Understanding patient perspectives on the quality of family planning care: a qualitative study

Abstract

Background

In 2024, the United States (US) Office of Population Affairs updated federal guidelines for the provision of quality family planning (QFP) services, outlining six guiding principles—person-centered, evidence-based, inclusive, accessible, sex- and body-positive, and trauma-informed care—to promote equitable, high-quality sexual and reproductive health (SRH) services. This study explores patients’ SRH care preferences and the extent to which asserted preferences are aligned with the systems-level definition of quality advanced in the QFPs.

Methods

We conducted a secondary qualitative analysis of data; the original study used a qualitative methodology where data were collected in a series of semi-structured interviews between 2018 and 2021. Interview participants were recruited through a survey conducted at publicly supported sexual and reproductive health clinics in Arizona and Iowa. Eligible individuals were those who opted into qualitative follow-up after taking a baseline survey at publicly funded sexual and reproductive health clinics in Arizona and Iowa (n = 80). We completed a content analysis of participant interview responses to identify themes that pertained to several domains of sexual and reproductive health care quality and preferences.

Results

We found substantial overlap between participants’ preferences for care and the 2024 Quality Family Planning guiding principles. Participants described their preferences for and experiences of care that were person-centered (feeling respected and listened to), inclusive (identities respected and considered), accessible (clinic wait times and appointment availability), sex-positive (were not judged or stigmatized), and confidential. Evidence-based and trauma-informed care, quality counseling, and informed consent were less prevalent in our findings, though largely because they were not assessable by patients or were not explicitly covered in the interviews.

Conclusions

Patient preferences are largely in keeping with the recommendations for providing quality family planning services, especially around the domains of person-centered care and accessibility. These guidelines should be adopted by clinics across the country to ensure that patients receive the highest quality family planning care possible and be able to achieve their reproductive autonomy.

Background

Of the 26 million women1 in the United States (US) who received at least one contraceptive service in the last year, almost one-fifth received care from a publicly supported clinic [1]. These clinics, funded in part through programs like Title X (the federal program that supports family planning) [2] and Medicaid (the state and federal program that provides health insurance to eligible people with low incomes) [3], play a role in serving patients that often face structural barriers to care, such as people living with low-incomes, people of color, or young people. While publicly supported family planning clinics provide care to all individuals, many of these clinics overwhelmingly provide services to patients assigned female at birth (e.g., 85% of family planning patients served by Title X clinics in 2023 were women) [4], in part because of the unevenly gendered burden of contraception [5]. For almost two-thirds of women visiting a publicly supported clinic, the clinic was their primary source of any medical care [6]. Understanding the extent to which these clinics provide person-centered care – care that is respectful of and responsive to individuals’ preferences, needs, and values – is especially important given their vital role in serving the populations experiencing marginalization.

A systematic review on family planning care quality found that patients often rated care poorly on multiple domains: accessibility (e.g., long wait times to obtain appointments, inconvenient hours of operation, lack of language interpretation services), communication/information (e.g., insufficient explanations, lack of tailored advice, dismissal of patient’s concerns), client-staff interactions (mostly friendly/respectful, but marginalized groups reporting feeling disrespected), efficiency/organization (e.g., long in-clinic wait times after arrival, lack of provider continuity), and facilities (e.g., low ratings on cleanliness and crowdedness) [7]. A more recent systematic review of client preferences related to contraceptive care found that participants identified the following factors as important: receipt of information on a range of contraceptive methods, providers with similar demographic backgrounds and life experiences as them, providers who can provide continuous care, and providers that engage in shared-decision making and support their autonomy [8]. Other research has found that sexual and reproductive health (SRH) care quality is shaped by the clinic providers, staff, and overall environment [9]. Patients report wanting compassionate, respectful, non-judgmental providers who provide information to support their decision-making [9]. While participants valued quality of care, they sometimes prioritized affordability of care due to financial constraints [9]. Measurement tools like the Person-Centered Contraceptive Counseling (PCCC) scale reflects patient preferences for care including respecting the patient as a person, asking what matters to them about their contraceptive method, taking their preferences seriously, and providing enough information for their decision-making [10].

