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

Integrating family planning (FP) services into non-FP care visits is an important approach to reduce maternal and newborn deaths through reduction of short birth intervals and unplanned pregnancies. Analyses of matched interviews with 1505 clients and 330 providers in Kigoma Region, Tanzania identified key factors for clients receiving FP information and a modern method. Clients were more likely to receive FP information if they were at the facility for pregnancy loss, had four or more pregnancies, and had discussed FP with their partner. Clients were less likely to receive FP information if they were 40 to 49 years old and attended religious services at least weekly. Providers were more likely to provide FP information if they perceived in-service training had helped their job performance, and had received more recent FP training. Clients were more likely to receive a FP method if they received information on two or more FP methods, had discussed FP with their partner, were at the facility for pregnancy loss, had no live births, made their own FP decisions, received FP information from two or more sources, and were in the middle or high wealth groups. Well-baby care clients, Other services clients, and married clients were less likely to receive a FP method compared to others. FP services need to be better integrated into well-baby and other routine outpatient services. Interventions are needed that encourage women to have FP conversations with their partners and providers, expand FP options and sources of information, and encourage providers to ask about reproductive health goals at each client encounter.

Sub-Saharan Africa experiences disproportionately high maternal mortality in comparison to other regions, contributing to two-thirds of the world’s total maternal deaths in 2015 [1]. Tanzania had an estimated 8200 maternal deaths in 2015, the fourth highest number of maternal deaths in sub-Saharan Africa and the sixth highest number in the world [1]. Family planning (FP) can reduce the risk of maternal and neonatal mortality by reducing the number of short birth intervals, as well as unplanned and high-risk pregnancies [2‐7]. In 2016, the total fertility rate (TFR) in Tanzania’s Western Zone, which includes Kigoma Region, was 6.7 births per woman – the highest TFR in all of Tanzania [8].

Research in Western and African clinical settings has found that quality FP counseling—identified as six distinct elements by the Bruce Framework [9]—has a significant impact on FP knowledge and use [10, 11]. To increase postpartum FP uptake and reduce unmet need, FP counseling and provision are routinely recommended for integration into antenatal, labor and delivery, and postnatal care services [12‐17]. However, evidence varies on whether the increase in FP use relates to the type of care services in which FP services are being integrated [13, 23, 27], number of times counseling is provided [17‐20], whether the FP counseling is provided during the antenatal versus postpartum period [15, 17‐21], and whether modern contraceptive supplies are available at the time/onsite. Moreover, some studies have found positive effects while others have found no effect [16, 21, 22].

Furthermore, many factors may influence FP uptake even when services are integrated. Necessary infrastructure improvements, increased staff resources, and availability of FP supplies rarely accompany the integration of FP services into other health services [14, 19]. Long wait times, unclear pathways to FP providers, and lack of privacy deter women from accepting a FP referral [23]. In health facility assessments in Kigoma Region, Tanzania in 2015, only 57% of dispensaries had implants and only 39% had intrauterine devices (IUD) available to clients [24].

Client and provider data were linked. Due to the focus of this study on FP integration into non-FP services, FP clients (n = 214), current FP users (n = 128), and providers who only gave care to FP clients (n = 38), were excluded from analyses. ANC (n = 225) and other pregnant clients (n = 40) were also excluded due to lack of data on desire for future childbearing and FP decision-making.

Data analyses were conducted using Stata 14. Bivariate analyses were conducted to identify client and provider variables associated with the outcome variables of interest. Client and provider variables with an unadjusted association with the outcomes of interest at a level of p < 0.10 were included in multivariate modeling. A multilevel mixed-effects logistic regression model was used to examine the effects of patient and provider characteristics on either receipt of FP information or receipt of a modern FP method, with random intercepts for each provider. A p-value of less than 0.05 was considered statistically significant for multilevel models. We included facility-clustered standard errors to account for unobserved heterogeneity within facilities.

From April 30–July 1, 2016, 2155 female clients (delivery n = 960, PL n = 230, outpatient n = 965 [inclusive of antenatal, postnatal care, HIV testing and management, STI, and other) and 361 providers were interviewed. Following removal of data from non-linked clients and providers, FP clients, pregnant clients, and current FP users, data from 1505 clients (primary reasons for visit: delivery n = 935, PL n = 229, well-baby n = 272, other routine services n = 69) and 330 providers (clinicians n = 69, nurses/midwives n = 176, other staff n = 85) were used in the analysis.

Integrating FP service provision into other types of healthcare visits can provide an important opportunity to reduce the unmet need for FP and ultimately lower maternal and neonatal mortality. We sought to understand the factors that predicted receipt of FP information and a modern FP method among women attending maternal, child, and reproductive health care services in Kigoma, Tanzania. The results demonstrate the association between the receipt of FP information with both the client and provider characteristics, while receipt of a modern FP method is associated with only client factors. This information will help inform FP training and programming in Kigoma, Tanzania.

