During the focus groups with women, perceptions of quality were identified through questions that focused on points of satisfaction, dissatisfaction, and women's expectations around FP services in their community. Below, we summarize the results in two parts. First, we discuss how women’s perceptions of quality are constructed and second, we identify the aspects of services that are most closely linked to quality perceptions.

Construction of notions of family planning service quality among women

The results of the FGDs show that according to the socio-demographic profiles of women, perceptions of quality are constructed in a variety of ways. Older and married women tend to evoke their perceptions of quality from their own positive or negative experiences with services. They also refer to discussions they have had with friends or family about these experiences. Younger women and those who are single, typically have less direct experience with FP services and learn about what to expect from listening to conversations with older family members or more experienced friends. Typically, young women are learning about these experiences from their female networks that include their friends, family members, or other female community members.

In the FGDs, it was reported that FP topics are discussed in a variety of scenarios and in different locations where women often congregate among themselves. In community settings (e.g., among neighbors, at the market, or at school), the topic of contraception may be raised following discussions about unwanted pregnancies and their consequences on the household and health. It was reported that women's exchanges about FP generally focus on the advantages and disadvantages of contraception, including side effects, but also on experiences and interactions with providers and their impressions of facility-based services more generally.

FGD participants also revealed that among older women and those who are married, FP does not seem to be a taboo subject and they discussed it easily with family and friends. These exchanges take place at the market, in health centers or when women meet in women's spaces such as association meetings, hairdressing salons or friend groups.

"The women's talk does not end. And there is no fixed place to talk. At times, if you cross two or three others, you know that a conversation will start. You may be discussing something else and then this is raised. And each wants to show her knowledge to the other. Or often, there are women who every time you see her, she is pregnant. In this case, if it is an easily accessible person and you can talk to her without there being any problem, you can also explain it [FP] so that this person can rest [from pregnancy]. Because motherhood is not easy. Often also in tontine places, in women's meeting places, you may be talking and you will address this topic. That's it, there is no fixed place."

Bobo Dioulasso, married women, FP users, ages 25–49

Among younger and unmarried women who have less experience with services, exchanges about FP use and FP services take place either in the community or at school when there are discussions of an unwanted pregnancy of one of their peers or when they are looking for contraceptive methods for themselves.

“It can happen that if you see one of your peers who is pregnant and you start talking about pregnancy, it is at this time we often enter these topics. It is from these talks that we take advantage of giving each other advice so that another among us does not get pregnant too and regret it later.”

Banfora, unmarried women, non-users, ages 15–19

The young women also learn about contraception and FP services in the community by listening to older women discussing these topics either within the family or in community settings (e.g., the market).

"You can learn this [about FP] from grown-up people too, you can sit in the courtyard and experienced women talk about it so you enjoy listening. Or you might be sent on an errand and while out you hear people talking about this or by sitting with the elderly in the courtyard or in the hair salons also when you go to do your hair they talk about it [FP] and you listen.”

Banfora, unmarried women, non-users, ages 15–19

But unlike older women, young people find it difficult to discuss FP, because of the fear of social stigma of discussing it in a group. This is especially a problem for those who need contraception because they fear being perceived as having loose morals. In this case, they prefer more confidential exchanges between one or two friends.

“Married women like talking about it in groups under the shade of trees. But us young girls, we would never do that. If I tell you one-to-one that I am using family planning, you will keep quiet! It’s a secret! In town everyone knows that women use it and that young girls use it - but the young girl who will admit to it (in a group discussion) does not exist!”

Bobo Dioulasso, unmarried women, users, ages 20–24

Perceptions of quality

Overall, when women shared their views and concerns about FP services, two aspects of service delivery emerge—namely, interactions with providers and selected system-level aspects of service provision. Important components of provider interactions relate to (a) the initial reception from the provider, (b) the quality of counseling received, (c) stigma and bias from providers, and d) privacy and confidentiality. At the health system level, discussions revolved around (a) wait time; (b) stockouts of methods; (c) costs of services/methods; (d) the expectation for tests as part of service provision; and (e) difficulties with method removal. Each of these are described below as they relate to community perceptions of service quality.

Interactions with providersInitial reception from providers

Interactions between women and providers begin from the moment a woman arrives at the facility for FP care. Whether the woman experiences and/or expects positive or negative interactions with the facility staff, including the FP providers, is at the heart of perceived quality of family planning services. The nature of the initial interaction with the staff and provider was often a key aspect discussed during the FGD.

