By Moses, T; Sampou,
WD (2023).
|
Greener Journal of
Medical Sciences Vol. 13(1), pp. 53-60,
2023 ISSN: 2276-7797 Copyright ©2023, the
copyright of this article is retained by the author(s) |
|
Quality
and Utilization of Family Planning Services in Africa; a Systematic Review and
Meta-Analysis
Department of
Preventive and Social Medicine, University of Port Harcourt.
BACKGROUND
Ensuring
access to family planning services is critical to enhancing health, human
rights, and economic development (Speidel, Thompson
& Harper, 2014). However, in 2013, over 289,000 women died in
underdeveloped nations, mainly in Africa (World Health Organization, 2014).
Studies reveal that family planning programs might have prevented up to 40% of
maternal fatalities (Ahmed, Li, Liu & Tsui,
2012). Globally, 64% of married or in-union women of reproductive age used
contraception, while just 33% of these women used contraceptives in Africa
(United Nations Department of Economic and Social Affairs Population Division,
2015). Globally, 225 million women seek to avoid pregnancy but do not use safe
and effective techniques (Darroch & Singh, 2013),
which resulted in unmet needs for contraception.
Studies have shown that the majority of women in low-and-middle-income
countries have unmet needs for contraception (Darroch
& Singh,2013). The unmet requirement is
attributable to population growth and a lack of family planning services
(UNFPA, 2014). As a result, boosting access to family planning services is a
global public health priority. Several worldwide collaborations, including the
International Conference of Population and
Development in 1994 (Cohen & Richards, 1994), the Millennium Development
Goal summit in 2000 (USAID, 2009), and the London Summit on Family Planning in
2012, approved Family Planning 2020 (FP2020).
By 2020, this alliance hopes to reach 120 million additional women and
girls in 69 of the world's poorest countries (Brown, Druce,
Bunting, Radloff, Koroma
& Gupta, 2014). Improving the quality of care in family planning services
is critical to increasing the utilization of family planning services in
developing countries (Arends-Kuennin & Kessy, 2007). It is vital to provide decision-makers in
developing countries, especially in Africa, with the best available information
on the factors that impact the quality of treatment in family planning services
from both the client and provider perspectives. Family planning services
include infertility treatment, STD screening, and treatment, pregnancy testing,
and counseling, assisting clients who want to conceive and providing
preconception health services outside of contraceptive provision (Gavin, Moskosk, Carter, Curtis, Glass, & Godfrey, 2014). The
condition or prescription of contraceptive methods after women get
contraception counselling to help postpone or prevent pregnancy (Wang et al., 2014) focused on earlier research assessing the
quality of treatment in family planning clinics. According to a study on the
quality of care in family planning services, different people have different
ideas about defining and measuring the quality of care and its factors (Conry, Humphries, Morgan, McGowan, and Montgomery, 2012).
Concept
of Family Planning
The World Health Organization (WHO,
2008) defined family planning as the ability of individuals and couples to
anticipate and attain their desired number of children, spacing, and timing of
their births through contraceptive methods and treatment of involuntary
infertility.
Family
planning can be considered as a program designed to regulate the number and
spacing of children in a family through the appropriate use and practice of
modern contraceptives or other methods of birth control.
Historically,
Family planning is known to have been practiced for centuries long before the
advent of modern methods of contraception. The earlier methods used by men and
women to regulate their fertility included coitus interruptus
(withdrawal of the penis from the vagina before ejaculation), abstinence
(abstaining from sex altogether or around the time of ovulation), herbs, and
amulets (Planned Parenthood Federation of America, 2006). The condom appeared
in the 17th century. Modern methods of family planning have a more recent
history since about 1960 when both the oral contraceptive pill and the
intrauterine device became available.
