Experience of contraceptive care by midwives for nonpostpartum individuals in the Netherlands: a mixed methods study

study Merel Sprengera, Megan D. Newtonb, Renee Finkenflügelc, Matty R. Croned, Jessica C. Kiefte-de Jonge, M. Nienke Slagboomf a. PhD Candidate. Health Campus The Hague/Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, the Netherlands. Correspondence: [email protected] b. Research Intern and Medical Student . Health Campus The Hague/Dep artment of Public Health and Primary Care, Leiden University Medical Center, The Hague, the Netherlands. c. Researcher and PMEL-advisor. Rutgers, Utrecht, the Netherlands. d. Professor. Department of Health P romotion, Maastricht University, Maastricht, the Netherlands. e. Professor. Health Campus The Hague/Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, the Netherlands. f. Assistant Professor. Health Campus The Hague/Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, the Netherlands. Health Campus The Hague/Public Health and Primary Care . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2

Since 2015, Dutch midwives have been authorised to prescribe all contraception. Initially providing contraceptive care to postpartum clients, they are increasingly offering it to anyone. It remains unknown how this broader population experiences this care. Therefore, this mixed

study aims to explore experiences of nonpostpartum individuals receiving contraceptive care from Dutch primary care midwives. At 13 midwifery practices in the Netherlands, participants were recruited to fill out a survey and participate in an in- depth semi -structured interview, both based on Levesque’s Conceptual Framework of Access to Health. Univariate and multivariate logistic regression analyses were applied to survey data (n = 91) and thematic analysis to interview data (n = 10). Most survey participants (87.8%) received an intrauterine device during their appointment. A majority (58.2%) rated their care a 10 out of 10. Giving full marks was significantly associated with a higher perceived income (adjusted OR = 3.19, 95% CI = 1.21-8.81, p = 0.021), adjusted for appointment type and time since appointment. Participants reported receiving understandable information, being taken seriously, and having enough time during their appointment. Interviews revealed that participants especially appreciate how midwives make them feel at ease, midwives’ expertise, and the convenience of access. To conclude, given the positive experiences reported by nonpostpartum individuals with contraceptive care from midwives, efforts should be made to improve task sharing and to increase awareness of midwives as contraception providers. Future research should compare care experiences across all types of providers and include a more representative population.

contraceptive care, midwife, experience of care, access to health . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 3 PLAIN LANGUAGE SUMMARY Dutch midwives have been allowed to prescribe contraception since 2015. They have mainly offered contraceptive care to people after giving birth. Recently, they started to provide contraceptive care to a broader population. However, it is unclear how these people feel about contraceptive care provided by midwives. That is why we studied the experience of accessing contraceptive care at midwifery practices in the Netherlands. 91 participants completed a survey and 10 people took part in interviews. Of the s urvey participants, 58.2% rated their care experience a 10 out of 10. People with higher incomes were more likely to rate the care a 10. Interviews showed that participants valued the midwives’ skills and knowledge. Participants also mentioned that they felt at ease and that it was easy to access contraceptive care at midwives. However, many thought midwives only provided care related to pregnancy. To conclude, participants reported very positive experiences with contraceptive care from midwives. To improve access to contraceptive care, it is important to raise awareness that midwives can also provide contraception. Future research should compare contraceptive care experiences across all providers and include a more diverse population. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 4

Contraception helps people in their reproductive years to exercise their right to decide if and when to have children. 1 Although widely available, there is no t one perfect contraceptive method, not in terms of effectivity nor in terms of risks .2 Moreover, while many different options exist, not everyone has the means, values or responsibilities to choose freely .3 Therefore, access to appropriate, high quality contraceptive care and counselling plays a n important role in the navigation of the biological and social reality of reproduction.4 In the Netherlands, various health care professionals are authorised to offer contraceptive care. Most often, people visit their general practitioner (GP) or GP assistant, with GPs being the first contraceptive care provider for 82% of Dutch under 25 -year-olds.5 Additionally, contraceptive care is provided by doctors and nurses at abortion or sexual health clinics, and gynaecologists.6 In 2008, another health care professional was added to this list: midwives were authorised to insert intrauterine devices ( IUDs). S ince 2015, they have also had the jurisdiction to prescribe all contraception methods including birth control pills .7,8 Midwives have since primarily provided contraceptive care postpartum. Nevertheless, an increasing number of Dutch midwifery practices are now expanding their services, offering contraceptive care to anyone in their reproductive period. This is in line with World Health Organization recommendations for family planning to improve access to contraceptive care through task sharing across different professional cadres.9 Internationally, health care systems are often not organised for midwives to be contraceptive providers. In Europe, Sweden is the only country where midwives play a primary role in family planning services. Swedish midwives are authorised to prescribe contraception and provide 80% of all contraceptive counselling. There are two other countries in Europe where midwives are allowed to prescribe contraception : Estonia and the Netherlands .10,11 Meanwhile, in the United States, midwives in Washington state recently (2022) gained prescriptive authority to prescribe contraception.12 Some studies have reported positive experiences with postpartum contraceptive care provided by midwives. These experiences were characterised by convenience, trust, comfort, and the extensive knowledge of midwives.13,14 However, there have been hardly any studies on experience of contraceptive care by midwives for anyone in their reproductive period, . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 5 regardless of postpartum status , and it remains unknown how this broader population experiences this type of care. The few studies that do not focus on the postpartum population explore the perspectives of midwives rather than the people receiving care, 15-17 or involve specific populations, like people with a migration background in Sweden.18 In that study, trust was the main driver for accessing contraceptive counselling at the midwife . After trust was established, the y saw the midwife as a ‘companion through life .’ Additionally, lack of knowledge about contraception, the reproductive system, and the position of midwives as primary contraceptive providers in Sweden impacted their access to and experience of contraceptive care.18

The aim of this study is to explore experiences of contraceptive care at the primary care midwife for nonpostpartum individuals. More specifically, we want to know 1) h ow nonpostpartum individuals evaluate and experience contraceptive care at the primary care midwife; and 2) wh ich sociodemographic factors and appointment characteristics are associated with this evaluation. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 6

