Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India.

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India.

PURPOSE: Youth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15-24 and mothers aged 25-48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers. METHODS: Data come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months. RESULTS: Results showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months. DISCUSSION: As India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.

Comparative analysis of contraceptive use in Punjab and Manipur: exploring beyond women's education and empowerment.

BACKGROUND: Women's education and empowerment are important predictors of contraceptive use across countries. However, two of the Indian states, namely, Punjab and Manipur, showed large variations in contraceptive use, despite the similar level of women's educational attainment and empowerment. Therefore, this paper attempts to understand variation in contraceptive use between these states, despite having similar level of educational attainment and empowerment among the married women. METHODS: This study primarily used cross-sectional data of the National Family Health Survey (NFHS) 2015-16 and to some extent the District Level Household Survey (DLHS) 2012-13 data. The analytical sample includes 13,730 currently married women in Punjab and 8,872 in Manipur. Modern contraceptive prevalence rate (mCPR) is the key outcome variable of this study. Bivariate, multivariate, and multilevel regression analysis are applied to understand the differences in mCPR between these states and its determinants. RESULTS: Mean years of schooling was about 8 years among women of both the states, and about 34% of the women in Punjab and 27% of the women in Manipur have high level of autonomy. Despite this, use of modern method was 66% in Punjab and only 13% in Manipur. Coverage of family planning program indicators were significantly lower in Manipur than Punjab - frontline workers' (FLWs) outreach for family planning was only 18% in Manipur compared to 52% in Punjab. Similarly, only 11% of the public health facilities in Manipur compared to 50% of the health facilities in Punjab were ready to provide at least one clinical method of family planning. CONCLUSION: Despite the similar level of individual level characteristics across the two states, poor coverage of family planning programs - low outreach of FLWs, low level of facility readiness, as well as sociocultural norms discouraging contraceptive use - might be responsible for lower contraceptive use in Manipur than Punjab. This implies for strengthening the health system for family planning in Manipur to meet the contraception needs of women by addressing sociocultural barriers in the state.

Mass media exposure and use of reversible modern contraceptives among married women in India: An analysis of the NFHS 2015-16 data.

Since the inception of the National Programme for Family Planning, messages on family planning (FP) have been promoted across India using different mass media platforms. Mass media plays an important role in disseminating important information among the masses, such as how reversible modern methods give women more reproductive choices than opting for permanent methods that limit their child-bearing capacity. Mass media can provide a continuous flow of information and motivation to deter women from discontinuing the methods they have opted for. However, very few studies have been conducted on this issue, especially using recently available data. This study particularly focuses on exposure to mass media and the use of reversible modern methods of family planning among married women in India. The data for this study was obtained from the National Family Health Survey (2015-16) on currently married women aged 15-49 years. The association of reversible modern method use with media exposure variables was examined, controlling for a set of independent variables from multiple levels-individual, district, state, and region. The findings from this study showed that television was the most important medium for disseminating information on FP among married women in India. Spatial analysis revealed that some districts in the north, parts of the northeast, and Kerala in South India lacked any television exposure. The results from the decomposition analysis showed that mass media exposure was associated with a 14% increase in the use of reversible modern methods. Results from the multilevel analyses showed that exposure to TV along with other media (AOR 1.57 95% CI 1.49-1.65) and exposure to FP messages through different media (AOR 1.22 95% CI 1.12-1.32) had a significant positive effect on the use of reversible modern methods even when various individual, district, state, and regional-level factors were controlled. The findings of this paper provide evidence supporting the use of mass media to promote and increase awareness of voluntary contraceptive use in India. An increase in mass media exposure coupled with improvement in coverage and services of the FP program can significantly increase the use of reversible modern methods in a cost-effective yet efficient manner among women in need of FP services.

Not All Women Who Experience Side Effects Discontinue Their Contraceptive Method: Insights from a Longitudinal Study in India.

