Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis.

BACKGROUND: Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently.
METHODS: We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling.
RESULTS: The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected.
CONCLUSIONS: High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care. TRIAL REGISTRATION: CTRI/2015/09/006219. Registered 28 September 2015.

Background

Family Planning (FP) supports the health and well-being of women and children globally [1, 2]. Use of modern reversible contraception has been shown to prevent unintended pregnancy [3] and short inter-pregnancy intervals, both of which lead to adverse health consequences for mothers and infants [4-8]. While there are several facilitators of contraceptive use, high-quality interpersonal communication from FP providers including counselling on proper use and side-effects [9-14], clarification of misconceptions [15, 16], and addressing spousal dynamics like covert use and couple communication [17-19] are associated with contraceptive uptake and continuation among women [20].

Efforts to bring the needs and rights of patients to the center was laid out way back in 1994 at the International Conference on Population and Development (ICPD) in Cairo [21], followed by the 2001 Institute of Medicine (IOM) report that outlined patient centered care as one of the 6 goals to improve healthcare [22]. Despite these early advances, focus on providing patient centered quality of care remained low. However, there has been a renewed focus on moving beyond the traditional approach of just focusing on promoting awareness around the array of contraceptive options according to tiered efficacy, towards a more patient-centered contraceptive counselling approach, that is respectful and focuses on aspects related to the quality of interactions between providers and patients [23]. This renewed focus on patient-centered care highlights the urgent need to move away from contraceptive target goals as metrics of success and focus on development of measures that are consistent with this focus on patient centered care.

There has been theoretical conceptualization to understand components of QoC in FP counselling [23-27]. In a landmark study Bruce [24] described measuring quality “in terms of potential demographic impact” … fails to value the “interpersonal dimensions of care.” She described six qualities of FP counselling that should be measured, including choice of methods, technical competency, provision of information, management of side effects, follow up care, and integration with other reproductive health services. Since then, this framework has been revised by Jain and Hardee [27] to include promoting the safe provision of contraceptive technologies, provision of information in a two-way exchange, follow up care which includes guidance on switching methods (or discontinuation of a method), interpersonal relations which focus on dignity, respect, privacy, and confidentiality [27]. Complementary to the FP quality of care framework, Huezo and Diaz [28] brought attention to the need for providers to focus on meeting their clients’ reproductive needs and recommended that training of providers is essential for them to be able to provide quality of care to their clients.

Key to the value of this approach is its measurement in practice. Although there has been some work around the development and validation of measures around quality of care in FP [29, 30], research assessing these multiple dimensions of quality of care and testing its association with contraceptive use in low- and middle- income countries like India is limited.

In India, about 54% women report use of contraception, and this use is predominantly female sterilization which is permanent (75% of all users) [31]. The use of reversible methods (short acting e.g. pill, condom, and Long Acting Reversible Contraceptives (LARC) e.g. IUD, implants) remains low while their discontinuation is high [31]. India has recently expanded the method-mix in the public health system to include injectable contraceptives and to ensure more providers are trained to provide IUD insertions [32, 33]. The Government of India is also assessing the feasibility of introducing contraceptive implants in public health facilities [34, 35]. India has committed to international goals, including Sustainable Development Goal 3.7, to ensure universal access to family planning by 2030 [36], FP 2020, to expand services to 48 million new users of contraceptives (40% of the global 120 million target), and 100 million current users in India [37]. However, chasing ambitious global targets for FP can increase the risk for pressure from FP providers to use certain methods, which can compromise reproductive autonomy of women. This, again, emphasizes the need for a validated measure of quality of FP counselling and understanding its association with contraceptive uptake.

In this paper, we developed and validated a measure for quality of family planning counselling (QFPC) for use with women seeking FP services from public health facilities in the state of Uttar Pradesh (UP), India and assessed its association with contraceptive choice among clients. UP is India’s most populous state which has very low rates of modern contraceptive use [38]. There is shortage of healthcare providers in the state [39, 40], and a large proportion of the population dependent on the public health system to access FP methods.

Aligning with the Bruce framework [24], our measure includes information on assessing women’s reproductive goals, exchange of information between counsellor and provider, and respectful interpersonal interaction. Findings from this work can offer measurement guidance for further research and our measure can be used in practice to help ensure quality of care FP counselling at a time of rapidly escalating targets and service provision in the country.

Materials and methods

Study setting

We analysed survey data from a study on Quality of Care in Family Planning services in UP, the most populous state in India with a population of more than 200 million. The state of UP has low contraceptive utilization, with only 29.3% of women using any modern method of contraceptive, of which close to 60 percent is Female Sterilization [31]. The state relies on its health system to provide access to FP services, with public health facilities reported to be the main source of accessing modern contraceptive methods for more than half the people (54.1%) in the state [38]. The study, conducted between December 2016 and February 2017 in 120 public health facilities, involved surveys with women receiving FP counselling, client’s interpersonal experience with the counsellor, readiness of facilities to provide FP services, knowledge and skills of providers to provide FP services, and providers’ adherence to clinical protocols during service provision.

Sampling procedure

Facilities for the study were sampled from public health facilities in the state that provided mini-laparotomy sterilization and IUD services. The sampling frame was obtained from the Health Management Information System (HMIS) data pertaining to the previous Indian financial year (April 2015 to March 2016). The list of facilities in the sampling frame was limited to District Hospitals (DHs) and Community Health Centres (CHCs) at the block level that provided mini-laparotomy sterilization and Intrauterine Device (IUD) insertion services in the previous financial year. We restricted inclusion to these facilities to allow for assessment of FP services with sterilization and IUD available on site. The sampling frame, thus obtained, included 178 facilities from 75 districts in the state. Finally, 120 facilities were sampled from the sampling frame, using probability proportionate to size (PPS) sampling based on the number of sterilization procedures conducted in the facility in the previous financial year. This number was chosen as a proxy to the client load in the facilities. Of these 120 facilities, 50 were DHs and the remaining 70 were CHCs. The research teams stayed at each of the facilities for a period of 3–5 days to observe clinical practices around sterilization and IUD insertion. During their stay at the facility, research staff invited all women who visited the facility for FP counselling to participate in the study. Of a total of 289 women who were thus invited, N = 237 women agreed to participate. The design is further described elsewhere [41].

Data collection

Female nurses trained in survey data collection, including ethical treatment of respondents for research and elicitation of sensitive information, served as our research interviewers for this study. These nurses were not affiliated with any public health facilities in the period of the study. Interviewers approached all women who had received counselling at the facility and asked if they would like to participate in a brief survey to share their experiences from the counselling session. Participants provided written informed consent before the interview and received no monetary incentive to participate in the study. The research staff interviewed participants in a private setting using handheld mobile devices. The interview included questions on aspects of quality of counselling received and the method selected by participants after the counselling session.

Ethics

Institutional review board (IRB) approval for this study was granted from Public Health Service- Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from human research protections program at the University of California, San Diego.

Measures

Dependent variable

The dependent variable used in the study was the FP method selected by women post counselling. We categorized responses as female sterilization, intrauterine device (IUD), short-acting methods (condoms and oral contraceptive pills) and, no preferred method.

