Quality of reproductive health services at primary health centres in an urban area of Iran : Emphasis on family planning

Background: Detailed knowledge of the present situation is needed in order to design and implement quality improvement programmes to achieve the national goal of ‘planned and safe fertility for all’ in Iran. An understanding of the perspectives and views of clients and providers are also much needed. When this study was initiated there was a lack of studies on the quality of family planning and other primary reproductive health services in the country. Aim: To describe and explore the quality of public primary reproductive health care services, especially family planning, in an urban area of Iran, in order to identify areas and measures for improvement. Methods: Structured observations of 469 client-provider interactions and some clinical procedures at 34 health facilities, and exit interviews with 416 of the observed clients. Quality of services was assessed using pre-defined indicators (study I). In the qualitative studies (II, III), content analysis was performed on material from nine focus group discussions (FGDs) with 53 married women of reproductive age (study II) and four FGDs with 20 midwives or other family health providers at the facilities (study III). In study IV, an educational programme on family planning services was applied at a regular monthly meeting with half of the in-charges after random selection of the total of 74 family health units (intervention group). The other half constituted the control group. The educated in-charges were requested to carry out a similar kind of programme with all peers at their health facilities within one month. All in-charges received one self-administered questionnaire one month (follow-up I) and 27 months (follow-up II) after the education. Such tests were also performed by the peers at their workplace within one month after the in-charges’ tests. Findings: The providers treated the clients respectfully in more than 80% of the consultations and discussed a return visit in 89%. Privacy was not assured in onethird of the cases. Over two-thirds of the clients were not encouraged to ask questions or raise concerns, and 54% were not satisfied with the amount of information given. The use of educational audio-visual and printed materials was very infrequent. Most new clients received their preferred contraceptive method, but were informed about neither other available methods, nor common side effects and warning symptoms related to the chosen method (study I). The women in the FGDs appreciated the public services for being generally accessible, but important shortcomings were identified. A need for improved privacy, a wider choice of contraceptive methods and clear information about side effects were stressed. Marital counselling was raised as a major unmet need. The women’s sense of having the right to make autonomous reproductive health choices and to be treated with dignity and respect emerged as the main theme. A second, cross-cutting theme was their wish to get their husbands more strongly involved in family planning and sexual counselling (study II). The most satisfying for the providers was working with clients. A dominant theme in all FGDs was the providers’ frustration about a number of factors, most of which were beyond their control. There were five categories of system and organisational barriers: multiplicity of tasks and incompatibility with the providers’ own basic training; suboptimal supervision and management; too little time for clients; lack of privacy and appropriate materials for education and counselling; and inadequate opportunities for continuing education (study III). The health centres and health posts located in low-income areas on average had the highest workload for family planning and the highest turnover of staff. Knowledge (percent of maximal possible score) was significantly higher in the intervention group than in the control group, both at follow-up I (63%) and at followup II (57%); with a difference of 16 and 5 percentage units, respectively. Two of the nine reported items were performed at a significantly higher level among the non incharges in the intervention group at follow-up II compared with the control group. Conclusions: There is a gap between the national policy and the reality in the public primary health facilities with regard to the quality of reproductive health services. Multifaceted interventions are recommended to improve performance of the providers, and quality and responsiveness of the services to ensure women’s reproductive health needs and rights. Special attention should be paid to interactive communication, information given to clients, privacy and confidentiality. Interventions should also address needs-based in-service education, including on-site peer education, supportive supervision and management, provision of educational materials, simplifying record management, and appointing more staff in socioeconomically deprived areas. Research is needed to identify the best ways to integrate the services without overloading and deskilling health workers and impairing their ability to deliver high quality services, as well as to find the most effective way of meeting the providers’ continuing educational needs.