FHI - What People Want From Services

In family planning programs, there can be gaps between the services offered and the services clients need. A better understanding of what women and men want from family planning programs can help bridge these gaps. Studies by FHI's Women's Studies Project (WSP) show that clients have clear ideas about what they want from reproductive health programs. For example, clients want explicit information about contraceptive method side effects. In addition, they want services for men.

The studies also show that people seek a comfortable environment for discussing their private health-care needs. Clients want programs that focus on quality, which includes a variety of contraceptive choices, thorough counseling from knowledgeable and skillful providers, and privacy during counseling and examinations. Above all, women and men say they want to be treated with dignity and respect.

Designing services with an awareness of gender, the roles prescribed by society for women and men, can help programs achieve some of these important expectations.

"I prefer to go there, even though it is far away, because they treat me kindly," said a woman from El Alto, Bolivia, describing a distant clinic she attends. "They talk to me, they explain things -- everything. And when I do not understand or do not know, he [the doctor] explains to me I am thankful to this doctor because, even though it is far, other people do not treat me as he does. Even though I have to pay, that's okay."¹

Side effects

Clients are especially concerned about contraceptive side effects. While providers may downplay side effects because they are not life-threatening, clients say side effects do alter their daily lives. Real or perceived, side effects are the reason many couples stop or refuse to use contraception. WSP research found that side effects were a major concern for women and men.

In a WSP study in Zimbabwe, women and men said family planning was an important element in quality of life. However, women also identified negative consequences of family planning -- method failure, headaches, and prolonged menstrual bleeding. They asked that health providers offer more information on methods and that men be included in counseling. "The couple can then decide together on how they can solve the problems," one man said. "They may choose to use traditional methods of birth spacing or agree that the husband uses a condom."²

In Indonesia, 31 percent of the 180 contraceptive users in South Sumatra and Lampung reported what they considered to be "major" problems related to contraceptive use. These included weight gain or loss, headache, amenorrhea, irregular menstrual bleeding and fatigue. One woman in Lampung said that oral contraceptives caused numerous difficulties, including loss of sexual desire.³

Another Indonesian woman, a 44-year-old mother of four, said she was unhappy with the "safari system" of family planning, in which health workers visit a village to provide methods, but leave shortly thereafter, unavailable to counsel women about side effects. "The acceptor had to take the risk" without readily available help, she said. "Protest? This is a village. It is not polite to protest."⁴

In Iloilo, the Philippines, efficacy and freedom from side effects were the first and second most important factors identified by 1,100 women regarding their use of family planning. When users were asked why they wanted to continue their current method, nearly one-fourth cited freedom from side effects. When people who do not use family planning were asked why they would be willing to select a particular method in the future, 12 percent said freedom from side effects was important.⁵

A study conducted by the Research Institute for Mindanao Culture (RIMCU) in the Philippines, with assistance from the Population Council, surveyed 400 married women who began using contraception in 1992 and found a dropout rate of 31 percent in public/government programs in the first year. More than half the dropouts said they discontinued because of side effects. Seventy-one percent of the 96 pill users cited side effects as the reason for abandoning their method.⁶

In Bangladesh, 40 percent of 104 women interviewed said they had experienced health problems from contraceptive use. For many, side effects brought physical discomfort as well as emotional distress when husbands became concerned about women's inability to work or the costs of treating side effects. "My husband became very angry and scolded me a lot when I became sick from using the Copper-T. He told me, 'I will not take care of you if anything happens, nor will I provide you with treatment.'"⁷

For some people, fear of side effects discourages them from starting family planning. In Cebu, the Philippines, nearly 40 percent of 296 non-contraceptives users in a WSP study said they were concerned about side effects.⁸ In addition, many women and men base their decisions not to use family planning on incorrect or misleading information. For some users, even those who received counseling, the reality of side effects is difficult to accept. Said a woman in Mali who experienced amenorrhea, "Even though they told me I would go all this time without seeing my period well, I wasn't really expecting that."⁹

Thorough counseling can help clients determine which symptoms are caused by contraception and which signal other health concerns. WSP scientists have recommended that providers receive special training in how to manage side effects -- for example, recommending ibuprofen or estrogen to curb heavy menstrual bleeding. The scientists also recommended that health providers work with women's advocates to establish peer networks, in which experienced users could counsel new users about potential side effects and practical strategies for coping with them. Research to develop methods that have fewer side effects is also important. "We should not be satisfied with women having to decide which side effects they will choose," said Edna Roland of FALA PRETA! [Speak, black women!] in Brazil, a women's health advocacy group.

