Documenting the Provision of Emergency Contraceptive Pills Through Youth-Serving Delivery Channels: Exploratory Mixed Methods Research on Malawi’s Emergency Contraception Strategy

Interviewee Characteristics

All 10 KIs were based in Malawi and worked for a variety of organizations: 5 local organizations, 2 international organizations, 2 members of MOH, and 1 from a donor agency (Table 1). KIs averaged more than 10 years of experience. Semistructured interview participants (n=46) were overwhelmingly involved in direct delivery of ECPs (n=43); thus, we refer to them here as providers. Providers’ representation across the districts and channels were similar, except there were fewer from youth clubs (n=9). Providers had a mean age of 32 years and were mostly male (67%).

Of the 24 ECP clients we interviewed, 75% (n=18) were female, 75% (n=18) were aged 18–24 years, and 75% (n=18) were living with their family, 92% (n=22) were unmarried, and (71%) (n=7) had a child. The majority (58%) (n=14) completed only primary education. Clients reported last receiving ECPs from a CBDA (n=7), general outreach (n=6), youth clubs (n=6), youth outreach (n=4), and an HSA (n=1). Due to training and implementation delays, HSA distribution had not yet been scaled widely at the time of the interviews.

Most clients we interviewed reported ever using short-term contraceptive methods (20 of 22 clients asked this question), while 2 clients reported ever using implants as well as short-term methods. Among the 20 clients who have ever used short-term methods, most (n=17) reported having used condoms, and a few used injections (n=3) or oral contraceptive pills (n=2). Among the 17 clients who had used condoms, all reported having used them to prevent pregnancy (n=17), and/or most used them to prevent sexually transmitted infections (STIs) (n=15). There were no large differences in clients’ previous method use and channel last visited for ECPs. Half of the clients (n=12) reported currently using condoms along or interchangeably with ECPs.

We use emergency contraceptive pills, but when they run out, like it is now, we use condoms. —CBDA client, female, age 18–24 years

Perspectives on Emergency Contraception Strategy Implementation

All but 1 KI (n=9) knew about the strategy before the interview, and those who were aware felt the strategy was working well overall. They said that many organizations were involved in developing the strategy and felt that the strategy had increased the focus on youth and rural areas and had increased ECP uptake. They mentioned these areas for improvement: further disseminating the strategy because some districts had not been reached yet, continuing to increase ECP demand, improving the supply chain, and having a better supply plan. KIs reported several challenges to implementing the strategy, including poor management and quality of FP data and the inability to link private-sector data with those from the public sector. Quantification of ECP commodities was also mentioned, with informants noting that poor data often led to inaccurate forecasting, resulting in stock-outs or stock levels that were not aligned with demand. The length of time it took to get budgets approved was another challenge reported. Several KIs noted that the supply of ECPs could not meet current demand and called for a better supply plan.

The recommendation is to have enough stock …ensuring that the stock management leadership at the facility, hospital, clinic or whatever, are well aware that it’s one of the methods that’s most preferred by young people among others. —KI, international nongovernmental organization, female, age 28 years

Fewer than half of the 46 participating providers (n=18) were aware of the strategy, and 1 respondent noted that awareness was constrained by the limited geographical roll-out of the strategy to date.

Yes. I wish that things about the strategy should be disclosed to everyone so that people should know that this is being implemented at a national level. These things must be known by everybody because these services are important. From my understanding this [strategy] is not being implemented in all areas but only to few randomly selected areas. It could have been better if it was being implemented country wide. —HSA provider, Mchinji, male, age 47 years

Perspectives on Implementation Barriers and Facilitators

Across both districts, providers highlighted what had been going well with ECP services, and many shared more than 1 reason. Of the 43 providers who commented on this, most mentioned a positive impact of the strategy on the community, including the perception of fewer unplanned pregnancies (n=21) and increased school continuation (n=3).

It must have been the past year when schools were suspended due to COVID when rumors circulated that in Phalombe district…where many young girls, about 5,000 had dropped out that time. More ECPs were distributed, which possibly assisted in preventing unwanted pregnancies among many young girls. —Outreach provider, Phalombe, male, age 41 years

The second most common reason was the providers’ perception that knowledge about and awareness of ECPs improved because of different demand creation efforts (n=10), which they believed contributed to higher demand for ECPs (n=11). Providers also described positive client experiences through improved delivery of ECP services in the community and clients’ increased comfort seeking ECPs (n=8).

