Understanding Quality of Contraceptive Counseling in the CHARM2 Gender-Equity Focused Family Planning Intervention: Findings from a Cluster Randomized Controlled Trial among Couples in Rural India

"Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve women's perceived quality of care."

Evidence suggests that gender-equity-focused programmes that engage men in contraceptive decision-making and address gender norms in contraceptive decision-making have the potential to improve women's reproductive agency. The Counseling Husbands to Achieve Reproductive Health and Marital Equity 2 (CHARM2) cluster randomised controlled trial (RCT) found that a gender-synchronised, gender-transformative family planning intervention for young married couples in rural India demonstrated significant improvements in women's contraceptive agency and couples' contraceptive communication at 18-month follow-up, as well as a significant effect on contraceptive use at 9-month follow-up. This paper expands the CHARM2 evaluation by assessing whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use.

In brief (see Related Summaries, below), CHARM2 (completed between 2018 and 2020) used a person-centred shared decision-making model for contraception counseling. CHARM2 was designed to engage men in, and to improve the quality of, family planning counseling using a model wherein the clinician shares medical knowledge about contraception, and the woman or couple shares their preferences, to arrive at a shared decision whether to use, or not use, contraception that is aligned with client preferences. Counseling sessions were supported by a desktop flip chart and contraceptive flash cards. Couples in the control condition were informed about local family planning services available at no cost from the public health sector but were not required to obtain contraceptive counseling or care.

This planned secondary analysis of the effect of the CHARM2 intervention on 1,201 married couples in rural Maharashtra, India, used the Interpersonal Quality of Family Planning (IQFP) scale, which consists of 11 items assessing client perceptions of interpersonal connection, receipt of adequate information, and decision support in their most recent family planning counseling. The difference-in-differences linear regression approach included a mixed-effects model with nested random effects to account for clustering.

Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, standard deviation (SD) 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). Intervention participants were nearly 3 times more likely to rate their provider highly (very good/excellent; 26% vs. 9%, p < 0.001) and were nearly 10 times less likely to rate their provider negatively (poor/fair; 6% vs. 58%, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% confidence interval (CI) 0.07-0.50). However, quality of care did not demonstrate mediation effects on contraceptive communication and contraceptive self-efficacy outcomes; these outcomes may be more attributable to engagement of men in the CHARM2 intervention rather than the quality of care women report.

The finding of low mean IQFP scores for both groups at baseline, and for the control group throughout the study, indicates the need for more person-centred counseling methods, like CHARM2, in this population. The study highlights the value of the person-centred shared decision-making approach utilised in CHARM2 to support quality of care in family planning counseling for women and that this care can increase women's uptake of contraceptive use, corresponding to prior evidence showing an association with person-centred care and contraceptive use.

Thus, according to the researchers, contraceptive interventions should focus on improving person-centred outcomes, such as quality of care, rather than contraceptive use targets, and quality of care should be a standard evaluation outcome in family-planning-related intervention research.