Independent variables

Our primary independent variable of interest was the scale—a measure developed for this survey. The thirteen items for this measure were developed based on expert input and literature review, as well as prior qualitative research on women’s and providers’ experiences with FP counselling. Cognitive testing was undertaken for the survey including these items with the population of focus and providers working with them, to ensure clarity of items for potential respondents. As our primary interest was specific to the patient-provider interaction during counselling, we used the following three elements of the Bruce [24] framework a) FP counsellors’ provision of information b) eliciting client’s FP history and preferences, and c) the respectful and engaging interaction between the counsellor and the client. The first element–provision of information included items on providers informing clients about different contraceptives, explaining method use, explaining possible side-effects and advising them on what to do in case they face problems. Based on extensive research, experiencing side-effects was identified as a primary reason for contraceptive discontinuation [42], so special emphasis was made to include items on this issue. The second element–eliciting client’s preferences included items on providers asking clients about their fertility goals, different FP methods used earlier, problems faced with methods used earlier and clients’ preferred method of choice. The third element—respectful and engaging interaction included items on clients being treated in a respectful and friendly manner by providers, providers spending sufficient time with them during the session and providers not applying any pressure to select a particular contraceptive (as reported by clients). All items were assessed with a yes or no.

Our secondary independent variable training of providers on FP counselling. Training of providers was used as a dichotomous variable coded as 1 if providers had received specific training on FP counselling and 0 otherwise.

Client level covariates

Our survey captured socio-demographic characteristics of participants including client’s age, caste, religion, education, number of living children, presence a male child and prior use of modern FP method by clients. Age of the client was used as a continuous variable in the survey. Caste was used as a categorical variable coded as Scheduled Caste/ Scheduled Tribe, Other Backward Classes (OBC) and General category. Religion was coded as a dichotomous variable classifying clients as Muslim and Non-Muslim. The choice of classifying religion of clients into Muslim and non-Muslim was made in accordance with the disproportionately low use of modern methods of contraceptives by Muslim couples in the state, relative to couples from other religions [38]. Educational attainment of clients was also used as a dichotomous variable coded as those who have completed at least primary education and those who have not. Number of living children was used as a categorical variable identifying couples who had one child, two children and three or more children. Presence of a male child was used as a dichotomous variable coded 1 if the client had any male child and 0 if not. This was done in accordance to the state level trend of lower use of modern contraceptive methods among couples who do not have any male children [38]. Prior use of modern FP method by clients was used as a dichotomous variable and was coded 1 to identify clients who had used any modern FP method before and 0 otherwise.

Provider level covariates

We also captured provider characteristics via structured interviews with providers who were provided counselling services to clients on FP. These included age, gender, designation, and previous training received on FP counselling. Provider age was used as a continuous variable. Gender of providers was used as a dichotomous variable identifying male and female providers. Provider designation was also treated as a dichotomous variable indicating if the providers were designated FP counsellors in the facility or whether they were staff-nurses or Auxiliary Nurse Midwives (ANMs). Provider data were linked with client data using unique identifiers assigned to both providers and clients at the time of initiating the survey at a facility.

Data analysis

We assessed internal reliability of our QFPC measure using Cronbach alpha, and we assessed construct validity using Principal Component Analysis (PCA). Since the items in our measure were not standardized, the correlation matrix was used to extract the components [43]. Kaiser’s criterion was used to retain the components with an Eigen value of more than 1.0 [44-46]. Varimax rotation was used to obtain the proportion of variance in the data explained by each of the retained components. Subsequent to extraction of the components, the proportion of variance explained by each component was used to generate weights for each of the components and was further multiplied by the predicted scores of each of the components and added together to obtain a composite index of quality [45]. The composite score was then normalized to range from 0 to 100 to generate the QFPC measure.

To assess criterion validity of QFPC, we used multivariable linear regression to test the associations between our QFPC measure and the training of providers on FP counselling.

To explore the association between contraceptive selected by the client post-counselling and the independent variables, we developed two multinomial logistic regression models. The first model (Model-1) tested the association between choice of contraceptive post-counselling and the QFPC measure. This model was adjusted for client’s religion, number of living children, presence of male child, education, and prior use of modern FP method by clients and provider’s age, provider’s gender, provider’s designation, and provider’s training on FP counselling. Model-2 tested the association between FP method selected post-counselling and training of providers on FP counselling. This model was adjusted for client’s religion, number of living children, presence of male child, education, and prior use of modern FP method by clients and provider’s age, provider’s gender, provider’s designation, and type of facility. We constructed parsimonious models [47] to ensure that we did not over-adjust our analyses. For both the models, we used backward stepwise technique to create parsimonious models and ensure that we did not over adjust our analysis. Analyses were conducted using R version 4.0.2.

Results

Client characteristics

Participant’s age ranged from 19 to 42 years (mean age = 27.51, Std. dev. = 4.25) (see Table 1). Majority of the participants were Non-Muslims (89.87%) and 21.94% of the participants belonged to socially marginalized groups (Scheduled Caste or Scheduled Tribe). Almost half of the participants (50.21%) had 3 or more living children and majority of them had at least one male child (86.50%). Close to two-thirds of the participants (64.98%) had completed primary education at the time of the survey and a similar proportion reported that they had never used a modern FP method before (64.14) (Table 1).

Table 1

Descriptive statistics of contraceptive method preferred post-counselling and key client level covariates (N = 237).

		n	% or Mean (Std. Dev.)
Dependent Variable
Method Preference post-Counselling	No Method	31	13.08
	Short-acting methods	46	19.41
	IUD	61	25.74
	Female Sterilization	99	41.77
Independent Variable
Quality of FP Counselling (QFPC)	Mean (Std. Dev)	237	70.33 (24.43)
Individual level covariates
Caste	SC/ST	52	21.94
	OBC	150	63.29
	General	35	14.77
Religion	Muslim	24	10.13
	Non-Muslim	213	89.87
Age of women	Mean (Std. Dev)	237	27.51 (4.25)
No. of living children	1 living child	41	17.30
	2 living children	77	32.49
	3 or more	119	50.21
Male Child	Yes	205	86.50
	No	32	13.50
Completed Primary education	Yes	154	64.98
	No	83	35.02
Prior use of modern FP method	Yes	85	35.86s
	No	152	64.14

Contraceptive selected by clients post-counselling

Clients were asked about the method that they selected after counselling. Almost half of the participants (41.77%) reported that they selected female sterilization, followed by a quarter of the respondents (25.74%) reporting they chose IUDs and one-fifth of participants (19.41%) reporting they selected a short-acting method (oral contraceptive pills or condoms). Thirteen percent of the respondents (13.08%) also reported that they did not have a preferred method post-counselling (Table 1).

Provider characteristics

A total of 144 healthcare providers counselled the women in the study sample. Health providers offering FP counselling were aged 21 to 59 years (mean age = 34.42 years, std. dev. = 9.21) and most were women (89.58%). A little less than half of the providers were designated FP counsellors (40.28%) while the remaining 59.72% of the providers comprised of staff-nurses and Auxiliary Nurse Midwives (ANMs) acting as FP counsellors. A little over one-third of the providers (38.89%%) had not received any training specific to FP counselling (Table 2).

