November 2021, Volume 71, Issue 11

Research Article

Uptake, satisfaction, and quality of family planning services in Pakistan: before and during Covid-19 outbreak: Stocktaking with clients of a private sector organisation

Authors: Muhammad Ali Awan  ( Marie Stopes Society, Pakistan, AAPNA - Institute of Public Health, Jinnah Sindh Medical University, Pakistan. )
Syed Khurram Azmat  ( Marie Stopes Society, Pakistan, AAPNA - Institute of Public Health, Jinnah Sindh Medical University, Pakistan. )
Wajahat Hussain  ( Marie Stopes Society, Pakistan. )
Aftab Ahmed  ( Marie Stopes Society Pakistan, Pakistan. )
Asma Balal  ( Marie Stopes Society, Pakistan. )


Objective: To report the uptake, satisfaction, and quality of family planning services in the clients of a private sector organisation during Covid-19 in Pakistan and compare it with the situation before Covid-19 pandemic.

Methods: This paper is based on the client exit interview data collected before and then after the outbreak of Covid-19, using a structured questionnaire. Clients were chosen at the exit of the social franchise (SF) clinics, situated in rural and peri-urban areas, and beneficiaries of the outreach services delivery channel in the remote rural area. Descriptive analysis was carried out in SPSS, and frequencies and percentages were computed.

Results: All respondents were married women of reproductive age (MWRA) with an average age of 30 years, with either no or very low literacy levels. During the pandemic, overall utilization of the intrauterine contraceptive devices (IUCDs) declined, while the condom remained popular. Client satisfaction remained high in both service delivery channels during a pandemic. However, some results varied vis-à-vis the residence of the client.

Conclusion: The effect of the COVID-19 pandemic could not undermine the FP services which is evident from the method specific changing trends and its varying effects with reference to geographical locations.

Keywords: Covid-19, Family Planning, Client's satisfaction, Client Exit Interview. (JPMA 71: S-78 [Suppl. 7]; 2021)




Pakistan faces an alarming population growth rate (2.4%) with 207 million people.1 Pakistan was a signatory to the global FP2020 pledge and still is committed to controlling its population growth by increasing the contraceptive prevalence rate (CPR) to 50% from 34.2%.2,3 Federal Task Force has also been set up to monitor the population growth rate reduction from 2.4% to 1.5% by 2024 and further reduce it to 1.1% by 2030.4

However, given the scenario of Covid-19, it appears that Pakistan is likely to face a challenging situation in achieving the desired targets set through improvement in the uptake of family planning methods, leading to a reduction in the population growth rate. UNFPA predicted that the accessibility and availability of family planning services might be affected during Covid-19. The need for family planning services will increase simultaneously5 due to lockdowns, restricted social mobility, and a shortage of commodities.5,6 UNFPA's statistics predicted a 10% decline in the use of modern contraceptives, which will cause the rise of the unmet need of the additional 1,228,827 women, resulting in additional 528,065 unintended pregnancies and 222,843 unsafe abortions. If the usage of modern contraceptives is to decline to 20%, this could double the aforementioned consequences.5,7,8

Therefore, client-exit interviews were employed, one of the essential techniques that help reveal facts about uptake, satisfaction with services, quality of care, and the likelihood of continuation of the family planning services obtained. Satisfied clients are most likely to return to the health facility for future services. They are also a source of passing on positive messages to adopt family planning services to other potential clients.9-11 Several factors can influence clients' uptake, satisfaction, and continuation of family planning services. These factors can be categorized into broader socio-demographic characteristics, including education, occupation, and age of the clients; health facility-related factors including cleanliness, the convenience of opening hours, waiting time; interpersonal factors including knowledge, attitudes, and side effect history; and client-provider factors including privacy at the service outlet, and counseling.10-13

The family planning sector of Pakistan faces significant challenges while addressing the clients' needs. Clients often come up with several issues such as receiving poor quality of family planning services, ranging from inappropriate behaviour of service providers, shortage of stocks, to inadequate counseling that negatively influences the uptake of family planning services. Resultantly, Pakistan has not achieved the desired objectives set for population control;14,15 moreover, it seems an uphill task to achieve the targets set for the next decade. Therefore, through this manuscript, an attempt has been made to provide an understanding of the situation of family planning about the quality-of-service delivery, uptake of family planning methods, and clients' satisfaction before and during Covid-19; anticipating that this piece of evidence might be helpful for the future action plan of the country.

Marie Stopes Society (MSS), a non-governmental organization, addresses the family planning needs of a diverse population in rural and peri-urban areas, through a Social Franchise (SF) network of clinics (branded as Suraj, meaning "Sun") with a network of over 400 mid-level private service providers and through outreach camps.

