Disrespectful care in family planning services among youth and adult simulated clients in public sector facilities in Malawi

Elizabeth Hazel, Diwakar Mohan, Ephraim Chirwa, Mary Phiri, Fannie Kachale, Patrick Msukwa, Joanne Katz, Melissa A. Marx

Research output: Contribution to journalArticlepeer-review


Background: Provision 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. Methods: We 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. Results: Some 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. Conclusions: We 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.

Original languageEnglish (US)
Article number336
JournalBMC health services research
Issue number1
StatePublished - Dec 2021


  • Family planning
  • Quality of care
  • Respectful care

ASJC Scopus subject areas

  • Health Policy


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