According to some providers, the most common challenge to delivering ECP services was around the health system having adequate ECP supply (n=37). When 44 providers were asked explicitly if ECP supply was meeting demand, most providers said “no” (n=38). They noted that demand for ECPs had been high for several reasons, including stock-outs of other methods.

Okay, I can be given 20 packets, yet I have about 5 CBDAs including myself, if given 20 we divide 4 or 5 to have equal share, so if a client comes, I can’t give her/him 3 packets otherwise I will remain with only 1 packet. With this I would say we don’t have enough stock for the high demand. We are supposed to give the client 4 to 5 packets so that it should take time before they come back for other packets, and this is what we learnt during COVID-19 period so that we shouldn’t be frequently meeting people. —CBDA provider, Phalombe, male, age 32 years

Some providers (n=6) reported that other providers still lacked knowledge and training around ECPs (n=6) or did not have adequate transport to deliver ECPs (n=5). Providers also reported challenges concerning clients. Some providers felt clients lacked accurate information about ECPs (n=5), had heard false rumors about ECPs (n=4), and feared judgment to obtain ECPs (n=2). By channel, those from the CBDA channel were more likely to report health system challenges, and those from the youth club channel were more likely to report provider-level challenges described earlier.

Channel Reach and Client Characteristics

From January through March 2023, 25 providers documented 3,988 visits from clients seeking ECPs (Table 2). The clients’ ages ranged from 13 to 56 years, with the average being 22 years. One percent of the total visits, or 40 visits, were made by clients ages 10–14 years (Figure 1). CBDA and youth club providers had the highest mean number of visits per provider, 198 and 140, respectively, whereas the outreach providers had the fewest at 65 visits. The lower outreach numbers may have resulted from the program just restarting at the time of data collection. Though differences were relatively small, youth clubs and CBDAs documented the youngest clients (average age: 22 years), and outreach documented the oldest clients (average age: 24 years). First-time ECP users made up 64% of visits. There was some variation by channel, but not substantial (range: 61% for HSAs to 68% for outreach). More than a quarter of ECP visits were made by male clients. While all channels served male clients, CDBAs and outreach documented the highest proportion of visits by male clients (32% and 28%, respectively, compared to 19% and 21% in HSA and youth clubs).

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FIGURE 1

Percent Distribution of Age-Sex Category of Client Visits by Delivery Channel, January–March 2023, Mchinji District, Malawi

Abbreviations: CBDA, community-based distribution agent; ECP, emergency contraceptive pill; HSA, health surveillance assistant.

Examining age-sex categories (Figure 1), we observed 32% of youth club client visits were made by girls ages 10–19 years (0.8% were made by girls ages 10–14 years) and 29% by women ages 20–24 years. The CBDA channel had the highest proportion of visits (11%) by boys ages 10–19 years of age (0.6% were made by boys ages 10–14 years).

During the in-depth interviews, we asked ECP clients which channel they preferred to receive ECPs. Of 15 clients who responded, the most common responses were youth club (n=6), followed by CBDA (n=4) and hospital (n=2). Some of the reasons that clients gave for preferring youth clubs were that the ECP provider (referring to the youth club leader) was close by or within their neighborhood and because the provider usually had ECPs in stock. Some clients mentioned they felt less judgment from the youth club providers compared to hospital staff.

Because the service provider lives within our neighborhood at [states neighborhood name], so when I ask him to take the ECP here and bring me home, he does exactly that. —Youth club client, female, age 15–17 years

[I prefer the youth club] because everyone opens up. We are able to ask questions that we can’t ask at the hospital. —Outreach client, female, age 18–24 years

During the semistructured interviews, of the 29 providers who were asked if ECPs should only be discussed with those who asked for it, 25 providers said “no.” Most felt that ECPs should be discussed with those who did not ask for it so that people of reproductive age would be able to make informed decisions about different methods. One provider reported an unfavorable attitude about youth using ECPs because ECPs are not as effective as other methods.

