July 31, 2023

Provider* Bias in Family Planning Services: A Review

By: Emily Dobrzynski, DO

Following Natural Family Planning (NFP) Awareness Week, we are featuring a 2019 research study summarized by Dr. Emily Dobrzynski, a former FACTS elective participant. The study by Solo and Festin, “Provider Bias in Family Planning Services: A Review of Its Meaning and Manifestations,”[1] highlights the importance of providing a broad range of family planning options and addresses how provider bias can impact people’s ability to make an informed choice. Ironically, the article fails to even mention fertility awareness-based methods (FABMs), which reinforces the need for more information about these methods so they may be included among the options. To help us share the facts about FABMs, make a donation of $50 or more and we will send you a Share the FACTS folder featuring the latest research and resources to share with your colleagues.

Introduction

It is well known that clinician bias influences many aspects of patient care, especially in providing adequate and appropriate family planning services. The World Health Organization (WHO) has established guidance on non-discrimination practices to ensure the protection of human rights in the context of family planning. [2] WHO recommends that:

“Comprehensive contraceptive information and services be provided equally to everyone voluntarily, free of discrimination, coercion, or violence (based on individual choice).”
“Special attention should be given to disadvantaged and marginalized populations.”

As such, this review is based upon a fundamental right to provide equal choice to everyone, particularly for those with the highest unmet need (most commonly, adolescents and lower socioeconomic populations). This summary aims to explore the prevalence of clinician bias, underlying causes, its impact, and how to effectively address it.

Methodology

Solo et al performed a PubMed search on “provider bias” and compiled relevant resources related to barriers to contraception. The findings summarize answers to the “what,” “why,” and “how” of medical professional bias. The authors acknowledge the lack of standardized measurements for bias, particularly how it concretely affects clinician choice. As a result, most of the data come from in-depth interviews from clinicians self-reporting. A smaller fraction of studies is based on clinician-patient interactions or simulated clients, which lends insight into more specific types of bias.

Results

The researchers compiled common types of provider bias, each with their own subtitles and implications. Their findings are summarized below.

Attitudes against provision of contraception were explored in a study in Malawi in 1994, where 61% of providers reported their attitudes had a large impact on their practice. The bias was against providing contraception to adolescents or young unmarried women for two reasons: (1) a fear of encouraging promiscuity and (2) potentially contributing to the spread of HIV. This suggests a possible reason for provider bias: medical professionals have a duty to protect their patients, and their definition of protection can be skewed by societal norms and cultural climate, such as an HIV epidemic.

“Medical professionals have a duty to protect their patients, and their definition of protection can be skewed by societal norms and cultural climate.”

As identified by the Urban Reproductive Health Initiative (URHI) implemented in Kenya, Nigeria, Senegal, and Uttar Pradesh between 2010 and 2015, the most prevalent type of bias found in most countries and categories of medical professionals was minimum age bias. This was consistent with the findings from the Malawi study mentioned above. These minimum age requirements were significant, with as many as 70-93% of practitioners in Nigeria imposing age restrictions, regardless of method type.

More complicated method-related bias exists as well, which is important to consider in the context of FABMs. Citing practitioners in Kenya as an example, “many were not concerned about the safety or efficacy of the methods for clients, [but] they were reluctant to provide it due to it being time-consuming and challenging and their fear of potentially being blamed for any fertility problems.” This pertained to long-acting reversible contraception (LARCs) such as intrauterine devices (IUDs), but the notion of ‘ease of provider use’ also applies to attitudes toward FABMs in the U.S. Healthcare professionals may feel more comfortable administering a long-acting shot, a quick prescription for oral contraceptives, or a one-time IUD insertion in lieu of offering a method that involves more in-depth teaching. Time constraints in busy clinics can perpetuate medical professional bias towards contraceptive options that are easier for them, and thus neglect to offer the complete spectrum of options to the patient.

“Time constraints in busy clinics can perpetuate medical professional bias towards contraceptive options that are easier for them, and thus neglect to offer the complete spectrum of options to the patient.”