In 2024, the federal Office of Population Affairs (OPA), part of the US Department of Health and Human Services (HHS), updated recommendations on quality family planning service (QFPs) to guide providers of sexual and reproductive health (SRH) care in delivering high-quality services. These recommendations reflect new evidence and adopt a health equity lens addressing structural inequities and historical oppression [11]. This guidance was designed to be broadly applicable across all SRH service providers, inclusive of Title X funded family planning programs and primary care clinicians. It lays out six guiding principles for the delivery of care: person-centered, evidence-based, inclusive, accessible, sex- and body-positive, and trauma-informed. It also highlights three approaches to care to support these principles: quality counseling, informed consent, and privacy and confidentiality.

While there is ample evidence on patient preferences for care, assessing how well the updated QFPs align with patient preferences for and experiences of SRH care is crucial as the guidelines serve as a benchmark for a nationally recognized standard of quality care. For this study, we define SRH services as including, but not limited to, contraceptive counseling or method provision, STI testing or treatment, pregnancy testing, well woman exams, and HPV vaccinations. Person-centered SRH care includes elements such as respect for personal autonomy, bodily integrity, and childbearing decision-making [12]. We aimed to understand the driving forces of people’s SRH care preferences and how aligned these preferences are with system-level definitions of quality, in particular the new QFPs.

Methods

Sample and data collection

This analysis draws on longitudinal, semi-structured interviews conducted with individuals seeking care at publicly funded SRH clinics in Arizona and Iowa [13, 14]. These interviews were conducted as part of the Reproductive Health Impact Study (RHIS), a multi-year, multi-state effort that documented the impact of policy changes on the publicly supported family planning network and its patients. Participants were recruited from a larger RHIS survey of patients assigned female at birth and aged 15 and older and were eligible if they completed a baseline survey, provided contact information, and reported experiencing barriers to contraceptive access in the previous year. All participants provided verbal consent to participate before each interview.

Interviews of Iowa respondents were conducted by three researchers at the Guttmacher Institute with similar demographic profiles to study participants. All were assigned female at birth, identified as women at the time of data collection, and were of reproductive age. Two identified as white, and one identified as Black. English-speaking Arizona participants were interviewed by three researchers at the Guttmacher Institute and Spanish-speaking participants were interviewed by four bilingual researchers at the Southwest Interdisciplinary Research Center. As in Iowa, interviewers had similar demographic characteristics to interviewees (assigned female at birth and identified as women of reproductive age). Three interviewers identified as white, one as Asian, and three as Latina/Hispanic. Interviewer identities may have shaped interview dynamics and participant interactions.

Interviews were conducted in three waves, spaced six to nine months apart, between 2018 and 2021, using semi-structured guides focusing on contraceptive use and preferences and experiences seeking and receiving SRH care, including access steps, provider interactions, care preferences, care settings, and barriers to care, with the same general set of topics covered in each wave. The interviews lasted between 39 and 120 min, with interviews on average lasting longer in the first wave. In Iowa, the sample was drawn from 147 eligible survey respondents, the final sample included 41 participants. All participants were recontacted for subsequent waves though, due to attrition, the total number of completed interviews in Iowa was 111. Interviews were also conducted either in person or virtually for Waves 1 and 2, with all Wave 3 interviews moved online due to COVID-19. In Arizona, the initial sample was drawn from 199 baseline survey respondents (57 Spanish-speaking and 142 English-speaking), the final sample included 39 participants and, with attrition, the total number of interviews completed in Arizona was 94. All Arizona interviews were also conducted via Zoom due to COVID-19. The original studies received approval from the Guttmacher Institute’s Institutional Review Board (IRB), DHHS identifier IRB00002197. Interview guides are publicly accessible on the Open Science Framework (OSF) online archive [15]. More methodological details are available in the previously published studies [13, 14].

Data analysis

This secondary analysis was reviewed by the Guttmacher Institute IRB independent of the original studies for which these data were collected and was deemed exempt because the data were previously collected and deidentified. Previous research using the interview transcripts analyzed the Iowa and Arizona data separately and addressed other research questions that leveraged the longitudinal design of the original study [13, 14]. For this secondary analysis, we conducted a content analysis of participant responses using previously cleaned, deidentified, and (for Spanish-language interviews) translated transcripts. A preliminary coding scheme was developed based on the 2024 QFP guidelines and the original interview guides [11, 13, 14]. Although the underlying data were collected longitudinally, for the purposes of this study, we combined transcripts from multiple interviews with each participant and analyzed them as a single narrative, rather than examining intra-participant change over time. This allowed us to capture the breadth and depth of participant experiences and preferences in our analysis.

