1. Introduction1.1. BackgroundFamily planning (FP) saves lives of women and children and improves the quality of life for all. It isone of the best investments that can be made to ensure the health and well-being of women, children,and communities (1) by decreasing maternal mortality and improves women’s health throughpreventing unwanted and high-risk pregnancies and reducing the need for unsafe abortions. Somecontraceptives also improve women’s health by reducing the likelihood of disease transmission andprotecting against certain cancers and health problems(2).One principal determinant of uptake and continued utilization of family planning services is overallclient satisfaction with those services(3). It is one of the factors that influences the use of FP and otherreproductive health services (4) . Women who reported having received contraceptive counseling weremore satisfied with their method.(5)World Health Organization (WHO) recommend to offer evidence-based, comprehensive contraceptiveinformation, education and counselling to ensure informed choice for all women who need theservices(6)According to Turkish Demographic health survey (DHS) 2013, 33% of all women use a moderncontraceptive method(7). United nation population fund agency (UNFPA) DHS analysis from 24countries in 2016,showed contraceptive prevalence and side effect counseling in Honduras, Senegal,Kenya and Ethiopia was 64& 49, 22&81, 53&60 and 27&33 respectively(8) which is low especiallyin EthiopiaTo increase modern contraceptive prevalence rate and decrease discontinuation rate, contraceptivecounseling is crucial. Contraceptive counseling is a type of client-provider interaction that involvestwo-way communication between a health care staff member and a client for the purpose ofconfirming or facilitating informed decision by the client, or helping the client address problems orconcerns (9)i. It also helps clients to obtain the information they need to use contraceptive methodscorrectly (10) and thereby decrease the likelihood that they will discontinue use of the method (11)and decrease unmet need of family planning.2Effective contraceptive counseling is one of the cornerstones for increasing family planningacceptance. The best decisions about family planning are those that people make for themselves basedon accurate information and a range of contraceptive options. Otherwise they can either deny theservice or discontinue the method if they are not properly counseled on minor side effects and mythsrelated to the method. It empowers people to exercise their right to good quality family planning care(12).Providing quality education, counseling and medical services related to family planning can lead toimproved reproductive health outcomes (13). Counseling clients properly during family planningservices was found to improve both long term outcomes, such as increased birth spacing and continueduse of modern contraception methods, as well as short term outcomes such as increased knowledgeand satisfaction with family planning services (14).These all facts suggest the need to reorient and refocus the contraceptive counseling to offer a tailoredapproach to meet individual needs of clients. Therefore, the study intended to examine clientsatisfaction with contraceptive counseling and client provider -interactions as related to familyplanning services and bring into focus the relevance of counseling and effective human relations tofamily planning in public health facilities in Asella town.1.2 .Statements of the problemsUnintended pregnancies and unplanned births can have serious health, economic, and socialconsequences for women and their families. One immediate outcome of unintended pregnancies—induced abortion—is unsafe in many countries .In these countries, abortion often damages women’shealth and sometimes results in their death (15). According to WHO 2010 report, nearly 99% abortiondeaths were caused by unsafe abortion secondary to unintended pregnancy(16)Unintended pregnancy is experienced by many women and remained high in all parts of the world. InUnited states for example, approximately 50% of pregnancies are unintended (17). A cross sectionalstudy conducted in Kenya in 2013 showed 24% of all the women had unintended pregnancy (18).According to Ethiopian demographic health survey (EDHS) 2016, 17% of pregnancies were mistimed(19). 3Research by Teshale Mulatu in 2014 also indicate, 50% respondents had had unwanted pregnancy andinduced abortion at some point in their livesUses of FP which is the best intervention to reduce rates ofunintended pregnancy is enhanced by contraceptive counseling.Numerous professional associations (including the American College of Obstetricians andGynecologists, American Academy of Family Physicians, and American Academy of Pediatrics)recommend counseling as part of clients service for preventing unplanned pregnancy (20).Helping women to achieve their reproductive goals, including assisting them in choosing how toprevent undesired pregnancies (contraceptive counseling), is essential to optimize the health of womenand their families (17). The role of FP counselling is to support a woman and her partner in choosingthe contraceptive that best suits them and to support them in solving any problems that may arise withthe selected method.Improving and optimizing the quality of contraceptive counseling is one approach to help women ofall race/ethnicities and socioeconomic status to improve their ability to plan pregnancies and preventthese unintended pregnancy and maternal death. In line with this, improving the quality ofcontraceptive counseling is key strategy to prevent unintended pregnancy(21).However nowadays, unintended pregnancy is not only a major health problem, but are also a greatsocial and financial burden on societies and countries. There are about 75 million unwantedpregnancies per year according to WHO statistics. When abortions were included, unintendedpregnancies increased to 49% of all pregnancies. Counseling prior contraception is a mandatory or amust to prevent these unintended pregnancies and their related risks. Unfortunately counseling is adeficient process in third world countries and sometimes not present at all. (22)Contraceptive counseling can also help in reducing unmet need of contraceptive utilization. Studydone in India in 2015 reveal receiving contraceptive counseling led to 3.1 % reduction in unmet need(12).According to research conducted in USA in 2016 entitled the role of contraceptive attributes inwomen’s contraceptive decision making, 60% of respondents discontinued contraceptive methodbecause of the side effect and it clearly play an important role in satisfaction and continuation. 