Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity

The authors conceptualize a distinction between “upward” provider bias that occurs when providers pressure or encourage clients to adopt contraception and “downward” provider bias in family planning that discourages contraceptive use. Key Findings “Upward” and “downward” provider biases are distinct manifestations of provider bias when providers pressure or encourage clients to adopt contraception (upward bias) or when providers hinder family planning access (downward bias). Seeking to expand the understanding of provider bias, we analyzed cross-sectional survey data of reproductive-aged women in Burkina Faso and found that 16% of women reported that providers had encouraged them to use contraception because of high parity (upward provider bias) and 1% of women reported providers had discouraged them from using contraception because of low parity (downward provider bias). Age, marital status, number of children, rurality, and attendance at a 45th-day postpartum visit were all associated with provider encouragement to use contraception due to high parity. Key Implication Further research is needed to understand the mechanisms through which upward provider bias operates and develop interventions to address provider bias to ensure contraceptive autonomy for all people. ABSTRACT Introduction: Provider bias has become an important topic of family planning research over the past several decades. Much existing research on provider bias has focused on the ways providers restrict access to contraception. Here, we propose a distinction between the classical “downward” provider bias that discourages contraceptive use and a new conception of “upward” provider bias that occurs when providers pressure or encourage clients to adopt contraception. Methods: Using cross-sectional data from reproductive-aged women in Burkina Faso, we describe lifetime prevalence of experiencing provider encouragement to use contraception due to provider perceptions of high parity (a type of upward provider bias) and provider discouragement from using contraception due to provider perceptions of low parity (a type of downward provider bias). We also examine associations between sociodemographic characteristics and experiences of provider encouragement to use contraception due to perceptions of high parity. Results: Sixteen percent of participants reported that a provider had encouraged them to use contraception due to provider perceptions of high parity, and 1% of participants reported that a provider had discouraged them from using contraception because of provider perceptions of low parity. Being married, being from the rural site, having higher parity, and having attended the 45th-day postpartum check-up were associated with increased odds of being encouraged to use contraception due to provider perceptions of high parity. Conclusion: We find that experiences of upward provider bias linked to provider perceptions of high parity were considerably more common in this setting than downward provider bias linked to perceptions of low parity. Research into the mechanisms through which upward provider bias operates and how it may be mitigated is imperative to promote contraceptive autonomy.