How well do perceptions of family planning service quality correspond to objective measures? Evidence from Tanzania.

This study examines the relationship between common objective measures of quality and perceptions of the quality of family planning facilities. Results of prior research indicate that such perceptions are an important determinant of contraceptive use in rural Tanzania. The data for this study are drawn from two surveys conducted in rural Tanzania. Three models are tested separately for women and for men. The important determinants of perceptions of quality among women and men are: perceived travel time to the facility, availability of immunizations, and availability of maternal and child health services. Additionally, the ratio of the number of staff to outpatients is important to men. The data explain a moderate amount of the variance in the quality measures, indicating that perceived quality is not fully predicted by common objective measures of quality. Future surveys of facility quality should develop objective measures to better predict the perceived quality, with the underlying goal of increasing contraceptive use.

The politics of population policy in the Islamic Republic of Iran.

The Islamic Republic of Iran arguably has one of the most successful family planning programs in the developing world. This success is all the more interesting for advocates of population programs because the political leaders of the Islamic regime were once strongly opposed to family planning. Indeed, after gaining power following the 1979 revolution, they were responsible for dismantling Iran's relatively new family planning program and introducing pronatalist policies. This article provides an account of the different phases of the population policy in Iran and examines the diverse elements that led politico-religious leaders to revise their views about fertility control and to participate in creating a workable family planning program. The complex formal and informal strategies that the political experts, the media, the religious authorities, and the government of the Islamic Republic adopted in order to achieve this about-face are described. The analysis is based on data collected by the first author during anthropological field research in 1993-96, by means of informal interviews with officials, with medical personnel, with family planning clients, and with religious leaders.

Way forward of the IP in Africa.

PIP: The guiding principle of the integrated project is its human centered approach, which considers reproductive health (RH) and family planning (FP) from the wider context of community needs. Central to this approach is the idea that RH/FP can best be promoted through priority community needs, emphasizing the empowerment of individuals to make informed choices through information, education and counseling. It is within this context that JOICFP worked to address the reproductive health and family planning challenges in sub-Saharan Africa. The article presents the issues identified in the program evaluation and the recommendations made for future program development at both country and regional levels.^ieng

Pregnancies averted among U.S. teenagers by the use of contraceptives.

CONTEXT: The personal and social costs associated with teenage pregnancy in the United States concern many policymakers and researchers, yet the role of contraception in preventing these pregnancies has not been adequately quantified. METHODS: Published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices in order to estimate the number of pregnancies averted through the use of contraceptives by U.S. teenagers. Four scenarios of contraceptives access--from current levels of access to highly restricted access--and teenagers' sexual and contraceptive practices in response to such restrictions are used to project the potential impact on pregnancies among teenagers. RESULTS: Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15-19-year-old women in the United States during 1995. If these young women had been denied access to both prescription and over-the-counter contraceptive methods, an estimated one million additional pregnancies (ranging from 750,000 to 1.25 million) would have occurred, assuming some decrease in sexual activity. These pregnancies would have led to 480,000 live births, 390,000 abortions, 120,000 miscarriages, 10,000 ectopic pregnancies and 37 maternal deaths. CONCLUSIONS: Contraceptive use by teenage women prevents pregnancies and negative pregnancy-related health consequences that can disrupt the lives of adolescent women and that have substantial societal costs. Continued and expanded access to contraceptives for adolescents is a critically important public health strategy.

PIP: An analysis of the number of adolescent pregnancies and pregnancy outcomes that are averted in the US each year by contraceptive use highlighted the importance of continued and expanded access on the part of young people to contraception. In this analysis, published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices among US teenagers. Four scenarios of contraceptive access--from current levels to highly restricted access--and sexual and fertility control practices in response to such restrictions were constructed. The 651 sexually active female adolescents enrolled in the national survey had used contraception during 80% of the times in which they were at risk of pregnancy. Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15- to 19-year-old US women in 1995. If these adolescents had been denied access to prescription and over-the-counter contraceptive methods, an estimated 750,000 to 1.25 million additional pregnancies would have occurred, assuming some decrease in sexual activity. These pregnancies would have resulted in 480,000 live births, 390,000 induced abortions, 120,000 miscarriages, 10,000 ectopic pregnancies, and 37 maternal deaths. The prevalence of adolescent sexual activity would have to decrease by 83% over current levels to avert the same number of pregnancies that are presently prevented by contraceptive use.

Population and development.