Using NVivo Collaboration Server (QSR International), four of the study authors coded several of the same transcripts and reviewed coding to ensure alignment, making revisions to the coding scheme as needed. Transcripts were then distributed among team members, who independently applied the coding scheme during the first round of analysis. The team met regularly to resolve discrepancies and ensure inter-coder consistency in our application of codes. The final coding framework, informed by our focus on patient preferences and definitions of quality in SRH care, integrated both deductive codes derived from prior research and inductive codes that emerged from the interview data. A second round of coding was conducted using the refined coding scheme to ensure thematic accuracy, aimed at assessing alignment between participants’ experiences and the QFP principles.

We generated code reports focusing on participants’ SRH care-seeking preferences and organized the data into thematic matrices to identify prominent patterns. The matrices informed the development of higher-order themes related to care-seeking experiences, provider interactions, and clinical environments. We reviewed the summary matrices and drafted sub-theme bullet points, which were then refined into overarching thematic categories aligned with the guiding principles of the QFP framework: person-centered, evidence-informed, inclusive, accessible, sex- and body-positive, and trauma-informed care, as well as the approaches to care: quality counseling, informed consent, and privacy and confidentiality.

Results

About half of our participants lived in Iowa and half in Arizona, and about half of the participants in Arizona were Spanish-speaking (Table 1). Nearly a third were in their early twenties, and 15% were under 20 years old, with the remaining 55% over 25 years old. Over a third of our participants were living under the federal poverty level (FPL), and 41% were living with incomes between 100% and 299% of the FPL. One participant identified as non-binary and the rest as women. Our participants were evenly split between having public insurance, private insurance, and no insurance, and over three-quarters were recruited from Planned Parenthood clinics.

Table 1.

Sample characteristics

	Number (N = 80)	Percentage (%)
State of residence
Arizona	39	49
Iowa	41	51
Primary language
English	63	79
Spanish	17	21
Age
18–19	12	15
20–24	25	31
25–29	13	16
30–34	11	14
35–39	8	10
40+	11	14
Race/ethnicity
Non-Hispanic White	44	55
Non-Hispanic Black	5	6
Non-Hispanic Other	3	4
Hispanic	27	34
Prefer not to answer	1	1
Employment
Employed for wages	36	45
Student	22	28
Unemployed	22	28
Education
Less than high school degree	7	9
HS GED Alt	14	18
Some college or Associate degree	38	48
College graduate or more	21	26
Poverty status
< 100%	28	35
100–299%	33	41
300%+	10	13
Unknown	9	11
Relationship status
Married	21	26
Unmarried	38	48
Other	20	25
Prefer not to answer	1	1
Gender Identity
Female	79	99
Male	0	0
Non-Binary	1	1
Facility type
Planned Parenthood	61	76
Community/migrant health center	6	8
Health department	6	8
Hospital	1	1
Other	6	8
Insurance status
Public	23	29
Private	27	34
Multiple	4	5
No insurance	24	30
Unknown	2	3

We found substantial overlap between participants’ preferences for care and the 2024 QFP guiding principles. We outline where the emergent themes regarding care preferences aligned with the QFPs, as well as a few aspects of care that were related to the QFP domains but were not explicitly mentioned in the guidelines.

Person-centered

In the QFPs, person-centeredness is “defined as a focus on an individual person’s needs, values, and preferences”, with a focus on respecting patient autonomy and attention to individuals’ life context. Person-centeredness emerged as a dominant theme in participants’ description of high quality care, with the vast majority describing the importance of feeling respected and listened to by clinic staff and having their needs taken seriously.

What’s important to me? Definitely, having that wraparound feeling of I am being cared for, that this is somebody that genuinely cares about me. A doctor that will actually look me in the eye and say, “We’re going to get you taken care of,” and having that knowledge that if something does [come] up, I can call and ask, and have those follow-ups available to me. -Participant 2202, Cisgender woman, White Non-Hispanic, English (AZ).

