Abstract
BackgroundProvision of high-quality family planning (FP) services improves access to contraceptives. Negative experiences in maternal health have been documented worldwide and likely occur in other services including FP. This study aims to quantify disrespectful care for adult and adolescent women accessing FP in Malawi.MethodsWe used simulated clients (SCs) to measure disrespectful care in a census of public facilities in six districts of Malawi in 2018. SCs visited one provider in each of the 112 facilities: two SCs visits (one adult and one adolescent case scenario) or 224 SC visits total. We measured disrespectful care using a quantitative tool and field notes and report the prevalence and 95% confidence intervals for the indicators and by SC case scenarios contextualized with quotes from the field notes.ResultsSome SCs (12%) were refused care mostly because they did not agree to receive a HIV test or vaccination, or less commonly because the clinic was closed during operating hours. Over half (59%) of the visits did not have privacy. The SCs were not asked their contraceptive preference in 57% of the visits, 28% reported they were not greeted respectfully, and 20% reported interruptions. In 18% of the visits the SCs reported humiliation such as verbal abuse. Adults SCs received poorer counseling compared to the adolescent SCs with no other differences found.ConclusionsWe documented instances of refusal of care, lack of privacy, poor client centered care and humiliating treatment by providers. We recommend continued effort to improve quality of care with an emphasis on client treatment, regular quality assessments that include measurement of disrespectful care, and more research on practices to reduce it.
Highlights
Provision of high-quality family planning (FP) services improves access to contraceptives
This study aims to document and quantify any instances of disrespectful care for adult and adolescent women accessing family planning through a cross-sectional facility assessment in Malawi
If we found an event that fit within the four domains of disrespectful care, it was coded with a binary score and triangulated with the quantitative data
Summary
Provision of high-quality family planning (FP) services improves access to contraceptives. Abdel-Tawab & RamaRao summarized studies in LMICs showing a positive association of provider-client interactions on contraceptive continuation but found limited evidence that interventions to improve quality of interactions impacted continuation [12]. They theorized this lack of consistency is related to differences in methodological design across the studies, and the general complexity of both provider-client interactions and contraceptive continuation. A more recent literature review of studies in LMICs and high income countries by Diamond-Smith et al, shows interventions aimed to support client dignity, autonomy, privacy/confidentiality, and communication are associated with improved client satisfaction and knowledge, but there are mixed associations/findings with contraceptive initiation and continuation [13]
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