RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

The 16th and current President of the Philippines, Rodrigo Duterte, aims to resolve poverty as a critical agenda.
Although annual growth rate of the Philippine gross domestic product exceeded 5% since 2012, the estimated
proportion of people living below the poverty threshold (2015) was 21.6% (22 million out of 100 million).
Indeed, a significant economic disparity exists as demonstrated in its GINI index of 43.0 in 2013, a level higher
than most Southeast Asian countries. Additionally, although the average total fertility rate in 2008 was 3.3 in
the Philippines, its number reaches as high as 5.2 in the poorest household that is estimated to spend only
around 2% of their total income on education.1 Actually, the children aged 6-17 in poorest households were less
likely to attend school compared to those in richest households in 2011 (85.6% vs. 97.2%). 2 As such, it has been
hypothesized that there may be strong links among high fertility rate, poverty and limited opportunities of
education in the country.

Given these speculations, President Duterte highlights the importance of population control using modern
family planning measures in his war on poverty. However, the inadequate sexual health education and
conservative sociocultural norms prove to be significant obstacles, as methods of contraception are widely
disrespected by the general population. The Philippines is predominantly Catholic, whereby 80% of the local
population subscribes to the teachings of the Church. Although constitutionally there is a separation of the
Church and State, the Church remains influential in defining policies particularly in areas of reproductive
health. Presently, abortion is prohibited in their constitution except for cases conducted to protect mothers’
health.

However, in reality, abortifacient agents are illegally sold in stalls adjacent to several Catholic cathedrals in
Manila. Additionally, the lowest rate of condom use in Southeast Asia and increasing rate of casual sex
contribute a considerable burden of sexually transmitted diseases, including human immunodeficiency virus
(HIV).3 The reported number of HIV infections is currently 30 000, 80% of which have been newly registered
since 2010.3 Further, the emerging risk of Zika virus infection or rubella would present a challenging situation
to pregnant women.4

Under such conditions, there is a growing need that policymakers and public health professionals take into
account the changing attitudes towards sexual intercourses among the general population in the country.

In 2012, Responsible Parenthood and Reproductive Health Act, also known as Reproductive Health Law, was
enacted in the Philippines to improve an access to birth control measures after years of struggle. 5 Although its
constitutionality was questioned by the Supreme Court in 2013, the court finally declared that the law was
constitutional in 2014.5 However, Temporary Restraining Order, which was subsequently issued by the
Supreme Court, has restricted (1) the registration of new contraceptives and the re-registration of currently sold
contraceptives when their permits expire, and (2) the purchase, d istribution and use of subdermal implants by
the Department of Health, eventually hampering the full implementation of the law until now. 6 It is obvious that
the current situation necessitates an early resolution, considering that there will be limited contraceptive
measures available in the Philippines, such as tubal ligation, vasectomy and natural family planning methods, if
the restraining order is not lifted and the current registration of contraceptives expire. 6 We urge President
Duterte to achieve a historic step to further improve healthcare in the Philippines – the full implementation of
the Reproductive Health Law.
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

This report which summarizes the major study findings on population and family planning trends in the
Philippines was prepared for the Research Unit of the Family Planning Services (FPS) of the Department of
Health (DOH). Specifically, the report was to be used by the FPS in its National Consultative Planning
Workshop which was scheduled in early 1994 to discuss and formulate the plans and activities for the Philippine
Family Planning Program (PFPP) for 1994-1995. The workshop participants included the DOH Regional
Family Planning Coordinators, representatives of local government offices engaged in population and health
activities, and local NGOs and women's groups. The report, therefore, was meant to alert participants to
population and family planning issues and trends which could assist them formulate their family planning
program targets and strategies in their own areas and localities. In earlier meetings with the FPS-Research Unit,
it was agreed that the study findings contained in this report would be organized into two major sections,
namely: 1) those that relate to indicators of family planning demand; and 2) those bearing on the supply of
family planning services. In view of the changes that have been made on the national family planning program,
moreover, it was agreed that the report would incorporate the basic policy changes that ought to guide local plan
formulation and program implementation. Additionally, the report was to touch on the 1991 Local Government
Code which devolves many of the functions and services earlier provided by the national government to local
government units and which affects the delivery of health and family planning services at local levels.
Considering the large number of population and family planning studies that have been made to date, this
review limits itself to a presentation of related trends in fertility and family planning awareness, approval and
use over time. The chief sources of these findings and which are presented in Section I of this report (Related
Indicators of Family Planning Demand), are the Censuses, the National Demographic Surveys (NDS), and some
of the FP-KAP (Family Planning Knowledge, Approval and Practice) surveys done since the 1970s. Undertaken
every five years since 1968, the NDS is on its sixth series (1968, 1973, 1978, 1983, 1988 and 1993). The NDS
provides updated information on fertility, fertility preferences, and family planning awareness, approval and
use, as well as related data on breastfeeding and maternal and child health practices. The NDS series has been
used largely by government and policy makers to monitor/evaluate the impact of national population program
initiatives, and to design strategies for improving the provision of health and family planning services.
Complementing the NDS is also the nationwide Contraceptive Prevalence Survey (CPS) undertaken in 1986,
which provides more detailed information on contraceptive adoption and use. In the review, attempts are made
to compare trends across the same time periods, i,e, as from 1968- 1973 to 1978-1983 and to 1988-1993. But
since data from the NDS survey rounds, as well as from other sources and the methods for analyzing these, are
not always uniform or comparable, the discussion of some trends may omit certain time periods. In almost all
cases, however, the latest available information on a trend or topic is included in the report. The report also
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