Table 2

Descriptive statistics of provider level characteristics (N = 144).

		N	% or Mean (Std. Dev.)
Age of provider	Mean (Std. Dev)	144	34.42 (9.21)
Gender of provider	Male	15	10.42
	Female	129	89.58
Provider Designation	FP Counsellor	58	40.28
	Staff-Nurse / ANM	86	59.72
Trained on Counselling	Yes	88	61.11
	No	56	38.89

Psychometric analysis of the QFPC measure

We used Principal Component Analysis (PCA) to test QFPC for construct validity. PCA generated 4 components with an Eigen value of more than 1.0.

The first component explained 34 percent of the total variation and represented the sharing of information between providers and clients: providers eliciting information from clients about their preference and experience with FP methods in the past and sharing information about FP methods suited to these preferences. We interpret this component as the exchange of information between the provider and the client, and elicitation of client preferences. The second component explained 13 percent of the total variance and showed strong positive loadings for participants reporting to have been treated in a friendly and respectful manner. We interpret this component as respectful interaction by the provider during the counselling session. The third component explained 11 percent of the total variation in the data and had strong positive loadings for participants reporting that they were encouraged to ask questions and that providers spent sufficient time with them during counselling. We interpret this as creation of an environment by the provider that is supportive of client’s autonomy. The fourth component explained 8 percent of the variance and had a strong positive loading for participants reporting that they did not feel pressured by providers to select any specific FP method (S1 Appendix). The mean score of the overall Quality of Family Planning (QFPC) measure received by clients was 70.33 out of 100 (std. dev. = 24.43) (Table 1).

We used Cronbach alpha to test for internal reliability for our 13 item QFPC measure, and found good internal reliability for this measure (Cronbach alpha = 0.80) (Table 3).

Table 3

Individual items used to assess Quality of FP Counselling (QFPC) (N = 237).

Individual Items to assess Quality of Counselling on Family Planning	n	%
Did the provider ask you about your reproductive goal, i.e. how many children do you have, how many you want?	150	63.29
Did the provider ask you about different methods you have used earlier?	139	58.65
Did the provider ask you about problems you have had with earlier methods?	115	48.52
Did the provider ask your method preference?	137	57.81
Did the provider tell you about different FP methods?	141	59.49
Did the provider explain you how to use the method you selected?	139	58.65
Did the provider tell you about possible side effects of the method you selected?	110	46.41
Did the provider tell you what to do if you experience any problem after using the method you selected?	146	61.60
Did the provider encourage you to ask questions?	177	74.68
Was the time spent in consultation sufficient to discuss your needs?	215	90.72
Did the provider treat you in a friendly way?	209	88.19
Did provider treat you in a respectful way?	219	92.41
Anytime during the discussion with the health provider, did you feel that he/she is pressurizing you to select a particular family planning method?	171	72.15
Cronbach Alpha	0.80

Criterion validity

To assess criterion validity, we examined the associations between our QFPC measure and training of providers on FP counselling, using multivariable linear regressions. We found that quality of counselling was positively associated with training of providers specific to FP counselling (adj. coef. = 6.73, 95% CI: 2.18–11.29) (Table 4).

Table 4

Adjusted linear regression to test the association between Quality of FP Counselling (QFPC) and training of providers on FP counselling characteristics (N = 237).

		Adjusted Coefficient	95% LCI	95% UCI
Provider trained on FP counselling a	No	Ref	-	-
	Yes	6.73	2.18	11.29

a Model adjusted for provider age, provider designation, type of facility and client’s caste.

Associations between FP method selected post-counselling and QCFP

Multinomial regression adjusted for client and provider level covariates (Model-1) shows that for each point increase in QFPC score the participants are more likely to select short-term methods (ARRR:1.02, 95% CI: 1.00–1.05) IUD (ARRR:1.03; 95% CI:1.00–1.05) and female sterilization (ARRR:1.06; 95% CI:1.03–1.08) as compared to choosing no FP method post-counselling (Table 5).

Table 5

Multinomial logistic regression models to test the association between type of FP method selected post-counselling and a) Quality of FP Counselling (QFPC) and b) training of providers on FP counselling (N = 237).

		ARRR	95% LCI	95% UCI
No method selected post-counselling		Base Outcome
Short-acting methods
Quality of FP Counselling (QFPC) a		1.02	1.00	1.05
Provider trained on counselling b	No	Ref	-	-
	Yes	1.27	0.42	3.78
Intra-Uterine Devices
Quality of FP Counselling (QFPC) a		1.03	1.01	1.05
Provider trained on counselling b	No	Ref	-	-
	Yes	8.20	2.67	25.11
Female Sterilization
Quality of FP Counselling (QFPC) a		1.06	1.03	1.08
Provider trained on counselling b	No	Ref	-	-
	Yes	4.52	1.62	12.56

a Model adjusted for client’s religion, number of living children, presence of male child, education, and prior use of modern family planning method by clients and provider’s age, provider’s sex, provider’s designation, and provider’s training on FP counselling.

b Model adjusted for client’s religion, number of living children, presence of male child, education, and prior use of modern family planning method by clients and provider’s age, provider’s sex, provider’s designation and type of facility.

Association between FP method selected post-counselling and training of providers on FP counselling

We also found that type of FP method selected by clients post counselling was associated with providers receiving previous training specific to FP counselling (Model-2). Clients who were counselled by providers previously trained in FP counselling were more likely to select IUDs (ARRR: 8.20, 95% CI: 2.67–25.11) and female sterilization (ARRR:4.52, 95% CI: 1.62–12.56), as compared to choosing no FP method post-counselling (Table 5).

Discussion

Findings from the study demonstrate the reliability and validity of the Quality of FP Counselling (QFPC) measure for use among women seeking FP counselling in India. The QFPC measure posits exchange of information between providers and clients, friendly and respectful interaction, supportive environment created by the provider and no pressure to uptake a method as important dimensions of quality of FP counselling. This is closely aligned with elements of the Quality of Care framework recommended by Bruce [24], especially–a) FP counsellors’ provision of information b) elicitation of client’s family planning history and preferences, and c) the respectful and engaging interaction between the counsellor and the client.

Findings are also aligned with recent studies that tested measures on Quality of Care in multiple settings. Sudhinaraset et al. [48] developed the Person-Centered Family Planning Scale in India and Kenya and identified two subscales related to “autonomy, respectful care, and communication” and “health facility environment” to be relevant in both the contexts. Holt et al. [49] developed the Quality of Contraceptive Counselling (QCC) Scale, in Mexico, and identified 1) information exchange, 2) interpersonal relationship, and 3) disrespect and abuse as the underlying dimensions of quality of contraceptive counselling. Jain et al. [50] used a similar approach to develop and validate a contraceptive care measure and identified 1) respectful care, 2) method selection, 3) effective use of method selected and 4) continuity of contraceptive use and care as the four underlying domains of quality. More recently, Johns et al. adapted the Interpersonal Quality of Family Planning (IQFP) scale [29] and validated it in the Indian context [30]. The 11 item IQFP scale also includes several items similar to the QFPC measure. While there are several measures around Quality of Contraceptive Counselling that have been developed and tested, our QFPC measure has been tested in the Indian context, has lesser items than most of the other scales and includes binary response patterns (yes/no) which makes it easier to administer in different contexts. This makes the QFPC measure a useful tool to measure patient-centered FP counseling in low- and middle- income settings.

