Introduction
Long-acting reversible contraceptive (LARC) methods have taken the family planning world by storm in the past two decades, but not without controversy. Both in the Global North and in the Global South, family planning programmes have expressed tremendous optimism about the contraceptive subdermal implants and intrauterine devices (IUDs) that constitute the LARC category, and the ability of these methods to reduce unintended pregnancies.1–3 Proponents of LARC methods tout their high efficacy at preventing pregnancy, their extended duration of protection, their lower levels of user error, and their suitability during the postpartum period.4 These perceived advantages over shorter-acting contraceptive methods have led to the rise of the ‘LARC-first’ approach to contraceptive service provision, in which implants and/or IUDs are presented as the first and best options for most users, with shorter-acting methods and fertility awareness-based methods presented last or not at all.1 5 6
The LARC-first model to contraceptive service provision has been implemented both throughout the Global North and Global South. In the USA, for example, LARC-first programmes such as the Contraceptive CHOICE Project in St. Louis encouraged clients to adopt implants and IUDs while less effective methods were de-emphasised.2 5 The New York Times wrote about how Upstream, a contraceptive access programme in Delaware, was promoting LARC methods as a means to reduce poverty, lauding their LARC-first approach for its ‘Set it and Forget It’ ease.7 As these programmes emerged in the USA, however, they faced a swift pushback from women of colour and reproductive justice advocates, both in activist circles and in the peer-reviewed literature.6 8 Critics of LARC-first programmes in the USA have called attention to the legacies of scientific racism and to stratified reproduction along racial/ethnic and class lines that had long subjected marginalised groups to fertility control.9 In 2016, for example, a group of leading reproductive health scholars wrote in the American Journal of Public Health that
Through unquestioned assumptions about whose reproduction is valued and whose is not, they [providers emphasising LARC methods] may be contributing to social inequality. Promotion of LARC methods above all others is particularly disconcerting given the longstanding devaluation of reproduction among a range of socially marginalised groups, including poor people, young people, and people of colour. From their inception, LARC methods have been employed in abusive and unconstitutional ways; our nation’s history of eugenics can be traced through them.10
A growing body of evidence suggests that these scholars’ concerns about the ways that a LARC-first approach can further stratify reproduction by targeting marginalised groups and through the use of coercion are well founded. Studies in the past 5 years have shown that patients from marginalised groups do indeed perceive racial discrimination in their contraceptive counselling, and that some programmes do use coercive tactics to promote LARC uptake and prevent method discontinuation.11–14
Rather than restricting contraceptive counselling to a few of the most efficacious methods, researchers and advocates of reproductive autonomy have instead demanded that LARC-first programming be replaced by a broader focus on high-quality person-centred reproductive care.6 8 In 2017, a coalition of reproductive rights and justice groups led by the National Women’s Health Network and the SisterSong Women of Color Reproductive Justice Collective put forth a LARC statement of principles which affirmed that ‘a one-size-fits-all focus on LARCs at the exclusion of full discussion of other methods ignores the needs of each individual …’ and that it is essential for programmes and providers to provide and receive ‘information that doesn’t privilege LARC over other methods’. As a result of these efforts, several LARC-oriented programmes in the USA have made efforts to broaden their focus on patient-centred care.15 The Upstream USA programme, for example, now writes that all Upstream programming is designed ‘to provide patient-centered, evidence-based contraceptive counseling and care that respects a patient’s time, goals and decision-making abilities’.16
At the same time that LARC-first programmes were cropping up in the USA, a spate of similarly conceived LARC-based programmes also sprang up throughout the Global South, with a focus on South Asia and sub-Saharan Africa. In the Global South, these programmes have tended to focus on a single LARC method (such as the implant alone or the IUD alone) and/or a specific time period in the reproductive life course (such as the postpartum period). Like other global family planning programmes, the majority of the LARC-first programmes implemented in the Global South have been funded and/or implemented by donors and non-governmental organisations from the Global North.17–20 Yet despite the similarity of these LARC-first programmes in the Global South to those in the Global North, those in the South have faced very little scrutiny over reproductive rights concerns in the global family planning literature. Though local media outlets and civil society groups have expressed concern, these models have been hailed mostly uncritically by the global health community as an important piece of the sustainable development agenda.4 21 22 Indeed, the vast majority of literature on LARC-first family planning programmes in the Global South over the last decade has been overwhelmingly positive, focusing on the myriad ways that LARC use could hypothetically improve outcomes ranging from maternal health to the demographic dividend.23–27,17–19 Scientific studies evaluating these programmes have tended to focus on barriers to implementation, user acceptance and uptake, provider perspectives, and other outcomes of programmatic interest.25 28–32 The effect of these LARC-first family planning programmes in the Global South on a broad understanding of contraceptive autonomy and reproductive well-being, beyond programmatic goals and method uptake has not yet been examined.
