A total of 213 women completed the questionnaires, of which nine were excluded because more than three values were missing from their questionnaires, leaving 204 participants, including 123 (60.0%) from the NGO clinic as well as 47 (22.9%) and 34 (16.6%) from the two government clinics respectively. From these 158 (77.6%) women were current contraceptive users and gave information on their current use. Altogether, five focus groups were conducted with a total of 51 participants, 35 in the NGO clinic and eight in each of the government clinics. Furthermore, 14 healthcare providers were interviewed from all clinics.
Characteristics of participants
The mean age of survey participants was 30.8 (±7.5) years; ranging from 19 to 50 years. The vast majority of 180 participants (88.2%) had benefitted from secondary school or university education. However, the majority were housewives, with low household incomes (Table 1). The mean age of women taking part in the focus groups was 30.1 (±6.2) years with 36 women (70.6%), having benefitted from education of secondary school level or above (Table 1). Most participants were housewives, although many expressed a wish to work, but only three (5.9%) were in formal employment, all of whom attended the same governmental clinic. Monthly household income varied greatly from 0 to $675, but was generally poor (Table 1). In total, 154 women (60.4%) reported incomes below $300 per month.
Perceptions of women using family planning services
Quantitative data analysis
Overall assessment of FP services showed similar trends in both NGO and government clinics, although overall assessments were more positive in the NGO clinic. In both groups, the most positive evaluation was given for ‘Written instructions are in a clear and understandable language’ with a mean of 3.59 and 3.15 (from the maximum score of 4) respectively. Similarly, the most negative response was gained on the same item, which was ‘I received adequate information about contraceptive choices, including advantages and disadvantages of each method’ with 3.30 and 2.66. The range between most positive and most negative response was greater in the government clinics than in the NGO (Table 2). All differences were statistically significant with p = < 0.01. Participants in the NGO clinic gave significantly higher mean scores in all categories, compared to those in the government clinics (p value < 0.01). However, no significant differences were found between the two government clinics. These are therefore, presented as one total in Table 2.
Qualitative data analysis
The main themes extracted from the qualitative data analysis were a general good level of satisfaction about the services in all clinics, with more positive views in the NGO clinic, when compared to government clinics. Most women went to the clinic with a certain method in mind, they felt the Staff were supportive and answered all questions well. Participants acknowledged a high prevalence of disparate, possibly misleading, information in the community.
Focus group participants at the NGO clinic experienced FP services as good and comprehensive. The Staff was described to be knowledgeable and professional, dealing equally well with feto-maternal complications or preeclampsia as with psychosocial difficulties. Participants described a holistic approach, which addressed the individual woman in the context of their family situation, which was appreciated by the participants and expressed as follows:
‘The fetus had a heart problem. They told me that there was a hole in his heart. They have a good ultrasound that helped in the diagnosis of this case’.
‘I used to be classified as a high-risk pregnancy. I have pregnancy diabetes and hypertension. Every time I go to the UNRWA clinic, they refer me to the hospital. When I came to the NGO clinic, they took care of me and made me feel that my case is not that dangerous. This gave me reassurance and I continued the pregnancy and gave birth safely.’
‘They talk to me and cheer me up. It is not only about medical treatment.’
Participants in the government clinics also reported general satisfaction with services and it was clear that the participants’ expectations were met. Although some found waiting times long, consultations brief and lacking detailed information about contraceptive choices, all agreed that questions were answered precisely. Participants reported to have heard many opinions about contraception, usually from relatives and friends, and often attended the FP clinics with a certain method in mind they wanted to use, not expecting to gain information from healthcare professionals, but to be given what they asked for at the consultation. This is reflected also in the mean scores of 2.66 and 2.74 (Table 2) for the two associated items, indicating most women were satisfied with the information they received. Advice given to women was reported to have impact on their contraceptive choice, by some women, while most decided without healthcare providers’ input.
‘I came to take contraceptive pills. Any question I ask they answer.’
‘They explained the disadvantages about IUD only, but didn’t explain all advantages and disadvantages of other methods, but the information was relatively enough. I changed my mind and selected pills.’
‘They don’t explain anything. I came here and asked for pills. They gave them to me without providing me any further explanation.’
The highest score in both clinics was given for clarity of written information. In the NGO clinic this was supported also by a video that was delivering information while women were waiting in the waiting room and accessible staff to ask questions. This informal delivery of information was found to be helpful by participants. Participants in the NGO clinic said:
‘I heard so many things about contraception that I did not know what was true and what was wrong. Here they give you good advice. I trust them.’
‘They give me complete information about contraceptives from A to Z.’
Although the question on the clarity of written information received the highest score in the government clinic with 3.15 of a maximum 4, focus group participants reported that they did not receive any written information. However, the research team saw pamphlets about contraception in the clinic, possibly reflecting inconsistency in their distribution to women.
Participants reported, and the actual use of contraception demonstrated, a limited choice of contraception for the women of the Gaza Strip (Table 3). The most commonly used contraceptives were the intrauterine device (IUD), used by 56 (35.4%) women, and combined oral contraceptives (COCP) by 41 (25.9%), followed by less reliable choices, namely condoms with 26 women (16.5%) and natural methods with 24 (15.2%). Although introduced to the NGO clinic as a novel choice 2 years prior to this study, only five women (3.2%) reported to be using the hormonal implant for contraception at the time of data collection. Participants reported that they were free to choose the method of contraception and that they were supported in this by staff with positive responses for both items in the questionnaire with 3.36 out of 4.0 for both items (Table 2). When asked who mostly influenced their choice of contraception, most focus group participants (n = 21; 41.2%) answered their husbands, 17 (33.3%) women decided together with their husbands and a minority of only six (11.8%) women reported to decide by themselves alone. Seven women (13.7%) also took the advice of healthcare staff to guide their choice.
Perceptions of family planning service delivery by healthcare providers
Healthcare professionals reported several barriers in the delivery of FP services to women in the Gaza Strip, which were present in both, NGO and government clinics. A big challenge described by healthcare professionals was the high prevalence of misconceptions about contraception in the community, including women attending all three healthcare facilities. The most common misconceptions were that contraceptive methods had a negative impact on future fertility as well as an overestimation of their association with cancer among females, especially breast cancer. Healthcare professionals found re-educating women on these issues was challenging.
‘Some challenges included the traditions of the community and their attitude toward family planning. It was hard to change their attitude. Let’s say not to change them, but let’s say to correct them and change or correct some behaviors. Always changing behavior is difficult. It takes a lot of effort from the team. It is difficult to change these misconceptions.’
Significant shortages of contraception have to be overcome regularly, requiring women to change their contraceptive method. Some women in the focus groups also reported this problem, but for healthcare professionals it was an even bigger challenge. Women were also referred from other clinics, if methods were unavailable at one place.
‘The contraceptive methods are not available all the time,’
‘Last year progesterone only pills were not available for eight months of the year.’
‘At UNRWA clinics, they serve a large number of women. When they are out of contraceptives, they send them to us [the NGO clinic].’
Generally, it was felt by healthcare staff that providing reliable contraception is not regarded as a priority in service provision by the Palestinian Ministry of Health (MoH), due to the high pressure on the service. But the staff in all three facilities reported working hard to provide adequate FP services.
‘Family planning is continuous, we offer this service throughout the year and even during the war. It is very essential in such hard economic conditions as in the Gaza Strip’