DHS ANALYTICAL 

STUDIES 60

Provider Counseling 

and Knowledge Transfer 

in Health Facilities of Haiti,

Malawi, and Senegal

August 2016

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Shireen Assaf, Wenjuan Wang, and Lindsay Mallick of ICF International.

DHS Analytical Studies No. 60 

Provider Counseling and Knowledge Transfer in Health 

Facilities of Haiti, Malawi, and Senegal 

Shireen Assaf 

Wenjuan Wang 

Lindsay Mallick 

ICF International 

Rockville, Maryland, USA 

August 2016 

Corresponding author: Shireen Assaf, International Health and Development, ICF International, 

530 Gaither Road, Suite 500, Rockville, MD 20850, USA. Phone: +1 301–407–6500; Fax: +1 301–407–

6501; E-mail: Shireen.Assaf@icfi.com 
Acknowledgment: 

The authors are grateful for the comments provided by Suresh Mehata on an earlier version of the report. 

Special thanks also goes to Paul Ametepi for his support on general questions related to SPA surveys. 

Editor: Bryant Robey 

Document Production: Natalie La Roche 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#GPO–C–00–08–00008–00). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about the DHS Program contact: 

DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. Phone: +1 

301-407-6500; Fax: +1 301-407-6501; E-mail: info@DHSprogram.com; Internet: www.DHSprogram.com 

Recommended citation: 

Assaf, Shireen, Wenjuan Wang, and Lindsay Mallick. 2016. Provider Counseling and Knowledge Transfer 

in Health Facilities of Haiti, Malawi, and Senegal. DHS Analytical Studies No. 60. Rockville, Maryland, 

USA: ICF International. 
iii 

Contents 

TABLES .............................................................................................................................................................. V 

FIGURES .......................................................................................................................................................... VI 

PREFACE ....................................................................................................................................................... VII 

ABSTRACT ...................................................................................................................................................... IX 

EXECUTIVE SUMMARY ............................................................................................................................. XI 

1. INTRODUCTION AND RATIONALE .............................................................................................. 1 

1.1. Literature Review ...................................................................................................................... 1 

2. DATA AND METHODS ...................................................................................................................... 5 

2.1. SPA Data ................................................................................................................................... 5 

2.2. Measures .................................................................................................................................... 5 

2.3. Analysis ..................................................................................................................................... 8 

3. RESULTS ............................................................................................................................................ 11 

3.1. Antenatal Care ......................................................................................................................... 11 

3.2. Family Planning ....................................................................................................................... 23 

3.3. Sick Child Care ........................................................................................................................ 29 

4. DISCUSSION AND CONCLUSION ................................................................................................. 35 

4.1. Antenatal Care ......................................................................................................................... 36 

4.2. Family Planning ....................................................................................................................... 37 

4.3. Sick Child Care ........................................................................................................................ 38 

4.4. Limitations ............................................................................................................................... 38 

4.5. Conclusion ............................................................................................................................... 39 

REFERENCES ................................................................................................................................................. 41 

APPENDICES ................................................................................................................................................... 45 

v 

Tables 

Table 1. Selection of indicators from the DHS surveys of the countries included in the analysis .......... 3 

Table 2. Number of facilities interviewed and consultations observed in SPA surveys included 

in this report ............................................................................................................................... 5 

Table 3. Percentage of providers observed to offer counseling on the following ANC items and 

the percentage of clients reporting receiving the counseling, with reported percent 

agreement and kappa statistics ................................................................................................ 12 

Table 4. Adjusted incidence risk ratios for counseling variables in the regressions of the number 

of danger signs the client knows .............................................................................................. 22 

Table 5. Adjusted incidence risk ratios for counseling variables in the regressions of the number 

of ways the client knows to prepare for delivery ..................................................................... 22 

Appendix 1. Quality of Counseling for Haiti: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 46 

Appendix 2. Quality of Counseling for Malawi: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 48 

Appendix 3. Quality of Counseling for Senegal: Cross tabulation of provider and client reported 

counseling and client, provider and facility background characteristics ................................. 50 

Appendix 4. Regression of the number of danger signs that could occur during pregnancy that 

the client knows with reported incidence risk ratios ................................................................ 52 

Appendix 5. Regressions of the number of way the client knows to prepare for delivery with reported 

incidence risk ratios ................................................................................................................. 54 

Appendix 6. Quality of Counseling for Haiti: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 56 

Appendix 7. Quality of Counseling for Malawi: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 58 

Appendix 8. Quality of Counseling for Senegal: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 60 

Appendix 9. Family planning client exit questions used to assess client’s general knowledge 

of method use .......................................................................................................................... 62 

Appendix 10. Quality of Counseling for Haiti: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 63 

Appendix 11. Quality of Counseling for Malawi: Cross tabulation of provider and client reported 

counseling and client, provider, and facility background characteristics ................................ 65 

Appendix 12. Quality of Counseling for Senegal 2012-13: Cross tabulation of provider and client 

reported counseling and client, provider, and facility background characteristics .................. 67 

Appendix 13. Quality of Counseling for Senegal 2014: Cross tabulation of provider and client 

reported counseling and client, provider, and facility background characteristics .................. 69 
vi 

Figures 

Figure 1. Percent of providers observed to offer counseling on the following items during 

ANC visits ............................................................................................................................... 11 

Figure 2. Agreement between observation and client’s report on ANC counseling items, Haiti ........... 14 

Figure 3. Agreement between observation and client’s report on ANC counseling items, Malawi ....... 14 

Figure 4. Agreement between observation and client’s report on ANC counseling items, Senegal 

2014 ......................................................................................................................................... 15 

Figure 5. Client’s report of advice given by provider ............................................................................. 16 

Figure 6. Number of danger signs client knows ..................................................................................... 17 

Figure 7. Number of ways client knows to prepare for delivery ............................................................. 18 

Figure 8. Number of side effects of iron pills client knows .................................................................... 18 

Figure 9. Client’s responses concerning knowledge of danger signs ..................................................... 19 

Figure 10. Client’s responses on what to have in preparation for delivery ............................................... 19 

Figure 11. Mean number of danger signs client knows by counseling variables ...................................... 20 

Figure 12. Mean number of ways client knows to prepare for delivery, by counseling variables ............ 21 

Figure 13. Percentage of providers observed to provide specific counseling items during family 

planning visits .......................................................................................................................... 23 

Figure 14. Agreement between observation and client’s report on family planning counseling 

items in Haiti ........................................................................................................................... 25 

Figure 15. Agreement between observation and client’s report on family planning counseling 

items in Malawi ....................................................................................................................... 26 

Figure 16. Agreement between observation and client’s report on family planning counseling 

items in Senegal 2012-13 ........................................................................................................ 27 

Figure 17. Percent of family planning clients with correct knowledge of method use and correct 

knowledge of method’s protection against STIs...................................................................... 28 

Figure 18. Percent of providers observed to provide counseling on child health items ............................ 29 

Figure 19. Agreement between observation and client’s report on sick child counseling items, 

Haiti ......................................................................................................................................... 31 

Figure 20. Agreement between observation and client’s report on sick child counseling items, 

Malawi ..................................................................................................................................... 31 

Figure 21. Agreement between observation and client’s report on sick child counseling items, 

Senegal 2012-13 ...................................................................................................................... 32 

Figure 22. Agreement between observation and client’s report on sick child counseling items, 

Senegal 2014 ........................................................................................................................... 32 
vii 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to analyze DHS data and provide findings that will be useful 

to policymakers and program managers in low- and middle-income countries. DHS Analytical Studies serve 

this objective by providing in-depth research on a wide range of topics, typically including several 

countries, and applying multivariate statistical tools and models. These reports are also intended to illustrate 

research methods and applications of DHS data that may build the capacity of other researchers. 

The topics in the DHS Analytical Studies series are selected by The DHS Program in consultation with the 

U.S. Agency for International Development. 

It is hoped that the DHS Analytical Studies will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program 

ix 

Abstract 

Effective counseling by health care providers can increase client’s knowledge and improve health 

outcomes. This study uses data from the Service Provision Assessment (SPA) surveys in Haiti (2013), 

Malawi (2013-14), and Senegal (2012-2013 and 2014) to examine levels of counseling and the extent to 

which observations of counseling given by providers agree or disagree with client reports of counseling 

received. The analysis focuses on counseling during antenatal care (ANC), family planning, and sick child 

visits in health care facilities of the three countries studied. The results reveal overall low levels of 

counseling observed for many of the counseling topics during ANC, family planning, and sick child visits. 

Overall, agreement in five counseling topics related to ANC is generally low. For family planning, estimates 

reveal a fair level of agreement between observed and client-reported counseling in all three countries. 

Agreement was low to fair for most topics related to sick child counseling, with the highest level of 

agreement when both the observation and client report agreed that counseling did not occur. Regression 

analysis revealed that the strongest predictor of client knowledge related to ANC was when both observed 

counseling and client reports agreed that counseling occurred. Results of this study indicate a need for 

improvement in the quality of counseling, suggested by the lack of overall counseling, the low level of 

client-observation agreement that counseling occurred, and the finding that a key factor in increasing client 

knowledge is for the client to acknowledge having received the counseling provided. 

KEYWORDS: provider-client interaction, antenatal care counseling, danger signs, preparation for 

delivery, family planning counseling, knowledge of methods, sick child counseling, child care counseling, 

Haiti, Malawi, Senegal 

xi 

Executive Summary 

Introduction 

If conducted effectively, provider counseling during health care visits can increase client’s knowledge of 

their health risks and responsibilities. Previous studies have found that counseling provided during antenatal 

care (ANC), family planning, and sick child visits can improve related maternal and child health outcomes. 

This study explores the level of counseling and knowledge transfer from the provider to the client during 

ANC, family planning, and sick child visits in health care facilities of Haiti, Malawi, and Senegal. The 

analysis considered both the observation of whether counseling was performed and the client’s report of 

whether counseling was received. 

Methods 

The analysis used data from four Service Provision Assessment (SPA) surveys in three countries: Haiti 

2013, Malawi 2013-2014, Senegal 2012-2013, and Senegal 2014. For each type of visit—ANC, family 

planning, or sick child—and for several counseling topics, the observation and client’s report were 

combined to examine the level of agreement. Cohen’s kappa statistics and percent agreement estimates 

were produced for each counseling item. In addition, regression analysis was performed on the number of 

danger signs during pregnancy known by the client and the number of ways to prepare for delivery. The 

regression included the combined counseling variable as well as client, provider, and facility characteristics. 

No regressions on family planning and sick child knowledge were performed, since there was little 

variability in the family planning knowledge outcomes and there were no questions asked to test clients 

(caretakers) on sick child knowledge. 

Results 

ANC: 

Eight different counseling topics were observed during the ANC visit: danger signs during pregnancy, 

nutrition during pregnancy, how to prepare for delivery, where to deliver, exclusive breastfeeding, family 

planning after delivery, how to take iron bills, and side effects of iron pills. All three countries had low 

levels of counseling observed for exclusive breastfeeding, family planning after delivery, and side effects 

of iron pills. With a few exceptions, both Haiti and Malawi had low levels of agreement between the 

observation and client’s report. Senegal had higher levels of agreement on five of the eight counseling 

items, indicating a moderate level of agreement according to the kappa estimates. However, Senegal also 

had the lowest levels of observed counseling. In both Senegal and Haiti, the lowest level of agreement was 

for counseling on danger signs during pregnancy. The level of positive agreement (both observation and 

client agree) on counseling for danger signs was 17% in Haiti, 23% in Senegal, and 33% in Malawi. The 

level of positive agreement for pregnancy preparation was 7% in Haiti, 18% in Senegal, and 55% in Malawi. 

Two knowledge variables related to ANC were analyzed: the number of danger signs known and the number 

of ways the client knows to prepare for delivery. Regression results for both outcomes revealed no statistical 

difference between the knowledge of clients who agreed with the observation that no counseling was given 

and the knowledge of clients who reported not being counseled but the provider was observed to have given 

the counseling. For both outcomes it was the client’s report that the counseling occurred that was 

significantly associated with increased knowledge, and the highest estimates were when both observation 

and the client’s report agreed that the counseling occurred. 
xii 

Family planning: 

Family planning providers were observed as to whether they provided counseling to clients who had 

questions or concerns about their current method, how to use a method provided or prescribed during the 

visit, side effects of the method, and when to return for follow-up services. In all three countries counseling 

on client’s questions on current method and how to use the method was more commonly observed than 

counseling on side effects and follow-up services. The kappa estimates showed a fair level of agreement 

for all the counseling items in all three countries. When combined with the client’s report on whether 

counseling occurred, high levels of positive agreement (client and observation agree) were found in Haiti 

for counseling on how to use method, and in Malawi and Senegal for counseling on problems with current 

method and how to use the method. 

In all three countries client’s knowledge on method use was very high. Client’s knowledge on their 

method’s protection from STIs was high in Haiti and Malawi, at 85% or more, while in Senegal 58% of 

clients had correct knowledge of their method’s protection from STIs. 

Sick child care: 

There were four different types of counseling observed during the sick child visit: whether or not the 

provider told the client what illness the child had, whether the provider informed the child’s caretaker about 

the signs or symptoms for which they should bring the child back immediately, whether the child’s weight 

or growth was discussed, and whether the provider asked about feeding the child when the child is sick. 

The highest level of counseling observed was on feeding when the child is sick (15%-25%), except for 

Malawi, where the highest level of counseling was observed for informing the caretaker of the child’s illness 

(41%). There was almost no agreement or only a fair level of agreement between the observation of 

counseling provided and the client’s report, for all four counseling items. In contrast, the level of agreement 

was high between the observation and client’s report that the counseling did not occur, in all countries and 

for all counseling items except in Malawi for counseling about the nature of the child’s illness. 

Conclusions 

Quality of counseling is generally poor in all three of the study countries. Health workers provided 

inadequate counseling on important elements related to ANC, family planning, and sick child issues, and 

the limited counseling given did not appear to transfer efficiently to client’s knowledge. The study provides 

evidence for the need to provide better training in counseling for health providers. Caution should be taken 

when using self-reported data from clients, because clients tend to over-report receipt of services. 
1 

1. Introduction and Rationale 

Counseling delivered to clients during health care visits can contribute to the increased knowledge of the 

client’s health risks and responsibilities and in turn can have an effect on improving health outcomes. 

However, this depends on the quality of the counseling and whether the information and health messages 

provided are effectively communicated and understood by the client. This study explores the level of 

counseling and knowledge transfer from the provider to the client during antenatal care (ANC), family 

planning, and sick child visits in health care facilities of Haiti, Malawi, and Senegal. The main questions of 

interest are whether providers gave specific counseling related to these services and whether the client 

reported that they received the counseling. Ideally, there should be no difference between the observation 

of counseling and the client’s report of it, with both agreeing that the counseling took place. In order for 

clients to be aware that counseling was provided, however, the counseling must be effective and understood. 

The study analyzes data from three countries with Service Provision Assessment (SPA) surveys that contain 

both observation of provider counseling and client exit interviews in ANC, family planning, and sick child 

services. Further analysis on the knowledge of clients in topics related to recognizing danger signs that 

could lead to pregnancy complications and preparation for delivery is conducted to show whether the 

counseling provided in these areas improved client knowledge after controlling for selected background 

characteristics of clients, providers, and facilities. 

1.1. Literature Review 

Many studies have demonstrated the importance of counseling during health care visits. Studies show that 

counseling provided during ANC visits can increase the likelihood of delivery by a skilled birth attendant, 

birth preparedness, newborn care, breastfeeding, and using contraception after delivery (Ahmad et al. 2012; 

Baqui et al. 2007; Dunlop et al. 2013; Mpembeni et al. 2007; Nikiéma, Beninguisse, and Haggerty 2009; 

Soliman 1999; Sonalkar, Mody, and Gaffield 2014). Specific counseling on danger signs that could lead to 

complications during pregnancy is important as this could help expecting mothers to recognize these danger 

signs and respond in a timely manner. Delays in seeking health care for pregnancy complications increase 

the risk of maternal mortality and morbidity; recognizing and acting on danger signs of pregnancy 

complications can help reduce these risks (Duysburgh et al. 2013; Mbalinda et al. 2014). In addition, women 

who are knowledgeable about danger signs during pregnancy are better prepared for delivery (Kabakyenga 

et al. 2011; Mbalinda et al. 2014). Counseling provided during family planning visits can increase the 

likelihood of contraceptive use and continuation (Kamhawi et al. 2013; Lee et al. 2011). In addition, Judith 

Bruce’s framework on quality of family planning services highlights the importance of the provider-client 

relationship in ensuring a high quality of family planning services (Bruce 1990). Studies have found that 

women who are more satisfied with the quality of family planning services are more likely to continue 

using contraceptive methods and to have higher modern contraceptive prevalence compared with women 

who are less satisfied with the quality of family planning services (Arends-Kuenning and Kessy 2007; 

Blanc, Curtis, and Croft 2002; Mariko 2003; RamaRao et al. 2003; Sanogo et al. 2003). Finally, counseling 

given to mothers on nutrition and feeding practices during child care visits can increase the knowledge of 

mothers and caregivers as well as improve the child’s growth and nutritional status (Santos et al. 2001; 

Zaman, Ashraf, and Martines 2008). 

For counseling to be effective in improving health outcomes for visiting clients and/or their children, it 

must be of good quality, and knowledge must be successfully communicated by the provider and retained 

by the client. Having an effective counseling session during a health facility visit can be related to the 

provider-client interpersonal relationship as well as the provider’s technical competency and attitude 

towards counseling, which is linked to the measurement of quality of care (Bruce 1990; Donabedian 1988; 

Hutchinson, Do, and Agha 2011; Vickers et al. 2007). It can also be linked to the type of counseling 

provided. A study in Egypt found that offering client-centered family planning counseling versus physician-
2 

centered counseling significantly increased the likelihood of contraceptive method continuation (AbdelTawab and Roter 2002). Client-centered counseling includes not only the provider’s communication of 

technical information but also a mutual understanding and collaboration between provider and client 

(Abdel-Tawab and Roter 2002; Clift 2001). In Benin another study found that the use of job aids as 

counseling materials significantly improved the number of counseling items provided, as well as the 

improving clients’ knowledge compared with a control group that did not use job aids (Jennings et al. 2010). 

Time constraints can also have an impact on the quality of counseling because they may prevent the 

provider from having enough time to transfer the required information to the client effectively (Magoma et 

al. 2011; von Both et al. 2006). Finally, language barriers may play a role in the effectiveness of providerclient communication, particularly in countries with multiple local and national languages (Groh et al. 

2011). 

Measuring quality of care at health facilities often relies on either observations of provider-client interaction 

during consultations or on client reports from exit interviews. However, there is limited research assessing 

the consistency or agreement between observations and client reports. This is particularly important when 

only one tool can be implemented because of resource constraints. Bessinger and Bertrand (2001) examined 

the comparability of data from observations and exit interviews at health facilities in Ecuador, Uganda, and 

Zimbabwe. They found that agreement on a majority of the indicators studied was good to excellent and 

was relatively higher on the indicators of interpersonal relationships but lower on those measuring 

information given to clients. Tumlinson and colleagues (2014) compared agreements between simulated 

client data with data from client interviews and observations of client-provider interaction. They found that 

observations more accurately measured indicators related to method choice and provider competence but 

less so for indicators related to information given. Client interviews also yielded low agreement on 

indicators of information given during consultations. 

As mentioned, the current report focuses on three countries with available SPA data on counseling during 

ANC, family planning, and sick child visits in health facilities in Haiti, Malawi, and Senegal. Table 1 shows 

the main indicators reported in the most recent Demographic and Health (DHS) surveys in these countries 

related to use of ANC, family planning, and sick child services. Less than half of women had four or more 

ANC visits in Malawi and Senegal, and less than half were informed of pregnancy complications in Senegal. 

Fertility rates were relatively high, especially in Malawi and Senegal, and modern contraceptive use was 

especially low in Senegal. Care-seeking behavior for symptoms of acute respiratory infections (ARI), fever, 

and diarrhea was higher in Malawi than in the Senegal and Haiti. 
3 

Table 1. Selection of indicators from the DHS surveys of the countries included in the 

analysis 

 

Haiti 

2012 

Malawi 

2010 

Senegal 

2014 

 % % % 

ANC indicators 

Four or more ANC visits for the last pregnancy* 67.3 45.5 48.1

Informed of signs of pregnancy complications* 65.0 79.5 44.0 

Family planning indicators 

Total fertility rate for the three years preceding the survey 3.5 5.7 5.0 

Modern contraceptive use among currently married women 31.3 42.2 20.3 

Knowledge of modern methods among married women 100.0 99.7 96.5 

Informed about side effects or problems with method among women

currently using a method 73.4 78.7 80.2 

Informed about what to do if experienced side effects with method 

among women currently using a method 63.7 74.9 76.6 

Sick child indicators 

Under-five mortality rate (per 1,000 live births) in the 10 years 

preceding the survey 88 112 54 

Knowledge of ORS packets* 98.2 95.9 73.4 

Children under age 5 with ARI symptoms taken to a health facility 37.9 70.3 42.2 

Children under age 5 with fever symptoms taken to a health facility 40.1 64.6 45.8 

Children under age 5 with diarrhea symptoms taken to a health facility 33.9 62.1 32.9 

* Among women with a live birth in the five years preceding the survey 

Source: STATcompiler

Of particular relevance to this report is the proportion of women who reported that they know or have 

received information on particular topics. As Table 1 shows, almost all married women have knowledge of 

modern contraceptive methods but not all reported receiving information about the side effects or problems 

of the methods or know what to do if they experience side effects. The percentage of women who reported 

receiving information on signs of pregnancy complications ranged from a high of 80% in Malawi to just 

44% in Senegal. Almost all women in Haiti and Malawi and almost three-fourths (73%) of women in 

Senegal have heard of ORS packages. These data suggest a need for improving the level of counseling or 

information provided to women about family planning as well as recognizing pregnancy complications. 

Further analysis of the counseling provided in health facilities can shed more light on the quality of the 

counseling in these areas and whether it is effective in transferring knowledge to clients visiting the facilities 

for ANC, family planning, and sick child services. 

5 

2. Data and Methods 

2.1. SPA Data 

The Service Provision and Assessment (SPA) surveys conducted by The DHS Program are designed to 

assess the delivery of services in the health care facilities of a country, taking a national sample of the 

country’s formal-sector health facilities or in some countries a census of all the health facilities in the 

country. The SPA surveys include a health facility inventory, which collects information on the 

infrastructure, equipment, commodities, and medicines available in the health facility and, if applicable, 

whether they are valid or functioning. The SPA survey also collects data on service providers and may 

include an observation checklist of providers during client consultations as well as exit interviews with the 

observed clients. 

