• Safety and effectiveness,
• Client satisfaction and, as a result, longer continuation,
• Wider use of contraception,
• Job satisfaction for providers,
• Better program reputation and competitiveness,
• Expanded access to services.

• Offer a range of methods that the program has the human, technical, and financial resources to deliver safely;
• Fully inform clients about methods, including possible side effects;
• Screen clients for medical eligibility;
• Help clients choose for themselves methods that suit their individual circumstances;
• Teach clients how to use their methods properly; and
• Support clients when they encounter problems or decide to switch methods (53, 136, 153, 210, 333, 338, 388).

Studies find that good services encourage people to continue using contraception when they want to avoid pregnancy. In China, for example, women were far more likely to continue using injectable contraceptives when they had been thoroughly counseled on how the method works and its side effects. Only 11% of women receiving good counseling had dropped out at one year compared with 42% of women receiving limited counseling (208).

In the Philippines, among family planning clients in Bukidnon Province, women were more likely to continue using their method if they thought the provider was friendly, if they were satisfied with services, and if they had been told about the advantages and side effects of several methods (321). In Bangladesh rural women were asked whether field workers serving them were responsive, sensitive to their need for privacy, dependable, sympathetic, and informative. Women who felt they received good care, as judged by their answers to these questions, were 27% more likely to adopt a family planning method and 72% more likely to continue using a method for up to 30 months than women who felt they had received poor care (195).

Other studies have found that poor care explains why some people stop using family planning. In general, research finds that poor medical care dissatisfies patients, discourages them from seeking care and returning for services, and prompts them to switch physicians (126, 183, 214). Family planning clients may discontinue their method or stop using family planning altogether:

• If use of the method is not explained and unintended pregnancy occurs (20, 71, 111, 120, 147, 152, 201, 358, 368, 369);
• If possible side effects are not explained in advance, or if side effects occur and are not taken seriously or managed appropriately (71, 111, 128, 152, 201, 208, 267, 312, 358, 368, 369, 400);
• If the program runs out of supplies (71, 152);
• If providers treat clients rudely (369);
• If clients cannot get the method they want (283).

A more recent study in Peru, however, suggests that quality of services does matter to levels of contraceptive use in an area (248, 250). Women who had told the 1996 DHS that they wanted to avoid pregnancy were asked 29 months later whether they had become pregnant (248). Unintended pregnancies were twice as common among women in areas with poor-quality services as among women in areas with adequate services—22% versus 11%. Quality was rated on a combination of eight indicators including contraceptive choice, provider bias, provider training, information to clients, and privacy.

Other studies have linked whether a person uses contraception with various specific aspects of quality of care, including the thoroughness of counseling (71, 346, 347), receiving one's preferred method (283), and the availability of services (24, 359).

More job satisfaction for providers. Providers derive greater personal and professional satisfaction from their jobs when they can offer good-quality care and can feel their work is valuable (393). For example, in Uganda both clinic- and community-based providers agreed that the most satisfying aspect of their jobs was helping people and the community recognition they received for it (150).

Giving providers the authority to solve problems and improve services, as many quality improvement methods do, raises morale (219, 242, 266). For example, projects that empowered health care workers to develop their own solutions to local problems reduced workers' absenteeism in Uganda (278) and increased staff motivation in Niger (272). In contrast, when health personnel feel that conditions prevent them from offering good quality care, they may become discouraged, and they may put most of their effort into other jobs (375).

Better program image and competitiveness. Programs that are known for good quality attract and retain clients and become competitive in service delivery. For example, 25% more pregnant women came to deliver at Kigoma Regional Hospital in Tanzania after the community recognized that the quality of maternal care had improved (233). A client of a maternal and child health (MCH) clinic in Chile summed it up simply: "You logically go where you are treated better" (376). Even where the choice of providers is limited, people can still turn to less effective traditional methods or not use family planning at all.

Programs that consistently provide good services enhance public perceptions of modern family planning and health services in general as well as their own public image. Conversely, if quality is poor, people may start to assume that serious problems are typical of contraceptive use. For example, a study in Nepal found that severe infections after sterilizations and IUD insertions were so common that villagers considered them to be a characteristic side effect of modern contraceptive methods rather than the result of poor care (341).

Ensuring access to services. Most health and family planning programs are built on the premise that people have a fundamental right to health care (371). In many countries governments are responsible for ensuring that everyone has access to health services (387). Governments also assume a regulatory responsibility to protect clients from harm caused by poor care—especially if the providers are government employees (269). Family planning associations and other nongovernmental providers also seek to assure universal access to health care (159, 160).

Quality of care is closely linked to accessibility. Ensuring access to services means making good-quality, affordable care available where and when convenient to the public. Access means more than the mere existence of a nearby health worker or facility. When a facility lacks properly trained staff, opens irregularly, suffers from supply shortages, charges high prices, or blocks care with unnecessary medical barriers, the community does not have adequate access to services (41). Improving the quality of services helps programs pursue their goal of making services universally available.