Study design This is a n explanatory mixed methods study , allowing for a comprehensive answer to our research questions through both quantitative, anonymous online surveys , and qualitative, semi-structured in- depth interview s, methods .19 B oth the survey and interview questions draw on Levesque’s Conceptual Framework of Access to Health .20 The relationship and sequence of the research components is presented in Figure 1. Figure 1. Diagram illustrating sequence of mixed methods research components. As presented in Figure 2 , this framework consists of five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. These dimensions provide information on the health care system, e.g., about available information, values, organisation, costs , and provider characteristics. Additionally, there are five abilities of individuals accessing health care, each related to one dimension: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage. This framework has been used to explore experiences of care as it considers different dimensions of health care access and as it challenges to not only look at the characteristics of the health care system and the care provided, but to also recognise individual abilities that may influence access to care. 20,21 Setting and data collection From March 2024 to July 2024, participants were recruited through 13 midwifery practices and two ultrasound centres, with a range of 1 to 12 midwives and a median of 6 midwives per practice, providing contraception in both urban (n = 11) and rural (n = 4) areas of the Netherlands. Midwives invited people receiving contraceptive care at their practice to take part by informing them with a flyer at the end of their appointment or via the practice’s social media. MN also visited practices and personally invited potential participants to take part. Step 1: Online survey, exploring satisfaction with contraceptive care at the primary care midwife Step 2: Semi-structured, in-depth interviews with a selection of participants from the survey, exploring experience of contraceptive care at the primary care midwife . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 7 Figure 2. Levesque’s Conceptual Framework of Access to Health. 20 People were eligible to take part if they were 16 years or older, accessed contraceptive care at the midwife, and had not given birth in the past six months. It was also necessary for them to understand Dutch or English, as the surveys were provided in these languages. The flyer and social media post led to a web page where additional information was presented and where participants could navigate to the consent section, followed by the anonymous survey. After completing the anonymous survey, participants could receive a voucher of €10 by contacting the research team . We then sent them the interview information letter and asked if they would like to participate in an interview and in case of a positive response , we contacted them to schedule an interview in person or via an online videocall. After explaining the study and answering any questions, participants provided informed consent in an online form before the start of the interview, which included consent to audio recording. They could pause or stop the interview at any time and could also skip any question if they did not want to answer. Participants received a voucher of €15 after the interview. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 8 Units of study The survey included questions on sociodemographic characteristics, previous experience s with contraceptive care , conversations about contraception, appointment characteristics, expectations and expe riences, subjects on which information was expected and received, satisfaction, and costs. In the last section, we asked participants to grade their appointment from 0 (very bad) to 10 (very good) separately for advice and insertion/prescription . Here, there were also open -ended questions on what they appreciated and what could be improved. All survey questions were mandatory, but participants could choose ‘do not know’ or ‘rather not say’ if they wished to skip a question. The survey data that support the findings of this study are available from the corresponding author, MS, upon reasonable request. The semi-structured in-depth interview consisted of two parts. The first part of the interview focussed on mapping participations use of contraceptive methods, across the life course. The second part of the interview addressed participants’ experience of contraceptive care at the midwife. We started by asking how participants accessed information about contraceptive care at the midwife , why they chose to go there and what they expected from the appointment. Next, participants walked us through their experience from the waiting room to leaving the midwifery practice, were prompted for more details if needed, and elaborated on what they appreciated and what could be improved. Finally, if applicable, participants were asked to compare their recent experience of contraceptive care at the midwife with earlier experiences with other providers (e.g., GP or gynaecologist). Ten people participated in an interview, one interview was conducted by MS and nine by MN. The interviews lasted an average of 50 minutes, ranging from 38 minutes to 1 hour and 12 minutes. Due to the nature of the research, interview data is not available. The interview guide can be found in Appendix A. Analysis Quantitative analysis was performed using RStudio (version 2022.02.3+492) by MS . The answers “do not know” and “prefer not to answer” were coded as missing. As there was very little missing data, all participants were included in analyses and there was no need for multiple imputation.22 Continuous data were presented with a mean and standard deviation (SD) or median and interquartile range (IQR), categorical data were presented as counts and percentages. To explore how nonpostpartum individuals evaluate contraceptive care at the . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 9 primary care midwife, the outcome variable was composed of the grade for advice, the grade for insertion/prescription, or the mean of the two i n case participants indicated they had received both advice and insertion/prescription . Based on the extremely negatively skewed distribution of this grade and majority of participants grading their appointment a 10 , we decided to create a binary outcome v ariable, distinguishing between participants who gave full marks and those that did not. Next, to assess which sociodemographic factors and appointment characteristics are associated with this evaluation, we first performed univariate logistic regression analyses with sociodemographic variables and appointment characteristics. Then, variables were selected for multivariate logistic regression analysis if p- values were <.10 in the univariate logistic regression analyses. Log odds from regression analyses were transformed into odds ratios (ORs) with their respective 95% c onfidence interval (CI) to facilitate interpretability. Interviews were transcribed verbatim and analysed using Atlas.ti. In our iterative coding process, we performed an integrated thematic analysis using both deductive coding based on Levesque’s Conceptual Framework of Access to Health and inductive coding, allowing for a more in-depth exploration of participants’ experiences. Coding was done by MN, supervised by MS. This analysis of interviews helps explore the experience of contraceptive care of nonpostpartum individuals at the primary care midwife and explain the survey results. Ethical approval The study was reviewed by the ethical committee and received a waiver from the Medical Research Ethics Committee of Leiden Den Haag Delft under reference number N21.127 as it was not deemed to be subject to the Medical Research Involved Human Subjects Act. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 10

