A ceiling fan swirled lazily above our heads, doing little to dissipate the intense heat of an afternoon in Western Kenya during the region’s dry season. Ten pairs of eyes watched me expectantly as I waited impatiently for my presentation to load and project onto the concrete block wall. It was the first day of a week-long training that would precede nearly three months of data collection at health care facilities in Kisumu, Kenya. This was my first experience serving as the principal investigator for a study, and I was a bundle of anticipatory nerves. My goal was to charge my data collection team with a sense of urgency and an understanding of the life-saving benefits of family planning for women and their children. The day stretched long as we unpacked the relationship between contraceptive prevalence and maternal, infant, and child health. At the end of the day, I felt encouraged when one member of my team stayed behind to share, “I learned so much today. You’ve given me a language to talk about family planning with women and their partners.”
Many years ago, I worked at my local Planned Parenthood for a program designed to prevent teen pregnancy. Drawing on these early experiences in service delivery, I often wonder if a woman’s decision to use contraception is influenced by her interaction with her health care provider. In many developing countries, we try to understand the relationship between the quality of family planning services and actual contraceptive use by collecting data at health facilities, usually in the form of interviews with family planning providers and their clients. Curious about the accuracy of this self-reported data, I traveled to Kenya in 2012 to implement an unusual study. I worked with a team of undercover data collectors—local women hired to pose at facilities as new family planning clients and then report back to research staff about their experiences.
Our study findings surprised me. Sometimes my data collectors came back to me with glowing reports of service providers truly devoted to the well-being of their clients. Other times, however, members of my team reported less positive experiences, such as waiting all day at a facility without ever receiving services or witnessing a family planning provider shouting at clients as the clients waited long hours to be served. I was also surprised when a number of my data collectors reported being charged for services that are reportedly provided for free. This often happened behind closed doors and without receipts. A more detailed account of our findings is available in our recently published article in the journal Global Health: Science and Practice.