PIP: This article highlights improvements in China's population development, particularly in its family planning programs. China first realized the importance of family planning in 1962. 2 years later, a Family Planning Office was established under the State Council, which was upgraded into a Leading Group in 1973, and population began to be incorporated into national planning. In 1981, the State Family Planning Commission was established as a ministry-level organization directly under the State Council. In 1982, the government further defined its population policy as "controlling population growth and improving population quality.¿ Moreover, in the wake of the International Conference on Population Development in 1994 and the Fourth World Conference on Women in 1995, China has called for reorientations in family planning programs and in social regulations. This article also presents the efforts of the Chinese government to protect the country's environment and the employment of certain measures to facilitate population migration in response to the needs of the migrant population for family planning and health care.^ieng

Pilot program sheds light on improved services.

PIP: This article reports the success of the State Family Planning Commission in controlling China's population through the proposed "two reorientations" approaches: 1) to reorient from focusing on birth control alone to a combination of population control and socioeconomic development; 2) to reorient from administrative measures only to a combination of economic, as well as administrative measures, publicity, services and management. Six counties (districts) were designated as the first group of localities experimenting with quality of care in family planning in 1995. Over the past 4 years, the group achieved encouraging results in improving management of and services in family planning, particularly in areas such as reproductive health, protection of women and children's interests and reduction of fertility rate. As a result, more than 600 counties (districts) nationwide have joined the pilot program by October 1999. In addition, the initiative has drawn widespread support from the international community. These organizations include the Ford Foundation, the Population Council and the University of Michigan. Consequently, the outside world has gained a better understanding of the family planning program in China.^ieng

QoC program institutes major change in FP work.

PIP: This article presents the results of a survey conducted in 1998 evaluating the effectiveness of the Quality of Care (QoC) program initiated in China. This program was part of the State Family Planning Commission strategy adopted by China in 1995 to advance its family planning program. Members of an assessment team visited the pilot counties (districts) and interviewed a total of 1021 service recipients, technical personnel, family planning workers, and government officials. Findings indicate that the QoC program had brought positive changes in the areas of management guidelines, organizational buildup, birth control, information management, performance review, publicity and education, informed choice, technical service, and services in general. Feedback from most of the people interviewed was satisfactory. They regarded the course materials as beneficial to physical health and income-generating.^ieng

Counseling and service-based family planning: Luwan, Shanghai.

PIP: This article presents the efforts made of the Luwan District in integrating the quality of care program in family planning. Efforts have been made to cultivate client-oriented awareness, intensify skill training of family planning management staff and service providers and set up family planning counseling service stations. Publicity and counseling activities were carried out, as well as different programs for different groups of people in the district. In addition, efforts within the community service centers included setting up of family planning counseling service stations, training for service workers and developing counseling programs. Reflections on the program pointed out that it is imperative to develop the quality of care program. In addition, the quality of care program should take into full consideration the extent of understanding of the local government, and the training of service workers is crucial to the success of the program. Moreover, problems cited consisted of outdated means of service delivery, few visitors in service stations, and inaccessibility of stations.^ieng

The introduction and use of Norplant implants in Indonesia.

In this study, patterns of Norplant use in Indonesia are reviewed to assess the implications of this experience for the introduction of new contraceptive methods. Data from the Norplant Use-Dynamics Study and the 1994 Indonesia Demographic and Health Survey are analyzed, and patterns of acceptance, continuation, and removal are described. Acceptance of Norplant has increased steadily since it was first introduced. The method is now used by more than 5 percent of all married women of reproductive age. Continuation rates among Norplant users are higher than among users of the IUD. One factor behind high continuation rates may be that a substantial proportion of acceptors were not told that removal before five years was possible. Results indicate that deficits occurred in the quality of service delivery and that a need exists for improved provider training, better supervision, and clearer and better-enforced guidelines regarding women's right to have Norplant removed on demand.