Indeed, while most participants described the importance of person-centered care in broad terms, some participants shared experiences that explicitly mirrored the language of person-centeredness in the QFPs, such as a focus on their individual needs.

[They] were very attentive and compassionate. They listened to me, they asked me follow-up questions. They asked me if I was looking to get pregnant or if I was more concerned with contraceptive methods. So, they wanted to know where I was at least in my stage of my life at that point. - Participant 2110, Cisgender woman, White Non-Hispanic, English (AZ).

This quote highlights how care that centers the individual’s needs and autonomy is experienced by the patient as “compassionate” and “attentive.” However, many patients provided counterexamples sharing experiences of care where they did not feel respected. They described clinic staff and providers as being rude, disengaged, or dismissive of their concerns.

I didn’t like how they made me feel like I was making the wrong choice, even though I knew I was making the right one. I just didn’t like having my decision questioned about eight billion times. – Participant 1602, Cisgender woman, White Non-Hispanic, English (IA).

These counterexamples serve to reinforce the centrality of person-centeredness to participants’ experiences of quality care, demonstrating that the absence of person-centeredness undermines efforts to provide SRH care.

One aspect of the care experience that emerged in our findings but is not explicitly covered in the QFPs is continuity of care. Familiarity with a provider (with whom prior interactions have established positive rapport) facilitates patient-provider communication and could be considered an aspect of person-centeredness. Several participants described how they preferred to see providers with whom they were familiar, while others relayed the difficulty of discussing SRH with unfamiliar clinicians.

I just wish I had a better doctor that I had a connection with. […] They don’t really know your history or your story or anything, then it’s hard just discussing that with just a random person. - Participant 2281, Cisgender woman, Black Non-Hispanic, English (IA).

Participants also described how continuity of care simplifies the hassle of relaying past medical history to new providers.

It would be more convenient if I had just had one person, I could go to for everything so that they are aware of and in the loop with everything else that has been done in terms of testing or like new treatments or new plans or whatever the case may be. And then I’m not having to explain to the new person or the person who wasn’t at the last appointment okay this is what I’ve done since I last saw you. - Participant 3260, Cisgender woman, Black Non-Hispanic, English (IA).

Evidence based

The second guiding principle in the QFPs is “evidence-based”, defined as “the use of evidence to inform clinic care, develop programs, and conduct quality improvement.” While patients may not assess adherence to clinical guidelines directly, aspects of this principle arose in the emphasis that patients put on having providers who are knowledgeable, confident, and able to offer clear guidance on SRH decisions.

If I have somebody who is willing to listen and will give me actual advice on what might be best in those situations, that tends to be better for me. – Arizona participant 2210, Cisgender woman, Hispanic, English (AZ).

Again, several participants described negative experiences linked to providers perceived as uncertain or uninformed.

She just was kind of all over the place and didn’t really seem confident in what she was saying. - Participant 1250, Cisgender woman, White Non-Hispanic, English (IA).

Furthermore, several participants described preferring a provider who is focused on SRH topics both because of their expertise and because they felt more comfortable receiving SRH care from someone who specializes in the area.

I like going to a women’s health care and OBGYNs. They are more specialized in […] those types of topics. I don’t know if I want to see a regular doctor for such personal things like that. - Participant 2112, Cisgender woman, White Non-Hispanic, English, (AZ)

However, given that patients may not be familiar with the evidence-base for SRH care, this principle was the least supported in our data.

Inclusive

The guiding principle of inclusion in the QFPs states that “the goal is for all services to reflect a patient’s circumstances appropriately without bias” and outlines three major aspects of inclusivity: LGTBQI+, cultural and linguistic, and workforce composition (i.e., staff characteristics). Our participants’ experiences demonstrated broad alignment with this principle insofar as these aspects of inclusivity reflected aspects of participants’ identities. Only a couple of participants in our sample identified as LGBTQI+, but among them, provider inclusivity of their identities resulted in higher quality care.

It was definitely way more supportive and way more inclusive. They asked me my pronouns and they asked me just questions that the other clinic wasn’t asking that maybe would apply non-binary people, which I really appreciate, because I don’t like people assuming. - Participant 2206, Cisgender woman, White Non-Hispanic, English (AZ).