4So, anticipatory counseling about method side effects can help increase the likelihood that thecharacteristics of the method and the woman’s preferences are aligned and minimize contraceptivediscontinuation (23).Causes and consequences of contraceptive discontinuation evidenced from 60 demographic and healthsurveys at three months after discontinuation reveal, 40% or more women were at risk of conception:in Egypt (40%), Ethiopia (42%), Kenya (51%), Malawi (73%), United Republic of Tanzania (56%)and Zimbabwe (47%). These high rates of discontinuation stress the need to improve service quality,particularly counselling(24).Study conducted in Egypt showed that family planning consultations in are predominantly physiciancentered and that client participation was to a large extent passive, mostly serving the doctor’s agenda,which is gathering information about the client(25)Although contraceptive counseling is acknowledged to be cornerstones for increasing acceptance anduse of family planning and addressing the unmet need, much has not been written about it by region orstate, less is known in our country specially the contraceptive counseling is not clearly known orevidenced by research still now as far as my search is concerned.Considering this gap, this study aims at identifying what client satisfaction with contraceptivecounseling and factors associated with it looks like in women attending family planning clinic inAsella public health institutions, 2018.2. Literature reviewFamily planning represents an urgent global health priority for the twenty-first century. It helpswomen and men make informed decisions about the number and spacing of their children, which makenewborn, child, maternal, and family healthy. The economic well-being of families, communities, andeven countries is improved by access and uses of FP services(26).Quality contraceptive counseling is the key interventions to promote family planning and helps toimprove the quality of care and reduce maternal deaths (12).5It is an important principle in the delivery of FP services(11) for confirming or facilitating a decisionby the client, helping the client address problems or concerns(9),improve patient outcomes(27),increase patient satisfaction, decrease contraceptive discontinuation rate and increase contraceptiveacceptance rate. It is one of the fundamental right of human being (the right to information andeducation) (28).2.1. Prevalence of contraceptive counselingContraceptive counseling is not provided for most women worldwide. Its quality and content greatlyvaries from country to country. Counseling is very important before women initiate drug for chronicdiseases. More than 45% of all Americans have chronic disease, and almost all women anticipate anunexpected illness that requires medication. These medications can be teratogenic which can affect thenewborn. This indicates as there is gap in contraceptive counseling to prevent this congenitalabnormality by using different contraceptive methods (29)According to evidence from 24 countries by UNFPA in 2016, recent changes in current use ofcontraception have not been accompanied by corresponding increases in contraceptive counselingregarding side effects and availability of other methods at the time of initiating use of moderncontraception. Thus, two of five women that started using any of the methods during the five yearsbefore the study did not receive counseling about possible side effects from the selected method, andnearly 50% did not hear about side effects or other methods (8).During contraceptive counseling, health care provider should stress on benefits of the contraceptivethan its adverse effects. But According to research in San Francisco Bay Area in 2009–2012, providersmore often discussed potential adverse effects of Intra uterine device (IUD ) use than benefits;counseling often was non interactive and did not address how patient preferences related tocharacteristics of IUDs. Counseling was frequently fragmented by the need for return visits or referralelsewhere for insertion (30). Similarly, according to qualitative descriptive study done in Pakistan in2013, IUCD was not discussed during participant’s visits, and they often had to request theinformationContraceptive counseling should be start from most effective contraceptive method and proceed to lesseffective so that the woman is encouraged to use the most effective contraceptive methods. 6Research conducted in Texas in 2014 show rates of postpartum counseling are higher, but even amongwomen who did report counseling, discussion of LARC, sterilization and vasectomy was infrequent,and very few women reported feeling encouraged to use these highly effective methods(20)A cross sectional study conducted in Northern Iran, Urmia in 2008 revealed 51.3% of participantscompletely satisfied by easiness and understandability of consultation from health care provider andonly 21.7% of participants was completely satisfied by the use of counseling tool duringconsultation(31)A result of research conducted in Ibrid Jordan in 2013 showed, 87% of respondents reported that theprovider had helped them choose a method and 70% of respondents chose a method that day. Of thosewho chose a method, 81% said that the provider had discussed how to manage the side effectsassociated with that method (32). Another research conducted in Australia in 2017 reported, doctorsdid not fully discuss the potential side-effects of contraceptives and they were unsupportive orjudgmental (33). According to research done in Egypt in 2016 ,none of the nurses introducingthemselves to clients (34).Ideally all women should be informed everything about the contraceptivethey use during counseling session. But UNFPA research analysis in 2016 from 24 countries reportedproportion of women counseled about side effects and other available contraceptive methods were25% and 80% in Ethiopia and Zambia respectively (8).Similarly in EDHS 2016, only 30% of all women currently using modern contraceptives