It was the end of a very long day in the office when I picked up her chart. I had already seen twenty patients and she was my last of the day. I recognized her name — Anna. I’d seen Anna before, about a year earlier; she was returning to the office for her annual checkup. She was healthy and didn’t have any concerns or complaints, so we chatted a bit while I performed her exam. We talked about her work and how her two small children were doing. She had recently started a new job as a waitress and was attending school at night.
When the conversation turned to her plans for pregnancy prevention, she told me that, although she knew that she didn’t want to have another baby “anytime soon,” she wasn’t interested in using anything for birth control.
She had used birth control pills in the past, but she experienced side effects that she didn’t like. We discussed other methods that might work for her given her preferences and past experiences. Her new job didn’t provide health insurance, so the birth control patch and the ring were financially out of reach for her. Given her new job and her school schedule, she was worried about being able to get to the office every three months, which is required for the Depo-Provera shot. When we got to the discussion about long-acting reversible contraceptive (LARC) methods — the implant or the intrauterine device (IUD) — she replied with a resounding, “No! My mom always told me, ‘Don’t let them put anything inside you.’ ” She told me about her mother’s experience with the IUD and about an older cousin who had an implant placed years earlier. Both women advised Anna not to use these methods or anything similar.
Anna went on to tell me that she preferred to use condoms, even though she understood that they “may not work as well” as some of the methods I mentioned. At least, in her words, “I know what I’m getting.”
We talked a bit longer about condom use and I gave her a prescription for emergency contraception, just in case she needed a back-up. She told me she would follow up if needed, and we wrapped up her visit.
Complex Lives, Complex Decisions
As an OB/GYN physician, with subspecialty training in family planning, my work is often laser focused on reproductive health. From contraceptive counseling to abortion services, I take care of women every day who are working to manage their reproductive lives. Some are planning a pregnancy. Others are trying to avoid one. But all of my patients share one thing in common: They are not making decisions about family planning in a vacuum. Contraceptive use, pregnancy, and abortion happen like everything else: within the context of one’s life and lived experiences.
When patients show up to see me with a pregnancy, planned or unplanned, they are often dealing with a myriad of other issues as well. Like Anna, some lack insurance coverage. Many are unemployed or under-employed. Others have concerns about their immigration status or violence in their homes or communities. All of these things factor into their decision-making process and cannot be separated from the way they seek or obtain care.
The influences of personal and community experiences with contraception decision-making and attitudes around pregnancy and abortion are complex. This is especially true for communities that have been historically marginalized and disenfranchised, such as communities of color. From government supported and sanctioned eugenics programs, to abusive and coercive sterilization practices in Black, Latinx, and Native American populations, to birth control trials without informed consent in Puerto Rico, to the linking of birth control implant placement to obtaining or maintaining public welfare benefits, when we look back at the history of reproductive healthcare in the United States, we see a pattern of stratified reproduction.
The fertility of women of color has often been devalued and intentionally suppressed. This has contributed to a legacy of suspicion and distrust of the medical system. Studies show that people of color, and African Americans in particular, are more likely to report a general distrust of the healthcare system. They often express concern about being experimented on during the course of routine medical care and about receiving substandard care due to their race or income, and they often report dissatisfaction with the patient-provider relationship.
Conspiracy theories regarding coercive birth control practices, and even genocide, are often pervasive in communities of color. Not surprisingly, these suspicions are negatively associated with attitudes toward modern contraception, and they particularly impact a woman’s likelihood of using methods that require the involvement of or are controlled by a healthcare provider. In other words, the more effective LARC methods like IUDs and implants are not trusted by many women of color. They are often likely to prefer short-acting methods like the pill or patch, despite a higher likelihood of failure — because they, not the healthcare provider, control the stopping and starting of these methods.
This distrust is not unfounded. Provider based bias has been identified as a contributor to disparities in healthcare outcomes overall. There has been a good deal of work examining the impact that biases play in contraceptive counseling on the provider side. Many studies have shown that providers are more likely to sterilize women of color and low-income women, and also that providers are more likely to recommend LARC methods to low-income women of color than to low-income white women. Women of color and low-income women are also more likely than more affluent white women to report being pressured to use birth control and limit their family size.
When we examine disparities in unintended pregnancy in this context, it becomes clear that those communities that are impacted the most by unintended pregnancy are also those that have been traditionally marginalized. Although almost half of all pregnancies in this country are unintended, we have made significant progress in reducing the overall rate of unintended pregnancy. The United States has also experienced significant declines in teen pregnancies.
But when we take a closer look, we find that these declines don’t occur uniformly. Women of color are roughly twice as likely to experience an unintended pregnancy as compared to white women. And Black women have the highest unintended pregnancy rate of any racial or ethnic group. At 79 unintended pregnancies per 1,000 women aged 15–44, the rate is more than double that of non-Hispanic white women (33 per 1,000). This remains true even when controlling for income.
