Date Published: July 25, 2019
Publisher: Public Library of Science
Author(s): Mari Nagai, Saverio Bellizzi, John Murray, Jacqueline Kitong, Esperanza I. Cabral, Howard L. Sobel, Elizabeth Ann Micks.
In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.
One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.
849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.
Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.
Unintended pregnancies remain an important public health problem worldwide. Between 2010 and 2014, there were an estimated 62 unintended pregnancies per 1000 women aged 15–44 years each year, with rates ranging from 112 in East Africa to 28 in Western Europe . In Philippines, 54% of all pregnancies (1.9 million pregnancies) are reported to be unintended and around 610 000 unsafe abortions are performed each year . Nine percent of women 15 to 19 years of age have begun child bearing .
A total of 849 non-pregnant sexually active women, 18–49 years of age, wanting to delay or limit childbearing were included in the study. Only one woman meeting the entry criteria refused to be interviewed. Of sampled women, 51.1% (434) were currently using an effective contraceptive method, 16.5% (140) a less effective contraceptive method and 32.4% (275) no contraceptive method. Of all women, 36.7% (312) were currently using short-acting effective methods (pills, patches or injectables), 8.9% (76) LARCs (IUD or implants) and 5.5% (46) female sterilization. An additional 18.2% (155/849) of women had used short-acting effective methods in the past and 2.4% (20) had used LARCs in the past. An effective method had never been used by 28.3% (240) of women (Fig 1).
Of 1664 cumulative total clinic visits reported by the women wanting to delay or limit childbearing in 2016, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility or socio-economic indicators. On the day of the interview in 2017, 83.7% of women had a missed opportunity. Although 55.9% of women reported health concerns about effective contraceptives on the day of the interview, 16% with a concern received family planning counseling and only 2.9% received counseling addressing her specific concerns. Only 0.6% of former effective contraceptive method users and 2.1% never-users said they would consider starting effective contraceptive method in the future. As relatively few facilities had stock-outs, most women in our study could have received an effective contraceptive on the day of the visit, if they had received high quality of counseling, been offered a method and had decided to use it.
As in other low- and middle-income countries, the Philippines faces substantial barriers to improving reproductive health services. This study showed that the vast majority of women who wish to delay pregnancy, attending public health clinics, did not receive family planning counseling regardless of their current status of contraceptive use or clinic attended. Over half of these women had health concerns about effective contraceptive methods which were not addressed. This striking finding means that many women in contact with the health system continue to use no contraception, use traditional and other less-effective methods or stop using contraception altogether. As a consequence, many women are put at unnecessary risk of short-spaced high-risk pregnancies and cycles of high fertility, lower educational and employment potential and poverty [49–51]. The study shows that effective contraceptive methods are generally available and that out-of-pocket expenditure was not a major barrier. Systems approaches for improving availability and quality of contraceptive counseling at all primary health care contacts are now needed. Since similar systems problems exist across low and middle-income countries, better quantification of missed opportunities to provide contraceptive counseling and barriers to use is an urgent priority .