focuses more on national trends, but cites marked regional variations where these are found. In Section II
(Factors Affecting the Supply of Family Planning Services), the report draws on a review of materials and
documents on the national population policy and program, particularly after the reformulation of these in the
late 1980s into the PFPP Plan for 1990-1994. This section also includes findings from earlier OR (operations
research) studies that were commissioned to look into various aspects of the family planning program and its
implementation. Among these are some of the OR studies done on the IEC and training components of the
program, the number and distribution of family planning service outlets, the accessibility and availability of
contraceptives, the referral system obtaining in clinics, clinic preformance and quality of services, and other
evaluations conducted on the program. Emphasis is placed on the more recent than on earlier OR study findings
since the latter are no longer as relevant or appropriate to the ongoing changes being made on the conduct of the
national family planning program. Finally, in both sections, the report calls attention to some of the policy and
program implications of earlier research and study findings, although it should be noted that not all study
findings are with direct policy or program implications. In general, by synthesizing information on family
planning activities and trends, the report hopes to provide a backdrop for the formulation and implementation of
local action plans to advance the national family planning program.

Methods for providing high-quality family planning services have been established and widely disseminated by
public health agencies and others.1-4 However, the technologies, staffing, and budgets required to achieve these
types of family planning services may be difficult to provide in countries with limited economic resources and
large populations of women of reproductive age. 5 Cultural and political barriers may also inhibit the quality of
family planning services since social stigma is an issue for these programs in many countries. Previous studies
have found a range of quality of care (QC) problems with family planning services in low- and middle-income
countries. Kriel et al. conducted qualitative research on family planning services with community members,
providers, and key informants in South Africa, and found a lack of technically trained providers, long waiting
times, poor infrastructure, poor interpersonal relations, lack of counselling and information exchange, fear, and
time constraints.6 Tafese et al. conducted survey research with family planning clients, provider interviews, and
observation of consultation sessions in Ethiopia, and found long waiting times and a lack of critical resources to
provide quality family planning services, including trained personnel, information education, and
communication materials, and other supplies, in all of the primary health care centres included in their study.7

Our study focused on family planning service delivery in the Philippines, a middle-income country with a
population of 26.1 million women of reproductive age in 2015. 8 In recent years, concerns have been raised in
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

this country regarding the limited utilisation of family planning services and high rates of teenage pregnancy,
with 425,000 teens beginning childbearing in 2018. 9 Family planning in the Philippines has been found to be
hampered by poor quality service, limited client engagement and feedback, and bias, stigma, and discrimination
towards clients from service providers.10 The goal of our study was to aid in developing family planning QI
programs.

Other studies have identified a range of factors that can promote or inhibit QC for family planning. 6, 7, 10-
17 However, these prior studies sometimes focused only on clients' or providers' perspectives or used survey
methods that assume the factors are known well enough to be limited to closed-ended survey questions. Most of
these other studies were also conducted in other countries. We were concerned to identify the factors most
salient for improving the quality of family planning care in the Philippines by investigating the range of factors
identified by client, potential client, and service provider stakeholders in family planning that were specific to
the health system and social and cultural context of the Philippines.

We sought to identify the components of quality of family planning care viewed as most important, key themes
and insights to illuminate the root causes of poor family planning service quality, key factors leading to the
limited effectiveness of past QI programs, ways in which provider bias and stigma affect quality and access to
care, and the respondents' perspectives on future approaches for QI that could be more effective. We also sought
to explore the current understandings of the concepts of QC, quality assurance (QA), QI, and continuous quality
improvement (CQI) in the Philippines, as they are often defined in different ways by different types of providers
and officials. Developing common understandings of these concepts, and the appropriate roles for providers in
them, is important for developing effective family planning QI programs in the Philippines.

2 METHODS

To address these issues, we conducted qualitative research in 2019 and 2020 with clients, potential clients, and
family planning service providers at multiple levels of the health care system in the Philippines on the barriers
and opportunities for improving the quality of family planning services. We included a range of different types
of respondents both receiving and providing family planning services to gain a more comprehensive perspective
on the factors affecting service quality. Our approach utilised focus groups and key informant interviews (KIIs)
to gather qualitative data.