Side effects are a primary reason why women stop using contraception, even though they may still want to avoid a pregnancy. The Demographic and Health Surveys (DHS), the largest source of nationally representative data on contraceptive discontinuation, only asks women who discontinued a method their reasons for discontinuation, for which side effects is an option. Yet, side effects are also experienced by continued users. Using longitudinal data collected from a cohort of contraceptive users in Odisha and Haryana, India, this study explores the effect of side effect severity and frequency on six-month discontinuation. Among women who experienced side effects of their enrollment method, 49.7 percent continued to use it by the six-month interview. Women who experienced moderate/severe side effects infrequently were 67 percent (adjusted odds ratio [AOR]: 0.33; 95 percent confidence interval [CI]: 0.16-0.64) less likely to discontinue the enrollment method compared to women who experienced moderate/severe side effects always. Women who experienced mild side effects were even less likely to discontinue (AOR: 0.15; 95 percent CI: 0.06-0.37). Study results suggest side effect severity and frequency are more important factors than simply the experience of a side effect in understanding contraceptive discontinuation. DHS and other national surveys should expand their exploration of side effects to include questions asked of current users.

Share of current unmet need for modern contraceptive methods attributed to past users of these methods in India.

Despite persistent efforts, unmet need for contraceptives in India has declined only slightly from 14% to 13% between 2005-06 and 2015-16. Many women using a family planning method discontinue it without switching to another method and continue to have unmet need. This study quantified the share of current unmet need for modern contraceptive methods attributed to past users of these methods in India. Data were drawn from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16. Using information on women with current unmet need, and whether they used any modern method in the past, the share of past users with current unmet need for modern methods was calculated. Bivariate and multivariate analyses were performed. Among 46 million women with unmet need, 11 million were past users of modern methods in 2015-16. The share of current unmet need attributed to past users of modern contraceptive methods declined from 27% in 2005-06 to 24% in 2015-16. Share of current unmet need attributed to past users was associated with reversible method use. This share rose with increased use of modern reversible methods. With the Indian family planning programme's focus on increasing modern reversible method use, the share of unmet need attributed to past users of modern methods is likely to increase in the future. The programme's emphasis on continuation of contraceptive use, along with bringing in new users, could be one of the key strategies for India to achieve the FP2020 goals.

Spousal Violence Against Women in India: A Social-Ecological Analysis Using Data From the National Family Health Survey 2015 to 2016.

Even after enactment of the Protection of Women From Domestic Violence Act 2005, over the last 10 years, the rate of decline of prevalence of spousal violence against women has remained low in India. This study attempts to explain the experience of spousal violence using a social-ecological framework. We analyzed the National Family Health Survey 2015 to 2016 (NFHS-4) data of 66,013 ever-married women aged 15 to 49 years. Participants in the domestic violence module of the NFHS-4 reported their experience of violence committed by their husband within the 12 months preceding the survey. Multilevel logistic regression analyses were done to determine the association between spousal violence and different explanatory variables of various levels of social ecology including variables on women's empowerment. About one fourth of ever-married women reported experiencing any form of violence during the last year. The experience of spousal violence was significantly associated with social ecology at multiple levels. At the individual level, the odds of experiencing physical violence were higher among younger women, who married at a younger age, had an age gap of 3 to 4 years with her husband, and had more children. Women in vulnerable groups, with poor economic status, and members of marginalized communities had higher odds of experiencing spousal violence. Women had high odds of experiencing spousal violence if living in a social ecology with unfavorable social norms, higher rates of domestic crimes, and a higher prevalence of underage marriage. The association of spousal violence with women's empowerment remained inconclusive. The results argue for manipulating contextual factors to empower women to challenge gender-related equations and investing in education for gender sensitization at the higher level social ecologies.

Quality of care in sterilization services at the public health facilities in India: A multilevel analysis.

Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015-16 and District Level Household and Facility Survey (DLHS) 2012-13. The study is limited to only districts whose data are available in both DLHS 2012-13 and NFHS 2015-16. The methods of analysis include bivariate statistics, Pearson's chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client's confidence in the services, which is the key to success for any voluntary family planning program like in India.

Client-provider interaction: understanding client experience with family planning service providers through the mystery client approach in India.