In this mixed methods study on experiences of contraceptive care for nonpostpartum individuals at the primary care midwife, a description of participants i s presented first, followed by our findings on evaluation and experience of care. Throughout, results will be linked to Levesque’s Conceptual Framework of Access to Health (Figure 2).20 Participants Of the 162 people who opened the survey, 52 did not start filling it out, 18 started but did not complete it, and 92 participants completed the survey . 1 participant was excluded because they had given birth in the past 6 months , resulting in a sample of 91 survey participants . There was 1.4% of missing data across all variables. For the variable time since appointment, there were 8 participants with missing data . One participant did not give a grade for advice and one participant did not give a grade for insertion . However, since these participants’ appointments included both advice and insertion, the grade they did provide was used for their outcome data. Table 1. Characteristics of participants for the survey and interviews. Survey (n = 91) Interviews (n = 10) Participant characteristic n (%) n (%) Age, mean (SD) 29.00 (6.87) 27.80 (6.96) Education Practical 26 (28.9) 3 (30.0) Theoretical 64 (71.1) 7 (70.0) Themselves and parents born in the Netherlands 82 (90.1) 8 (80.0) Religion No religion 74 (82.2) 8 (80.0) Christian 16 (17.8) 2 (20.0) Income Difficult or coping 32 (36.4) Comfortable 56 (63.6) In a relationship 82 (90.1) 10 (100.0) Has children 6 (60.0%) Ever visited a midwife 63 (69.2) 10 (100.0) Contraception providers visited before Midwife 33 (36.3) 3 (30.0) General practitioner 77 (84.6) 8 (80.0) Gynaecologist 18 (19.8) 4 (40.0) . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 11 Table 1 describes both survey and interview participants. They had a mean age of 29 (SD: 6.87) in the survey and 28 (SD: 6.96) in the interviews. A majority had a theoretical education, were born in the Netherlands, were not religious, and were in a relationship. Most survey participants reported a comfortable income. 69.2% of survey participants had ever visited a midwife and about a third had sought contraceptive care from a midwife before. Four interview participants had never been pregnant before and of the six that had received prenatal care from a midwife, three went to the same midwife for contraception. All interview participants had either a hormonal intrauterine system (IUS, n = 6) or IUD (n = 4) inserted. Evaluation of care and associated characteristics Appointment and experience of care characteristics are presented in Table 2. Most survey participants (86.8%) had contraception prescribed or inserted and when they did, they often chose an IUS or IUD (87.8%). Their experience was incredibly positive, with a median of 10 on a 1-10 scale (range = 5 -10) and with 58.2% of participants grading it a 10. In the interviews, one participant reflected on her positive score by saying: “Then I will just give a 10. I really can’t think of anything that did not go well or what could have been done differently.”(P8) This positive evaluation is further illustrated in answers to other questions about experience within the Appropriateness dimension and the Ability to engage, with 89.0% finding the information during the appointment very understandable, 95.6% feeling at ease, 96.7% feeling like they were taken seriously, and 98.9% feeling like there was enough time for the appointment. With regards to the Ability to perceive, for all subjects asked about, participants received information more often than they had expected to. Notable results are that 59.3% received information on the effectiveness of the contraception method in preventing pregnancy, while only 47.3% expected this. Information on side effects seemed to be more important and had the smallest difference between expectation and experience, with 75.8% expecting information and 79.1% having received information. The largest difference was for costs, with 34.1% expecting information and 52.7% having received information on costs. Related to Acceptability, most received care from female midwives (97.8%) and while some participants did not hav e any preference for their contraception provider’s gender, most preferred a female provider for both advice and insertion (68.1% and 83.5% respectively). An interview . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 12 Table 2. Appointment characteristics and experience from survey data (n = 91). Appointment characteristic n (%) Type of appointment Advice only 12 (13.2) Insertion/prescription only 15 (16.5) Advice and insertion/prescription 64 (70.3) Time since appointment Less than 1 week ago 30 (36.1) Between 1 week and 2 months ago 17 (20.5) More than 2 months ago 36 (43.4) Contraception in month before appointment No 56 (64.4) Yes 31 (35.6) Area of midwifery practice Urban 51 (56.0) Rural 40 (44.0) Role of costs in choice of contraception provider No role 45 (50.6) Small role 34 (38.2) Large role 10 (11.2)