2.1 Study setting

RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

Our study was conducted mainly in Batangas province in the Philippines in order to plan for a pilot CQI system
for family planning services in that province. Some of the focus groups with providers were conducted in other
provinces in the Philippines, to gain complementary perspectives on family planning quality from other regions.

2.2 Data collection

2.2.1 Family planning service providers

We conducted focus groups and KIIs with the range of family planning service delivery staff working at all
levels in the Philippines service delivery network, including the primary, secondary, and tertiary levels, and
including both female and male staff. The participants were recruited from hospitals, public health facilities, and
rural health units. The interviews and focus groups were conducted in hospitals, public health facilities, and
private venues, at mutually agreed upon times to ensure minimal disruption of services. Some focus groups
included participants all from one facility while others included participants from a mix of different facilities.
The interviews and focus groups included barangay health workers (BHWs; a barangay is the smallest political
unit in the Philippines), who are volunteers from their communities, nurses, midwives, and physicians. The
participants included:

• 10 BHWs in KIIs

• 122 nurses and midwives in 12 focus groups

• 29 nurses and midwives in KIIs (different respondents than the nurses and midwives in the focus
groups)

• 28 physicians in KIIs

Semi-structured interview and focus group guides were developed separately for each type of service provider,
pre-tested, and revised before conducting the data collection. The topics covered included how to define QC for
family planning services, factors affecting quality, how service delivery staff bias affects quality, what can be
done to improve family planning services, barriers to improvement, and others. The topics and questions for the
focus group and interview guides were selected based on evaluations and other studies on family planning
services in the Philippines and in other countries. 18-23 The interviews and focus groups were conducted by
experienced Filipino qualitative researchers in Tagalog and Cebuano, audio recorded and transcribed, and then
translated into English for analysis.

The service provider focus groups included midwives and nurses. They were separated into focus groups with
younger or less-experienced nurses and midwives and other focus groups with older or more experienced nurses
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

and midwives to better ensure that the younger and lower-ranking participants could speak freely. The focus
group participants were provided with snacks at the focus group sites and a roundtrip transportation allowance
of up to PhP 600 ($11.50) per person.

2.2.2 Family planning clients and potential clients

We also conducted focus groups and KIIs with female clients (family planning acceptors) and female potential
clients (family planning non-acceptors). The focus groups included adult clients and potential clients. The KIIs
included adolescent clients and potential clients to provide better assurances of confidentiality for the
adolescents. Clients were recruited from healthcare facilities by local government unit staff and healthcare
facility staff. Potential clients were recruited from their communities by BHWs. Overall, the participants
included:

• 7 adult clients in one focus group

• 11 adult potential clients in a different focus group

• 6 adolescent clients with no children in KIIs

• 8 adolescent clients with one or more children in KIIs

• 6 adolescent potential clients with no children in KIIs

• 8 adolescent potential clients with one or more children in KIIs

Semi-structured interview and focus group guides were developed separately for each type of respondent, pre-
tested, and revised before conducting the data collection. The topics included perceptions of what is QC for
family planning services, what are the factors affecting quality, their preferences for family planning, how
satisfied are they with family planning services, how have they obtained family planning services or
commodities in the past, how well they are treated by family planning providers, what social and health system
barriers they face in obtaining family planning services, and others. The topics and questions for the focus group
and interview guides were selected based on evaluations and other studies of family planning services in the
Philippines and in other countries.18-23 The KIIs and focus groups were conducted by experienced Filipino
female qualitative researchers in Tagalog and Cebuano, audio recorded and transcribed, and then translated into
English for analysis. All the client and potential client participants were provided with snacks at the focus group
and KII sites and a roundtrip transportation allowance of up to PhP 800 ($16.80) per person.

2.3 Data analysis

RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

We conducted thematic content analysis on the qualitative data from the focus groups and KIIs, following
methods commonly used in other health care settings. 24, 25 Our aim was to generate themes and practical
insights from the qualitative data that could be used to improve the quality of family planning services in the
Philippines. We first developed a set of deductive codes from the concepts used to develop the KII
questionnaires and focus group guides. We also developed a set of inductive codes following initial review of
the transcripts. Our final analysis included both the deductive and inductive codes, that we developed and
reviewed jointly to promote intercoder reliability.

Our qualitative analysis began with the transcripts of all of the focus groups and KIIs, that constituted the data
set for this study. The transcripts for the providers and clients were analysed separately. The participants'
responses were coded according to the deductive and inductive codes representing key issues and concepts for
defining QC for family planning services, problems with QC, practical ways to improve quality, and others. The
segments of the transcripts associated with each code were then combined using Microsoft Excel and Word
software and reviewed to identify themes. The themes included challenges, opportunities, practical insights, and
key implementation factors to aid in developing programs and interventions for improving the quality of family
planning services in the Philippines.

