Why do family planning providers restrict access to services? An examination in Ghana

Context: Understanding family planning provider practices is fundamental to designing training, supervision and logistic systems that maximize clients' access and quality of care. It has not always been clear, however, why providers impose inappropriate restrictions on clients or perform medically unnecessary procedures. Methods: Situation analysis data from Ghana were used to identify 46 facilities offering family planning services where clients were at high risk of facing medical barriers and other obstacles. Interviewers visited a purposive sample of 97 providers in late 1994 and used closed- and open-ended questions to identify restrictive practices and probe providers about their reasons for these practices. Results: Providers enforced a variety of restrictions known to impede clients' access to services. Concerns about client safety and morals were the most often cited rationales for restricting services according to age and parity. Many providers were especially concerned that contraceptives might cause future fertility problems, and used minimum age or parity requirements to ensure that only women of proven fertility could obtain contraceptives. A number of providers apparently believed in particular that injectable contraceptives cause permanent infertility. Providers also cited health concerns as the reason for enforcing strict resupply and revisit schedules, as well as for routinely conducting laboratory tests. Conclusions: While protecting clients' health is an admirable goal, providers who lack technical knowledge of contraception may exaggerate the dangers of various methods. In seeking to impose their personal morals on clients, providers violate basic client rights.