I feel good seeing the youth using ECPs, you know youth of nowadays started doing wrong things whilst young and this disrupts education, especially for the women. They get pregnant but with the use of pills things became good and they can continue with their education without any disruption. —CBDA provider, Mchinji, male, age 26 years

I prefer if they [youth] used other FP methods because if they use ECP they can get pregnant because they are not 100% effective. At least they should opt for a better method that can help them. —Outreach provider, Mchinji, female, age 27 years

How Emergency Contraceptive Pills Are Being Used

The providers collecting the tally sheet data were asked to document each visit by clients seeking ECPs over the observation period. However, for 29% of these visits, clients did not receive any ECPs primarily due to stock-outs (Table 3). HSAs and CBDAs had the highest proportion of client visits in which ECPs were not obtained (36% of visits), and outreach had the lowest proportion not served (12%). Among visits where ECPs were received, 31% received only 1 pack. The number of packs dispensed varied by channel. Youth club providers distributed 1 pack during 46% of their visits, whereas HSAs gave 3 or more packs during 56% of their visits. Outreach providers were more likely to distribute 6–10 packs, which they did for 20% of their visits, perhaps because they provided periodic services compared to the other channels.

During the interviews, we asked the providers how many packs they usually distributed and most said 1–3 packs. Some providers noted that the number of packs varied by factors including availability, if a client was in boarding school, distance the client traveled, or if the client was using other methods.

Usually it is only 1 pack [I give out]. Because they are scarce so if we give them more than 1, we can run out of stock. —Outreach provider, Mchinji, female, age 27 years

Although providers tended to give out few packs, they said that most clients requested 5 or more packs.

I wanted to receive 6 packets because these youth day events take months to come along, so it doesn’t happen often. —Outreach client, female, age 15–17 years

Providers also documented in the tally sheet whether ECPs were being obtained for immediate or future use, (or both, if multiple packs were dispensed). During 46% of the 1,763 visits, clients reported getting ECPs for immediate use only, while during 33% of the visits, clients reported it was for future use only (Figure 2). Outreach had the highest proportion of clients (63%) planning to use the ECPs in the future.

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FIGURE 2

Among Visits Where ECP Was Received, Client Reported Timing of ECP Use by Delivery Channel, January–March 2023, Mchinji District, Malawi

Abbreviations: CBDA, community-based distribution agent; ECP, emergency contraceptive pill; HSA, health surveillance assistant.

Many of those who obtained ECPs reported already using other contraceptive methods or planned to use another method (data not shown). Among nearly 70% of visits, the clients obtaining ECPs for immediate use reported that the ECP user was using another method (the person obtaining ECPs did not have to be the user but could be a friend or partner). This was reported most often during youth club visits (77%) and least often during outreach visits (56%). Overall, during more than half (58%) of visits, the clients who were getting ECPs for future use reported that they would use other types of methods with ECPs in the future. The highest was for CBDA (67%) and lowest for HSA visits (46%).

We used the information from the client interviews to help understand the quantitative findings from the tally data. The clients who participated in the interviews reported a variety of reasons why they obtained ECPs at their last visit. Of the 22 participants who answered this question, 11 specifically mentioned they obtained ECPs for future use. Other less common responses included: protection against pregnancy (n=9), had unprotected sex (n=9), obtained for someone else (n=3), and for extra protection (n=2).

Though we did not ask about it explicitly, misconceptions arose spontaneously. Two clients said they were using ECPs to protect against STIs.

I did not want to have unexpected pregnancies. … I also did not want to get sexually transmitted diseases. —HSA client, female, age 18–24 years

In addition to holding this same misconception, a male client from youth outreach incorrectly believed that ECPs can be taken by men and stated the outdated duration of ECPs (72 hours instead of 120 hours).

Aah when it comes to contraceptive emergency pills then they are used by women, but I can just say yes, I can say yes, they can be used by anybody. Anybody who has them at that time. And if he drinks the pills within 72 hours, that means every disease whether gonorrhea, syphilis, genital herpes, HIV, that means the diseases will be inactive. —Youth outreach client, male, age 18–24 years

Most of the clients interviewed reported learning about ECPs through youth clubs (n=14/23 who were asked). The second most cited source was interpersonal channels, including friends, network, or boyfriend (n=5), followed by CBDAs (n=3), and hospitals (n=2). During the interviews, we asked clients what the provider told them about ECPs (Table 4). The most common response among those asked (n=20/24) was restrictions or requirements (n=18), followed by how to use ECPs (n=12), efficacy (n=15), frequency of use/repeat use (n=9), when to use ECPs (n=9), how ECPs work (n=8), and side effects (n=6). There were not large differences in responses by channel. While most clients reported being told correct information, 2 responded to this question with incorrect information, including that ECPs protect STIs and the outdated duration for ECPs (72 hours instead of 120 hours):

