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We explore whether differential access to family-planning services and the quality of those services explain variability in uptake of contraception among young women in Malawi. We accomplish this by linking the Malawi Schooling and Adolescent Study, a longitudinal survey of young people, with the Malawi Service Provision Assessment collected in 2013–14. We also identify factors that determine choice of facility among those who use contraception. We find that the presence and characteristics of nearby facilities with contraception available did not appear to affect use. Rather, characteristics such as facility type and whether contraception was provided free of charge determined where women deciding to use contraception obtained their contraception. We argue that in a context where almost all respondents resided within 10 kilometers of a health facility, improving access to and quality of family-planning services may not markedly increase contraceptive use among young women without broader shifts in norms regarding childbearing in the early years of marriage.

Background Provision of HIV prevention and sexual and reproductive health services in Zambia is largely characterized by discrete service provision with weak client referral and linkage. The literature reveals gaps in the continuity of care for HIV and sexual and reproductive health. This study assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and sexual and reproductive health services. Methods Adult clients 18+ years of age accessing family planning (females), HIV testing and counseling (females and males), and male circumcision services (males) were recruited, enrolled and individually randomized to one of three study arms: 1) the standard model of service provision at the entry point (N = 1319); 2) an enhanced counseling and referral to add-on service with follow-up (N = 1323); and 3) the components of study arm two, with the additional offer of an escort (N = 1321). Interviews were conducted with the same clients at baseline, six weeks and six months. Uptake of services for HIV, family planning, male circumcision, and cervical cancer screening at six weeks and six months were the primary endpoints. Pairwise chi-square and multivariable logistic regression statistical tests assessed differences across study arms, which were also assessed for incremental cost-efficiency and cost-effectiveness. Results A total of 3963 clients, 1920 males and 2043 females, were enrolled; 82 % of participants at six weeks were tracked and 81 % at six months; follow-up rates did not vary significantly by study arm. The odds of clients accessing HIV testing and counseling, cervical cancer screening services among females, and circumcision services among males varied significantly by study arm at six weeks and six months; less consistent findings were observed for HIV care and treatment. Client uptake of family planning services did not vary significantly by study arm. Integrated services were found to be more efficiently provided than vertical service provision; the cost-effectiveness for HIV/AIDS and cervical cancer was high in the enhanced service models. Conclusions Study results provide evidence for increasing the linkages and integration of a selection of HIV and sexual and reproductive health services. The study provided cost-effective service delivery models that enhanced the likelihood of clients accessing some additional needed health services. Trial registration ISRCTN84228514 Retrospectively registered. The study was retrospectively registered in the ISRCTN clinical trials registry on 06 October 2015. The first recruitment of participants occurred on 17 December 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3450-x) contains supplementary material, which is available to authorized users.