Predictors of quality of family planning counselling in Ethiopia: multilevel analysis of the SPA survey 2021/22

Background: High-quality family planning (FP) counselling is essential for informed contraceptive choice, reducing discontinuation, and improving reproductive health. However, many women in sub-Saharan Africa continue to face barriers. This study examined client-, provider-, and facility-level determinants of FP counselling quality in Ethiopia using nationally representative, multi-source data. Methods: We analysed data from the 2021/22 Ethiopia Service Provision Assessment, including 2,224 women who received or were prescribed injectables, pills, or implants. Counselling quality was assessed using a 15-item checklist derived from direct observations and client exit interviews. Multilevel ordinal logistic regression was applied to identify predictors at the client-, provider-, and facility-levels. Results: Only 32% of clients received high-quality FP counselling, with key information on side effects, STI protection, and a follow-up frequently omitted. High-quality counselling was more likely among women who had never used FP (aOR 1.40; 95% CI: 1.01-1.95) or were past users (aOR 2.05; 95% CI: 1.44-2.92), those counselled by providers with more than five years of experience (aOR 1.91; 95% CI: 1.26-2.89), and those served by providers with high adherence to medical-eligibility screening (aOR 1.67; 95% CI: 1.22-2.29). The presence of a FP-trained provider and national FP guidelines was also positively associated. Marked regional disparities were observed, with facilities in Sidama performing better and those in emerging regions lagging behind. Facility-level factors accounted for approximately 52% of the variation in counselling quality. Conclusion: The quality of FP counselling in Ethiopia remains suboptimal and is largely driven by provider and facility-level factors. Strengthening provider training, ensuring guideline availability, addressing regional disparities, and improving counselling for current users are essential for enhancing service quality, reducing discontinuation, and improving reproductive health outcomes.