This study is based on data from the SPA surveys in Haiti 2013, Malawi 2013-2014, Senegal 2012-2013, 

and Senegal 2014. For Haiti and Malawi, the SPA was a census, including all formal-sector health facilities 

in the country. The two Senegal SPA surveys are part of the Senegal continuous survey project, which 

began in 2012 and is expected to end in 2017. Each year or round of the Senegal continuous survey contains 

an SPA component and a DHS component. In the 2012-2013 Senegal SPA, observation and exit interviews 

were performed for family planning and sick child services but not for ANC, and in 2014 there were 

observation and exit interviews for ANC and sick child services but not for family planning. The Haiti and 

Malawi SPAs contained observation and exit interviews for all three components. Table 2 summarizes the 

number of facilities and observations included in the SPA surveys analyzed in this study. 

Table 2. Number of facilities interviewed and consultations observed in SPA surveys included in 

this report 

 Haiti 2013 Malawi 2013-2014 Senegal 2012-2013 Senegal 2014 

Number of facilities included in 

the SPA 905 977 364 363 

Number of ANC consultations 

observed 1,620 2,068 NA 1,211 

Number of family planning 

consultations observed 1,302 1,499 968 NA 

Number of sick child 

consultations observed 2,442 3,329 1,311 1,212 

NA = data not available 

2.2. Measures 

The analysis was divided into three main components of ANC, family planning, and sick child services. 

The variables constructed for the analysis of each of these components are described below. 

2.2.1. ANC measures 

Counseling variables: 

The ANC observation checklist contained several observations of counseling during the client’s ANC visit. 

These included counseling on danger signs of pregnancy complications, nutrition during pregnancy, how 

to prepare for delivery, where to deliver, exclusive breastfeeding, family planning after delivery, how to 

take iron bills, and side effects of iron pills. For each of these observations the checklist indicated whether 

the provider asked about, advised, or discussed these topics. The client exit interview included questions 
6 

on whether the counseling items listed above were performed by the provider, with five possible responses: 

1) yes, this visit only; 2) yes, this and previous visit; 3) previous visit only; 4) no; and 5) don’t know. In 

order to match the client’s report on the counseling with the observation of whether the provider gave the 

counseling (i.e. asked about, advised, or discussed the topic), only the responses that included the current 

visit (i.e. responses 1 and 2) were combined to indicate that the client reported that counseling was provided 

during this visit. A variable was then created to combine the observation of the counseling and the client’s 

report of whether the counseling took place. This combined variable has four categories: 1) both agree that 

counseling was not provided; 2) the provider was not observed to give the counseling but the client reported 

receiving it; 3) the provider was observed to give the counseling but the client did not report receiving it; 

and 4) both agree that the counseling was given. For this combined variable (categories 1 and 4), the 

agreement is between the observation checklist and the client’s report. 

In addition to the questions on the counseling items, clients were also asked about specific advice they 

received from the provider during their ANC visit. One of these questions about the advice that the provider 

gave if the client experienced any signs of pregnancy complications. The responses were: 1) seek care at a 

facility; 2) reduce physical activity; 3) change diet; 4) other; and 5) provider did not advise. Only the 

response “seek care at facility” was considered to be the correct advice and was therefore used as a measure 

of the quality of the counseling provided. Another question on exclusive breastfeeding asked of the client 

was how many months the provider recommended exclusive breastfeeding. Only the response of six months 

was considered to be the correct advice. 

Knowledge variables and their associated counseling variables: 

Three main questions in the ANC exit interview tested client knowledge related to danger signs of 

pregnancy complications, how to prepare for delivery, and side effects of iron pills. For the question that 

tested the client’s knowledge of danger signs of pregnancy complications, the possible responses included: 

vaginal bleeding; fever; swollen face or hands; tiredness or breathlessness; headache or blurred vision; 

seizures or convulsions; reduced or no fetal movement; other; and don’t know—for a total of seven possible 

signs that the client could report. The danger signs in the client exit interview were largely the same as 

those in the observation checklist for counseling on danger signs of pregnancy complications, except that 

the question on seizure or convulsions replaced a question about cough or difficulty breathing in the 

observation checklist. 

For the exit interview question testing client knowledge on how to prepare for delivery, the possible 

responses included: emergency transport; money; disinfectant; sterile blade or scissors to cut the cord; 

other; and don’t know—for a total of four main ways to prepare for delivery that the client could report. In 

the observation checklist, counseling on preparation for delivery included whether the provider advised the 

client to prepare for delivery and whether the provider discussed with the client what items to have on hand 

or at home for emergencies. These two observations were combined to create the variable for provider’s 

counseling on preparation for delivery. 

The responses to the exit interview question testing client knowledge on the side effects of iron pills 

included: nausea; black stools; constipation; other; and don’t know. The providers were also observed as to 

whether they counseled clients on side effects of iron pills. 

2.2.2. Family planning measures 

Counseling variables: 

Family planning providers were observed during the counseling process as to whether they asked clients if 

they had questions or concerns regarding their current contraceptive method; whether they counseled on 

how to use the method; whether they discussed side effects of the method; and whether they gave advice 
7 

on when to return for follow-up services. Counseling on problems with the current method and how to use 

the method were observed for all contraceptive method users, while discussion on side effects and when to 

return were observed only for clients who were provided or prescribed the pill, injectable, IUD, or implant. 

In the exit interview family planning clients were asked if the provider had covered each of these counseling 

elements. Combing observation data and client reports data, four variables were created, one for each 

counseling item, to measure agreement between the observations and client reports. These variables, which 

are measured specifically for the method provided or prescribed to the client, have four categories: 1) both 

agree that counseling was not provided; 2) the provider was not observed to give the counseling but the 

client reported receiving it; 3) the provider was observed to give the counseling but the client did not report 

receiving it; and 4) both agree that the counseling was given. 

Knowledge variables: 

Based on exit interview data, two variables were created to assess client’s knowledge on contraceptive 

methods. The first is client’s general knowledge on the method they are using or intend to use. For example, 

pill users were asked “how often do you take the pill?” Clients who reported “once a day” were considered 

to have correct knowledge on pill use. Questions asked for users of other methods are listed in Appendix 4. 

The other knowledge variable is whether clients had correct understanding about STI protection of their 

method. This variable was created based on client’s response to the question “does your method protect 

against sexually transmitted infections (STIs), including HIV/AIDS”. Users of male or female condoms 

who reported “yes” and users of other methods who reported “no” are considered to have correct knowledge 

of method protection against STIs. 

2.2.3. Sick child measures 

Counseling variables: 

The observation of sick child visits included a number of items for counseling of the caretaker (client) 

regarding diagnosis or care for the child. The observer recorded whether or not the provider told the client 

what illness the child had, whether the provider informed the caretaker of the signs or symptoms for which 

they should bring the child back immediately, whether the child’s weight or growth was discussed, and 

whether the provider asked about feeding the child when he or she is ill. In the exit interview clients also 

were asked if the provider spoke to them about the above topics. For the signs and symptoms that indicate 

a caretaker should immediately bring the child back, the client was asked if the provider told them of any 

signs or symptoms for which they must immediately bring the child back. This question included several 

response options listing different signs or symptoms, including: fever, breathing problems, becomes sicker, 

blood in stool, vomiting, poor eating, and poor drinking. If the client reported that the provider mentioned 

at least one of these signs or symptoms, a variable was created to indicate that the client reported receiving 

the counseling. For the other three items, whether the provider told the client what the illness was, whether 

the provider discussed the child’s weight and growth, and whether the provider discussed feeding the child 

when sick, responses of “yes” or “no” were coded as a dichotomous variable. Missing responses or 

responses of “don’t know” or “cannot remember” were treated as no response. 

Consistent with the methodology for creating variables related to the ANC and family planning analyses, a 

variable for each counseling topic related to child illness was created that combined the observation of the 

provider and the client’s report of receiving counseling on that topic, to assess the level of agreement 

between provider and client. As described above, the categories were 1) both agree that counseling was not 

provided; 2) the provider was not observed to give the counseling but the client reported receiving it; 3) the 

provider was observed to give the counseling but the client did not report receiving it; and 4) both agree 

that the counseling was given. 
8 

The sick child exit interview did not contain any questions that could qualify as testing the knowledge of 

the caregivers. Therefore, no knowledge variables were constructed. 

2.2.4. Independent variables 

Characteristics related to the client, provider, and facility were used to construct independent variables for 

the analysis. For the client, this included client’s age (<20, 20-29, 30-35, 36 and above, and don’t know), 

and client’s education (none, primary/post primary, and secondary or more) for analysis of ANC, family 

planning and sick child services. For ANC analysis, the number of ANC visits (first visit, 2, 3, 4 or more) 

and client’s first pregnancy (yes, no) were also included. For the family planning analysis, whether the 

client is a new or returning client and client’s contraceptive method type (pill, progestin injectable, or other) 

were also included. For the sick child analysis, the caretaker relationship (mother or other), and child’s sex, 

child’s age (under age 1, one up to age 3, and age 3-6) were included. The provider variables used in the 

analysis included the provider category (categories varied by ANC, family planning, and sick child 

analysis), years of education (<16, 16-18, 19 or more), provider received training in counseling within 24 

months (yes, no) for the ANC and family planning analysis, and within 36 months for the sick child analysis, 

and the number of items on which they were supervised (none, 1-5, 6). Finally, the facility-related 

independent variables included the managing authority (private/faith/NGO/other or government), health 

facility type (hospital, health center, other, which includes health posts, health huts, etc.), location (urban, 

rural), and region. For Haiti, regional departments were grouped into North (North, Northeast and 

Northwest regions), Center (Artibonite and Center regions), South (South, Southeast, Grand-Anse, and 

Nippes regions) and West (West region). Malawi only contained three regions and so no grouping of regions 

was necessary. For Senegal, provinces were grouped as Northern (Louga, Matam, and Saint Louis regions), 

Dakar, Theis, Central (Diourbel, Fatick, Kaffrine and Kaokack regions), East (Kedougou and Tambacounda 

regions) and South (Kolda, Sediou, and Ziguinchor regions). In addition to the characteristics of client, 

provider, and facility, the duration of the consultation in minutes was also included as an independent 

variable. 

2.3. Analysis 

Cohen’s kappa statistic and percent agreement was used to measure the level of agreement between 

observation of the provider giving the counseling and the client’s report of whether the counseling occurred. 

This procedure was conducted for the counseling measures in ANC, family planning, and sick child 

services, as described above. A kappa estimate between 0.81-1.0 indicates perfect agreement and a kappa 

of zero or less indicates no agreement (McHugh 2012; Viera and Garrett 2005). Between these two 

extremes, a kappa between 0.21-0.40 is considered fair agreement, between 0.41-0.60 is moderate 

agreement, and between 0.61-0.80 is substantial agreement (McHugh 2012; Viera and Garrett 2005). 

Cohen’s kappa can be low when there is a substantial imbalance in the marginal totals of a cross-tabulation 

between two variables or if the component examined is a rare event (Feinstein and Cicchetti 1990; Viera 

and Garrett 2005). However, the kappa statistic has the advantage over the percent agreement statistic in 

that it takes into account that the agreement is not due to chance (Viera and Garrett 2005). Therefore, the 

study reports both the kappa and the percent agreement in the results. A cutoff point of at least 80 percent 

agreement is recommended and is considered acceptable (McHugh 2012); however, this depends on the 

study discipline. In addition, cross tabulations and chi-square tests of independence were performed 

between the counseling variables, which combined the observation and the client’s report and independent 

variables related to the client, provider and facility. For the duration of consultation, an F-test was 

performed to test the independence of the mean duration times with the consultation variables. 

To examine the level of knowledge in ANC-related topics, the outcome variables were the number of danger 

signs during pregnancy the client reported and the number of ways the client knew to prepare for delivery. 

As these outcomes are count data, they were modeled using either Poisson or negative binomial regression. 
9 

A client could report up to a total of seven danger signs and four ways to prepare for delivery. To determine 

whether to use Poisson or negative binomial regression, a test of the goodness of fit of the Poisson model 

was used as well as a likelihood ratio test of the overdispersion parameter. A significant p-value in both 

cases would indicate that a Poisson regression model is not appropriate and a negative binomial regression 

model should be used instead. For these regressions, one model was fit for all clients and a separate model 

was fit for clients with their first pregnancy. In addition, separate models were fit to include the counseling 

variable on whether the provider gave the counseling related to the knowledge and another model to include 

the counseling variable that combined the observation of counseling and the client’s exit interview report. 

For the analysis of family planning knowledge, levels of correct knowledge on method use and STI 

protection were described for each of the three countries. Multivariable regression analysis was not 

performed since most women, 85% or higher (Figure 5), had correct knowledge, except in Senegal for 

knowledge on STI protection. In Senegal only 58% of women correctly identified whether their method 

protects against STIs, but it is not possible to model the transfer of knowledge because the Senegal SPA 

did not ask clients whether they received such counseling during the visit. In Senegal, Assaf, Wang, and 

Mallick (2015) analyzed the effect of whether counseling provided information on method’s protection 

from STIs (obtained for the observation checklist) improved the client’s knowledge on method protection 

against STI. The study showed that counseling did not significantly improve client’s knowledge. 

All analyses took into consideration the cluster and weights for each survey. For Haiti and Malawi the SPA 

was a census and therefore no stratification was required. For the Senegal SPA surveys the stratification 

was achieved by combining facility type and region. 

11 

3. Results 

3.1. Antenatal Care 

3.1.1. Provider-Client Counseling in ANC 

The ANC observation checklist includes eight different types of counseling: counseling on danger signs of 

pregnancy complications, nutrition during pregnancy, how to prepare for delivery, where to deliver, 

exclusive breastfeeding, family planning after delivery, how to take iron bills, and side effects of iron pills. 

Figure 1 shows the percentage of providers who were observed offering these different types of counseling 

during the ANC consultation. In general, in all three countries little counseling was provided on these topic, 

especially counseling on exclusive breastfeeding, family planning after delivery, and the side effects of iron 

pills. Counseling on how to prepare for delivery was also relatively infrequent in Haiti and Senegal. Malawi 

had the highest percentages of counseling observed, compared with Haiti and Senegal, in all areas except 

nutrition during pregnancy, where it was a close second after Haiti. In Malawi over 50% of providers were 

observed to offer counseling on the danger signs of pregnancy complications, how to prepare for delivery, 

where to deliver, and how to take iron pills. 

Figure 1. Percent of providers observed to offer counseling on the following items during ANC visits 

Table 3 includes the client’s reports of whether counseling was provided in all eight ANC counseling items 

during the visit observed for the survey. In general, with a few exceptions such as counseling on danger 

signs, clients reported a higher level of receiving counseling than was observed during the ANC visit. In 

addition, Cohen’s kappa statistics of agreement were performed between the observation of the provider 

offering counseling and the client’s report of having received the counseling. All of the kappa estimates 

were significant and most did not show a high level of agreement, especially for Haiti and Malawi. 

0

10

20

30

40

50

60

70

80

90

100

danger signs of

pregnancy

nutrition during

pregnancy

how to prepare

for delivery

where to deliver exclusive

breastfeeding

FP methods

after delivery

how to take iron

pills

side effects of

iron pills

Percent

Haiti Malawi Senegal 2014
12

Table 3. Percentage of providers observed to offer counseling on the following ANC items and the percentage of clients reporting receiving the counseling, with reported percent agreement and kappa statistics 

Haiti Malawi Senegal 2014 

Provider 

observed 

Client 

reported 

Percent 

agreement Kappa Provider observed Client reported 

Percent 

agreement Kappa Provider observed Client reported 

Percent 

agreement Kappa 

% C.I. % C.I. % % C.I. % C.I. % % C.I. % C.I. % 

Danger signs of 

pregnancy complications Any signs 51.0 [47.3,54.6] 30.3 [26.8,33.8] 52.3 0.053 54.0 [49.3,58.7] 51.3 [47.5,55.1] 60.1 0.200 38.0 [33.6,42.3] 51.3 [46.8,55.9] 56.4 0.134 

Maintaining a 

health pregnancy 

Nutrition during 

pregnancy 

43.3 [39.3,47.3] 33.7 [30.3,37.0] 69.9 0.370 38.7 [33.6,43.8] 49.3 [45.0,53.7] 70.2 0.401 29.8 [25.4,34.2] 28.2 [24.1,32.3] 88.5 0.720 

Preparing for 

delivery How to prepare for 

delivery 

13.7 [11.1,16.3] 17.4 [14.8,20.0] 82.7 0.342 64.8 [60.4,69.1] 74.5 [71.2,77.7] 71.1 0.324 20.3 [16.8,23.9] 23.0 [19.3,26.8] 91.6 0.752 

Where to deliver 23.4 [19.6,27.3] 29.2 [25.6,32.8] 77.7 0.426 51.0 [46.6,55.5] 55.5 [51.4,59.5] 63.1 0.261 5.9 [3.8,8.0] 9.7 [7.2,12.1] 91.7 0.428 

Newborn and 

postpartum recommendations 

Exclusive 

breastfeeding 

5.6 [3.9,7.4] 22.9 [19.9,25.9] 78.9 0.188 6.6 [3.6,9.7] 35.7 [32.1,39.3] 68.1 0.152 0.9 [0.2,1.7] 3.6 [2.0,5.1] 96.7 0.264 

Family planning 

methods after delivery 

8.7 [6.7,10.7] 19.2 [16.7,21.8] 83.8 0.340 11.4 [7.7,15.1] 31.0 [27.6,34.4] 72.0 0.208 2.5 [1.2,3.9] 5.7 [3.9,7.5] 96.1 0.504 

Iron 

How to take iron or 

folic-acid pills 

32.5 [28.7,36.2] 59.3 [55.7,62.9] 59.9 0.247 60.8 [56.2,65.4] 82.8 [79.6,86.1] 71.8 0.342 36.0 [31.3,40.6] 54.5 [49.9,59.1] 75.5 0.522 

Side effects of iron 

pills 

2.9 [1.6,4.1] 13.9 [11.3,16.4] 85.1 0.063 9.4 [6.8,12.0] 12.8 [10.6,15.1] 83.7 0.178 1.1 [0.0,2.2] 3.1 [1.6,4.7] 97.3 0.367 
13 

The significance of the kappa estimates indicates that the reported estimates are not due to chance. In Haiti 

the kappa estimate was less than 0.41 (the threshold for moderate agreement) in all the counseling items 

except for where to deliver, with the lowest agreement for counseling on danger signs (0.053) and side 

effects of iron pills (0.063). The percent agreement in Haiti was above 80% for counseling on how to 

prepare for delivery, family planning after delivery, and side effects of iron pills. The low kappa but high 

percent agreement found in Haiti for counseling on family planning after delivery, exclusive breastfeeding, 

and side effects of iron pills is due to the low levels of counseling provided in these areas, making them 

rare events (Viera and Garrett 2005). 

In Malawi the kappa estimates were also below 0.41 for all counseling items but with counseling on 

nutrition during pregnancy very close to the 0.41 threshold (kappa of 0.401). The lowest kappa was found 

for counseling on exclusive breastfeeding (0.152). Only counseling on side effects of iron pills had a percent 

agreement above 80%; this counseling had a kappa 0.178, and the discrepancy between these two measures 

is again due to the low level of counseling provide in this area. Four counseling items had a percent 

agreement above 70%: nutrition during pregnancy, how to prepare for delivery, family planning after 

delivery, and how to take iron pills. The kappa estimates for these counseling items indicate a fair level of 

agreement. 

Senegal had the highest kappa estimates of the three countries, with five of the eight counseling items 

having a kappa above 0.41, two of which were above 0.61, for counseling on nutrition during pregnancy 

and how to prepare for delivery, indicating substantial agreement for these two counseling items. The lowest 

kappa estimate in Senegal was found for counseling on danger signs of pregnancy complications (0.134), 

and this was also the counseling item with the lowest kappa estimate in Haiti (0.053). While Senegal had 

the highest level of agreement among the three countries, it was the country with the lowest levels of 

observed counseling. Therefore, most of the agreement was due to both the observation and client’s report 

indicating that no counseling was performed in these areas. 

Figures 2-4 show the distribution of the combination of the provider observation and client’s report on the 

counseling items for Haiti, Malawi, and Senegal. The combined counseling variables were not produced 

for counseling on exclusive breastfeeding, family planning after delivery, and the side effect of iron pills 

due to the low percentages of counseling in these areas. In Haiti the level of positive agreement between 

observation and the client’s report that the counseling took place (both agree, yes) was relatively low for 

all counseling items. The level of disagreement between the observation and client was over 40% for 

counseling on danger signs and how to use iron pills. While over 50% of the providers were observed to 

give counseling on danger signs of pregnancy complications (Table 3), there was only 17% agreement 

between the observation of counseling and the client’s report that the counseling occurred. Moreover, there 

was 76% agreement between the observation and client’s report that no counseling was provided on 

preparation for pregnancy. 
14 

Figure 2. Agreement between observation and client’s report on ANC counseling items, Haiti 

Figure 3. Agreement between observation and client’s report on ANC counseling items, Malawi 

35.5

46.5

75.8

62.5

34.1

13.5

10.2

10.5

14.1

33.5

34.2 19.9

6.8

8.3

6.6

16.8 23.4

6.9

15.1

25.8

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

danger signs of

pregnancy

complications

nutrition during

pregnancy

pregnancy

preparation

where to deliver how to use iron

pills

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes

27.4

41.1

15.9

28.3

14.1

18.6

20.2

19.3

20.6

25.1

21.3

9.6

9.6

16.2

3.1

32.7 29.1

55.2

34.8

57.7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

danger signs of

pregnancy

complications

nutrition during

pregnancy

pregnancy

preparation

where to deliver how to use iron

pills

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
15 

Figure 4. Agreement between observation and client’s report on ANC counseling items, Senegal 

2014 

In Malawi the percentages of positive agreement between observation and client’s report that the counseling 

occurred were approximately 30% or above, with the level of agreement in counseling on pregnancy 

preparation and how to use iron pills over 55%. The highest level of disagreement was for counseling on 

danger signs, at almost 40%. 

For Senegal the level of agreement between observation and client’s report on counseling was also 

relatively low, as for Haiti. The least agreement was found in counseling on where to deliver, with only 4% 

agreement that the counseling occurred but with 88% agreement that counseling did not occur. The highest 

level of disagreement was, again, found for counseling on danger signs, at over 40%. 

Cross-tabulations of the five counseling items that combine the observation and client’s reports with client, 

provider, and facility variables are shown in Appendices 1-3. Very few variables were found to be 

significant across all counseling items and in all three countries. In Haiti and Malawi the duration of the 

consultation was significant for most of the counseling items, with the longest duration found when both 

client and observation agree that the counseling took place. In Senegal the duration of consultation was 

only significantly different for counseling on danger signs and nutrition. 

