Patient-centered care—or care that “is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions”—is a key element in providing high-quality family planning care. Core to the patient-centered care approach is ensuring that patients’ contraceptive preferences are met—that is, making sure that the contraceptive method a person is using (including no method at all) is a method they actually want to be using.
In our survey of family planning clients with low incomes, we found that almost 40 percent of our total sample had an unmet preference for contraception—that is, their reported method was not one they reported wanting to use (see Figure 1). These rates varied by current contraceptive method use: Over one quarter (27%) of those currently using any contraceptive method were not using a preferred method, while 84 percent of clients not currently using any method had an unmet preference.
It’s useful for family planning providers to know whether a client’s contraceptive preferences are being met, beyond other commonly used indicators such as whether they have an unmet need for contraception (i.e., they are not using any method when they wish to be) or whether they are satisfied with their current method (regardless of having more desired alternatives). In line with the principles of patient-centered care, contraceptive preference assesses what a client’s ideal contraceptive approach would be if they had no barriers to using it. Thus, having an unmet contraceptive preference is a key indicator of a lack of reproductive autonomy—a situation that research finds is associated with important reproductive health outcomes such as inconsistent method use, method discontinuation, and unwanted pregnancy.
For this analysis, we used responses to a Child Trends survey of clients with low incomes who had recently received family planning care, and who were neither pregnant nor trying to get pregnant [N=808], to learn more about the prevalence of unmet contraceptive preference (see Figure 1) and identify which methods clients would prefer to use if they could (see Figure 2). These clients were all eligible to be served through publicly funded family planning programs, such as Title X, which strive to implement high-quality, patient-centered care standards. Knowing more about the prevalence of unmet contraceptive preference—and about what methods these clients prefer—can help strengthen the care provided by family planning clinics.
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Findings
Among respondents currently using contraception, the rate of unmet contraceptive preference varies by the type of method used. At the higher end, approximately one third of clients using only long-acting reversible contraceptive (LARC) methods (IUDs or implants) or only condoms reported having an unmet contraceptive preference (36% and 33%, respectively) (Figure 1). Those using multiple methods (e.g., condoms and a short-term hormonal method such as birth control pills, the shot, the patch, or the ring) had the lowest rate of unmet contraceptive preference (22%), indicating that at least one of the methods they reported using was one they wanted to use.
Figure 1. Overall, 40 percent of family planning clients with low incomes—and over one quarter (27%) of current contraception users—have an unmet preference for contraception
Rates of unmet contraceptive preference by current contraceptive method use
Source: Child Trends Family Planning Client Survey, 2023 https://www.childtrends.org/publications/methodological-approach-family-planning-client-survey
Interestingly, in contrast to our findings, other research has found that users of provider-dependent methods such as LARC and short-term hormonal methods often have the lowest levels of unmet contraceptive preference. Notably, levels of unmet contraceptive preference can vary widely depending on the characteristics of the sample. For example, they vary depending on whether the sample is nationally representative or limited to those within specific states (who may have different contexts shaping access to methods), or whether respondents have a particular social status (e.g., veterans) or are in a specific stage in their life (e.g., post-partum clients). Levels can also vary depending on how researchers measure unmet preferences. It will be important for clinicians to measure contraceptive preference among their own clients to get a better understanding of unmet need.
When our survey asked clients about their preferred methods—again, defined as the contraceptive methods they would use if they could—clients were able to select more than one response. In fact, just under half (43%, results not shown) of all clients with unmet preferences indicated an interest in more than one method. Figure 2 displays the two most frequently reported preferred methods among those with an unmet contraceptive preference: The first row shows preferred methods for all clients with an unmet preference, while subsequent rows show preferred methods by type of method currently used.[1] As in Figure 1, we considered clients using each method alone, those using multiple methods, and those not using any method.
Clients with unmet contraceptive preference reported preferring short-term hormonal methods (35%)—primarily the pill—followed by condoms (30%). Among those not currently using any method at all, condoms (48%) were the most common preferred method, followed closely by short-term hormonal methods (46%, mostly the pill).
Clients with unmet contraceptive preferences reported wanting to use methods that were both more and less effective than their current method. For example, current LARC users reported preferring both short-term hormonal methods (43%), which are less effective than LARCs, and female sterilization (24%), which is more effective. Similarly, short-term hormonal method users preferred both female sterilization (28%), which is more effective, and condoms (22%), which are less effective. Side effects, affordability, and ease of use are some factors, in addition to efficacy, that may be associated with clients’ preferences for specific methods.
Figure 2. The methods that clients with an unmet preference would prefer to use, if they could, differ based on their current contraceptive approach
Method preference by current method use, among those with unmet preference
Source: Child Trends Family Planning Client Survey, 2023 https://www.childtrends.org/publications/methodological-approach-family-planning-client-survey
A patient’s satisfaction with their current contraceptive method does not always mean that it is one of their preferred methods (see Table 1). Researchers and health care providers often ask family planning clients whether they are satisfied with their current contraceptive method. Table 1 indicates that, even among those who were “completely satisfied” with their current method, 18 percent had an unmet contraceptive preference. This figure is even higher (40%) among those who were only “somewhat satisfied” with their current method.
Providers may need to pay particular attention to how they ask about clients’ experiences with contraception, as their clients might respond differently when asked about their preferences than when asked about satisfaction. There are a range to ways to assess contraceptive preference. For example, providers may ask about what method or methods their patients would like to use, whether they have any barriers to accessing it (e.g., cost or availability), or—as we did in our survey—what method clients might want to use, even for reasons other than preventing pregnancy (see Table 3).
Table 1. Unmet preference and satisfaction with current methods, among method users
Source: Child Trends Family Planning Client Survey, 2023 https://www.childtrends.org/publications/methodological-approach-family-planning-client-survey
Unmet preference for contraceptive methods is a salient indicator of whether family planning care is of high quality, and providers should monitor unmet preference as they strive to provide high-quality, patient-centered care. Some research finds that a range of contextual factors—such as access to prescription methods, having insurance coverage, and poverty status—are linked to unmet contraceptive preference. In addition to asking about preferences, more research is needed to help identify the full range of factors that prevent clients from accessing their preferred contraceptive methods. This information will help strengthen many health care providers’ efforts to ensure that their clients’ preferences, needs, and values are centered in the provision of family planning care.
Data, Sample, and Methods
Data and sample
Measures and methods
Acknowledgments
This publication was supported by the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,548,353 with 100 percent funded by OPA/OASH/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by OPA/OASH/HHS, or the U.S. Government. For more information, please visit https://opa.hhs.gov/.
The authors would like to extend their gratitude to our project officer, Callie Koesters, for her leadership and for her careful review of this brief. We would additionally like to thank Kate Welti for her review, Krystal Figueroa and Catherine Nicols for their design work, Quynh Nhu Dao for her fact checking, and Brent Franklin for his copy editing.
Footnotes
[1] We report results where 10 or more clients indicated a preference for each strategy. Due to limited sample sizes, we suppressed responses for methods preferred by female sterilization, vasectomy, withdrawal, and natural family planning users.
[2] The survey was conducted in the fall of 2023, so services received in the prior year refer to services in 2022.
Suggested citation
Pliskin, E., Wildsmith, L., & Manlove, J. (2024). Unmet contraceptive preferences among family planning clients with low incomes. Child Trends. DOI: 10.56417/2151i620f
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