Charisse Loder, MD, MSc

Contraceptive care is an essential health service; however, inequities will persist until care provision is designed to address the needs of groups who have been marginalized. Patients who come from groups who have been marginalized, or pushed to the periphery of society, are likely to experience racism, discrimination, and overall poor health outcomes.

Research has uncovered disparities in contraceptive use in the United States.

 Individuals who identify with groups that have been marginalized are less likely to use contraception in general, and those who do use contraception are less likely to use highly effective methods (implant, intrauterine devices, or sterilization).

 Traditionally, contraceptive care has focused on the need to prevent pregnancy and unintended pregnancy, rather than considering contraception as a tool that can improve overall health. However, it is important to expand the scope of conversations around hormonal contraception, which can be used as an instrument that both prevents pregnancy and treats a range of reproductive health conditions.

Contraceptive use may be influenced by a number of factors, such as patient education and knowledge, insurance status, access to reproductive health services, health system factors (counseling, trust, satisfaction with provider, and access to same-day devices), and structural factors (systemic racism, laws, policies, and economic inequality). Here, we focus on approaches to contraceptive care that can promote equity.

Obstetrician-gynecologists (ob-gyns) providing contraceptive care must understand the history of coercive reproductive health care among populations that have been marginalized and how this affects communities today. In the 20th century, thousands of individuals were coerced into sterilization based on their racial, gender, or socioeconomic identities and/or ability status.

 Even today, individuals from marginalized groups report bias in contraceptive care. According to findings from a study about contraception use in young individuals, participants felt pressured to use long-acting contraception and perceived provider bias regarding their contraceptive choices.

 Black women reported bias and coercion in data from another study about contraception in the postpartum period.

 It is not surprising, therefore, that patients and their families or communities may hold feelings of mistrust regarding reproductive health care. We must, then, incorporate this knowledge into our contraceptive care and use approaches to care that mitigate bias and discrimination.

Given this historical context, ob-gyns who approach contraceptive care with attitudes aligned with reproductive justice and patient-centered approaches will be well poised to care for patients who have been marginalized. Reproductive justice supports the ability to parent or not parent and to raise children in sustainable environments.

 Health care providers who practice with reproductive justice values are knowledgeable about historical oppression, have skills in leveling power differentials, and work to combat barriers to reproductive autonomy. The American College of Obstetricians and Gynecologists (ACOG) supports adopting a reproductive justice approach to contraceptive care.

 To do this, health care providers must understand their own biases, which they can initiate by completing an assessment such as the Implicit Association Test and by attending unconscious bias workshops or training.

Next, providers should commit to a lifelong approach of mitigating bias that embraces self-reflection, normalizing and destigmatizing bias, and exploring the lived experiences of patients while breaking down power structures.

 This often involves understanding one’s own identity and the identities in the communities they serve, which are often multidimensional. A reproductive justice approach includes using cultural safety skills—those that acknowledge diverse beliefs by engaging patients in humble and inquisitive conversation about their needs.

Finally, focusing on the patient by eliciting their goals and preferences and providing balanced information can reduce bias, establish trust, and promote reproductive justice in contraceptive care 

TABLE. Patient-Centered Approach to Contraceptive Counseling

Ob-gyns who apply the concept of intersectionality to contraceptive care may improve care for marginalized communities. Intersectionality allows a provider to consider how the inequalities that patients of various identities face can be compounded to create poor health outcomes.

 In contraceptive care, intersectionality can help health care providers understand or support contraceptive decision-making. For example, a provider may consider injectable contraception to be the best method for a patient based on the patient’s preferences and medical history. However, by inquiring about their geographic location and socioeconomic and parenting status, for example, as well as their identity-based experiences, the provider may realize that the patient may not have adequate transportation to the clinic or affordable childcare, which would make it difficult for them to return for regular injections. Additionally, the patient may say that their experiences with racism contribute to their wish to avoid multiple visits to the health center. Therefore, this broader understanding of the patient and their experiences may lead the provider to make a different recommendation regarding contraceptive methods. With the understanding that patients come from unique cultures, backgrounds, and communities, health care providers can use an intersectionality lens to provide comprehensive contraceptive care.

Providers who engage in conversations with community members and leaders are well placed to understand barriers and facilitators to reproductive health care and create an open dialogue for advocating for change. Several advocacy initiatives have been successful at improving access to reversible contraceptive methods for marginalized communities; these have focused on improving barriers to contraception such as lack of patient knowledge, cost, lack of provider training in provision of long-acting reversible contraception (LARC), and inability to provide same-day contraception. Contraceptive programs, such as the Contraceptive CHOICE Project, have focused on improving access to reversible contraception among communities that have been marginalized, with a goal of increasing the uptake of LARC.16 This approach has some concerns; for example, the focus on LARC may impair the patient’s ability to exercise reproductive autonomy and result in further marginalization.