During the FGD, the majority of women across the different groups, whether discussing their own or others’ experiences, mentioned the initial interaction with the providers as crucial to forming perceptions of quality of care. This interaction, which is seen as the first contact with the provider, is essential for the construction of trust between health workers and clients of FP services. A good reception that includes being positively received was considered a sign of respect whereas a less warm welcome and poor treatment discouraged women/clients. Women perceive the mood of the provider at first contact as an important aspect of their satisfaction with the services they receive. A good welcome, according to the respondents, is generally reflected in the friendliness, the "smile," the "good words," and the warm or affectionate relationships that the providers show. For women, a good welcome gives confidence and reassures the woman and it allows her to "open up" and "explain her real problems" to the provider.

"It's like what P3 said, if you go into a health center and the provider welcomes you with a smile, you'll be happy. So you can talk about your problems transparently to the health worker.”

Bobo Dioulasso, unmarried women, users, ages 20–24

"If a person welcomes you well, at the entrance even you understand it. He welcomed me with good humor, questioned me about my problems that I explained to him. Well, he didn't make a face at me. He spoke with a smile on his face."

Banfora, married women, non-users, age 25–49

A positive reception and experience also encourages women to return to the clinic for follow-up services.

"A provider did it in such a way that I wanted to return a second time. I was doing injectables and my menstruation had stopped. I went to explain to the provider who was on duty and he prescribed pills that made my period normal. The day he saw me again in consultation, he said, "Oh then my dear, what is it like? I say it's okay. He says, " oh great!" I was very happy with the way he welcomed me."

Banfora, married women, users, age 25–49

On the other hand, a bad reception leads to negative perceptions and is often likely to discourage women from visiting providers for FP services and using FP methods.

“I've never been but there's one of my girlfriends who says she's already been to the facility ward once and she found a lady, that the lady there received her coldly, that she had a drawn face and then she couldn't do what she went to do. She went another time and she found a man who received her well so she had the courage to say what she came for.”

Banfora, unmarried women, non-users, age 20–24

Beyond the trust between service providers and clients that a good reception can create, it also reflects the respect and consideration that providers have for clients. This trust and respect encourage clients to return but also may lead to clients encouraging other women in their community to visit the FP clinic.

“Everyone loves respect. When you take courage to go do something and you are respected, it motivates you more. But when you go to find that there are insults and that the person is mostly in a bad mood, you will feel his anger, it discourages you and you go home. So you will not be able to recommend the facility to someone else - on the contrary you will devalue it in the eyes of this person. This person may refuse to go.”

Banfora, unmarried women, users, age 15–19

Quality of counseling

The majority of women in FGDs mentioned the importance of counseling, including the quality of information received during a consultation; this was often tied with a woman’s satisfaction with FP services. Many women mentioned that they view services as higher quality when the provider offers detailed information on each contraceptive method, including the benefits of each method, its potential side effects, and how to manage side effects. Notably, the women who talked about quality of counseling were typically the ones who had experience with method use.

For women, this detailed information is important because it helps to orient them on the choice of the most suitable method and prepares them to face the potential side effects and know how to deal with them.

“There are some who say that the service from there is good that when you go there they take good care of you, they do not rush, they exchange with you so that you are happy with them, they show you how you should behave, how you should use the method, they show you the products and ask you to make a choice that will go with your needs, they show you everything, they tell you all this and then when you say what suits you and they offer you that”

Banfora, married women, users, age 15–24

"In my opinion, their job is good because they talk to us, they explain all the drugs to us. If you take that, here's what it causes. Or others even tell us that if you take this medicine and it causes you a problem, you can come back. All these were good manners."

Bobo Dioulasso, married women, users, age 15–24.

For younger women and those who are single, these explanations are important insofar as they help them in the choice of their method, especially when it comes to their first use of contraception and the FP services.

"When you go for the first time you are different from others because you have never done it. She [the provider] calls you and shows you all the methods and you make the choice of what you want, she will administer it to you or offer it to you. I liked it because someone can't make the choice for you. When you arrive there, they welcome you, those who have already been know what they have to do. But you who have never been, the health worker shows you all the methods. You choose what you want. They don't impose a method on you. I really liked this way of doing things. They show you all the methods and you choose. I like it because they let you choose.”

Bobo Dioulasso, unmarried women, users, age 20–24

Also, high-quality counseling is likely to counter rumors and other misconceptions that are conveyed through social networks around contraceptive use and specific contraceptive methods and reassures women who may have had doubts and fears about use.

