New research finds that family planning providers and administrators in Ethiopia, India, and Mexico largely view high-quality contraceptive counseling as a means to get patients to use birth control.

There’s been a recent shift toward a human rights framework for contraceptive programs, focusing on the quality of the care rather than contraceptive uptake. During this period of transition, the two views often co-exist within research, program and policy spaces. This tension is underscored by the roots of contraceptive policies in the eugenicist population control movement, which prioritized fertility control over individual rights and preferences.

In the context of these shifting narratives about why quality matters, it’s important to understand how health care systems and providers navigate potential conflicts between these approaches. New research initiated by Kelsey Holt with analysis led by Lauren Suchman sought to understand how providers and administrators are motivated by instrumentalist (quality counseling is a means to encourage contraceptive uptake) versus rights-based (quality counseling is an end goal in itself) approaches to quality care.

Through interviews with providers and administrators in Ethiopia, India, and Mexico, researchers suggested a tension between using contraceptive counseling to meet population-level goals versus meeting needs and preferences of individual patients.

When discussing how they oversee providers and ensure quality, administrators showed more concern for meeting goals related to population growth and maternal health. Providers described valuing high-quality counseling as an end in itself, suggesting that counseling appropriately and comprehensively was more important than meeting goals set for the whole population. Since administrators are responsible for meeting performance goals set by local government and reported being held directly accountable or experiencing subtler pressure, it’s unsurprising that these goals were more important to them.

Providers have to answer to clients directly on a daily basis and may be more likely to draw their definition of quality from these interactions. However, most people interviewed converged around contraceptive uptake when it came to articulating the ultimate goal of contraceptive counseling. Despite general agreement among providers and administrators that it’s important to counsel women according to their needs and respect their choices, they all seemed to agree that successful counseling should result in a woman either starting to use contraception or continuing to use her current method unless she has immediate plans to get pregnant. Having a client refuse contraception after counseling essentially was considered a failed interaction.

Ongoing discussions in the field offer practical solutions for governments to transition to a rights-based approach. While such recommendations maybe useful and relevant, it’s important to note that local and national policies are informed by and must be contextualized within global politics, including those that reinforce encouraging reproduction for the wealthy and privileged while discouraging it among those with less privilege and resources. These findings highlight a need to reconcile the sometimes-conflicting narratives, which can sometimes lead to reluctance to respect clients’ choices to use, continue, switch, or stop contraception.