2.4 Ethics review

The methods we used for qualitative data collection and data analysis for this study were reviewed and
approved by the St. Cabrini Medical Center—Asian Eye Institute Ethics Review Committee in the Philippines
and by the Institutional Review Board at RTI International in the U.S. All of the respondents aged 18 or older
were provided with informed consent forms to read and sign before the KIIs and focus groups were conducted.
Respondents under age 18 were provided with assent forms to read and sign and their parents were provided
with informed consent forms to read and sign before the KIIs were conducted.

3 RESULTS

The family planning providers who participated in our focus groups and KIIs had an average of 15 years in
service and an average age of 43. The family planning clients and potential clients who participated in our study
included adults over age 19 and adolescents who ranged in age from 15 to 19.

The results of our qualitative research are presented as the themes, practical insights, and key implementation
factors identified within the domains central to our study. The domains included: quality of family planning care
as defined by providers and clients; factors influencing QC; challenges for improving QC; and provider bias in
the types of family planning services offered to clients.
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

3.1 Quality of family planning care as defined by providers and clients

We found that QC was a familiar concept to the providers, clients, and potential clients who participated in this
study. For these respondents, quality in family planning services includes seven major elements: (1) safety, (2)
effectiveness, (3) client relations, (4) client education and counselling, (5) prompt service, (6) access to family
planning supplies, and (7) client satisfaction.

Safety is viewed as part of the result of a family planning service. For providers, safety results when they
prevent and manage the risks and complications for their clients. Similarly, clients and potential clients viewed
safety in terms of being protected from harmful advice, procedures, and products received from the providers,
including harmful side effects. As an adolescent client put it, ‘I have concerns about using IUD [intrauterine
device]. I heard it has side effects’. An adult client said, ‘In our place, some women don't use family planning
because of fear of the side effects’. From the provider side, a BHW indicated that, ‘Since I also use injectables, I
will be able to explain to the client my own experience so that they will not worry too much about safety’. A
midwife stated that, ‘Safety is a big part of family planning. Patients must be taken care of and their safety is
secured’.

Effectiveness includes both preventing pregnancy and having a method that is hiyang (suitable) for the client.
An adult potential client said, ‘My sister got pregnant even if she was using the injectable method. So,
effectiveness is important to avoid such incidents’. A doctor said, ‘It is effective if we are able to control the
population. We are able to decrease teenage or unwanted pregnancies. It is effective if families are really able to
plan their families well’. Providers cited several factors needed for achieving effectiveness, including: (a) the
client's correct understanding of and adherence to the proper use of the contraceptive; (b) the client's regular
visits for monitoring contraceptive use and side effects; and (c) the provider's vigilance over the expiration dates
of commodities.

For clients and potential clients, another aspect of effectiveness is when the contraceptive method they use is
suitable for them. In Filipino parlance, it is hiyang, a personal experience where only the individual could tell if
something is agreeable to her. If a woman's body experiences untoward side effects, the method is rejected as
not hiyang. As an adult client said, ‘I want my preferred method because I know what is best for me. It's my
body so I would know what method is agreeable for me. If complications occur, I can switch to another
method’. Similarly, a BHW said, ‘The patient using a family planning method will know whether or not such a
method is hiyang for her body’. Conversely, an adolescent potential client said a concern she had about family
planning is that, ‘It might be hindi hiyang (not suited) for you’.
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

Client Relations in the context of quality requires providers to accord clients with respect, patience, and
fairness, to engage in pleasantries (being nice, smiling), and to exhibit a non-judgemental attitude. As an
adolescent client put it, ‘I'd be satisfied if I like their approach or the way they speak to me is gentle and calm’.
Respectful treatment means not only being courteous, but also observing privacy and confidentiality regarding
clients' sensitive personal information. As an adult potential client indicated, ‘I am a bit shy when I say things
that involved family planning. And when the staff do not make it a secret and people might know it, I will feel
shy. As a person and as a woman, we always need privacy’.

To be non-judgemental is to treat clients equally or fairly; hence providers must not look down on a client
because of her poverty, lack of education, early pregnancy, or marginalised ethnic affiliation. As a doctor put it,
‘For instance, we cannot judge patients even if you know they are sexual workers. In fact, they are the ones who
need family planning and screening to take care of them. Confidentiality means respect, and you are not judging
them’. In contrast, adolescent clients and potential clients reported concerns about encounters with hostile and
judgemental health staff. Similarly, some providers also reported concerns that clients are too often subjected to
health care staff who are not approachable, bad tempered, or who scold clients for perceived bad behavior or
repeated pregnancies. As an adult potential client put it, ‘Whole day of waiting in a heated environment is tiring.
And then when they call you, they scream. They also judge you because of the smell. So, they just better work
in a private facility to have better smelling patients’.

Client Education and Counselling is perceived to be an important aspect of quality because it is how women
and adolescents get informed about the correct protocols and behaviours for family planning. As a nurse said,
‘Counselling is a very important component of our services. We are able to empower our clients to decide which
method they want, a method that will fit with her body’. An adolescent potential client said, ‘Then I told her
[boyfriend's sister] that we are engaging into sex already and I am afraid that I might get pregnant. For me, I
would like to learn more about preventing pregnancy and that there are other family planning methods besides
pills’.

