Assessing family planning service denial and its outcomes: A mixed method cohort study in Malawi

Abstract

Introduction. Despite being an international priority linked to eliminating extreme poverty, family planning remains underutilized, partially due to barriers to access. Common barriers to family planning include distance, finances, provider bias, long waiting times, and stockouts of the contraceptive methods themselves. Many of these barriers arise from inequities in the social determinants of health such as education, employment status, and income. Despite global declarations to remove major barriers to family planning, including the 2000 United Nations (UN) Millennium Development Goals (MDGs) and the 2015 Sustainable Development Goals (SDGs), barriers persist. Objectives. This research aimed at a better understanding of family planning barriers in Malawi resulting in female clients being turned away from a facility without an effective method, termed “turnaway” in the thesis and publications. The research objectives were to (1) Outline the extent women received a method during a family planning initiation visit and describe their socioeconomic and demographic background with a focus on equity, (2) Identify, describe, and analyze the reasons for turnaway and the degree of alignment between facility services and national service delivery guidelines, (3) Explore and analyze the role of the provider in turnaway and what can be done to reduce it, and (4) Discuss and appraise the short-term family planning outcomes of women turned away at the initiation visit. Methodology. A subset of Ministry of Health and Population-supported family planning clinics in three districts in Malawi (Kasungu, Machinga, and Zomba) were included as part of the purposive-sample for this mixed-methods study. It was primarily a cross-sectional study conducted in purposively selected clinics with clients and providers, with a longitudinal follow-up of a subset of turnaway clients at six and 12 weeks, followed by a qualitative component with both clients and providers. Results. Data collectors screened 2,246 women exiting family planning service areas. Of those screened, 562 (25%) were new or re-starting users and were thus eligible for primary analysis of turnaway. Of these 562, 83 (15%) reported having been turned away from receiving a family planning method on the day they sought it. Clients cited 12 different reasons for turnaway—the three most common were that the method was not available (34%), the provider was not available (17%), and they were told to come back on a family planning day (15%). Data collectors conducted quantitative surveys with 57 family planning providers; three facilities had only one family planning provider present on the day of the surveys.

In addition, in-depth interviews (IDIs) were conducted with eight providers. The surveyed providers reported being most uncomfortable providing contraception to nulliparous women, regardless of age or marital status. During IDIs, they also noted cultural constraints in providing family planning, especially to adolescents. Providers worried that by providing adolescent girls with contraception, they were encouraging or enabling them to take sexual risks with potentially negative consequences, such as sexually transmitted infections, being accused of being prostitutes in the community or having to drop out of school if they did become pregnant. Providers also have their fears about providing methods to nulliparous women, given the strong value placed on motherhood in Malawi. Besides the reasons cited in the quantitative survey, during focus group discussions, clients also discussed being turned away due to arriving late, financial constraints, or provider refusal. Provider refusal included circumstances such as a provider being tired, about to take a lunch break, or having other responsibilities to tend to. Providers also turned away clients coming for reinjection on a non-family planning day. Conclusions. Client turnaway for family planning may not be as widespread in Malawi as it once was but still has the potential to harm clients, and is nearly always preventable. A better understanding of the influences of the provider ecosystem would help program implementers to set providers up for success. In a strong primary health care system, with better staffing and training of providers grounded in behavioral change, a reliable supply of methods and supplies, and community education on how methods work, methods could be more equitably available and turnaway could be nearly eliminated. The results of this research will support national policymakers, healthcare providers, and the global family planning community to improve the quality of family planning services and address unmet contraceptive needs.