"The idea is what they said there. They need to be made to understand the consequences. This makes most women who know about all these consequences be discouraged from family planning. And they will advise each other that the methods do not stand up, it is useless. They will use for two years, three years and have problems afterwards. So if they [providers] could explain to them what's next. That if you do this it will give certain advantages and that it helps you with this and that. And there they will integrate that. If that happens they would have been warned. It's much better"

Bobo Dioulasso, unmarried women, non-users, age 20–24

Stigma and bias of providers

Respondents in some FGDs, especially those with young and single women, cited negative attitudes on the part of some providers. These include the judgment and stigma they show towards youth during consultations which young clients perceive to reflect problems with quality of care. These judgmental attitudes that were typically based on age and marital status include the view that young people should not be having early or premarital/non-marital sex. Such provider attitudes stand out as one of the aspects most negatively felt by young and unmarried women and are likely to discourage their visits to FP services. Thus, unmarried girls who are looking for contraceptive methods fear being stigmatized which serves as an important barrier to their accessing contraceptive services.

“One of my aunts says she once went there when she was a young girl. When she arrived, they asked her, “You a little girl, you come to do the injection to do what?” They didn't respect her, I don't know how to say it... It upset her, she didn't like how she was treated."

Bobo Dioulasso, unmarried women, non-users, age 20–24

“What I want to add, she said that there are some when you go, they don't speak; it's as if they don't like to talk. There is a friend who told me that when she went, there was a female provider and she started insulting her; that she is a little girl, is she old enough to do methods? That she is small, that instead of working, it is to do methods and look for boys [sleeping with boys] that interests her. When my comrade told me this, I myself was afraid to go, they will tell me the same thing.

Bobo Dioulasso, unmarried women, users, age 15–19

For respondents, the negative attitudes of providers may also relate to the choice of the method desired by young girls. The providers would not be in favor of young people asking for long-acting methods, in particular implants, and implicitly label them as having loose sexual morals.

“What I do not like in their service, if you say that you come to put the norplant, the person [provider] welcomes you badly and tells you that you have not arrived anywhere [to say still a minor] and that it is the norplant that you want to put, that it is the boys that interest you, so when you leave, they reprimand you, that's what I don't like.”

Bobo Dioulasso, unmarried women, users, age 15–19

"They're not even going to go. My daughter went to a health center and the providers chased her away as a teenager. They refused to insert an implant into her. Because of that, she got pregnant. I gave her the money to go and do it and the providers sent her away. We can't say everything because if you want to talk too much it frustrates."

Banfora, married women, non-users, age 25–49

Privacy and confidentiality

In the FGD with the younger and unmarried women, participants raised the importance of confidential FP service provision since contraceptive use remains taboo for this group. Meeting aunts, other family members, or other older community members in the same FP services causes discomfort for young and unmarried women. The breach of confidentiality during the search for care is therefore legitimately perceived by these women as a reason for dissatisfaction and a reason not to use the services.

"No, this is not all due to the behavior of the providers but to the people in the waiting room for the FP service especially adults who are the age of our mothers. You, a young girl, if you go to sit there and if your neighbor or someone who is your mother's age finds you there and asks you what you came to do, often you will be forced to lie that you came to accompany someone and get up and disappear from the place now"

Banfora, unmarried women, non-users, age 20–24

“Which makes me not like to go to this place, because if you go there are benches like that, you sit down. I tell myself that if you go, people will look at you and say that hum it looks like these children love sex too much but because of norplant and others they do not get pregnant. So I calculate all this and it makes that I do not like to go to this place.”

Banfora, unmarried women, users, age 15–19

The difficulty of maintaining confidentiality and privacy when visiting FP services by young people is linked to the way the facility is physically laid out in terms of organization of the reception areas and in relation to other services. In most health centers, respondents report that FP services are often provided in the same locations as, for example, maternal and neonatal care. In addition, there are also no separate spaces or specific schedules for young people.

“I can say that there are barriers because it is a health center and there is only one public health center. So if you go you can meet one of your acquaintances and they can say that you have not reached a certain age and you come to do what here? Especially for us who are students, they will say that it is because you do not want to study that you come to do this. If you meet one of your aunts like this and you're going to have to turn around.”

Banfora, unmarried women, users, age 15–19

Other women also deplored the fact that consultations may take place in the presence of several providers. Such a lack of privacy during FP consultations is also likely to cause discomfort and shame especially when it comes to methods to be inserted such as the intrauterine device (IUD).

"Also my older brother's wife was going to get an IUD. When she went, in my opinion, the one who does the work there should just take her. The women should not be left so that others can come in and see her when she is naked. I didn't like that side of her experience. Whoever knows his work just has to go and do his job."