A challenge is that myths, rumours, and culture-based misperceptions about birth control, pregnancy, and
childbirth are widespread in many communities and need to be dispelled or debunked. For example, an
adolescent potential client said that, ‘I'm scared to use family planning methods. It happened to my friend that
the condom they use was punctured. My boyfriend and I practice withdrawal’. Another adolescent potential
client said, ‘Three months after my first child was born, I used pills. I stopped using it after 1 month because I
was having headaches. I was afraid because my mother said it could be high blood’. A BHW noted that, ‘It is
hard to talk to patients who have misconceptions or who believe in superstitions. It is really difficult to convince
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

them’. Similarly, a doctor indicated that, ‘Old ideas cause misconceptions about family planning, like if you are
on IUD, you should not carry heavy things, so we only have few acceptors of IUD. This barrier is magnified if
grandmothers or mother-in-law accompany the potential acceptors. They have myths. They don't accept facts
easily’.

Counselling should enable the provider to transmit knowledge about planning one's family, and to give clear
explanations and relevant instructions about contraceptives. Adolescents wanted more information on the range
of family planning methods, their safety, and their side effects. Good counselling leads to informed choices
about contraceptive methods. As an adolescent client put it, ‘They listened well, and they gave advice. They
responded to my questions like which is better between injectables and pills’.

At the same time, many are afraid to ask about family planning methods for fear of being labelled as sexually
active and gossiped about. As an adolescent client put it, ‘They will also call her malandi (flirt). The family will
be embarrassed because of her’. In response, some potential clients are using the Internet as a source of
information on family planning that enables them to avoid the fear of embarrassment. An adolescent potential
client said, ‘For me, it is important but sometimes I feel ashamed to go to them [providers], that's why I get
information from Google’. Another adolescent potential client indicated, ‘I only know about condoms and pills.
I learned it from the Internet’. A focus group with adult potential clients also included the potential for the
Internet to reach more girls and women, ‘P1: The knowledge and information about family planning must be
promoted in the community. Although the seminar or forum is organised in the barangay, only a few residents
attend. The rest cannot attend because of work, or they have small children at home’. P2: ‘The problem can be
addressed by social media. Maybe the DOH [Department of Health] can do that. The information can be
disseminated through social media’.

Prompt Service means the provider is able to serve the client in a timely manner and the client is able to receive
the service at the time she needs it. Lack of prompt attention is often perceived by clients and potential clients
as bad care. As a doctor indicated, ‘If waiting time is too long, patients become impatient so they will leave
because they have things to do at home. When that happens, you can no longer convince her to come back to
you’.

At the same time, respondents expected waiting time as inevitable at public facilities where family planning
services and commodities are given free of charge, with the resulting high volume of clients. As an adult
potential client said, ‘You need to wait because you don't pay anything. Just sacrifice for the waiting’.

The usual waiting period was reported to be about 20–30 min but may extend to 2–3 h in a hospital setting.
Some providers try to make the waiting time more bearable for clients by giving relevant reading materials or
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

flyers, lightening the mood through happy conversation, encouraging sharing of women's experiences with
family planning, and making them comfortable through good ventilation in the health facility.

Access to Family Planning Supplies was stressed by the clients as an important element of quality. Because
supplies are given freely at the public facilities, the clients in the lower socioeconomic class need not worry
about the cost of procuring them. However, clients underscored their dependence on the consistent availability
of supplies from public facilities and worried about possible shortages. As an adult client said, ‘The health
facility must always have a continuous supply of family planning methods like pills and injectable. If I don't get
injected as scheduled, I'll get pregnant’. Providers had similar concerns. A doctor said that, ‘Quality of care
means that commodities or supplies are available’. As a BHW said about clients, ‘They ask if the supplies are
available like condoms, pills, and injectables’.

Clients also reported consistent availability of contraceptives at pharmacies, and indicated they were sold for a
price that was usually considered affordable. However, some clients had concerns about affordability. As an
adult client said, ‘The family planning supply is given free. So, if it is not available at the health centre, the user
will have to buy it. It's a problem if there is no budget for that’.

In addition, adolescents reported having to lie about their age or get others to purchase contraceptives for them
at pharmacies. This is because the legal age for purchasing contraceptives is 18 in the Philippines. As one
adolescent client put it, ‘When I told them I was 17 years old, they didn't give me the pills. So, I asked the older
sister of my friend to buy it for me’. Some respondents also reported fearing that others would know of their
sexual activity if they purchased contraceptives in a public place.

Client Satisfaction is the culmination of having met the abovementioned aspects of quality. There were
reportedly two major indicators of client satisfaction. First, routine data collected by health facilities to show if
clients continue to return for family planning services (they do not drop out). As an adult client said, ‘Clients are
satisfied with the services when they return to the health centre’.

