Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation

Study setting

We selected India and Kenya as study sites because of their long-running PPFP programs, which provided us a unique opportunity to evaluate provider and client experiences from different PPFP program models. The study was conducted in two of the 29 states in India (Jharkhand and Bihar), and two of the 47 counties in Kenya. (Embu and Siaya).

PPFP integration programs began in five states in India in 2010 and provided support for introducing PPFP counseling during antenatal care (ANC) and reorganizing intrapartum and immediate postpartum care to offer postpartum intrauterine device (PPIUD) services immediately after birth. This integration of services built upon the rise in institutional deliveries following the Janani Suraksha Yojana (JSY) incentive scheme established in 2005. Jharkhand was among the first five states to initiate PPFP services. Hospital providers received both a 3-day training on clinical services for PPIUD as well as a 2-day training in PPFP counseling. Hospitals also received tools and job aids to support counseling, services and data management, and program staff offered supportive supervisions visits jointly with health authorities. Programs replicated the same approach as in Jharkhand in Bihar, India, starting in 2012, but added community outreach and messaging on birth spacing and PPFP during home visits through a 1-day training of Accredited Social Health Activists (ASHAs) and auxiliary nurse midwives on family planning methods and key PPFP messages. Subsequent to experiences in the first states, PPFP continued to expand across India. Furthermore, the government created a dedicated PPFP counselor position and opened an initial 1,300 posts. The 2013 reproductive, maternal, newborn and child and adolescent health (RMNCH+A) strategy incorporated PPFP to make services available across India, but renamed the counselors as RMNCH+A counselors.

In Kenya, PPFP programs began on a small scale in Embu from 2006 to 2010 as part of a pilot study, and then through a Ministry of Health sanctioned training on integrated maternal and newborn and family planning training. This training consisted of an orientation on PPFP for providers in facilities with a high volume of deliveries, followed by a 5-day clinical training in PPIUD and infection prevention for nurse-midwives. Community health workers also received a 2-day orientation on PPFP. Program staff worked with county officials to offer supportive supervision and to identify PPFP “champions” to support postnatal care and PPFP. Meanwhile at national level, the 2009–2015 National Reproductive Health Strategy included the integration of family planning into other reproductive health services as a key approach for improving access to comprehensive reproductive health services. The National Family Planning Guidelines for Service Providers 2010 specifies the postpartum timing for initiating various contraceptive methods. In 2012, a program in Siaya, Kenya, used a multidisciplinary approach to demonstrate integration of family planning and maternal, infant, young child nutrition (FP/MIYCN) into antenatal, intrapartum, postnatal, and early childhood care services at facility- and community-levels. A baseline assessment informed this demonstration project and the development of materials, followed by capacity building of facility providers, community health volunteers on how to counsel on family planning and nutrition, integrate FP/MIYCN in all service delivery areas (maternity, maternal and child health/family planning, outpatient department) and manage program data. Bondo subcounty- (formally referred to as a district) was the only subcounty- out of six in Siaya where PPFP and nutrition services had been integrated thus through the time of the study. Unlike the other three locations, the Bondo facilities did not offer PPIUD as an option immediately after birth. At the sub-county hospital, FP/MIYCN training took place onsite for three days along with a one-day whole-site orientation, while health center providers underwent five days of training with clinical practice.

Sampling and data collection

In consultation with local health authorities, we purposively selected 15 health facilities in the two countries: six public health facilities from Bondo subcounty in Kenya and three facilities each from Embu county in Kenya, and Jharkhand and Bihar states in India. In India, the facilities were chosen based on health officials’ assessment of high performance, given the study objective to learn about what works to integrate PPFP. In Embu, Kenya, the health facilities were selected based on both performance and ease of access. There were six public facilities included in Bondo to capture all facility types participating in the nutrition and PPFP integration program. We published a separate manuscript on the family planning and nutrition integration experience from Bondo subcounty¹⁷. Data collection methods in this study included a client flow analysis (Dataset 1, published elsewhere^18,19); surveys of MNCH clients (Dataset 2) and providers (Dataset 3), and in-depth interviews with local authorities, facility management and health care providers. A convenience sampling approach was used for provider surveys and interviews. The number of participants at each facility was determined by the number of PPFP providers expected to be on duty, not a sample size/power calculation or content saturation.

