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Methodology and Data

This brief is part of a larger research study on trends in publicly-funded family planning services. From February 2020 to January 2021, Child Trends conducted 46 interviews with clinic staff—of which 21 were located in rural communities. From March to May 2022, we conducted semi-structured interviews with 12 clients who accessed family planning services at two of these rural Title X clinics.

Table 1 presents demographic data on the clients interviewed. In total, we interviewed 12 family planning clients who had recently received services in one of two rural clinics. Eight clients received services in one clinic located in the Southeast region of the United States and four clients received services in the second clinic located in the Pacific Northwest. The majority (10 out of 12 clients) were between 20 and 40 years old. About half identified as Black or African American, three participants identified as White, and one participant each identified as Hispanic, Asian, American Indian or Alaska Native, and multiracial.

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Table 1. Client Demographics

To reach clients that recently accessed family planning services, we partnered with two clinics that had participated in our provider interviews. Clinic staff integrated the recruitment process into their visit check-in and check-out procedures and posted flyers both in their clinic spaces and on their social media accounts. We also solicited referrals from interviewees. We asked clients about their awareness of family planning services; their experiences trying to access family planning services; their experiences with family planning services that they accessed, including how they were treated by their provider, how they felt about the contraceptive counseling they received, their experience choosing a contraceptive method during their visit, and whether they were satisfied with the care received; and suggestions for improving client access and experiences.

Interviews were transcribed and then coded in Dedoose using a blended approach of combining codes developed from the interview protocol and were responsive to the data. To ensure inter-rater reliability, we double coded multiple interviews and then reconciled differences through a consensus-building process. We coded experiences as either positive or negative based on client descriptions. Positive experiences were defined as those described as “good,” “great,” “friendly,” “caring,” “welcoming,” “organized,” or something similar, and negative experiences were defined as those described as “not good,” “not great,” “horrible,” “unsatisfactory,” or something similar. We thematically analyzed coded excerpts to understand the reported client experiences and identify the patterns and frequency of positive, negative, and neutral experiences during various aspects of the family planning visit. We defined neutral experiences as those that were described as “okay,” “alright,” or “so-so,” or as those with an absence of positive or negative descriptors. Then, we identified factors that significantly impact clients’ experiences during their family planning visit, which include interactions with the provider, contraceptive counseling, and choosing a preferred contraceptive method. The findings in this brief are focused on the extreme ends of positive and negative client experiences.

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Presentation of Findings

We found that clients’ interactions with providers and clinic staff were a key determinant of having a positive, negative, or neutral experience. In particular, the extent to which clients felt respected, heard, and listened to by their provider shaped their experience. For example, one client recalled, “The people make a difference…. because of that doctor, I decided to stay away from that clinic altogether.” Another client noted that their experience changed when “the people (they were) dealing with” changed. Most clients we interviewed received services over a period of years and were able to compare multiple experiences at one or more clinics. The length of time clients attended their clinic ranged from 5 months to over 30 years, with half of the clients receiving services at their clinic for at least eight years. Most clients described a combination of positive, negative, and/or neutral experiences over time. Given that clients described a combination of experiences, all clients reported positive experiences and most clients also reported negative experiences.

Positive experiences

All clients interviewed reported having at least some positive experiences accessing services at clinics. The types of positive experiences recalled by participants, and the way these experiences were described, were relatively similar across participants. There were many more reports of positive experiences than negative experiences. However, clients seldom provided as much detail about their positive experiences.

Client-provider interactions

When clients described positive experiences, they focused on their interactions with providers. In particular, clients described providers who were knowledgeable, friendly, acted “like they actually enjoyed what they were doing,” didn’t make clients feel “weird” or “judged,” talked to them like they were a “normal person,” and created a space where clients felt like they were “making [their] own choices and were supportive of whatever that would be.” When discussing contraceptive counseling, a client shared how important it felt to them that the provider listened to their needs and preferences and provided options based on that information:

“And she took in my concerns about not wanting to be on something that would make me gain more weight. Because I’m trying to lose weight. She didn’t just discount anything I said. She took it all in and gave me options and told me what the other options were.”

Other provider characteristics that clients described positively were being caring, professional, and time efficient. One client recalled that practitioners had gone above and beyond by calling the client multiple times after their exam to see how they were doing, ask if they needed anything, and ensure that they could talk to someone if they needed to.

Contraceptive counseling

All clients said that providers gave thorough explanations of the contraceptive method options available to them, and many clients felt like they received an appropriate amount of information. During counseling sessions, providers discussed method side effects, improvements to current methods, and new methods, while taking into consideration clients’ preferences and family planning goals. One client said that although contraceptive counseling did not change their mind about which method they preferred, they were “glad they were informing me about it, because if I did want to switch up the one that I was going to get, then I would know about it.”

Contraceptive method choice

Clients said that providers were responsive when clients expressed wanting to switch methods. Most clients felt comfortable expressing when a specific method of contraception was or was not working effectively for them and their goals. One client recalled that the clinic staff were always respectful and supportive of their contraceptive method choice. This client also said that switching from an IUD to another type of contraceptive methods was easy:

“They were real easy with taking it out and then just putting me on a birth control pill. I’ve had issues with the birth control pill in the past. And so, they were really good with giving me information about different birth control pills that I could try that wouldn’t affect me the way that the ones that I have already tried.”

Negative experiences

Most clients reported also having some negative experiences when receiving reproductive health services. Clients described negative experiences that were different from one another. While clients had both positive and negative experiences, clients provided more details about their negative experiences and contrasted them with positive experiences. When describing these negative experiences, clients said that providers made them feel “uncomfortable,” “stupid,” unheard, not taken seriously, and “treated like a teenager rather than a woman.” Clients also expressed that the demeanor of employees was not “friendly and kind.” Clients did not report stopping the use of SRH services due to negative experiences with providers or at particular clinics but instead switched to a new provider within the clinic or attended another nearby clinic.