Bobo Dioulasso, married women, non-users, age 25–49

Health system level factorsWait time

Women also discussed the long wait times they usually experience at health centers. The older women who were in union were the main ones who mentioned this quality factor which is not surprising since they typically had more experience with FP services and may have had more household responsibilities awaiting their return. They felt the long wait time was related to the overload of work for providers and the fact that FP consultations and other care (e.g., prenatal and neonatal) take place in the same locations and are also offered by the same providers. Women felt that under these conditions, providers typically prioritized the maternal health visits over FP consultations. This causes long wait times or even postponement of FP appointments. Notably, a long wait time may affect use and FP visits, especially for those women who are trying to use a method covertly.

“Often, when you go to the health center, you find that there are pregnant women they are weighing. You who came for FP they put you on hold. You will sit down and leave your fate in God's hand. They forget you, they will say that they will finish weighing pregnant women first before taking care of you. Yet, at home you hid to come and do it [FP]. Now, if you go to spend the day there, when you go back, nothing will be done, and there are other problems that you have created?”

Bobo Dioulasso, married women, users, age 25–49

" I'm going to the clinic [private clinic] now, because in the [private] clinic, if you get up at that time you arrive for FP, you can have some. But in public [clinic], if you leave, (chié!) you will sit waiting for a long time. Yet, people like us, we want to come back to cook. Now, if you have to get up go spend the whole morning [to get FP] that it's you who wants to do FP? You're not even going to get along with your mother-in-law, let alone with your husband. Now, if they could review that side.”

Bobo Dioulasso, married women, users, age 25–49

Some of the younger, married women who had experience with family planning services also complained about problems with long wait times.

“What we don't like sometimes you can happen to sit for a long time and you are told to come back after when you had already waited for a long time. You are told sometimes to come back tomorrow when you have already lost enough time, they let you sit down they come to pass you without saying anything now after a long wait they tell you to come back next time. You can last before someone comes to ask you what you want and you are told to come back after right now you see your time and essence in loss.”

Banfora, married women, users, age 15–24

Stockouts of methods

During the focus groups, especially with older women and those who were married, the issue of the availability of contraceptive methods was raised. These experienced FP users noted dissatisfaction with the unavailability of contraceptive methods desired (i.e., stockouts) that forces women to use methods other than their preferred method. It also leads to wasted time finding the method either at the pharmacy or at another facility. This may lead to discontinuation or non-use of a method.

“Most often if you arrive at the hospital, you find that the injection is stocked out, so you are forced to take the pill, then you come back to do the injection when it is available. Often there is not even the pill, you are forced to do what is available after you will come back to do what you want.”

Bobo Dioulasso, married women, users, age 15–24

"I have a friend who has already told me that she went there once to take a method and the midwife says that there was a stockout but she can leave and with what she had already been using she cannot get pregnant even in a month. She left and figuring that it was someone qualified who said it, she took this for real and she had sex and when she went again she was already pregnant, you see this kind of thing.”

Banfora, unmarried women, non-users, age 20–24

Costs of services/methods

Since September of 2020, the Government of Burkina Faso made FP services, including contraceptive methods, free in public sector facilities [30]. During the FGD, some women described the non-implementation of this policy based on their experiences of going to facilities for a contraceptive method and being asked to pay for the method or the service. Further, women reported differential requests for payment based on familiarity with the provider; this was considered a sort of favoritism.

"For me, because when you go for childbirth, they exchange well with you, and tell you that seven days after your delivery, you come back to do the FP and it's free. But when you go back to find another person, she asks you for a large sum. So, for me, there was a change at that level. That they are giving the same information even if there is a rotation of health workers that it is the same thing they are saying. That there is a change at this level.”

Bobo Dioulasso, married women, users, age 25–49

"What I want to ask doctors is to find unanimous prices for drugs. Or it is by relationship that they act. You can go to the hospital, they will do a free method for one person, the person will come and tell you. You are looking for some money to go, arrived they will give you a prescription you will go pay at pharmacy. If it's their relatives they do free, if they don't know you they take money.“

Bobo Dioulasso, married women, users, age 15–24

Expectation for blood tests as part of service provision

In the FGDs, participants discussed their concerns about side effects of contraceptive methods. When asked about how these concerns about side effects related to service use and quality of services, women reported that higher quality of services were when providers offered blood tests to “verify the compatibility of methods with one’s body.” Indeed, according to a number of participants across the FGD with the different age groups and user statuses, to avoid the adverse effects of the methods it was felt that the providers, who have a better knowledge of the contraceptive methods, should carry out a battery of tests, including blood tests. These tests are considered important to determine which contraceptive method "goes with the blood" of each woman before deciding on the final choice of the method to be used. This, for them, will help reduce the side effects of contraceptive methods that many women experience and was related to being offered higher quality services.

