Nirali M. Chakraborty

Decades of progress in global sexual and reproductive health programming and data availability are threatened as over 80% of donor funding for family planning (FP) comes from governments that have announced significant cuts to Official Development Assistance. This commentary examines how FP2030 is adapting its Measurement Framework and annual reporting given uncertainty around the future of household surveys, such as the Demographic and Health Survey, and the loss of technical resources. FP2030 will pivot from reporting on 22 indicators to a “minimum set” of 15 priority indicators. FP2030 arrived at these recommendations through consensus built during a series of working meetings with its Performance Monitoring and Evidence Working Group (PME WG), a group of FP measurement experts. The 15 indicators leverage existing mathematical models and health management information systems (HMIS). Moreover, this commentary provides a complementary set of indicators that should be prioritized if new data collection opportunities arise. Ultimately, while FP2030 and the PME WG believe that models and HMIS data will become more essential, these tools cannot fully replace household surveys. Continued investment in FP data availability remains critical to ensuring the community can review data that protects the rights and needs of individuals through current programming.

Objectives: To evaluate and compare self-managed abortion (SMA) user-reported quality of care between users accessing a safe abortion hotline versus proprietary patent medicine vendors (PPMVs) that provide medicines to rural communities in Nigeria, and identify factors associated with increases in total quality scores and key indicators of abortion access and information provision. Methods: We leveraged exit surveys and 30-day follow-up data collected from users of a safe abortion hotline and PPMVs in Nigeria used to develop the Abortion Care Quality Tool (ACQTool). We used bivariate statistics to compare 17 user-reported quality indicators across six domains and eight abortion outcomes, by care source (hotline vs PPMV). We used multivariable linear regression to identify factors associated with total quality scores and multivariable logistic regression to identify factors associated with abortion affordability and preparedness for a complication, controlling for user sociodemographic characteristics. Results: Hotline users (n=182; 40.8%) scored higher than PPMV users (n=264; 59.2%) on 9 of 17 quality indicators, particularly in the decision-making and information provision domains. Mean total quality score was significantly higher for hotline users (16.53 vs 14.53; p<0.001). Hotline users were associated with an increase of 1.87 points in the total quality and higher odds (aOR=3.23; 95% CI 1.07 to 12.02) of feeling prepared if a complication occurred, but had lower odds (aOR=0.10; 95% CI 0.05 to 0.21) of indicating the abortion was affordable, adjusting for sociodemographic factors. Conclusions: This study highlights the high overall quality of abortion care from both hotlines and PPMVs but identifies key areas for improvement, such as affordability for hotline users and decision and information support for PPMV users.

Objective We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. Methods We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. Results Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). Conclusions In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

Measurement of the quality of abortion services is essential to service improvement. Currently, its measurement is not standardized, and some of the tools which exist are very long, and may deter use. To address this issue, this study describes a process used to create a new, more concise measure of abortion care quality, which was done with the end users in mind. Using a collaborative approach and engaging numerous stakeholders, we developed an approach to defining and selecting a set of indicators, to be tested against abortion outcomes of interest. Indicators were solicited from 12 abortion service provision entities, cataloged, and grouped within a theoretical framework. A resource group of over 40 participants was engaged through surveys, webinars, and one in-person meeting to provide input in prioritizing the indicators. We began with a list of over 1,000 measures, and engaged stakeholders to reduce the list to 72 indicators for testing. These indicators were supplemented with an additional 39 indicators drawn from qualitative research with clients, in order to ensure the client perspective is well represented. The selected indicators can be applied in pharmacies, facilities, or with hotlines, and for clients of surgical or medical abortion services in all countries. To ensure that the final suggested measures are most impactful for service providers, indicators will be tested against outcomes from 2,000 abortion clients in three countries. Those indicators which are well correlated with outcomes will be prioritized.

Purpose: Poor privacy and confidentiality practices and provider bias are believed to compromise adolescent and young adult sexual and reproductive health service quality. The results of focus group discussions with global youth leaders and sexual and reproductive health implementing organizations indicated that poor privacy and confidentiality practices and provider bias serve as key barriers to care access for the youth. Methods: A narrative review was conducted to describe how poor privacy and confidentiality practices and provider bias impose barriers on young people seeking sexual and reproductive health services and to examine how point of service evaluations have assessed these factors. Results: 4544 peer-reviewed publications were screened, of which 95 met the inclusion criteria. To these articles, another 16 grey literature documents were included, resulting in a total of 111 documents included in the review. Conclusion: Poor privacy and confidentiality practices and provider bias represent significant barriers for young people seeking sexual and reproductive health services across diverse geographic and sociocultural contexts. The authors found that present evaluation methods do not appropriately account for the importance of these factors and that new performance improvement indicators are needed.