Our study also suggests that the quality of counselling is positively associated with providers being previously trained on FP counselling. This is especially concerning given that more than a third of the providers in the sampled facilities had not received training on FP counselling. This may be indicative of a shortage of staff in general as well as those dedicated to FP counselling. Severe shortages of staff in public health facilities result in facilities being unable to spare providers to attend trainings organized by the Government, lest the facility will have no / few providers left to provide healthcare services during the course of the training. While there is limited literature addressing the lack of dedicated FP counsellors in India, the general gap in the availability of health workforce in the country and its adverse effects is well documented in prior research [51, 52] and appears to extend to FP counselling as well.

We also found that the choice of contraceptive post-counselling was associated with the quality of counselling received by women. Better quality of counselling was associated with higher uptake of short-term methods, IUDs and female sterilization relative to choosing no method at all. Choice of contraceptive was also found to be associated with training of providers on FP counselling. Providers who were trained on FP counselling were more likely to have clients who opt for IUDs and female sterilization after counselling relative to choosing no method at all. This is especially relevant to the Indian context where the distribution of FP users is highly skewed towards sterilization and only 3% of women using modern contraceptives use long acting reversible contraceptives (LARCs) such as IUDs, which are more effective than other forms of reversible contraceptives such as pill or condom [31]. Our study indicates that training of providers specific to FP may facilitate capacities to engage with clients on a broader array of contraceptive options, and thus improve uptake of more effective reversible forms of contraceptives. These findings highlight the value of investing in filling the HR gaps and training of providers to provide comprehensive contraceptive counselling, as it has potential to positively affect the health of mothers and infants by increasing the pregnancy intervals and reducing unintended pregnancies [7, 8].

Overall, these findings highlight the utility of the QFPC measure in assessing delivery of patient-centered care. Our findings also underscore the need for enhancing both the quality and quantity of trainings for providers to deliver the multidimensional elements of quality FP counselling in UP, though importantly, they are achieving supportive and respectful care. Nonetheless, the value of training specific to FP counselling cannot be understated given its association with higher quality counselling and client’s preference for more effective contraceptives post-counselling. Given the low prevalence of IUD use in the country [31], these findings support the value of high-quality person-centered FP counselling to help broaden the array of spacing contraceptives used in India.

While findings are promising regarding the value of high-quality FP counselling as well as the standard delivery of respectful care in these settings, it must be noted that a not small percent of women coming in for FP counselling leave with a preference for no contraceptive. Current findings indicate that this may be, at least in part, attributable to poor quality counselling, based on the findings of a negative association between quality counselling and preference for no contraceptives. Another reason for women not selecting any method post-counselling could be the receipt of counselling by untrained providers as evident from the association between counselling by trained providers and choice of more efficient contraceptive methods. This further substantiates the need to ensure that every facility providing FP services should have providers trained on FP and measurement of patient-centered quality of care be prioritized using tools like the QFPC. Further research is needed to understand better why women opt to leave with no contraceptives at all following poorer delivery of care, particularly as this sample was women who had come for FP counselling.

Strengths and limitations

The study is based on a unique quality of care study for FP services in public health facilities in Uttar Pradesh. The study furthers the measurement discourse around quality of FP counselling and provides interesting insights into the associations between contraceptive uptake and characteristics of clients and providers.

The study is not without limitations. The unique study design and sampling approach resulted in limiting the sample to women approaching select public health facilities in the state. This makes it challenging to generalize the findings of the study. Selection bias is also a concern, as findings are limited to women presenting at public FP clinics, who may belong to a specific socio-economic background. While the study included variables on social marginalization, it did not capture information on the economic status of the participants. This may add to the challenge of generalizing the findings to all women in Uttar Pradesh or India. In addition, the study did not capture information on motivations of women to visit these facilities or whether they had received prior counselling and advise from community level health workers, both of which can act as confounding variables in the association between quality of counselling and type of contraceptive selected post-counselling. Our inability to adjust for these confounders in the analyses another limitation. Variables used in the study largely rely on self-report and thus are subject to social desirability bias. The small number of participants per clinic also limited our ability to understand clinic level differences that may contribute to findings. Recall bias is expected to be minimal as study variables are largely indicative of preferences and counselling at the time of assessment or just preceding it. This study is cross-sectional, so causality cannot be assumed and effect of quality counselling on use and continuation cannot be assessed. Longitudinal analysis with patient follow-up would offer greater insight into uptake of contraceptives as well as continuation subsequent to counselling.

Program implications

The study presents important implications for programs that work towards improving quality of care and uptake of contraceptives. The association of the QFPC measure with training of providers on FP counselling highlights the need to expand the number of providers who have been specifically trained on FP counselling skills. The association of contraceptive uptake post-counselling with the QFPC measure underscores the need to improve the quality with which providers interact with clients during these sessions, with special focus on dimensions of quality identified in the paper viz. information exchange, respectful interaction, supportive environment and no pressure to uptake a method.

Conclusion

The aim of the study is to provide a new measurement of quality of FP counselling and to examine the relationship between quality counselling and contraceptive uptake. The study posits a measure for quality of FP counselling that is aligned with the Bruce framework [24] on quality of care, and finds the measure valid and reliable in the context of FP counselling in Public Health facilities in UP.

The composite measure for quality of counselling developed in the paper suggests that dimensions of information exchange, respectful interaction, supportive environment, and no pressure to uptake a method are important dimensions of quality of FP counselling. The study calls for sensitization of providers to lay special emphasis on these dimensions during counselling as quality of counselling can have a significant bearing on the contraceptive choice of women and also underscores the need for an enhanced emphasis on training more providers on topics related to FP counselling. The study also calls for further research to enable a deeper dive into the reasons for women not choosing any method at all after counselling, so that no woman seeking FP counselling for pregnancy prevention should leave the clinic without provision of a woman’s choice of contraceptive.

Rotated components matrix.

(DOCX)

Click here for additional data file.

26 Nov 2020

PONE-D-20-28620

Measuring quality of family planning counseling and its effects on uptake of contraceptives in Public Health Facilities in Uttar Pradesh, India: a cross-sectional analysis

PLOS ONE

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ACADEMIC EDITOR: All five reviewers and I find that this paper has merit and can be considered if the authors address the reviewer comments. All five reviewers are well-respected scholars in the subject. Their comments range from a solid justification for the study at the introduction to giving more details on study design and to strengthen the statistical analyses and presentation of the tables. I believe many of these comments can be easily addressed. I hope to receive a revised version of this paper.