For Haiti, Appendix 1 shows that none of the background variables were significantly associated with the 

combined variable for counseling on danger signs of pregnancy complications. However, the number of 

visits the client previously had made, the provider’s category, the provider’s years of education, and the 

total number of supervisory items were significantly associated with the combined counseling variables on 

nutrition during pregnancy, pregnancy preparation, and where to deliver. The client’s number of visits to 

the facility was also significantly associated with counseling on how to use iron pills. In general, the highest 

percentages of agreement that the counseling was performed were for clients making a first visit to the 

facility and for clients seeing a provider other than a doctor, specialist, or technician. 

33.6

65.2

74.1

88.1

42.5

28.5

4.9

5.6

6.0

21.5

15.1

6.6

2.9

2.3

3.0

22.9 23.3 17.5

3.7

33.0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

danger signs of

pregnancy

complications

nutrition during

pregnancy

pregnancy

preparation

where to deliver how to use iron

pills

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
16 

In Malawi, as Appendix 2 shows, some client variables were significantly associated with most of the 

counseling items, including client’s age, whether the pregnancy was the client’s first, and the number of 

visits to the facility. As in Haiti, clients visiting the facility for the first time had the highest percentage of 

agreement on whether the counseling was offered, although the number of visits to the facility was not 

significant for counseling on danger signs. In Senegal, as Appendix 3 shows, substantially fewer significant 

associations were found compared with Haiti and Malawi. The number of visits to the facility was 

significantly associated with counseling on pregnancy preparation, where to deliver, and how to use iron 

pills. However, compared with Haiti and Malawi, an opposite pattern was observed for counseling on 

pregnancy preparation and where to deliver with clients, with clients making four or more visits having the 

highest percentage of agreement that the counseling occurred. The region variable was also significantly 

associated with all counseling items in Senegal. 

Two more measures were examined to assess the quality of the advice that providers gave to clients during 

their consultation. In the exit interviews clients were asked what advice the provider gave them on what to 

do if complications arise during pregnancy and on how many months to exclusively breastfeed. Figure 5 

shows that in Haiti only 39% of clients reported that the provider advised them to seek care in a facility if 

complications arise during pregnancy, followed by Malawi at 61%, and Senegal at 76%. In Haiti and 

Malawi about two-thirds of clients reported that the provider advised them to exclusively breastfeed for six 

months, compared with about one-quarter of clients in Senegal. 

Figure 5. Client’s report of advice given by provider 

0

10

20

30

40

50

60

70

80

90

100

seek care if complications arise during

preganancy

exclusively breast feed for 6 months

Percent

Haiti Malawi Senegal 2014
17 

3.1.2. Client’s knowledge 

During ANC visits, clients’ knowledge was tested during the exit interview by asking what danger signs 

they know of that could lead to complications during pregnancy, how to prepare for delivery, and the side 

effects of taking iron pills. As Figure 6 shows, in all three countries more than half of the clients knew at 

least one danger sign of pregnancy complications; however, less than 20% knew more than two danger 

signs and less than half a percent knew all seven possible danger signs. 

Figure 6. Number of danger signs client knows 

The level of knowledge on how to prepare for delivery was lowest in Haiti, with two-thirds (66%) of clients 

not knowing any of the four possible ways to prepare for their delivery (Figure 7). In Haiti only one-third 

(34%) of clients knew at least one way to prepare for delivery, while in Malawi two-thirds (65%) of clients 

and in Senegal nearly two-thirds (60%) of clients knew. Clients’ knowledge of the side effects of iron pills 

was low in all three countries. Figure 8 shows that in Haiti 82% of clients did not know any of the side 

effects of iron pills, and in Malawi 91%. In Senegal about two-thirds (65%) of clients did not know any 

side effects of iron pills. Due to these low levels of knowledge as well as the low percentages of counseling 

on the side effects of iron pills provided to clients (Figure 1), this knowledge outcome was not analyzed 

further in the regressions. 

42.6

44.5

34.9

20.9

22.5

26.6

18.2

18.3

18.9

13.6

10.7

8.7

3.2

3.0

5.8

0.6

0.8

3.3

0.6

0.1

1.5

0.3

0.1

0.3

0 10 20 30 40 50 60 70 80 90 100

Haiti

Malawi

Senegal 2014

0 1 2 3 4 5 6 7

Percent
18 

Figure 7. Number of ways client knows to prepare for delivery 

Figure 8. Number of side effects of iron pills client knows 

Figure 9 shows that in all three countries the most reported danger sign that clients reported knowing about 

was vaginal bleeding, followed by headache or blurred vision. In Malawi and Senegal over 45% of clients 

66.0

35.6

40.9

22.6

47.4

31.9

8.6

13.2

23.4

2.3

3.7

3.5

0.5

0.2

0.2

0 10 20 30 40 50 60 70 80 90 100

Haiti

Malawi

Senegal 2014

0 1 2 3 4

Percent

81.8

91.0

65.4

14.4

7.5

28.8

3.2

1.5

5.0

0.5

0.0

0.8

0 10 20 30 40 50 60 70 80 90 100

Haiti

Malawi

Senegal 2014

0 1 2 3

Percent
19 

reported vaginal bleeding as a danger sign compared with 29% of clients in Haiti. Figure 10 shows that 

clients primarily reported knowing about having money in preparation for delivery, at 25% in Haiti and 

49% in Senegal, but for Malawi the most reported knowledge about how to prepare was having a sterile 

blade or scissors to cut the cord (58%). In general, there was a low level of knowledge of the three main 

side effects of iron pills, with nausea as the most reported by clients in all countries, at an estimated 15% 

in Haiti, 8% in Malawi, and 25% in Senegal (not shown). 

Figure 9. Client’s responses concerning knowledge of danger signs 

Figure 10. Client’s responses on what to have in preparation for delivery 

0

10

20

30

40

50

60

70

vaginal

bleeding

headache or

blurred

vision

swollen face

or hand

seizures or

convulions

fever tiredness or

blurred

vision

no fetal

movement

Percent

Haiti Malawi Senegal 2014

0

10

20

30

40

50

60

70

money sterile blade or scissors

to cut cord

emergency transport disinfectant

Percent

Haiti Malawi Senegal 2014
20 

Figure 11 shows the mean number of danger signs the client knows by the two counseling variables of 

interest. There are a total of seven possible danger signs indicating a pregnancy complication that clients 

should know, but for all three countries the mean number of danger signs known did not exceed 1.5. This 

mean differed by the counseling variables. In general, all countries showed a higher mean number of danger 

signs known if the provider gave counseling, but this difference does not appear to be significant in Haiti. 

For the counseling variable that combines the client’s report and the observation of counseling, the mean 

number of danger signs known increases significantly, to almost two or more, when the observation and 

client’s report agree. There was no significant difference in all three countries in the means between clients 

who agreed with the observation that no counseling was provided and clients who reported that no 

counseling was provided but observation showed that counseling was given. For Senegal, there was no 

significant difference between the three categories of agreement that no counseling was given, provider not 

observed to give counseling but client reported counseling given, and provider observed but client did not 

report counseling was given. 

Figure 11. Mean number of danger signs client knows by counseling variables 

0

0.5

1

1.5

2

2.5

3

No Yes both agree,

no

prv no, cl yes prv yes, cl no both agree,

yes

Provider gave counseling

on any of the danger signs

Agreement on counseling of danger signs Total

Mean

Haiti Malawi Senegal 2014
21 

Figure 12 shows the mean number of ways the client knows to prepare for delivery by the counseling 

categories for delivery preparation. There are a total of four possible ways to prepare for a delivery but for 

all three countries the mean number of ways that clients knew was below one, with Haiti having a mean of 

just one-half. Similar to the findings for knowledge of danger signs, the mean number of ways the client 

knew to prepare for delivery was highest when there was agreement between observation and client’s report 

that the counseling took place, at 1.5 in Senegal, 1.0 in Malawi, and 0.7 in Haiti. Also for this type of 

counseling, in all three countries there was no significant difference in the means between clients who 

agreed with observation that no counseling was provided and clients who reported that no counseling was 

provided but the counseling was observed to be given. 

Figure 12. Mean number of ways client knows to prepare for delivery, by counseling variables 

Poisson or negative binomial regressions were used depending on the goodness of fit test and the test of the 

overdispersion parameter, as described in the methods section. Four models were fit for each country and 

each outcome. Two models were fit for all clients, one of which includes the variable of whether the 

provider was observed to give counseling and the other to include the counseling variable that combines 

the observation and client’s report. The same two models were also fit for clients having their first 

pregnancy. The results for the main independent variable of interest, counseling, are found in Tables 4 and 

5, and the summary of the estimates for all the independent variables in the model are found in Appendices 

4 and 5. 

As Table 4 shows, all models indicated that receiving counseling on any of the seven danger signs increased 

the expected number of danger signs the client knew, and this was significant except in Haiti. In Malawi 

and Senegal the effect of counseling was much higher for clients with their first pregnancy compared with 

all clients. In both countries the number of danger signs known increased by 190% if clients received 

counseling for their first pregnancy compared with those that did not receive counseling. However, as 

shown with the combined variable of observation and client’s report on counseling, if the provider gave 

counseling but the client did not report receiving it, this did not significantly increase the number of danger 

signs the client knew compared with clients who agreed with the observation that no counseling was given. 

In Haiti and Malawi, even if observation did not show that the client was given the counseling but the client 

reported receiving counseling, the number of danger signs clients knew increased compared with clients 

who agreed with the observation that no counseling was given. For all countries and all models, there was 

0

0.5

1

1.5

2

No Yes both agree,

no

prv no, cl yes prv yes, cl no both agree,

yes

Provider counseling on

preperation for delivery

Agreement on counseling for preperation of delivery Total

Mean

Haiti Malawi Senegal 2014
22 

no significant difference in the number of danger signs known between clients who were counseled but did 

not report being counseled and clients who agreed with the observation that the consultation was not given. 

The highest incidence risk ratios in the number of danger signs known for all countries were found for 

clients who agreed with the observation that the counseling occurred. 

Table 4. Adjusted incidence risk ratios for counseling variables in the regressions of the number of danger 

signs the client knows 

Haiti Malawi Senegal 2014 

Distribution nbreg nbreg poisson nbreg 

Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients

1st 

preg 

all 

clients

1st 

preg 

all 

clients 

1st 

preg 

all 

clients

1st 

preg 

all 

clients

Counseled on any of the seven signs of pregnancy complications (ref.=no) 

Yes 1.1 1.1 2.9*** 1.6*** 2.9*** 1.7*** 

Agreement on counseling on signs of pregnancy complications (ref.= both agree no counseling) 

Provider did not counsel, but 

client reported receiving 

 1.8*** 1.6*** 7.4*** 4.5*** 1.1 1.0 

Provider counseled, but client 

did not report 

 0.9 1.0 1.0 0.9 0.9 0.9 

Both agree counseling was 

provided 

 2.4*** 2.0*** 11.9*** 5.7*** 3.9*** 2.4***

Notes: Distributions are either negative binomial or poisson. Adjusted results control for client, provider and facility variables. For 

full adjusted models see Appendix 4. * p<0.05, ** p<0.001, *** p<0.001 

Table 5 summarizes the adjusted incidence risk ratio for the counseling variables in the regression of the 

number of ways the client knows to prepare for delivery. In Malawi and Senegal receiving counseling on 

how to prepare for delivery significantly increased the number of ways the client knows to prepare for 

delivery compared with those who did not receive counseling, but this was not significant in Haiti. When 

the clients report is combined with the observation of the counseling, we find similar results as in Table 5. 

In all three countries it was the presence of the clients report that the counseling was given that significantly 

increased their knowledge. If the provider was observed to give counseling but the client did not report 

receiving it, this did not increase the client’s knowledge in the number of ways to prepare for delivery 

compared with clients who agreed with the observation that the counseling was not given. 

Table 5. Adjusted incidence risk ratios for counseling variables in the regressions of the number of ways the 

client knows to prepare for delivery 

Haiti Malawi Senegal 2014 

Distribution nbreg poisson poisson 

Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients

1st 

preg 

all 

clients

1st 

preg 

all 

clients 

1st 

preg 

all 

clients

1st 

preg 

all 

clients

Counseled on how to prepare for delivery (ref.= no)

Yes 1.1 1.2 1.4** 1.3*** 3.2*** 1.5*** 

Agreement on counseling on preparation for delivery (ref.= both agree no counseling)

Provider did not counsel, but 

client reported receiving 1.7*** 1.6*** 3.6*** 2.3*** 2.4*** 1.4***

Provider counseled, but client 

did not report 0.9 1.0 1.1 1.1 2.2 1.3 

Both agree counseling was 

provided 1.6* 1.6** 3.4*** 2.4*** 4.0*** 1.6***

Notes: Distributions are either negative binomial or poisson. Adjusted results control for client, provider and facility variables. For 

full adjusted models see Appendix 5. * p<0.05, ** p<0.001, *** p<0.001
23 

3.2. Family Planning 

3.2.1. Provider-client counseling in family planning 

Family planning providers were observed as to whether they counseled clients on their questions or 

concerns on current contraceptive method, how to use a method provided or prescribed during the visit, 

side effects of the method, and when to return for follow-up services. Figure 13 presents the percentage of 

providers who were observed to provide each of the counseling items. In all three countries counseling on 

client’s questions on current method and how to use the method was more commonly observed than 

counseling on side effects and follow-up services. Among the countries, Malawi had a higher percentage 

of family planning providers observed to counsel clients on each of the four counseling items compared 

with Haiti and Senegal. For example, 76% of providers in Malawi compared with 64% in Haiti and 56% in 

Senegal were observed to discuss with the client how to use the method. Counseling on side effects, the 

least-provided service, was observed for 38% of providers in Malawi, 26% in Senegal, and 21% in Haiti . 

Figure 13. Percentage of providers observed to provide specific counseling items during family 

planning visits 

0

10

20

30

40

50

60

70

80

90

100

Questions or concerns

with current method

How to use method Side effects When to return

Percent

Haiti Malawi Senegal 2012-13
24 

Table 6 shows that, overall, clients reported higher levels of receiving the four counseling items than was 

observed during the consultation, except counseling in Malawi on how to use the method, where a lower 

percentage of clients reported receiving this counseling than the percentage observed. While counseling on 

when to return for follow-up services was the second-least observed, it was the most reported by the clients 

(over 90% in all three countries). Kappa statistics verify that the agreement between the observation and 

client’s report was fair (all were below the threshold of 0.40), especially for counseling on how to use a 

method, which had the lowest kappa among the counseling items in each country. All of the kappa statistics 

were significant, indicating that they are not due to chance, except for the kappa estimates in Haiti for how 

to use method, and in Malawi and Senegal for when to return for follow-up. A non-significant kappa 

indicates that the kappa estimate may be due to chance. The percent agreements between observation and 

client’s report were all below 80%. Only counseling on questions or concerns with current method in 

Malawi and Senegal had a percent agreement above 70%. 

Table 6. Percentage of providers observed to offer counseling on the following family planning items and 

the percentage of clients reporting receiving the counseling, with reported percent agreement and kappa 

statistics 

Haiti Malawi 

Provider 

observed 

Client 

reported 

Percent 

agreement Kappa

Provider 

observed 

Client 

reported 

Percent 

agreement Kappa

% C.I. % C.I. % % C.I. % C.I. % 

Questions or 

concerns 

with current 

method 

40.2 [35.9,44.5] 55.2 [51.0,59.4] 62.4 0.267 72.2 [67.0,77.4] 71.6 [66.3,76.9] 70.5 0.242

How to use 

method 

64.4 [59.7,69.2] 65.0 [61.1,68.9] 57.3 0.057 75.6 [70.2,81.1] 67.6 [61.4,73.8] 61.7 0.062

Side effects 20.9 [17.6,24.3] 57.4 [53.5,61.3] 57.1 0.209 37.5 [32.4,42.6] 59.3 [54.3,64.3] 61.7 0.266

When to 

return 

22.8 [19.5,26.0] 92.0 [89.4,94.6] 29.4 0.028 40.9 [36.3,45.5] 93.4 [91.4,95.5] 40.8 -0.022

Senegal (2012-13) 

Provider 

observed 

Client 

reported 

Percent 

agreement Kappa 

% C.I. % C.I. % 

Questions or 

concerns 

with current 

method 

51.4 [46.7,56.2] 79.9 [75.7,84.1] 74.1 0.346 

How to use 

method 

56.1 [51.9,60.3] 86.8 [83.7,90.0] 60.7 0.085 

Side effects 25.6 [21.7,29.6] 75.1 [70.5,79.7] 45.9 0.119 

When to 

return 

34.2 [30.2,38.2] 98.4 [97.3,99.5] 37.9 0.011 
25 

Figures 14-16 present the percent distribution by four categories of agreement between observation data 

and client’s report for each counseling element. Generally, it is desirable to see a high level of positive 

agreement: that is, the provider was observed to give the counseling and the client reported receiving the 

counseling. In Haiti the highest level of positive agreement was on counseling on how to use the method: 

in 44% of these consultations the provider was observed to give the counseling and the client reported 

receiving it. Disagreement between the observation and client’s report includes two scenarios: the provider 

was observed to give the counseling but the client reported not receiving it, or the provider was not observed 

to give the counseling but the client reported receiving counseling. The highest disagreement occurred for 

counseling on when to return for follow-up services; in 70% of cases clients reported receiving counseling 

but providers were not observed to give the counseling. There was 39% agreement that the counseling on 

side effects did not take place, which was the highest among the four counseling times (Figure 14). 

Figure 14. Agreement between observation and client’s report on family planning counseling items 

in Haiti 

34.7

13.3

39.2

7.2

27.5

21.0

39.6

69.8

10.1

21.7

3.3

0.8

27.8

43.9

17.8 22.2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problems with current

method

How to use the method Side effects When to return

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
26 

In Malawi the highest level of positive agreement was for counseling on problems with the current method, 

at 59%, followed by counseling on how to use the method, at 53%. In Malawi as in Haiti, a considerable 

proportion of clients (56%) reported receiving counseling on when to return for follow-up services but the 

provider was not observed to provide the counseling. Counseling on side effects had the highest level of 

agreement that the counseling did not take place, at 32% (Figure 15). 

Figure 15. Agreement between observation and client’s report on family planning counseling items 

in Malawi 

11.6 9.0

32.2

3.2

12.7 14.9

29.8

55.8 16.8 23.4

8.5

3.3

58.9

52.7

29.5

37.6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problems with current

method

How to use the method Side effects When to return

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
27 

Figure 16 shows that in Senegal there was 61% agreement between the observation and the client’s report 

that counseling on problems with current method occurred during the consultation. The highest level of 

disagreement was again found for counseling on when to return follow-up. In 62% of cases, clients reported 

that the counseling took place but the providers were not observed to give the counseling. Among the three 

countries, Senegal had the lowest percentages of agreement that the counseling did not occur. 

Figure 16. Agreement between observation and client’s report on family planning counseling items 

in Senegal 2012-13 

Provider-client agreement on counseling items was also examined by client, provider, and facility 

characteristics (Appendices 6-8). Overall, few characteristics were associated with agreement on 

counseling. In Haiti the type of method that the client received was significantly associated with all four 

family planning counseling categories. Being a new client was also associated with a higher percentage of 

positive agreement, except for the counseling on problems with current method. Provider and facility 

characteristics were less relevant to provider-client counseling agreement. 

For Malawi a few more variables were significantly associated with agreement on counseling on how to 

use the method. As Appendix 7 shows, in addition to client’s status and client’s method type, provider’s 

recent training, facility type, and type of residence (urban-rural) were also significant. Provider category 

was associated with agreement on counseling on when to return for follow-up services. 

Results for Senegal (Appendix 8) shows that client status was significantly associated with agreement on 

all counseling elements. Except for counseling on problems with current method, returning clients had a 

higher percentage of positive agreement that the counseling occurred compared with new clients. Regional 

variation was also significant for all the counseling items except for counseling on when to return. 

3.2.2. Client’s knowledge 

The study analyzed two variables related to client knowledge about family planning: general knowledge of 

method use and knowledge of STI protection of the method. Appendix 9 describes the correct knowledge 

a client should report for each contraceptive method. In Haiti 93% of clients knew general use of their 

13.4 7.1

21.8

1.3

19.2 33.3

50.9

61.8

6.7

6.0

3.2

0.3

60.7

53.6

24.2

36.6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problems with current

method

How to use the method Side effects When to return

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
28 

method and 85% correctly identified whether the method protects against STIs. The knowledge level among 

women in Malawi was also high, at 88% and 93% respectively for these two variables. In Senegal, while 

85% of clients were aware of the general use of their method, only 58% had correct knowledge on STI 

protection. Due to the high level of client’s knowledge except in Senegal for method’s protection against 

STIs, no regression analysis could be performed. In addition, in Senegal clients were not asked if they had 

received the counseling on their method’s protection from STIs, and therefore the counseling variable that 

combines the observation and client’s report could not be created and analyzed for this knowledge outcome. 

Figure 17. Percent of family planning clients with correct knowledge of method use and correct 

knowledge of method’s protection against STIs 

0

10

20

30

40

50

60

70

80

90

100

Correct knowledge of method use Correct knowledge of STI protection

Percent

Haiti Malawi Senegal 2012-13
29 

3.3. Sick Child Care 

3.3.1. Provider-client counseling in sick child visits 

Four different types of counseling were observed during sick child visits—whether the provider told the 

caregiver about the illness; gave counseling on signs or symptoms for which to immediately bring back the 

child; gave counseling on child’s weight or growth; and gave counseling on feeding when the child is sick. 

Figure 18 shows the observed provision of counseling on each topic by country and survey. No country or 

survey stands out in terms of consistently providing more counseling than the others. The single item most 

counseled was informing the client of the child’s illness, at over 40% in Malawi, the counseling observed 

on feeding when a child is sick was 25% in Haiti and 15-16%, in Malawi and Senegal (both survey years). 

Signs and symptoms to bring the child back immediately was the least frequently counseled topic related 

to sick child visits. 

Figure 18. Percent of providers observed to provide counseling on child health items 

Table 7 presents the percentage of visits where providers gave counseling on each of the four sick child 

topics as well as whether or not the client reported receiving counseling on those topics, with Cohen’s kappa 

statistics of agreement. In general, clients reported a higher level of counseling for almost all counseling 

items and all the countries compared with the observation that the counseling was provided. All kappa 

estimates indicated a no-to-fair level of agreement; all the estimates were below the 0.40 threshold for fair 

agreement, and many were between 0.01 and 0.2, indicating only slight agreement. The percent agreement 

statistics were all below 80% except for being told the illness and counseling on signs and symptoms for 

which to bring back the child in the Senegal 2014 survey. In some situations there was a relatively high 

percent agreement compared with the kappa estimate. For example, there was 76% agreement in Haiti that 

counseling was provided on signs or symptoms for which to bring back the child, but the kappa estimate 

was only 0.06. This is due to the very low levels of counseling provided on this topic in Haiti, with only 

4% of providers observed to be giving this counseling. 