An exit interview survey is a practical approach to assess the uptake of family planning methods, the quality of services, and clients' satisfaction. However, since the family planning service delivery got interrupted during the pandemic, it is essential to cross-examine the data of the client exit interviews for both years, i.e., 2019 and 2020. The study's overall objective is to report the uptake, satisfaction, and quality of FP services during Covid-19 in Pakistan and compare it to the situation before Covid-19.




Cross-sectional facility-based client exit interviews were conducted in selected districts of Sindh, Punjab, and Khyber Pakhtunkhwa provinces of Pakistan. Data collection took place between April and May 2019 and June and July 2020. A total of 1644 clients receiving FP services were selected for interview in 2019 (pre-pandemic period), comprising 1423 clients interviewed at 60 Suraj SF facilities while 221 clients at the 15 outreach camps. Likewise, a total of 1040 clients receiving FP services were interviewed in 2020 (during the pandemic), comprising 757 clients interviewed at 60 Suraj SF facilities while 283 clients at the 15 outreach camps.

A structured questionnaire was used for data collection, which covered: a) Socio-demographic characteristics of clients, b) Poverty, c) Service utilization, d) Method choice. e) Communication channels and sources of information, f) Quality of care, g) Client satisfaction, etc. However, the data presented in this paper is mainly on client satisfaction and quality of care.

Written informed consent was obtained from all study participants using a standard consent form at the beginning of the interview. The participants were assured that their information would be kept confidential, and only relevant people will have access to identifier information. All interviews took place in privacy at the service providers' clinic. Ethical approval for this study was provided by the Institutional Review Board of Research and Development Solutions, Islamabad, Pakistan, in December 2020, with IRB approval number IRB00010843.

The quality of the data was of prime importance for accurate, reliable, and valid results; therefore, an independent agency was hired for data collection. The agency trained all enumerators, and the data was collected using Computer Assisted Personal Interviewing (CAPI) programme. The ODK Collect v1.20.0 was used to develop the questionnaire. Data logical checks were applied to the programme to minimize errors and omissions, and the completed questionnaires were transferred to the central server at the end of the day, where all data was stored. Final data were exported to SPSS v17 for analysis. A descriptive data analysis was done; frequencies were run for categorical data.




All the respondents of this study were married women of reproductive age (MWRA), in which a majority (about 60%) of the clients of the Suraj Social Franchises were aged 30 years and above. Similarly, in the outreach service camps, half of the clients were aged 30 and above. Every second client had no educational background, while every third client had studied till grade 5 only.

The comparative analysis, before and during the pandemic, of family planning service utilization indicates that the trends for the usage of IUCD reduced from 38.4% in 2019 to 33.7% in 2020. However, every second client (51.4%) opted for a condom as a family planning method in 2020, compared to 2019 when every fourth client (25.5%) used a condom. Similarly, a slight increase (18.6%) was also observed in the utilization of injectable as a family planning method in 2020 compared to trends captured for the same method in 2019 (15.7%). For details, refer to Table-1.

A similar trend was observed in the outreach camps, where the utilization of IUCD decreased from 56.1% in 2019 to 35% in 2020. Similarly, injectable use dropped from 12.2% in 2019 to 10.2% during the pandemic in 2020. Nevertheless, the prevalence of male condoms was reported at 21.3% in 2019, and it jumped to 74.9% in 2020 (Table-2), which is consistent with the findings coming from the areas of Suraj Social Franchises.

Clients' choice and preference to receive modern FP methods from MSS-associated SF clinics increased from 45.9% in 2019 to 51.3% in 2020. However, the proportion of the clients visiting the service provider for first-time family planning services decreased from 29% in 2019 to 17% in 2020. Likewise, the proportion of clients who used modern contraceptive family planning methods from MSS's operated outreach camps increased from 20.8% in 2019 to 24.2% in 2020. However, the proportion of the clients visiting the outreach camp for first-time utilization of family planning services significantly decreased from 44% in 2019 to 10% in 2020.

Quality of Care: Overall, clients' expectations increased for the quality-of-care indicators during the pandemic. For instance, in 2019, 83% of SF clients reported receiving information on side effect management, compared to the post-pandemic period in 2020, i.e., 81%. Similarly, in 2019, 83% of the SF clients affirmed that service providers gave due information and counseling on all methods and services they could receive. In 2020, the same variable trends were reported around 80%. Among the outreach clients in 2019, 87.7% said they were provided information on the side effect management, while in 2020, a similar trend was observed for the same variable, i.e., 85.2%. Similarly, in 2019, 78.7% of the outreach clients reported that service providers gave due information and counseling on all methods and services they could receive, while in 2020 for the same variable trends were reported at 75.3%.

Among the clients of SF, the percentages for most of the indicators such as waiting time at the facility, its opening hours, clients counseling, treating clients with respect, and satisfaction with price were reported to be 90% and above, both before and during Covid-19. At the same time, the overall client satisfaction remained above 90% before and during the pandemic.