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Additional Editor Comments:

All five reviewers and I find that this paper has merit and can be considered if the authors address the reviewer comments. All five reviewers are well-respected scholars in the subject. Their comments range from a solid justification for the study at the introduction to giving more details on study design and to strengthen the statistical analyses and presentation of the tables. I believe many of these comments can be easily addressed. I hope to receive a revised version of this paper.

Journal requirements:

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Partly

Reviewer #3: Partly

Reviewer #4: Yes

Reviewer #5: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The motivation of paper is interesting nut the execution is weak. The paper need to improve in presentation and implications. The limitations of the study should also be highlighted. I put few of the point for consideration

1. Introduction: It may be meaningful to begin with Quality of Care . Following this its linkages with contraceptive use. 2.Review of literature Beyond Bruce framework is needed

3. Highlight why Uttar Pradesh and study sample

4. All tables need to be scientifically presented. I suggest you give 2 column , one for % and other for N. Moreover, many of the table are conbfusing to reader. For ex: table 1 n (%) or Mean (SD)? What is ecactly presented? Is it N and % or mean and SD. there are 2 values in tables. Most of the tables arein similar fashion

5. Drop table 2

6. Move table 3 to appendix

7. OBC is not marginalised group as mentioned in text . Correct it

8. Give mean value of composite score-QOFC

9.Drop table 5. Too much segregation of small sample of about 80 is dangerous in a scientific manuscript.

10. Add Strong note on limitations . the sampe is not true for generalisation. More over you are taking a selected sample. hecne do not generalise it

11. Mention value addition of this and implications for policy

Reviewer #2: Overall, this paper has the potential to make an important contribution to the literature, particularly by pointing out the development and psychometric testing of a Quality of Family Planning Counseling. However, the sampling design and its description is not clear. The following are some of the comments.

Abstract

The abstract needs editing.

The background section of abstract need to re-write. In the background section, it is written ad “This study involves the development and psychometric testing of a Quality of Family Planning Counseling (QFPC) measure for India….. I am not sure whether this statement is correct, as this analysis use a 237 women sample from public health facilities in Uttar Pradesh and generalised for India. Even there is no clear description on sample design in method section of abstract as well as in main methods. Whether the sampled public sector facilities spread across the state o

Background

I suggest that the authors say more accurately that the purpose of the analysis in the background section. There are no specific details on the family planning services or counciling in Uttar Pradesh. It is not clearly reading the background in connection with this study objective.

Methods

Methods section is inadequate. The current method section in this manuscript reads in a very choppy way.

This section not explained how did the sample facilities selected from Uttar Pradesh, and how did the women sampled. I suggest that the authors say more accurately about the sampling design including public health facility selection, women selection etc.

Line no 123-124, it is mentioned that …. 178 facilities that met inclusion criteria, we sampled 120 facilities for study inclusion. Are these 178 facilities in the 75 districts in Uttar Pradesh or selected districts?

Line 124-125, it is mentioned that “The design is described in Mozumdar et. al. (46)” Did you use the same data and analysed for Uttar Pradesh. It would be useful to explain the sample design in this manuscript as well. This will be helpful for the readers.

Line 172-173, it is mentioned that “We additionally included measures on provider characteristics, captured through structured interviews with the specific providers who counseled women on FP services”. It would be useful to describe this clearly.

Result

Did you collect the information on usage of family planning among women. If so it is useful to show the prevalence of family planning usage.

I could understand more than 60% of FP councillors were females as most of them where ANM or Nurses. Whether any male councillors were available in these facilities?

Table 7 can modify. Please show only odds ratio and 95% CI. For example, 1.05 (1.03-1.070. P value is not required as the odds with 95% CI is sufficient for interpreting the statistical significance.

Discussion

In the discussion section, the sentence However, given the relevance of findings for public clinics, generalizability to this…………..." could be more explicit and mention clearly the reason. I am still doubtful, how the authors can generalize the result for India.

Reviewer #3: The paper titled “Measuring quality of family planning counseling and its effects on uptake of contraceptives in Public Health Facilities in Uttar Pradesh, India: a cross-sectional analysis” is a good attempt to examine the quality of contraceptive counselling and its subsequent effects on uptake of specific methods in Uttar Pradesh, India. The results are informative. Nevertheless, I suggest the followings to make the paper more suitable for publication:

Sampling design must be described in the paper, as the article is expected to stand alone; although it has been explained in other published article.

Does the survey captured the main motivator/factor that made sampled women to visit these facilities for contraception? Do these women come to the facility alone or with any family member or any grass root level health worker like ASHA/ANM? It is quite possible that these women might have been counselled for visiting these facilities for a particular method well in advance before visiting these facilities. How did the authors address this?

It is evidenced that usually most of the people seeking health care utilization from public health facilities are from low economic background. Hence inference drawn from this analysis has its own limitation so far as generalization is concerned. This may be marked in the discussion section. Does this survey gathered information about economic status of these women, if so inclusion of this in the analysis is suggested?

It is suggested to discuss in details the possible reasons for those 13% women who preferred no method post-counselling; though they visited the facility for adopting/accepting any FP method.

Why the religion was classified as Muslim and Non-Muslims? It is assumed that majority of that Non-Muslims are Hindus, who constitute a majority of the sample women. In that case why not to classify Hindus and Others.

The purpose behind capturing education up to primary level needs to be presented? Role of education may have been much better understood if it would have been collected beyond primary level.

The non-inclusion of the type of facility i.e. DH & CHC in the analysis, is unclear

Table 7: It is not very clear OR at what level significance is shown/made bold.

Were there any non-literate participant? Especially when 35% of them had not completed primary education. If so, how did the consent sought and taken from them to participate in this study.

The conclusion section must be revisited to limit it as per the analysis carried. Authors may restrict themselves from overgeneralization of the results looking at the sample size and design.

Reviewer #4: No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

Reviewer #5: Thanks for giving me an opportunity to read this interesting paper. The authors have used a facility level exit interview data to present a topic which needs more and more research to improve quality of care for family planning services in India. While the paper has several strengths, I feel the statistical analysis is not that great. Following are observations which may help the authors in strengthening the paper.

INTRODUCTION

1. The introduction is too lengthy and I feel it can be shortened significantly. The authors should should strengthen the last but one paragraph in the introduction section (Page 6 Line 98-103) with more solid justification on why this study is called for. The current articulation is somewhat vague and may be supplemented with specific contextual example to strengthen it.

2. Line 102: Please elaborate what do you mean by coercive FP services in India?

METHOD:

3. In the materials and method section, please provide brief description about the study setting. For an international reader, it is difficult to know the context in which health services are being offered.

4. Line 122. Is it Indian financial year. If yes, please mention it.

5. The authors say design is described in Mozumdar et al. I think it would be appropriate for the authors to provide a gist of the method in this paper also.

6. Line 127: Was the facility manager/provider aware that women were being interviewed after the consultation? If Yes, I suggest authors to discuss how such prior knowledge would have influenced the study findings? Also, what steps were taken to reduce such bias?

observed?

7. Line 134: Authors suggest written informed consent was taken from all respondents? I am wondering how did you do that with women who could not read and write?

8. Line 173: Did you collect information on sex of the provider? If no, don't you think it is an important variable to consider.