Benefits
of Family Planning
Historically, family planning has
served the purse of preventing unwanted pregnancy and sometimes ensuring
appropriate timing or spacing of births among couples. In recent times, family
planning has served the purpose of preventing the transmission of sexually
transmitted infections in addition to preventing the complications of unwanted
pregnancy and even sexually transmitted infections that could result in
secondary infertility. Cases of obstetric complications from abortion from
unwanted pregnancies are also prevented (WHO, 1994; WHO, 2016). Other benefits
of family planning, according to Habumuremyi and Zenawi (2012) include the promotion of maternal and child
health, promoting human rights, and ensuring sustainable and economically
viable population and national development in addition to environmental
sustainability. The aforementioned benefits are discussed herein:
Maternal
and Child Health
Improvement of maternal and child
health is often cited as one of the reasons for family planning, especially in
highly populated nations with a high burden of maternal, newborn, and child
morbidity and mortality (Seltzer, 2002). Ross and Smith (2011) stated that
improvements in maternal health have been the main reason for support and
implementation of family planning programs since 1972. This trend is currently
the focus of current obstetric practice that has associated grand multiparity with the poor maternal outcome. Family planning
gives women a voice and the necessary autonomy in the decision-making process
for them to pursue their careers and live endeavors that could be constrained
by unwanted pregnancies or pregnancies. For low and middle-income countries
like Nigeria, contraceptives are an effective primary prevention strategy
against maternal and child deaths (Ahmed et al., 2021). This is because the
high fertility rates of some of these low and middle-income countries with
existing weak health systems do not guarantee successful delivery of women with
poorly spaced children or grand multiparity, which is
associated with maternal death. Ross and Blanc (2012), noted that an estimated
1.7 million fewer maternal deaths have been averted as a result of an increase
in contraceptive use from 1990 to 2008. They observed that improved family
planning utilization resulted in a reduction in fertility rates of women of the
reproductive age group which brought about a 53% decline in maternal mortality
and a 47% lower maternal mortality rate per birth during the review period. Unwanted
pregnancies are often the reasons for abortions among young women. Often,
abortions are carried out in poor conditions by quacks which have consequences
of maternal morbidity and mortality following complications such as sepsis and
hemorrhage. This outcome can be prevented by the use of appropriate family
planning methods such as condoms and emergency contraceptives that prevents
pregnancy and sexually transmitted infections if properly used.
Rutstein et al., (2008) noted that family
planning has a significant effect on child health. Evidence from Demographic
Health Surveys of 52 countries showed that children born within two years of a
previous birth have a 60 percent increased risk of infant death, and those within
two to three years have a 10 percent increased risk of infant death, compared
with children born after an interval of three or more years from the last
sibling. This implies that the more spaced children are, the less the
likelihood of infant mortality. The burden of malnutrition is highest among
children who are poorly spaced as seen in low and middle income where
malnutrition continues to account for almost 50% of childhood mortality.
Well-spaced children often benefit from exclusive breastfeeding, appropriate
complementary feeding, and child care practices that ensure improved immunity
of the child and bonding between mother and child for a healthy life. The
absence of family planning or its practices can therefore adversely affect the
health of maternal, newborns, and child health. There is therefore needs to
promote family planning as a means of improved maternal and child health
outcome which is beneficial to the family and prevents them from the cycle of
poverty.
Population
and Development
In the 1960s, following concerns on
rapid population growth and a possible population explosion which could
adversely affect the economic growth and development of societies mostly in
low- and middle-income countries with poor governance and leadership, poor economy,
poverty and lack of means of livelihood for improved wellbeing of citizens was
a concern Birdsall, et al 2001; Bongaarts
et al., 2012). It was observed that this rationale for family planning while it
was supported by some governments, was out of favor with
other governments in developing nations. Even though this rationale is resisted
or misinterpreted in some corners, recent evidence clearly shows the positive
relationship between slower population and sustained population growth and
economic development of a nation with those rapid growing and unplanned nations
faltering in economic development. This trend is noted at least at the initial
phase of the demographic transition when countries enjoy a demographic dividend
if other economic and human capital policies are constant. The demographic
dividend allows countries to take advantage of a beneficial dependency ratio
between the working-age population and those who need support, such as children
and the elderly (Bloom, Canning, and Sevilla 2003).