The benefits of employing a rights-based approach in family planning (FP) programmes have made the client's rights to informed choices and quality care an essential part of any such programme. client-provider interaction is one of the critical components of the quality of care (QoC) framework of FP. While several studies have assessed QoC in FP services in India, very few have focused on the in-depth assessment of the interaction between the client and the provider during service delivery. The present study used the mystery client approach to assess the quality of interactions between clients and FP service providers in two of the most populous states of India: Bihar and Uttar Pradesh (UP). Findings highlighted that the providers spent very little time with the clients, gave them information on only one or two FP methods, and rarely talked about possible side-effects of the methods. Furthermore, the providers seemed hesitant to suggest any FP method other than condoms to newly married women. This study concluded that despite being a government priority, the quality of client-provider interaction in these two states was extremely poor.

Intrahousehold influence on contraceptive use among married Indian women: Evidence from the National Family Health Survey 2015-16.

BACKGROUND: India, where more than one married woman of reproductive age often live in the same household, provides an ideal setting to promote family planning through intrahousehold influence. OBJECTIVES: This study examined the association between use of modern contraceptives by young married women, and other married women live in the same household. METHODS: We included 31,361 currently married women of 15-24 years from women data of the National Family Health Survey 2015-16. Each of these women was living with another married woman within the same household, who was also interviewed. From each household, we labeled the woman with the shortest marital duration as the Index Woman. The second woman in each household was either labeled as Peer or Other or Elderly (had married within 5 years or 5-19 years after or 20 or more years after the marriage of Index women, respectively). The association between use of modern contraceptives by Index Women and the second woman in household was examined using logistic regressions-controlled for the background characteristics of Index Women. RESULTS: Index Women had 2.9 times adjusted odds (95%CI 2.5-3.3) of using modern contraceptives if living with Peers, who were also using modern contraceptives. Similarly, when the second women using modern contraceptives, an Index Woman had 1.7 times adjusted odds for using modern contraceptives (95%CI 1.5-1.9) if living with Elderly, and about 2.5 times adjusted odds if living with Other women (95%CI 2.1-2.8). The association between contraceptive use by an Index Woman and the second woman in the household remained significant even after controlling for background characteristics, showing the independent effect of intrahousehold influence on contraceptive use. CONCLUSION: The conclusive evidence of positive intrahousehold influence on contraceptive use of Index Women will encourage program managers to promote intrahousehold communication to increase use of family planning.

Health workers' outreach and intention to use contraceptives among married women in India.

BACKGROUND: The influence of health workers on uptake of maternal healthcare services is well documented; however, their outreach for family planning (FP) services and influence on the intention to use contraceptives is less explored in the Indian context. This study examined the extent of health worker outreach for FP service and its effects on intention to use contraceptives among currently married women aged 15-49 years. METHODS: This study used data from two rounds of the National Family Health Survey (NFHS) of India, conducted during 2005-06 and 2015-16 respectively. Bivariate analysis and multivariate logistic regression were used to understand the level of and change in health worker outreach for FP services over time, and its association with intention to use contraceptives among currently married women. RESULTS: In the past 10 years, health workers' outreach for FP service has significantly increased by about 10 percentage points, although the level is not optimal and only 28% of non-users were reached by health workers in 2015-16. Increase in the outreach to younger and low parity women was higher than their respective counterparts. Intention to use contraceptive among women who were not using any method was 41% when health workers contacted and discussed FP, compared to only 20% when there was no such contact with health workers. Multivariable analysis suggests that contact with health workers has significant positive effects on intention to use contraceptive (AOR = 3.05; p < 0.001; 95% CI 2.85-3.27). CONCLUSION: Increased scope of outreach of frontline health workers to provide FP communication and services will not only help in building knowledge of contraceptive methods but will also increase women's intention to use a method. For India, this may be the most promising way to achieve the Sustainable Development Goals 3.7, which calls for universal access to reproductive health services.

Association between modern contraceptive use and child mortality in India: A calendar data analysis of the National Family Health Survey (2015-16).