They said you should be taking them when you are about to have sex and also when you want to prevent sexually transmitted diseases. That’s all. —Youth club client, female, age 15–17 years

They said they are to be taken by a person who has had unprotected sex. They are supposed to take them after 72 hours. I mean before 72 hours elapse. —Youth outreach client, female, age 15–17 years

Among the 32 providers who commented on when ECPs should be taken, 28 said that ECPs should be taken within a 72-hour window, while only 4 said that ECPs should be taken within a 120-hour or 5-day window.

For the ECP, if it is more than 72 hours after sex, the pills will not work. —Outreach provider, Phalombe, male, age 37 years

Aaaa what I know about EC strategy is that they added strength from 3 days or 72 hours but now it is 5 days for ECP to be effective that’s what I know changed. —Youth club provider, Phalombe, male, age 22 years

During the interviews, we asked providers what they thought about clients using ECPs more than once in the same month. Among the 44 providers who answered this question, 20 had unfavorable attitudes. The most common reason (n=10) for having unfavorable attitudes was because providers felt that these clients should be using another method that was more effective. By channel, most of those with unfavorable attitudes were from the outreach channel, while most of those who had favorable attitudes were from the CBDA channel. We also asked 38 providers for their perspectives on clients using ECPs as a regular method, and 19 of these had unfavorable attitudes. By channel, the majority of those who had unfavorable attitudes were HSAs.

…they need to be given more information on other [FP] methods because these are emergency pills, and it’s not the only way to prevent unplanned pregnancies. …They can have a wide variety of choices and…can know that these emergency pills are for emergency use, but there are more sustainable methods. So, we can tell them about condoms, or pills or the other methods. —HSA provider, Phalombe, male, age 49 years

During the interviews, we asked providers about whether women and girls might be coerced into taking ECPs by their male partners. Of the 21 providers who discussed this topic, 5 said that women were and 1 said that women might be coerced into taking ECPs by their partners. However, most providers who were asked said they had not heard of clients being coerced.

Provider and Client Perspectives on Improving Emergency Contraceptive Pills Services

Providers gave a variety of reasons as to how ECP services could be improved. The most reported opportunities concerned the health system and included improving the supply of ECPs (n=30/46), logistics (n=18/46), and data systems (n=13/46). The next common responses were about providers and included having trainings or refreshers on ECP service provision (n=36/46), additional supervision (n=12/46), and providing incentives to providers (n=9/46). Providers also said more awareness about ECP services was needed (n=35/46). By channel, similar proportions of providers from across the channels reported that health systems improvements were needed, while more CBDAs and HSAs reported improvements for providers.

The clients interviewed also had several recommendations for improving ECP services, most commonly concerning increasing the supply, consistency, and availability of ECPs (n=7/23).

I think the supplies of the pills should be consistent, because sometimes we find that they have run out of stock when we go to get some. —Youth club client, female, age 18–24 years

Madam [provider] should have a lot of things so that we shouldn’t be suffering…. She should have ECPs, condoms, and other FP methods so that we just collect from her. Right now, we have to wait for another gathering so that we get ECPs. —Outreach client, male, age 15–17 years

Clients also suggested increasing the number of ECP providers and having them closer to their homes (n=4/23).

If they could have the service providers right in our communities whereby, they can be providing the ECPs door by door, it could really help. —Youth club client, female, age 18–24 years

Related, some clients recommended increasing the number of outlets offering ECPa and specifically mentioned youth clubs, CBDAs, and outreaches (n=3/23).

I think there is need for additional CBDAs so that if one doesn’t have (ECPs) the other may be able to have, and sometime there is too much work for them, they cover big villages and they get overwhelmed with walking long distances and they don’t have any means of transport. So, it is difficult for them to reach many people in a short time. —CBDA client, female, age 18–24 years

Client participants also recommended sensitization activities to increase ECP awareness and demand (n=4/23). We asked clients about costs they incurred getting ECPs. Most said that they did not have to pay for ECP services; however, many experienced opportunity costs, such as missing work.