of contraception chosen* Combined pill 2 (2.2) Progesterone-only pill 1 (1.1) Intrauterine system (IUS) (hormonal) 54 (60.0) Intrauterine device (IUD) (copper) 25 (27.8) Contraceptive implant 5 (5.6) Male condom 3 (3.3) Natural family planning 1 (1.1) Sterilisation 2 (2.2) Grade, median (IQR) 10 (9-10) Grade <10 38 (41.8) 10 53 (58.2) *Participants could choose up to two methods of contraception. participant elaborated on her preference by comparing what male versus female providers might understand, based on their embodied knowledge: “Women amongst themselves, you truly understand what you are talking about. Whether it's about inserting contraception or getting contraception, in whatever form. I think that, by and large, men have less experience with that.”(P3) Table 3 reports the results from the univariate and multivariate logistic regression analys es. In the univariate logistic regression analyses, perceived income, appointment type, and time since appointment had a p-value of <0.10 and hence were included in the multivariate logistic . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 13 Table 3. Univariate and multivariate logistic regression analyses for sociodemographic and appointment determinants of giving full marks for contraceptive care experience at the primary care midwife. Univariate Multivariate (n = 79) Determinant aOR (95%CI) P-value aOR (95%CI) P-value Age 0.99 (0.93-1.05) 0.793 Education Practical Ref. Theoretical 1.07 (0.42-2.69) 0.883 Ethnicity (Parents) born in the Netherlands Ref. (Parents) born abroad 0.54 (0.13-2.18) 0.382 Religion Not religious Ref. Christian 0.50 (0.16-1.49) 0.215 In a relationship No Ref. Yes 0.37 (0.05-1.62) 0.226 Perceived income Difficult or coping Ref. Ref. Comfortable 3.09 (1.27-7.76) 0.014 3.19 (1.21-8.81) 0.021 Midwife area Urban Ref. Rural 0.95 (0.41-2.20) 0.899 Ever visited a midwife No Ref. Yes 1.07 (0.43-2.62) 0.887 Time since appointment Less than two months Ref. Ref. More than two months 0.41 (0.17-1.00) 0.052 0.43 (0.16-1.11) 0.084 Contraception in month before appointment No Ref. Yes 1.47 (0.60-3.70) 0.407 Appointment type Insertion and advice or insertion only Ref. Ref. Advice only 0.31 (0.08-1.06) 0.071 0.35 (0.08-1.31) 0.129 Previous contraception at midwife No Ref. Yes 1.17 (0.49-2.82) 0.730 Previous contraception at GP No Ref. Yes 0.74 (0.21-2.35) 0.619 Previous contraception at gynaecologist No Ref. Yes 1.16 (0.41-3.47) 0.783 . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 14 regression analysis. In this model, only for perceived income a significant association with giving full marks remained, with an adjusted odds ratio of 3.19 (95% CI (1.21-8.81), p = 0.021). This means that, while adjusting for time since appointment and appointment type, people with a comfortable perceived income have more than three times the odds of reporting full marks compared to people who report to have a difficult perceived income or are coping. This finding may therefore be related to the Ability to pay. Experience of care 89 participants responded to the open survey question elaborating on what they appreciated and commonly responded that the midwife scheduled plenty of time for the appointment, made participants feel at ease, clearly explained every step of IUD insertion, and was familiar because of previously received care . As for what participants found unpleasant, 21 wrote nothing or responded with a hyphen or x, 47 participants explicitly noted that nothing was unpleasant, while 12 noted that the IUD insertion hurt. To further understand the experience of contraceptive care at the midwife , we now present the results of the ten in -depth interviews with nonpostpartum individuals who had visited a midwife for IUD insertion. In the analyses of the interviews, four themes emerged: feeling at ease, convenience of access, trust in midwife as expert, and preconception of pregnancy being midwives’ preoccupation. An overview of the findings in light of the dimensions and corresponding abilities of Levesque's Conceptual Framework of Access to Health (Figure 2) is presented in Table 4.20 Feeling at ease The theme ‘feeling at ease’ reflects the overarching positive experience of the participants with regards to the dimensions of Appropriateness , Ability to engage, and Availability and accommodation. Participants attributed feeling at ease to the midwives' approach, which was characterised by managing expectations and consent, taking a personal approach , taking time, and performing an ultrasound after IUD insertion. Managing expectations and consent Not all participants had expected the midwife to fully explain the procedure before the insertion. Nevertheless, an appreciation of knowing what to expect was a reoccurring theme, as it allowed them to understand what was going to happen and to get comfortable with the . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 15 midwife before the insertion. Moreover, before each next step during the insertion procedure, the midwife would explain what was going to happen and ask for consent before proceeding. This was appreciated because the participants knew what was happening and it made them feel involved in the procedure, like they were doing it together . They were also told in advance when something might be painful. This was seen as a positive thing because they knew what to expect. One participant, who reported a very positive experience of IUD insertion, elaborated that the explanation and consent process played a signi ficant role in making her feel at ease, she said that “each step of the way, she would genuinely check in with me every time if I was okay, and ask if she could continue when she saw that it was unpleasant.”(P9) Personal approach Three participants shared the feeling of the midwife seeing them as a person instead of a number, especially when compared to earlier experiences at the gynaecologist: “In the hospital they don't know, there you are just the umpteenth patient number on a day. They don't know what happened in terms of children, childbirth and the like.”(P6) Compared to their previous experience of IUD insertion at the GP, two participants shared that they did not feel like they were being seen as a person and felt like they were s ent away quickly. The midwife really made them feel seen as a person. Having a prior relationship helped, as is illustrated by the following quote: “I don't actually know my GP that well, I barely ever visit. And this midwife, I knew very well, so I think I also had a better relationship than with my own GP.”(P5) Participants further elaborated on the midwife being very open and friendly, taking a personal approach and sharing her own experiences, which put them at ease. One participant shared that the IUD insertion became a more positive experience because the midwife seemed to really enjoy her job, which was different compared to the GP where she had felt more like a burden. Time The feeling of enough time that the participants experienced mostly stemmed from not feeling rushed by the midwife. They felt like the midwife took the time to explain all the information and to answer all their questions. Especially when reflecting on the invasive and vulnerable procedure of an IUD insertion, one participant phrased this as follows: “It is not . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 16 like: you walk in, it (the IUD, red.) is pushed in and you’re out the door again, so to speak. They really take their time with you.”(P10) All the participants stated that they felt like they could raise concerns if they had them and felt like they were listened to well. Compared to for example the GP, the participants reported that they had more time at the midwife and felt less rushed. Ultrasound Something that was also widely appreciated was the fact that the midwives performed an ultrasound either directly after insertion, or six weeks after the insertion. This gave participants a feeling of reassurance that their IUD/IUS was correctly inserted. They compared this to the GP where an ultrasound is not done and preferred to have this additional examination: “She checked with the ultrasound if it was properly in place. So that was also nice to immediately get that confirmation.”(P8) Convenience of access The theme ‘convenience of access’ explores the logistics around Availability and accommodation, Ability to reach, and Affordability that participants encountered when visiting a midwife as a contraception provider. The participants appreciated the fact that they did not have to go into hospital and that they did not have to travel far: “The midwife is nice and close to home, more accessible to call. Yes, then a hospital is further away.” (P6) In addition, participants felt like they were able to book an appointment at the midwife within a reasonable time. One participant also noted that they were able to book an appointment in the evening and that this would not have been possible at the GP. Finally, participants deemed the costs of seeking contraceptive care from a midwife lower than the gynaecologist, while comparable to the GP. Trust in midwife as expert The theme ‘trust in midwife as expert’ reflects the Approachability of and Ability to perceive midwives as contraceptive providers. Participants trusted the midwife to have a lot of expertise, both in terms of knowledge and ski lls to insert an IUD. Participants commonly related their trust in the midwife to their familiarity with female anatomy and the frequency in which midwifes insert IUDs. One interviewee, for example said: “She is so experienced in placing those things (IUDs , red.), who knows how many times in a week! You gain so much . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 17 more experience and are so much more skilled in it.” (P7) Participants frequently compared the midwife with the GP: “I feel like the midwife does insert contraception or at least IUDs more often than the GP. Of course, the GP has a much larger range of duties, and the midwife also has a broad range of duties, but that is mainly focused on pregnancy, childbirth, ‘uterus stuff.’ (...) And they just know a lot and I know that they can do it wel l, inserting contraception. So, I did have a much better or safer feeling compared to my GP.” (P5) Presumption of pregnancy being midwives’ preoccupation The themes above illustrate the participants’ explanations of their positive experiences at the midwife, but participants also reflected on potential disadvantages, related to the dimensions of Acceptability, Ability to seek and Approachability. The main disadvantage was that it is unknown that midwives provide contraception, that it is presumed they only provide care around pregnancy. Consequently, although described by four participants, there a meaning is ascribed when being seen walking into a midwifery practice. Two participants mentioned that around their contraception appointment, one in the waiting room and one after, they were approached by someone asking them if they were pregnant, because they had been seen at a midwife: “And I received a text afterwards from someone who happened to see me there saying: hey, you were at the midwife, do you have to tell me something? And I said yes, I go t an IUD, so there is nothing. That is kind of a small- town thing in our area. Like to just check, and that a midwife is immediately associated with you being pregnant. And that clearly doesn't have to be the case.” (P3) A third participant mentioned this as a hypothetical situation, and another had her own prejudices that only changed while on placement for her midwifery degree: “At first, when the GP suggested (to go to a midwife for IUD insertion, red.), I thought: I’m not going, the midwife is something for women who are slightly older or for women who just got pregnant and want contraception after that. Until I also saw younger women (come for contraception, red.) on placement. Then I thought: actually, this is also just a place to get it done as a younger woman.” (P4) . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 18 While these participants shared that they did not mind explaining others that they were at the midwife for contraception, they did mention that this might not be the case for everyone. Although not described by all participants, these stories reiterate the idea that midwives are for pregnant people only. Hence, it is no surprise that all Dutch participants shared that many people are unaware of the possibility of contraceptive care at the midwife. On the other side, for the two participants who grew up outside of the Netherlands, the Dutch health care system was new to them and after searching the internet for places to get an IUD and finding the midwife, they simply assumed that this was how contraceptive care is organised in the Netherlands. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 19 Table 4. Overview of findings in light of Levesque's Conceptual Framework of Access to Health. Dimension, ability Approachability, Ability to perceive Acceptability, Ability to seek Availability and accommodation, Ability to reach Affordability, Ability to pay Appropriateness, Ability to engage Survey - 83.5% prefer a female provider for insertion - Midwife was familiar because of previous visits - 98.9% felt there was enough time for the appointment - People with a more comfortable perceived income have more than three times the odds of reporting full marks, adjusted for time since appointment and appointment type - 89.0% found information during appointment very understandable - 95.6% felt at ease - 96.7% felt taken seriously - More information received than expected - Midwife clearly explained every step Interviews Trust in midwife as expert - Midwife is familiar with female body - Midwife often inserts IUDs Presumption of pregnancy being midwives’ preoccupation - Not widely known that midwives provide contraception Presumption of pregnancy being midwives’ preoccupation - Common idea that midwife is for pregnancy care only Feeling at ease - Midwife took enough time - Midwife could perform an ultrasound Convenience of access - Short travel distance - Appointment was booked within reasonable time Convenience of access - Lower costs than gynaecologist - Indirect costs: short travel distance Feeling at ease - Midwife clearly explained each step of the procedure and asked consent before proceeding - Midwife made participants feel like a person - At ease because of expertise and frequency of doing this - Could raise concerns, were listened to well - Open, friendly, personal . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 20

