Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh

Background Low rates of contraceptive continuation in Bangladesh are a symptom of poor quality family planning (FP) counseling. Improving family planning counseling by the country's community health care workers (CHWs) could improve contraceptive continuation. This study explores client experiences of care from CHWs, as measured by the method information index plus (MII+) and communication quality metric. Methods Conducted in a peri-urban sub-district with low contraceptive use rates, this mixed methods study explores FP client experiences with community-based counseling and referrals by Family Welfare Assistants (FWAs), a CHW cadre providing FP services. Client- and patient-reported experience with community FP services was measured by the MII+ and communication quality metric. A quantitative post-service exit survey was coupled with observations of the interactions between 62 FWAs and 692 female clients to measure FWA and client FP knowledge, FWA capacities, attitudes, quality of FP communication, FP referrals, and contraceptive uptake. Results Summary MII+ scores suggest that only 20% of clients reported adequate provision of information for informed decisions. Observations and self-reporting alike suggest moderate to high quality of communication during FWA and client interactions. Despite FWAs' theoretical knowledge of long-acting reversible and permanent FP methods, few clients were referred to facilities for them; 81% of clients who preferred a pill received it, while only 34% of clients seeking long-acting methods received needed referrals. Conclusions Quality community-based FP counseling could help address rising contraceptive discontinuation rates in Bangladesh. While MII and MII+ scores in this study were low, and FWA evinced numerous misconceptions, FWAs demonstrated strong communication skills that facilitate rapport and trust with their clients and communities. Bangladesh's policy and programs should capitalize upon these relationships and enhance CHWs' knowledge of all method types, and side effects management, with updated job aids, refresher training, and supervision.