Rapidly growing economics is characterized by supportive economic policies and
labor laws that a nation enjoys from the potential benefits of a carefully
planned and well-controlled demography that encourages judicious and
sustainable use of the available natural resources. Sub-Saharan African
countries and those in Asia that are struggling with their economies and
maternal and child health burdens need to coordinate the development of their
economies through effective reproductive health policies which will fully
benefit from the dividend of family planning that empowers women and couples to
lead a productive life and contribute to the growth and development of the
nation. Also, through proper planning and youth empowerment programs, the high
population growth could be harnessed for improved productivity of the available
workforce in the nation. However, insecurity in most low and middle-income
countries and lack of job opportunities, and an uncontrolled population will
spell doom for these countries where humanitarian crises are caused by a poorly
planned economy that often disallows women and couples to benefit from the
dividends of family planning utilization.
Human
Rights and Equity
Reproductive health including family
planning is a fundamental human right that is often abused in many low and
middle-income countries. According to the United Nations (1968), couples and
individuals have the right to decide freely and responsibly on the number and
spacing of their children. Subsequent international population conferences in 1974, 1984,
and 1994 reaffirmed this right upon which most policies are based (Singh 2009).
The human rights rationale has focused on sexual reproductive health and
rights, with family planning implicitly included. Hardee et al (2014) opined that
efforts are underway to more explicitly define a rights-based approach to
implementing voluntary family planning programs. Gillespie et al (2007), In
their study of 41 countries, noted that although variations were observed among
countries, the number of unwanted births in the poorest quintile was more than
twice that in the wealthiest quintile, at 1.2 and 0.5, respectively. This
explicitly explains the gap within and across countries and the need for equity
in promoting family planning services.
Environmental
Sustainability and Development
One of the major challenges in recent
times that has adversely affected several countries is
climate change. Climate change has greatly affected soil fertility and the
atmosphere such that once previously very fertile soils now require the
addition of fertilizers to ensure high yield from crops. This practice in
addition to deforestation is known to further degrade the environment which
affects the sustainable growth and development of a population. The devastating
effect of climate change has resulted in food insecurity in many countries
across the globe (Martine and Schensul 2013; Moreland
and Smith 2012). Whether the future demographic trends work
for or against sustainable development, will depend on policies that are put in
place today (UNFPA 2013, 5). The need to ensure sustainable growth in a
period characterized by climate change and pandemics like Covid-19 becomes
eminent. This can be achieved through appropriate family planning practices.
Family
Planning Utilization Factors
All seven studies discovered distinct factors
influencing the quality of treatment in seven African nations' family planning
programs. Client frequency of use and other socioeconomic characteristics are
connected with the quality of family planning utilization. These criteria were
connected to client demographics, the provider participating in family planning
client provision, and the general features of the health facilities in terms of
location and ownership.
Three research (Agha, 2009, Wogu et al,
2020, and Fantahun, 2005) found that the client's age
was related to client satisfaction. However, the influence of age was
inconsistent, as (Assaf, 2015) discovered that young
customers were less likely to be happy with family planning services, but Agha
et al. discovered that young clients were more likely to be satisfied than
their older counterparts. Another study (Lukymazi et
al, 2021) discovered no statistically significant relationship between client
age and client satisfaction. Three studies discovered a substantial
relationship between a client's educational status and the quality of in-person
family planning services usage (Agha, 2009, Wogu et
al, 2020 Fantahun, 2005). In the trials, clients with
higher educational levels were found as being more likely to be happy with the
quality. According to one study, repeat family planning clients were happier
with the service than first-time consumers (Tafase et
al, 2013). In terms of provider factors, the provider's years of education and
number of years of experience were both strongly related to client satisfaction
with family planning services (Hong et al, 2006).
METHODS
This study
was conducted by best practice recommendations for conducting a systematic
review of quantitative and qualitative data. The review was conducted by a
published methodology and by the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA reporting standards) developed by the
Institute of Medicine.
Inclusion and Exclusion Criteria
Exclusion
Criteria
All studies published in another
language and articles that do not have a full text or abstract were be excluded.
Inclusion
Criteria
In
this study, we looked at 7 quantitative African studies of all design types
that were published in peer-reviewed journals and grey literature between the
years 2000 and 2022.