First, level of FP integration is not consistent across non-FP care types. Unlike results from a study in Senegal, which found low receipt of FP information among PL clients compared to clients of other care types [16], our study found that women who sought PL services had nearly two times greater odds of receiving FP information and more than four times greater odds of receiving a modern method compared to women seeking other types of services. In contrast, women who sought well-baby care services and other routine care services had 86 and 92% lower odds of receiving a modern FP method, respectively.

Women’s self-efficacy, assessed with questions about past FP discussions with partner and ability to make one’s own FP decisions, was strongly associated with receipt of information and modern FP methods. Women who reported past FP discussions with their partner as compared with those who did not had nearly two times greater odds of receiving FP information and more than five times greater odds of receiving a FP method. In addition, women who reported the ability to make their own FP decisions had three times greater odds of receiving a method compared to women unable to make their own decisions. These results align with previous studies in India, Senegal, and Turkey, which also found that that partner communication [16, 25] and self-efficacy [20] are positively associated with FP uptake. These findings suggest that women who have had conversations with their FP partners and/or feel they can make their own decisions may be initiating FP conversations with providers, thereby driving the receipt of information and a method during a care visit.

The quantity of FP information received at the visit, including the number of methods information was received about and the number of sources information came from, was strongly associated with FP method receipt. Women who received FP information about two or more methods had seven times greater odds of receiving a contraceptive method compared to women who received FP information about one or zero methods. Similarly, women who received FP information from two or more sources had nearly three times greater odds of receiving a method compared to women who received FP information from one or zero sources. These findings may inform elements of counseling in clinical practice.

Additional demographic characteristics, including parity, marital status, religiosity, and wealth, were also associated with receipt of FP information and modern FP methods. Women with four or more live births had nearly two times greater odds of receiving FP information compared to women with three or fewer live births. One possible explanation for this is providers’ perceptions of women’s eligibility for receiving methods. A study on provider-imposed barriers to family planning in Kenya found that women’s parity influenced providers’ method offerings; specifically, providers reported to impose FP method restrictions on women without children [7]. However, we found that women reporting having no children born alive had nearly four times greater odds of receiving a FP method. This finding may represent a desire to postpone childbearing. Specifically, among this sub-group of clients with no live births, a comparatively higher proportion were teenagers (38.1% vs 13.6%), unwed (25.6% vs 8.9%), and seeking PL care (93.0% vs 13.0%) compared to those with live births. We also found that women with no live births were not more likely to receive FP information, suggesting that this sub-group of clients were driving the requests for receipt of FP methods.

Women who reported more frequent attendance at religious services had 39% lower odds of receiving FP information compared to women with less frequent attendance. This finding suggests that religiosity either influences women’s request for FP information or influences provider’s perception of client interest in FP. Women in the middle and high wealth categories had two and two and a half times greater odds of receiving a FP method, respectively. This finding aligns with previous findings that poorer women receiving FP counseling and education have lower uptake of FP methods [12]. Given that FP is available at no cost to women in Tanzania, this difference may reflect an inverse relationship between future fertility preferences and wealth. Alternatively, this finding might suggest a provider’s bias in offering modern methods to wealthier clients.

Recent in-service training and positive perceptions of in-service training as a whole among providers were important factors for client receipt of FP information. Other studies have found that a greater proportion of providers without in-service FP training imposed parity, age, marital, and other restrictions on provision of FP methods [7, 29, 36, 37]. In our study, clients of providers who had recent in-service training on a higher number of FP topics had one and a half times greater odds of receiving FP information at their visit compared to clients of providers who had recent in-service training on a lower number of FP topics. Similarly, clients of providers who reported that in-service training has helped their job performance had more than two times greater odds of receiving FP information compared clients of providers who reported in-service training has not helped. While we found that provider factors were important for client’s receipt of FP information, provider factors were not predictive of client’s receipt of a FP method. This suggests that client’s desire for adopting a modern method expressed during non-FP visits may be the primary driver of receiving FP methods.

Findings from this study corroborate evidence that women’s self-efficacy in FP decision-making [20], women’s specific demographic characteristics (e.g., religiosity, wealth) [12], and providers’ in-service training [7, 29] influence women’s odds of receiving a FP method. This study adds new evidence pertaining to important elements of FP counseling and receipt of a method—namely, the quantity of FP information received at a single care visit (e.g., number of methods described, number of sources of FP information). While many studies address factors associated with receipt of FP methods, this study also adds new insight into factors associated with receipt of FP information, including provider characteristics related to the timing FP in-service training, partner communication, high parity, older age, and lack of religiosity.

Despite much evidence establishing the salient role of FP counseling to improve reproductive health outcomes, there is less consensus about the relative impact of client or provider attributes on the receipt of FP information or a modern method. We address the question of whether including both client and provider characteristics adds predictive value when analyzing the risk of FP integration or uptake. Our findings demonstrate that both client and provider factors significantly influence FP integration. Improved understanding of the interplay between clients and providers is critical for the effective provision of FP services and should be considered in the design of reproductive health policies and future data collection exercises.