0

10

20

30

40

50

told illness signs or symptoms for

which to immediately

bring back child

child's weight or growth feeding when child is

sick

Percent

Haiti Malawi Senegal 2012-13 Senegal 2014
30 

Table 7. Percentage of providers observed to offer counseling on the following sick child items and the 

percentage of clients reporting receiving the counseling, with reported percent agreement and kappa 

statistics 

Haiti Malawi 

Provider gave 

counseling 

Client 

reported 

receiving 

counseling 

Percent 

agreement Kappa

Provider gave 

counseling 

Client reported 

receiving 

counseling 

Percent 

agreement Kappa

% C.I. % C.I. % C.I. % C.I. 

Told illness 9.7 [8.2,11.5] 22.5 [20.2,25.0] 76.9 0.17 40.6 [36.6,44.8] 62.5 [59.4,65.6] 58.8 0.21 

Signs or symptoms 

for which to 

immediately bring 

back child 3.7 [2.9,4.8] 23.3 [20.4,26.5] 76.3 0.06 11.6 [9.7,13.8] 33.4 [30.6,36.3] 66.3 0.10 

Child’s weight or 

growth 9.1 [7.5,10.9] 39.4 [36.3,42.6] 63.4 0.11 8.8 [7.2,10.7] 23.5 [20.0,27.4] 73.1 0.05 

Feeding when child 

is sick 25.2 [22.8,27.8] 35.4 [32.7,38.1] 62.5 0.12 15.3 [13.2,17.6] 15.1 [13.2,17.2] 76.7 0.09 

 

Senegal 2012-13 Senegal 2014 

Provider gave 

counseling 

Client 

reported 

receiving 

counseling 

Percent 

agreement Kappa

Provider gave 

counseling 

Client reported 

receiving 

counseling 

Percent 

agreement Kappa

% C.I. % C.I. % C.I. % C.I. 

Told illness 10.3 [7.6,13.8] 27.9 [24.5,31.5] 75.2 0.23 5.5 [3.9,7.7] 14.9 [12.2,18.0] 87.5 0.34 

Signs or symptoms 

for which to 

immediately bring 

back child 6.6 [4.8,9.0] 21.7 [18.9,24.8] 79.9 0.21 3.8 [2.7,5.5] 14.0 [11.3,17.3] 87.0 0.23 

Child’s weight or 

growth 8.6 [6.6,11.2] 27.3 [24.1,30.7] 76.2 0.24 9.4 [7.1,12.4] 31.2 [26.9,35.8] 75.1 0.28 

Feeding when child 

is sick 15.6 [13.0,18.6] 26.4 [23.3,29.7] 74.8 0.25 16.0 [13.2,19.2] 26.6 [22.9,30.7] 75.3 0.28 

 

Figures 19-22 show the distribution of the different levels of agreement when combining observation of 

provider counseling and client’s report of counseling for the four items related to sick child visits, for each 

of the four surveys covered in this report. Overall, there was a low level of positive agreement between the 

observation and client’s report that the counseling occurred for all countries and all counseling items with 

the exception of being told illness in Malawi. There was also a high level of agreement that the counseling 

did not occur, with the highest levels in Senegal. 
31 

Figure 19. Agreement between observation and client’s report on sick child counseling items, Haiti 

Figure 20. Agreement between observation and client’s report on sick child counseling items, 

Malawi 

72.3 74.6

57.5 50.9

18.0

21.6

33.5

23.8

5.2

2.0

3.1

13.7

4.5 1.7

5.9 11.5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

told illness signs or symptoms

for which to

immediately bring

back child

child's weight or

growth

feeding when child is

sick

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes

27.8

60.7

70.4 73.1

31.6

27.8

20.8 11.6

9.7

5.9 6.1 11.8

31.0

5.6 2.7 3.5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

told illness signs or symptoms

for which to

immediately bring

back child

child's weight or

growth

feeding when child is

sick

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
32 

Figure 21. Agreement between observation and client’s report on sick child counseling items, 

Senegal 2012-13 

Figure 22. Agreement between observation and client’s report on sick child counseling items, 

Senegal 2014 

68.5 75.8 70.1 66.4

21.2

17.6 21.2

18.0

3.6 2.5 2.6

7.2

6.7 4.1 6.0 8.4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

told illness signs or symptoms

for which to

immediately bring

back child

child's weight or

growth

feeding when child is

sick

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes

83.6 84.6

67.2 66.3

10.9 11.6

23.3 17.6

1.6 1.4

1.6 7.0

4.0 2.4

7.8 9.0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

told illness signs or symptoms

for which to

immediately bring

back child

child's weight or

growth

feeding when child is

sick

Percent

both agree, no prv no, cl yes prv yes, cl no both agree, yes
33 

In Haiti (Figure 19) a very small percentage of clients and providers agreed that counseling occurred in all 

areas, with the highest positive agreement for counseling on feeding a sick child. The highest level of 

disagreement was for counseling on feeding the child when sick, followed by counseling on child’s weight 

or growth, with most of the disagreement due to the client reporting that the counseling took place when it 

was not observed to be given. The highest level of agreement that the counseling did not take place was for 

counseling on signs or symptoms for which to bring the child back (75%), followed by being told the 

illness (72%). 

In Malawi (Figure 20) observations and client reports agreed that the client was informed about the child’s 

illness in less a third (31%) of the consultations. There was a high proportion of disagreement for this item, 

where 32% of clients reported that their provider told them the child’s illness when the provider was not 

observed to do so, and 10% of clients said that they were not counseled when the provider was observed to 

give the counseling. In 28% of cases client reports agreed with observation that the provider did not provide 

counseling on this topic. Across the other three items, the client agreed that the provider did not provide 

counseling for over 60% of the consultations, while agreement between the observation and client’s report 

that counseling did occur was less than 6%. As in Haiti, more clients reported that the provider gave 

counseling when observation showed that the provider did not: 28% for symptoms to bring a child back, 

21% for child’s weight and growth, and 12% for feeding children when sick. 

For Senegal 2012-13 and Senegal 2014, Figures 21 and 22 show consistently high proportions of 

consultations in which the provider did not give counseling. Most often the client report agreed with the 

observation of whether counseling occurred. In both Senegal surveys, however, a higher proportion of 

clients reported that the provider gave counseling on each item when observation showed that the provider 

did not compared with the proportion of observations and client reports agreeing that counseling occurred. 

Overall, there appears to be slightly more disagreement among clients and providers in the 2012-13 survey 

compared to the 2014 survey and especially concerning being told illness and signs or symptoms for which 

to bring the child back to the facility. 

Appendices 10-13 contain results of cross-tabulations between the counseling items in each country by 

client, provider, and facility background characteristics. Looking at all four appendices together, no strong 

patterns emerge for any counseling item or any background characteristics. In Haiti, as Appendix 10 shows, 

there are no significant differences by background characteristics for whether or not a provider gave 

counseling regarding the signs and symptoms for which to bring a child back immediately. Several 

characteristics have significant associations with a provider discussing weight and growth, including client 

education, caretaker relationship, child’s age, provider category, provider’s years of education, provider’s 

salary type, and region. Appendix 11 shows more significant associations in Malawi compared with Haiti. 

Across the four counseling items, child’s age, provider category, location of facility, and managing 

authority are significantly related to agreement of counseling. 

As Appendices 12 and 13 show for the two Senegal surveys, there are several significant associations 

between background characteristics of client, provider, and facility, and agreement or disagreement of 

counseling on the selected items. In both Senegal surveys region is significantly associated with all four 

counseling items. Also in both surveys the client’s education, provider’s salary type, and the facility type 

are significantly associated with agreement that the provider told the child’s illness. Most of the client and 

provider characteristics are not associated with agreement on counseling on signs and symptoms for which 

to bring the child back, in both surveys. For counseling on child’s weight or growth, the Senegal 2012-13 

survey shows significant associations with child’s age, provider’s training, provider’s salary, facility type, 

and region, while the Senegal 2014 survey shows the client’s age, client’s education, provider’s salary type, 

and region to be significantly associated with counseling. The caretaker type and the child’s age are 

significantly associated with agreement on feeding of child when sick, in both surveys. 

35 

4. Discussion and Conclusion 

One of the strengths of the SPA surveys is that they include both information obtained from observations 

performed during a consultation between a provider and a client and information obtained directly from the 

client following the consultation. Since the individual client data are linked to the specific provider 

observations during consultation, comparisons can be made between the consultation observation and the 

client’s exit interview. The current analysis is concerned both with the content of the counseling provided 

during a consultation and with whether the client was aware of receiving this content, when asked in the 

exit interview. Three services, ANC, family planning, and sick child visits, were analyzed in three countries: 

Haiti, Malawi, and Senegal, with data available in Senegal from two surveys in consecutive years. 

In general, with some exceptions, clients in all three countries reported in exit interviews that they received 

counseling more frequently than observation showed to be the case. Kappa estimates generally showed only 

slight to moderate agreement between the observation and client’s report. While the percent agreement on 

some counseling topics was over 80%, especially for ANC counseling, this was usually because both 

observation and exit interviews agreed that the counseling did not occur—which reflects the low levels of 

counseling provided. In addition, there were high levels of disagreement between the observation and 

client’s report, mainly when the client reported that a consultation occurred when it was not observed to 

occur. This gap in perception could be due to several reasons. The client might have misidentified the type 

of counseling the interviewer was asking about—for instance counseling on problems with the current 

contraceptive method could be considered as similar to counseling on side effects of the method. The client 

might also be recalling an experience during a previous visit without realizing that the question was about 

the current visit. Also, clients might want to report receiving counseling even if they had not in order to 

avoid alienating their providers or reporting dissatisfaction with services (Donabedian 1988), or appearing 

to lack information they were expected to have. 

Of equal or perhaps greater concern is the disagreement between the observation and client’s report when 

the provider was observed to offer counseling but the client did not report receiving it. This type of 

disagreement was substantial in Haiti and Malawi for counseling on danger signs of pregnancy 

complications and how to use a family planning method, and also in Haiti on counseling on nutrition during 

pregnancy. Such disagreement could indicate that the client did not understand or retain the information 

provided in these areas during the consultation. 

Counseling that involves the use of job-aids, is client-centered, and has good provider-client interaction can 

improve effectiveness in transferring information from provider to client (Chewning and Sleath 1996; Clift 

2001; Jennings et al. 2010; Roter 2000). A randomized control study in Benin found that use of job aids in 

a trial group for ANC counseling significantly increased the mean percent of recommended messages 

provided to clients and increased the proportion of women with correct knowledge compared with a control 

group (Jennings et al. 2010). A client-centered approach in family planning counseling has been found to 

increase the number of new users, satisfaction with services, and method continuation (Abdel-Tawab and 

Roter 2002; Kamhawi et al. 2013). Another study shows that children demonstrated more favorable weight 

gain when parents received counseling from providers who underwent training on nutrition counseling 

compared with children whose parents were counseled by providers who did not receive training, and that 

counseling provided by those with training was more likely to be client-centered (Santos et al. 2001). A 

challenge in achieving client-centered counseling is that it may require more time. A study in Tanzania 

found that implementing a new model for ANC consultation that included proper counseling would add 

another 15 minutes on average per visit—twice the average duration of the visit without using the new 

model (von Both et al. 2006). Providers may have only a limited amount of time to spend with their clients, 

especially if they need to see many clients in a day. Shortages in health personnel contribute to increased 

workload and decrease the amount of time providers can spend with each patient, which in turn can affect 
36 

the quality of the visit and thus the outcome for the patient (Adam et al. 2005; Duffield et al. 2011; Igumbor 

et al. 2016). The 2006 World Health Report highlighted the global crisis in the health workforce and named 

57 countries facing a critical shortage of staff—Haiti, Malawi, and Senegal were all included in the list 

(World Health Organization 2006). 

4.1. Antenatal Care 

The importance of counseling during ANC visits can be vital for the health of the child and mother. 

Knowledge on danger signs of pregnancy complications can save lives, as it is vital for the mother to 

recognize these signs quickly in order to get help in time. Knowledge on nutrition during pregnancy and 

how to take iron pills is important for the growth of the child and maintaining the health and strength of the 

mother. For the health care provider, counseling can be an important method to transfer this knowledge to 

mothers. Our analysis of SPA data has shown a relatively low level of counseling observed, especially in 

exclusive breastfeeding, use of family planning methods after delivery, and side effects of iron pills, which 

in all three countries were all observed in approximately 10% or less of consultations. In Senegal only 25% 

of clients reported that the provider told them to exclusively breastfeed for six months. Many studies in 

several settings have reported low levels of ANC counseling (Ali et al. 2010; Anya, Hydara, and Jaiteh 

2008; Dhandapany et al. 2008; Jennings et al. 2010; Magoma et al. 2011; Singh et al. 2012). In the three 

countries in our study, counseling on danger signs was given for approximately half or less than half of the 

clients. An average of one danger sign was observed to be given in the counseling of clients in Haiti and 

Senegal and in Malawi the average was 1.5 [results not shown]. The kappa estimate for the agreement 

between the observation and clients on counseling for danger signs was the lowest for Haiti and Senegal 

and was one of the lowest for Malawi. Furthermore, knowledge of danger signs of pregnancy complications 

and how to prepare for delivery was low, and most women were only able to report an average of 

approximately one or less danger signs or ways to prepare for delivery. Several other studies have found 

low levels of counseling on danger signs and low knowledge of danger signs (Ali et al. 2010; Anya, Hydara, 

and Jaiteh 2008; Duysburgh et al. 2013; Jennings et al. 2010; Kabakyenga et al. 2011; Magoma et al. 2011; 

Nikiéma, Beninguisse, and Haggerty 2009; Pembe et al. 2009). While our results showed that vaginal 

bleeding was the most reported danger sign known by clients, less than 50% of clients reported this danger 

sign, and in Haiti less than 30%. Hemorrhage and hypertensive disorders are the major causes of maternal 

deaths (Khan et al. 2006; Ronsmans, Graham, and group 2006). In Haiti and Senegal, however, less than 

13% of the clients were observed to be counseled on vaginal bleeding as a danger sign, and in Malawi 29% 

[results not shown]. Very few client, provider, or facility characteristics were found to be significantly 

associated with agreement on counseling for danger signs. For the remaining ANC counseling items, the 

client’s number of ANC visits had a significant association with counseling, and in Haiti and Malawi clients 

who had already made their first visit had the highest level of positive agreement that counseling occurred. 

In Senegal this was only found for counseling on how to use iron pills. This finding may be due to providers 

feeling that they only need to provide the information to the client only once (i.e. in the first visit), perhaps 

to save time. A study in Benin found that ANC counseling in revisiting clients was hardly conducted at all 

compared with clients in their first visit (von Both et al. 2006). 

A low level of knowledge about the number of danger signs and how to prepare for delivery can be expected 

if counseling is rushed and ineffective. In fact the regression results showed that even when observation 

showed that counseling was given, unless the client reported that it was received it did not increase the 

client’s knowledge, net of other factors—indicating that the knowledge transfer from the provider to the 

client did not occur and the counseling was not effective. An effective, client-centered type of counseling 

requires skills and training that many providers in the study countries may not have. Clients may also feel 

there is too much information to retain in the short time with the provider, and the provider may feel there 

is not enough time to give all the counseling necessary. WHO indicates that the first ANC consultation 

should take between 30-40 minutes (World Health Organization 2002). In the current analysis consultations 

times were on average 15 minutes long in Haiti, 18 minutes in Senegal, and only 12 minutes in Malawi, 
37 

which may not be enough time to conduct the necessary ANC checkup and give key information to the 

client. Only in Senegal, which has the highest average consultation duration among the three surveys, was 

the duration of the consultation significantly associated with the knowledge of danger signs and preparation 

for delivery, with slightly increased knowledge with increasing duration. The low level of knowledge 

shown in the ANC results can also be due to certain client, provider, and facility characteristics. The 

regression results showed that only a few other characteristics significantly increased the number of danger 

signs or ways to prepare for delivery that clients know. For all countries the number of danger signs known 

increased with increasing education level, except in Haiti for clients in their first pregnancy. In general, for 

all countries the more ANC visits the client had the higher the number of danger signs known, and in 

Malawi only the higher the number of ways known to prepare for delivery. Other studies have also found 

higher awareness of danger signs among women with more education and/or more ANC visits (Duysburgh 

et al. 2013; Hailu and Berhe 2014; Kabakyenga et al. 2011; Pembe et al. 2009). Kabakyenga et al. (2011) 

found a significant relationship between knowledge of danger signs and knowledge of birth preparedness, 

after controlling for probable confounding factors. Few other patterns were found in the regression results; 

however, in Senegal all clients residing in all regions had significantly higher knowledge in number of 

danger signs and ways to prepare for delivery compared with the Northern region. 

4.2. Family Planning 

In general, low levels of counseling were observed during family planning consultations on important 

aspects of contraceptive methods, even though providers were aware of the presence of the observer. In 

Haiti only one in five family planning consultations were observed in which the provider counseled clients 

on side effects of the client’s method. In contrast, much higher proportions of providers spoke about how 

to use the method and asked clients if they had general questions and concerns about their methods. Low 

levels of provider emphasis on side effects compared with other information about contraceptive methods 

have also been observed in other countries. For example, a study in Kenya found that providers in 74% of 

family planning counseling sessions with new clients discussed how to use pills, while only 26% talked 

about side effects (Kim, Kols, and Mucheke 1998). In the Kenya study providers were concerned that too 

much negative information about the method could scare clients away from using contraception. Side 

effects are among the commonly reported reasons for contraceptive discontinuation, particularly for 

hormonal methods (Bailey 2010; Bradley, Schwandt, and Khan 2009). Therefore, it is important for 

providers to give clients sufficient consultation on side effects to help them choose appropriate methods 

and guide them on what to do when side effects occur. 

Provider observation and client reports have been used frequently to assess the quality of family planning 

services, but usually not both together. Limited research has assessed the comparability of the two types of 

data obtained by these methods. In this study the availability of information from direct observation of 

family planning consultations and from client reports of the same counseling allowed us to assess the 

agreement between observation data and client exit interview data on various family planning counseling 

aspects. The agreement indicated by kappa statistics was low to fair (kappa statistics ranging from 0.03 to 

0.35). In their comparisons of provider observations and client interviews, Bessinger and Bertrand (2001) 

found a fair to good agreement (kappa statistics 0.4-0.98) for a wide range of indicators. In their study, 

however, indicators on information given to client, which are similar to the ones included in this study, 

demonstrated poorer agreement than other indicators such as interpersonal relations. 

From the perspective of quality of care, the provider should be observed to give counseling and the client 

should also report receiving the counseling. However, our study found that such agreement between 

providers and clients was low, from 18-44% in Haiti, 30-59% in Malawi, and 24-61% in Senegal. Many 

providers were observed to discuss with their clients how to use the current contraceptive method but their 

clients did not report such a discussion. In Haiti and Malawi in one in every five consultations the provider 

was observed to give counseling on how to use the method but the client reported that the provider did not 
38 

discuss how to use the method. Client recall bias could be a reason for the difference. Clients might not 

remember all the information they were given when they were interviewed immediately before leaving the 

facility and might not have had time to process the information (Bessinger and Bertrand 2001; Tumlinson 

et al. 2014). Poor quality of counseling could also contribute to such discrepancies. Providers could mention 

how to use the method but perform poorly in explaining in details that might ensure that clients could 

understand the message. As discussed previously, good-quality counseling takes time. With an average of 

just 10-15 minutes of consultation time, providers face extra difficulties to provide detailed information. In 

our study, with new clients and users of pills, however, providers seemed to provider better counseling, 

reflected in a high level of positive agreement between providers and clients. In general, clients reported 

high levels of knowledge on general use of the method and on its STI protection, especially in Haiti and 

Malawi. Besides obtaining knowledge from the current visit, many clients might have already known from 

other sources how to use the method and its protection from STI. 

4.3. Sick Child Care 

Overall, these SPA surveys reveal a deficit in observed counseling for caregivers during sick child visits. 

For most of the counseling items, providers gave counseling in 16% or less of the sick child visits observed. 

Among the four counseling items assessed, the item with the most counseling was for the diagnosis of the 

child, at 41% in Malawi, while the smallest proportions of visits involved counseling on signs and 

symptoms for bringing the child back, at 4% in Haiti. In all surveys, based on observation less than 10% of 

clients were counseled on the child’s weight or growth. These findings are particularly concerning since 

counseling has been proven to improve caretaker knowledge and practices, which can improve child health 

outcomes, such as improving child weight gain with better feeding practices (Santos et al. 2001, Zaman, 

Ashraf, and Martines 2008). The analysis shows a fair level of agreement between providers and clients 

when counseling was not provided, particularly in both rounds of surveys in Senegal. Despite the lack of 

counseling provided overall, discordance was still pervasive between observed counseling and client reports 

of receiving counseling. Disagreement between the two accounts for different counseling topics was as high 

as 41% in Malawi, 38% in Haiti, and 25% in Senegal 2012-13 and 2014. Additionally, our study found that 

in all surveys the average time spent in sick child visits was only 10-20 minutes. 

One strategy proven to improve the quality of sick child visits is the Integrated Management of Childhood 

Illness (IMCI), a health-system intervention developed by WHO and partners intended to strengthen health 

worker case management skills through a set of guidelines for diagnosis and treatment of sick child visits 

and corresponding training of providers (Armstrong et al. 2004; Campbell and Gove 1996; Nguyen et al. 

2013; Tulloch 1999). Implementation of this strategy of care can improve child health outcomes, and 

training of health care providers in this strategy has been seen to improve both the quality of counseling 

(Armstrong et al. 2004; Gilroy et al. 2004) and time spent on counseling (Adam et al. 2005). Results from 

a study by Adam and colleagues (2005) also indicate that these two components of care, quality and time, 

are linked in that providers who received training in IMCI not only spent more time in consultations but 

also were more likely to make a correct diagnosis. Further, client-centered counseling is a core component 

of IMCI provider training. Client-centered counseling has been shown to improve caretaker’s recall of the 

information exchanged during visits, which is critical if a caretaker is to implement the provider’s 

recommendations (Santos et al. 2001; Zaman, Ashraf, and Martines 2008). 

4.4. Limitations 

One of the limitations in the analysis of the counseling effect on level of knowledge in ANC is that the 

client’s information may have been gained elsewhere and not necessarily from the observed counseling 

session. This was evident in the regression results, in which clients who were not observed to be counseled 

but who reported being counseled significantly increased their apparent level of knowledge for number of 

danger signs and ways to prepare for delivery compared with clients who agreed that counseling was not 
39 

given. While the regression analysis did control for many variables in order to address this possible source 

of bias, a separate analysis for clients in their first pregnancy was also conducted to attempt to capture 

women who are receiving their knowledge from the consultation. Despite the possibility that the knowledge 

can be gained elsewhere, the level of knowledge found for the number of danger signs and the number of 

way to prepare for delivery was relatively low, with most clients unable to report any danger signs, or only 

one. However, the results still found that even when counseled the clients did not increase in their level of 

knowledge except if they reported receiving the counseling that the provider was observed to have given. 

