UCLA

High quality contraceptive care is person-centered and ensures client autonomy. However, a focus on contraceptive uptake and use of long-acting reversible contraception (LARCs) may engender provider attitudes that favor LARCs over other methods and provider behavior that restricts client autonomy.

This multi-methods dissertation uses five sources of data from the Beyond Bias study, to assess provider attitudes and beliefs related to contraceptive care and the quality of care received by contraceptive clients in Tanzania and Burkina Faso. The first paper analyzed 29 in-depth interviews from health care providers in Dar es Salaam, Tanzania. Providers described preferences for LARCs due to their concerns regarding injectables’ slow return to fertility, long-term exposure to hormones for clients when using injectables and pills, and concerns about client adherence in using pills and injectables. While providers understood the importance of centering a client’s preference in method choice and removal, providers also described counseling clients toward their own preference, highlighting a tension between what providers wanted for their clients and client preferences.

The second paper utilized four data sources in both Tanzania and Burkina Faso to assess biased attitudes about young clients, unmarried clients, and nulliparous clients among providers and measure contraceptive care disparities across three domains of contraceptive care quality: counseling quality, contraceptive method provision, and perceived treatment. Providers reported biased attitudes against young, unmarried, and nulliparous women in surveys. Disparities in contraceptive care quality varied by domain; young clients received lower quality of care in contraceptive method provision, nulliparous clients received worse counseling quality, and unmarried clients perceived worse treatment.

The third paper examined provider attitudes and training on LARC removals, client receipt of desired LARC removals, and the person-centeredness of care received. While most clients received their desired LARC removal (87%), clients who were younger, of lower perceived socioeconomic status, and who visited facilities not enrolled in the Beyond Bias intervention less often received their desired LARC removal. Clients who received their desired LARC removal reported higher levels of person-centered care than clients who did not. Most providers held mixed attitudes about LARC removal prior to the method’s expiration and if they disagreed with the client’s decision to get the method removed then. Together, the three studies show action is needed to ensure people have access to person-centered care, which centers their own autonomy, values, and preferences over that of their providers, governments, or donors.