One factor that may contribute to these disparities is contraception non-use. Couples who do not use any method of contraception have an 85-percent chance of experiencing a pregnancy over the course of a year. Black and Latina women are more likely to report not using any contraception at all, and to report using less effective methods.
About half of unintended pregnancies are experienced by women who were not using contraception at the time that they became pregnant; the other half are experienced by women who became pregnant despite reported use of contraception (though they may not have been using it consistently or correctly). According to a study by the Guttmacher Institute, only 5 percent of unintended pregnancies are experienced by women who report using contraception consistently and correctly. The evidence clearly shows that contraception works.
Reproductive Justice in Theory and Practice
The incorporation of a reproductive justice framework into clinical care provision creates a unique opportunity for healthcare providers to examine the ways that the systems and circumstances in our patients’ lives influence their health. This is distinctly different from the way many of us were taught to provide reproductive healthcare.
Reproductive health most commonly refers to the reproductive process — diseases, disorders, and conditions that affect the functioning of the male and female reproductive systems during all stages of life. This is different from reproductive rights, a term that is sometimes incorporated into the reproductive health framework. The World Health Organization (WHO) defines reproductive rights as the recognition of the basic right of all individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information to do so. The reproductive rights framework has historically focused on protecting everyone’s legal rights to abortion and contraception, and their freedom to make reproductive choices.
In contrast, reproductive justice places reproductive rights within a social justice and human rights framework. This framework was developed by a group of Black women who wanted to address the limited attention paid to diverse communities in the reproductive rights movement. Reproductive justice has its origins in grassroots mobilization and public policy change. It draws attention to the importance of changing the structural inequalities that impact women’s reproductive health and their ability to control their reproductive lives. Structural change is critical because individual and community experiences with abortion, contraception, and unintended pregnancy are influenced by the social, political, and historical context in which we work, live, and play.
For many, the healthcare system serves to reinforce the already existing inequities in their lives. Anna’s story is demonstrative, but not unique. As a healthcare provider, I’ve had these interactions many times. Although Anna was sure that she didn’t want to become pregnant, her decision to use condoms was not based on the contraceptive efficacy of the method. There were other considerations and preferences that influenced her decision.
Without considering the ways structural barriers, historical influences, and lived experiences impact the receipt of care, it might be difficult to understand the way individuals make decisions around reproductive healthcare. If we, as healthcare providers, don’t take these influences into account, we will continue to struggle to provide the care for our patients that they need.
This is what reproductive justice looks like in practice. It means considering the context of the patient’s life and lived experience when providing care. It means asking our patients how the other structural barriers in their lives impact the way they experience the healthcare system in general, and contraceptive care specifically. And finally, once a patient has chosen a method, it means incorporating the reproductive justice framework into her continuing contraceptive care, and obtaining the desired method that same day, if possible.
The Case for Intersectionality
The lives of our patients are complex. So are the systems in which we live and practice. One way to account for these complexities through the reproductive justice framework is to incorporate the concept of intersectionality. The term, coined in 1989 by scholar and critical race theorist Kimberlé Williams Crenshaw, is grounded in the notion that our individual identities are not separate, just as our oppressions are not. The multiple layers of our identities combine to create unique experiences in our lives and unique oppressive existences for certain individuals.
Despite the intersectionality of our lives, we operate within a health framework that urges us to collapse individual identities into neat boxes for our own ease, comfort, and simplification. This can result in separate and unequal care. For Anna, this means acknowledging that, as a person of color in the United States, her willingness to use contraception may be impacted by the history of contraceptive and reproductive coercions experienced by her community. Additionally, as a woman of color, the structural racism and sexism that she experiences in larger systems result in a greater likelihood that she will be under-educated and under-employed. Intersectionality highlights the concept that oppressions that people of color, immigrants, low-income people, and trans people experience are often not additive, but multiplicative.
It is important to note that reproductive oppression doesn’t only occur in obvious ways, such as forced sterilization or lack of consent for care. It also occurs in more subtle ways that contribute to inadequate access to quality healthcare in low-income communities and communities of color. One obvious example is the Hyde Amendment, which prohibits the use of federal Medicaid funds to pay for abortion — the policy essentially makes abortion unaffordable for the people who are already struggling the most.
Considering the Context
When we evaluate our patients using the reproductive justice framework and taking into account the intersectionality of their lives, it’s clear that considering the political, social, and racial contexts in which they live is necessary to fully understanding their sexual and reproductive health decision-making. Acknowledging, addressing, and confronting systemic injustices and oppressions can help us better care for our patients and, most importantly, help them care for themselves.
Dr. Jamila Perritt is a board-certified, fellowship-trained OB/GYN with a comprehensive background in family planning and reproductive health. She provides community-based care focusing primarily on the intersection of sexual health, reproductive rights, and social justice. Dr. Perritt collaborates with various organizations to provide ongoing support and expertise on sexual and reproductive health, family planning, and reproductive justice.