Clinician bias is clearly informed by personal beliefs and societal norms, but perhaps a more nuanced cause of bias is a medical professional’s well-intentioned duty to protect their patients or clients, which can inadvertently create a barrier: “Findings in Uttar Pradesh showed that practitioner-imposed restrictions stemmed from the fact that practitioners, at times, make judgments about their clients’ education, needs, and ability to understand options, thereby imposing unnecessary barriers to [family planning] methods.” Authors from a study in Ghana concluded that “while protecting client’s health is an admirable goal, clinicians who lack technical knowledge of contraception may exaggerate dangers of various methods.” This is a more subtle form of bias, and perhaps more difficult to target. Medical professionals who intend to do what they believe is best for the patient may be thus hampered in their ability to identify another underlying bias.

Potential bias also exists due to a lack of accurate knowledge about the method itself. Two-thirds of providers from the Malawi study agreed that “every method could be dangerous to someone.” Yet, one benefit of fertility awareness-based methods is their lack of side effects.[3] Modern FABMs are not routinely offered to patients by practitioners due to the inadequacy and/or lack of education regarding the subject. This review found that “simply providing evidence about contraceptives and their safety is typically inadequate to reduce provider bias.”

Discussion

Given the challenges presented, how do we mitigate bias surrounding contraceptives, particularly as it relates to FABMs? A study in Jordan emphasized that “Evidence-based medicine may not be as effective as a stand-alone program targeting a family planning method with a high level of provider and consumer bias.” The FACTS electives are a significant step in this direction, as they offer opportunities for physician and clinician awareness training regarding FABMs.

“Evidence-based medicine may not be as effective as a stand-alone program targeting a family planning method with a high level of provider and consumer bias.”

Regarding social and behavioral change, this review provides examples of initiatives such as the Nigeria Urban Reproductive Health Initiative 2 (NURHI 2), which uses human-centered design to address health professional bias. The Breakthrough ACTION and Breakthrough RESEARCH are two projects funded by the United States Agency for International Development that focus on evidence-based behavior change, which addresses an established challenge in studying the behavioral outcomes of bias. The Beyond Bias project, funded by Bill and Melinda Gates, has developed categories for bias drivers, and works to address behaviors that translate into barriers for youth access to contraceptive services.

This review emphasizes the need for guidelines without restrictions as well as the need for clear and proactive messages about not restricting access based on one’s beliefs. Thus, the review calls for global organizations like WHO to publish consensus statements to provide clear messages to medical professionals about standards and effective interventions. Although this review holds the potential to change the way we provide contraceptive care to our most vulnerable populations, it also acknowledges inherent difficulties in alleviating bias. Regarding FABMs, beneficial interventions include specific training, early education, continued awareness, and emphasis by leading organizations on their use and effectiveness.

* Director’s Note: At FACTS, we avoid the term “provider,” as it devalues the important role, education, and professional judgment that physicians and other clinicians exercise in the care of patients. The term provider implies the delivery of health care is based on a commercial transaction, which fails to recognize the importance of professionalism and the doctor-patient relationship.

References

[1] Solo J, Festin M. Provider Bias in Family Planning Services: A Review of Its Meaning and Manifestations. Glob Health Sci Pract. 2019;7(3):371-385. Published 2019 Sep 26. doi:10.9745/GHSP-D-19-00130
[2] World Health Organization (WHO). Ensuring Human Rights in the Provision of Contraceptive Information and Services: Guidance and Recommendations. Geneva: WHO; 2014. https://apps.who.int/iris/bitstream/handle/10665/102539/9789241506748_eng.pdf. Accessed Sep 3 2022.
[3] Festin MP, Kiarie J, Solo J, et al. Moving towards the goals of FP2020 – classifying contraceptives. Contraception. 2016;94(4):289-294. doi:10.1016/j.contraception.2016.05.015

ABOUT THE AUTHOR

Emily Dobrzynski, DO

Emily Dobrzynski, DO is a recent medical school graduate from Des Moines University and will be completing a combined residency in medicine and pediatrics at Loyola Medical Center outside Chicago, IL. She participated in the FACTS electives during her final year of medical school. As a future med-peds physician, she has a wide range of interests, including adolescent medicine and women’s health. She hopes to incorporate FABMs into her practice.