Our Arizona sample was designed to explicitly include Spanish-speaking respondents, and many of these participants described ways in which Spanish-language provision of care enhanced their experience or, alternatively, how the lack of fluent providers hindered it.

The only service they have is on the telephone, but it is not as comfortable as speaking in person in one’s own language. I believe that it is much better to talk personally with the doctors when one needs something. […] the language has been a barrier, because one always has to wait. You don’t want a translator because the conversation is about one’s private life, so you want to talk to the doctor in privacy. - Participant 1202, Cisgender woman, Hispanic, Spanish (AZ).

The most prevalent aspect of inclusion described by our sample relates to workforce composition, particularly around provider gender, as well as race/ethnicity and age to a more limited extent. While a few participants described positive experiences with male doctors, the vast majority of those who mentioned gender as a factor preferred to be treated by a woman who they assumed would be more likely to understand their experiences and provide respectful care.

I’m biased about male doctors. […] I had those males and I was not happy with my services, because I felt like they would talk down to me, because I’m a girl. - Participant 4110, Cisgender woman, White Non-Hispanic, English, (IA)

A few participants who were women of color mentioned a preference for racial or ethnic similarity between themselves and their providers.

I prefer it to be a woman, and a woman of color because I feel like they can kind of understand where I come from. - Arizona participant 2101, Cisgender woman, Hispanic, English, (AZ)

Accessible

The QFPs define accessible as including several domains, including logistics, finances, and physical accessibility, and our findings reinforce the centrality of logistics and finances in facilitating receipt of care. Our participants highlighted several logistical aspects that can facilitate or hinder receipt of SRH care, including in-clinic wait times, clinic location, appointment availability, scheduling process, and availability of other services onsite.

Many participants described clinic location and associated travel time to the clinic as central to making care accessible, as well as the importance of in-clinic wait times, with clear preferences for shorter waits. Appointment availability – both in terms of clinic hours that aligned with participants’ schedules and access to walk-in appointments – also affected participants’ ability to access care, in alignment with the QFP’s call for “offering expanded hours, telehealth options, and walk-in appointments.”

The logistics of scheduling appointments also factored into participants’ experiences, with difficulty navigating scheduling processes serving as a deterrent to care in some instances, while ease of scheduling facilitated care in others. Several participants mentioned that having multiple types of care co-located facilitated their care-seeking, which is a key aspect of logistic accessibility that was not made explicit in the QFPs.

I feel good about it just because it’s nice to get both [SRH and general healthcare] done there if you don’t have to go to two different places. And they have—I think they have their own lab. - Participant 1500, Cisgender woman, Hispanic, English (IA).

Similarly, several participants mentioned the importance of access to prior medical records, sometimes encapsulated in difficulties transferring records or ensuring EHRs are complete.

My OBGYN, she can open up my entire file and see everything that my regular physician can see and so it definitely does make that a bit easier, especially when things get a little complicated. - Participant 4110, Cisgender woman, White Non-Hispanic, English, (IA)

In addition to logistical accessibility, financial considerations played a central role in many participants’ care-seeking experiences. However, because these results have been highlighted in other publications, we summarize them only briefly here. Several participants described the difficulty of experiencing uncertainty around cost of care, such as unexpected charges or unclear billing practices, as well as how this could lead to unfulfilled contraceptive preferences. Additionally, for participants who were uninsured, many were upfront about their perceived lack of care options.

I don’t know, because it is the only clinic I can go to. As I told you, I do not have insurance, and it is the only clinic that accepts people like me. - Participant 1201, Cisgender woman, Hispanic, Spanish, (AZ)

While the guiding principle of accessibility describes physical accessibility as a key domain, our participants did not mention it specifically. However, one aspect of physical space that the QFPs do not explicitly address is clinic ambiance, yet this was a key feature of many interviewees’ accounts of their care experiences, with many describing the importance of cleanliness and “feel” to their overall care experience.

The environment, the waiting room, as I mentioned, it was very clean and you could just feel the positivity and the safeness of the space. […] So, it was visually nice to look at and it felt nice to be in. - Participant 2103, Cisgender woman, Hispanic, English (AZ).