In remote rural areas served by outreach camps, percentages for most of the indicators such as waiting time at the facility, its opening hours, clients counseling, treating clients with respect, and satisfaction with price were reported to be about 89% and above, prior to and during Covid-19 (Table-3).

At the same time, the overall client satisfaction remained above 90% before and during the pandemic.

The reason and purpose for choosing MSS's Services was analysed. It was observed that the trend for using family planning services from the NGO clinics reduced from 60.5% in 2019 to 36.6% in 2020. Before the onset of the outbreak (i.e., in 2019), 9.7% of clients consulted MSS affiliated clinics citing low cost, while in 2020 (during Covid-19), this percentage increased to 24.7%. Although in outreach camps, a slight increase was observed from 55.2% in 2019 to 56.2% in 2020 for the FP service clients. A significant increase from 5.9% (2019) to 14.1% (2020) was noted for the clients who offered FP service from outreach camp because of its low cost.

Data gathered from the Suraj Social Franchises areas reveals that the social franchise service provider influenced 15.9% of the clients in 2019 in their decision about family planning uptake. It reduced to 5% in 2020. Similarly, in 2019, 22.5% and 8.5% of clients were influenced by LHW and LHV, while, in 2020, it fell to 2.2% and 1.2%, respectively. As for MSS's FHEs, it was increased from 17.5%, in 2019, to 74.1% in 2020 to influence clients for uptake of family planning services. Likewise, data gathered from the clients who attended outreach camp shows that the MSS social franchise service provider influenced 5% of the clients, increasing to 9.9% in 2020. At the same time, LHVs influence on clients for FP uptake reduced from 15.8% in 2019 to 3.9% in 2020. While, the same for LHWs dropped from 33.5% in 2019 to 24.4% in 2020, respectively. Significantly, Traditional Birth Attendants (TBA) influenced the decision of 23.3% of the clients to uptake family planning methods in 2020, as opposed to only 6.8% in 2019.

The survey data from the SF areas reveal that television was the most common type of media accessed by 55.6% of clients in 2019, and it decreased to 53% in 2020. Similar declining trends were observed for radio from 5.9% in 2019 to 2.1% in 2020. While increasing trends were observed for the internet from 1.6% in 2019 to 4.4% in 2020 and social media from 2.0% in 2019 to 5.7% in 2020. Similarly, the clients who visited the outreach camp reported television as the most common type of media in their area, as the access to television increased from 37.5% in 2019 to 49.5% in 2020. However, usage for radio significantly declined from 10.9% in 2019 to only 0.7% in 2020.




The data from our study shows that during the pandemic in 2020, the overall usage of IUCD declined notably in remote rural areas. Similar declining trends of IUCD use in Sindh were reported in the contracted-out public health facilities.6 However, male condoms remained the most prominent FP method during the pandemic, mainly among the clients of the remote rural areas. These trends can be linked to the fact that people are most likely afraid of close contact and apprehension of contracting Covid-19.16,17 The same is valid with service providers, who avoided longer consultations with clients due to the high risk of infection transmission.7,18,19

Moreover, the IUCD insertion takes longer and increases the vulnerability to contracting the viral infection than receiving a male condom.20 Similar declining trends were observed for the first-time users/adopters of the modern family planning methods in SF and outreach service delivery channels In addition, people living in peri-urban areas have been subjected to strict lockdowns and social distancing, inhibiting their access to FP services.21 The outreach FP camps were executed per the convenience of remote rural clients, where mobility was not an issue for them to access the FP services. In Pakistan, the response to Covid-19 negatively affected the delivery of family planning services, such as the suspension of lady health workers' homes services22 due to their engagement in Covid-19 related activities. Similarly, the closure of outdoor patient departments of health facilities3 negatively affected FP services. Hence, the decreasing trend of LHVs and LHWs' influence on FP users is reflected in our results.

A timely response to the FP service delivery gap came from developing the capacities of the service providers who were a part of the SF network by providing them with necessary supplies, enabling IP protocols, and ensuring that SOPs are in place. Moreover, the outreach camps also addressed the services accessibility issue during the pandemic. This fact reported in our study concurred with other studies conducted in Tanzania and Port Said city.23,24

Furthermore, our findings on overall user satisfaction are consistent with two separate studies that tested both service delivery models such as Suraj social franchise clinics25 and outreach services.26 The studies also cited user satisfaction as very high and indicative of good service quality provided to users. Therefore, improving FP services uptake needs a system's approach,27 which has worked in this NGO's model. Furthermore, client flow remained persistent in the franchised clinics because of low cost, which is in concordance with the model found in Ethiopia.28




Covid-19 significantly impacted the uptake of family planning methods. Among people regarding their choice of FP method, geographical access, and history of family planning. Therefore, it is essential to adopt mitigation strategies per type of FP clients, their needs, and their limited access due to mobility restrictions.




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