9. Why the authors choose to use PCA not exploratory factor analysis. I feel this is the key weakness of this paper.

RESULTS:

10. Table 1: What is quality of counseling index? Did I miss the definition in the measure section?

11. Interesting you had more women with a male child. Can you clarify, if this is the sex of the last living child or something else? Also, given this biased distribution of women with male child, how it has an effect on the contraceptive use and quality of care received?

12. In Table 1, why provider characteristics are presented at patient level? They should presented at provider level, then only one can understand the distribution. I suggest rectifying this.

13. Line 218: There is nothing called confirmatory PCA. But, yes, there is confirmatory FA. I suggest authors to review the statistical analysis thoroughly.

14. Table 5: Instead of saying bivariate analysis, the author should present the title as "percent distribution of quality of counseling by....". Again, for providers, the analysis should at provider level by calculating the average of QoC at provider level

15. Table 6. If the focus of the paper is to understand relationship between QoC and contraceptive use, then Table 6 and 7 should be combined and only results for depicting this relationship should be presented. The rest of covariates, obviously, should be adjusted in the model. Presenting results for other covariates does not make much sense.

16. Table 6 and 7: Why authors did not use the categorical variable to test the association between QoC and contraceptive use? I strongly recommend the authors to remain consistent in use of measures across the paper.

DISCUSSION:

17. Line 307-314: While it is true that a fair share of women do not receive good QoC, the discussion should have focused in highlighting what are the structural, individual and provider level factor contributing it. Though some discussion is there in the subsequent paragraph, I feel more contextualization is required at the beginning itself.

18. Line 344-345. Can you elaborate more on how the study findings suggest that target-based family

planning without focus on QoC is a challenge? Challenge to what, how and to what extent?

19. Line 359-360: Authors recommend qualitative research on this issue. I feel this is very generic recommendation. It would be more useful to indicate what is the specific issue that needs more exploration. Already, several qualitative research is available exploring variable contraceptive use and non-use dynamics among women. What additional issues needs to be understand.

**********

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Reviewer #1: Yes: Sanjay K Mohanty

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

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16 Feb 2021

Response to reviewers

Additional Editor Comments

All five reviewers and I find that this paper has merit and can be considered if the authors address the reviewer comments. All five reviewers are well-respected scholars in the subject. Their comments range from a solid justification for the study at the introduction to giving more details on study design and to strengthen the statistical analyses and presentation of the tables. I believe many of these comments can be easily addressed. I hope to receive a revised version of this paper.

Journal requirements

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https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

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We note that one or more of the authors are employed by a commercial company: Sambodhi Research and Communications.

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The Authors would like to thank the editors and the reviewers for the time taken to provide insightful comments on the manuscript. We have addressed the Journal requirement by ensuring that the manuscript follows PLOS ONE’s style guidelines and added additional information including an amended Funding statement and an updated competing interest statement in the revised manuscript. We have also addressed the feedback from the reviewers and the response to their comments are described below:

Reviewer’s comments

Reviewer #1 comments

The motivation of paper is interesting nut the execution is weak. The paper need to improve in presentation and implications. The limitations of the study should also be highlighted. I put few of the point for consideration

Thank you for your consideration and feedback. We have addressed your comments in the revised manuscript and detail the way in which we have addressed these comments in the lines below.

1. Introduction: It may be meaningful to begin with Quality of Care . Following this its linkages with contraceptive use.

Based on this comment and comments from other reviewers, we have edited the Introduction substantially. The introduction now starts with a focus on QoC.

2.Review of literature Beyond Bruce framework is needed

To address this comment, we have referenced relevant work by Huezo and Diaz (1993) that focuses on meeting providers’ needs to ensure QoC and included Jain and Hardee’s work around revising the Bruce / Jain framework.

3. Highlight why Uttar Pradesh and study sample

We have created a section called ‘Study Setting’ under Materials and Methods and explained the reason for selecting Uttar Pradesh and the study sample in that section.

4. All tables need to be scientifically presented. I suggest you give 2 column , one for % and other for N. Moreover, many of the table are conbfusing to reader. For ex: table 1 n (%) or Mean (SD)? What is ecactly presented? Is it N and % or mean and SD. there are 2 values in tables. Most of the tables arein similar fashion

Thank you for this feedback. We have edited the presentation of all the tables in the manuscript, to make them clearer. Based on the guidance, we have created two separate columns to present n and % in all tables and clearly described cells where we present mean (std. dev.) or percentages.

5. Drop table 2

Based on this comment, we have dropped table 2 from the manuscript and also replaced its mention from the text.

6. Move table 3 to appendix

Based on this comment, we have moved table 3 to appendix. This table is now referred as Appendix A in the manuscript.

7. OBC is not marginalised group as mentioned in text . Correct it

We recognize this oversight in our original text and have corrected it in the revised manuscript.

8. Give mean value of composite score-QOFC

We have added the mean value of the composite QFPC score in line 291 in the revised manuscript (without track changes):

9.Drop table 5. Too much segregation of small sample of about 80 is dangerous in a scientific manuscript.

We agree that the cell sizes become too small given the small sample size in the study. Based on this feedback we have replaced the bivariate analysis in Table 5 by adjusted linear regression with the QFPC score as the dependent variable. This analysis helps with criterion validity of the QFPC measure and avoids the issue of low cell-sizes of bi-variate analysis. The new table is referred as Table 4 in the revised manuscript.

10. Add Strong note on limitations . the sampe is not true for generalisation. More over you are taking a selected sample. hecne do not generalise it

We concur that generalization is a challenge in our study sample. We have added text in the ‘strengths and limitations’ section to that effect and have modified the text in the discussion section to be cautious of generalization.

11. Mention value addition of this and implications for policy

Based on this comment, we have added a new section to the manuscript ‘Program Implications’. This section discusses the implications of findings from this study in detail.

Reviewer #2 comments

Reviewer #2: Overall, this paper has the potential to make an important contribution to the literature, particularly by pointing out the development and psychometric testing of a Quality of Family Planning Counseling. However, the sampling design and its description is not clear. The following are some of the comments.

Thank you for your detailed comments on the manuscript. We have addressed the comments in the revised manuscript as follows:

Abstract

The abstract needs editing.

The background section of abstract need to re-write. In the background section, it is written ad “This study involves the development and psychometric testing of a Quality of Family Planning Counseling (QFPC) measure for India….. I am not sure whether this statement is correct, as this analysis use a 237 women sample from public health facilities in Uttar Pradesh and generalised for India. Even there is no clear description on sample design in method section of abstract as well as in main methods. Whether the sampled public sector facilities spread across the state o

To address this comment, we have edited the abstract to clearly state that 120 public health facilities were sampled across Uttar Pradesh in India. We have also avoided implications that the measure is generalizable for India in the abstract.

Background

I suggest that the authors say more accurately that the purpose of the analysis in the background section. There are no specific details on the family planning services or counciling in Uttar Pradesh. It is not clearly reading the background in connection with this study objective.

Based on this comment and comments from other reviewers, we have edited the Background substantially to make it more focused. We have also added context around Uttar Pradesh in the background as well as in the study settings.