Partly, yeah, but also every Planned Parenthood even is kind of similar, in that they have a similar layout […]. You see the signs everywhere. You really just know where you are. It’s very familiar. – Iowa participant 1260, Cisgender woman, White Non-Hispanic, English (IA).

Sex- and body-positive

The guiding principle of sex- and body-positivity encourages providers to be “affirming and supportive” of all bodies as well as consensual, safe sexual activity through the use of “nonjudgmental, open-ended language.” Our findings support the inclusion of this QFP guideline, particularly around sex-positivity. Indeed, nonjudgmental SRH care emerged as a major concern of participants, some of whom relayed negative interactions where providers stigmatized sexual behavior.

The nurse-practitioner was just… really short, was like, “It’s not a partner if you have two of them, and if you want to be seen, you can just go to Planned Parenthood,” which doesn’t really trigger me, but the tone– I knew what she meant: “You’re slutty and you don’t really deserve care here. - Participant 2206, Cisgender woman, White Non-Hispanic, English (AZ).

It was just like the tone in their voice. It’s like, “Wow, three kids before 21?” I don’t know. […] She was like, “I would kill my daughter if she ever had three kids before 21.” I was like, what? I was not happy. – Participant 3261, Cisgender woman, Other Non-Hispanic, English, (IA)

Similar to participants’ preference for providers with specialized SRH knowledge above, many participants perceived specialized SRH clinics such as Planned Parenthoods to provide less judgmental care than other types of clinics. Participants described efforts to destigmatize SRH and put patients at ease at these specialized sites.

I feel right out the gate that going to Planned Parenthood I know that this is their wheelhouse. There is no judgment. I feel no judgment whatsoever. I could tell them I had an orgy with 50 people, and they wouldn’t bat an eye. You do that in an OB/GYN and yes, you’re going to get eyes. - Participant 1701, Cisgender woman, White Non-Hispanic, English, (IA)

Trauma-informed

In the QFPs, the trauma-informed guiding principle highlights the need for providers to recognize that many patients may have experienced trauma, including sexual violence, and urges providers to “practice universal trauma precautions and trauma-informed care with all patients.” The QFP principle centers on trauma screening, but this was not explicitly mentioned by our participants. Two participants explicitly linked an experience of sexual assault to their preference for clear explanations of procedures.

[…] there is still this feeling of this reminds me of when somebody hurt me, and there have been many times when I wished that a doctor would sit down with me and say, “I’m just letting you know this is what I’m going to be doing. This is what I’m looking for and I need you to tell me if you are starting to get scared or if you start feeling a certain way, so then I can stop. - Participant 2202, Cisgender woman, White Non-Hispanic, English, (AZ)

Similarly, participants described other elements of care that can be considered trauma-informed, such as getting permission before touching and intentionally being gentle when performing exams.

She made sure to tell me everything she was doing. In regards to Pap smear, like “Okay I’m going to scrape the inside of your cervix now. You may feel a little discomfort, but it shouldn’t hurt.” Telling me when she was going to touch me and what she was doing. I just felt very comfortable in an uncomfortable situation. Participant 1230, Cisgender woman, White Non-Hispanic, English (IA).

Approaches to care

The QFPs detail three approaches to care that are meant to assist in enacting the guiding principles: quality counseling, informed consent, and privacy and confidentiality. Our data provide broad support for these approaches, with themes emerging around informed consent and confidentiality in particular. Because our interviews were about SRH care experiences broadly, many of them did not cover experiences of contraceptive counseling in-depth. In places where counseling did come up, participants’ desired experiences aligned with the QFP approach.

They answered all my questions. We did talk about the IUD that one time and yeah, I thought they were willing to answer my questions and gave me enough time. Nobody was rushing. They weren’t rushed or anything. I felt like they were giving me time. – Participant 1273, Cisgender woman, White Non-Hispanic, English (IA).

Many participants described preferring and/or experiencing their providers giving clear explanations of procedures and care options, which overlaps with the “informed consent” approach in the QFPs. In particular, participants described preferring when providers communicate explicit steps in a procedure and assist patients in preparing emotionally and physically for intimate experiences such as Pap smears.