 Additionally, these programs have not considered how to approach access to LARC removal to ensure that all aspects of contraception are considered with an equity lens.

In Puerto Rico, however, the Zika outbreak resulted in the initiation of the Zika Contraception Access Network (Z-CAN) program, which advocated for increased provider training of LARC management, secured contraceptive product donations, and negotiated nominal pricing from pharmaceutical manufacturers.

 Innovative partnerships between health care workers, community leaders, and social media influencers were also used to increase knowledge regarding availability of reversible contraceptive methods. This led to an increase in information-seeking behaviors related to contraception use.

 Patients everywhere are increasingly turning to social media platforms such as TikTok, Instagram, and Twitter for information—including regarding their health.

 As we consider how epidemics affect contraceptive care, it will be important to use social media and engagement to improve education and access.

The Zika crisis in Puerto Rico further exemplified the gains in contraceptive access that can be made when advocacy extends beyond the individual patient-provider interaction. The Z-CAN program was able to provide contraceptive care to over 21,000 women, with over 20,000 receiving same-day provision of their contraception of choice.

 Expansion of contraceptive coverage through the Affordable Care Act (ACA) was associated with improvements in contraceptive refills and a decrease in births among commercially insured women,

 but did not improve access for women without commercial insurance. In recent years, contraceptive coverage under the ACA has been under attack through policy changes such as the Supreme Court upholding the religious exemptions from the contraceptive mandate.

Ob-gyns are uniquely positioned to advocate on a national level and affect policy decisions that disproportionately affect marginalized populations. Presently, ACOG supports continued access to both FDA-approved contraceptive options without cost sharing and OTC access to oral contraceptives without a prescription from a physician or pharmacist.

The COVID-19 pandemic accelerated innovations in telehealth and virtual care that can be used to increase access to contraception.

 Though the expansion of telehealth services is a viable option to increase access to contraceptive services, it may not address issues related to cultural concerns for privacy or lack of telecommunication connectivity. Telehealth—whether conducted in real time, through interactive audiovideo communication, or asynchronously—allows patients to forgo a physical exam and reduce traveling distance and travel-related costs. This is particularly important in areas of the country that lack readily available access to contraceptive providers or where wait times for receiving care may be prohibitive. Telehealth services provide an opportunity to access a provider remotely and fill prescriptions closer to home through a local pharmacy or mail delivery service.

 Research findings have uncovered concerns about low use of telehealth for contraceptive visits among patients identifying as Black or multiracial compared with all other racial identities.

 This is consistent with health service data showing lower telehealth usage for preventive care among individuals living in marginalized areas.

 There are several concerns about the use of telehealth, such as inequities in accessing the necessary devices or high-speed internet required for 2-way audiovisual communication, discrepancies in reimbursement for telehealth visits,

 and lack of formal telehealth training for providers. Prior to the pandemic, reimbursements for telehealth visits by the Centers for Medicare & Medicaid Services were limited to 2-way audiovisual communication. Since the pandemic, restrictions for reimbursement of some telephone-only encounters have been waived, allowing health care providers to be compensated for visits completed via telephone.

 Formal training can equip providers with tools to establish rapport in the virtual setting and education on common pitfalls encountered with telehealth.

Improving contraceptive access for marginalized populations is a complex and multifaceted challenge that calls for innovative approaches. It requires that ob-gyns first examine their own biases alongside the historical context of the development of contraception in the United States, which often involved coercion of marginalized individuals. Using a patient-centered framework and cultural safety approach is the first step in increasing access to contraceptive services. The role of the ob-gyn is constantly evolving and requires that we serve as advocates for our patients in the exam room and at the national level through policy changes that directly impact them. 

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Articles

Consider the needs of marginalized patients to promote equity

Improving  contraceptive care for marginalized populations

Oral contraceptive pills are the most commonly used method of hormonal contraception in the United States. According to the National Survey of Family Growth conducted in 2015-2017, 80.5% of reproductive-aged women who had ever been sexually active had used oral contraceptive pills (OCPs) at some point. 

A survey of reproductive-aged women who have ever been sexually active found that 12.6% currently use pills.

There are two general types of OCPs—combined oral contraceptives (COCs), which contain both ethinyl estradiol (EE) and progestin, and progestin-only pills (POPs). Current COCs offer a range of doses and progestins to choose from.

COCs are a moderately effective method of contraception. They have a perfect use failure rate of <1% and a typical use failure rate of 9%.