The study teams obtained letters of support from state- or county-level officials, alerted facilities ahead of arrival, then met with the person in charge for briefing and identification of providers available at the facility. Providers on duty on the day of interviews were approached for interviews or surveys. A study information sheet was posted at each facility and provided to in-charge and anyone else upon request.

MNCH service provider and client surveys were conducted at all 15 health facilities. At each facility, the number of providers surveyed using the structured questionnaire varied between one and four depending on the number of clinical staff at a facility and types of services provided. We collected data on the proportion of consultations that include PPFP counseling as well as their perceptions on PPFP services they provided.

With regard to clients, we surveyed a sample of pregnant women and mothers of children under age 2 years attending maternal or child health services to determine whether they received PPFP counseling during their visit on the day of the survey. For the client survey, the number of respondents sampled was designed to provide a study power of 80% to estimate ±10% with 95% confidence, in the estimation of the proportion of clients receiving integrated PPFP services. Clients responded to questions about wait time before consultation with a service provider, privacy during consultations (audio and visual), comfort discussing private/sensitive health matters, perceptions of service providers’ behavior towards them, and the availability of medications and FP commodities. Surveys were conducted using tablets loaded with CommCare software (CommCare v.2.11.0, Dimagi Inc.); it took 1–3 days to complete the surveys at each health facility. In India, service provider and client surveys were conducted in either Hindi or English depending on a respondent’s preference. In Kenya, all service provider surveys were conducted in English whereas client surveys were conducted in English, Swahili, or Luo, depending on the respondent’s preference. Surveys are available on Open Science Framework²⁰.

Client flow analysis was conducted at two facilities in each Indian state and in three facilities in each county in Kenya; five facilities with low client loads were excluded. Client flow tools were modified from a tool used previously to assess integration of HIV and sexual and reproductive health services²¹. On days of data collection, research assistants approached all women aged 18 years or older who were at the health facility seeking MNCH services (ANC, postnatal, well-, or sick-child care), screened those who were willing to participate and consented those who met study eligibility criteria. Those who were pregnant and/or had a child under 2 years old and consented to participate were asked to carry a client-flow form which was completed by service providers at various service delivery points during the visit. Women in active labor were excluded since we could not expect them to keep track of providers caring for them and the form during childbirth. The client-flow form allowed up to five healthcare workers to check off services provided on a standard list of possible services and note any referral recommendations. The client-flow forms were collected at the point where each client exited the health facility.

Semi-structured, key informant interviews were conducted with local health authorities (district or sub-county officials), facility management and service providers to understand perceived benefits of PPFP integration, challenges in implementing integrated services, and the institutionalization of integrated services in the health system. In India, experienced qualitative interviewers from the International Institute of Health Management Research (IIHMR) conducted interviews. In Kenya, two independent consultants were hired and trained to conduct interviews. Key informants were selected on the basis of their involvement in supervising MNCH and PPFP services in the selected facilities. Each service provider was interviewed only once either as a facility health in-charge or about the PPFP services they provided. Providers were asked which service delivery unit they worked in (ANC, labor and delivery, postnatal care and/or child health). They were also asked to pick one of those units which they spend more time in and to answer subsequent questions about their work in that unit. At each site, qualitative researchers conducted interviews in a single day using structured interview guides designed specifically for each type of respondent: key informant, in-charge, or provider. Key informants and in-charges had to have a role in overseeing MNCH services in the facility including integration of PPFP. Service provider interviews were conducted in either Hindi or English in India, and solely in English in Kenya. Interviews lasted between 30 and 60 minutes and were conducted in private. While the study team discussed the concept of saturation with data collectors, they completed the number of interviews assigned, with no overlap between quantitative survey and qualitative interview respondents. All interviews were recorded, transcribed, and, if necessary, translated to English prior to analysis.