Background: Studies in the literature have found mixed results on the effect of microcredit on health outcomes. Of the five previous experimental studies that included microcredit and a health intervention, three reported no significant changes in health status or behaviors. The purpose of this study was to test for marginal and interactive effects of increased microcredit and provision of basic health services. Methods: This study had a 4-celled experimental design in 128 villages in rural Bangladesh. For villages in one cell, an additional microcredit worker was assigned. For those in a second cell, a health assistant visited households each month, provided simple medicines and announced a satellite clinic held monthly in each village. For a third cell, both interventions were combined, and villages in a fourth cell served as control. A baseline survey was completed and a follow-up survey was done three years later. Outcome measures were food security, contraceptive use, having a trained birth attendant at last birth, and measles immunization. Results: Comparison of follow-up with baseline levels of the four outcome measures (for 3787 households (96% completeness) and 3687 women (94% completeness)) showed significant improvement in food security in all study arms and a significant increase in trained birth attendant at last birth in the health services villages. Due to confusion within Grameen Bank about which workers would provide the additional microcredit work, that intervention was poorly implemented so in multivariate analyses, the data for that intervention arm were grouped with data from the control arm. Logistic regression with values of the outcomes at follow-up as dependent variable and study arm and women’s schooling as covariates showed no significant effects of either separate or grouped study arms. Conclusion: Two of the three health behaviors showed no significant changes over time but having a trained birth attendant at last delivery did increase significantly in the health services arm. Therefore, community health education can sometimes be effective in promoting healthy behaviors. Trial registration: This was a field trial rather than a clinical trial, so trial registration was unnecessary.

Background: The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation. Methods: We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception. Results: The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (P<.001). In Uganda, an increase in the management support domain was associated with a 33% reduction in discontinuation risk, controlling for age and baseline method (P=.005). Conclusions: We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all.

Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low- and middle-income countries. Recent guidance from WHO and others has pro...

BackgroundStudies in the literature have found mixed results on the effect of microcredit on health outcomes. Of the five previous experimental studies that included microcredit and a health intervention, three reported no significant changes in health status or behaviors.MethodsThis study consisted of a 4-celled experimental design in 128 villages in rural Bangladesh to test for marginal and interactive effects of increased microcredit and provision of basic health services. For villages in one cell, an additional microcredit worker was assigned. For those in a second cell, a Health Assistant visited households each month, provided simple medicines and announced a satellite clinic held monthly in each village. For a third cell, both interventions were combined, and villages in a fourth cell served as control. Baseline questionnaires were completed with a sample of 3933 women (98.7% completed) and, three years later, attempts were made to re-interview the same women (93.7% completed). Outcome measures were food security, contraceptive use, having a trained birth attendant at last birth, and measles immunization. ResultsComparison of follow-up with baseline levels of the four outcome measures showed significant improvement in food security in all study arms and a significant increase in trained birth attendant at last birth in the health services villages. Due to confusion within Grameen Bank about which workers would provide the additional microcredit work, that intervention was poorly implemented so in mulitivariate analyses, the data for that intervention arm were grouped with data from the control arm. Logistic regression with values of the outcomes at follow-up as dependent variable and study arm and women’s schooling as covariates (women’s schooling was the one covariate that was not balanced across study arms) showed no significant effects of either separate or grouped study arms. ConclusionTwo of the three health behaviors showed no significant changes over time but having a trained birth attendant at last delivery did increase significantly in the health services arm. Therefore community health education can sometimes be effective in promoting healthy behaviors.

Introduction: Several measures to assess family planning service quality (FPQ) exist, yet there is limited evidence on their association with contraceptive discontinuation. Using data from the Measurement, Learning & Evaluation (MLE) Project, this study investigates the association between FPQ and discontinuation-while-in-need without switching in five cities in Kenya. Two measures of FPQ are examined – the Method Information Index (MII) and a comprehensive service delivery point (SDP) assessment rooted in the Bruce Framework for FPQ. Methods: Three models were constructed: two to assess MII reported in household interviews (as an ordinal and binary variable) among 1,033 FP users, and one for facility-level quality domains among 938 FP users who could be linked to a facility type included in the SDP assessment. Cox proportional hazards ratios were estimated where the event of interest was discontinuation-while-in-need without switching. Facility-level FPQ domains were identified using exploratory factor analysis (EFA) using SDP assessment data from 124 facilities. Results: A woman’s likelihood of discontinuation-while-in-need was approximately halved whether she was informed of one aspect of MII (HR: 0.45, p < 0.05), or all three (HR: 0.51, p < 0.01) versus receiving no information, when MII was assessed as an ordinal variable. Six facility-level quality domains were identified in EFA. Higher scores in information exchange, privacy, autonomy & dignity and technical competence were associated with a reduced risk of discontinuation-while-in-need (p < 0.05). Conclusions: The MII has potential as an actionable metric for FPQ monitoring at the health facility level. Furthermore, family planning facilities and programs should emphasize information provision and client-centered approaches to care alongside technical competence in the provision of FP care.