Response of clients on what they were asked by health care provider, Addis Ababa 2022.

Regarding the use of any visual materials only 149(25.7%) of the respondents said the service provider didn’t use any visual materials while describing the methods whereas 369(63.7%) of the respondents said the provider didn’t present some methods more favorably than others (Table 4).

Table 4: Response of clients on usage of visual material and presenting more favorable methods Addis Ababa 2022.

Response of family planning clients regarding help health care provider 

Out of 576 family planning clients, 339(58.5%) of them were not asked what worried them about using a modern family planning method. About two third (61.7%) of respondents reported health care provider explained their results of physical examination and 445(76.9%) of respondents said health care provider encourage them to participate in choosing a method (Table 5).

Table 5: Response of family planning clients on what they were helped by health care provider Addis Ababa 2022.

Response of family planning clients on what they were explained by health care provider 

Out of total respondents, 453(78.2%) reported health care provider explained how to use or obtain the method to them during consultation. Client reported that health care provider explained how the method works in only 106(18.3%) cases. Only 29.7% of respondents said that health care provider explained possible side effects of the method (Table 6).

Table 6: Response of family planning clients on what they were explained by health care provider Addis Ababa 2022

Response of family planning clients on what they were recommended by health care provider 

Out of total respondents, 579(100%) of them reported they were Scheduled for a follow-up appointment while 100% of them were told to come back if there is any problem even before the appointment. One hundred fifty-six (26.9%) of them said they were referred for further family planning services Table 7.

Table 7: Response of family planning clients on what they were recommended by health care provider Addis Ababa 2022

Response of family planning clients on interpersonal communication skills of health care provider and use of materials during consultation 

Of 579 respondents, 70.6% of them reported that they were treated politely by health care provider while 191(33.0%) of them reported that they were consulted by words they can speak and understand. Service provider use flip chart, poster and contraceptive samples in 49.1%, 36.4% and 64.6% respectively Table 8.

Table 8: Response of family planning clients on interpersonal communication skills of health care provider and use of materials during consultation Addis Ababa 2022

Satisfaction with contraceptive counseling

This study showed nearly three fourth (71.1%) of the respondents were satisfied with counselling given (figure 2a).

Figure 2a: satisfaction level of the study participants.

Figure2b: satisfaction level of the study participants.

Association of selected factors with client satisfaction of contraceptive counseling 

A multivariate analysis was done to identify independent predictors of client satisfaction with contraceptive counseling. Independent variables which had a P value of less than 0.25 in bivariate analysis were entered to multivariate analysis to get adjusted odd ratio. Binary Logistic regression was performed to assess the association of each independent variable with satisfaction with contraceptive counseling. The factors that showed a p-value of less than 0.25 and deemed important were added to the multivariable regression model. The result revealed that on the bivariate analysis: residence, income, demonstrate how to use, acknowledge and respond to client’s concern, explain the result of physical examination, encourage to choose contraceptive method and use visual material were significantly associated with satisfaction with contraceptive counseling. After controlling the confounding factors, the multivariate revealed that acknowledge and respond to client’s concern, demonstrate how to use and income were significantly associated with client satisfaction with contraceptive counseling. Clients who were acknowledged and responded to their concern were 1.6 times more likely (AOR=1.602, 95%CI=1.020,2.518) satisfied with contraceptive counseling compared with their counterparts. Clients who were showed how to use were 1.6 times more likely (AOR=1.580, 95%CI=1.066,2.341) satisfied with contraceptive counseling compared with their counterparts. Clients who had income greater than or equal to 5000 birrs were 1.8 times more likely (AOR=1.789, 95%CI=1.232,2.600) satisfied with contraceptive counseling compared with their counterparts (Tabl 9).

Table 9: Association of selected variables with client satisfaction with contraceptive counseling in bivariate and multivariate analysis in Addis Ababa government health institution, 2022 (n-579)