Methods

Methods section is inadequate. The current method section in this manuscript reads in a very choppy way.

We have modified the methods section considerably to make the language smoother and more comprehensive.

This section not explained how did the sample facilities selected from Uttar Pradesh, and how did the women sampled. I suggest that the authors say more accurately about the sampling design including public health facility selection, women selection etc.

Based on this comment, we have added a new section in Materials and Methods titled ‘Sampling Procedure’ that describes the sampling of facilities and women in detail.

Line no 123-124, it is mentioned that …. 178 facilities that met inclusion criteria, we sampled 120 facilities for study inclusion. Are these 178 facilities in the 75 districts in Uttar Pradesh or selected districts?

These facilities were from the 75 districts in Uttar Pradesh. We have modified the text to explicitly mention this point in the revised manuscript.

Line 124-125, it is mentioned that “The design is described in Mozumdar et. al. (46)” Did you use the same data and analysed for Uttar Pradesh. It would be useful to explain the sample design in this manuscript as well. This will be helpful for the readers.

We have added text to describe the entire sampling design for the study without relying on Mozumdar et al. in the ‘Sampling Procedure’ section of the revised manuscript.

Line 172-173, it is mentioned that “We additionally included measures on provider characteristics, captured through structured interviews with the specific providers who counseled women on FP services”. It would be useful to describe this clearly.

Thank you for this comment. Based on it, we have added a new section detailing the provider level covariates used in the study. This section is titled ‘Provider level covariates’ in the revised manuscript.

Result

Did you collect the information on usage of family planning among women. If so it is useful to show the prevalence of family planning usage.

Yes, we had asked women if they used any modern method before and have included it as a dichotomous variable in our analysis. We also revised our multivariable models to include this variable in our manuscript.

I could understand more than 60% of FP councillors were females as most of them where ANM or Nurses. Whether any male councillors were available in these facilities?

Thank you for this comment. A total of 144 providers counseled the N = 237 women in the sample. Of this, 15 providers were men. We have added this in the table as well as the text. The addition can be found in ‘Table 2’ and under the ‘Provider Characteristic’ section in the revised manuscript. In addition, we have included sex of the provider in our multivariable models and have revised our analyses accordingly.

Table 7 can modify. Please show only odds ratio and 95% CI. For example, 1.05 (1.03-1.070. P value is not required as the odds with 95% CI is sufficient for interpreting the statistical significance.

We have modified table 7 substantially based on this comment and comments from other reviewers. We do not report the p-values in the revised table and have made other structural changes to the presentation of the table. The new table is referred as Table 5 in the revised manuscript.

Discussion

In the discussion section, the sentence However, given the relevance of findings for public clinics, generalizability to this…………..." could be more explicit and mention clearly the reason. I am still doubtful, how the authors can generalize the result for India.

We concur that generalizing the findings from this study to India is a challenge. We have modified this in the discussion section and have been cautious not to generalize the findings to India. We have also added text to the Strengths and Limitations section in the revised manuscript to address this as a significant limitation of the study.

Reviewer #3 comments

Reviewer #3: The paper titled “Measuring quality of family planning counseling and its effects on uptake of contraceptives in Public Health Facilities in Uttar Pradesh, India: a cross-sectional analysis” is a good attempt to examine the quality of contraceptive counselling and its subsequent effects on uptake of specific methods in Uttar Pradesh, India. The results are informative. Nevertheless, I suggest the followings to make the paper more suitable for publication:

Thank you for taking the time to review our manuscript. We have addressed your comments in the sections below:

Sampling design must be described in the paper, as the article is expected to stand alone; although it has been explained in other published article.

We have developed a new section under Materials and Methods titled ‘Sampling Procedure’ where we describe the sampling design for the study in detail.

Does the survey captured the main motivator/factor that made sampled women to visit these facilities for contraception? Do these women come to the facility alone or with any family member or any grass root level health worker like ASHA/ANM? It is quite possible that these women might have been counselled for visiting these facilities for a particular method well in advance before visiting these facilities. How did the authors address this?

The survey did not include the main motivating factors for women to visit these facilities. It also did not capture any prior counseling received by these women from front line health workers like ASHAs or ANMs. We recognize this as a limitation of the study and added text in the Strengths and Limitations sections to reflect this.

It is evidenced that usually most of the people seeking health care utilization from public health facilities are from low economic background. Hence inference drawn from this analysis has its own limitation so far as generalization is concerned. This may be marked in the discussion section. Does this survey gathered information about economic status of these women, if so inclusion of this in the analysis is suggested?

The survey did not include items to assess the economic status of the participants during the exit interview. This is a limitation of the study and we have added text in the Strengths and Limitations section to indicate the lack of this variable in our analysis.

It is suggested to discuss in details the possible reasons for those 13% women who preferred no method post-counselling; though they visited the facility for adopting/accepting any FP method.

To address this comment, we have added text that discusses the reasons for women not choosing any contraceptive post-counseling. This description can be found in lines 378 – 390 in the discussion section of the revised manuscript (without track changes).

Why the religion was classified as Muslim and Non-Muslims? It is assumed that majority of that Non-Muslims are Hindus, who constitute a majority of the sample women. In that case why not to classify Hindus and Others.

We categorized religion into Muslim and Non-Mulsim as modern contraceptive usage in Uttar Pradesh was disproportionately low among Muslim couples. We have added a justification for this classification in the measures section of the revised manuscript.

The purpose behind capturing education up to primary level needs to be presented? Role of education may have been much better understood if it would have been collected beyond primary level.

Education was considered a confounding variable in the association between quality of counselling and contraceptive method used. Primary education was considered as a covariate based on the lower proportion of women in the state who complete higher education beyond primary.

The non-inclusion of the type of facility i.e. DH & CHC in the analysis, is unclear

We acknowledge the non-inclusion of this variable in the original manuscript and have revised our analyses to include the type of facilities in the revised manuscript.

Table 7: It is not very clear OR at what level significance is shown/made bold.

We have removed all bold fonts from the tables and have reported 95% Cis to indicate level of significance.

Were there any non-literate participant? Especially when 35% of them had not completed primary education. If so, how did the consent sought and taken from them to participate in this study.

Yes, there were are few participants in the study who could not read or write. For such participants, the consent form was read out and in case they agreed to participate in the study, the interviewer sought their thumbprints as a proxy to their signature on the consent form.

The conclusion section must be revisited to limit it as per the analysis carried. Authors may restrict themselves from overgeneralization of the results looking at the sample size and design.

We have revised the conclusion section substantially based on this comment and comments from other reviewers. The discussion and conclusion in the revised manuscript avoids the pitfalls of overgeneralization.

Reviewer #4 comments

Reviewer #4: No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

No comments at this time.

Reviewer #5 comments

Reviewer #5: Thanks for giving me an opportunity to read this interesting paper. The authors have used a facility level exit interview data to present a topic which needs more and more research to improve quality of care for family planning services in India. While the paper has several strengths, I feel the statistical analysis is not that great. Following are observations which may help the authors in strengthening the paper.