 Several clinical trials have quoted failure rates of POPs between 1-13% in the first year.

Little data is available directly comparing the efficacy of different types of progestins; however, a few studies suggest no difference.5,6 It is likely that typical use failure rates are higher in POP users due to the strict dosing timeframe, including recommendations to take the pill within a 3-hour window.

EE and progestin each work separately, as well as synergistically, to provide contraceptive benefit. EE mainly works by suppressing the release of follicle-stimulating hormone (FSH) from the pituitary, which hinders folliculogenesis. 

It is also suggested that EE causes endometrial edema, which affects implantation. EE has an added benefit of stabilizing the endometrium, which reduces spotting—a favorable effect. As EE potentiates the effects of progestin, smaller doses of progestin may be used in COCs.

Progestin works in three major ways: 1) it suppresses GnRH release from the hypothalamus, decreasing LH and FSH release; 2) it prevents the LH surge from the pituitary, which prevents ovulation; and 3) it thickens cervical mucus, which impedes sperm entry into the uterus. 

There may be some inhibition of peristalsis and tubal mobility as well. Progestin causes endometrial atrophy, which impairs implantation. Each progestin has a different potency and dose for which it blocks ovulation. POPs rely on these multiple mechanisms to prevent pregnancy.

Although oral contraceptives are a great choice for many women, it is important to understand the conditions that may increase risk for the user. We will outline some of the risks below and the CDC Medical Eligibility Criteria chart can be referenced for more information.

It is important to remember that the risks and benefits must be weighed for each woman individually and that in most cases, pregnancy is more dangerous than pill use. 

In patients who have conditions in which pregnancy would increase their risk of adverse health outcomes (Table 1), long-acting reversible contraception (LARC) may be the best choice to avoid unintended pregnancy.10 It is also important to review a patient’s medication history, as there may be drug interactions that reduce efficacy of COCs and POPs.

EE is pro-coagulable and is contraindicated in a number of situations. Progestin also has risks to the user. Providers should screen for personal or family history of venous thromboembolism, as this increases coagulation risk in COC users. 

Additionally, because of hypercoagulability in the postpartum state, COCs should not be used until 6 weeks after childbirth. Women who smoke and are over age 35, women with migraine with aura, or those who have uncontrollable hypertension or vascular disease are at increased risk of stroke and should not use estrogen-containing methods.

There are self-screening tools available to check for COC eligibility, such as the one used in a study by Grossman et al, which showed a sensitivity of 83.2% and specificity of 88.8% in patients using the survey to determine true contraindications to COC use.

 These tools can be helpful to both providers and patients, particularly as we increase use of telemedicine (Table 2).

As with any medical decision, it is exceptionally important to utilize shared decision-making in choosing the right contraceptive method for each patient, which should improve satisfaction, encourage compliance, and reduce unintended pregnancy. 

Shared decision-making involves the patient and provider working together to make a decision through discussion of all options while taking patient preference into account.

Because there are many contraceptive options available, it is important to discuss values (including the acceptability of an unplanned pregnancy if there is a contraceptive failure), beliefs, dosing frequency, financial considerations, and risks and benefits of each method. 

Other considerations include how often women want to have withdrawal bleeding, and desired benefits such as improvement in dysmenorrhea, acne, and mood symptoms. All women should be provided with a multiple-month prescription to improve medication adherence.

As with any method, there are side effects of COCs and POPs that are important to discuss with patients as they decide which method is best for them. Of women who have ever discontinued using COCs or POPs, 34% reported that they were dissatisfied and 64.4% stopped due to side effects.

Some common side effects to discuss with women are breast tenderness, nausea, bloating, and breakthrough bleeding—all of which often improve or completely resolve after the first several months.

 Women may not always discuss their choice to stop taking COCs or POPs, making it essential for clinicians to ask about the experience of past side effects, as well as to provide preventive guidance about the possibility of side effects before starting a new method.

Once a woman and her provider have decided on using COCs, there are multiple options. Patients desiring a withdrawal bleed may prefer a pill pack with monthly placebo pills, while patients desiring fewer menses prefer continuous use without placebo pills and may opt for extended cycle use. 

Additionally, providers may identify other co-existing conditions that may be treated with COCs such as acne, undesired facial hair growth, bloating, and/or headaches. COCs can also help reduce risk of ovarian cysts, fibroids, and benign breast disease.

As mentioned earlier, all COCs have a progestin and EE component and doses differ by pill type. COCs have a range of EE between 10-35 mcg. 

A systematic review showed higher discontinuation rates for COCs with lower doses of EE, due to side effects such as breakthrough bleeding. To reduce estrogenic risks, it is reasonable to start at 20 mcg EE and increase if necessary,15 although for adolescents, data supports using a dose of 30 mcg EE or greater as lower doses of EE have been associated with impaired bone acquisition.

