Contraceptive nonuse and misuse contribute to rates of unintended pregnancy and STDs among young women in the United States. Clinical providers assume an important role in guiding youths’ contraceptive method choices.

Sixty‐seven women aged 16–21 were recruited as part of a cohort study, conducted in 2009–2012, that examined provider‐patient interactions during family planning visits at six San Francisco clinics. Interactions between patients and providers were audio‐recorded. Participants completed questionnaires about method preference immediately before seeing the provider; they reported on method choice immediately after the visit and by telephone three and six months later. Transcripts were analyzed to examine providers’ strategies for guiding decision making and addressing youths’ contraceptive concerns. Missed opportunities for promoting young women's reproductive health were identified.

Twenty‐one percent of young women who did not report desiring a hormonal or long‐acting reversible method (IUD or implant) before seeing their provider chose one after counseling. Use of a hormonal or long‐acting reversible contraceptive method at follow‐up was more common among women who had received interactive counseling by providers who guided them to consider contextual influences than among those who had not received such counseling. Attention to relationship characteristics, sexual behavior patterns and STD risk was largely absent from contraceptive counseling.

High‐quality strategies used by providers to guide contraceptive decision making were tailored to adolescents’ developmental and environmental needs. Several areas of counseling require increased attention and seem vital to providing comprehensive reproductive health care to adolescents.