Promoting more respectful and inclusive care in reproductive health cinics

Millions of young women around the world face stigma and bias when seeking reproductive health services, often limiting their access to contraception and quality care. A new USC-led study conducted in over 200 clinics across Burkina Faso, Tanzania, and Pakistan shows that a focused intervention combining storytelling, peer support, and provider incentives can reduce this bias and expand contraceptive access for the young women who need it most.

Young women - especially those who are unmarried or don't have children - often face subtle but powerful barriers when trying to access contraception. This bias can shape the care they receive - or whether they seek care at all."

Zachary Wagner, health economist at the Center for Economic and Social Research, USC Dornsife College of Letters, Arts and Sciences and study's corresponding author

Published in The Economic Journal, the findings offer a promising way to improve reproductive health services by tackling the root causes of provider bias. By promoting more respectful and inclusive care, the intervention helps ensure that young women - regardless of their marital status or motherhood - can make informed choices about contraception.

Shifting provider attitudes

Bias in family planning clinics can take many forms. For example, providers may tell young women they are "too young" to be sexually active and suggest abstinence instead. Others may limit contraceptive options based on age or marital status, implying that young women shouldn't use certain methods or any contraception at all, Wagner said.

In collaboration with the nonprofit Pathfinder International, the researchers designed a three-part intervention that was randomly assigned to 227 clinics across Burkina Faso, Tanzania and Pakistan. First, healthcare providers attended educational sessions where they heard first hand stories from young women about their experiences with bias, alongside honest reflections from providers who recognized their own past prejudices.

To sustain progress, providers joined a dedicated WhatsApp group to share experiences, offer support, and reinforce learning throughout the year. Regular in-person refresher sessions kept the focus on reducing bias, while clinics demonstrating the greatest improvements received quarterly awards to motivate ongoing progress.

To assess how providers treated different types of patients, the study used "mystery shoppers"-young women trained to pose as real clients seeking family planning services. These shoppers were randomly assigned profiles varying by age, marital status, and motherhood status. They completed the full consultation like any other client but did not select a contraceptive method, instead saying they needed more time or wanted to discuss their options with family members.

Alongside mystery shopper data, researchers collected exit surveys and conducted qualitative interviews with providers and clients to gain a fuller understanding of clinic practices.

The results showed that clinics receiving the intervention offered young women a broader range of contraceptive options-including long-acting methods-and treated them with greater respect and empathy. This improvement was especially notable for women without children, who initially faced the highest levels of bias.

"Our interpretation is that the women most likely to experience bias-such as younger, unmarried women without children - simply don't visit clinics very often," Wagner said. "While our mystery shoppers represented these groups, many real women in these categories are unlikely to seek care."

Among patients surveyed after their visits, there was little difference in contraceptive methods provided, largely because most weren't at high risk of bias in the first place, he added.

"The intervention's success across three very different countries shows its potential for broader impact," Wagner said. "Reducing provider bias is a crucial step toward ensuring all young women can make informed decisions about their reproductive health."