Provider attitudes, long-acting reversible contraception, and quality of care: A mixed methods study in Tanzania

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Abstract Global contraceptive programs increasingly promote the use of long-acting reversible contraception (LARC)— implants and intrauterine devices (IUDs)—to reduce the 121 million unintended pregnancies each year. LARCs are highly effective, low maintenance, long lasting, and have lower rates of discontinuation. Unlike other reversible contraceptive methods, LARCs require removal by a clinician to discontinue use. These features have caused providers, advocates, and scholars to promote LARC uptake globally—however, a LARC-first approach may infringe on a client’s right to choose what type of contraceptive method to use and when to stop using a method. Contraceptive programs targeting reduction of unintended pregnancy may engender provider attitudes and behaviors that favor LARCs and restrict client autonomy and choice in contraceptive care. There is little evidence on these dynamics from low- and middle-income countries (LMICs) where LARC use has been explicitly embedded in country-specific contraceptive uptake goals. This study will fill a gap in the literature by (1) describing providers’ attitudes, beliefs, and care practices surrounding LARC- related care, (2) modeling the influence of provider attitudes on clients’ LARC uptake and LARC removals, and (3) assessing the association between quality of care and LARC uptake and LARC removals in a sample of 73 facilities in Dar es Salaam, Tanzania. Tanzania is a compelling setting to study provision and removal of LARCs as use of implants has risen by 1240% since 2004. The Tanzanian government has set explicit targets for increasing LARC use—aiming for 20% and 13% increases in implant and IUD use respectively between 2019 and 2023, increasing the structural emphasis on LARC uptake. A focus on the quality of services is essential to ensure the emphasis on contraceptive uptake has not come at the expense of high-quality, person-centered contraceptive care. The study utilizes three data sources: 29 in-depth interviews with contraceptive providers, a client exit survey capturing 13,036 contraceptive clients seeking either a method of contraception or a LARC removal, and a survey of 259 providers. The proposed study will employ constant comparative thematic qualitative methodology to examine provider attitudes and care practices in the qualitative interviews and hierarchical Bayesian models to jointly model provider- and client-level survey data. Understanding the influence of provider attitudes on LARC uptake, removals, and quality of care will facilitate targeting interventions to address poor quality care.