Advancing contraceptive security, availability, and choice in Malawi using a quality improvement methodology

Many initiatives to improve contraceptive security (CS) rightly focus on strengthening national and regional systems. However, local health facilities are often under-resourced and lack technical capacity that feed into the larger supply chain. This study’s objective was to assess whether changes in facility CS indicators were associated with participation in 2014-2016 implementation and scale-up of a quality improvement methodology—Client-Oriented, Provider efficient services (COPE®) for Contraceptive Security—in 60 facilities across 10 districts of Malawi. The intervention included facility self-assessment guides and action plans to address local challenges. Results showed significant improvements in facilities having both a trained provider and contraceptive supplies. The percentage of health centers with all requirements for implant services increased significantly, including implant removal (from 26.5%; 95% CI: 14.9-41.1 to 77.6%; 95% CI: 63.4-88.2, p<.001). Health centers (from 0.0%; 95% CI: 0.0-7.3 to 10.2%; 95% CI: 3.4-22.2, p<0.05) and hospitals (from 45.5%; 95% CI: 16.7-76.7 to 90.9%; 95% CI: 58.7-99.8, p<0.05) significantly improved in the percentage of facilities able to insert intrauterine devices. Hospitals improved their ability to offer female sterilizations (27.2%; 95% CI: 6.0-61.0 to 63.6%; 95% CI: 30.7-89.1, p<0.05) and male sterilizations. Low performing health centers showed significant improvement in staff capacity, logistics management information systems, equipment, and total CS performance. The percentage of facilities placing emergency orders for contraceptives during the three months prior to an assessment showed a decreasing, non-significant trend among hospitals but was significant among health centers (from 69.2%; 95% CI: 54.6-81.7 to 36.7%; 95% CI: 23.4-51.7; p<0.001). Facility staff commitment was associated with action item completion. Improvements tended to be sustained over time. Community engagement is thought to be important to intervention success. COPE for CS may be an effective intervention and future research/programs can build off of this preliminary programmatic experience when seeking to address last mile challenges.