The analysis of agreement between consultation observations and client reports could be improved if there 

are parallel questions in both questionnaires. Family planning counseling on STI protection was observed 

but clients were not asked whether such counseling was given. Also the questions in the exit interview were 

not specific enough, which could lead to misclassification of different counseling items. 

In the sick child analysis, the main limitation was lack of information on child’s condition or health. Unlike 

the counseling provided in ANC and family planning visits, many counseling topics given during sick child 

consultations depend on the child’s health condition or diagnosis. For instance, there may be no need to 

counsel on what to feed the child when sick if the child’s condition does not require special feeding 

instructions. Also, counseling on the child’s weight or growth may not be required if the visit was for a 

specific illness and the child does not show signs of malnourishment. This may be the reason that we see 

very high levels of agreement between the observation and client’s report that the counseling did not occur. 

However, there are still high levels of disagreement, which may be an indicator of the poor quality of 

counseling provided. In addition, there is the possibility that the interviewer did not recognize that the 

counseling was provided to the client. While The DHS Program goes through a thorough training before 

implementing an SPA survey, interviewer bias may still be possible and especially if the observation was 

made at the end of the day and after several observations, leading to interviewer fatigue. Another limitation 

is the inability to conduct any regression analysis on client’s knowledge in the family planning and sick 

child analysis. This was due to the high level of knowledge shown in responses to the questions related to 

family planning and the lack of any questions about client knowledge in the sick child exit interviews. 

Therefore, the effect of counseling on the client’s knowledge in these areas could not be examined. 

4.5. Conclusion 

Low levels of counseling have been observed during ANC, family planning, and sick child visits. Also, 

levels of agreement were low between client reports of whether counseling occurred and the observation 

that counseling in fact did occur. Ideally, we would like to see complete agreement between the client’s 

report and the observation, especially a positive agreement that the counseling occurred. In the analysis of 

knowledge on danger signs and preparation for delivery, it was necessary for the client to report that the 

counseling occurred in order to significantly increase their knowledge. Inclusion of other questions in the 

exit interview that test the client’s knowledge in topics related to family planning and sick child treatment 

would be useful to be able to study the effect of counseling on knowledge in these areas. In general, there 

appears to be evidence that more emphasis is required in training providers on the importance of providing 

counseling to all clients and also on how to provide counseling that is more focused on the client’s needs 

and is more client-centered. Health facilities need to evaluate the amount of time spent with clients during 

their visits and how to efficiently use this time to provide the required services as well as effective 

counseling to increase client knowledge and in turn improve maternal and child health outcomes. 

41 

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45 

Appendices 
46 

Appendix 1. Quality of Counseling for Haiti: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue 

Duration of consultation 

Average in minutes 14.2 13.7 15.8 18.0 0.002 13.6 16.3 16.2 17.6 <0.001 15.0 15.0 15.8 18.9 0.073 14.5 16.7 16.1 17.1 0.094 15.2 14.5 13.9 17.0 0.035 

Client’s age 0.281 0.556 0.939 0.634 0.212 

<20 37.7 8.7 40.8 12.8 47.7 9.1 18.2 25.0 77.7 9.5 7.2 5.6 61.7 14.1 11.1 13.1 31.1 34.6 5.7 28.7 20-29 35.5 14.0 33.2 17.2 45.1 9.8 21.2 23.9 74.6 10.6 6.9 7.9 62.0 14.1 8.6 15.3 32.8 31.6 7.6 28.0 30-35 33.0 15.5 34.3 17.3 46.5 12.2 17.1 24.2 76.1 11.0 7.1 5.8 61.3 15.3 6.6 16.8 35.3 37.5 5.7 21.5 36+ & DK 38.7 12.1 31.0 18.1 51.1 9.2 22.2 17.5 78.5 10.0 5.6 5.9 68.6 11.0 7.4 13.1 40.8 31.7 5.1 22.4 

Client’s education 0.107 0.352 0.131 0.049 0.654 

No school 32.2 13.8 40.5 13.5 47.3 8.9 16.2 27.6 74.8 10.9 4.9 9.4 59.1 15.9 5.9 19.2 33.7 36.2 4.8 25.3Primary & post-primary 39.0 11.2 33.8 16.0 44.6 10.6 19.6 25.2 74.7 10.4 6.4 8.4 58.5 15.0 9.1 17.4 33.7 33.4 5.6 27.3Secondary+ 33.9 15.2 32.7 18.3 47.5 10.3 21.2 20.9 76.8 10.4 7.7 5.1 66.4 12.9 8.4 12.3 34.4 32.8 7.8 24.9

Client’s first pregnancy 0.369 0.467 0.950 0.067 0.535 

No 34.3 13.9 33.9 17.9 46.6 9.7 20.9 22.8 75.6 10.3 6.9 7.1 59.9 14.7 8.8 16.6 33.8 32.9 6.4 27.0 Yes 37.9 12.8 34.7 14.7 46.1 11.2 18.0 24.7 76.0 10.8 6.6 6.5 67.4 12.9 7.3 12.4 34.7 34.6 7.1 23.6 

Number of visits to 

facility 0.448 0.026 0.003 0.007 <0.001 1 35.7 11.2 35.3 17.9 46.5 8.2 20.1 25.2 76.7 8.7 5.5 9.1 59.1 13.0 8.7 19.2 38.1 27.3 6.8 27.72 37.9 13.1 34.5 14.6 46.2 9.7 20.5 23.6 78.4 13.2 5.0 3.3 70.0 11.4 7.4 11.3 33.0 34.2 9.1 23.73 35.0 16.2 32.9 15.9 41.8 10.6 22.4 25.1 75.2 9.2 10.0 5.6 67.8 14.2 8.5 9.4 27.2 42.3 7.1 23.44+ visits 32.2 17.8 32.5 17.5 49.4 16.5 16.9 17.2 69.8 13.5 10.4 6.3 58.4 20.6 8.0 13.0 28.5 43.4 2.5 25.6

Provider category 0.359 <0.001 <0.001 <0.001 0.060 

Nurse/midwife/other 34.1 13.7 33.4 18.8 39.6 11.3 20.3 28.8 70.5 11.7 8.1 9.7 54.8 15.2 9.2 20.8 33.3 31.1 5.9 29.8 Doctor/specialist/tech 37.3 13.2 35.1 14.4 54.8 8.9 19.4 16.9 82.3 9.0 5.3 3.5 71.9 12.8 7.1 8.2 35.0 36.4 7.5 21.1 

Provider’s number of 

years of schooling 0.506 0.018 0.012 0.001 0.245 <16 37.1 14.1 32.1 16.7 42.4 11.1 20.4 26.1 75.2 10.3 6.3 8.1 64.1 15.6 6.5 13.8 32.0 27.6 5.1 35.316-18 31.6 14.1 33.9 20.4 37.0 12.1 21.5 29.4 66.7 14.2 9.4 9.7 51.1 14.0 10.2 24.7 31.8 33.3 7.2 27.719+ 37.4 13.2 34.4 15.1 51.6 9.2 19.1 20.1 80.1 8.9 5.7 5.3 67.4 13.8 7.9 10.9 35.5 35.0 6.8 22.8

Total number of 

supervisory items 0.651 0.049 0.009 0.001 0.733 

None 35.4 14.5 35.5 14.6 50.8 6.7 19.5 23.0 83.9 8.7 4.0 3.4 73.8 12.7 4.4 9.2 36.6 34.4 6.7 22.2 1-5 37.6 13.5 32.2 16.7 45.1 10.9 17.9 26.1 70.8 11.7 8.6 8.9 59.1 14.8 9.6 16.5 32.5 32.5 7.2 27.8 6 31.8 12.3 36.2 19.7 43.6 13.3 24.3 18.8 75.2 10.4 7.0 7.3 55.0 14.5 10.6 19.9 33.9 34.2 5.3 26.6 

Continues
47

Appendix 1–Continued 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue 

Provider received 

training in ANC counseling within 24 months 

0.238 0.953 0.964 0.560 0.031 

No 37.2 12.6 33.9 16.3 46.5 10.4 19.5 23.6 75.4 10.7 6.9 6.9 63.6 14.3 8.1 14.0 34.1 34.6 5.2 26.0Yes 29.7 16.6 35.2 18.4 46.3 9.7 21.1 22.8 77.0 9.7 6.6 6.8 58.6 13.3 8.7 19.3 34.1 29.3 11.5 25.2

Facility type 0.284 0.007 0.205 0.788 0.204 

Hospital 39.3 14.7 30.0 16.0 51.9 9.5 22.1 16.5 78.3 9.1 7.1 5.5 62.4 13.5 8.4 15.7 36.4 33.2 8.2 22.1 Health center 31.5 12.4 37.6 18.5 44.6 9.8 18.5 27.1 74.3 11.0 7.9 6.9 61.5 15.2 9.2 14.1 33.4 33.6 6.3 26.7 Other 37.8 13.9 34.7 13.5 38.2 13.5 18.3 30.0 73.9 12.6 3.1 10.4 65.9 12.4 5.1 16.6 30.2 33.5 3.6 32.7 

Location 0.247 0.510 0.600 0.136 0.208 

Urban 37.4 14.5 33.0 15.1 48.6 10.0 18.7 22.8 76.7 10.5 6.9 5.9 64.8 15.1 7.1 13.0 34.9 34.2 7.6 23.3Rural 32.9 12.2 35.8 19.1 43.4 10.6 21.6 24.3 74.5 10.4 6.7 8.3 59.3 12.7 9.8 18.2 32.8 32.5 5.3 29.4

Managing authority 0.188 0.407 0.903 0.972 0.830 

Private/faith/NGO/other 32.2 13.6 36.4 17.9 43.9 10.9 20.1 25.1 74.9 11.1 7.0 6.9 62.1 14.3 8.6 14.9 35.4 33.0 6.7 24.9 Government 39.6 13.4 31.5 15.5 49.5 9.4 19.7 21.4 76.9 9.7 6.6 6.9 63.0 13.7 7.8 15.4 32.5 34.1 6.5 27.0 

Region 0.352 0.086 0.001 <0.001 0.057 

North 33.8 15.4 30.6 20.2 53.0 8.7 14.8 23.6 75.7 9.7 6.5 8.1 64.6 13.3 5.2 16.9 33.6 35.5 9.3 21.6Center 37.3 10.3 36.2 16.2 40.6 13.0 21.6 24.9 68.8 10.7 11.9 8.6 53.6 9.0 13.5 24.0 33.2 37.4 4.7 24.6South 32.2 18.0 33.8 16.0 37.7 11.6 21.7 29.0 67.3 15.2 8.1 9.3 53.7 25.2 7.4 13.8 31.5 25.6 5.0 37.8West 37.2 11.9 35.3 15.6 50.5 8.9 21.0 19.6 84.1 8.4 3.5 4.0 70.9 11.7 7.6 9.8 36.1 34.1 7.0 22.8

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
48

Appendix 2. Quality of Counseling for Malawi: Cross tabulation of provider and client reported counseling and client, provider, and facility background 

characteristics 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue 

Duration of consultation 

Average in minutes 10.7 12.9 10.4 13.5 0.127 10.7 12.9 9.1 14.1 0.041 11.8 13.1 9.7 12.0 0.158 9.5 14.6 9.2 13.8 <0.001 9.1 13.6 6.6 12.3 <0.001 

Client’s age 0.020 0.646 0.015 0.002 0.713 

<20 30.5 15.0 22.9 31.6 44.0 16.8 11.0 28.2 20.1 16.8 10.0 53.2 34.8 16.3 17.6 31.4 15.8 22.9 2.7 58.6 20-29 27.3 16.9 21.3 34.4 40.5 21.5 8.7 29.3 16.0 19.0 7.3 57.6 29.0 20.6 15.3 35.1 13.4 26.2 3.3 57.1 30-35 22.8 25.5 20.9 30.8 38.6 19.5 10.7 31.2 12.1 20.8 13.6 53.4 21.6 24.5 14.4 39.5 14.9 23.9 2.0 59.2 36+ & DK 30.5 22.7 18.4 28.5 43.2 21.9 9.5 25.4 14.0 23.7 13.7 48.6 23.6 22.7 22.9 30.7 12.5 26.4 5.0 56.1 

Client’s education 0.339 0.815 0.135 0.800 0.634 

No school 33.3 20.5 18.8 27.3 44.5 19.2 9.1 27.2 11.5 27.7 9.0 51.8 31.0 17.3 17.8 33.9 15.6 22.7 4.9 56.8 Primary & post-primary 26.3 18.5 21.9 33.4 40.4 20.6 9.8 29.2 16.6 18.0 9.5 55.9 27.7 21.2 16.1 34.9 14.0 25.3 2.9 57.9 Secondary+ 30.9 14.0 16.5 38.6 43.2 13.7 6.9 36.2 18.6 19.2 14.3 47.9 32.7 18.7 10.6 38.0 8.9 32.1 1.5 57.4 

Client’s first pregnancy <0.001 0.063 0.008 0.007 0.819 

No 25.7 21.3 20.4 32.6 39.6 21.7 9.6 29.1 14.5 20.7 9.2 55.6 26.1 21.0 16.3 36.5 14.1 25.6 3.1 57.2 Yes 32.6 10.3 24.2 32.9 45.5 15.7 9.7 29.1 20.3 15.0 10.9 53.8 35.2 19.4 15.9 29.5 13.9 23.5 3.2 59.5 

Number of visits to 

facility 0.057 <0.001 0.004 <0.001 <0.001 1 24.9 19.1 17.9 38.1 35.4 20.5 6.6 37.5 13.9 16.0 7.4 62.7 19.4 16.4 11.6 52.6 11.0 24.1 1.5 63.5 2 28.3 20.1 22.9 28.7 44.6 19.6 10.7 25.1 18.7 24.4 9.8 47.1 37.1 24.8 19.9 18.1 11.8 23.5 3.6 61.1 3 30.2 16.3 22.1 31.4 45.9 17.3 13.2 23.7 17.8 20.3 11.3 50.6 36.5 22.0 19.6 22.0 16.6 25.6 4.4 53.5 4+ visits 29.0 18.1 27.1 25.9 44.7 24.4 11.5 19.3 14.6 18.9 13.2 53.4 28.1 23.8 18.5 29.6 23.2 30.2 5.2 41.5 

Provider category 0.374 0.528 0.036 0.868 0.155 Nurse/midwife/other 27.0 18.6 21.2 33.2 40.6 20.5 9.7 29.2 15.5 19.7 9.3 55.5 28.1 20.8 16.2 34.9 13.8 24.6 3.1 58.4 Doctor/specialist/tech 37.4 18.9 22.6 21.1 51.4 13.8 8.2 26.6 26.1 9.8 16.6 47.5 33.9 17.1 15.6 33.4 20.2 37.0 2.0 40.8 Provider’s number of 

years of schooling 0.652 0.949 0.425 0.122 0.637 <16 29.1 20.0 21.2 29.8 41.3 20.0 10.3 28.4 15.1 17.2 11.3 56.4 25.1 19.5 19.5 35.9 15.2 23.8 3.6 57.3 16-18 24.5 17.2 21.8 36.5 40.5 20.5 9.6 29.4 15.7 21.7 7.8 54.8 31.4 22.5 11.6 34.5 11.7 26.8 2.4 59.1 19+ 32.1 17.8 19.2 30.9 42.6 19.9 5.6 31.9 22.7 19.9 7.9 49.5 32.1 18.1 20.3 29.5 19.7 24.6 3.2 52.5 

Total number of 

supervisory items 0.697 0.301 0.139 0.743 0.030 

None 24.8 20.8 20.3 34.1 40.4 22.4 6.8 30.5 16.1 23.5 7.2 53.2 26.7 22.0 13.9 37.3 8.7 22.7 2.8 65.8 1-5 28.4 17.7 24.2 29.8 45.9 19.4 9.2 25.5 19.4 18.8 9.1 52.7 31.3 20.1 16.0 32.5 17.0 30.0 3.0 50.0 6 27.9 18.3 19.2 34.6 37.0 19.8 11.5 31.6 12.6 17.5 11.4 58.5 26.5 20.4 17.6 35.6 14.3 22.0 3.3 60.4 

Continues
49

Appendix 2–Continued 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue 

Provider received 

training in ANC counseling within 24 months 

0.531 0.476 0.529 0.225 0.378 

No 27.7 18.2 20.7 33.4 41.3 20.9 9.0 28.8 16.2 20.0 9.4 54.3 29.3 21.4 15.7 33.7 14.9 24.4 3.2 57.6 Yes 25.6 21.6 25.0 27.8 39.7 16.0 13.5 30.9 14.0 15.0 10.6 60.4 22.3 15.8 19.7 42.2 9.1 29.9 2.7 58.3 

Facility type 0.401 0.137 0.913 0.484 0.121 

Hospital 25.8 19.4 22.0 32.9 36.8 20.4 8.4 34.4 16.4 19.5 8.7 55.4 25.5 21.1 15.8 37.6 12.7 25.2 3.2 59.0 Health center 28.4 17.3 21.2 33.2 43.7 19.4 10.4 26.5 15.9 18.9 10.2 55.0 30.8 20.0 16.6 32.6 15.1 23.6 3.1 58.1 Other 28.9 36.5 14.2 20.4 45.0 33.8 10.7 10.5 10.6 25.4 8.6 55.3 16.1 27.8 13.7 42.4 11.3 54.4 1.9 32.4 

Location 0.735 0.220 0.643 0.206 0.133 

Urban 25.9 17.2 20.6 36.3 38.2 16.8 8.2 36.8 18.1 20.5 7.9 53.5 23.8 23.5 12.8 39.9 9.8 27.9 1.1 61.1 Rural 27.9 19.2 21.6 31.4 42.1 21.5 10.1 26.3 15.1 18.9 10.2 55.8 29.9 19.6 17.5 33.0 15.6 24.1 3.8 56.5 

Managing authority 0.905 0.093 0.879 0.698 0.617 

Private/faith/NGO/other 26.8 20.1 20.3 32.9 36.8 26.4 7.9 28.9 15.0 19.1 8.8 57.0 30.7 21.7 14.5 33.0 16.6 26.0 2.8 54.6 Government 27.6 18.1 21.7 32.6 42.7 17.9 10.3 29.2 16.3 19.4 9.9 54.5 27.4 20.2 16.8 35.5 13.1 24.8 3.2 58.9 

Region 0.273 0.250 0.936 0.051 0.087 

North 21.1 15.8 19.0 44.2 35.2 20.9 8.0 35.9 17.3 18.6 10.9 53.1 19.9 25.8 14.2 40.1 10.2 30.5 3.4 55.9 Central 27.6 21.4 19.7 31.4 43.4 15.9 9.0 31.7 16.9 19.7 9.9 53.5 25.6 18.1 17.0 39.2 10.1 27.0 3.2 59.6 South 28.6 16.8 23.3 31.2 40.3 23.9 10.6 25.2 14.7 19.2 9.0 57.1 32.7 21.7 16.0 29.6 18.5 22.2 2.9 56.4 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
50

Appendix 3. Quality of Counseling for Senegal: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both 

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both 

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both 

yes4

pvalue 

Duration of consultation 

Average in minutes 16.7 19.2 18.1 20.0 0.003 16.9 18.8 17.3 22.7 <0.001 17.9 18.0 19.4 20.0 0.278 18.0 20.0 18.3 22.7 0.278 18.5 17.5 15.3 19.0 0.300 

Client’s age 0.083 0.621 0.550 0.013 0.137 

<20 32.3 29.1 14.3 24.3 69.1 6.6 4.7 19.6 77.8 3.7 3.5 15.0 92.2 3.5 2.1 2.2 47.6 20.0 0.6 31.7 20-29 33.9 27.6 16.9 21.6 64.6 5.1 7.5 22.8 74.9 6.0 2.9 16.3 88.0 7.5 1.8 2.7 40.1 22.2 4.3 33.4 30-35 27.6 33.7 11.7 27.0 63.7 4.5 5.7 26.1 70.4 4.8 2.8 22.0 87.3 5.0 1.0 6.7 44.8 17.8 2.0 35.4 36+ & DK 44.5 22.4 13.9 19.2 65.8 2.4 6.5 25.3 71.8 7.7 2.3 18.2 84.0 4.4 7.1 4.5 43.0 26.8 1.8 28.3 

Client’s education 0.320 0.580 0.726 0.420 0.564 

No school 32.4 29.3 16.4 22.0 66.7 4.6 5.9 22.8 74.6 5.6 3.0 16.8 87.6 6.6 2.2 3.6 42.8 21.8 3.0 32.4Primary & post-primary 33.4 26.2 15.5 24.9 61.1 6.3 7.1 25.5 71.3 5.4 2.3 21.0 89.4 4.3 3.3 3.0 42.5 21.1 1.5 34.9Secondary+ 39.1 29.0 8.8 23.2 66.2 4.0 8.7 21.2 76.8 5.7 3.5 13.9 87.5 6.7 0.7 5.1 41.6 21.0 5.3 32.1

Client’s first pregnancy 0.330 0.832 0.944 0.323 0.094 

No 33.0 28.3 16.2 22.5 65.2 4.7 6.8 23.3 73.7 5.6 2.8 17.8 87.5 6.7 2.1 3.6 41.9 21.1 3.6 33.4 Yes 35.6 29.2 11.2 24.0 65.4 5.9 5.7 22.9 75.4 5.5 3.0 16.2 90.1 3.4 2.7 3.9 44.7 23.0 0.7 31.6 

Number of visits to 

facility 0.283 0.174 <0.001 <0.001 0.003 1 35.3 30.9 13.0 20.8 62.6 4.4 6.3 26.7 86.0 4.1 1.2 8.7 91.2 6.2 0.9 1.7 38.6 18.5 3.4 39.62 33.6 25.9 18.3 22.1 65.8 6.6 6.1 21.5 79.5 5.1 3.5 12.0 92.5 4.1 1.6 1.8 41.1 24.1 3.5 31.33 32.2 24.5 15.6 27.8 64.6 2.6 7.7 25.1 64.8 5.4 3.1 26.7 85.2 3.9 5.0 5.9 39.8 24.9 1.9 33.54+ visits 31.0 32.8 13.8 22.4 70.3 6.3 6.7 16.7 51.6 9.7 5.0 33.7 77.6 11.5 2.7 8.2 57.1 19.7 1.8 21.4

Provider category 0.663 0.175 0.867 0.081 0.569 

Nurse/midwife/other 33.9 28.2 14.4 23.5 65.2 5.6 6.9 22.4 73.9 5.9 2.8 17.4 87.4 6.9 2.5 3.3 42.8 20.7 2.7 33.8 Doctor/specialist/tech 31.5 30.1 18.7 19.6 65.4 1.5 5.1 28.1 74.9 4.0 3.3 17.8 91.9 1.4 1.0 5.6 41.2 25.8 4.2 28.8 