A total of 215 MNCH clients and 39 health care providers were surveyed, and 10 key informants and 33 facility informants interviewed, across the four study sites (Table 1).

Data management and analysis

Quantitative data analysis. Research assistants entered quantitative data from client and provider surveys into REDCap, version v6.0.1., a web-based software for data capture and management. Descriptive analysis was conducted using SPSS Statistics (version 22) and Stata (version 12). The investigators carried out frequency distributions and cross-tabulations and reported the outputs in percentages. No statistical testing was done.

FP integration and qualitative data analysis. We analyzed qualitative data using a grounded theory approach. Interview scripts were read iteratively and open/conceptual codes generated. We conducted the FP integration analysis in three phases. The first phase comprised of four steps, as follows: Step 1: quantitative data from client surveys, health worker surveys, and client-flow analysis by facility were collated using Microsoft Excel. We excluded two facilities from Kenya where we did not collect client flow data because they had fewer than five client respondents per service area. Step 2: three research team members separately analyzed the collated client and provider survey data to generate independent assessments of the level of PPFP integration within maternal and child health services, to develop an approach similar to previous studies^22,23. However, wide variation in levels of integration across service areas at many facilities, made it difficult to come to agreement about the overall level of integration in each facility. To address disagreements between the independent assessment of level of integration, we further disaggregated data by service area within each facility (ANC, Labor and Delivery, PNC, Child Health) and jointly analyzed the level of PPFP integration within each service area of each facility. In only two facilities were women having given birth in that visit interviewed. For each facility, analysis included the number of clients interviewed at the unit they initially sought care from (ANC, PNC or child health), and the percentage that indicated PPFP was discussed. Step 3: the number of providers surveyed, and their responses to the question as to how many among the last 10 clients seen in their ‘primary’ unit to whom they provided PPFP counseling or services (range 0–10). Step 4: client flow data were considered, specifically the number of clients who indicated that the purpose of the visit was ANC, labor and delivery, PNC or immunization/child health, as well as the number where the provider ticked having offered FP counseling or provision of a method. Box 1 provides further details about the specific survey used for this analysis and explains how the three researchers compiled the data for analysis.

Similar to previous studies^22,23, we used an ordinal scoring system to characterize the level of service integration, where 1 = low levels of integration (0-29% of MNCH client visits included PPFP and survey data suggested little integration), 2 = moderate levels of integration (30–59% of visits included PPFP and survey data suggested some integration), and 3 = high levels of integration (60–100% of visits included PPFP and survey data suggested integration). In cases where there was not concordance between client flow and interview data, we relied on the client flow data as a more robust source. Independent rankings were then reviewed by all three researchers, although at that point the analysis relied on scores so the discussion focused more on whether there was sufficient data to determine an integration level. We set a minimum of 5 clients responses. There was insufficient data to consistently analyze level of PPFP integration in PNC and child health services. We thus used the levels of integration in ANC to disaggregate health facilities with high and moderate levels of integration and grouped these as well integrated (shown in bold text in Table 2) and those with low-levels of integration we termed poorly integrated (shown in non-bold text in Table 2). The decision to group the middle tier of integration as “well integrated” was made on the assumption that this integration was unlikely to be by chance, but as a result of the program having some effect.

The second phase of analysis involved reviewing the semi-structured interview transcripts to identify factors enabling and limiting integration of PPFP services at each facility and coded the text using a combination of thematic and free-coding in ATLAS.ti 7.5 (Scientific Software Development GmbH, Berlin, Germany). We reviewed qualitative findings across sites to identify characteristics common to well-integrated facilities separately from those that were poorly integrated.