BACKGROUND: Influence of contraceptive use on increased gap between successive births and attributed reduced risk of child deaths is well documented in developing countries. However, there is scarcity of evidence on direct contribution of contraceptive use on child survival especially in Indian context. METHODS: Using information given in the reproductive calendar history of the National Family Health Survey of India conducted in 2015-16, this study examines the effect of modern contraceptive use on childhood mortality - infant mortality rate (IMR) and under-five mortality rate (U5MR). Bivariate analysis and cox proportional hazard model is applied in the study. RESULTS: Finding reveals that use of reversible contraceptives prior to birth resulted in low childhood mortality rates. IMR is 35 per 1000 live births among births with preceding use of modern reversible contraceptives as compared to 44 per 1000 live births among births with no use. Similarly, U5MR is 41 per 1000 live births as compared to 61 per 1000 live births among births with preceding use of contraceptive and no use respectively. The use of reversible modern contraceptives prior to birth is protective against child mortality even among births with preceding birth interval of less than 24 months. CONCLUSIONS: This study provides evidence of dual benefit of contraceptive use. Such information is important for promoting evidence-based advocacy to expand use of family planning services. This will help the country to achieve Sustainable Development Goal 3.2 which calls for end of preventable deaths during childhood.

The relationship between attitudes towards pregnancy and contraceptive continuation: Results from a longitudinal study of married women in India.

To understand the relationship between pregnancy intentions and contraceptive use, a growing body of research has begun to examine various domains of women's attitudes towards pregnancy, acknowledging that these attitudes may contradict one another, and women may be ambivalent. This study examines pregnancy ambivalence and assesses the relationship between attitudes towards pregnancy and contraceptive continuation after nine months among a sample of women in Odisha and Haryana, India. Data come from a longitudinal study of married women age 15-49 who began using a modern reversible method of contraception at the time of study enrollment. To assess their cognitive attitudes (beliefs/knowledge) towards pregnancy, women were asked "how important is it you to avoid a pregnancy now?" To assess their affective attitudes (feelings/emotions), women were asked about their agreement with the statement: "If I found out I was pregnant in the next several weeks, I would be happy." A joint, 4-category measure combining these cognitive and affective attitudes towards pregnancy was created to measure concordance and ambivalence in attitudes towards pregnancy. Multivariate random-effects logistic regression models were employed to examine the relationship of these two measures with method-specific contraceptive continuation nine months later. Two models were conducted, one with the two attitude variables included independently and the second with the joint, 4-category measure included. Results showed that affective and cognitive attitudes were both significantly associated with continuation, but that there were no significant differences between those that were ambivalent and those whose attitudes were concordantly anti-pregnancy. This study suggests that attitudes towards pregnancy are multifaceted and both cognitive and affective attitudes towards pregnancy may play an important role in contraceptive use in India.

Is economic inequality in family planning in India associated with the private sector?

This study examined the pattern of economic disparity in the modern contraceptive prevalence rate (mCPR) among women receiving contraceptives from the public and private health sectors in India, using data from all four rounds of the National Family Health Survey conducted between 1992-93 and 2015-16. The mCPR was measured for currently married women aged 15-49 years. A concentration index was calculated and a pooled binary logistic regression analysis conducted to assess economic disparity (by household wealth quintiles) in modern contraceptive use between the public and private health sectors. The analyses were stratified by rural-urban place of residence. The results indicated that mCPR had increased in India over time. However, in 2015-16 only half of women - 48% (33% from the public sector, 12% from the private sector, 3% from other sources) - were using any modern contraceptive in India. Over time, the economic disparity in modern contraceptive use reduced across both public and private health sectors. However, the extent of the disparity was greater when women obtained the services from the private sector: the value of the concentration index for mCPR was 0.429 when obtained from the private sector and 0.133 when from the public sector in 2015-16. Multivariate analysis confirmed a similar pattern of the economic disparity across public and private sectors. Economic disparity in the mCPR has reduced considerably in India. While the economic disparity in 2015-16 was minimal among those accessing contraceptives from the public sector, it continued to exist among those receiving services from the private sector. While taking appropriate steps to plan and monitor private sector services for family planning, continued and increased engagement of public providers in the family planning programme in India is required to further reduce the economic disparity among those accessing contraceptive services from the private sector.

Determinants of low birth weight in India: An investigation from the National Family Health Survey.

