Impact of the Quality of Family Planning Services on Modern Contraceptive Prevalence

INTRODUCTION: This study evaluates the association between family planing (FP) service quality and modern contraceptive prevalence (MCP) in Ethiopia. Reducing unmet need for FP in low and middle income countries (LMICs) can reduce child and maternal mortality and disabilities through improved birth spacing, education, women’s empowerment, and reduction of unwanted pregnancies, poverty, and hunger. Evidence regarding the effect of FP service quality (FPSQ) on MCP has been slow due to the challenge of obtaining measures of FPSQ. The Bruce-Jain framework provides one of the earliest comprehensive literature reviews and theoretical frameworks describing the dimensions of FPSQ. Our study uses a potentially generalizable method of data reduction by using an expert panel to score potential variables linked to FP service quality and to prepare a smaller set of FPSQ indices that are in keeping with the Bruce-Jain framework. METHODS: We used Performance, Monitoring and Accountability data from 2015 to assemble a cross-section dataset for Ethiopia with enumeration area (EA) level data from the service delivery points (SDP) and woman of reproductive age household (HH) surveys. We used multivariate ordinary least square regression models with Huber/White robust standard errors clustered at the region level. The dependent variable was mean MCP and the independent variables were six different FPSQ Bruce scores at the EA level. The six different FPSQ Bruce scores were tested combined and individually in the models. Control variables included socioeconomic status (SES), marriage, husband cohabitation, and education status, age groups, and urban. EA level MCP and controls were calculated by averaging across individual female respondents within an EA. RESULTS: Among the 215 EA-observations in Ethiopia, 44% of the women were between 15 and 24 years old, 58% were married, out of those married 92% cohabited with their husband, 29% had a high school education, and 27% (EA range: 0%-71%) were a current user of a modern contraceptive method. Regression results show that for every unit increase in the EA mean FPSQ Bruce 1 score (on choice of method) and Bruce 4 score (on provider-patient interpersonal relations), the mean MCP increased by 21.4% (p<0.01) and by 18.0% (p<0.01) respectively. Bruce scores 2, 3, 5, 6 did not show statistically significant association with EA level MCP. Results were robust to multiple specification tests. CONCLUSION: Multivariate statistical analysis using PMA data from Ethiopia showed that two out of six of the Bruce domains of FPSQ are linked to modern contraceptive prevalence. These results show that efforts to strengthen FP service quality have the potential to significantly increase contraceptive use in LMICs. Likewise, this results may help child and maternal health policymakers advocate for increased investment in interventions that improve FPSQ in LMICs. Future extensions to our analysis will exploit the panel nature of data with three waves and multiple countries to adjust for fixed effects.