Provider’s number of 

years of schooling 0.833 0.392 0.715 0.619 0.611 <16 34.0 30.5 13.0 22.5 61.9 6.9 5.8 25.4 73.2 6.3 2.6 17.9 89.4 5.0 2.2 3.4 43.6 21.3 2.1 32.916-18 32.9 28.6 16.2 22.3 67.3 4.5 6.4 21.8 73.1 5.3 3.0 18.6 86.6 7.0 2.6 3.9 44.0 20.7 3.1 32.119+ 36.2 20.9 15.2 27.7 63.0 1.2 10.4 25.4 83.1 5.1 3.1 8.7 93.1 3.3 0.4 3.1 29.1 27.4 4.8 38.7

Total number of 

supervisory items 0.605 0.449 0.740 0.141 0.165 

None 33.7 31.3 15.7 19.3 70.2 6.4 6.6 16.9 79.1 5.4 3.0 12.5 90.2 5.2 2.8 1.8 47.9 17.0 3.4 31.7 1-5 34.1 21.0 20.5 24.5 61.1 4.7 8.3 25.9 72.9 6.1 2.0 19.0 86.3 4.0 5.7 4.0 26.2 26.9 4.3 42.5 6 33.4 28.9 13.8 24.0 64.1 4.4 6.2 25.2 72.3 5.5 3.0 19.1 87.6 6.7 1.3 4.3 43.7 22.2 2.5 31.6 

Continues
51

Appendix 3–Continued 

Danger signs of pregnancy 

complications Nutrition during pregnancy Pregnancy preparation Where to deliver How to use iron pills 

both 

no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both 

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both

yes4

pvalue both no1

prv 

no, 

cl 

yes2

prv 

yes, 

cl 

no3

both 

yes4

pvalue 

Provider received 

training in ANC counseling within 24 months 

0.068 0.538 0.269 0.513 0.520 

No 34.4 29.8 16.4 19.4 66.8 4.8 6.7 21.7 76.7 5.1 2.7 15.4 88.5 5.2 2.2 4.1 43.5 22.7 3.0 30.9 Yes 31.9 25.8 12.4 29.9 61.9 5.3 6.3 26.6 68.6 6.6 3.2 21.7 87.2 7.7 2.4 2.7 40.6 19.2 2.9 37.3 

Facility type 0.009 0.419 0.290 0.720 0.048 

Hospital 31.8 25.2 22.4 20.6 76.1 6.1 5.7 12.0 85.7 4.4 0.0 9.9 93.1 2.3 1.9 2.6 38.9 27.7 9.4 24.1 Health center 25.0 40.4 8.6 26.1 62.2 6.3 7.6 23.9 68.7 4.9 2.3 24.1 85.4 7.7 2.2 4.6 42.0 14.9 2.7 40.4 Other 35.2 26.5 15.8 22.4 65.1 4.6 6.5 23.8 74.3 5.8 3.1 16.8 88.2 5.9 2.3 3.6 42.8 22.3 2.6 32.2 

Location 0.493 0.342 0.225 0.386 0.061 

Urban 35.0 29.8 12.1 23.1 60.9 6.0 7.1 26.0 72.1 7.8 1.9 18.3 85.3 7.1 3.0 4.7 44.3 25.9 3.2 26.6 Rural 32.7 27.7 17.0 22.7 68.0 4.3 6.3 21.5 75.4 4.2 3.5 16.9 89.9 5.3 1.8 3.0 41.4 18.8 2.8 37.1 

Managing authority 0.073 0.049 0.561 0.310 0.564 

Private/faith/NGO/other 49.4 22.2 14.5 13.8 58.4 0.4 11.9 29.4 75.2 7.9 0.3 16.6 80.8 8.8 2.4 8.0 45.0 26.7 1.6 26.7 Government 31.9 29.1 15.2 23.8 65.9 5.4 6.0 22.6 74.0 5.3 3.1 17.6 88.8 5.7 2.2 3.2 42.3 21.0 3.1 33.6 

Region 0.024 0.020 0.001 0.048 <0.001 

Northern 36.9 28.6 16.1 18.4 71.4 6.0 3.3 19.3 81.8 2.2 3.1 12.9 94.4 3.0 1.6 1.0 44.6 13.0 2.1 40.2 Dakar 42.8 26.0 14.6 16.7 57.8 8.2 8.2 25.8 72.6 12.3 1.3 13.8 80.1 8.5 4.6 6.8 41.4 33.2 4.8 20.6 Thies 37.1 23.7 8.9 30.3 55.0 6.9 7.7 30.4 67.4 3.5 4.0 25.0 86.1 4.9 2.6 6.4 39.6 32.2 4.9 23.3 Central 27.2 24.2 19.4 29.2 62.8 4.3 6.5 26.3 68.7 7.7 3.7 20.0 85.1 9.1 2.3 3.6 31.6 21.7 1.5 45.3 East 37.6 33.6 17.6 11.2 84.1 0.0 9.9 6.0 89.7 1.9 2.5 5.9 95.5 3.7 0.3 0.6 70.6 9.4 1.1 18.9 South 22.3 43.1 9.3 25.4 68.9 1.4 5.7 24.0 71.9 1.2 1.9 25.0 93.2 3.2 0.8 2.8 47.9 14.8 4.3 33.0 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
52

Appendix 4. Regression of the number of danger signs that could occur during pregnancy that the client knows with reported incidence 

risk ratios 

Haiti Malawi Senegal 2014 

Distribution nbreg nbreg nbreg nbreg nbreg nbreg poisson poisson nbreg nbreg nbreg nbreg Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

Duration of consultation 

Average in minutes 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0** 1.0 1.0** 

Client characteristics 

Client’s age 

(ref.=<20) 

20-29 1.4* 1.4** 1.4* 1.3* 0.9 0.9 0.9 1.0 0.8 1.0 0.8 1.0 

30-35 1.6** 1.6*** 1.5* 1.5*** 1.5 1.1 1.1 1.1 1.1 1.0 1.0 1.0 36+ & dk 1.2 1.6** 1.3 1.5** 0.8 1.0 0.7 1.1 1.3 1.1 1.1 1.1 

Client’s education 

(ref.=none) 

Primary & post primary 1.0 1.3* 1.1 1.2 1.8 1.2* 1.7 1.2 1.4 1.1* 1.4 1.1* 

Secondary + 1.2 1.4** 1.2 1.3** 3.2** 1.6* 2.0* 1.4* 1.9** 1.3** 1.7** 1.3* 

Number of previous ANC 

visits (ref.= first visit) 

2 1.1 1.2** 1.3 1.3** 1.1 1.2 1.1 1.3*** 1.2 1.2 1.2 1.2 

3 1.1 1.3* 1.2 1.2* 1.1 1.2* 1.2 1.4*** 1.7** 1.2* 1.5* 1.1 

4 or more 1.2 1.3*** 1.1 1.3** 1.4 1.3* 1.3 1.5*** 2.6*** 1.5*** 2.5*** 1.5*** 

Client’s first pregnancy 

(ref.=no) yes 1.0 1.0 0.7*** 0.9* 0.8** 0.7** 

Counseling 

Counseled on any of the 

seven signs of pregnancy complications (ref.=no) 

yes 1.1 1.1 2.9*** 1.6*** 2.8*** 1.7*** 

Agreement on counseling 

on signs of pregnancy complications (ref.= both agree no counseling) 

Provider did not 

counsel, but client reported receiving 

1.8*** 1.6*** 7.4*** 4.5*** 1.1 1.0 

Provider counseled, but 

client did not report 0.9 1.0 1.0 0.9 0.9 0.9 

Both agree counseling 

was provided 2.4*** 2.0*** 11.9*** 5.7*** 3.8*** 2.3*** 

Continues
53

Appendix 4–Continued 

Haiti Malawi Senegal 2014 

Distribution nbreg nbreg nbreg nbreg nbreg nbreg poisson poisson nbreg nbreg nbreg nbreg Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 

Provider characteristics 

Provider category 

(ref.=nurse/midwife/other) 

doctor/specialist/ 

technician 1.0 1.0 1.0 1.1 1.0 0.7 1.1 0.9 1.2 1.0 1.2 1.1 

Provider’s years of 

education (ref.=<16) 

16-18 0.9 0.9 1.0 0.9 0.7* 1.0 0.8* 0.9 0.8 0.9 0.7* 1.0 

19+ 0.8 0.8 0.9 0.9 0.5* 0.8 0.6** 0.8* 0.7 1.0 0.6* 1.0 

Provider’s training in ANC 

counseling (ref.=no) 

yes 0.9 0.9 0.8 0.9 0.9 1.0 1.2 1.1 1.4* 1.3*** 1.4 1.2** 

Total number of 

supervisory items (ref.=none) 

1-5 1.3 1.3* 1.3 1.3* 1.0 0.9 1.1 1.0 0.8 1.0 0.9 1.0 

6 0.9 1.1 0.9 1.1 1.3 1.1 1.2 1.1 1.3 1.1 1.1 1.1 

Facility characteristics 

Managing authority 

(ref.=private/faith/NGO/ other) 

Government 0.9 0.9 0.9 0.9 1.0 1.0 1.0 1.1 0.9 1.0 0.8 0.9 

Health facility type 

(ref.=hospital) 

Health center 0.9 1.0 0.9 1.0 1.1 1.1 1.1 1.0 1.5 1.2 1.6 1.1 Other 0.8 0.9 0.9 0.9 1.0 1.2 0.9 1.0 0.8 1.0 0.9 1.0 

Locality 

(ref.=urban) Rural 0.9 0.9 0.9 0.9 1.0 1.0 0.9 1.1 1.3 0.9 1.3 1.0 

Region 

(ref.=North) 

Center 0.8 1.0 0.9 1.1 0.7 0.8 0.8 0.9 

South 1.1 1.1 1.2 1.1 0.6** 0.7** 0.7* 0.8* 

West 0.9 0.9 0.9 0.9 

Region 

(ref.=Northern) 

Dakar 1.8 1.7** 1.7 1.8*** 

Thies 1.4 1.8*** 1.1 1.7*** 

Central 1.1 1.6*** 1.1 1.6*** 

East 1.6 2.4*** 1.5 2.5*** 

South 1.2 1.9*** 1.1 1.8*** 

Observations 531 1,603 531 1,603 489 2,025 489 2,025 256 1,206 256 1,206 

* p<0.05, ** p<0.001, *** p<0.001 
54

Appendix 5. Regressions of the number of way the client knows to prepare for delivery with reported incidence risk ratios

Haiti Malawi Senegal 2014 

Distribution nbreg nbreg nbreg nbreg poisson poisson poisson poisson poisson poisson poisson poisson Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 

Duration of consultation 

Average in minutes 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0* 1.0 1.0** 1.0 

Client characteristics 

Client’s age 

(ref.=<20) 

20-29 0.9 0.9 0.9 0.9 1.0 1.0 1.0 1.0 1.4 1.1 1.5 1.1 

30-35 1.3 1.2 1.1 1.2 1.5* 1.0 1.1 1.1 1.1 1.1 1.0 1.136+ & DK 1.4 1.2 1.4 1.2 0.6 0.9 0.5 1.0 1.1 1.1 0.8 1.1 

Client’s education 

(ref.=none) 

Primary & post primary 0.8 1.3 0.8 1.3 0.9 1.0 1.0 1.1 1.0 1.1 0.9 1.1 Secondary + 0.9 1.2 1.0 1.2 0.8 0.8 0.8 0.9 0.8 1.0 0.7 1.0 

Number of previous ANC 

visits (ref. = first visit) 

2 1.1 1.0 1.1 1.0 1.4** 1.1* 1.4** 1.2** 1.3 1.0 1.2 1.0 3 0.8 0.9 0.8 1.0 1.5*** 1.2** 1.6*** 1.2*** 1.3 1.1 1.3 1.14 or more 1.2 1.1 1.2 1.1 1.6*** 1.3*** 1.7*** 1.4*** 1.6 1.2** 1.4 1.2*

Client’s first pregnancy 

(ref.=no) yes 1.0 1.0 0.9* 0.9 0.6*** 0.6*** 

Counseling 

Counseled in how to prepare 

for delivery (ref.= no) 

Yes 1.1 1.2 1.4** 1.3*** 3.2*** 1.5*** 

Agreement on counseling on 

preparation for delivery (ref.= both agree no counseling) 

Provider did not counsel, 

but client reported receiving 

1.7*** 1.6*** 3.6*** 2.3*** 2.4*** 1.4*** 

Provider counseled, but 

client did not report 0.9 1.0 1.1 1.1 2.2 1.3 

Both agree counseling 

was provided 1.6* 1.6** 3.4*** 2.4*** 4.0*** 1.6*** 

Provider characteristics 

Provider category 

(ref.=nurse/midwife/other) 

Doctor/specialist/ 

technician 1.7 1.6* 1.7 1.6* 0.9 0.8 0.9 0.9 0.9 0.8 0.9 0.8 

Provider’s years of education 

(ref.=<16) 

16-18 1.3 1.2 1.3 1.2 0.9 1.0 0.9 1.0 1.1 1.1 1.1 1.1 

19+ 0.7 0.8 0.7 0.8 0.9 0.7 1.0 0.7 1.0 1.1 1.1 1.2 

Provider’s training in ANC 

counseling (ref.=no) 

Yes 0.9 1.0 0.9 1.0 0.9 0.9 1.0 0.9 0.8 1.1 0.8 1.0 

Total number of supervisory 

items (ref.=none) 

1-5 1.0 1.1 1.0 1.1 1.1 1.0 1.1 1.0 1.2 0.9 1.1 0.9 

6 1.1 0.9 1.1 0.9 1.0 1.0 1.0 1.1 1.5* 1.0 1.5 1.0 

Continues
55

Appendix 5–Continued 

Haiti Malawi Senegal 2014 

Distribution nbreg nbreg nbreg nbreg poisson poisson poisson poisson poisson poisson poisson poisson Client type 

1st 

preg 

all 

clients 

1st 

preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 1st preg 

all 

clients 

Facility characteristics 

Managing authority 

(ref.=private/faith/NGO/ other) Government 

1.1 1.1 1.2 1.1 1.1 1.1 1.1 1.1 1.1 1.0 1.1 1.0 

Health facility type 

(ref.=hospital) 

Health center 1.2 1.0 1.1 1.0 1.3 1.3** 1.4* 1.3*** 0.4** 0.9 0.4* 0.9 

Other 1.9* 1.5* 1.9* 1.4* 1.4 1.5*** 1.4 1.4*** 0.3*** 0.8 0.3** 0.8 

Locality 

(ref.=urban) Rural 0.6** 0.7** 0.6** 0.7** 1.0 1.0 1.0 1.0 1.2 1.0 1.3 1.1 

Region 

(ref.=North) 

Center 1.1 1.2 1.1 1.3 0.9 1.0 0.8 1.0 

South 1.2 1.1 1.1 1.1 1.0 1.1 0.9 1.0 

West 1.8* 1.4* 1.8* 1.5** 

Region 

(ref.=Northern) 

Dakar 2.3* 2.0*** 2.1 2.0*** 

Thies 1.6 1.8*** 1.5 1.8*** 

Central 1.5 1.8*** 1.3 1.8*** 

East 2.6* 2.1*** 2.4 2.1*** 

South 1.9 2.2*** 1.7 2.1*** 

Observations 531 1,603 531 1,603 489 2,025 489 2,025 256 1,206 256 1,206 * p<0.05, ** p<0.001, *** p<0.001 
56

Appendix 6. Quality of Counseling for Haiti: Cross tabulation of provider and client reported counseling and client, provider, and facility 

background characteristics 

Problems with current method How to use Side effects When to return 

Both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue 

Duration of consultation 

Average in minutes 10.2 13.4 15.9 12.1 0.062 10.8 13.5 12.2 13.4 0.487 10.8 12.4 16.7 17.4 0.001 14.6 11.7 13.0 15.6 0.023 

Client’s age 0.006 0.129 0.520 0.005 

<20 58.6 20.7 6.3 14.4 20.3 23.2 17.9 38.5 39.7 31.9 2.6 25.8 13.7 54.3 1.2 30.720-29 31.3 29.9 8.6 30.2 14.0 19.0 20.3 46.7 37.1 40.6 3.5 18.8 7.0 67.5 1.2 24.3 30-35 38.3 25.5 11.8 24.4 9.2 24.2 26.7 39.8 43.9 38.1 3.3 14.7 7.0 71.8 0.3 20.836+ & DK 31.8 25.7 12.9 29.5 13.8 21.8 20.8 43.6 39.2 41.7 3.2 16.0 5.3 79.3 0.4 14.9

Client’s education 0.243 0.764 0.443 0.108 

No school 39.3 26.2 9.1 25.5 12.1 19.3 23.9 44.6 38.2 39.5 3.0 19.2 4.8 74.2 0.4 20.6Primary & post-primary 34.2 28.0 12.4 25.4 13.2 19.9 22.5 44.4 42.5 35.9 3.3 18.3 5.9 68.2 1.1 24.8Secondary+ 33.1 27.4 8.1 31.4 14.0 23.2 19.7 43.1 36.1 43.8 3.5 16.7 9.7 69.4 0.8 20.0

Client status 0.466 0.037 <0.001 0.001 

New client 34.4 28.2 12.8 24.6 9.6 24.9 17.3 48.2 24.7 37.9 2.5 34.9 7.6 52.1 2.0 38.2Returning client 34.7 27.3 9.4 28.7 14.1 19.6 23.5 42.8 44.5 40.6 3.4 11.5 7.0 76.5 0.4 16.0

Client’s method 0.010 <0.001 <0.001 <0.001 

Other 46.7 19.7 15.6 18.0 21.0 26.1 13.3 39.6 59.3 28.8 0.8 11.1 36.4 50.9 2.3 10.4Pill 29.1 23.9 10.6 36.4 1.4 17.8 7.2 73.5 32.0 52.4 3.7 11.9 3.7 74.6 0.8 20.9Progestin injectable 33.7 29.0 9.3 28.0 13.8 20.8 24.6 40.8 37.5 39.4 3.6 19.5 3.7 71.7 0.6 23.9

Provider category 0.166 0.009 0.248 0.170 

Nurse/midwife/doctor 30.9 27.3 12.8 28.9 15.6 26.5 18.6 39.3 37.4 38.1 3.5 21.0 8.2 65.2 1.1 25.5Auxiliary nurse 37.7 27.6 7.9 26.8 11.5 16.8 24.1 47.6 40.7 40.8 3.2 15.3 6.3 73.4 0.7 19.6

Provider’s number of years 

of schooling 0.077 0.710 0.533 0.006 <16 41.5 25.6 10.6 22.2 12.4 18.6 22.7 46.3 38.7 41.1 3.8 16.4 6.6 74.7 0.4 18.316-18 28.9 29.0 9.8 32.4 13.9 23.8 20.3 42.0 40.2 39.5 2.5 17.8 7.8 69.5 1.2 21.519+ 37.1 26.5 10.2 26.1 14.2 15.9 24.6 45.3 37.2 33.7 5.7 23.5 6.5 53.4 0.8 39.3 

Total number of 

supervisory items 0.266 0.092 0.760 0.766 

None 37.4 31.2 11.0 20.4 22.7 22.5 20.8 34.1 45.8 35.0 4.0 15.2 6.8 73.7 0.5 19.0 1-5 38.1 24.8 10.0 27.1 11.1 22.8 22.8 43.3 38.7 40.0 2.9 18.3 6.5 69.3 0.5 23.76 29.5 28.7 9.8 32.0 12.1 18.3 20.7 48.9 37.1 41.0 3.5 18.4 8.1 68.8 1.4 21.8

Provider received training 

in family planning counseling within 24 months 0.356 0.762 0.307 0.312 No 36.7 28.0 9.4 25.9 12.7 20.6 23.0 43.7 41.4 39.1 3.3 16.2 7.5 71.5 0.5 20.5Yes 30.5 26.4 11.6 31.4 14.5 21.9 19.2 44.4 35.2 40.5 3.4 20.9 6.5 66.6 1.5 25.4 

Continues
57

Appendix 6–Continued 

Problems with current method How to use Side effects When to return 

Both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue 

Facility type 0.397 0.376 0.563 0.421 

Hospital 34.9 33.1 7.6 24.3 15.5 23.8 16.2 44.5 36.1 40.2 3.2 20.4 6.0 69.3 1.1 23.6 Health center 34.4 23.5 11.8 30.3 13.9 21.2 23.0 41.9 38.5 39.3 3.7 18.5 6.5 68.6 1.1 23.9 Other 34.9 29.0 9.6 26.5 9.6 17.4 25.4 47.6 44.3 39.4 2.8 13.5 10.0 73.0 0.0 17.1 

Location 0.447 0.824 0.001 0.358 

Urban 36.1 28.6 8.4 26.9 12.9 19.8 22.6 44.7 34.1 39.4 4.4 22.2 7.3 67.2 1.1 24.4 Rural 33.0 26.2 12.0 28.8 13.9 22.5 20.6 43.0 45.2 39.8 2.1 12.8 7.0 72.8 0.5 19.7 

Managing authority 0.042 0.167 0.572 0.288 

Private/faith/NGO/other 35.2 22.4 10.6 31.7 12.0 25.2 20.7 42.0 41.0 38.7 2.6 17.7 7.2 66.5 1.1 25.2 Government 34.1 32.4 9.6 23.9 14.5 17.2 22.6 45.7 37.6 40.4 4.1 17.9 7.1 72.9 0.6 19.4 

Region 0.653 0.127 0.042 0.017 

North 38.8 24.5 8.9 27.7 7.5 16.2 28.9 47.3 46.7 37.7 2.2 13.4 11.3 68.9 0.3 19.5 Center 34.2 27.6 11.9 26.3 14.9 20.4 20.3 44.4 31.8 42.0 3.6 22.6 3.4 68.1 0.6 27.9 South 27.0 32.8 10.1 30.0 14.2 24.4 15.7 45.8 34.6 43.7 2.9 18.8 4.0 70.1 1.7 24.2 West 38.8 24.9 8.9 27.4 17.1 24.0 21.6 37.3 45.9 33.9 4.8 15.4 11.0 72.9 0.9 15.1 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
58

Appendix 7. Quality of Counseling for Malawi: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Problems with current method How to use Side effects When to return 

Both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue

Duration of consultation 

Average in minutes 6.8 6.9 10.0 8.2 0.320 5.2 7.0 6.5 12.5 <0.001 7.4 8.8 7.4 13.4 0.001 13.5 7.1 13.2 12.7 0.001 