OBJECTIVE: This study aimed to estimate the change in prevalence of low birth weight (LBW) over the last decade in India and to identify its associated factors-biological, demographic, socio-economic, and programmatic. METHODS: We used the data from the National Family Health Survey of 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4). The sample of this study included 11 300 children from NFHS-3 and 99 894 from NFHS-4 data; all these children were the last full-term singleton live-births, born within the last 3 years prior to the survey. RESULTS: In India, the prevalence of LBW has significantly declined from 20.4% (95%CI 19.4-21.4) to 16.4% (95% CI 16.1-16.8) in the last decade. The prevalence of LBW remained high in girl children (OR = 1.2, 95% CI 1.2-1.3; P < .001), whose mothers were adolescent (OR = 1.2, 95% CI 1.1-1.3; P < .001), and were stunted (OR = 1.3, 95% CI 1.3-1.3; P < .001). Prevalence of LBW declined among second or higher birth order child (OR = 0.8, 95% CI 0.8-0.9; P < .001), whose mothers educated up to secondary level and above (OR = 0.6 to 0.8), belonged to rich wealth quintiles (OR = 0.9 to 0.8), were from rural area (OR = 0.9, 95% CI 0.9-1.0; P < .001), received better nutrition and adequate antenatal care (OR = 0.8, 95% CI 0.8-0.8; P < .001), and were from eastern, northeastern, and southern regions of India (OR = 0.9 to 0.5). CONCLUSION: Although the prevalence of LBW in India has declined over the past decade, the extent of the decline is modest. In the coming years, health programs in India need to gear up with greater convergence between maternal health services and maternal nutrition to reduce LBW.

Dietary Adequacy Among Young Children in India: Improvement or Stagnation? An Investigation From the National Family Health Survey.

BACKGROUND: This study assessed the trend of minimum acceptable dietary practices among children aged 6 to 23 months in India in the past decade. METHODS: Data collected in the National Family Health Survey during 2005 to 2006 (NFHS-3) and 2015 to 2016 (NFHS-4) were used. The sample size for this study was 11 727 children for NFHS-3 and 61 158 children for NFHS-4. Bivariate and multivariate analyses were done to identify the predictors of feeding practices. We analyzed data of last-born singleton children aged 6 to 23 months who were living with their mother (ever-married women aged 15-49 years). RESULTS: In India, a low proportion (10%) of children aged 6 to 23 months received a minimum acceptable diet, and its estimate remained the same in the past 10 years. Older mothers, educated mothers, antenatal care, high economic status, and place of residence were the most consistent predictors of minimum acceptable dietary intake. Over the past decade, however, the minimum acceptable dietary intake has declined among older children (odds ratio [OR] = 0.57, 95% confidence interval [CI], 0.47-0.70; P < .001), children with overweight mothers (OR = 0.40, 95% CI, 0.31-0·50; P <.001), and children of well-off families (OR = 0.29, 95% CI, 0.23-0.37; P < .001). The odds for minimum acceptable dietary intake were significantly higher among children of high (4+) birth order (OR = 1.74, 95% CI, 1.41-2.15; P < .001), rural areas, and children living in the central, eastern, and north-eastern region. CONCLUSION: Results indicate the need for further investigations of poor dietary intake among children living in well-off families and in the northern region. This study suggests policymakers and program managers to address contextual barriers against minimum acceptable dietary intake among children and to reconsider existing strategies in India.

Adding a Question About Method Switching to the Method Information Index Is a Better Predictor of Contraceptive Continuation.

