Beyond Efficacy: Applying a Reproductive Justice Framework to Contraceptive Counseling for Young People
In recent years, widespread excitement over long-acting reversible contraception (LARC) to reduce unintended pregnancy in the United States has intensified among the public health community, policy makers, and legislators. In addition, medical organizations such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have adopted practice recommendations listing LARC as a “first-line” contraception for adolescents.1
LARCs, consisting of intrauterine devices (IUDs) and implants, are highly effective, reversible, and cost-effective. Many practitioners praise the control over reproduction that LARCs provide young women, allowing them to avoid unintended pregnancy throughout their education. However, for some young women, control may mean the ability to choose a method that can be started and discontinued without provider involvement. For this and many other reasons, young women still may not choose LARC even with complete knowledge and without access barriers.
Review Reproductive Justice History
While the benefits of LARC use are compelling, these contraceptive methods also are part of a shameful history concerning reproductive injustices and abuses in the United States.2 Forced sterilization, financial incentives to encourage LARC use, and reduced prison sentences in exchange for LARC insertion or sterilization are well-documented coercive measures targeting women of color, low-income and uninsured women, indigenous and immigrant women, young women, and those with disabilities as recently as 2010.3
Although one population-level goal may be to increase LARC use, a narrow focus on LARC does not consider young women’s attitudes about their contraceptive counseling experiences. In a 2016 study, researchers collected qualitative data from 50 Wisconsin women, ages 18-29, to understand their perceptions as contraceptive users related to provider bias and influence, mostly with LARC methods. Women across all racial groups expected that providers would be more likely to recommend LARC methods to marginalized communities, and women of color were more likely to link historical injustices of reproductive coercion to their own experiences of racialized LARC promotion. Findings also presented evidence of provider resistance to LARC removal.4
More recently, researchers conducted a qualitative study to explore patient experiences with contraceptive coercion by health providers at the time of abortion using the Integrated Behavioral Model and the Reproductive Autonomy Scale to inform their interview guide. They interviewed 31 women who were predominantly young, black, and Medicaid-insured. Nearly half of participants perceived a form of coercion during their contraceptive counseling; 42% reported feeling “pressured” into choosing some type of method, while 26% voiced that providers “pushed” a specific method or appeared to prefer LARC methods. Participants who were offered a range of methods and given appropriate time for deliberation displayed greater reproductive autonomy and reported less feelings of coercion.5
Reproductive coercion is not about the provider’s intent, even when well meaning, but it is about the individual’s perception. Another qualitative study of 38 Latina and black women ages 18-24 assessed ways in which patients experience pressure from health providers during contraceptive care, and what affect that has on their decision-making and reproductive autonomy. The analysis showed that those who accepted a form of contraception based on what they perceived as their provider’s biased suggestion, discontinued the method sooner than those who did not.6
One of the tenets of reproductive justice is recognizing that the main reproductive challenge facing young and poor women of color is not unintended pregnancy by itself, but rather socio-economic and cultural inequalities that provide some people with easier access to self-determination and bodily autonomy than others.7 SisterSong Women of Color Reproductive Justice Collective and the National Women’s Health Network developed the LARC Statement of Principles.
Hundreds of organizations, including the Society for Adolescent Health and Medicine, Advocates for Youth, and Physicians for Reproductive Health, endorse the principles that “commit to ensuring that people are provided comprehensive, scientifically accurate information about the full range of contraceptive options in a medically ethical and culturally competent manner to ensure that each person is supported in identifying the method that best meets their needs.”8
Consider Your Recommendations
Negative healthcare experiences during adolescence and young adulthood can reinforce health inequities and mistrust of providers, and can affect future health-seeking behavior, especially among young people of color.6 Once we acknowledge the history of reproductive coercion and abuse, we can begin to address the social and health disparities that exist and truly provide patient-centered contraceptive counseling. Health professionals may do this by saying, “I want you to know that I recommend these methods to all of my patients, regardless of their race, social class, or number of children; however, these methods might not be right for everyone, and I want to make sure we find the one that works best for you.”4 It also is critical for healthcare professionals to self-evaluate how their personal biases may affect their contraceptive counseling methods with young people.9
Adolescent medicine providers and reproductive justice advocates have suggested the following questions to help clinicians support the young person’s agency while reinforcing shared decision-making:
- What matters most to you in a contraceptive method?
- What are your preferences?9
In shifting the counseling approach from a tiered efficacy model, which may not be relevant to patients, to one that supports bodily autonomy, dignity, and agency of persons, particularly those whose fertility has been historically oppressed, we work toward ensuring reproductive justice for all.
- Foster DG, Barar R, Gould H, et al. Projections and opinions from 100 experts in long-acting reversible contraception. Contraception 2015:92;543-552.
- Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspect Sex Reprod Health 2014;46:171-175.
- Gold RB. Guarding against coercion while ensuring access: A delicate balance. Guttmacher Policy Rev 2014;17:8-14.
- Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: Perceptions of young adult women. Am J Public Health 2016;106:1932-1937.
- Brandi K, Woodhams E, White KO, Mehta PK. An exploration of perceived contraceptive coercion at the time of abortion. Contraception 2018;97:329-334.
- Gomez AM, Wapman M. Under (implicit) pressure: Young Black and Latina women’s perceptions of contraceptive care. Contraception 2017;96:221-226.
- Higgins JA. Celebration meets caution: LARC’s boons, potential busts, and the benefits of a reproductive justice approach. Contraception 2014;89:237-241.
- LARC Statement of Principles. Available at: www.tinyurl.com/LARCprinciples. Accessed April 19, 2018.
- Shah B, Akers A. Collaboration or coercion: Challenges in prioritizing vulnerable youths’ agency and autonomy in contraceptive counseling interactions with health care providers. Presented at the Society for Adolescent Health and Medicine Annual Meeting. Seattle; March 2018.
A counseling approach that supports bodily autonomy, dignity, and agency of persons works toward ensuring reproductive justice.
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