Thank you for taking the time to review our manuscript and for sharing your comments on the paper. We have addressed your comments in the following ways:

INTRODUCTION

1. The introduction is too lengthy and I feel it can be shortened significantly. The authors should should strengthen the last but one paragraph in the introduction section (Page 6 Line 98-103) with more solid justification on why this study is called for. The current articulation is somewhat vague and may be supplemented with specific contextual example to strengthen it.

To address this comment, we have made substantive changes to the Introduction section that has made it much more comprehensive and has solid justification for the study.

2. Line 102: Please elaborate what do you mean by coercive FP services in India?

We have edited the introduction substantially and have dropped reference to the coercive FP services in India in the revised manuscript.

METHOD:

3. In the materials and method section, please provide brief description about the study setting. For an international reader, it is difficult to know the context in which health services are being offered.

We have added text in the material and methods section to describe the study setting.

4. Line 122. Is it Indian financial year. If yes, please mention it.

Yes, we were referring to the Indian Financial year. We have added text to clarify that in the revised manuscript.

5. The authors say design is described in Mozumdar et al. I think it would be appropriate for the authors to provide a gist of the method in this paper also.

Based on this comment and similar comments from other reviewers, we have added a new section titled ‘Sampling Procedure’ that describe the study design and does not rely on Mozumdar et al for the description.

6. Line 127: Was the facility manager/provider aware that women were being interviewed after the consultation? If Yes, I suggest authors to discuss how such prior knowledge would have influenced the study findings? Also, what steps were taken to reduce such bias?

observed?

Yes, the facility in-charge were informed about the interviews being conducted. However, the providers were not aware of the clients being interviewed after the consultation. Care was taken by the survey team to ensure that the post-consultation interviews were conducted away from the vicinity of the place where the counseling services were being provided.

7. Line 134: Authors suggest written informed consent was taken from all respondents? I am wondering how did you do that with women who could not read and write?

There were a few respondents who could not read or write. In such cases, the consent form was read to them and if they agreed to participate in the interview, their thumbprints were taken as a proxy to their signatures on the consent form.

8. Line 173: Did you collect information on sex of the provider? If no, don't you think it is an important variable to consider.

Yes, we collected information on sex of providers. Out of a total of 144 providers who counseled the clients sampled in the study, 15 were males. We have included a variable on sex of provider in the analysis in our revised manuscript.

9. Why the authors choose to use PCA not exploratory factor analysis. I feel this is the key weakness of this paper.

We used PCA because one of our objective was to create a composite score of quality of Family Planning counseling from our survey items. PCA allowed us to create a linear combination of these items and create the QFPC measure, which is the outcome of interest in our study.

RESULTS:

10. Table 1: What is quality of counseling index? Did I miss the definition in the measure section?

Thank you for pointing this oversight. We were referring to the Quality of Family Planning Counseling (QFPC) measure. We have rectified this in the revised manuscript.

11. Interesting you had more women with a male child. Can you clarify, if this is the sex of the last living child or something else? Also, given this biased distribution of women with male child, how it has an effect on the contraceptive use and quality of care received?

Thank you for this comment. The variable on presence of a male child identifies women who have at least 1 male child. This male child can have any birth order and is not specific to the last birth. We included this variable as a confounder between our dependent and independent variables and adjusted for it in all our analyses.

12. In Table 1, why provider characteristics are presented at patient level? They should presented at provider level, then only one can understand the distribution. I suggest rectifying this.

We agree that providing provider level characteristics separately would clearly describe the distribution to readers. Based on this comment, we have created a new table that contains information on characteristics of providers. This new table is referred as Table 2 in the revised manuscript.

13. Line 218: There is nothing called confirmatory PCA. But, yes, there is confirmatory FA. I suggest authors to review the statistical analysis thoroughly.

We acknowledge this oversight and have corrected the wordings in the text to reflect our analysis accurately.

14. Table 5: Instead of saying bivariate analysis, the author should present the title as "percent distribution of quality of counseling by....". Again, for providers, the analysis should at provider level by calculating the average of QoC at provider level

We have changed the analysis in the paper substantially. The purpose of table 5 was to assess criterion validity for the QFPC measure. Instead of undertaking a bivariate analysis, which suffered form low cell sizes, we developed adjusted linear regression models for the purpose, which are more robust. The new table is referred as Table 4 in the revised manuscript.

15. Table 6. If the focus of the paper is to understand relationship between QoC and contraceptive use, then Table 6 and 7 should be combined and only results for depicting this relationship should be presented. The rest of covariates, obviously, should be adjusted in the model. Presenting results for other covariates does not make much sense.

Based on this comment and comments from other reviewers, we have modified the analysis in the paper substantially. For all our multivariable models, we only present the coefficients for the primary independent variables and adjust for the rest of the covariates as suggested.

16. Table 6 and 7: Why authors did not use the categorical variable to test the association between QoC and contraceptive use? I strongly recommend the authors to remain consistent in use of measures across the paper.

Based on this comment, we have ensured consistency in the use of the QFPC measure across the paper. In order to preserve the information in the data, we chose to use the QFPC measures as a continuous variable throughout the paper. This revision is reflected across all the revised tables and the results section in the revised manuscript.

DISCUSSION:

17. Line 307-314: While it is true that a fair share of women do not receive good QoC, the discussion should have focused in highlighting what are the structural, individual and provider level factor contributing it. Though some discussion is there in the subsequent paragraph, I feel more contextualization is required at the beginning itself.

The initial two paragraphs in the discussion section are focused on reliability and validity of the QFPC measure and placing it in the context of other similar studies. To address this comment, we have edited the third paragraph of the discussion section (lines 345-354 in the revised manuscript) to focus on the structural factors associated with Quality of Counselling.

18. Line 344-345. Can you elaborate more on how the study findings suggest that target-based family

planning without focus on QoC is a challenge? Challenge to what, how and to what extent?

We recognize that this statement was a bit out of context from our main discussion point. We have removed this and enhanced focus on the quality and quantity of training to providers in the revised manuscript.

19. Line 359-360: Authors recommend qualitative research on this issue. I feel this is very generic recommendation. It would be more useful to indicate what is the specific issue that needs more exploration. Already, several qualitative research is available exploring variable contraceptive use and non-use dynamics among women. What additional issues needs to be understand.

To address this comment, we have removed the generic recommendation for Qualitative research and call for further research to understand the reasons behind women arriving at facilities for FP methods, but leaving without selecting any method.

Submitted filename: Response to reviewers.docx

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12 Apr 2021

Measuring quality of family planning counseling and its effects on uptake of contraceptives in Public Health Facilities in Uttar Pradesh, India: a cross-sectional analysis

PONE-D-20-28620R1

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Reviewer #3: All comments have been addressed

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Reviewer #3: No

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Reviewer #3: Thank you for revising the paper based on the comments. This draft is much focused and deemed to add to the Family Planning evidence base.

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Reviewer #3: Yes: Manas Ranjan Pradhan

23 Apr 2021

PONE-D-20-28620R1

Measuring quality of family planning counselling and its effects on uptake of contraceptives in Public Health Facilities in Uttar Pradesh, India: a cross-sectional analysis

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