Discussion
We found that the CHARM2 intervention had a significant effect on women’s perceptions of interpersonal quality of care received from their family planning providers and that this effect on quality of care mediated observed effects of the CHARM2 intervention on contraceptive use. Interestingly, quality of care did not demonstrate mediation effects on contraceptive communication and contraceptive self-efficacy outcomes; these outcomes may be more attributable to engagement of men in the CHARM2 intervention rather than the quality of care women report. However, our study design does not allow us to compare male engagement components to women’s person-centered counseling components. These findings indicate the value of the person-centered shared decision-making approach utilized in CHARM2 to support quality of care in family planning counseling for women and that this care can increase women’s uptake of contraceptive use, corresponding to prior evidence showing an association with person-centered care and contraceptive use [We found low mean IQFP scores for both groups at baseline, and for the control group throughout the study, highlighting the need for more person-centered counseling methods, like CHARM2, in this population. Our findings support the capacity for health systems to support person-centered care for women while engaging men in family planning counseling simultaneously, with gender synchronized sessions. Concerns regarding male partner engagement as compromising female reproductive agency [Our study has several limitations. Outcomes were reliant on self-report and collected by interview, and are, therefore, vulnerable to recall and social desirability biases. High follow-up rates (> 80%) reduce follow-up biases, though the sample is reduced in analyses restricted to women who reported receiving family planning care in the prior 9 months. At 9-month follow-up, all women in the intervention arm who received at least one intervention session (95% of intervention participants) had in fact seen a family planning provider in the prior 9 months; however, this item was asked directly of women and 33 women who received sessions reported they had not seen a provider and did not provider IQFP scale responses. This may be due to issues of recall or misunderstanding the question.Another limitation is that we cannot ascribe the quality of care outcomes to CHARM2 intervention participation with certainty (respondents were not asked to name the provider for whom they were rating quality of care). Treatment condition respondents would most likely have seen a CHARM2 provider in the prior 9 months at 9-month follow-up due to the nature and timing of the intervention, and would likely revisit that provider given an established relationship, physical proximity, free services, and continuity of care, particularly if perceived quality of care was high. Additionally, observed intervention effects, particularly at 18-month follow-up, may be attributable to women more effectively engaging with providers subsequent to CHARM2 receipt, whether or not the provider was trained in the CHARM2 intervention. Findings from this study have limited generalizability, to the region of India in which we worked and to rural young married couples. Nonetheless, findings may inform efforts to increase person-centered contraceptive care and use of preference-aligned outcome indicators to assess intervention effects in other contexts and populations, particularly within India. While our rigorous cluster randomized controlled trial design is a strength of the study, multiple arms to compare intervention components would offer greater insight into the mechanisms by which the intervention led to significant improvements in outcomes. Data collection at follow-up encompassed the period of the COVID-19 pandemic and subsequent lockdown periods in India, and the pandemic may have affected access to contraceptives as well as women’s agency [In summary, gender equity focused family planning interventions such as CHARM2, which utilize person-centered care models improve women’s perceived quality of care. Effects on quality of care mediate the observed effects of the intervention on contraceptive use. These findings highlight the value of shared decision-making counseling strategies to support male engagement interventions while still prioritizing women’s reproductive agency and the importance of utilizing preference-aligned outcome measures to assess the effect of family planning interventions.