PIP: Norplant implants, introduced to Indonesia's national family planning program in 1986, are currently used by more than 5% of married women of reproductive age. Most Indonesian Norplant acceptors are rural women 25-34 years of age with some primary education and 2 or more living children; they tend to receive the implants from public health centers, private midwives, and health posts. A substantial proportion of Norplant users had the implants inserted during mass campaigns (safaris) in Indonesia's rural areas. On the basis of continuation rates, Norplant appears to be more popular among Indonesians than the IUD or sterilization. This report, based on data from the Norplant Use Dynamics Study and the 1994 Indonesia Demographic and Health Survey, assesses the service quality associated with introduction of this method. The survey data indicate that, although acceptors are aware of Norplant's 5-year effectiveness, few were counseled about potential side effects or the possibility of early removal. The data further identified deficiencies in terms of provider training, supervision, and clear guidelines regarding a woman's right to have the implants removed on demand. Lacking in Indonesia is the presence of consumer groups and advocates to play a watchdog role and disseminate information to potential acceptors. The inadequate counseling received by many Norplant acceptors requires attention from family planning program managers. Also needed is a policy shift from a preoccupation with increasing the numbers of family planning acceptors to an emphasis on client satisfaction.

From efficacy to effectiveness: selecting indicators for a community-based lactational amenorrhoea method promotion programme.

This paper reviews the results of clinical trials and community studies of lactational amenorrhoea and its role as a contraceptive method (LAM). Indicators which are used in efficacy trials and effectiveness interventions are compared and sets of indicators of effectiveness appropriate to community-based LAM programmes are recommended. A five-tiered ecological framework is used to facilitate selection of indicators which range from individual to policy level outcomes. The indicator framework is intended as a tool for health practitioners in family planning and maternal and child health service delivery settings who are interested in designing programmatic interventions for the promotion of LAM, particularly among less well-educated women of lower socioeconomic communities.

PIP: If lactational amenorrhea (LAM) is to reach its full potential as a method of child spacing, additional programmatic interventions must be conducted at the community level--especially in developing countries--to demonstrate its effectiveness. A review of clinical trials and community studies of LAM conducted both before and after the Bellagio Consensus Conference was undertaken in order to develop a set of indicators for the effectiveness of LAM promotion efforts under a range of field conditions. The resultant framework is intended as a tool for health professionals in family planning and maternal-child health service delivery settings who are interested in designing community-based LAM programs. A 5-tiered (individual, interpersonal, community, health system, and macro-policy factors) ecological systems model was used as the framework for indicator development. Laboratory, physiological, and behavioral measures were rated and weighted according to their scientific rigor (quality of data collected, technical feasibility), administrative feasibility (cost to administer, time required and likelihood of compliance), and community appropriateness (cultural sensitivity, contribution to women's knowledge and skills). Included among the suggested indicators are hormonal levels in urine or blood samples, timing of first vaginal bleed, duration of breast feeding, use of pacifiers or nipples, breast feeding knowledge and cultural influences, number of breast feeds per 24 hours, and frequency of intercourse.

A profile of family planning audit in England 1994-1997.

Audit has been entered into enthusiastically by most of the multidisciplinary teams giving family planning services but the nature of the subject makes audit particularly difficult in this field. In many cases it has been used as a tool for determining standards rather than a tool for determining compliance to them. If family planning audit and evaluation is to substantially improve in quality, a great deal of work needs to be done, particularly in the formation of appropriate guidelines and in the increased utilisation of audit/research specialists to advise on methodology. It is hoped that the new clinical effectiveness committee of the faculty will take a lead in this; if so it will undoubtedly gain support from faculty members.

PIP: The British government invested considerable resources in clinical audit during 1994-97. While by 1993/94, 83% of consultants and 86% of general practitioners had contributed to 20,000 different audit projects, few data were available on the participation of other health care professionals. Recognizing that a sizeable percentage of these latter practitioners work in the field of family planning, the National Coordinating Unit (NCU) for Clinical Audit in Family Planning established a national database of unpublished clinical audits in the field of family planning and reproductive health care, which was subsequently passed onto the Faculty of Family Planning Effective Health Care Unit. Since late 1994, practitioners have been encouraged to submit audits for inclusion in the database as a resource for faculty members and others interested in auditing their own services. The national family planning audit database is now comprised of over 300 unpublished audits of varying complexity. Findings are presented from an analysis of the database with regard to the number of audits submitted annually, the choice of topics for audit, progression around the audit cycle, the disciplines involved in conducting audits, and the challenges of family planning audit. Work remains to be done in order to substantially improve the quality of family planning audit and evaluation.

Does the timing of the first family planning visit still matter?