INTRODUCTION: The Method Information Index (MII) is 1 of 18 core indicators used to monitor progress toward achieving Family Planning 2020's goal of 120 million more women using a modern method of family planning by 2020. The 3 questions of the MII are intended to measure informed choice at method initiation. Although routinely used in the Demographic and Health Surveys and the Performance Monitoring and Accountability 2020 project in cross-sectional household surveys, the MII may not adequately reflect all key aspects of quality of care or predict contraceptive continuation. In the current study, a question was added to the MII regarding the possibility of switching to a different contraceptive method if the current method is not suitable. The revised MII is referred to as MIIplus. METHODS: A total of 2,699 married women aged 15-49 who started a new episode of use of intrauterine device, injectable, or oral contraceptive pills between December 2016 and October 2017 were followed for 1 year in India and interviewed at method start and 3, 6, and 12 months later. Of these women, 2,267 were interviewed 3 months later and included in the analysis. Using 3 Cox proportional hazard models, we estimated hazard ratios for risk of discontinuation, based on the MII, MIIplus, and a recategorization of MIIplus into a 3-category variable. RESULTS: The modern method continuation rate 100 days (∼3 months) later was 91% overall. Women who received the information in MIIplus were more likely to continue using a method at 100 days (95%) compared to those who received information covered in the MII (82%) or less than 3 components of the MII (89%) (P<.001). Women who received all components in the MIIplus were 69% (adjusted hazard ratio, 0.31; 95% confidence interval: 0.17 to 0.61) less likely than those who received information in the MII to discontinue using a modern method 100 days later. Discontinuation was not significantly different between women who received information on less than the 3 components of the MII compared to the complete MII. CONCLUSION: We recommend including the question about the possibility of switching to another family planning method in routine measurement because it better predicts contraceptive continuation than the MII alone and ensures that another domain of quality of care is reflected in the measurement. When programs provide information on the possibility of switching, women are better informed about voluntary family planning choice and their options to continue family planning when a method is not suitable.

Choice of contraceptive methods in public and private facilities in rural India.

BACKGROUND: Client-centric quality of care (QoC) in family planning (FP) services are imperative for contraceptive method adoption and continuation. Less is known about the choice of contraceptive method in India beyond responses to the three common questions regarding method information, asked in demographic and health surveys. This study argues for appropriate measurement of method choice and assesses its levels and correlates in rural India. METHODS: A cross-sectional study was conducted with new acceptors of family planning method (N = 454) recruited from public and private health facilities in rural Bihar and Uttar Pradesh, the two most populous states in India. The key quality of care indicator 'method choice' was assessed using four key questions from client-provider interactions that help in making a choice about a particular method: (1) whether the provider asked the client about their preferred method, (2) whether the provider told the client about at least one additional method, (3) whether the client received information without any single method being promoted by the provider, and (4) client's perception about receipt of method choice. The definition of method choice in this study included women who responded "yes" to all four questions in the survey. The relationship between contraceptive communication and receipt of method choice was assessed using logistic regression analyses, after adjusting for socio-demographic characteristics of the respondents. RESULTS: Although 62% of clients responded to a global question and reported that they received the method of their choice, only 28% received it based on responses about client-provider interactions. Receipt of the information on side-effects of the selected method (Adjusted Odds Ratio [AOR]: 7.4, 95% Confidence Interval [CI]: 3.96-13.86) and facility readiness to provide a range of contraceptive choice (AOR: 2.67, 95% CI: 1.48-4.83) were significantly associated with receipt of method choice. CONCLUSIONS: Findings demonstrated that women's choice of contraceptive could be improved in rural India if providers give full information prior to and during the acceptance of a method and if facilities are equipped to provide a range of choice of contraceptive methods.

Validation of Two Quality of Care Measures: Results from a Longitudinal Study of Reversible Contraceptive Users in India.

Bruce's quality of care framework, developed nearly three decades ago, brought needed international attention to family planning services. Various data collection efforts exist to measure the quality of contraceptive services. Our study validates two process quality measures and tests their predictive validity related to contraceptive continuation among 2,699 married women who started to use a reversible contraceptive method in India. We assessed four process quality domains with 22 items, which were reduced to 10 items using exploratory factor analysis. Weighted additive indices were calculated for the 22- and 10-item measures. Scores were trichotomized into high, medium, and low process quality received. The predictive validity of the two measures was assessed related to modern contraceptive continuation three months later. The adjusted odds of continuing a modern contraceptive three months later was nearly three times greater (AOR: 2.78; 95% CI: 1.83-4.03) for women who received high process quality at enrollment compared with low quality with the 22-item measure, and 2.2 times greater (95% CI: 1.46-3.26) with the 10-item measure. Results suggest that the 22- and 10-item measures are valid, and while the larger 22-item measure can be used in special studies, the 10-item measure is more suited for routine data collection and monitoring.