Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.

BackgroundMalawi has made progress in increasing its overall modern contraceptive prevalence rate since 2000, resulting in a dramatic reduction in its total fertility rate. However, youth, 15–24 years, have not had the same successes. Teenage pregnancies are on the rise and little progress has been made in reducing unmet need for family planning among youth. With two-thirds of the population under the age of 25 and with Malawi’s rapid population growth, reducing unmet need for family planning among youth remains a priority for the government’s reproductive health agenda. To further explore this situation, we conducted a qualitative study to explore the perspectives of youth and adults about the drivers and barriers to youth accessing family planning in Malawi and their ideas to improve services.MethodsWe conducted 34 focus group discussions with youth aged 15–24 and parents or legal guardians of female youth in 3 districts in Malawi. Focus groups were translated and transcribed. Data was input into Dedoose and analyzed using a thematic framework to identify broader patterns and themes.ResultsYouth participants felt motivated to use family planning to protect themselves from sexually transmitted diseases and to prevent unwanted pregnancies. Females focused on the consequences of unplanned pregnancies and believed family planning services were targeted primarily at them, while males thought family planning services targeted males and females equally. Barriers to youth accessing family planning included contraception misconceptions, the costs of family planning services, and negative attitudes. Parents had mixed views on family planning. While many parents acknowledged they could play a role in supporting youth, most said they are reluctant to support youth using family planning. Participants said improving counseling services, integrating family planning services and education within school curricula, and utilizing youth clubs could improve family planning services for youth.ConclusionsPolicy makers and program implementers should consider the diverse preferences among youth and parents and continue seeking their input when designing policies and programs. Youth clubs and school-based services were among the most common suggestions. However, the effectiveness of youth clubs and school-based initiatives to increase contraceptive use among youth in Malawi is not clear.Electronic supplementary materialThe online version of this article (10.1186/s12978-018-0549-9) contains supplementary material, which is available to authorized users.

How strong are Malawi's family planning programs for adolescent and adult women? Results of a national assessment of implementation strength conducted by Malawi's National Evaluation Platform Background To assess the strength of implementation of family planning programs targeting youth (15-24) in Malawi with a specific focus on youth and the Youth-Friendly Health Services program Methods We conducted 9781 mobile phone interviews with facility in-Charge Nurses and health workers (health facility workers, health surveillance assistants [HSAs] and community-based distribution agent [CBDAs]) who provide family planning (FP) services across the 28 districts. Responses were entered in tablet using Open Data Kit. They were summarized and presented using R, Stata (College Station, TX, USA), StatsReport (JHU, Baltimore, MD, USA) and ArcView GIS (ESRI, Redlands, CA, USA). Results Availability of key products was a challenge across all health worker types as only 39% of health facilities, 29% of HSAs and 45% of CBDAs had all the FP methods they are supposed to provide on the day of the interview. About 50% of health workers were supervised within past 90 days preceding the study. Despite most facilities saying that they provide youth friendly health services, youth-specific FP guidelines or protocols were not available in 43% of facilities that provide these services and only 33% of facilities had special rooms and 58% have special days for youth. Conclusions The commodity supply system needs to ensure that all facilities and workers have a consistent supply of all contraceptive methods. Government and program implementers should ensure availability of all FP guidelines and information, education, communication materials at all service delivery points and facilitate creation of special rooms or days for youth.

To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility’s catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

Globally, with increase in need for evidence for relevant and effective responses in this century, holistic stocktaking and documentation of subjects has been heightened. In the same vein, Malawi has successfully conducted censuses from 1966 to 2018. Unlike other censuses, the latest round adopted use of Satellite imagery for mapping, Computer Assisted Personal Interviewing (CAPI) technology for data capturing and wireless and on-line data transmission to significantly reduce processing time and improve reliability and timeliness of census results. However, in the face of CAPI and built-in data quality control features, data processing is irreplaceable and key since censuses are never perfect and errors do occur. Further, whilst incorporation of technology demonstrates benefits and merits, the approach comes with some logistical, financial and technical implications. It is also evident that Knowledge sharing between National Statistical Offices (NSOs) is worthwhile, and incorporation of technological innovations has advantages irrespective of significant costs. Finally, being optimistic, positive minded and pro-active is key to implementation of a successful census.

17 18 19 20 21 22 49 statistically significantly positive relationship between increasing implementation strength and 50 higher rates of modern contraceptive use. Decisionmakers at the various levels of health 51 authority can use this type of summary measure to better understand the combined impact of 52 their diverse FP programming and inform future programmatic and policy decisions. The 53 findings also reinforce the idea that having a well-supported and supplied cadre of community 54 health workers supplementing FP provision at the health facility can be an important health 55 systems mechanism, especially in rural settings and to target youth populations. 56 57 58 59 60 61 62 63 64 65 66 Page 5 of 25 91 multiple national and subnational FP programs. 17,18,19 This is evident in their recent national 92 strategy policies and initiatives, such as their Youth-Friendly Health Services (YFHS) 93 program. 20,21 94 95 The Malawi FP delivery system includes government, faith-based (Christian Health Association 96 of Malawi -"CHAM"), and NGO facilities, as well as two types of community health workers: 97 paid Health Surveillance Agents (HSAs) who can provide male condoms, oral contraceptive pills 98 (OCPs), and injectables (the most popular form of FP in Malawi) and voluntary Community-99 Based Distribution Agents (CBDAs), who can provide male condoms and OCPs directly to 100 women. 101102 Previous studies have shown mixed results in demonstrating a clear association between 103 structural quality or readiness (an analogue to implementation strength) and contraceptive 104 use. 22,23,24 Yet, very few of these studies include outreach services or analyze the combined 105 impact of the implementation of multiple FP programs at the national scale. 25,26,30 We conducted 106 an Implementation Strength Assessment (ISA) in 2017 to measure the strength of FP programs 107 delivered across the community and facility levels in Malawi and developed a summary measure 108 that reflects the combined implementation strength of FP programs across these levels. 27 Using 109 this summary measure, this paper reports on the association between the implementation strength 110 of FP programs and modern contraceptive use among Malawian women. 112 Materials and Methods 113 This study draws from two data sources from Malawi: the 2017 ISA of FP programs and the 114 2015 Malawi Demographic and Health Survey (DHS). 115 116 Data source for independent variable 117 We reported previously on the methods the ISA conducted in Malawi in 2017. 27 The ISA was a 118 cross-sectional, mobile phone-based survey conducted from May to July 2017 that aimed to 119 understand how strongly FP programs, especially those directed at youth, were being 120 implemented at the health facility and CHW levels across all 28 districts of Malawi. Data were 121 collected across five domains: training of health workers, supervision of health workers, 122 contraceptive method and supply availability, FP demand generation, and accessibility of FP 123 services. 124 125...

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