Client-provider interactions

Some clients described negative provider interactions during their gynecological examinations. One client said the experience was “not fun” and that they did not feel heard or taken seriously. Another client said that the provider did not listen to their requests for the provider to be gentle and described being very uncomfortable. This client recalled this as a traumatic experience, which they described as “literally my worst visit.” The client mentioned that they did not “think it had anything to do with [her]” and that they thought that the provider was “already mad about something”:

She’s being very impatient, and she was being very rough. And I was telling her at first, “Hey, look, that’s very uncomfortable.” And she continued to do it. And then I’ll let her know, “Hey, this is very uncomfortable for me. I don’t normally feel like this when I’m having my annual.” And she continued to be rough. I was crying and everything. She didn’t apologize. I mean, she just quit talking. She was just continuing to work like a robot or something. It hurt physically and it was uncomfortable, but her demeanor was very uncomfortable. It was very weird…

When clients in our sample faced a negative experience, they did not stop accessing services and instead switched providers or changed clinics. For example, one client communicated a preference for not having children, and an interest in getting a tubal ligation, but felt that their provider was unsupportive and disrespectful. The client recalled that the provider said, “You’ll change your mind.” This experience prompted the client to use a different clinic for a period of time because they were not “being heard.” When the client returned to the original clinic, they found a new provider that respected their opinions and discussed whether they would want to consider sterilization. The client said that “probably since 2018 – since I started going back [to the clinic]- I’ve had no problems.”

Contraceptive counseling

While most clients appreciated receiving comprehensive information, some clients expressed that the information provided was excessive. Most clients arrived at the clinic knowing which contraceptive method they wanted and did not change their mind after contraceptive counseling with a provider. In most cases, the clients were long-time users of their preferred contraceptive. For example, one client said that the information “may have been a little too much, because I kind of knew what I wanted already.” As such, in some cases contraceptive counseling did not feel tailored and responsive to individual client needs.

Contraceptive method choice

While most clients felt respected around their contraceptive method choice, a few clients felt either pushed towards a specific method of contraception or away from one that they wanted. Although these clients felt that they had communicated their preferences and family planning goals, their providers suggested alternative methods that they considered to be a better fit for the client based on effectiveness and client characteristics like age, weight, and sexual activity. In these instances, clients felt like their preferences and/or needs were dismissed or disregarded by their providers. For example, one client’s experience with their provider focused heavily on IUDs despite their indication that they were not interested in an IUD:

“I think because of the whole IUD preferences that they had, I think it was like they wanted to educate me more on, like the IUD, like, they were telling me, oh, there’s a copper version. You don’t have to get one with hormones, like, but if you’re scared of this, like, we have one with, like, lower amount of hormones and like this and that and that. And so I learned a bunch about the IUD, but I only learned, like, very little about the other contraceptive methods.”

Additionally, a client—who is engaged in a variety of seasonal work in multiple states—had a similar experience repeatedly. This client had a history of using the shot for many years and was not looking to change methods but was told by a series of providers at different time points that they should consider getting an IUD or an implant. The client said that providers suggested an IUD or an implant so that they did not need to come to the clinic every three months, but the client was clear that they did not mind.

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Conclusion

This brief expands on previous research by describing rural clients’ positive and negative experiences around provider interactions, contraceptive counseling, and contraceptive choice. In these interviews we found that clients’ experiences receiving SRH services were shaped by the extent to which they received patient-centered care—particularly if they felt respected, heard, and listened to by their provider. Clients reported having a range of experiences within a single clinic depending on the individual provider they saw. The importance of respectful and supportive client-provider interactions as well as the issue of pressures around contraceptive method choice were discussed across multiple interviews and highlight ways providers can improve client experiences. Positive SRH care experiences were far more common than negative. However, clients’ negative experiences were impactful and sometimes outweighed positive experiences.

Clients did not report that they stopped using SRH services due to negative experiences with providers or at particular clinics. This was surprising given the declining access to reproductive health services in rural settings and is likely a result of interviewing current family planning clients, thereby missing individuals who may have ceased using SRH services after negative experiences. Most of the clients we interviewed switched providers within the same clinic or went to another clinic for services after a negative SRH experience. However, the option to switch providers or clinics may not be feasible for many individuals, which underscores the importance of delivering high-quality patient-centered care to all clients.

These interviews with rural Title X clients highlight that high-quality, patient-centered SRH care is key to ensuring client satisfaction and continuity of care. SRH providers may benefit from incorporating strategies to improve patient-centered care and increase patient satisfaction, such as using feedback forms that capture patient experiences and implementing staff trainings that center on shared decision-making in contraceptive counseling and culturally responsive service provision. Future research can explore provider perspectives on patient-centered care and interactions with clients receiving SRH services. Future research should also expand the sample of clients interviewed to build insight on both experiences accessing services and experiences receiving family planning services.

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Resources

• Tip sheet with strategies for providers to address client barriers to accessing family planning services
• Guide and information sheets on how providers can support the exploration of patient values and preferences
• Guide and information booklet designed for youth-serving providers to facilitate conversations around birth control methods

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Acknowledgments

The authors would like to extend their gratitude to the Office of Population Affairs for supporting this research under grant FPRPA006070. We would especially like to thank our project officer, Roshni Menon, for her leadership.

We additionally thank Asari Offiong, Lisa Kim, and Brent Franklin for their reviews and Catherine Nichols for her design work. Finally, the authors are deeply grateful to the patients who offered their time and critical perspectives to this research.