Access to the full range of reproductive health services, and especially to contraception, remains an issue for many Americans. For instance, in New Jersey, where I work, data show that 25% of all pregnancies in our state are "unintended" and nearly 435,000 women live in "contraceptive deserts," which means there's no reasonable access to these services. The COVID-19 pandemic has only exacerbated barriers to care and highlighted inequities everywhere.
Providers can promote quality and comprehensive care by using the reproductive justice lens to drive equity across systems and with individuals. Reproductive justice, as defined by the SisterSong Women of Color Reproductive Justice Collective, is "the human right for people to maintain personal bodily autonomy, to have children or not have children, and to parent those children in safe and sustainable communities." Prioritizing reproductive justice involves centering these rights and supporting actions that actively uphold them, at the patient level and beyond.
While many barriers to care, like transportation and insurance coverage, are the overall result of larger societal problems, we cannot underestimate the role of individual providers to improve access to quality contraceptive care. We all have a part to play in addressing obstacles that prevent patients from receiving the very best care, and this is especially true for reproductive health services -- where stigma, shame, coercion, and other systemic factors make it difficult for individuals to receive the care they need. A patient's single interaction with a provider can be an empowering experience -- or one that negatively impacts all subsequent interactions they have with the healthcare system.
Consider the experience of M.K., a mother of three who needs to take unpaid time off of work and use public transportation to attend an appointment with her provider to obtain birth control. During her appointment, she feels rushed to select a birth control method. She wants to ask questions but feels talked down to by her provider. Based on the provider's comments, M.K. feels like a clear preference for her to use an IUD is based on preconceived ideas about her race, number of children, and insurance type, instead of her priorities. She agrees to the IUD and schedules an appointment for the insertion, but knows she won't be able to get the time off work and, as a result, doesn't get a birth control method at all -- her goal for the appointment.
We currently are coming to grips with the realities of many social injustices in our nation. Included in these is a troubling past of reproductive injustice, such as surgeries on enslaved people, forced or unconsented sterilization, and contraceptive coercion. These practices, primarily directed toward people of color and other marginalized people, such as those who were incarcerated, teens, low-income people, or those living with disabilities, lasted well into the 1990s. The current accusations surrounding hysterectomies performed on immigrant women demonstrates that we are not far removed from this history. Coercion in reproductive health, although more subtle, still exists in the form of persons being given inadequate or misleading information about sterilization, or cash incentives for contraceptive use and other infractions.
To combat this, a reproductive justice lens must guide and inform our efforts to address access at every level of intervention. That means evaluating policies to assure they are grounded in evidence and support individual rights. It means acknowledging the impact of structural determinants of health -- racism, sexism, ableism -- on the systems that our patients must navigate to obtain care. As providers, we must commit to practices that address the ways structural determinants play out in our systems and support patient autonomy and high-quality care.
We can take steps in five key areas to center the voices and needs of our patients.
- Listen to the person's lived experience and how that experience informs the patient's wishes around reproductive health and contraceptive choices. Honor the concept that the patient is the expert in their own lives. Practice cultural humility.
- Prioritize patient-centered/patient-led care and a shared decision-making process. Patient values must guide all clinical decisions. Seek patient input, share information about options guided by that input, arrive at a decision together, and discuss with the patient how to evaluate that decision over time.
- Commit to identifying and addressing implicit biases. These unconscious beliefs can influence not only the way we perceive patients, but also how we approach their care, as they are, by definition, unconscious. We are not aware of these biases. But tools such as the Harvard IAT (Implicit Association Test) can be used to take the first step to understand our biases, so that we can do the essential work of addressing them. Understand that addressing our biases is a lifelong journey.
- Identify and address privilege. Privilege is unearned social power that some groups have, and others do not, which includes your position as a healthcare provider. It can influence not only the patient/provider relationship, but also how we "package" the information we deliver to patients. Addressing privilege means reframing interactions with patients as being between collaborating equals, rather than a high-status and low-status person.
More information about reproductive justice, and best practices for providing contraceptive care in New Jersey, can be found in the materials created for the New Jersey Health Care Quality Institute's New Jersey Reproductive Health Access Project (NJ-RHAP).
So, what does this look like in practice? Let's create an alternative scenario for M.K.'s experience. Her provider, recognizing the limitations in scheduling, has the office send materials on birth control options to M.K. before her appointment, so that she could review them and come prepared with questions. This should include information about whether each method could be started at the next visit or might require more than one visit. The provider conducts M.K.'s visit with a patient focus, asking about her priorities, what is most important in a birth control method, and if she has questions or concerns based on materials sent. Utilizing shared decision making, M.K. leaves the visit with a birth control plan with which she feels comfortable.
It's clear that using a reproductive justice lens can positively improve access for all people in need of reproductive healthcare -- and, as providers, we need to make every effort to incorporate this critical insight into our daily work.
Linda Sloan Locke, CNM, MPH, LSW, FACNM, has been a midwife for over 40 years and is on the Board of Directors of the New Jersey Health Care Quality Institute.