Involving men

In many cultures, contraceptive use is viewed as women's responsibility. Yet, decisions about family size and family planning are seen as men's responsibility. A study of 711 men in Zimbabwe found that 39 percent thought men should make family planning decisions and 54 percent thought men should prevail in decisions about family size; however, 60 percent thought women should assume responsibility for obtaining contraceptive methods.¹⁰ Even though men are often the chief decision-makers, they receive little, if any, counseling that would enable them to make informed choices or help their wives make choices about contraceptive use.

"When family planning started, it was integrated with maternal-child health," says Dr. Firman Lubis of Yayasan Kusuma Buana (YKB), a family planning organization that provides services and conducts research in Indonesia. "One of the disadvantages when we started is that family planning focused on women and contraception. We really need to change programs to focus on men and fit the men's situation."

Men say they want more information about male methods and side effects, about female methods and side effects, and about access to services. In a "mystery client" survey in Kenya, where men posed as clients to help evaluate services, the men were treated with courtesy and promptly received private counseling about vasectomy. However, there were no educational materials for men and the female providers were uncomfortable talking to them.¹¹

In China, WSP research funded by the Rockefeller Foundation found that a majority of people surveyed said male contraceptive services were available at local family planning clinics. Nonetheless, men did not routinely seek contraceptive services. One 40-year-old man from South Jiangsu explained that male methods are less popular because "males take less responsibility for family planning. They have primary responsibility for physical labor. Publicity for family planning always targets females."¹²

Women in Jakarta and Ujung Pandang, Indonesia, were asked how family planning services could involve men. Their suggestions included: more information and counseling; more advertising about men's methods; information provided through the work place; and more services and male methods. They also mentioned special clinic hours to accommodate men and strategies to make men more comfortable.

Not all women want men to participate in family planning. The same study found that 39 percent of women in Jakarta and 11 percent in Ujung Pandang would rather not have men involved in family planning programs.¹³

Gender sensitivity

In order to serve both women and men better, providers should consider ways to make programs more "gender-sensitive" -- to consider how roles prescribed by society affect men and women differently in terms of health needs, access to information and access to services.

In Bolivia, WSP is developing guidelines to help understand how gender roles affect family planning services. Based on a thorough examination at several clinics, a committee of health professionals, activists, women's advocates and researchers will share ideas about how to make programs more gender-sensitive, by developing a manual providers can use to incorporate gender awareness into their programs.

For example, many women interviewed in Bolivia said they did not discuss contraceptive use with husbands because they were too shy. The reluctance was multiplied when they confronted a health provider -- who was often a stranger and a male.

The same gender norms that encourage women to be submissive and silent with their husbands, and norms that equate female sexual knowledge with promiscuity, also affect women's ability to talk openly with male health providers about intimate sexual issues. For some women, reproductive health services offered by men are unacceptable.

Women in Jakarta and Ujung Pandang, Indonesia, said they would not accept certain services from male health providers. For example, about 40 percent of women in Jakarta said they would refuse counseling from a male worker, while more than half said they would refuse breast and pelvic exams, Pap smears, IUD insertions, diagnoses for a sexually transmitted disease, or injections in the buttocks. More than half the 500 women interviewed suggested clinics hire more female providers.

In Egypt, many women participating in a study on quality of care refused services from male providers, citing Islamic religious traditions as their reason. "The most important thing for me in the examination is to have a female doctor," said one older Egyptian woman. "I went once to the clinic to insert an IUD. I paid the money and waited and when it was my turn, I entered the examination room and there stood a male doctor. I refused the IUD insertion, of course. I left the money I paid and returned back home. Later on I got pregnant."¹⁴

Egyptian men cited a female doctor as the most important element of quality of care for their wives. "Especially in the gynecological diseases, the woman likes the doctor in front of her to be a female, in order to have the same feelings, as this is very important to feel the same pain -- which is different if the doctor is male so he will not feel the same importance, and his diagnosis will not be 100 percent correct," said one husband.