** significant at p-value less than 0.05

Facility based cross sectional study was conducted to assess client satisfaction with contraceptive counselling and associated factors. The findings of this study revealed that 71% of women attending family planning clinics in Addis Ababa governmental health institutions were satisfied with contraceptive counseling. This result is low compared to other reports of 88% in the United States [15], 83% in Jordan [46], 85% in Egypt [47]., and 97% in Indonesia [48],91% in Tanzania [37] and 95.7%in Addis Ababa, [31] and higher than country wide Ethiopia (58.5%) [43], in Assela where satisfaction rate was 62.8% [30], in Bahirdar (66.1%),[41] and Hossana (75.3%),[42] The difference might be due to difference in study setting. The study also showed only 29.7% of respondents said that health care provider explained possible side effects of the method. This finding is similar with a study in Assela town Ethiopia where only 23,2% of clients reported side effects were explained by health care provider [43].  In this study only 37.1% of the clients reported their privacy `was maintained which is much lower as compared to a study in Rwanda and Assela where 93.8% clients reported their privacy `was maintained [29,30]. In this study family planning poster (wall chart) was noticed only by 36.4%. this finding is higher as comared to a study in Ibrid Jordan [49] and Assela where only 12.3% of the clients noticed Family Planning poster (wall chart) [30] in This inconsistency may be due to difference in socio demographic characteristics of the health care provider, shortage of counseling aid and poor counseling technique in this study. This study also showed only 55.4% of client report that health care provider introducing themselves to them. This finding lower than a study done in Egypt where 100% of client report that health care provider introducing themselves to them [26]. All of the participants were told when to return to the facility for method resupply. This finding is in-line with a study in Kenya where 94.3% of the respondents had been told when to return to the facility for method resupply which is in line with study conducted in Kenya [50].

Clients who were acknowledged and responded to their concern were positively associated (AOR=1.602, 95%CI=1.020,2.518) satisfaction with contraceptive counseling compared with their counterparts. This finding is supported by a study in Jimma Ethiopia where Clients who were acknowledged and responded to their concern were 2.2 times more likely to be satisfies with contraceptive counseling (AOR=2.239, 95%CI=1 (1.348,3.720)) [51] and in Addis Ababa [31]. The study showed no association between clients who were asked reproductive history by health care provider and satisfaction with contraceptive counseling. This finding is in contrast with a study conducted in Kenya [51] where there was an association between clients who were asked reproductive history by health care provider and satisfaction with contraceptive counseling [52].  Similarly this  study showed no association between  Clients whose privacy was not maintained during examination and procedure and satisfaction  with contraceptive counseling and time taken to reach nearby health facility satisfaction with contraceptive counseling which is in contrast with studies done in Hossana where an association was preset between those who reported their privacy was maintained and satisfaction  with contraceptive counseling [53]., Gondar where  clients who took shorter to reach a facility had a higher odds of satisfaction [54] This study also showed no association between residence and satisfaction  with contraceptive counseling. This finding was supported by a study in Benishangul Gumuz [55].

Strength of the study 

Study can be considered as base for further similar and large-scale studies.

Add significant contribution to Addis Ababa public health institutions.

Limitation of the study 

Since data on dependent and independent variables was collected at the same point in time, no causal interpretation can be made of the relationships between variables. Women who attend family planning clinic at private health facilities were not included in the study. The study may have social desirability factors. Lack of adequate literatures on the same or related topic especially in Ethiopia. Client satisfaction may be over-reported because women might have considered that their service would be compromised on next visit if they expressed negative feelings about the counseling service (i.e., courtesy bias).

• Based on the findings of this study, the following conclusions were made: 
• Present study showed that 71% of clients who came for f/p services were satisfied with contraceptive counseling 
• Acknowledge and respond to client’s concern, demonstrate how to use and income were significantly associated with client satisfaction with contraceptive counseling. 

Recommendation

• As per the findings of this study, the following recommendation were made: 
• Addis Ababa health office 
• Should strengthen and maintain regular supervision on how clients are counseled 
• Facilitate separate room for family planning clinic so that client’s privacy and confidentiality will be maintained
• Health care providers 
• Counsel clients according to national guideline so that clients can be satisfied 
• Counsel the clients on all contraceptive methods by telling possible side effects 
• Researcher 
• Should do further studies both with qualitative and quantitative researches to improve satisfaction with contraceptive counseling 
• Community based cross sectional should be done

Ethical approval and consent to participate; the ethical clearance was obtained from Institutional Review Board of KEA-MED University college and official letters was submitted to each respective health facility. After explaining the objectives of the study, informed written consent was obtained from all mothers, and anonymity and confidentiality of the data were kept. Respondents have the right not to participate or withdraw from the study at any stage, and all study methods were performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and materials

The data used to support the findings of this study are available from the corresponding author upon request

Competing interests

The authors declare that they have no conflicts of interest

Funding

Not applicable.

Author contributions

C.G: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing – original draft

H.Z: Conceptualization, Formal analysis, Methodology, Resources, Software, Visualization, Writing and original draft

Acknowledgements

The authors would like to express their gratitude to respective health facility, data collectors, supervisors and study participants for their diligence and dedication in the collecting and inputting high quality data used in the study.