This mixed-methods study explored how nonpostpartum individuals evaluate and experience their contraceptive care at Dutch primary care midwives. The survey showed that participants evaluate this with high grades, with people with a more comfortable perceived income more often giving full marks. The interviews identified feeling at ease, convenience of access, and trust in the midwives’ expertise as common the mes in participants’ explanations of their positive experiences during for IUD insertion appointments. These findings are comparable to other studies on contraceptive care at midwives where convenience,13,14 trust,13,18 comfort, and midwives ’ knowledge were appreciated. 13 Although international studies on contraceptive care experiences at primary care providers, reproductive health care providers, and certified nurse midwives have also reported positive experiences, the ratings in this first study on contraceptive care from midwives in the Netherlands were remarkably high.23-25 Now, we will discuss our findings in light of the Levesque Conceptual Framework of Access to Health (Figure 2) and existing literature.20 Starting with Approachability, midwives seem to be relatively approachable for contraceptive care : our survey showed that information during appointments is understandable, but in the interviews, we found that midwives are not well known as a contraceptive care provider . The Ability to perceive is not as present, but participants did trust the midwife because of their expertise. As for the Acceptability dimension and the Ability to seek , some interview participants experienced prejudice about them being pregnant after being seen at a midwife. However, they did not mind explaining the actual reason for their visit, which is in contrast with findings from Kolak et al. where immigrant women who migrated to Sweden from outside of Europe feared their parents would find out they had visited a midwife for contraception. 18 Although there is a misconception of pregnancy being midwives’ sole preoccupation, our survey and interview findings show that they are an acceptable contraceptive care provider for two reasons in addition to their expertise. First, most participants preferred a female provider for contraceptive care, which is in line with the preference for female primary care physicians and gynaecologist s.26,27 Second, even though our participants were not postpartum at the time of their appointment, if they received care from a midwife before, they had already established a relationship, which is known to be of great value. 13,18 . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 21 With regards to A vailability and accommodation and the Ability to reach , both research

showed midwives plan sufficient time available for appointments, something that has also been associated with satisfaction of contraceptive care at Dutch GPs.5 Interviews showed that appointments can be booked soon and in evenings , and that m idwives are nearby, they are usually located in the community , resulting in short travel time. This is contrary to findings from Reed et al. at a sexual health clinic, where participants described difficulty booking an appointment and lack of transportation. Participants without private insurance particularly had trouble booking an appointment, something we did not find, which may be attributed to differences between the Dutch and American health care financing systems. 28 Regarding Affordability and the Ability to pay, while short travel time results in lower indirect costs, in terms of direct costs, midwives are a more affordable choice compared to accessing contraceptive care at a gynaecologist. Costs was something about half of survey participants considers when choosing their contraceptive care provider. Additionally, we found that adjusted for appointment type and time since appointment, full marks were more often given by those with a highe r perceived income. An association between income and quality of contraceptive care has previously been found in the United States, where affordability was also found to be a large barrier in accessing contraceptive care. 29,30 Finally, numerous factors contribute to the Ability to engage with and the Appropriateness of midwives as contraceptive providers , found in both the survey and interviews : they make clients feel at ease through scheduling ample time and taking a personal approach, asking consent before each step, providing sufficient understandable information, making an ultrasound which reassures clients, and earning clients’ trust because of their expertise. Time, trust, expertise, positive interactions, and a supportive environment have previously been highlighted as key factors in contraceptive care both at midwives and other providers.5,18,28,31 Furthermore, there is relatively equitable access to all contraception methods at midwives, as they are authorised to prescribe all contraceptive methods, although there seems to be a notable concentration of IUD/IUS provision. While all five dimensions from the framework appeared in our study, the Appropriateness dimension emerged most often. This is not s urprising, as according to the Levesque Conceptual Framework of Access to Health, this dimension and the Ability to engage become . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 22 relevant in particular after having accessed care and these concepts consequently influence satisfaction, or experience with care .20 Concurrently, these concepts, related to midwi ves' interpersonal skills, being most relevant is in line with studies on another care experience when one might feel vulnerable : the mammogram. Interpersonal skills and positive attitude of mammography staff are important factors related to satisfaction of care, and explanation before and during the procedure resulted in fewer women experiencing pain during the mammogram.32-34 Strengths Through this study’s mixed methods design, we were able to both quantitatively study the evaluation of contraceptive care at the primary care midwife and perform a qualitative in - depth exploration of experience of care. Our questions were based on Levesque’s Conceptual Framework of Access to Health, 20 providing us with structure and a theoretical foundation, and on previous mixed methods work on contraceptive care at Dutch GPs. 5 The study fills a gap in the literature, as there are barely any studies internationally, and to our knowledge none in the Netherlands, on midwives as a contraceptive provider for all and more specifically not on people that did not receive this type of care as a continuation of prenatal care after delivery. A final strength is that we purposefully sampled our interview participants to ensure they had not received postpartum contraceptive care at the midwife.