In both Egypt and Indonesia, FHI researchers recommended the addition of female doctors to family planning programs. But that is not always an easy task. Gender norms often restrict women's access to the education and training necessary to work, restrict movement outside the home or community, and delegate primary childcare and housework responsibilities to women, even if they earn income.

A WSP study in Egypt found that 82 percent of the nation's 19,610 family planning employees are women. However, only 48 percent of physicians are female. For the Ministry of Health and Population, the country's largest provider of family planning services, only 27 percent of gynecologists are women.¹⁵

The presence of female providers does not guarantee better service, nor does it promote gender equity. In Bangladesh, the national family planning program has employed nearly 30,000 female health workers nationwide to provide contraceptive services to women in their homes, accommodating purdah, which requires women to be secluded in their homes or villages. However, some researchers have concluded that, despite the advantage of greater accessibility, this system may actually reinforce women's subordination and isolation. They suggested that freestanding clinics might encourage women to venture outside their homes and provide them with a broader array of health-care services, especially treatment for side effects.¹⁶

Gender is not the only factor that creates an imbalance of power between client and provider. Class, race, ethnicity, age, education -- all can influence provider-client communications. "An imbalance of power exists between provider and client," says Dr. Aníbal Faúndes of the State University of Campinas in Brazil. "This can be true of female providers as well. The provider is the one who decides what information to give, which methods are indicated or contraindicated, when and how to treat side effects, and even the number of patients to attend to on any given day. Gender is only one factor that affects the balance of power between client and provider."

In Bolivia, for example, women who wore the pollera, the traditional female dress of the Altiplano, said they experienced discrimination when they sought care from providers in urban El Alto.

Client satisfaction

Clients want quality services and providers strive to offer quality. However, definitions of quality can differ.

In El Alto, Bolivia, WSP researchers explored three aspects of service quality: interpersonal relationships between clients and providers; availability of contraceptive methods; and acceptability of services from the perspectives of 217 clients, 85 providers and 215 non-clients.¹⁷ Findings show that clients and providers often had different points of view.

While nearly all providers said they explained procedures before physical exams, only about 70 percent of clients said they received explanations. In addition, contraceptive supplies were often limited. Fifteen of 36 health centers surveyed had no reversible methods in stock.

Researchers recommended that health centers increase access to contraceptive methods, that providers receive training to improve their interactions with clients and that providers receive training to update their clinical skills and medical knowledge. In addition, researchers recommended that providers counsel clients in private so that women and men would feel more comfortable asking questions.

In a Population Council study in Kenya, clients said counseling about side effects and method choice was a major element of quality services, as were costs and access. Clients said they were dissatisfied when they received information about only one method or a limited number of methods. Ironically, when questioned about quality, providers did not mention counseling as an issue.¹⁸

While WSP found that most family planning clients say they are satisfied with services, these clients also have suggestions for improvements.

In Indonesia, where government family planning has been widely available since the 1970s, women say contraception has helped them improve the quality of their lives, brought peace and harmony at home and helped them be more efficient at work, in addition to helping them earn more money. However, while women have access to methods, they often want more information.

In South Sumatra and Lampung, 69 percent of the nearly 600 women interviewed said they were satisfied with their most recent family planning methods.¹⁹ However, when asked if they received enough information, some women said no.

In Central and East Java, more than three-fourths of the 900 women interviewed were satisfied with family planning services. However, 20 percent listed problems with service delivery, including long distances to clinics, long waiting times, unfriendly providers, lack of access to desired methods, unskilled providers and insufficient information.²⁰ When asked what additional information they would like to help them make contraceptive decisions, more than one-third said they wanted information on side effects, while 23 percent wanted information about method safety and 21 percent wanted information on efficacy.