werecounseled at the time they started the current episode of method use about the method’s side effects,what to do if they experience side effects, and other available methods(19).In addition research donein wonji hospital, Ethiopia in 2017 showed, 55% of FP users do not got the service with information(35)According to client and facility level determinants of quality of care in family planning services inEthiopia in 2017 research report, information was not provided about how to use the contraceptivemethod for 26.7% of respondents and information about the contraceptive method’s potential sideeffects was provided for only 53.6% of respondents (36).72.2. Factors associated with contraceptive counselling2.2.1. Socio demographic and client related FactorsAccording to research done in university of Pittsburgh Medical Center in 2010, the most commonperceived patient barrier for contraceptive counseling was patient preference for particularcontraceptive methods (37)Result of assessing women’s satisfaction with family planning services in Mozambique in 2016showed, user had the opportunity to ask questions in only 45.2%(4).Research conducted in University of Michigan has also shown that, women ages 40–44 were lesslikely than younger women to receive counseling and to use contraception if at risk of unintendedpregnancy (38)If a woman, preferably with her partner, is able to make an informed choice, she is more likely to besatisfied with the method chosen and continue its use(39)2.2.2. Provider related factorsResearch done in 2008 in Uganda showed almost all providers felt that the quality of care they couldoffer was compromised because they were overloaded with work, and managers confirmed someclinics were understaffed. Individual providers take on multiple responsibilities in addition to FPservices. These all compromise contraceptive counseling (40)Nurse working in a primary care facility in Kaduna, Nigeria in 2014 justified her limited counselingtime because of the number of patients she must attend to in one day and she did not talk much aboutimplants because she did not know much about it and how to insert it. She need in-service training(41)According to research in Bangladesh in 2014, though paramedics interviewed in FP clinics knew thebasic principles of counselling, their interpersonal skills were inconsistent and often poor.There remains a non-communicative, hierarchical attitude between clients and paramedics, which maycontribute to poor understanding of potential side effects and incorrect method(42).Qualitative descriptive study done in Pakistan in 2013 showed, health providers were not motivatedand were reluctant to provide the IUCDs because of inadequate counseling skills, lack of competence(43).8Results of qualitative Analysis approaches to contraceptive counseling in Texas showed, shareddecision-making approach counseling technique was the least common approach overall (accountingfor 22% of visits), but patients expressed a preference .In the same study the most common approach(used in 48% of visits) in counseling was foreclosed approach by assuming patient had already madea decision (44).According to research done in University of Colorado in 2014, the majority of faculty and residentsreported that they perceive inadequate time (75.3%) and inadequate knowledge (74.0%) as reasons fornot performing contraceptive counseling (45).According to research in Bahirdar in 2013 ,only 24-37% of respondents were informed about theavailable family planning methods and their utilization(46).Research done in wonji hospital, Ethiopia, showed, 55% of family planning users do not got theservice with information (35).According to assessment of Family Planning Services in Kenya in 2009,the most notable finding isthat only 15% of the providers used visual aids during the consultation and only 12% of staff took inservice training in any family planning topic in past year(47).2.2.3 Facility relatedAccording to research entitled “Counseling and Client Provider-Interactions as Related To FamilyPlanning Services in Nigeria in 2015, 41.18% of the facilities do not have visual and auditoryspace.61.11% do not have good client respectful orientation .Using the language the clients understandwas observed in only 23.53% of family planning centers. Interactive communication between clientsand providers was observed in 42.94% of the centers(48).Research conducted in Ibrid Jordan in 2013 showed ,family planning wall chart was noticed by 85% ofall interviewed women, 96% reported that it was useful (32).According to qualitative descriptive study conducted in Pakistan in 2013, facility had impropersupporting infrastructure(43).A cross sectional study conducted in Northern Iran, Urmia in 2008 revealed , only 21.7% ofparticipants was completely satisfied by the use of counseling tool during consultation(31).92010 Kenyan service provision assessment key finding reveal, only 25% of family planning facilitieshave all the items necessary for counselling(49)A Qualitative Study conducted in Rwanda in 2015 showed limited method choice, and long waitingtimes but short consultations at facilities were barriers to accessing high-quality services and werecommon complaints of respondents(50)2.3. Significance of the studyThere is inadequate study conducted on client satisfaction with contraceptive counseling in Ethiopia ingeneral and Asella town in particular as far as my search is concerned. Thus, this study aims to answerwhether women are satisfied with the contraceptive counseling they receive and what are theindividual correlates of satisfaction with the method. It also used as input for planning andimplementation of FP service in Asella town. Finally, this research finding will be used for universitystudents and health professionals as a reference to build on or generate new knowledge in the area ofcontraceptive counseling which ultimately improves service quality and coverage.2.4. Conceptual frameworkBased on reviewed literatures, client satisfaction with contraceptive counseling can be affected bydifferent factors. These factors can be categorized as Provider related, Facility related, Sociodemographic related interpersonal communication related and Client related. The following figure isconstructed based on reviewed literatures and shows the relationship of contraceptive counseling andassociated factors.