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Contraceptive prevalence is relatively high in Egypt with 56 percent of currently married women use a method according to the Egypt 2000 Demographic and Health Survey (El Zanaty and Way 2001). However, the family planning program is concerned about discontinuation rates showing that three in every 10 users stop using a method within the first 12 months of adoption. Evidence also suggests that the quality of care in Ministry of Health and Population (MOHP) clinics has improved and in many respects is quite good, yet some elements remain inadequate. A two-phase operations research study was launched in Egypt in early 2000 with the goal of demonstrating how improving the quality of client-provider interaction (CPI) could be achieved in large health care systems, specifically in relation to family planning. The study was designed to explore how CPI improvements could enhance family planning knowledge, method continuation rates, client satisfaction, and achievement of fertility goals. This study forms part of a global initiative conducted in comparable fashion in two other countries, Peru (León et al. 2003) and Uganda (Okullo et al. 2003). Research Questions The CPI study in Egypt has been designed to answer the following research questions: 1. Can measurable improvements be made in client-provider interaction by introducing practical systems-oriented, provider-oriented, and client-oriented interventions? 2. If client-provider interactions are improved, will there be measurable improvements in: (a) women's knowledge about available contraceptive choices; (b) women's satisfaction with contraception; (c) continued use of any method; (d) women's ability to obtain their preferred method (unless there is clear contraindication); (e) correct use of the chosen method; (f) prompt switching to another method; (g) women's ability to achieve their fertility goals or reproductive intentions (to delay a first birth, to space or to limit pregnancies); (h) increased numbers of new and continuing clients attending the clinic; and (i) a more diverse method mix in family planning clinics? 3. What is the impact of the intervention package on the job satisfaction of providers? 4. What are the costs of the various components of the intervention (training, technical assistance, additional monitoring, and client visits)? 5. Do the costs of carrying out family planning visits increase, and if so, by how much? Research questions (1), (3), (4) and (5) were investigated in Phase I of the study (SPAAC 2002). Research question (2) was examined through Phase II of the study (the present study) in which a cohort of new family planning acceptors was enrolled and followed-up for a period of 13 months after the index visit. Client outcomes were measured at seven and 13 months through home interviews.

This report analyzes the results of an operations research project carried out at two sites in Egypt to improve the medical care and counseling of postabortion patients. Preintervention and postintervention surveys and observations were conducted. After the introduction of vacuum aspiration under local anesthesia, the number of cases treated with dilatation and curettage under general anesthesia dropped from an average of 169 per month to 16. The majority of the remaining cases (an average of 119 per month) were treated with vacuum aspiration. Both providers' and women's knowledge about postabortion complications improved. Family planning information provided to postabortion patients increased as a result of the project's training program. The proportion of patients intending to use a contraceptive method increased by 30 percentage points due to the improved counseling. Future programs linking family planning and postabortion medical services should be prepared to improve the medical care of existing emergency health services and to add counseling services.

Adequate counseling is necessary for greater acceptance and for sustained and effective family planning use. In addition to providing technical information (e.g. side-effects), family planning counseling should include issues related to gender and sexuality that can be affected by the family planning method chosen (e.g., potential changes in sexual desire due to hormonal methods). This counseling is particularly relevant for coitus-dependent barrier methods.The Population Council studied the acceptability of including sexuality issues in family planning in Egypt, a conservative society with social restrictions around discussions of sex. The study focused on the following research questions:1. Would family planning clients in Egypt accept discussing issues of sexuality during family planning counseling? 2. Would family planning providers in Egypt accept training on gender and sexuality? 3. Would training in sexuality and gender have an impact on providers' attitudes and counseling practices, and on clients' acceptance of barrier methods?The study was conducted in six family planning clinics selected from Ministry of Health and Population and Clinical Services Improvement Project clinics. Clinics were randomly assigned to three intervention and three control clinics. Physicians and nurses/counselors in all six clinics received contraceptive update training. In addition, providers in intervention clinics received three days of training on issues of gender and sexuality as they relate to family planning use.The study design included both a descriptive and a hypothesis testing component. The descriptive component examined clients' acceptance of sexuality counseling and providers' acceptance of the sexuality training. Client acceptance of discussing issues of sexuality was assessed qualitatively using focus group discussions. Client exit interviews were also conducted with family planning clients from both intervention and control clinics to gauge their satisfaction with various aspects of providers' counseling behavior. In the exit interview, clients who received sexuality counseling were asked to indicate if they were embarrassed by the discussion they had with service providers.Provider acceptance of sexuality training was assessed through observation of providers' reactions during the course, course evaluation forms, and a provider questionnaire that was completed six weeks after the training course. The hypothesis testing component used a post-test only non equivalent control group design. The impact of sexuality training on providers' attitudes towards barrier methods and sexuality counseling was measured using multi-item indices relating to the principal features of barrier methods and dimensions of the sexuality counseling. Changes in counseling practices were measured both qualitatively and quantitatively using "mystery clients" and client exit interviews. Client acceptance of barrier methods was also measured in the two groups of clinics using client exit interviews. Three levels of acceptance were distinguis...

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In settings where abortion is legally restricted and socially sanctioned, the medical treatment of women who have had unsafe or incomplete abortions is often a willfully neglected service. Research conducted in the 1990s brought attention to the low quality of care and inhumane treatment that many patients receive as a result of this neglect. 1 The concept of postabortion care was central to this research, which highlighted three essential services for providers to offer women who seek care for an incomplete abortion: emergency medical treatment of complications, family planning counseling and services, and referral for other reproductive health care needs. By clearly positioning the problem within the health care domain-as opposed to religious, legal or social arenas-advocates of postabortion care have created a less-volatile atmosphere for research and program development.Yet, tension continues to surround activities concerned with abortion. As postabortion care programs expand out of the pilot phase and scale up their activities as elements of larger, ongoing health care programs, they test the limits of public officials' support. The literature offers little evidence of how successfully these programs have managed resistance associated with the politics of abortion and grown from pilot studies to national programs.An additional difficulty confronting postabortion programs concerns the supply of manual vacuum aspiration instruments. The overwhelming body of evidence favors the use of manual vacuum aspiration for the treatment of incomplete abortion at an early gestational age; 2 as a result, it has become the standard for postabortion care. 3 Pilot postabortion projects and small-scale expansion programs generally operate with donated instruments, because they are conducted before the commercial importation or local manufacturing of instruments receives regulatory approval. This partly reflects the sociopolitical tensions surrounding abortion-related health care, which create extraordinary pressure to demonstrate medical benefits and acceptability of new clinical practices. Attention to ensuring sustained provision of manual vacuum aspiration is generally put off until after the program has achieved a degree of success and recognition.Foundations' and donor agencies' generous donations of manual vacuum aspiration instruments have greatly eased the implementation of demonstration projects and research studies. However, the long-term viability of a program that relies on donated instruments is uncertain (at best), and a sustainable supply of instruments is crucial for a national program. In settings where access to abortion is legally restricted, it is extremely difficult to gain approval to purchase or manufacture the instruments, because of their association with abortion. Procurement decisions are frequently made by officials who are not clinicians or who are unfamiliar with the need for improved postabortion services. 4 As a result, operational policies that govern the availability of manual vacuum aspirati...