Lack of information was a concern expressed by women in the Egypt quality of care study.²¹ One young family planning client explained her reluctance to try Norplant. "They say that the capsules are put under the skin -- no one knows what it does -- so a woman can have it placed but she would not know what could happen to her."

Clients in the Egyptian study also said that other important elements of quality are that providers treat them with respect, regardless of education or income; that family planning services be integrated with other health services; that services be affordable and accessible; and that they have a choice of methods.

"The important thing," said one female study participant, "is for the doctor to sit down and discuss with the woman what suits her, and not just to tell the woman right after examining her that she needs an IUD. The doctor should discuss [methods] with the patient. The doctor should consider the method the woman feels comfortable with."

Another Egyptian woman, who does not use family planning services, expressed her needs more simply. "I want to be treated as a human being," she said. Providers should "not recoil from us."

-- Barbara Barnett

References

Velasco C, de la Quintana C, Jové G, et al. Calidad en los Servicios de Anticoncepción de El Alto, Bolivia. La Paz: PRO MUJER and Family Health International, 1997.
Mutambirwa J, Utete V, Mutambirwa C, et al. Zimbabwe: The Consequences of Family Planning for Women's Quality of Life, Draft Women's Studies Report. Research Triangle Park, NC: Family Health International and University of Zimbabwe, 1998.
Irwanto, Poerwandari EK, Prasadja H, et al. In the Shadow of Men: Reproductive Decision-making and Women's Psychological Well-being in Indonesia, Women's Studies Final Report. Research Triangle Park, NC: Family Health International and Atma Jaya Catholic University, 1997.
Dwiyanto A, Faturochman, Suratiyah K, et al. Family Planning, Family Welfare and Women's Activities in Indonesia, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International and Gadjah Mada University, 1997.
David FP, Chin FP, Herradura FS. Family Planning: Its Economic and Psychosocial Influences on the Lives of Women in Western Visayas, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International and Central Philippines University, 1998.
Factors Affecting Family Planning Dropout Rates: Philippines, Operations Research Summaries. New York: The Population Council, 1998.
Schuler SR, Hashemi SM, Cullum A, et al. The advent of family planning as a social norm in Bangladesh: women's experiences. Reprod Health Matters 1996;7:66-78.
Adair LS, Viswanathan M, Polhamus B. Cebu Longitudinal Health and Nutrition Survey, Follow-up Study, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International, Carolina Population Center and University of San Carlos, 1997.
Konaté MK, Djibo A, Djiré M. Mali: The Impact of Family Planning on the Lives of New Contraceptive Users in Bamako. WSP transcripts. Research Triangle Park, NC: Family Health International and Centre d'Etudes et de Recherche sur la Population pour le Développment, 1998.
Mbizvo MT, Adamchak DJ. Family planning knowledge, attitudes and practices of men in Zimbabwe. Stud Fam Plann 1991;22(1);31-38.
Wilkinson D, Wegner MN, Mwangi, et al. Improving vasectomy services in Kenya: lessons from a mystery client study. Reprod Health Matters 1996;7.
Gu B, Xie Z, Hardee K. The Effect of Family Planning on Women's Lives: The Case of the People's Republic of China, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International and China Population Information and Research Center, 1998.
Hidayati Amal S, Novriaty S, Hardee K, et al. Family Planning and Women's Empowerment: Challenges for the Indonesian Family, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International and University of Indonesia, 1997.
Kafafi L, Waszak C, Abou-Taleb H, et al. Consumer Perceptions of Quality of Family Planning Services in Egypt. Research Triangle Park, NC: Family Health International and The Population Project Consortium/POPIII, 1998.
El-Deeb B, Maklouf H, Waszak C, et al. The Role of Women as Family Planning Employees in Egypt, Women's Studies Project Final Report. Research Triangle Park, NC: Family Health International and Cairo Demographic Center, 1998.
Schuler SR, Hashemi SM, Jenkins AH. Bangladesh's family planning success story: a gender perspective. Int Fam Plann Perpsect 1995;21(4):132-37, 166.
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Identifying Client and Provider Perceptions in Quality of Care: Kenya. Operations Research Summaries. New York: Population Council, 1998.
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What People Want From Services

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