Client’s age 0.618 0.669 0.813 0.014 

<20 15.1 15.0 10.5 59.4 12.8 12.4 19.7 55.1 27.7 29.2 9.3 33.8 2.8 43.3 3.8 50.2 20-29 10.9 11.0 19.4 58.7 9.5 14.7 22.8 53.0 32.9 31.0 7.4 28.7 3.0 54.3 4.3 38.4 30-35 11.3 16.8 13.8 58.1 7.9 14.3 26.4 51.5 30.7 27.0 11.0 31.2 2.9 64.6 1.4 31.2 36+ & DK 13.8 10.7 13.2 62.3 4.0 20.3 24.3 51.4 35.8 29.1 9.3 25.7 6.0 56.9 0.9 36.2 

Client’s education 0.415 0.406 0.499 0.215 

No school 15.1 9.1 21.8 54.0 8.0 16.6 23.2 52.1 37.9 31.0 6.0 25.1 3.9 57.5 6.1 32.5 Primary & post-primary 11.1 13.2 16.1 59.5 9.2 14.4 23.6 52.8 31.3 29.7 8.9 30.0 3.0 55.6 2.9 38.4 Secondary+ 0.0 6.2 0.0 93.8 4.5 42.5 0.0 53.0 29.7 17.6 0.0 52.7 16.8 51.1 0.0 32.1 

Client status 0.331 0.003 0.001 0.111 

New client 14.1 17.6 16.5 51.8 4.3 11.2 16.2 68.4 25.9 28.8 4.5 40.9 3.3 51.0 1.9 43.9 Returning client 11.0 11.5 16.9 60.6 10.8 16.3 26.2 46.8 34.6 30.2 10.0 25.1 3.2 57.6 3.9 35.3 

Client’s method 0.058 <0.001 0.135 <0.001 

Other 15.4 8.8 29.1 46.7 1.9 11.4 9.2 77.5 28.0 33.6 4.5 34.0 9.8 34.2 5.4 50.6 Pill 14.7 7.0 21.5 56.8 4.0 6.5 8.7 80.8 30.1 19.8 7.2 42.9 9.6 37.5 14.8 38.0 Progestin injectable 10.9 13.6 15.1 60.4 10.4 16.0 26.6 47.0 32.9 30.2 9.2 27.7 1.8 60.3 2.1 35.9 

Provider category 0.618 0.938 0.484 0.024 

Clinician/technician/other 14.3 13.1 19.6 53.0 10.5 15.5 22.1 52.0 35.7 25.1 6.4 32.9 6.7 62.4 1.6 29.3 Nurse/midwife 11.2 12.6 16.4 59.8 8.8 14.8 23.6 52.9 31.7 30.5 8.8 29.0 2.7 54.9 3.6 38.8 

Provider’s number of years of 

schooling 0.133 0.108 0.502 0.878 <16 11.3 12.5 18.1 58.1 11.7 16.9 21.3 50.1 34.9 27.8 9.6 27.7 3.4 56.7 2.9 37.0 16-18 9.4 12.2 15.9 62.6 6.2 12.4 23.6 57.9 27.4 33.0 7.5 32.1 3.2 54.1 4.1 38.5 19+ 34.9 19.3 11.0 34.9 5.7 15.9 47.5 30.9 49.5 20.6 6.1 23.7 1.0 63.1 0.0 35.9 

Total number of supervisory items 0.001 0.181 0.766 0.883 

none 9.3 9.4 13.3 68.0 11.5 15.0 30.2 43.3 36.0 27.8 6.5 29.7 3.5 60.0 3.1 33.5 1-5 19.1 18.2 20.5 42.1 11.6 13.8 23.7 50.9 34.0 30.1 9.3 26.7 2.9 55.8 2.7 38.7 6 6.4 10.1 16.1 67.4 4.8 15.7 18.4 61.1 27.9 31.0 9.2 31.9 3.4 53.0 4.1 39.6 

Provider received training in family 

planning counseling within 24 months 

0.851 0.007 0.153 0.180 

No 11.5 13.6 17.6 57.3 11.2 16.1 17.0 55.7 29.1 31.7 10.2 29.0 3.2 56.7 2.0 38.0 Yes 11.7 11.1 15.5 61.7 5.3 12.7 34.2 47.8 37.4 26.7 5.7 30.3 3.2 54.3 5.5 37.0 

Continues
59

Appendix 7–Continued 

Problems with current method How to use Side effects When to return 

Both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue Both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

Both 

yes4

pvalue

Facility type 0.897 0.010 0.885 0.259 

Hospital 10.6 13.3 15.1 61.0 8.2 10.7 33.7 47.4 33.7 27.4 9.1 29.8 1.7 56.6 4.3 37.4 Health center 11.7 12.1 18.3 57.9 9.7 18.0 14.7 57.6 30.3 32.3 7.9 29.4 3.7 56.2 2.4 37.7 Other 15.1 12.7 17.2 55.1 8.7 17.0 22.0 52.3 34.8 28.1 8.8 28.3 7.4 50.8 3.6 38.3 

Location 0.404 0.013 0.487 0.466 

Urban 9.9 10.2 13.6 66.3 6.4 11.5 36.0 46.1 34.5 26.3 11.1 28.1 3.1 59.7 4.0 33.1 Rural 12.7 14.2 18.9 54.3 10.5 16.8 16.1 56.6 30.8 31.9 7.0 30.3 3.3 53.6 2.9 40.2 

Managing authority 0.824 0.191 0.178 0.364 

Private/faith/NGO/other 14.1 13.3 15.7 56.9 11.8 19.7 24.0 44.4 37.2 32.6 5.9 24.3 4.6 54.6 1.6 39.2 Government 10.9 12.5 17.1 59.5 8.3 13.6 23.3 54.8 30.9 29.1 9.2 30.8 2.9 56.1 3.8 37.2 

Region 0.468 0.478 0.049 0.488 

North 4.9 15.7 8.8 70.6 8.5 26.7 16.3 48.5 24.7 30.0 9.7 35.6 2.4 67.1 0.7 29.8 Central 13.0 13.6 17.9 55.5 8.8 12.2 25.6 53.4 31.2 25.2 11.0 32.7 3.6 54.0 3.2 39.3 South 11.5 11.0 17.3 60.2 9.3 15.7 22.1 52.8 34.9 35.4 5.3 24.4 2.9 55.8 4.1 37.2 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
60

Appendix 8. Quality of Counseling for Senegal: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Problems with current method How to use Side effects When to return 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Duration of consultation 

Average in minutes 15.5 15.0 11.7 12.4 0.364 11.9 12.1 10.5 19.6 <0.001 12.0 13.4 29.5 23.4 <0.001 9.4 12.4 14.0 22.4 <0.001 

Client’s age 0.089 0.108 0.378 0.148 

<20 13.0 13.6 2.9 70.5 4.5 20.3 5.2 70.0 12.1 45.2 2.3 40.4 0.0 55.0 0.0 45.0 20-29 18.7 22.1 6.7 52.6 7.8 28.7 5.4 58.0 23.3 49.9 3.9 22.9 0.3 60.2 0.6 38.9 30-35 12.1 16.0 6.6 65.3 6.4 39.0 6.5 48.1 23.9 52.4 2.5 21.2 3.3 62.6 0.0 34.1 36+ & DK 7.5 19.4 7.6 65.5 7.4 39.0 6.8 46.8 19.1 52.6 2.8 25.5 1.4 65.8 0.0 32.7 

Client’s education 0.221 0.591 0.681 0.254 

No school 11.1 18.0 8.1 62.8 7.4 36.1 6.1 50.4 22.7 52.7 2.7 21.8 2.0 64.9 0.3 32.8 Primary & post-primary 18.7 17.4 6.0 57.9 6.0 32.4 5.1 56.5 23.4 47.7 3.2 25.7 1.3 59.2 0.0 39.5 Secondary+ 11.0 25.0 4.3 59.7 8.0 28.1 7.1 56.8 17.2 51.3 4.1 27.4 0.0 58.4 0.6 41.0 

Client status <0.001 <0.001 <0.001 <0.001 

New client 18.0 43.4 6.1 32.6 0.4 12.9 2.0 84.7 11.8 37.7 5.3 45.2 1.4 40.1 0.0 58.4 Returning client 13.0 16.6 6.8 63.7 10.0 42.0 7.7 40.3 26.0 56.5 2.3 15.2 1.3 71.1 0.4 27.2 

Client’s method 0.751 <0.001 0.525 0.013 

Other 11.4 20.9 6.2 61.4 10.7 32.1 4.1 53.1 19.3 47.7 4.8 28.2 1.3 52.6 0.0 46.1 Pill 14.0 23.8 6.2 56.0 1.2 22.8 1.9 74.1 21.7 56.2 3.1 19.1 3.1 69.8 0.6 26.6 Progestin injectable 14.0 16.7 7.1 62.2 8.5 37.8 8.2 45.5 22.5 49.7 2.7 25.0 0.7 61.4 0.2 37.7 

Provider category 0.613 0.508 0.478 0.447 

Nurse/doctor/technician 13.0 17.5 5.0 64.5 8.1 36.3 4.3 51.3 19.4 53.6 1.9 25.1 1.5 60.6 0.7 37.2 Midwife 13.7 20.1 7.6 58.6 6.6 31.5 7.0 54.9 23.1 49.3 3.9 23.7 1.2 62.5 0.0 36.2 

Provider’s number of years 

of schooling 0.723 0.350 0.509 0.169 <16 14.5 16.3 6.6 62.6 7.6 37.2 3.8 51.4 21.0 53.5 1.4 24.1 1.5 64.2 0.0 34.4 16-18 13.4 22.3 6.4 58.0 6.5 29.5 6.8 57.2 21.0 50.1 4.7 24.3 0.8 59.1 0.2 39.9 19+ 10.6 13.8 8.6 67.0 8.8 39.5 8.9 42.7 27.8 46.9 1.2 24.1 3.6 68.0 1.2 27.2 

Total number of supervisory 

items 0.466 0.165 0.408 0.492 

None 10.1 15.0 7.7 67.2 10.2 26.8 6.5 56.5 23.3 44.4 1.9 30.5 1.7 60.4 0.6 37.3 1-5 14.6 15.7 6.1 63.5 6.2 42.4 3.6 47.8 22.4 55.8 2.3 19.4 1.4 56.3 0.5 41.8 6 14.1 23.0 6.6 56.3 6.4 30.8 7.2 55.6 20.7 50.8 4.2 24.3 1.1 65.5 0.0 33.3 

Provider received training in 

family planning counseling within 24 months 0.308 0.250 0.378 0.644 No 14.9 21.1 5.5 58.4 8.6 31.3 6.8 53.3 24.5 48.8 3.2 23.5 1.5 62.6 0.4 35.4 Yes 11.2 16.3 8.5 64.1 4.8 36.4 4.7 54.1 17.3 54.3 3.2 25.3 1.0 60.5 0.0 38.5 

Continues
61

Appendix 8–Continued 

Problems with current method How to use Side effects When to return 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Facility type 0.396 0.098 0.523 0.230 

Hospital 20.1 21.0 9.4 49.6 2.4 18.6 11.0 68.1 20.0 55.8 1.6 22.6 0.8 49.7 0.0 49.5 Health center 9.7 25.2 7.8 57.3 3.7 38.3 8.7 49.3 21.4 57.4 3.5 17.7 0.9 71.3 0.0 27.8 Other 14.0 17.9 6.4 61.8 8.0 32.8 5.3 53.9 21.9 49.4 3.2 25.6 1.5 60.3 0.3 37.9 

Location 0.161 0.011 0.261 0.521 

Urban 14.6 22.8 7.5 55.1 5.5 27.4 7.5 59.6 22.8 47.2 4.3 25.7 1.0 62.5 0.0 36.5 Rural 12.2 15.4 5.9 66.6 8.9 39.7 4.4 47.0 20.6 54.9 1.9 22.6 1.7 61.1 0.6 36.6 

Managing authority 0.459 0.490 0.527 0.962 

Private/faith/NGO/other 19.8 0.0 15.1 65.1 16.1 15.1 3.6 65.2 34.6 47.0 3.6 14.9 0.0 68.3 0.0 31.7 Government 13.3 19.5 6.5 60.6 7.0 33.6 6.1 53.4 21.5 51.0 3.2 24.3 1.4 61.7 0.3 36.7 

Region 0.043 <0.001 0.001 0.128 

Northern 10.6 13.5 10.7 65.2 4.2 48.2 1.0 46.6 11.0 69.4 2.3 17.2 3.2 67.8 0.8 28.3 Dakar 17.4 29.1 6.5 47.0 3.9 23.3 10.1 62.7 21.3 50.3 5.8 22.6 1.0 69.6 0.0 29.4 Thies 8.5 18.8 6.3 66.3 3.8 33.3 2.7 60.3 13.0 47.9 4.5 34.7 0.7 58.6 0.0 40.7 Central 11.3 19.4 4.0 65.2 9.9 48.3 0.3 41.6 30.3 43.8 2.4 23.6 1.9 50.0 0.7 47.4 East 11.2 19.6 11.6 57.6 9.2 55.0 1.2 34.7 4.8 59.8 1.1 34.4 0.0 72.4 0.0 27.6 South 16.7 7.8 4.5 71.0 14.6 12.9 14.5 58.0 35.3 41.5 0.0 23.3 0.4 56.2 0.0 43.3 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
 62 

Appendix 9. Family planning client exit questions used to assess client’s general knowledge of method 

use 

Method Question Correct knowledge 

Pill How often do you take the pill? Once a day 

Condom (male) How many times can you use one condom Once 

Condom (female) What type of lubricant can you use with the 

female condom? 

Any oil or lubricant 

IUCD What should you do to make sure that your 

IUCD is in place? 

Check string 

Progestin injectable How long does the injection provider protection 

from pregnancy? 

2-3 months 

Monthly injectable How long does the injection provide projection 

from pregnancy 

1 month 

Implant How long does your implant provide protection 

against pregnancy 

3-5 years 

Natural method How do you recognize the days on which you 

should not have sexual intercourse 

One of the following: 1) Body temperature; 2) 

mucus in vagina; 3) days 12-16 of the menstrual 

cycle; 4) white bead days/days 8-19 of menstrual 

cycle 

Vasectomy After you have been sterilized (and after the first 

3 months), can you make a woman pregnant 

again? 

Only slight risk 

Tubal ligation After you have been sterilized, could you ever 

become pregnant again? 

Only slight risk 

LAM Can you use this method if your menstrual 

period has returned? 

No 
63

Appendix 10. Quality of Counseling for Haiti: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue

Duration of consultation 

Average in minutes 14.1 16.2 16.2 18.9 0.082 14.1 16.8 17.3 16.8 0.032 13.9 15.2 15.3 20.2 0.054 13.4 16.2 14.6 18.1 0.001

Client’s age 0.634 0.148 0.526 0.784

<20 74.7 15.3 4.5 5.5 79.5 17.9 1.6 1.0 57.0 33.7 3.9 5.4 55.0 20.4 13.8 10.8 20-29 72.0 18.1 5.9 4.0 75.0 20.6 2.7 1.8 57.8 33.1 3.4 5.7 51.2 24.6 12.8 11.3 30-35 72.0 18.4 5.3 4.3 76.0 21.0 1.4 1.6 55.4 35.7 3.7 5.2 50.5 22.4 16.0 11.1 36+ & DK 72.5 18.1 3.5 5.9 70.5 26.3 1.3 1.8 59.1 31.9 1.6 7.4 49.2 24.7 13.2 12.9 

Client’s education 0.242 0.191 0.001 0.161

No school 72.6 16.5 4.4 6.5 76.8 19.9 1.5 1.7 66.1 23.9 2.5 7.4 52.1 19.1 15.5 13.4 Primary & post-primary 74.6 16.3 4.9 4.1 74.2 21.4 1.7 2.7 57.8 32.2 4.1 5.9 49.8 23.6 15.1 11.6 Secondary+ 70.7 19.5 5.6 4.3 74.2 22.3 2.4 1.0 54.6 37.2 2.7 5.5 51.4 25.4 12.2 10.9 

Caretaker Relationship 0.670 0.440 0.046 0.172

Mother 72.3 18.1 5.3 4.3 75.0 21.4 2.2 1.5 56.6 33.7 3.6 6.1 49.8 24.3 14.0 11.9 Other 72.4 17.2 4.8 5.6 73.2 22.8 1.5 2.4 61.1 32.5 1.3 5.0 55.8 21.8 12.2 10.2 

Child’s sex 0.463 0.135 0.147 0.302

Female 72.0 18.0 5.9 4.2 74.5 21.3 1.9 2.3 57.4 32.3 3.7 6.6 49.1 24.4 14.7 11.8 Male 72.6 17.9 4.4 5.0 74.8 22.0 2.2 1.0 57.6 34.8 2.6 5.1 53.0 23.2 12.6 11.3 

Child’s age 0.212 0.200 <0.001 <0.001

0-11 months 71.7 18.8 4.8 4.7 75.6 20.1 2.6 1.7 52.0 37.5 4.1 6.5 40.6 28.8 14.5 16.1 12-35 months 72.1 16.8 6.7 4.5 73.1 23.3 1.5 2.1 57.8 32.9 2.8 6.4 54.3 22.2 13.5 10.0 36-71 months 73.8 18.6 3.1 4.5 75.8 21.3 2.0 0.8 67.5 26.7 1.9 3.8 64.6 17.4 12.5 5.5 

Provider category 0.024 0.472 0.001 0.608

Nurse/midwife/other 76.0 17.1 3.1 3.9 74.5 21.8 1.4 2.3 53.7 33.2 3.6 9.5 50.4 23.1 13.4 13.1 Doctor/specialist/tech 70.6 18.4 6.2 4.9 74.7 21.5 2.3 1.4 59.2 33.6 2.9 4.3 51.2 24.2 13.8 10.8 

Provider’s number of years 

of schooling 

 0.091 0.531 0.001 0.927

<16 75.0 19.1 1.7 4.2 74.5 21.7 1.4 2.4 50.3 36.1 2.9 10.7 53.7 20.9 13.1 12.3 16-18 75.9 14.6 4.8 4.7 73.8 21.6 2.0 2.7 58.4 29.3 3.6 8.7 50.3 23.8 14.0 11.9 19+ 70.9 18.5 5.8 4.7 74.6 21.9 2.3 1.2 58.6 34.2 3.0 4.2 50.5 24.0 14.2 11.2 

Total number of 

supervisory items 

0.377 0.448 0.368 0.685

None 74.0 16.4 5.6 4.0 76.9 20.0 1.3 1.8 60.4 31.3 2.7 5.5 50.5 23.1 15.4 11.0 1-5 73.4 17.3 4.7 4.5 72.5 23.6 2.6 1.3 55.9 35.5 3.6 5.0 51.4 25.3 11.5 11.8 6 68.0 21.4 5.1 5.5 74.0 21.5 2.5 2.0 54.8 34.1 3.2 7.8 51.0 23.0 14.0 12.0 

Continues
64

Appendix 10–Continued 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue

Provider received training 

in child health/illness in the past three years 

 0.938 0.114 0.105 0.075

No 72.9 17.3 5.0 4.8 73.4 24.1 1.4 1.1 60.8 31.8 3.0 4.4 52.8 24.0 14.3 8.9 Yes 71.9 18.5 5.1 4.6 75.3 20.2 2.6 2.0 54.9 35.0 3.2 6.9 49.6 23.2 13.9 13.3 

Provider salary type 0.165 0.072 0.002 0.012

None 69.8 20.4 5.7 4.0 77.9 18.6 2.0 1.5 63.1 30.1 2.5 4.3 54.5 20.1 15.1 10.3 Regular salary 74.8 16.0 4.6 4.7 70.3 26.0 2.3 1.4 50.6 38.7 3.6 7.1 46.3 27.7 13.0 13.0 No regular salary but other pay 

74.0 14.9 5.0 6.0 75.0 20.3 1.7 2.9 56.8 31.1 4.1 8.0 51.3 26.1 10.9 11.8 

Facility type 0.001 0.112 0.086 0.571

Hospital 64.9 22.9 7.3 5.0 73.5 24.5 0.9 1.0 59.4 33.6 2.8 4.2 52.5 25.4 12.2 9.9 Health center 75.8 15.6 4.6 4.0 75.1 19.9 3.1 1.8 57.9 33.6 3.3 5.2 50.2 22.4 15.0 12.3 Other 76.5 15.3 3.1 5.1 75.4 20.9 1.4 2.4 53.2 33.1 3.5 10.2 50.2 24.5 13.0 12.3 

Location 0.827 0.940 0.333 0.255

Urban 71.6 18.7 5.4 4.3 74.5 21.7 2.2 1.5 56.1 35.6 3.1 5.2 48.9 25.9 13.6 11.6 Rural 73.1 17.2 5.0 4.8 74.8 21.5 1.9 1.8 58.9 31.2 3.2 6.7 53.2 21.5 13.8 11.4 

Managing authority 0.041 0.627 0.278 0.347

Private/faith/NGO/other 71.2 17.1 6.2 5.5 74.3 22.0 2.3 1.4 55.9 34.1 3.8 6.2 49.9 23.2 14.8 12.0 Government 73.9 19.2 3.7 3.2 75.1 21.1 1.7 2.1 59.8 32.6 2.2 5.4 52.4 24.8 12.0 10.8 

Region 0.019 0.120 0.040 0.072

North 75.8 18.3 2.9 3.0 75.4 22.9 0.8 0.9 63.1 31.9 1.4 3.5 56.4 21.1 14.7 7.8 Center 71.3 21.8 3.7 3.3 78.6 17.5 1.9 1.9 63.2 28.6 2.2 6.0 51.4 24.2 12.4 12.1 South 71.0 15.6 5.3 8.1 74.5 22.6 0.6 2.2 50.5 36.2 4.7 8.6 54.6 24.9 10.0 10.5 West 71.7 17.3 6.8 4.2 72.7 22.3 3.3 1.7 55.7 35.0 3.6 5.7 46.8 24.4 15.4 13.5 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
65

Appendix 11. Quality of Counseling for Malawi: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue

Duration of consultation 

Average in minutes 17.0 22.7 17.2 22.0 <0.001 20.5 20.9 19.7 16.8 0.216 19.9 21.7 19.1 20.4 0.758 20.1 17.5 23.2 24.9 0.035

Client’s age 0.245 0.289 0.164 0.735

<20 26.4 35.1 7.3 31.2 61.7 29.9 3.7 4.7 69.5 22.5 4.6 3.4 72.1 11.9 11.0 5.0 20-29 29.0 31.7 9.9 29.3 60.1 28.3 6.2 5.5 69.8 20.9 6.4 2.9 72.5 11.3 12.7 3.4 30-35 27.3 31.8 9.9 31.0 59.2 28.7 5.5 6.7 70.5 23.2 4.5 1.9 73.7 12.4 11.0 3.0 36+ & DK 24.1 27.1 10.1 38.8 65.4 21.5 7.6 5.5 74.1 14.6 8.5 2.8 76.1 11.2 9.2 3.6 