Second, hearing that clients advocate for other women in their family or community to avail themselves of
family planning services from the same facility. As a nurse said, ‘When clients encourage other family members
and friends to seek the same services, that means the client is satisfied with our services’.

3.2 Factors influencing quality of care

Three types of factors were reported to influence QC in either favourable or unfavourable ways: (1) service-
related, (2) provider-related, and (3) client-related. The service-related factor most mentioned by the providers
was the resources available for family planning in the health facility. Financial resources matter greatly because
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

they affect staffing, training, the capacity to upgrade health centres, and availability of contraceptive supplies.
As a nurse said, ‘Sometimes instead of giving the full package of intervention, we are forced to only give half or
less because supplies are really limited. In some situations, they are forced to shift to another method, or they
have to spend out-of-pocket, or worse the clients will not come back anymore’.

To improve quality another nurse said what was needed was, ‘Staffing, additional manpower for family
planning services. Two family planning providers are not enough to accommodate all the clients in the facility’.
A doctor indicated that, ‘In terms of manpower, our trained staff on IUD has just retired so we can't deliver IUD
yet’. Another doctor said, ‘It is a fact, and we should accept this reality, that we are really understaffed. This one
must be addressed given the population we have in the country…You know you want to accommodate everyone
but because of the number of patients you have to limit your patients for the day’.

The provider-related factors concerned the personality traits of the providers. Facilitating factors for quality
were providers' traits like knowing how to keep clients' information private and confidential to protect the client
from gossip, attentiveness and willingness to listen to clients' concerns and worries, responding to questions,
being patient and considerate, being able to calm and assuage patients' fears, and dedication to the job. As a
doctor said, ‘But of course, some health providers cannot avoid saying comments like “how come you are so
young and got pregnant” in a loud voice’. Similarly, a BHW said, ‘We know many cases where patients were
judged. Like if you are taking pills but you got pregnant, we will laugh at that’.

The client-related factors that affect quality mainly pertained to their capacity to understand important
information from provider counseling. This includes knowledge about family planning, the types of sources
(like peers or the Internet) they consult for family planning information, their cultural and religious beliefs,
misconceptions about family planning methods, and their own or others' experiences with the side effects of
family planning methods.

The consent of husbands or boyfriends was also reported to be a crucial factor in clients' acceptance of family
planning. Disagreements over the use of family planning was reported to be a common cause of conflict with
male partners. As an adult client indicated, ‘Oftentimes, the husband is difficult to convince. The topic has
become a source of disagreement between husband and wife. Although it is explained during the pre-marriage
seminar, a more convincing explanation is needed’. Similarly, another adult client said, ‘A woman in our
community, my kumare (close female friend), does not use family planning because her husband does not allow
her to use it. Although, she wants to use family planning. Her husband threw the pills in the river’.

Providers reported similar concerns. A BHW said, ‘Then there are those patients who tell us that their husbands
don't want it…We tell the client to bring her husband to the health centre so we can explain family planning to
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

him’. A midwife indicated that, ‘The husbands usually get angry when they don't know that their wives used a
family planning method, like IUD. So, they must be involved’.

3.3 Challenges for improving quality of care

Three challenges for improving QC were reported by the respondents: (1) equalising opportunities for
upgrading knowledge, (2) difficult and uncomfortable family planning-related topics, and (3) using data for
improving QC.

Equalising Opportunities for Upgrading Knowledge. This challenge focuses on having well-trained staff to
ensure QC for family planning. There was a clamour among the provider respondents who were nurses,
midwives, and BHWs, the front-line staff for family planning, to equalise opportunities for continuing education
on recent developments in family planning. As a nurse said, ‘When there is training you should cover all health
service providers, and not only one or two. Because if these trained people will leave, then nobody can actually
provide the services to the clients’. Similarly, a midwife indicated that a barrier to improving quality is, ‘Lack of
trained personnel. Even if the client wants a certain family planning method but there's no trained personnel
who can give the service, it becomes a barrier’.

Difficult and Uncomfortable Family Planning-Related Topics. Providers often need to know sensitive
information about the sex life of couples. However, sex was reported to be a matter that many providers find
uncomfortable to discuss openly with their clients who are usually shy about these things. Half of the BHWs we
interviewed (5 of 10) reported discomfort in talking about sex with clients. For example, one BHW said, ‘I am
not comfortable about sex. I find it difficult to talk about sex’. In addition, half of the focus groups with nurses
and midwives (6 of 12) included discussion about discomfort in talking about sex with clients. Interviews with
adolescent clients also revealed that their sex life at that age is usually a taboo topic; it was rarely discussed
among friends and never tackled with parents or family members.

Unmarried women and adolescents reported being hesitant to seek family planning services from health centres
because of Filipino society's adverse opinions about having sex outside of marriage. As an adolescent client put
it, ‘Some people would see her as a maduming babae (dirty woman) because she engages in sex’.