The participants in the research were individuals who
had used or were in the process of using family planning services. It was
decided to examine consumers and providers of various ages and socio-economic
backgrounds, as well as clients and providers from all ethnic and linguistic
groups throughout Africa. All levels (lower levels such as health posts, or
higher levels such as tertiary hospitals) and types (public or private) of
health service facility types in Africa were taken into consideration. Family
planning services were defined as the provision or prescription of
contraceptive methods after women have received contraception counseling to assist them in delaying or preventing
pregnancies, according to the definition. A particular area of concern for the
quantitative component of the review was exposure to characteristics that were
associated with the quality of care provided in family planning services. When
a study found a statistically significant link between the exposure
(independent variable) and the outcome (dependent variable), the exposure
factor was determined. Studies that looked into aspects such as facility,
client, and provider characteristics that were connected with the quality of
care in family planning services in Africa were taken into consideration for
inclusion.
Data Extraction
Data
was gathered from qualifying articles using a data extraction form that had
been piloted previously. From the pooled studies, data on place/location,
sample size, the purpose of study, research design, study constraints, and use
of family planning were extracted at the study level, as well as data on
overall family planning use. The researchers followed the recommendations for
methodological scope for systematic reviews or meta-analyses of observational
studies. Double entries were removed from the database, and the entire text of
all papers that met the initial inclusion criteria was acquired. Both the
researcher and the supervisor separately collected data using a pre-piloted
electronic data extraction form that had been standardized and pre-tested. A
consensus was reached between the assessors to reconcile differences in data
abstraction. Researchers looked at the validity and reliability of research
measures, the methodological quality of the study, the population and
recruitment strategy, and the quality of the research design.
Search
strategy and data sources
Using Google
Scholar and Science Direct, a systematic search was conducted for relevant literature for our investigation.
Researchers searched the internet for research studies on the quality and
utilization of family planning services to identify promising findings. The
studies were thoroughly reviewed to ensure that they met the inclusion
requirements for this study, which allowed for the collection of high-quality
data for analysis.
Quality
Assessment
The potential for bias within each
study was assessed using the Cochrane Methodological Quality Assessment of
Studies. Discrepancies in the estimated level of bias by consensus were
resolved and a final assessment of the probability of bias for each study was
reported. A detailed description of bias analysis was included in the
Systematic Review (This quality assessment is as proposed by the Cochrane
Methodological Quality Assessment of Observational Studies).
Data
Synthesis
The analysis of Quality
and Utilization of Family Planning Services that was employed for this meta-analysis and systematic
review was proportion, correlation, odds ratio, and standard error or 95%
confidence interval from each study. The results from an individual study
showing the association between Family Planning Utilization and
womens perception of usage quality
were pooled. The meta-analysis was performed by reporting the proportion, odds
ratio, and standard error for each of the papers reviewed. Forest plots were also used to
summarize pooled estimates. All analyses were done using Stata
16 (64 bit)
statistical software.
RESULTS
Table 1: Overview of included studies
and quality ratings
|
First author and year of publication |
Country and participants |
Year o study |
Data used |
Odds ratio
and Confidence Interval |
Methods |
Quality rating* |
|
Agha, 2009 |
Kenya |
2009 |
2004 Kenya Service Provision
Assessment
Survey |
1.8 (1.36 - 2.24) |
Quantitative |
6 |
|
Assaf, 2015 |
Senegal |
2015 |
20122013 Senegal Service Provision Assessment
survey |
3.7 (3.66 - 3.74) |
Quantitative |
6 |
|
Tafese
et al, 2013 |
Ethiopia |
2013 |
Primary data |
0.2 (0.15-0.29) |
Quantitative |
6 |
|
Hong et al, 2006 |
Egypt |
2006 |
Demographic and Health Survey |
1.36 (1.34 -1.38) |
Quantitative |
6 |
|
Lukyamzi
et al, 2021 |
Uganda |
2021 |
Primary Data |
2.21 (1.72 -4.52) |
Quantitative |
6 |
|
Wogu
et al, 2020 |
Ethiopia |
2020 |
Primary Data |
3.14 (1.02 -9.79) |
Quantitative |
6 |
|
Fantahun, 2005 |
Ethiopia |
2005 |
Primary Data |
10.7 (2.4 - 66.4) |
Quantitative |
6 |
*The quality rating score was calculated
by awarding 1 point for each of the criteria.
