"I was told it was the pill that suits me": A qualitative study of women's perceptions and experiences of medical reasons for non-preferred contraceptive use.

BACKGROUND: People have contraceptive autonomy when they can obtain their preferred contraceptive method. Non-preferred method use may result from inappropriate medical contraindications, which occur when providers apply incorrect contraceptive eligibility criteria during consultations. Non-preferred method use and inappropriate medical contraindications are understudied in the Global South, partially due to measurement challenges. OBJECTIVES: This study provides the first evidence in over two decades that inappropriate medical contraindications are still a barrier to preferred method use in the Global South and offer a new conceptual frame for a neglected medical barrier to contraceptive use. DESIGN: We collected qualitative data from 49 in-depth interviews and 17 focus group discussions (n = 146) with women of reproductive age (15-49) in an anonymized African country. METHODS: We deductively identified instances of preferred method denial for medical reasons, then analyzed these episodes to determine whether the medical reasons for denial were evidence-based. RESULTS: We found that many women who reported preferred method denial described being offered medical reasons discordant with evidence-based guidelines, often resulting in what we determined to be contraceptive coercion. Specifically, we identified that (1) women experienced bi-directional contraceptive coercion with medical rationales, (2) women trusted providers' medical authority and felt unable to ask for more information, and finally, (3) women's personal reasons for their contraceptive preferences were rendered illegitimate by providers' use of biomedical language and (often incorrect) medical rationales. Consequentially, some women self-reported information indicating a legitimate contraindication to the non-preferred method their provider encouraged them to use. CONCLUSION: Inappropriate medical contraindications are an under-studied facility-level barrier to contraceptive access that can result in contraceptive coercion, negative health outcomes, discontinuation of wanted methods, and loss of reproductive autonomy. Addressing inappropriate medical contraindications will require solutions that negotiate both structural factors and individual provider behavior to improve the quality of contraceptive service provision.