Using Data for Improving QC. Data on family planning were reportedly being collected and reported for their
facilities by the provider participants in this study. These were data for the various reports and documents that
they prepared and submitted to higher-level health authorities. However, none of the providers knew about
analysing those data or using the data to improve the quality of family planning care. As a doctor said,
‘Feedback mechanism is needed. Right now, we don't have it yet’.
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

Providers also reported that they were undertaking a range of QA and QI activities in their health facilities.
Examples of these activities that they cited covered a range of quality data and community education topics,
including the Usapan (talk) series such as Usapang Barako (male talk) and Usapang Beki (gay
talk), Buntis (pregnant women) Congress, and Mothers' Classes, outreach programs, data quality check
monitoring, process reviews, and monthly and quarterly audits. Notably, the community education programs
they included are not QA or QI activities, so this represents a misunderstanding by providers.

3.4 Provider bias in the types of family planning services offered to clients

For the provider KIIs with nurses, midwives, and physicians, we asked a series of questions regarding providers'
biases in the types of family planning services offered to clients. They included: (1) the minimum age to offer
family planning methods; (2) the minimum number of children a client must have before offering family
planning methods; and (3) whether a partner's consent is required before providing a family planning method.

Minimum age to offer family planning methods. Nurses, midwives, and doctors reported a willingness to offer
only the six reversible family planning methods (combined oral pill, progestin-only pill, male condom, IUD,
injectable, and implant) to younger clients in their teens. (Healthcare providers can offer information and
counselling to younger clients under age 18 at any time, although parental consent is required to provide family
planning methods to them.) Providers would only offer the two irreversible sterilisation methods (vasectomy
and tubal ligation) to older clients, usually only those in their 30s. Regarding the minimum age for offering a
vasectomy, a doctor said, ‘No age, I don't recommend it. Ideally, maybe 37’.

Minimum number of children required before offering a family planning method. These results varied by the
level of the health system. For nurses and midwives, most at the primary, secondary, and tertiary levels would
require at least one child before offering most family planning methods, and some at the secondary and tertiary
levels would require three or more children.

For physicians at the primary level, most indicated that one child was required before offering most family
planning methods, and many would require two or more children. For physicians at the secondary level, most
indicated that three children were required before offering any family planning methods. For physicians at the
tertiary level, most indicated that no children were required before offering any family planning methods.

Whether to require a partner's consent before providing a family planning method. Most nurses, midwives, and
physicians reported requiring a partner's consent before providing clients with most family planning methods,
even though this is inconsistent with Philippine government law and policy. A nurse said, ‘If the husband
doesn't want it, I won't provide it to the wife’. Similarly, a doctor said regarding a partner's consent, ‘We require
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

it so that they as a couple won't have any problem’. The exception was the physicians at the tertiary level, who
would not require a partner's consent before providing most family planning methods.

4 DISCUSSION

The quality of family planning services has been an ongoing concern of the Philippine government in recent
decades, in light of mediocre contraceptive prevalence rates and the continuing unmet need for family planning
among women of reproductive age in the Philippines. In addition, it is believed that family planning can
contribute to reducing maternal mortality by reducing the number of unwanted pregnancies. 26 Our study
illuminated five key implications for improving the quality of family planning services.

Reduce Provider Bias. We found that most of the nurses, midwives, and doctors we interviewed reported serious
and concerning biases in requiring clients to have one or more children before offering family planning services
and requiring the consent of male partners. Both of these requirements are contrary to the Philippine
government's landmark Responsible Parenthood and Reproductive Health (RPRH) law of 2012 that gives
Filipino couples and individuals the right to choose the timing, spacing, and number of children they want to
have, or if they want to have children at all.27 These provider biases are major barriers to improving the quality
of family planning services. They are also barriers to reducing the teenage pregnancy rate and likely contribute
to the hostility that adolescent clients reported encountering from family planning providers. Changing these
types of entrenched provider biases will not be easy, and developing and testing provider education,
supervision, and other interventions will need to be part of a family planning QI programme. A recent study by
Solo and Festin highlighted similar issues of provider bias in family planning services in multiple countries and
recommended several ways to address it, including values clarification training, providing regular evidence-
based accurate information, identifying and using early adopters, promoting doing good, not just avoiding harm,
promoting justice for all clients, and supporting rather than blaming health workers.28 Further study is needed
regarding which of these interventions or others may be most effective in the Philippines.

Level Off the Understanding of Quality Concepts and Roles. Our findings point to the need for levelling off
understanding of the terminology and providers' roles for developing a family planning QI programme. This
includes differentiating major concepts like QC, QA, QI, and CQI. We found that different types of providers
and clients often used the same terms to mean quite different things. Due to high case workloads and multi-
tasking, there was also some blurring of the perceived roles and functions among the front-line providers for
promoting QC. Levelling off concepts and roles is imperative at the start of a family planning QI programme,
along with training and coaching on how data can be used to improve QC.
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

Involve Men More Actively. Family planning programs focus mainly on women since they carry the burden of
pregnancy and childbirth. This study has once again indicated the importance of male partners in women's and
adolescents' decisions to start (or stop) family planning. Potential champions among male partners need to be
identified and trained so that men can have more active roles as advocates for family planning in activities like
the Usapang Barako (male talks). Some male partners accompany their wives to health centre visits, so those
occasions can be an opportunity for providers to enhance the male partners' knowledge of family planning and
as a vehicle for promoting male peer support.