Table 2:
Effect size and Confidence intervals of studies
|
|
|
95% Confidence Interval |
|
|
|
Study |
Effect size |
Lower Boundary |
Upper Boundary |
Weights |
|
Agha (2009) |
1.800 |
1.360 |
2.240 |
0.15 |
|
Assaf (2015) |
3.700 |
3.660 |
3.740 |
18.74 |
|
Tafese
et al (2013) |
0.200 |
0.150 |
0.290 |
6.12 |
|
Hong et al (2006) |
1.360 |
1.340 |
1.380 |
74.97 |
|
Lukyamzi
et al (2021) |
2.210 |
1.720 |
4.520 |
0.02 |
|
Wogu
et al (2020) |
3.140 |
1.020 |
9.790 |
0.00 |
|
Fantahun (2005) |
10.700 |
2.400 |
22.400 |
0.00 |
|
|
|
|
|
|
|
I-V pooled
Effect Size |
0.148 |
0.147 |
0.148 |
100.00 |
|
Heterogeneity
chi-squared |
12471.7
(d.f. = 6) p = 0.000 |
|
||
|
I-squared |
100.0% |
|
|
|
|
Test of
ES=0 |
z=
195.631
p = 0.000 |
|
|
|
Figure 1:
Forest Plot
DISCUSSION
Using a
systematic evaluation of mixed data, this study intended to provide
evidence-based knowledge of the factors that influence the quality of treatment
in African family planning services. A total of seven moderate to high-quality
studies conducted in numerous African nations were discovered and included to
help researchers better understand the factors that influence the quality of
care in family planning services in Africa. Only the quantitative component of
the study was utilized to assess the quality of care in African family planning
services. Client, provider, facility, structural, and process variables were
among them. The most often cited process elements in quantitative research were
the client's waiting time before obtaining services, provider competency,
supply of injectable techniques, and protection of privacy and confidentiality.
The most often cited structural component identified by quantitative data was
the quality of stock inventories. Furthermore, quantitative research identified
facility ownership type as an essential factor impacting the quality of
treatment in family planning services. Privately held facilities, in
particular, were associated with greater levels of client satisfaction than
publicly operated facilities. The synthesis findings reflected several criteria
identified by the quantitative research as critical determinants impacting the
quality of treatment in family planning services.
CONCLUSION
The
small size and variable character of the evidence base uncovered by this
analysis made it impossible to determine the factors most relevant in a wide
variety of African contexts for the provision of high-quality treatment in
family planning services in Africa. This limits health planners from developing
clear evidence-based recommendations for implementing interventions to improve
the quality of care in family planning services across all health settings in
Africa. Our results regarding the determinants determining the quality of
treatment in family planning services, on the other hand, provide some guidance
for health planners about which initiatives should be prioritized. First, the
positive relationship discovered between the quality of care and structural
factors related to the facility, such as proximity to clients' residence,
service costs, and the number of days in a week that the service is open,
indicates the need for planners to implement strategies that reduce these
access barriers. Subsidized or free treatment, outreach services,
clinic/hospital operating flexible hours, and transportation arrangements are
all possibilities. Second, the discovery that provider competency is a key
factor influencing the quality of care in family planning services shows that
investing in provider skills and enabling providers to offer care by best
practice is critical. Third, the discovery that providing information about
planning methods is an important factor in determining the quality of care
suggests that strategies to ensure that clients are provided with necessary
information about the various methods and their potential side effects are
important to support a high quality of care in family planning services.
Fourth, our review's findings indicate the necessity for planners to employ
measures to reduce client wait times while still ensuring client privacy and
confidentiality in family planning services.
Overall, the few, moderate to high-quality quantitative research on
factors influencing the quality of the utilization of family planning services
in Africa identified several parameters connected to client usage and sociodemographic features. As a result, increasing the
quality of care in African family planning programs necessitates several
initiatives that address these various concerns. More study is needed to
identify the major parameters linked with the quality of care in African
nations' family planning programs.
Conflict of Interest:
Author
have declared that there was no conflict of interest
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|
Cite this Article: Moses, T; Sampou, WD (2023). Quality and Utilization of Family
Planning Services in Africa; a Systematic Review and Meta-Analysis. Greener Journal of Medical Sciences,
13(1): 53-60. https://doi.org/10.5281/zenodo.7801952
|