In the third phase, we analyzed antenatal care client reports of privacy, interactions with staff, and waiting times to compare experiences at well-integrated and poorly integrated facilities by calculating percentages per site. We did not use the same approach for postnatal care or child health clients because of the small numbers of these respondents. To synthesize findings, we triangulated analyses described above, and examined trends in client, provider and management experiences at well-integrated and poorly integrated facilities in each study county, country, and overall.

Ethical considerations

The study was approved by the Johns Hopkins School of Public Health institution review board (No 5517), IIHMR’s Institutional Review Board in India, and the Kenya Medical Research Institute (KEMRI) Ethical Review Committee in Kenya. All participants provided oral informed consent, in accordance with approved research protocols, in order to avoid collecting personal identifiers for study participants.

Phase 1: Levels of service integration

Table 2 shows the level of PPFP integration across groupings of MNCH services at each facility: 1) within maternal health services (ANC or labor/delivery) and 2) within child health services (postnatal and well- or sick- child care services). Of the 13 facilities examined, only two (one from Kenya and one from India) were deemed to have a high level of integration in both groupings of MNCH services. There were six facilities (three from Kenya and three from India) that demonstrated a high level of service integration in either maternal health or child health services.

Because some determinants of integration may be a function of contextual factors, it is reasonable to expect facilities within the same national or subnational health system to be more similar to each other than to facilities in other areas. Our analysis revealed some similarities in levels of integration by facility type and service area, but scores were not consistent enough to draw strong conclusions about overall levels of integration achieved in all study sites. For example, in Jharkhand, India, PPFP appeared to be well integrated in maternal health services, but only one of three facilities had integrated PPFP in child health services. Health centers in Bondo, Kenya, integrated PPFP in child health services relatively well and performed better than the larger health facility that supports them (the sub-county hospital). Health facilities (a hospital and two health centers) in Embu, Kenya, showed the lowest degree of PPFP integration, while facilities in Bihar, India, showed the most variation between well- and poorly integrated services. Analysis was also limited by imbalance in the number of clients surveyed at each facility. It is worth noting that the number of clients surveyed at well-integrated facilities in India was about four times greater than at poorly integrated facilities.

Phase 2: Factors influencing success of service integration

Although levels of integration varied by service area and health facility, common themes were expressed in semi-structured interviews at both well-integrated and poorly integrated facilities. The themes were related to the importance of: (1) dedicating appropriate space for PPFP services, (2) considering health workforce composition, capacity, and motivation, and (3) ensuring consistent and affordable supply of a range of contraceptive methods. The influence of these factors on the level of PPFP integration were also evident in findings from provider and client surveys.

Appropriate space for PPFP services. Space provisions, including appropriate spaces for PPIUD insertion, were frequently mentioned as factors enabling PPFP integration. Highly integrated facilities were more likely to have dedicated spaces for PPFP counseling, which may or may not be separate rooms but provide privacy and space for client and counselor. However, our findings also show that a dedicated space for PPFP services alone is not sufficient for successful integration of services, and that not all dedicated spaces adequately meet provider needs:

In addition to not having dedicated spaces for PPFP services, poorly integrated facilities were characterized by chaotic environments:

Additional infrastructure issues, such as the physical layout of a facility, may pose challenges to effective integration of PPFP services. Data collection team members shared that one Bihar facility layout required clients to navigate complicated pathways to various units; this facility was independently ranked as being poorly integrated.

Health workforce composition, capacity, and motivation. Having a dedicated, well-trained PPFP counselor on staff was another factor identified as contributing to successful integration of services, as it increases the likelihood that clients will have their PPFP needs addressed in the same visit. As an in-charge of a well-integrated Jharkhand facility explained, “We have the counselor here specifically for counseling, and she is able to give enough time.” Well-integrated facilities were also more likely to have motivated staff willing and able to take on additional responsibilities. One Bihar provider at a well-integrated site noted, “I have learned by hearing others. And I made my mind that [counseling] is my responsibility, and I have to do it.”