Design New Digital Communication Strategies for Reaching Clients and Potential Clients. Use of digital
technology (i.e., mobile phones and social media) for communication, recreation, and information has greatly
increased in recent years for people from practically all walks of life in the Philippines. This study found that
there is a need to provide more accessible and confidential sources of accurate medical information for women
and girls about family planning options, their safety, and their side effects. Many respondents indicated that the
Internet and social media were widely used by family planning clients and potential clients as sources of family
planning information and for many other purposes. Because both local communities in the Philippines and the
digital world are awash with rumours and misinformation about family planning, it is imperative for a family
planning QI programme to design and disseminate a website where the public can access links to accurate
information about the range of family planning methods, the locations they can be accessed in public and
private facilities, frequently asked questions on reported side effects, issues of safety and effectiveness, the
many myths and misinformation about family planning, and the ‘Do's and Don'ts’ to guide choices and
decision-making. Web links may present the best strategy for unmarried and adolescent family planning clients
and potential clients to efficiently access information without embarrassment or fear of being judged and
gossipped about.

Explore Collaborations with Private Sector Pharmacies. Another mechanism worth exploring is partnering with
private pharmacies for delivering family planning services. We found that female adult and adolescent clients
and their male partners often obtain the contraceptive commodities including pills and condoms from a
pharmacy. Because these stores have stable supplies of contraceptive commodities by selling them for
affordable prices, they have become an alternative source of contraceptives for users who do not obtain free
supplies from a public health centre or hospital. Since pharmacies are ubiquitously present in all communities, a
role can be developed for them in family planning QI. The pharmacy could designate and train a focal person in
the store to be oriented about the programme, to deal with family planning customers in a welcoming and
helpful manner (much like the current pharmacy practice of assigning someone to attend to senior citizens), to
answer questions pertinent to family planning products being sold in the store, to distribute printed family
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

planning briefs or flyers, and to publicise and promote the website included in the digital family planning
communications strategy.

Our study was guided by existing family planning QC guidelines and frameworks but focused on aiding
development of a pilot QI programme in the Philippines. As a result, we did not focus equally on the elements
of existing frameworks, such as the well-established one developed initially by Bruce and recently revised and
expanded by Jain and Hardee.4 Our study touched on most of the structure and process elements of that
framework, including choice of methods, availability of trained providers, privacy, constellation of services,
appropriate information exchange with clients, and interpersonal relations, but we emphasised investigating the
perspectives of the key stakeholders in the Philippines that can help or hinder the development and
implementation of effective and sustainable QI programs.

5 LIMITATIONS

Several limitations of this study must also be noted. First, the study focused on qualitative research in one
country, due to our focus on improving the quality of family planning in the Philippines. Other studies may
want to expand this work to other countries to learn if these results are generalisable. Second, within the
Philippines, we focused our qualitative data collection mainly in one province, Batangas, due to the goal of
using the results of this study to inform development of a pilot QI programme there. Other studies may want to
include more qualitative data collection in other provinces to learn if the results may differ. Third, we were
unable to recruit respondents from two of our initial target groups, adult female clients with no children and
adult female potential clients with one or more children, due to budget limitations. Other studies may want to
devote more resources to recruiting respondents from those groups to complement the other types of adult
female clients and adult female potential clients who were included in this study.

6 CONCLUSIONS

This qualitative study documented how QC for family planning services is defined by providers, clients, and
potential clients in the Philippines, identified factors affecting QC, and investigated a range of challenges and
opportunities for improving QC. This is the first study in the Philippines with a wide range of different types of
respondents to gain a more comprehensive perspective on QC for family planning.

The findings from this study can guide the development of a pilot family planning QI programme in the
Philippines. The findings provide themes and practical insights for an intervention-focused theory of change on
how to improve current family planning programs, design new programs, be more responsive to the needs and
concerns of clients and potential clients and be well-accepted and sustained by providers. This can lay the
RESEARCH WHY WE SHOULD CONSIDER FAMILY PLANNING

groundwork for improving family planning outcomes and reducing teenage pregnancy rates and the unmet need
for family planning throughout the Philippines.

ACKNOWLEDGEMENTS

The authors acknowledge the resources and comments provided by Laura Nyblade and Rebecca Fluekiger. This
work was supported by the U.S. Agency for International Development under Cooperative Agreement No.
72049218CA00009. This document is made possible by the support of the American people through the United
States Agency for International Development (USAID). The authors' views expressed in this report do not
necessarily reflect the views of USAID or the United States Government.