She made sure to tell me everything she was doing. In regards to Pap smear, like “Okay I’m going to scrape the inside of your cervix now. You may feel a little discomfort but it shouldn’t hurt.” Telling me when she was going to touch me and what she was doing. I just felt very comfortable in an uncomfortable situation. - Participant 1230, Cisgender woman, White Non-Hispanic, English (IA).

The approach to the care that was most prevalent in our findings was privacy and confidentiality. Participants positively described practices followed by clinic staff that respected their privacy.

I do like that they kind of – they talk low, so as to not have your information spread out to the waiting room. - Participant 1264, Cisgender woman, White Non-Hispanic, English (IA).

A few participants described experiences of care-seeking that felt like threats to the confidentiality of care, such as protestors outside clinics attempting to dox patients.

I actually remember feeling really scared going to Planned Parenthood last year when I went, because that was happening and I remember, I parked really far away and then walked there, because I didn’t want my license plate taken down. I just felt scared of him [a protestor] showing up at my house or something, which sucked. - Participant 2104, Non-Binary, White Non-Hispanic, English (AZ).

Several participants perceived SRH clinics as more confidential than other healthcare sites.

I also just feel more confidential, I guess, for some reason, going to a clinic that’s specifically for reproductive health versus going to a clinic where you have multiple branches and multiple types of doctors working around each other, different things going on. - Participant 1260, Cisgender woman, White Non-Hispanic, English (IA).

Discussion

Overall, our findings provide broad support for the guidance published in the updated QFPs. In particular, participants echoed the importance of person-centeredness, inclusivity, accessibility, sex-positivity, and confidentiality. Although evidence-based and trauma-informed care, quality counseling, and informed consent were less prevalent in our findings, this is largely a reflection of our data and should not be taken as a critique of the principles and approaches themselves. Measuring alignment between what patients value and what providers and health systems are supposed to deliver helps us to understand if evidence-based, patient-centered care is being achieved in practice. This study’s results reinforce prior research, offering additional support for the importance that SRH patients place on relational aspects of care, including feeling cared for, being listened to, not experiencing judgment, having their identities respected, and maintaining privacy and confidentiality. Additionally, participants consistently emphasized the importance of making SRH care easily accessible. For some, this meant co-location with other health care services, such as primary care, as a way to streamline care and reduce barriers. This finding is in line with other research on patient preferences for receiving SRH care in family medicine or primary care settings [16–19]. At the same time, others expressed a strong preference for specialized SRH settings, where they felt providers were more knowledgeable, attentive, or better equipped to meet their needs, echoing similar findings from prior studies of US-based women generally and patients at family planning clinics in particular [20, 21]. These findings reinforce that no single model of care will meet everyone’s needs. A person-centered system must include a diverse range of care formats – including models that integrate primary care and SRH care, stand-alone family planning clinics, and specialty providers – to accommodate the varying preferences, priorities, and lived experiences of patients. Designing broad, flexible networks that reflect this diversity is essential to delivering truly person-centered care. Relatedly, while participants did mention nonjudgmental language around sex-positivity, participants did not frequently mention experiences of providers using positive language inspiring patient confidence or agency. Providers should aim to promote open dialogue about sexual pleasure and empower patients to achieve their highest level of sexual health [22].

Our findings also underscore the importance of workforce composition. Many participants expressed a preference for providers who share similar characteristics, such as race, ethnicity, or gender, which contributed to feeling more comfortable, respected and understood. This aligns with prior research demonstrating that provider-patient discordance can result in lower ratings of patient experience, while concordance can foster trust and communication [8, 23–26]. These insights suggest that health care organizations should make intentional efforts to recruit and retain staff who reflect the demographics and lived experience of the patients they serve. This includes diversification across race and gender, as well as language ability, cultural background, and life experience [8]. Investing in inclusive hiring practices and workforce development is key to building care environments that are truly responsive to patients’ needs and expectations, and essential for advancing more equitable, person-centered care. Furthermore, well-established, collaborative counseling tools like shared-decision making can help build rapport and trust between patient and provider [8, 27, 28].

In addition, our findings highlighted aspects of care that are not represented in the QFPs directly, namely continuity of care and clinic ambiance. The QFPs describe rapport as an essential element of care, yet for many patients, maintaining the rapport they have established with one provider is preferrable to seeing a new provider. While this may be hard to put into practice given staffing models at many publicly supported SRH clinics, it is nevertheless important to recognize this is an aspect of preferred care [8].

