Zachary Wagner, PhD, discusses the harms of bias in reproductive care

In a recent interview with Contemporary OB/GYN, Zachary Wagner, PhD, associate professor of economics at the University of Southern California, discussed a study exploring how bias and stigma in reproductive health settings negatively affect young women’s access to contraceptive care.

Led by Wagner in partnership with Pathfinder International and the Gates Foundation, the study sought to understand how provider attitudes influence contraceptive counseling and services for different types of clients, particularly young, unmarried, or nulliparous women. Using mystery shoppers at 226 clinics across Burkina Faso, Tanzania, and Pakistan, the researchers found that provider bias manifests in specific, nuanced ways depending on client characteristics.

Young women aged approximately 15 or 16 years old were often denied contraceptive methods altogether. Women without children received limited counseling, particularly being steered away from hormonal methods due to incorrect beliefs about future fertility. Unmarried women were not necessarily denied services or method options, but experienced noticeably worse treatment from providers because of the stigma associated with premarital sexual activity.

To address these issues, the research team developed an intervention using a human-centered design approach that combined storytelling, peer support, and public recognition. This intervention included 3 core components: summit sessions, which brought providers together to reflect on experiences with bias and hear directly from affected clients; a peer support program lasting 8 to 10 weeks to sustain conversation and behavioral change; and non-financial awards that recognized clinics demonstrating low bias in their care practices.

The intervention was associated with a significant reduction in biased attitudes and an improvement in the actual care provided, as measured by exit surveys of 35,000 young clients over 12 months. Young clients reported receiving more comprehensive counseling and more respectful treatment.

To help other clinics replicate these improvements, Pathfinder has developed a “how-to” guide. While the intervention was originally designed for broad clinic networks, individual components such as the summit and peer support groups can be implemented at the clinic level.

Wagner emphasized that while he’s not a clinician, adherence to clinical guidelines and presenting all contraceptive options to clients—regardless of the provider’s personal preferences—is crucial. One unexpected finding was that women most likely to experience bias—those very young or without children—rarely visited clinics, suggesting that fear of poor treatment may discourage care-seeking altogether. Therefore, reducing bias not only improves in-clinic care but may also increase clinic utilization by marginalized populations over time.

No relevant disclosures.

References

Wagner Z, Moucheraud C, Shah M, Wollum, A, Friedman W, Dow WH. Reducing bias among health care providers: experimental evidence from Tanzania, Burkina Faso and Pakistan. The Economic Journal. 2025. doi:10.1093/ej/ueaf012