Staffing and wait time are often linked in provider statements, but providers who are motivated to implement integrated services may portray the issue differently. For example, a service provider from a well-integrated facility noted:

Poorly integrated facilities were often staffed by individuals either unable or unwilling to take on responsibilities beyond what they saw as their traditional job tasks. In many cases, the facilities ascribed this to shortages of health workers, especially in rural and remote areas. A nurse in a poorly integrated site in Bihar, India, explained that at the facility where she works, “No one fulfills his/her responsibilities appropriately due to scarcity of staff.” Additionally, service providers in Embu echoed this constraint, explaining that the integration of PPFP counseling has increased wait times for clients, generating complaints that negatively impact job satisfaction. As one Bondo In-charge explained, “If the staffing improves, then I think the services will also improve more because sometimes someone may not have all time…like now you see [a family planning patient] is waiting for you…so sometimes one may be tempted to move faster than it should be and that may compromise the service.”

A related but distinct issue around staffing relates to provider training and preparation to offer integrated services. As a manager in a poorly integrated facility in Embu, Kenya, explained, “What we needed most was training of which we still need up to now. As you have heard, we had one person trained on PPIUD who now left, so we would like more people to be trained.” Providers also saw training on PPFP counseling and service provision as a professional development opportunity and noted the integration of counseling in other service areas provided clients with opportunities for closer interaction with service providers, resulting in increased trust in the health system:

Although we only surveyed 17 ANC providers, responses found that higher proportions of providers in well-integrated facilities reported having knowledge and skills to provide both PPFP counseling and services, compared to providers in poorly integrated facilities.

Consistent, affordable supply of contraceptive methods. Key informants and facility staff in Kenya and India highlighted the importance of access to and affordability of contraceptive commodities. A Jharkhand facility in-charge in a well-integrated facility also mentioned the role of educational materials, recalling earlier times before a counsellor joined the staff: “We were not able to tell about the methods, and, also, we didn’t have this kit so we were not sure whether [the mother] understood about the methods or not.” Because the type of family planning supplies needed vary across service areas, it was challenging to assess differences in commodity availability within our relatively small sample of well- and poorly integrated facilities.

At some facilities, staff reported that increased demand for contraceptives generated by integrating services initially resulted in stock-outs, but, over time, they were able to establish systems to address this issue. Others reported occasional stock-outs or little information on availability of commodities. Facilities with mid to high levels of PPFP integration tended to have a well-functioning supply chain management system while some poorly integrated facilities did not monitor their supply levels. As a government official with oversight responsibilities for a poorly integrated facility in Bihar explained, “Yes, there have been [stock-outs] sometimes. […] I cannot tell you much about this, frankly speaking as many times our staff could not check these things.”

In some facilities, commodities may be available, but repeated travel to the facility remained a barrier to the continuum of care. For example, a manager in a poorly integrated facility in in Embu, Kenya noted “…depending on where she is coming from and her status she may not be able to afford all these journeys, so [PPIUD] saves time for everybody.”

Context matters: Additional factors affecting the success of integration efforts. In addition to the issues discussed above, two context-specific themes were raised throughout semi-structured interviews in Jharkhand and Bihar, India, as major factors affecting the success of integration efforts: provider-client power dynamics and demand-side financing programs.

In both Bihar and Jharkhand, providers articulated that they think some challenges to PPFP uptake are due to what they perceive as clients’ religious beliefs and education levels. In Jharkhand, a head nurse described the clients as “backwards,” “uncivilized,” and “uneducated.” In Bihar, providers counsel religious clients that not spacing and caring for kids is a sin against God. Providers in both Jharkhand and Bihar opined that Muslim women refuse PPFP because of their cultural beliefs, specifically citing that if a woman is operated on, she will not be placed for burial after death. Additionally, providers highlighted that how they counsel a woman is often based on the number of children the woman already has rather than the woman's expressed preferences or needs. As one counselor in Bihar (well-integrated facility) explained, “We try to motivate those for sterilization who have two children.” While these attitudes are independent from integration efforts, integration implies an increase in number of providers discussing family planning with clients and that these providers need additional guidance on the rights of family planning clients to make voluntary and autonomous decisions about contraception.