Although clinic appearance and ambiance are not explicitly emphasized in the QFP guidelines — perhaps because they are considered implicit with existing principles — our data suggest that are a meaningful aspect of perceived care quality. Participants frequently referenced clinic cleanliness, comfort and overall “vibes” as shaping their experiences, indicating that these environmental factors should not be overlooked in efforts to deliver person-centered care. Moreover, the physical layout and visual cues within a clinic — such as signage, posters, waiting room design — were interpreted by patients as indicators of how they would be treated and valued. These elements can either reinforce or undermine a sense of respect, inclusion, and safety. A welcoming, thoughtfully designed space can facilitate stronger rapport and signal a clinic’s commitment to dignity and inclusion, and research suggests that spaces should be carefully designed to address the needs of the communities served [29]. Recognizing the interconnections between physical environment and provider relationships, there may be value in the QFP guidelines more explicitly addressing how the physical environment contributes to person-centeredness and to the relational aspects of care. While a welcoming clinic ambiance may seem implicit or self-evident, its significance to patients’ experience — evident in the frequency and depth with which it was raised — suggests that it warrants explicit consideration.

This study’s limitations should be considered. First, interviews were conducted prior to the publication of the revised QFPs, so our interviews did not directly probe participants’ experiences using the framework’s updated principles or approaches. It is possible that participants would have shared experiences that endorse the centrality of some principles (e.g., trauma-informed, physical accessibility, body-positivity) with prompting. Other principles are inherently difficult to assess from patients’ perspectives, such as evidence-based care. Additionally, our sample was largely drawn from publicly supported clinics specializing in SRH care. As such, the preferences for specialized SRH care expressed by participants align with the populations served by Title X clinics but may not be generalizable to the broader population. Future research should investigate whether similar themes arise for participants receiving SRH care in other settings and whether the constellation of services received relates to the relative prevalence of themes. In addition, participants often shared experiences of care that fell outside the study timeline, and we included these in our analysis because they are germane to patient preferences and ideas of quality; however, some quotes may represent care received at other types of care sites. Due to the complexity of the interviews, we were not able to directly link each experience to a given care site. Furthermore, our sample does not include those who could not access care at these clinics; therefore, preferences and challenges less directly resonant with the principles practiced at these clinics could be underrepresented.

Conclusions

In sum, our findings provide strong support for the principles of the QFPs that are most directly assessable from patient perspectives. Indeed, the counterexamples from participant experiences that highlight experiences of care that were not person-centered or were judgmental help to illuminate how services that are misaligned with the evidence-based standards laid out in the QFPs fall short of meeting people’s needs and erect barriers to future care-seeking. To ensure that care is designed to meet patients’ needs, it is essential that policymakers, advocates, researchers, and program administrators continue to center patients’ perspectives both where they explicitly align with the QFPs and, crucially, where they extend or contradict them.

Abbreviations

FPL

federal poverty level

HHS

the U.S. Department of Health and Human Services

OPA

the Office of Population Affairs

QFPs

recommendations on quality family planning service

RHIS

Reproductive Health Impact Study

SRH

sexual and reproductive health

US

the United States

Authors’ contributions

AV and MK were responsible for study design and oversight. AV, JM, ADH, and SS conducted data analysis, composed the manuscript and prepared it for publication. All authors participated in the revision of the final manuscript and approved the final version.

Funding

This publication was supported by the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $2.25 million with 100% funded by OPA/OASH/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by OPA/OASH/HHS, or the U.S. Government.

Data availability

The datasets analyzed in the current study are available from the corresponding author on reasonable request. The interview guides are publicly accessible on the Open Science Framework (OSF) online archive.

Declarations

Ethics approval and consent to participate

The original studies were reviewed by and received approval from the Guttmacher Institute’s Institutional Review Board (IRB), Department of Health and Human Services (HHS) identifier IRB00002197. All participants provided verbal consent to participate before each interview in the original study. In addition, the Guttmacher Institute’s IRB reviewed this study and deemed it exempt because the study did not involve human subjects as defined by the HHS Office for Human Research Protection as the data were collected previously and contained no personal identifiers. This study adhered to the principles outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.