CONTEXT: The timing of a first family planning visit relative to first intercourse can affect the likelihood of an early unintended pregnancy. METHODS: Nationally representative data from the 1982, 1988 and 1995 cycles of the National Survey of Family Growth were used to examine changes in the timing of first family planning visits and to explore the degree to which young women are now more likely than in the past to practice contraception independently of making a visit to a provider. Cox proportional hazards models were used to estimate how background variables, visit status and the initiation of contraceptive use affected risks of unintended pregnancy in the four years preceding each survey. RESULTS: The proportion of women who waited a month or more after their first intercourse to see a provider grew slightly between 1978 and 1995, from 76% to 79%; women waited a median of 22 months after first intercourse in 1991-1995. Any contraceptive use at first intercourse increased among both women who delayed a first visit (from 51% to 75%) and among those whose first visit occurred before their first intercourse or within the same month (from 61% to 91%). Cox proportional hazards analysis suggests that the protective effect of a first family planning visit decreased over the period studied, due in part to the increase in early contraceptive use. CONCLUSIONS: The importance of the first family planning visit appears to be declining, as sexually active young women who delay their first visit increasingly do so because they are already using a provider-independent method (primarily the condom). Thus, a multifaceted approach to providing family planning may now be needed, in which independent method use and visits to providers both play a role.

PIP: The timing of a first family planning visit relative to first intercourse can affect the likelihood of an early unintended pregnancy. Nationally representative data from the 1982, 1988, and 1995 cycles of the National Survey of Family Growth were studied to identify changes in the timing of first family planning visits and to investigate the degree to which young women are now more likely than in the past to practice contraception independently of visiting a provider. The proportion of women who waited a month or more after their first intercourse to see a provider grew from 76% to 79% between 1978 and 1995, with women waiting for a median of 22 months after first intercourse in 1991-95. Any contraceptive use at first intercourse increased among women who delayed a first visit from 51% to 75%, and among those whose first visit occurred before their first intercourse or within the same month from 61% to 91%. The importance of the first family planning visit seems to be declining, as sexually active young women who delay their first visit increasingly do so because they are already using a provider-independent method, mainly the condom. This greater use of the condom is related to the advent of the HIV/AIDS pandemic and the associated broader awareness of condoms' ability to block the transmission of HIV and other STDs.

More than eight million births averted in Shandong.

PIP: This short article discusses implementation of the Shandong Family Planning Regulations, in 1987, which has resulted in fewer but healthier births, and by which the public has learned to keep their reproductive behavior within the limits of the Regulations. The third baby boom since the founding of the People's Republic, in 1949, occurred during the past decade; the population of Shandong Province increased from 80.6 million, in 1987, to 87.3 million in 1997, an increase of only 7.24 million. Approximately 8.73 million births have been averted based on the 1987 fertility level, and 87.3 billion yuan have been saved based on an average of 10,000 yuan to raise a rural child to maturity. During this period, the birthrate decreased from 17.8/thousand to 13.3/thousand, and the natural increase rate declined from 11.3/thousand to 6.6/thousand. The average number of children born to each woman decreased from 5.0 in the 1950s and 1960s, to 3.2 in the 1970s, to 2.3 in the 1980s, and to below 2.0 currently. The percentage of late marriages by women rose from 39.6%, in 1987, to over 95% in 1997. Approximately 5.1 million couples decided to have only 1 child, and 117,000 rural families chose not to give birth to a second baby.^ieng

A reduction in the number of unwanted pregnancies among female army draftees through a controlled intervention.

OBJECTIVE: To assess the possibility of reducing the risk of unwanted pregnancy through a controlled intervention program that was based on a sex education workshop. DESIGN: Educational intervention study. SETTING: Newly drafted women in a central absorption army base in Israel. PATIENT(S): One thousand seven hundred ninety-three female draftees in the Israeli Defence Force. INTERVENTION(S): A 2-day workshop on sex education at the beginning of army service. MAIN OUTCOME MEASURE(S): Rate of unwanted pregnancy. RESULT(S): After 2 years of follow-up, there were approximately 40% fewer unwanted pregnancies among women with a lower socioeconomic and intellectual profile. CONCLUSION(S): Structured intervention programs may reduce significantly the rate of unwanted pregnancy in young women.