There is, however, a rich body of scholarship examining patient-centred family planning programming in the Global South on which to draw. In the past, this line of inquiry has been most often framed as part of the discourse on ‘quality of care,’ dating back to Judith Bruce’s 1990 well-known framework for quality of care in family planning.33 Using the Bruce framework as a guide, the global family planning community has seriously engaged with questions of quality of care, seeking to improve dimensions of interpersonal quality, technical quality and access to a wide range of methods, often focusing on the counselling interaction between provider and patient.34 35 Although a major focus of these works has been on rights and well-being, much of the work around family planning quality of care, from Bruce’s original framework to contemporary examples, draws explicit links between improved quality and increased contraceptive acceptance and/or continuation.33 36–38
A growing number of researchers and advocates argue, however, that providing all contraceptive clients a high standard of care should be pursued regardless of its eventual impact on contraceptive uptake or continuation.39–41 Recent work by Holt and colleagues advances a conceptual framework for person-centred family planning that frames the provision of high-quality counselling as the end goal in and of itself, rather than as a tool to help achieve the goal of higher contraceptive prevalence.42 Defining person-centredness as ‘a core dimension of quality’ focused on the ‘necessity of assessing individuals’ specific needs, preferences and prior experiences with contraceptive methods,” Holt and colleagues identify three phases of the counselling process: (1) needs assessment; (2) decision-making support and (3) method choice and follow-up, emphasising relationship-building elements such as privacy, respect and trust as foundational to the counselling experience. The Holt framework emphasises the need for neutral, evidence-based and understandable information throughout the counselling process, with the goal of helping people meet their own contraceptive and reproductive goals.42
Under the banner of quality, a growing number of recent studies document the ways that family planning programmes, intent on providing LARC methods, are failing to help clients make free, full and informed contraceptive decisions.11 43–45 A recent study by Yirgu et al43 from Ethiopia found that ‘some women felt manipulated toward using LARCs’ and that some providers refused to help women discontinue LARC methods they no longer wished to use. A 2019 South African study from Towriss et al found that ‘the delivery of injectable contraceptives to women in the hours following birth is a procedure that emerged during apartheid and became so common that healthcare workers referred to it as the ‘fourth stage of labour’, and that, even today, ‘healthcare workers may not always present the procedure as optional’.44 Other studies from throughout the Global South show that provider bias, directive counselling, limited method mix, as well as outright coercion have been found in a wide array of programmes.11 36 46
Despite the longstanding focus on quality of care in global family planning and the emerging work on method choice, few studies have assessed the ways that LARC-oriented family planning programmes impact method choice, counselling quality and other patient-centred outcomes in the Global South. We begin to fill this gap by drawing on the Holt framework and in-depth interviews with Tanzanian women accessing antenatal care in facilities participating in a postpartum family planning programme. Through its local Tanzanian affiliate, the International Federation of Gynecology and Obstetrics (FIGO) led a programme beginning in 2016 to train providers in six tertiary hospitals throughout Tanzania and their accompanying satellite clinics on postpartum family planning counselling for women receiving antepartum, peripartum and postpartum care. The intervention also built capacity for a new postpartum family planning service, immediate postpartum IUD (PPIUD) insertion. Though the programme was intended to increase access to postpartum family planning more broadly, FIGO named it the ‘PPIUD Project’ due to its emphasis on PPIUD as a newly added service.47 PPIUD project implementers have cited ‘poverty, gender inequality, lack of access to health services and poor quality services’ as contributors to unmet need for contraception that motivate the programme.24 We conducted an independent mixed-methods stepped-wedge cluster randomised evaluation of this intervention, nesting a qualitative component within our larger quantitative study to better understand women’s subjective experiences of the PPIUD Project.48 Using data from this nested qualitative study, we explore how women describe the contraceptive counselling they received as part of this PPIUD intervention, with a focus on the ways that counselling aligns or fails to align with a high quality, patient-centred approach to family planning counselling.