Contraceptive access initiatives often have focused on long-acting contraceptive methods, such as intrauterine devices (IUDs) and implants. These initiatives analyzed provider-level and financial access barriers to contraceptive methods.
But this way of thinking has changed. Family planning experts now are examining access issues within a person-centered contraceptive care framework. This framework conceptualizes access according to what individual women want in contraceptives — not just around what they can afford and what is available.
“Increasingly, it has been recognized that these are excellent methods of contraception, but they are not the best methods for all people,” says Christine Dehlendorf, MD, MAS, professor, vice chair for research, family, and community medicine, and director, person-centered reproductive health program at University of California, San Francisco. “An access initiative should not prioritize one method over another, but provide access to the full range of methods and support women in their use of these methods. It’s about what works for them.”
This change considers cultural issues and historical context around contraceptive access. For instance, for decades there has been an undercurrent of racism involved in how healthcare providers handled contraceptive recommendations for black women.
“Black women recognize the history of birth control as population control and eugenics,” says Joia Crear-Perry, MD, FACOG, president of the National Birth Equity Collaborative in New Orleans. Through medical research and public health practices that would be criminal now, black women’s bodies have been exploited, she notes.
For example, the United States government funded sterilization programs in the 20th century. These were used to control populations of people of color, immigrants, poor people, disabled or mentally ill people, and others. (More information is available at: https://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states/ and: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449330/.)
In a 2018 study, investigators found that racism and discriminatory healthcare practices that began with slavery have compromised the reproductive health of African American women. These historical experiences continue to affect how black women perceive healthcare systems.1
For these reasons, family planning providers cannot assume all of their patients perceive contraception the same way they do, Crear-Perry says. “We live in different spaces,” she adds.
While an OB/GYN might perceive a long-lasting contraceptive as a good option for a sexually active teenager, the teenager might desire a form of contraception over which she has more control, she explains.
Providers also should be aware of their own underlying biases. For instance, when a care provider sees a young woman who lives in poverty and does not have access to quality education, the provider might believe the myth that access to better contraception will reduce poverty, Crear-Perry says.
These prejudices cut in both directions. Some providers put barriers on the use of IUDs, despite their effectiveness, Dehlendorf says.
“A number of our studies have shown that some providers will not place an IUD in a teenager or someone who has not had a baby previously,” she adds. “In the past decade, this has improved because of evidence-based recommendations about eligibility.”
The main concern was that IUDs would cause infertility, but that concern was misplaced. “Studies have found that infections like chlamydia — not IUDs — caused infertility,” Dehlendorf explains. “Women who use IUDs are not more likely to get chlamydia.”
Individual providers might consider their own motivations and conceptual understanding of what their patients need within the framework of societal prejudice and inequality. “There has been a lot of framing around contraceptive access as a public health initiative and initiative for societal benefits,” Dehlendorf explains. “But it’s an unfounded assertion that contraceptive access is a tool to address poverty on a societal level. Thinking this way can affect how providers view their work.”
The goal of a new framework is to help providers view contraceptive access and equity in a new way — more in terms of the individual’s needs and less in terms of perceived societal goals, she says.
“This is an ongoing conversation in our field, and I think it’s encouraging people to be critical about the assumptions we make about people’s reproductive health and choices,” Dehlendorf says.
- Prather C, Fuller TR, Jeffries WL, et al. Racism, African American women, and their sexual and reproductive health: A review of historical and contemporary evidence and implications for health equity. Health Equity 2018;2:249-259.