PIP: This study evaluates the success of sex education workshops in preventing unwanted pregnancy among 1793 newly drafted women in 1987 in the central absorption army base in Israel. The sex education workshops were held over a 2-day period at the beginning of army service. The study sample included 968 women in the intervention group and 825 controls. The sex education program included information on sexuality, the anatomy and physiology of the reproductive system, contraceptive methods, pregnancy and childbirth, decision making processes, interpersonal relations, pregnancy prevention, sexually transmitted diseases, and personal hygiene. Each of the 4 daily sessions aimed to involve young women in verbal participation on sex-related topics and to correct myths and prejudices. Questionnaires were administered pre and post army service among cases and controls. The extent of unwanted pregnancy was assessed at a point 2 years after induction. During the 2-year study period, 58 women became pregnant. 2.6% in the intervention group and 4% in the control group had unwanted pregnancies. Unwanted pregnancy was significantly higher among controls and among lower socioeconomic groups. The rates of contraceptive use at first intercourse and visiting a gynecologist were higher in the case group than in the control group after the workshops. Logistic models confirmed the statistical significance of the relationship between unwanted pregnancy and the low Caba subscale (education, Hebrew language proficiency, and language and scholastic fluency), low level of language skill, and controls.

Tracking the progress of reproductive health services in the highland district. Case scenarios for training and group discussion.

PIP: This issue of The Family Planning Manager presents a narrative of a fictional workshop for District Health Officers on consolidation of vertical family planning (FP) programs into integrated reproductive health programs that offer a full range of services. In the main session of the workshop, participants are told that the progress of a reproductive health program can by tracked by: 1) identifying the main reproductive health program areas, 2) identifying national and local indicators for each program area, 3) developing baseline objectives for each indicator, 4) preparing an indicator panel that will allow comparison of the current situation with objectives, 5) collecting and analyzing data on a periodic basis and entering data on the indicator panel, and 6) determining how well objectives for each indicator are being met and devising a management action to improve the program. The workshop than breaks into small groups representing various districts, and the narrative follows one such group as it creates a chart identifying the main reproductive health program areas for the district, identifying local indicators for each program area, assigning local-level data to each indicator, and establishing year-end objectives. The resulting chart presents 11 indicators for six reproductive health areas (FP, infant health, maternal health, infant nutrition, reproductive tract infection/sexually transmitted disease/HIV services, and adolescent health). Additional activities presented (and completed) are to 1) identify two possible sources of data collection for each indicator, 2) analyze progress meeting objectives based on quarterly statistics, and 3) list management actions that would help the program reach each objective.^ieng

Using evaluation as a management tool.

PIP: Managers must pay close attention to whether their programs and services are meeting their clients' needs, are being provided efficiently and effectively, and are contributing to the achievement of organizational and program objectives. This publication discusses the role of ongoing, regular internal program evaluation and gives managers advice on how to plan for and incorporate evaluation into their programs. Particular focus is given to the importance of regularly collecting and analyzing program data so that managers have good information with which to make important decisions. Examples are also provided of how managers can use the resulting information to make necessary programmatic changes and improve the effectiveness of their programs and services.^ieng

Mrs. Chege conducts an internal evaluation to measure program performance. Case scenarios for training and group discussion.

PIP: The case is presented of a family planning services zonal supervisor preparing for her year-end visit with the State Family Planning Coordinator. The supervisor oversees the delivery of family planning services in four clinics. Three case discussion questions are provided. Readers are asked to review the information presented in the case and consider which factors the two women would consider when deciding whether to design and implement a community-based distribution program, and what additional information they should acquire in order to best decide. Case readers are next asked which issues might the zonal supervisor discuss on her next supervisory visit to a particular clinic described in the case. Finally, participants can discuss what is important about how the zonal supervisor conducted her evaluation. Ideal answers/feedback to the case discussion questions are presented.^ieng

Costs of family planning programmes in fourteen developing countries by method of service delivery.

The cost effectiveness of several modes of family planning service delivery based on the cost per couple-year of protection (CYP), including commodity costs, is assessed for 1991-92 using programme and project data from fourteen developing countries (five in Africa, four in Asia, three in Latin America and two in the Middle East). More than 100 million CYP were provided through these family planning services during the 12 months studied. Sterilisation services provided both the highest volume (over 60% of total) and the lowest cost per CYP ($1.85). Social marketing programmes (CSM), delivering almost 9 million CYPs, had the next lowest cost per CYP on average ($2.14). Clinic-based services excluding sterilisation had an average cost of $6.10. The highest costs were for community-based distribution projects (0.7 million CYPs), which averaged $9.93, and clinic-based services with a community-based distribution component (almost 6 million CYPs), at a cost of $14.00 per CYP. Based on a weighted average, costs were lowest in the Middle East ($3.37 per CYP for all modes of delivery combined) and highest in Africa ($11.20).