Client’s education 0.012 0.086 0.141 0.011

No school 29.5 26.4 13.0 31.1 66.9 24.9 4.4 3.9 73.6 17.6 6.3 2.4 76.8 9.4 10.7 3.2 Primary & post-primary 27.8 32.4 9.4 30.4 59.7 28.4 6.1 5.8 70.4 21.0 6.0 2.7 73.0 11.9 11.5 3.6 Secondary+ 20.2 26.1 2.2 51.5 61.9 18.7 8.8 10.6 53.7 31.1 8.7 6.5 58.4 10.7 28.7 2.2 

Caretaker Relationship 0.365 0.009 0.611 0.066

Mother 26.7 32.0 10.0 31.3 59.0 28.4 6.6 6.0 70.3 21.3 5.7 2.7 73.8 11.5 10.8 3.9 Other 31.4 30.1 8.7 29.8 65.8 25.8 4.0 4.4 70.7 19.2 7.4 2.7 71.0 12.0 14.6 2.3 

Child’s sex 0.223 0.704 0.373 0.882

Female 29.3 30.5 8.7 31.4 61.7 26.6 5.9 5.8 71.2 19.4 6.2 3.2 72.7 12.0 11.5 3.7 Male 26.3 32.5 10.6 30.6 59.6 28.9 6.0 5.5 69.6 22.2 6.0 2.3 73.5 11.2 12.0 3.4 

Child’s age 0.039 0.033 0.024 <0.001

0-11 months 31.0 29.5 9.8 29.6 58.3 28.4 5.7 7.6 66.9 22.5 7.9 2.7 65.4 17.1 11.8 5.7 12-35 months 27.5 33.0 9.2 30.3 61.3 28.5 5.8 4.4 73.1 18.8 5.2 2.9 75.4 9.0 13.0 2.5 36-71 months 22.0 32.1 10.5 35.3 64.2 24.5 6.7 4.7 71.0 22.1 4.6 2.3 83.5 6.5 8.6 1.3 

Provider category 0.002 0.868 0.028 0.041

Nurse/midwife/other 19.3 29.1 13.0 38.6 58.9 28.5 6.8 5.8 72.8 14.4 9.4 3.3 66.6 16.2 12.4 4.8 Doctor/specialist/tech 29.2 31.9 9.1 29.8 60.9 27.7 5.8 5.6 70.0 21.8 5.6 2.6 74.2 10.9 11.7 3.3 

Provider’s number of years of 

schooling 0.168 0.045 0.232 0.843

<16 28.8 31.0 9.5 30.7 60.8 28.5 5.6 5.1 71.1 21.3 5.4 2.2 73.3 12.0 11.3 3.4 16-18 26.3 34.8 9.7 29.2 62.9 24.9 5.8 6.5 68.5 19.4 7.9 4.2 72.6 10.7 12.8 4.0 19+ 18.4 24.6 12.1 44.8 47.2 29.6 13.3 9.9 68.8 18.7 8.3 4.2 72.8 9.3 15.1 2.8 

Total number of supervisory 

items 0.002 0.374 0.003 0.448None 29.6 33.2 9.4 27.8 60.1 30.1 5.4 4.4 63.0 30.8 3.7 2.5 75.2 10.4 11.8 2.6 1-5 33.3 33.9 7.8 24.9 63.1 26.5 5.9 4.5 73.6 17.6 5.7 3.1 75.0 10.5 10.7 3.8 6 22.4 28.7 11.3 37.7 59.1 27.3 6.3 7.3 72.5 17.1 7.9 2.5 70.4 13.2 12.6 3.9 

Continues
66

Appendix 11–Continued 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1

prv 

no, cl 

yes2

prv 

yes, cl 

no3

both 

yes4

pvalue

Provider received training in 

child health/illness in the past three years <0.001 0.008 0.152 0.002

No 37.8 33.9 8.5 19.8 66.8 25.5 4.3 3.5 70.0 23.5 4.0 2.5 78.9 10.9 7.9 2.3 Yes 23.0 30.4 10.2 36.3 57.7 28.9 6.7 6.7 70.6 19.5 7.1 2.8 70.4 11.9 13.6 4.1 

Provider salary type 0.073 0.071 0.188 0.296

None 20.3 30.6 9.1 40.0 61.6 24.8 7.3 6.3 59.2 30.0 5.7 5.0 68.6 14.2 15.2 2.0 Regular salary 25.3 32.4 10.8 31.5 56.3 29.3 7.0 7.4 72.2 19.7 6.0 2.1 74.5 10.0 11.6 3.9 No regular salary but other pay 31.4 31.1 8.9 28.6 63.8 27.2 4.8 4.2 71.5 19.6 6.2 2.6 73.1 12.3 11.1 3.5 

Facility type <0.001 0.387 <0.001 0.252

Hospital 35.7 33.5 7.6 23.2 63.9 26.8 5.4 3.9 61.0 33.7 3.0 2.3 75.4 11.5 11.2 1.9 Health center 24.9 30.8 11.0 33.3 59.4 28.0 6.1 6.5 75.5 13.9 7.7 3.0 71.3 11.9 12.3 4.5 Other 16.6 28.9 9.7 44.8 56.9 29.5 6.8 6.8 75.0 14.3 7.8 2.8 75.5 10.1 10.7 3.6 

Location 0.004 0.059 <0.001 0.011

Urban 36.8 32.7 7.7 22.8 64.8 28.0 3.7 3.4 62.5 31.2 3.2 3.1 79.4 10.7 8.6 1.2 Rural 23.9 31.1 10.5 34.5 58.9 27.7 6.9 6.6 73.8 16.3 7.3 2.6 70.4 12.0 13.1 4.5 

Managing authority <0.001 0.001 0.048 <0.001

Private/faith/NGO/other 19.0 30.4 10.4 40.1 55.8 27.5 9.6 7.0 68.6 19.1 9.0 3.2 63.6 13.7 16.7 6.0 Government 30.7 31.9 9.4 28.0 62.3 27.8 4.7 5.2 71.0 21.3 5.1 2.5 76.3 10.9 10.1 2.7 

Region 0.520 0.004 0.079 0.194

North 29.6 36.2 9.6 24.6 64.4 26.9 3.4 5.2 80.9 13.3 4.8 1.1 79.0 10.4 8.0 2.6 Central 27.7 30.0 9.3 33.0 57.1 28.0 7.7 7.2 68.5 22.4 6.3 2.8 71.1 11.6 12.9 4.3 South 27.2 31.9 10.3 30.7 64.4 27.8 4.4 3.4 68.7 21.6 6.4 3.3 73.6 12.0 11.7 2.7 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
67

Appendix 12. Quality of Counseling for Senegal 2012-13: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Duration of 

consultation Average in minutes 10.4 11.4 13.0 13.4 0.112 10.7 10.8 16.2 11.9 0.007 9.8 12.8 15.8 14.1 <0.001 10.0 11.9 12.5 14.1 <0.001 

Client’s age 0.796 0.424 0.594 0.299 

<20 68.6 23.9 3.2 4.3 76.8 13.7 5.3 4.2 79.2 16.7 0.9 3.2 65.4 20.7 5.4 8.5 20-29 68.8 21.1 4.6 5.5 78.5 15.5 2.2 3.8 68.7 23.0 2.4 5.9 64.5 20.2 6.8 8.5 30-35 68.2 21.7 2.4 7.7 70.6 22.4 2.5 4.5 67.7 22.3 2.9 7.1 63.7 20.0 8.5 7.8 36+ & DK 68.3 19.9 3.5 8.3 76.3 17.6 2.1 4.0 71.5 19.0 3.3 6.2 72.3 12.0 7.2 8.6 

Client’s education 0.002 0.240 0.200 0.211 

No school 71.6 19.5 3.0 5.9 73.6 18.6 3.0 4.8 73.1 18.0 3.0 5.9 64.9 17.5 7.4 10.2 Primary & postprimary 72.2 16.3 4.4 7.1 76.0 19.1 1.2 3.7 65.2 26.1 1.8 6.9 67.6 18.7 6.1 7.7 Secondary+ 55.7 31.8 4.3 8.2 81.5 13.1 2.6 2.7 68.2 24.2 2.4 5.2 69.2 18.5 8.0 4.2 

Caretaker 

relationship 0.480 0.160 0.059 <0.001 

Mother 68.5 21.9 3.4 6.2 75.0 18.0 3.0 4.0 68.4 22.2 2.7 6.6 63.4 20.1 7.2 9.3 Other 68.5 18.5 4.4 8.6 78.9 15.9 0.7 4.5 77.1 17.2 2.2 3.5 78.7 9.5 7.2 4.6 

Child’s sex 0.025 0.693 0.684 0.331 

Female 68.5 23.3 1.8 6.4 76.6 17.7 2.3 3.4 71.7 20.1 2.7 5.4 66.9 19.1 7.3 6.7 Male 68.5 19.5 5.1 6.9 75.1 17.6 2.7 4.7 68.8 22.1 2.5 6.5 66.1 17.1 7.1 9.8 

Child’s age 0.852 0.403 0.006 <0.001 

0-11 months 71.1 19.9 3.7 5.3 74.9 18.2 3.3 3.5 64.1 25.4 3.4 7.1 54.4 28.1 6.9 10.6 12-35 months 67.4 21.4 3.7 7.5 75.9 16.1 3.0 5.0 68.5 20.7 2.8 8.0 66.0 15.4 7.8 10.9 36-71 months 66.7 22.5 3.5 7.3 76.8 18.6 0.9 3.7 79.3 16.8 1.4 2.5 81.4 8.9 6.9 2.8 

Provider category 0.010 0.060 0.169 0.738 

Nurse/midwife/other 71.4 19.7 3.2 5.7 74.8 18.1 2.7 4.5 71.7 20.1 2.3 5.9 66.7 18.2 6.8 8.3 Doctor/specialist/tech 48.3 31.9 6.4 13.3 82.9 14.5 1.2 1.4 59.3 29.1 4.6 7.0 64.7 16.8 9.9 8.6 

Provider’s number of 

years of schooling 0.002 0.815 0.349 0.475 

<16 72.3 20.3 2.4 5.1 74.1 18.3 2.3 5.3 72.1 20.2 3.0 4.7 68.9 17.7 5.2 8.2 16-18 73.7 17.2 3.5 5.5 78.2 16.5 2.4 2.9 70.3 19.8 1.6 8.3 64.9 17.2 8.1 9.8 19+ 52.9 29.4 6.2 11.5 75.1 18.1 3.1 3.6 66.2 25.6 3.4 4.8 64.3 19.8 9.5 6.4 

Continues
68

Appendix 12–Continued 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Total number of 

supervisory items 0.393 0.146 0.710 0.876 none 62.5 24.7 4.0 8.8 80.8 14.3 3.6 1.3 67.1 24.0 2.6 6.3 65.7 17.7 7.0 9.6 1-5 70.5 17.6 4.2 7.6 74.3 16.9 2.7 6.1 68.7 20.8 2.4 8.1 64.6 20.9 6.8 7.7 6 70.4 21.7 3.0 4.9 74.1 19.9 1.8 4.2 72.7 20.0 2.7 4.5 68.0 16.3 7.5 8.1 

Provider received 

training in child health/illness in the past three years 0.851 0.044 0.007 0.040 

No 70.2 19.6 3.1 7.1 82.0 15.1 1.9 1.0 73.4 19.8 3.5 3.3 73.2 15.3 7.2 4.3 Yes 67.8 21.8 3.8 6.5 73.3 18.6 2.8 5.3 68.8 21.8 2.3 7.1 63.8 19.1 7.2 10.0 

Provider salary type <0.001 0.008 0.007 0.032 

None 68.1 25.0 3.0 3.9 85.3 11.8 1.4 1.6 75.4 18.4 0.0 6.2 70.8 22.0 3.1 4.1 Regular salary 74.0 19.8 2.1 4.0 70.3 22.5 2.2 5.0 75.1 18.1 2.4 4.4 68.4 17.0 6.5 8.1 No regular salary but 

other pay 58.5 22.0 6.7 12.8 81.6 11.2 3.6 3.5 58.6 28.3 4.1 9.0 60.8 17.9 10.4 10.9 

Facility type 0.002 0.115 0.026 0.727 

Hospital 51.6 40.5 0.9 7.1 78.0 17.2 2.5 2.3 62.8 34.2 0.9 2.1 69.5 19.8 7.3 3.4 Health center 68.3 25.1 2.8 3.9 83.5 13.6 2.1 0.8 71.5 23.9 1.6 2.9 67.0 16.3 7.7 9.0 Other 69.8 19.3 3.9 7.0 74.7 18.2 2.6 4.6 70.5 19.9 2.9 6.7 66.1 18.1 7.1 8.7 

Location 0.254 0.001 0.406 0.061 

Urban 65.2 22.5 4.3 8.0 82.1 14.0 1.7 2.2 69.1 23.4 2.6 4.9 69.6 17.4 7.3 5.7 Rural 71.9 19.9 3.0 5.3 69.3 21.4 3.3 6.0 71.2 19.0 2.6 7.2 63.2 18.6 7.1 11.1 

Managing authority 0.466 0.341 0.626 0.371 

Private/faith/NGO/ 

other 61.9 26.1 3.9 8.0 81.8 14.4 1.2 2.7 68.4 20.2 4.2 7.2 65.9 22.2 4.3 7.6 

Government 70.2 20.0 3.5 6.3 74.3 18.4 2.8 4.4 70.6 21.5 2.2 5.7 66.6 16.9 7.9 8.6 

Region <0.001 <0.001 0.011 0.001 

Northern 57.0 27.4 6.5 9.1 81.4 7.1 6.4 5.1 53.8 31.0 4.0 11.2 51.0 21.3 13.3 14.5 Dakar 56.9 25.8 7.6 9.6 87.5 10.7 1.4 0.4 67.9 23.2 5.2 3.7 68.0 17.0 8.4 6.6 Thies 61.8 28.6 2.2 7.4 62.6 28.1 3.8 5.5 73.4 17.3 1.1 8.2 69.9 21.7 2.7 5.7 Central 72.3 18.9 2.9 6.0 62.2 29.0 2.1 6.6 76.1 18.2 1.6 4.1 66.4 22.2 5.3 6.1 East 85.5 14.5 0.0 0.0 74.1 22.5 1.7 1.7 79.7 17.1 3.3 0.0 77.2 6.9 10.6 5.4 South 88.3 8.1 0.0 3.5 90.9 5.6 0.0 3.5 71.5 20.5 1.0 7.1 70.2 10.4 6.8 12.6 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided. 
69

Appendix 13. Quality of Counseling for Senegal 2014: Cross tabulation of provider and client reported counseling and client, provider, and facility background characteristics 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Duration of 

consultation Average in minutes 11.1 14.9 13.4 14.5 0.002 11.1 14.3 15.4 19.6 <0.001 11.0 13.1 13.6 12.9 0.035 10.9 13.3 12.5 14.2 0.002 

Client’s age 0.865 0.564 0.033 0.113 

<20 82.0 11.1 1.0 5.8 87.9 8.1 0.3 3.7 55.2 68.4 65.4 72.1 59.8 25.6 6.4 8.3 20-29 83.2 10.5 1.6 4.8 84.4 11.8 1.3 2.5 28.0 22.8 25.1 20.5 64.8 16.3 7.2 11.8 30-35 83.5 11.8 1.5 3.2 82.1 13.6 2.6 1.7 0.9 1.5 1.0 2.7 68.1 19.8 6.0 6.0 36+ & DK 84.9 10.6 1.9 2.6 86.2 10.6 0.7 2.6 15.9 7.4 8.5 4.7 69.9 14.6 8.0 7.5 

Client’s education 0.005 0.862 0.031 0.730 

No school 84.9 11.0 1.0 3.0 83.7 12.7 1.4 2.1 70.5 21.2 2.2 6.1 65.0 18.8 7.6 8.6 Primary & post-primary 84.4 8.4 3.9 3.4 86.5 9.5 1.0 2.9 67.7 22.6 0.9 8.8 70.7 15.2 5.5 8.6 Secondary+ 78.8 13.5 0.4 7.3 84.7 10.9 1.7 2.7 57.5 30.2 0.7 11.7 65.0 17.2 7.2 10.6 

Caretaker relationship 0.180 0.275 0.542 0.008 

Mother 83.5 11.4 1.7 3.3 84.7 12.0 1.2 2.2 66.4 24.0 1.6 8.1 64.4 19.2 7.0 9.4 Other 83.7 8.1 1.0 7.2 84.1 9.6 2.5 3.8 71.9 19.9 1.6 6.7 76.7 9.6 7.0 6.7 

Child’s sex 0.178 0.652 0.314 0.521 

Female 82.1 12.9 1.3 3.7 85.5 10.5 1.3 2.7 65.3 24.0 2.0 8.8 64.9 17.5 7.3 10.2 Male 85.0 9.0 1.8 4.2 83.7 12.7 1.5 2.2 69.1 22.7 1.2 6.9 67.7 17.8 6.7 7.8 

Child’s age 0.164 0.763 0.062 <0.001 

0-11 months 81.5 12.5 2.2 3.9 83.3 12.6 1.3 2.9 65.6 26.6 0.9 6.9 55.3 26.6 6.2 11.8 12-35 months 84.1 10.5 0.7 4.7 86.5 9.9 1.6 2.0 66.7 21.1 2.5 9.7 69.9 13.5 7.5 9.1 36-71 months 86.3 8.7 2.5 2.5 82.9 13.5 1.1 2.5 71.6 22.0 0.9 5.5 79.1 9.9 7.4 3.6 

Provider category 0.068 0.443 0.426 0.156 

Nurse/midwife/other 87.9 8.2 1.2 2.6 86.0 9.8 1.1 3.0 65.7 26.2 1.6 6.4 69.5 18.0 6.0 6.4 Doctor/specialist/tech 80.3 12.9 1.8 5.0 83.5 13.0 1.6 2.0 68.4 21.1 1.6 8.9 63.9 17.3 7.8 11.0 

Provider’s number of 

years of schooling 

 0.726 0.486 0.313 0.365 

<16 82.6 11.6 1.9 4.0 81.9 14.0 1.6 2.5 65.7 24.1 1.6 8.6 63.1 21.4 5.9 9.5 16-18 85.9 9.7 1.3 3.1 87.7 9.7 0.9 1.7 67.3 21.6 2.0 9.1 68.1 14.9 8.4 8.7 19+ 80.3 11.9 1.5 6.3 84.8 9.2 2.1 3.9 71.8 25.7 0.6 1.9 71.7 13.2 6.9 8.2 

Continues
70

Appendix 13–Continued 

Told illness 

Signs or symptoms for which to 

immediately bring back child Child’s weight or growth Feeding when child is sick 

both 

no1

prv no, 

cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue both no1 prv no, cl yes2

prv 

yes, cl 

no3

both 

yes4

pvalue 

Total number of 

supervisory items 

0.852 0.707 0.317 0.152 

None 84.4 10.6 0.7 4.3 88.5 8.8 0.4 2.3 68.8 24.2 1.2 5.8 72.7 12.0 7.8 7.5 1-5 80.7 11.7 2.9 4.7 85.5 10.0 1.8 2.7 57.2 32.4 2.5 7.9 64.2 24.7 2.7 8.5 6 84.0 10.8 1.6 3.6 82.7 13.2 1.7 2.4 69.3 20.6 1.5 8.6 64.4 18.1 7.9 9.7 

Provider received 

training in child health/illness in the past three years 

 0.687 0.012 0.623 0.118 

No 83.4 9.6 2.9 4.0 95.7 4.3 0.0 0.0 66.3 27.9 1.2 4.6 76.8 10.8 7.2 5.2 Yes 83.6 11.1 1.4 4.0 82.9 12.7 1.6 2.8 67.4 22.7 1.7 8.3 64.8 18.7 7.0 9.5 

Provider salary type 0.014 0.183 0.024 0.069 

None 71.9 23.1 3.8 1.2 79.3 14.2 1.2 5.4 55.9 29.5 3.5 11.2 64.6 31.8 0.0 3.6 Regular salary 82.6 11.1 1.8 4.4 83.4 13.3 1.1 2.2 71.7 21.1 1.2 5.9 68.4 15.0 7.6 9.1 No regular salary but 

other pay 

89.8 7.0 0.1 3.1 89.9 5.3 2.5 2.3 55.1 29.2 2.4 13.3 60.0 23.0 7.1 10.0 

Facility type 0.002 0.549 0.332 0.061 

Hospital 63.8 21.5 3.6 11.1 89.6 8.2 0.0 2.2 65.2 23.2 1.4 10.2 66.6 9.1 10.2 14.1 Health center 83.4 12.6 0.6 3.4 88.2 8.3 1.0 2.5 62.5 31.7 1.5 4.2 75.6 9.9 9.5 5.0 Other 85.1 9.8 1.6 3.5 83.6 12.4 1.6 2.4 68.2 22.0 1.6 8.2 64.8 19.6 6.4 9.2 

Location <0.001 0.323 0.334 0.305 

Urban 75.0 16.4 2.5 6.2 84.8 12.2 1.8 1.2 68.3 24.2 2.1 5.4 63.2 17.4 8.1 11.3 Rural 89.1 7.3 1.0 2.5 84.4 11.2 1.1 3.2 66.6 22.8 1.3 9.4 68.4 17.8 6.4 7.5 

Managing authority 0.274 0.100 0.831 0.243 

Private/faith/NGO/other 76.7 16.4 2.5 4.4 78.8 20.0 1.2 0.0 70.4 20.7 2.2 6.6 61.1 25.4 5.4 8.1 Government 84.7 10.0 1.4 3.9 85.5 10.3 1.4 2.8 66.7 23.7 1.5 8.0 67.2 16.4 7.3 9.1 

Region <0.001 0.001 0.001 <0.001 

Northern 90.3 8.1 1.1 0.6 86.0 7.1 1.2 5.7 56.4 29.0 3.4 11.3 49.0 25.0 9.4 16.7 Dakar 68.3 18.7 3.7 9.3 82.4 14.0 3.2 0.3 75.0 20.5 1.3 3.2 63.6 18.0 7.2 11.2 Thies 81.5 13.7 2.6 2.2 74.8 17.5 2.0 5.7 56.3 25.6 0.9 17.3 60.1 24.7 5.1 10.1 Central 85.5 10.7 0.4 3.4 82.0 14.9 0.9 2.2 71.2 18.0 1.5 9.3 67.2 21.2 6.1 5.5 East 94.5 2.7 0.0 2.8 94.2 5.5 0.3 0.0 79.4 16.2 1.7 2.7 91.3 2.0 5.2 1.5 South 88.4 6.4 1.3 3.8 94.2 5.2 0.0 0.6 63.4 33.8 1.0 1.8 75.4 6.9 9.3 8.5 

Notes: 1. Both agree no counseling provided; 2. Provider not observed but client reported; 3. Provider observed but client did not report; 4. Both agree counseling provided.