Turned Away: The role of providers in denying family planning to women in Malawi

In this blog post, I highlight research conducted with my co-authors to better understand the role of family planning providers in turnaway and how to prevent it.
Despite the recognition of family planning as a human right, and the great emphasis on it through declarations, policies, and funding, 218 million women in low- and middle-income countries were estimated to have an unmet need for family planning in 2019. In many cases, unmet need is a result of the various barriers women face including medical, financial, geographic, cultural, and religious barriers.

Where medical barriers are concerned, these can include non-medically necessary policies or practices, such as requiring direct observation of menstruation through checking a soiled menstrual pad during the visit to rule out pregnancy, lab tests, or vaccinations. Clients may also face barriers due to a lack of information on how family planning methods work or stockouts of supplies at their area facilities.

Although the barriers above have been the subject of many studies, here and here, one additional barrier warrants examination: the role of provider bias in causing turnaway of clients seeking family planning. In this blog post, I highlight research conducted with my co-authors to better understand the role of family planning providers in turnaway and how to prevent it based on a study implemented in Malawi, which was recently published in the International Journal of Environmental Research and Public Health, here.

BACKGROUND

Family Planning in Malawi

Women in Malawi must often expend considerable time, financial resources, and effort to visit public family planning facilities.
The decision to use family planning in Malawi is not an easy one. Many unmarried women and adolescent girls risk being seen by others as “prostitutes” and married women risk their fidelity being questioned by their husbands or other members of their community who may find out they are using family planning. The methods themselves are often misunderstood, with many women believing or fearing they can lead to sterility or cancer. For women without children, the fear of sterility can be particularly difficult to overcome, given the strong value placed on motherhood in Malawian society. Sterile women are not uncommonly divorced in favor of a wife who can bear children.

After having decided that family planning is indeed the right decision for them, women in Malawi must often expend considerable time, financial resources, and effort to visit public family planning facilities. Starting a new method can take the better part of a day, including travel times, attending a group counseling session, waiting to see a provider, and finally either having a method inserted or obtaining a method from a pharmacy, which may not be located at the health facility where services are provided. If a woman is trying to conceal her use of family planning, she may decide to travel to a facility a bit further from her home community, thus increasing the amount of time and money expended.

After coming as far as making the decision to use family planning and getting to the facility, imagine the disappointment and frustration of being turned away without a method. Yet this is what happens all too often to many women and adolescent girls in Malawi. In related research conducted in three districts of Malawi, we found that 15 percent of women seeking family planning were turned away.

Role of Providers in Turnaway

Providers tend to implement family planning methods that reflect their opinions on and comfort with dispensing these services.
Provider bias is often cited as a cause of turnaway. Providers’ beliefs and cultural views about the appropriate family size and timing of pregnancy can influence their decision to provide family planning to clients. Additionally, requirements surrounding the marital status of clients and minimum age are sometimes established by providers based on their own beliefs and biases. Moreover, providers tend to implement family planning methods that reflect their opinions on and comfort with dispensing these services. For example, preferring injectables compared to IUDs, which require pelvic examination, as discussed here.

CONTEXT AND METHODS

It was important for us to hear directly from providers what went into their decisions to turn women away without a method.
The research was conducted in Malawi, a country of nearly 18 million people located in sub-Saharan Africa. Often referred to as one of the poorest countries in the world, Malawi has a total fertility rate of 4.4, an infant mortality rate of 42 per 1,000 live births, and a maternal mortality ratio of 349 per 100,000 live births, according to the Malawi National Statistics Office and World Health Organization. The study was conducted in the highly populated districts of Kasungu, Machinga, and Zomba, covering 30 public health facilities. The selected districts were chosen based on feasibility of data collection and diversity in characteristics, such as religion and modern contraceptive prevalence rates.

The data were collected as part of a larger study, in which data collectors spoke with clients exiting from family planning  service areas to determine the proportion of clients turned away, as well as the reason for turnaway. To better understand the nuances behind turnaway, we also conducted surveys with 57 family planning providers and in-depth interviews with eight. It was important for us to hear directly from providers what went into their decisions to turn women away without a method.

FINDINGS

Findings show that providers themselves were frustrated with several structural issues.
Our findings show that providers themselves were frustrated with several structural issues that hampered their ability to effectively provide family planning services. These structural issues included stockouts of methods and supplies, lack of training on all methods, and limited space in facilities to provide services in a timely manner. For example, if an exam room is occupied with a woman wanting a method such as IUD, which takes longer to initiate than other methods, other clients would need to wait for the exam room to be available.

We also asked providers about their level of comfort providing family planning to clients both above and under the age of 18 years old, married, unmarried, and those with children and without. While few providers expressed discomfort with any of these groups, those who did were most uncomfortable with nulliparous clients. We were able to explore this further in the in-depth interviews, where providers explained that while they were aware from their training that family planning use would not impact future fertility, they could not help but worry that it would.

Figure 1: Providers that responded they were uncomfortable providing family planning services to each type of client. (Graphic by Sue-Lyn Erbeck, 2021)

Figure 1: Providers that responded they were uncomfortable providing family planning services to each type of client. (Graphic by Sue-Lyn Erbeck, 2021)

Providers also worried about adolescent girls seeking family planning services. They worried that if adolescent girls were found out to be using these services in their communities, they would face verbal abuse, such as being called prostitutes. They also worried that family planning would enable girls to start or continue sexual relationships, and consequently would lose focus on their studies and not finish school.

One of the most commonly cited reasons for turnaway by clients surveyed in the larger study was that they were not able to show they were not pregnant. As pregnancy tests tend to be in short supply at facilities, providers often ask women to come to the facility when they have their periods—an obvious inconvenience for women. Through the in-depth interviews, providers were able to better explain to us why they required this, given that initiating most modern methods, except for IUDs, will not negatively impact a pregnancy. According to providers, many people believe that common family planning methods such as oral contraceptive pills, injectables, and implants will cause abortions. Additionally, they worried that women were seeking such services as a method of abortion, which is illegal in Malawi. Moreover, in the event women were pregnant before initiating family planning, they worried people would lose faith in modern methods, blaming their pregnancy on family planning failure, rather than recognizing the pregnancy occurred before service initiation.

IMPLICATIONS

Public health officials can support providers by providing training on all methods.
When we asked providers what suggestions they had for reducing the instances of turnaway, they mentioned increased staffing and more comprehensive training for providers. They also mentioned improved facilities with more exam rooms. Perhaps most interestingly, they mentioned working with communities to ensure greater understanding of how the methods work and to dispel myths and misconceptions about family planning.

Public health officials can support providers by providing training on all methods and on how to effectively rule out pregnancy before a missed period or when clients are not menstruating. They can also work to eliminate stockouts in methods and supplies, including pregnancy tests, and ensure there are adequate exam rooms to accommodate the full client load. Additionally, they can support education of the community on how contraceptive methods work, as well as dispelling common myths and encouraging more acceptance of the use of family planning, particularly for adolescent girls.

Photo credit: Daria Golubeva

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