This study has several limitations. First, related to recruitment, although we aimed to include only nonpostpartum individuals in both the survey and interviews, some midwife practices shared a social media post to inform clients about the study. It is likely that this was the reason a larger than expected proportion of survey participants reported their appointment to be more than two months ago, and why this variable had most missing data. Fitting our inclusion criteria and not being postpartum at the time of survey participation, it is possible that these participants could have been postpartum d uring their appointment. Secondly, our sample is relatively homogenous, especially when it comes to education, ethnicity, religion, and income. As a result, we have unfortunately not been able to explore in the interviews why people with a more comfortable perceived income more often evaluated their appointment with full marks. Our homogenous sample might be the result of our recruitment methods and entry into research, an online survey, not being as inviting for people with a practical . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 23 education, lower inc ome, a religion, or migration background to participate. It is possible there was selection bias, resulting in more people with a positive experience taking part, both for the survey and interviews. Or these groups might not seek contraceptive care at midwives so often , as our results showed that the midwife is not well known as a contraception provider. Implications Various implications follow from this study. First, given recommendations from the World Health Organization on access to contraception, it might be an option to increasingly implement task sharing and shift part of contraceptive care from GPs to midwives, specifically for IUD/IUS insertion , creating a more even distribution of contraceptive care across the workforce and decreasing the high GP workload in the Netherlands.9,35 To realise this, more midwives should be trained to provide contraception and awareness should be raised about midwives serving as primary care contraception providers, as recommended by participants in this study. Second, since the experience of contraceptive care provided by midwives seems to be so positive, other contraceptive care providers might take some inspiration from the specific characteristics that were most appreciated, if they are not implementing these already: asking consent before each step, scheduling enough time, and taking a personal approach. Finally, a comparative study of the experience of contraceptive care at all available contraceptive providers should be performed, including a representative population.

This study demonstrated that contraceptive care provided by primary care midwives in the Netherlands is highly valued , primarily due to trust in their expertise, the comfort they establish, and the convenience of access to care. Despite the enduring misconception that midwives focus solely on care related to pregnancy, our findings reveal that they are a suitable contraception provider for all. This presents an opportunity for task sharing of contraceptive care between Dutch midwives and GPs , particularly for IUD insertions. To realise this, more midwives should be trained in providing contraceptive care and awareness about their position as contraceptive provider should be increased. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 24 AUTHOR CONTRIBUTIONS Merel Sprenger: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing. Megan Newton: Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Renee Finkenflügel: Methodology, Writing – review & editing. Matty R. Crone: Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing. Jessica C. Kiefte-de Jong: Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing. M. Nienke Slagboom: Conceptualization, Methodology, Supervision, Writing – review & editing. FUNDING STATEMENT This work was supported by ZonMw under Grant number 554002006. CONFLICT OF INTEREST No conflict of interest to declare.

We want to thank all midwifery practices and participants for contributing to our study. Additionally, we want to acknowledge the following people for their contribution to the study design: Astrid van der Duijs, Leanne Bakker, Ineke van der Vlugt, Ingvil de Haan, Rodante van der Waal, Riny van Melzen, Wendy Wielenga, Charlotte Jacques, and Maylis Sanjuan. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 25

