Provider bias in family planning services: A review of its meaning and manifestations

Abstract

Family planning programs are guided by the principle of informed choice as well as the goal of providing a broad choice of contraceptive methods to clients. Provider bias is an important barrier to realizing this goal, but it must be clearly defined and understood to be effectively addressed. This review presents an overview of the concept of provider bias in family planning, focusing on the following issues: (1) what it is, (2) how widespread it is, (3) its underlying causes, (4) its impacts, and (5) how it can be effectively addressed. The definitions of provider bias include common themes about providers creating barriers to choice, typically based on the characteristics of either a client or a contraceptive method. However, an agreed-upon definition is lacking. Measurement of provider bias has often relied on self-reports by providers but has also included observation and use of mystery clients for supplemental data. The general trend in the data is clear: large numbers of providers impose barriers and restrictions beyond those that are in guidelines or are necessary for any medical reasons. This trend indicates the presence of bias. Providers have shown bias based on age, parity, marital status, and other criteria, with a bias against provision of various contraceptive methods to youth being the most common. Provider bias often stems from broader social norms, particularly judgments about sexual activity among youth and concerns about the impact of hormonal methods on future fertility. Little documentation of the impact of provider bias exists, although method mix skew has been identified as a possible red flag for bias. Newer approaches to address bias that have moved beyond traditional training and guidelines development to more fundamental behavior change efforts show promise, and learning from their lessons will be important. A major question is how to scale up such approaches.