Quality of facility-based family planning services for adolescents in Malawi: findings from a national census of health facilities

Aim – To describe the quality, in terms of provision and experience of care, of facility based family planning services for adolescents compared to older clients in Malawi. Methods- Secondary data analysis of 1388 observations of consultations, reflecting provision of care, and client exit interviews, reflecting experience of care, undertaken in the Service Provision Assessment survey 2013-14, a census of all formal health facilities in the country. Results- The youngest clients (age group 13-19) had twice the odds of reporting a better experience of care compared to clients aged 26 and older (OR 2.03, 95% CI 1.15 to 3.54, P=0.013). The standard of observed provision was low, typically with half or more of the mandated elements of care omitted. Compared with clients aged over 25, provision of care was slightly better for adolescents with a coefficient of 4.56 on a percentage scale (95% CI 0.90 to 8.23, P=0.015) and a coefficient of 2.33 for those aged 20-25 (95% CI 0.21 to 4.44, P=0.032). Clients seen in facilities under non-government organisation management had better provision of care compared to government facilities with a coefficient of 12.35 (95% CI 6.70 to 18.01, P<0.001); care was worse for clients seen in clinics compared to hospitals (coefficient -6.88, 95% CI -11.41 to -2.35, P=0.003) and also for clients seen by Health Surveillance Assistants compared to those seen by a clinician (coefficient -9.41, 95% CI -15.53 to -3.29, P=0.003). Conclusion- Quality of care for adolescents attending facility based family planning services was slightly better than for older clients but this is overshadowed by the finding of a low standard of care overall. We conclude that health system strengthening especially at clinic level is a policy and programming priority that will contribute to adolescent reproductive health in Malawi, building on successful existing models.