In addition, many key informants and facility staff in both states of India mentioned the effects of financial incentives, specifically the JSY conditional cash transfer program, on PPFP uptake. Incentives are frequently used in India to assist in motivating clients as well as health workers. The role of incentives varied across Bihar and Jharkhand, but respondents in all sites agreed that they are very important. In Jharkhand, an in-charge of a well-integrated facility highlights how the incentives have shifted community norms and helped motivate other clients to come: “we keep on telling one thing, so people understand and after that they tell others also. Then they are also getting money [JSY], so people come.” However, whether these incentives are in the best interest of the client is cloudy.

Semi-structured interviews conducted in Kenya did not yield as rich descriptions of factors affecting the success of service integration efforts as interviews conducted in India. However, one provider in Bondo expressed a sense of teamwork with the sub-county health management team:

This teamwork approach was also expressed by providers resolving commodity issues or coordinating with mobile teams to offer female sterilization at their facility.

Phase 3: Client experiences

All ANC clients surveyed were asked about privacy concerns if PPFP was discussed during their visit. A greater proportion of clients in Kenya than in India, reported acceptable levels of privacy (88.2% in Kenya versus 39.5% in India) and feeling comfortable discussing private/sensitive health concerns (84.7% in Kenya versus 45% in India). When comparing well-integrated and poorly integrated facilities in Kenya, the vast majority of clients at facilities in both categories reported that visual and auditory privacy were not a problem (92.7% at well-integrated facilities versus 87.3% at poorly integrated facilities). In India, by contrast, stark differences emerged between well- and poorly integrated facilities. At well-integrated facilities, the majority (69.7%) of clients reported privacy as a problem, compared with 20.0% at poorly integrated facilities, as shown in Table 3. In all sites, having concerns about visual/auditory privacy was correlated with concerns about discussing private/sensitive health concerns.

In the qualitative analysis, some providers reported that long client wait time was a disadvantage of integrating PPFP counseling with MNCH services. This concern was not highlighted as consistently by ANC clients in Kenya, where only 35.7% of clients in well-integrated facilities and 38.0% in poorly integrated facilities reported wait time as a problem. However, in India, the majority of ANC clients (66.7%) in highly integrated facilities reported wait time as a problem as compared with only 26.7% of ANC clients at poorly integrated facilities, as shown in Table 3. We note that all well-integrated facilities in Kenya were health centers, whereas all sampled India facilities were hospitals.

Underlying data

Dryad: Data from: Postpartum family planning integration with maternal, newborn, and child health services: a cross-sectional analysis of client flow patterns in India and Kenya. https://doi.org/10.5061/dryad.11313¹⁹. The base dataset for client flow data is available in SAV, DTA and CSV formats. A codebook is available in DOCX format. Data were generated in a previous study¹⁸.

Open Science Framework: PPFP Integration in India and Kenya. https://doi.org/10.17605/OSF.IO/5TFA7²⁰. The following underlying data files are available:

In addition, we collected, transcribed and translated, where appropriate, in-depth interviews (qualitative data). The study team feels it would be impossible to completely de-identify qualitative interviews. Furthermore, since the protocol approved by 3 ethical review committees (United States, India and Kenya) did not allow for sharing of qualitative data, we are not able to provide this dataset. If researchers would like to use the qualitative data, to either replicate our analysis or for other purposes, they may contact the corresponding author. They will be asked to sign a data use agreement prior to receiving any transcripts. We may also request that they obtain permission from the corresponding in-country IRBs.

Extended data

Open Science Framework: PPFP Integration in India and Kenya. https://doi.org/10.17605/OSF.IO/5TFA7²⁰. The following extended data files are available:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).