1. United Nations. Report of the International Conference on Population and Development: Cairo, 5-13 September 1994. New York: 1995. 2. Teal S, Edelman A. Contraception selection, effectiveness, and adverse effects. JAMA. 2021;326(24):2507. doi: 10.1001/jama.2021.21392. 3. Ross LJ, Solinger R. Reproductive justice: an introduction. Oakland, California: University of California Press; 2017. 4. Cadena DS, Chaudhri A, Scott C. Contraceptive care using reproductive justice principles: beyond access. A merican Journal of Public Health. 2022;112(S5):S494 -S9. doi: 10.2105/AJPH.2022.306915. 5. Ditzhuijzen Jv, Olofsen S, Knibbeler R, Vlugt Ivd. Het eerste anticonceptieconsult bij de huisarts: tevredenheid, verwachtingen, en ervaringen van jonge vrouwen. Utrecht: Rutgers, 2021. 6. Rutgers. Anticonceptie regelen 2024. Available from: https://seksualiteit.nl/onderwerpen/anticonceptie/anticonceptie-regelen/. 7. KNOV. Algemene maatregel van bestuur 2022 [updated 8- 11-202228-05-2024]. Available from: https://www.knov.nl/werk-en-organisatie/informatie/algemene-maatregel-van-bestuur. 8. Wagemakers A, Vaandrager L. Een nieuwe rol voor de verloskundige. Onderzoek naar kansen en belemmeringen voor de Wageningse verloskundigen. Wageningen: Wetenschapswinkel Wageningen, 2015 Contract No.: 309. 9. WHO. Task sharing to improve access to family planning/contraception. Geneva, Switzerland: Department of Reproductive Health and Research, World Health Organization, 2017. 10. Kopp Kallner H, Thunell L, Brynhildsen J, Lindeberg M, G emzell Danielsson K. Use of contraception and attitudes towards contraceptive use in Swedish women - a nationwide survey. PLOS ONE. 2015;10(5):e0125990. doi: 10.1371/journal.pone.0125990. 11. Sedlecky K, Rašević M, Bitzer J. Education and training of health care workers for contraceptive service delivery in 21 countries across Europe. Sexual & Reproductive Healthcare. 2020;24. doi: 10.1016/j.srhc.2020.100498. 12. Zell B, Effland K, Snyder M, Hays K, Gordon W. Prescriptive authority for direct entry midwives in Washington state: increasing client access to contraception. Journal of Midwifery & Women's Health. 2024. doi: 10.1111/jmwh.13606. 13. Walker SH, Hooks C, Blake D. The views of postnatal women and midwives on midwives providing contraceptive advice and methods: a mixed method concurrent study. BMC Pregnancy and Childbirth. 2021;21(1). doi: 10.1186/s12884-021-03895-2. 14. Carr SL, Singh RH, Sussman AL, Rogers RG, Pereda B, Espey E. Women’s experiences with immediate postpartum intrauterine device ins ertion: a mixed -methods study. Contraception. 2018;97(3):219-26. doi: 10.1016/j.contraception.2017.10.008. 15. Kolak M, Jensen C, Johansson M. Midwives' experiences of providing contraception counselling to immigrant women. Sex Reprod Healthc. 2017;12:100 -6. Epub 2017/05/10. doi: 10.1016/j.srhc.2017.04.002. PubMed PMID: 28477921. 16. Kettyle EP, Klima C. Adolescent emergency contraception: attitudes and practices of certified nurse-midwives. Journal of Midwifery & Women's Health. 2002;47(2):68-73. doi: 10.1016/s1526- 9523(02)00219-2. 17. Höglund B, Larsson M. Midwives’ work and attitudes towards contraceptive counselling and contraception among women with intellectual disability: focus group interviews in Sweden. The European Journal of Contraception & ; Reproductive Health Care. 2019;24(1):39- 44. doi: 10.1080/13625187.2018.1555640. 18. Kolak M, Löfgren C, Hansson SR, Rubertsson C, Agardh A. Immigrant women’s perspectives on contraceptive counselling provided by midwives in Sweden – a qualitative study. Sexual and Reproductive Health Matters. 2022;30(1). doi: 10.1080/26410397.2022.2111796. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 26 19. Creswell JW. A concise introduction to mixed methods research. Thousand Oaks, California: SAGE Publications, Incorporated; 2015. 20. Levesque J -F, Harris MF, Russell G. Patient -centred access to health care: conceptualising access at the interface of health systems and populations. International Journal for Equity in Health. 2013;12(1):18. doi: 10.1186/1475-9276-12-18. 21. Cu A, Meister S, Lefebvre B, Ridde V. Assess ing healthcare access using the Levesque’s conceptual framework– a scoping review. International Journal for Equity in Health. 2021;20(1):116. doi: 10.1186/s12939-021-01416-3. 22. Jakobsen JC, Gluud C, Wetterslev J, Winkel P. When and how should multiple imputation be used for handling missing data in randomised clinical trials – a practical guide with flowcharts. BMC Medical Research Methodology. 2017;17(1):162. doi: 10.1186/s12874-017-0442-1. 23. Dehlendorf C, Anderson N, Vittinghoff E, Grumbach K, Levy K, Steinauer J. Quality and content of patient –provider communication about contraception: differences by race/ethnicity and socioeconomic status. Women's Health Issues. 2017;27(5):530-8. doi: 10.1016/j.whi.2017.04.005. 24. Hart L, Parsons G, Beaudoin J, Alonge O, Karp C. A mixed methods study of contraceptive counseling and care at a federally qualified health center in Maryland. Journal of Patient Experience. 2023;10. doi: 10.1177/23743735231183572. 25. Dehlendorf C, Henderson JT, Vittinghoff E, Grumbach K, Levy K, Schmittdiel J, et al. Association of the quality of interpersonal care during family planning counseling with contraceptive use. American Journal of Obstetrics and Gynecology. 2016;215(1):78.e1 -.e9. doi: 10.1016/j.ajog.2016.01.173. 26. Walker B, Wisniewski J, Tinkler S, Torres J, Sharma R. Identity and access: gender -based preferences and physician availability in primary care. Journal of Economic Behavor & Organization. 2024;224:1022-36. doi: 10.1016/j.jebo.2024.07.009. 27. Spaich S, Weiss C, Sütterlin M. Altered patient perceptions and preferences regarding male and female gynecologists: a comparison between 1997 and 2018. General Gynecology. 2019;300:1331-41. doi: 10.1007/s00404-019-05315-5 28. Reed R, Osby O, Nelums M, Welchlin C, Konate R, Holt K. Contraceptive care experiences and preferences among Black women in Mississippi: a qualitative study. Contraception. 2022;114:18 -25. doi: 10.1016/j.contraception.2022.05.009. 29. Wingo E, Sarnaik S, Michel M, Hessler D, Frederiksen B, Kavanaugh ML, et al. The status of person-centered contraceptive care in the United States: results from a nationally representative sample. Perspectives on Sexual and Reproductive Health. 2023;55(3):129 -39. doi: 10.1363/psrh.12245. 30. Newton-Levinson A, Griffin K, Blake SC, Swartzendruber A, Kramer M, Sales JM. “I probably have access, but I can’t afford it”: expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA. BMC Health Services Research. 2024;24. doi: 10.1186/s12913-024-11133-6. 31. Fulcher K, Archibald A, Francoeur J. 'They really hear you out': lessons on providing contraceptive care from a community -based sexual health clinic. The Canadian journal of human sexuality. 2021;30(2):243-51. doi: 10.3138/CJHS.2021-0018. 32. Van Goethem M, Mortelmans D, Bruyninckx E, Verslegers I, Biltjes I, Van Hove E, et al. Influence of the radiographer on the pain felt during mammography. European Radiology. 2003;13(2384-2389). doi: 10.1007/s00330-002-1686-6. 33. Whelehan P, Evans A, Ozakinci G. Client and practitioner perspectives on the screening mammography experience. European Journal of Cancer Care. 2016;26(3):e12580. doi: 10.1111/ecc.12580. 34. Almog R, Hagoel L, Tamir A, Barnett O, Rennert G. Quality control in a national program for the early detection of breast cancer: women’s satisfaction with the mammography process. Women's Health Issues. 2008;18(2):110-7. doi: 10.1016/j.whi.2007.12.007. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 27 35. Geit Ed, Vis E, Flinterman L, Keuper J, Schaaijk Av, Batenburg R. De arbeidsmarkt van de Nederlandse huisartsenzorg in 2021: toelichting en samenvatting van het onderzoek – en de regionale factsheets Utrecht: Nivel, 2022. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 28 Appendix A: Interview guide contraception at the midwife - Thank you for wanting to participate in this interview. I emailed you the information letter before this interview. Have you had time to read it through? Do you have any questions about that? - Have you filled out the consent form? - Getting contraception from the midwife is fairly new in the Netherlands, which is why we are doing this study. I will first ask you about previous experience with getting contraception and in the second part we will go more into your experience at the midwife. The interview will last about 45 minutes. - There are no right or wrong answers. - If I ask a question that you would prefer not to answer, please let me know. And if for any reason you want to stop or pause during the interview, you are welcome to say as well. - The interview will be anonymized. Your name will not be mentioned anywhere and all information that can be traced back to you will not be included in the typed interview. - Do you have any questions before we start? - Then I will start the recording and start with the questions. Sociodemographic characteristics - What is your age? How old are you? - Where were you born? And where did you grow up? - Where do you live now? - Are you in a relationship? (Do you live together? Are you married?) - Have you ever been pregnant? (Do you have kids?) - What kind of school did you go to after primary school? What school did you finish? - Do you work? (What kind of work do you do?) - Were you raised with a religion? (Which one?) . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 29 Contraception life course - I am curious about the different contraceptive methods you have used in your life and how you experienced the access to them. Let’s list all the contraception you have used, and I’ll ask questions about each. (Draw out.) o How old were you when you first started using contraception? (including condoms) o Why did you want to start? o What form of contraception were you using at the time?  Here is a list of different methods (with Rutgers visual aid) o Where did you get [contraceptive method] back then? (e.g., general practitioner, gynaecologist, abortion clinic, midwife) Add place/caregiver to life course.  Why did you decide to go there?  How was your experience there? o How much did it cost you to get [contraceptive method] back then?  Was part of it covered by your health insurance? Did you know?  Did costs play a role for you at the time? If so, what kind of role? o Does it play a role for you if health care statements show that you use contraception (e.g., if parents/partner pay for health insurance)? If so, what kind of role? o How long did you use [contraceptive method] then? / How old were you when you stopped using it?  If stopped: Why did you want to stop using the contraception? Did you discuss this with the person who prescribed it? o Did you start using something else after that to prevent getting pregnant? - Repeat the above questions up to and including the current method: o 1. Starting age, 2. Reason start, 3. Which contraceptive method (including condoms), 4. Place of access, why there, experience. 5. Costs. 6. Stopping age, 7. Reason stop/discussed with HCP. Also note if nothing has been used for a period. - Which midwife practice did you visit? . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 30 Experience with the midwife Now I would like to talk about your experience with contraceptive care at the midwife. - First, I'm curious about how you chose contraception for the midwife. o How did you know you could go to the midwife for contraception?  Where did you find (your) information?  What did you think about the information about contraceptive care at the midwife? • To what extent was this information understandable to you? What would you change about this?  How did you make an appointment? What did you think of the availability? • How fast were you able to get an appointment?  What kind of appointment did you have? Insertion and/or consultation. o What made you choose to go to the midwife for birth control?  Personal, social, cultural norms and values; Gender (caregiver) - What did you expect from the contraceptive care at the midwife? (first open, then ask further questions if necessary) o How many/which different forms of contraception did you expect the midwife to inform you about? o What kind of information about the different methods? (e.g., reliability, side effects, use, period, costs, STI’s, appropriate to personal (medical) situation) o To what extent did you expect the midwife to be able to help you make your choice? Did you expect that your final choice would be made by you, the midwife or together?  Did the midwife ask you why you chose [self chosen contraception]? o Expectations of satisfaction, nerves/tension, asking about sexual relationships, asking about reason for AC use, trust that midwife wouldn't tell anyone else. - Then I am curious how the contraceptive care at the midwife went. o How did you go there (e.g., by tram, bicycle, on foot, etc.)? Was it easy to reach? o Did you have a (telephone) intake before? If so, how did that go?  Did they ask about STI test? Pregnancy test? . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 31 o How did it go during your appointment? (first open, then ask further questions if necessary) Can you take me along through your appointment from the moment you arrived?  Waiting room: What was the waiting room like? How long did you have to wait? Was it busy/lot of other people?  Before: where did you sit? On the bench or on a different chair?  Insertion  Ultrasound?  After  How long did the appointment take?  How many/which different forms of contraception did the midwife give you information about? • What kind of information about the different methods? (e.g., reliability, side effects, use, bleeding pattern, costs, STIs, appropriate to personal (medical) situation)  How did you choose the method you finally chose? (guidance from midwife, self, together)  In addition to the chosen form of contraception, did you also receive information about the use of condoms to prevent sexually transmitted infections? o To what extent did you understand all the information you received from the midwife? And what the midwife did?  How comfortable did you feel asking the midwife all your questions and raising your concerns? o After the first meeting with the midwife, was there a follow-up appointment (physical or telephone) to discuss whether you were satisfied with the contraceptive method? o To what extent did that match what you expected?  Did you feel a need for a follow up? . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 32 - How did you experience contraceptive care at the midwife? (first open, then ask questions) o What did you appreciate about the midwife? o What did you dislike?  How could that be better? o To what extent did the midwife meet your needs?  Would you recommend the midwife for contraception to a friend? • Why? Why not? • Specifically, this one or midwives in general? o Would you recommend the midwife to your younger self? o If not named, ask questions about professionalism of midwife, sufficient time, social skills (friendly, open, safe, respectful), continuity (follow-up) - Costs / covered by health insurance o Method o Insertion o Ultrasound o Follow-up - What was it like for you to see a midwife when you are not pregnant? - Are there any specific things that need to be changed regarding contraception at the midwife? - How did this experience compare to your previous experiences with getting birth control? Depending on previous experience: o General practitioner, gynaecologist, abortion doctor o In terms of accessibility, degree of acceptance, accessibility, affordability, and appropriateness o Gender of healthcare provider - Where would you go next time? For example, for removal or getting new contraception o Why would you take the contraception out? E.g., desire to have children? - What else do you need to get contraception and use it properly? o Any other wishes for contraception and/or access to contraception? . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint 33 Closing - This was my last question. Is there anything else you would like to add? - Do you have any questions for me? - Then I will stop the recording now. - I want to thank you very much for your cooperation and time. Here is the gift card. . CC-BY-NC-ND 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 2, 2024. ; https://doi.org/10.1101/2024.08.01.24311261doi: medRxiv preprint