PIP: This study of cost effectiveness of family planning programs is important in light of declining donor support. The study examines cost per couple years of protection (CYP) for family planning programs in 14 developing countries. Cost effectiveness is evaluated by mode of service delivery. Modes of service delivery include sterilization, clinic-based services (CBS) excluding sterilization, community-based distribution (CBD) excluding sterilization, and contraceptive social marketing (CSM). Costs are determined by a variety of methods: actual expenditures, budget allocations, or estimation. Costs include donor and government support related to service delivery. Omitted costs include, for example, nonspecific health care training, research and evaluation, data collection, and general IEC (information, education, and communication). In combined family planning and maternal/child health services, estimates are used to distinguish between the separate functions. CSM costs do not include revenues from inside the CSM sale system. Findings indicate that service volume includes about 60% or more of total services provided by organized family planning programs in 1991, excluding China. 55% of services provided in study countries were devoted to sterilization, 31% were devoted to CBS, and 9% were devoted to CSM. In 1991, almost 57 million CYP were provided by sterilization. The least expensive mode of service delivery was sterilization, based on data from India and Colombia. The next most cost-effective delivery mode was contraceptive social marketing, except in African countries where programs are new and small in scale. The most expensive service was CBS, which includes CBD. Costs were lowest in the Middle East and highest in Africa. Except for Africa, CSM within countries showed the lowest costs. The authors recommend that programs meet country and AIDS prevention needs.

Regional dissemination of Senegal's situation analysis study results: a promising way to maximize operations research utilization.

PIP: A situation analysis was performed to provide a comprehensive description of the availability, functionality, and quality of family planning (FP) services and to identify strengths and weaknesses of the national program in Senegal. The 1994 situation analysis included 180 functional service delivery points (SDPs). This report documents the methods used to disseminate the situation analysis and reports the principal findings and lessons learned. The regional dissemination strategy aimed to inform regional and district FP personnel about service delivery issues specific to their location, to involve regional and district FP personnel in the recommendation process, and to maximize the impact and use of findings. The presentation of findings by region encountered difficulties in interpreting data due to small sample sizes, especially that relating to quality of care issues. 1-day seminars were conducted in each of the 10 regions in 1995. It proved very time consuming to schedule a 1-day meeting among district and regional staff. The 10 seminars included 47 districts and 10 directors of health, 10 MCH-FP coordinators, 10 regional supervisors, 47 district medical chiefs, 47 MCH-FP midwives, 47 SDP district supervisors, and personnel from the 2 leading nongovernmental FP groups that serviced 55 SDPs in private and parastatal sectors. Participants were grouped by district. Discussion focused on activities in the SDPs, functional capacity of SDPs, and quality of services. Recommendations emphasized IEC, personnel training and experience, and management and supervision. The seminars revealed the wide differences in perceived program strengths and weaknesses between local and national personnel and in the problems to be solved. Districts were relatively autonomous in deciding how FP services should be delivered and improved. The decentralized dissemination of results was effective in fostering change.^ieng

Evaluating rural Bangladeshi women's perspectives of quality in family planning services.

Several frameworks for understanding the quality of family planning care have been proposed. However, efforts to measure and quantify their components remain underdeveloped, especially with regard to nonclinical care and community-based distribution. This study examines a large-scale field survey conducted among married women of reproductive age in rural Bangladesh in 1989 and 1990 to measure and evaluate rural women's perceptions of the quality of outreach services they received. Initial analysis indicates that rural women are able to distinguish between good and poor quality of care and that these perceptions can be accurately documented and quantified through sample survey approaches. Implications of the use of a survey in the measurement of quality of care are discussed, as well as implications of the results for managers within the Bangladesh government family planning program, which has been regarded by donor agencies as having limited responsiveness to clients' needs.

PIP: While frameworks have been proposed for understanding the quality of family planning care, there has been too little effort to measure and quantify program components, particularly with regard to nonclinical care and community-based distribution. Findings are presented from a study which analyzed data from a large-scale field survey conducted among 10,127 married women of reproductive age in rural Bangladesh during 1989-90 to measure and evaluate their perceptions of the quality of outreach services they received. The initial analysis indicates that rural women are able to distinguish between good and poor quality of care and that these perceptions can be accurately documented and quantified through sample survey approaches. The authors discuss the implications of the use of a survey in the measurement of quality of care, as well as the implications of the results for managers within the Bangladesh government family planning program.