“I want that if you go [to the facility] that you are given a blood draw to do tests and see the method that suits your body before doing it [use FP] because you can go and make a choice of method and it will not suit your body but when you go to stop the method they tell you that it has not yet lasted long enough but if you do a blood sample for examinations before you use it there is no problem.”

Banfora, married women, users, age 15–24

"If they too could draw blood to see what suits you. As the big sister said if you go and it's norplant you want, that's what they give you. If it didn't suit you if you go back and you want the pills, you are told to go take the pills. But if they could give you what suits our blood it would please us.”

Bobo Dioulasso, married women, users, age 25–49

“For example, people don't have the same blood. The taking of the pills by some, leads to the change of date of the period. For others it is the implants that causes this. So if there was a method to check compatibility to avoid effects.”

Banfora, unmarried women, non-users, age 15–19

Using blood tests to determine which method will best meet a client’s needs is not an established approach to FP service provision. Some methods do require checking blood pressure or potential risk factors prior to offering the method; however, there is no blood test that will tell a person what method is correct. This is discussed further in the discussion section.

Difficulties with method removal

In the focus groups, especially with the older women and those who are married, the problem with the withdrawal of long-acting contraceptive methods, particularly implants, was raised. These women discussed the difficulties encountered when they, or a friend, wanted to remove the implant following the experience of adverse effects of the method. In their view, the providers, for reasons that are not related to the client’s needs, refuse to withdraw the method or were unavailable to do so.

“For me the most important thing, if you go to withdraw the method, they just have to be forgiving and accept to withdraw otherwise they make people work for it. Even when I went to remove my 2nd implant, they didn't want to do it. They made me jump through hoops a lot and I suffered.”

Banfora, married women, non-users, age 25–49

"Like what someone said here, if you insert the implant and go to remove it, the providers tell you heee there is no removal material. There is no time to withdraw, or it is these people who do it. You are forced to return home. Sometimes you come back, if they don't tell you that there is no anesthesia, they tell you that there is something else [so they cannot do it]. They have already done this to me even until I went to Mali to withdraw. When I arrived, the providers from Mali told me heee you have to come from Burkina Faso to do the withdrawal here? I said yes since I sought in vain in Burkina for the withdrawal and I did not get it. And then the implant had worsened my blood pressure, so I was told to remove it. There are difficulties regarding all this. They only have to forgive on this side. Remove! Or why refuse to withdraw?” (Speaking with an angry tone)

Banfora, married women, non-users, age 25–49

"True true there, if you go to put [the implant], it happens but if you go to remove it we are made to wait. We are even made to hang around. You can do three to four rounds in the hospital to get someone there, often if you have a relationship with someone at the hospital, he helps you remove it. I didn't like this experience."

Bobo Dioulasso, married women, non-users, age 25–49

Summary of results

Table 2 provides a summary of the results by age group, marital status, and contraceptive use experience. Overall, all women recognized the importance of interactions between providers and clients, including a welcoming and respectful visit and quality counseling. That said, some issues such as stigma and bias, and confidentiality and privacy were more salient for the youngest women and single women, who typically had less experience with facilities and methods and who were at greater risk of stigmatization due to premarital pregnancy (and sex) taboos. Indeed, for this category of women who use contraception in a context of social stigma because of their status, good relations with providers including a warm welcome and non-stigmatizing interactions are likely to build confidence and encourage future visits to a facility by the young women and their peers. In addition, a large proportion of the young people have little experience with maternal health and contraceptive services and methods. As a result, quality counseling is perceived by them as important for increasing their knowledge of contraceptive methods and to counter misinformation and other rumors related to their side effects.

Table 2 Quality characteristics identified as important by characteristics of FGD groups, Bobo Dioulasso and Banfora, Burkina Faso 2021

In terms of the health system-level factors, while most focus group discussions referred to issues like wait time, costs of methods and services, blood tests, and challenges with removal of long-acting methods, many of these aspects of service provision were specifically raised among the women who were older and in union, that is the women with more experience of method use. For these women, who are generally much less stigmatized in relation to FP use, the regular availability of contraceptive methods, waiting times and fear related to side effects are among the most important issues influencing their perceptions of service quality. Also, the possibility of withdrawal of contraceptive methods (long-term) at the right time and a belief that doing blood tests to help identify an appropriate method were important aspects raised by them.