Postpartum contraception: perspectives from clients and providers in six countries.

PIP: This article presents preliminary findings of a study conducted by the Association for Voluntary Surgical Contraception (AVSC) designed to investigate women's interest in postpartum contraception and the preferred timing for getting information. A pioneering study, AVSC's research took place in Colombia, the Dominican Republic, India, Kenya, Mali, and Turkey. In each countries, AVSC conducted 4-6 focus groups with pregnant women, interviews with 100 postpartum women, and interviews with 30 service providers. While a final report is due out in January, AVSC has established some preliminary findings. Except in Turkey, more than 1/2 the postpartum women said that they would have been interested in receiving family planning information before and during pregnancy. In nearly all the countries, the unmet need for information was great. Only in Mali and Kenya, where AVSC introduced postpartum IUD projects last year, was there less of an unmet need. While 40% of Kenyan women leaving the hospital after delivery had adopted a contraceptive method, only 3% and 2% of the women in the Dominican Republic and Turkey, respectively, were leaving the hospital with a method. The overwhelming majority women thought that family planning should be provided prior to pregnancy or during prenatal care. Focus group discussions revealed that virtually all women thought that during labor was a bad time to get information, and that information could be given during postpartum visits or before a woman leaves the hospital after delivery. Responses by service providers were similar to those of women, except that most thought it would be appropriate to discuss family planning during labor. AVSC will use the findings of this study to design informational materials for postpartum contraception programs.^ieng

Using self-assessment to improve the quality of family planning clinic services.

A follow-up study was conducted to evaluate the effect of a self-assessment technique called COPE (client-oriented, provider-efficient) on the quality of family planning clinic operations in Africa. In 1991 the Association for Voluntary Surgical Contraception revisited 11 clinics where it had introduced COPE from five to 15 months earlier. Changes that had occurred as a result of the COPE intervention were assessed by (1) determining how many of the clinic problems identified by staff at the COPE introduction had been solved; (2) comparing the results of a second client-flow analysis with the initial analysis; and (3) interviewing service providers to obtain their opinions of the effects of COPE. Of the problems identified by staff nearly three-fourths of those that could be solved internally were solved. The study revealed improvements in the quality of care provided as well as increased staff involvement in solving clinic problems.

PIP: The association for Voluntary Surgical Contraception (AVSC) had developed a family planning (FP) clinic operations assessment approach called COPE: client oriented and provider efficient. The COPE method were employed in 11 sites in Ghana, Kenya, Nigeria, and Uganda and evaluated 5-15 months after implementation. COPE aims to improve client services through change in the organization, by continually revising plans and services, and by evaluating outcomes. The focus is not on outcome or distributional statistics, but on qualitative and quantitative data on the process of service delivery. Cope meets the criteria of using multiple methods, being flexible in research design, and being simple. The 4 main components of COPE are as follows: 1) self-assessment; 2) client interviews (10); 3) client-flow analysis (CFA); and 4) plan of action. COPE is currently integrating into its methodology the routine for follow-up evaluation visits by COPE facilitators. Evaluation of COPE implementation took into consideration the number of problems solved or addressed since the introduction of COPE, the results of the client-flow analysis, and the results of interviews of providers. The lack of baseline information on client satisfaction prevented analysis of changes. The instruments of evaluation included a table of lists of problems and proposed staff solutions, several CFA summary sheets, and a structured interview questionnaire for service providers involved with COPE. AVSC staff found that the proportion of solvable problems that were solved varied by site and ranged from 33-75%. It appeared that the level of dedication of service providers and the interest, cooperation, and involvement of administration determined the disparity in problems solved. There were 109 problems identified at all sites and 59% solved. 73% of the problems did not call for outside help. 88% of these solvable problems were solved or partly solved or had attempts at solutions. The cases involved a need for more training of staff in FP the lack of a forum to discuss FP, the lack of directional signs to the FP unit, the long client waiting times, the inadequacy of FP supplies, and the incompleteness of records. Positive results of COPE centered on decreased waiting times, improved morale and staffing, and increased satisfaction. Lessons learned and future directions are given.