Providers should consider the progestin component of the COC, or which progestin to use on its own in a POP, as this may result in undesired side effects.

Some progestins are noted to have androgen-like effects, with users reporting oily skin, facial hair growth, or acne. Of note, all COCs have been shown to help with acne, but it is reasonable to choose a pill with a less androgen-like progestin and/or higher estrogen content if this is a concern.

First-generation progestins have a lower potency and half-life, which can result in breakthrough bleeding. While second-generation progestins are more potent with a longer half-life, they may have an androgen-like effect. Third-generation progestins maintain a high potency but have lower androgen-like effects. 

Some third-generation formulations are even approved to treat mild to moderate acne. Finally, the only fourth-generation progestin, drospirenone, has both anti-mineralocorticoid and anti-androgenic properties and is newly available in a progestin-only pill.

 It has an improved bleeding profile while matching COCs in efficacy, as well as extending the missed-pill window to 12 hours for ease of use23 (Table 3).

Many of the common side effects of COCs will resolve on their own in the first few months. Thus, in the absence of severe side effects, patients should be encouraged to continue their pills for an initial 3-month interval. If these side effects continue or are particularly bothersome, Table 4 shows some options providers can use to approach them.

In addition to bleeding patterns and progestin options, COCs can be monophasic or multiphasic. We recommend that most providers start with a monophasic preparation for ease of use and ability to extend to continuous use, although some data show that triphasic preparations—specifically those with newer progestins—help reduce acne, irregular bleeding, and menorrhagia.

Non-contraceptive benefits: dysmenorrhea and menorrhagia

In addition to contraception, COCs have non-contraceptive benefits that can be advantageous to patients. One of these benefits is helping to improve menstruation, reduce pain, and improve blood loss. Dysmenorrhea is the most common menstrual symptom complaint, affecting up to 90% of women.

COCs have been shown to reduce dysmenorrhea by 60%, and in those with severe dysmenorrhea even further (90%). This reduces absences for school or work, as well as a patient’s need for pain medication. In women who suffer from dysmenorrhea, it can be especially helpful to be on extended or continuous COC preparations to further decrease pain.

 The desogestrel-only POP has also been shown to help improve dysmenorrhea.

Menorrhagia is less common, yet still problematic, for patients, as it can lead to iron-deficiency anemia. COCs are particularly helpful for normalizing bleeding patterns and decreasing both amount and duration of bleeding. 

However, other forms of contraception, such as hormonal intrauterine devices, can have similar effects—enhancing the need for shared decision-making with a patient when deciding which hormonal method is right for her.

Additional benefits to COCs include the ability to allow a woman to predict her bleeding episodes and skip them if desired. While older generations of POPs often caused abnormal bleeding patterns in patients, new drospirenone-only pills have a more favorable bleeding profile.

COCs can also improve premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). A study looking at both POPs and COCs and their effect on premenstrual mood found that use of either one of these pills did not affect mood in over 71% of women. The remaining women were split as to whether their mood was improved or worsened. 

Having a history of premenstrual mood changes prior to starting a POP or COC was a strong predictor of the ability to improve mood, as was onset of premenstrual mood disturbance at a younger age. However, those with a history of depression prior to pill use were twice as likely than those without a history to have mood deterioration.

Studies have also shown that in women being treated for depression, COCs containing drospirenone can improve mood deterioration in the premenstrual period, as well as reduce both physical and behavioral symptoms of PMDD.

 Another way to reduce PMS and PMDD symptoms is with extended or continuous cycles and reduction of withdrawal bleeding.

Non-contraceptive benefits: Endometriosis

COCs can also be very useful to women who suffer from endometriosis. COCs have been shown to reduce pain associated with endometriosis and continuous cycles are often even more beneficial for pain reduction. 

However, it is important to remember that COCs work by causing endometriotic implants to undergo atrophy and become inactive. Upon discontinuation of COCs, the implants become active again, resulting in return of pain and other symptoms. 

Initiation of COCs after surgery for endometriosis can reduce recurrence rates of endometriomas, as well as the size and growth rates of those that do recur.31 For women who cannot take COCs but suffer from endometriosis, desogestrel-containing POPs have been shown to be equally effective in reducing endometriosis pain.

Oral contraceptive pills are a widely used form of contraception and nearly all providers in all specialties will encounter patients who are taking them. 

While different variations between pills can seem complicated, thereby making it hard to choose a pill, it is important to tailor the decision to each patient’s needs and desires. Sometimes it can take several adjustments to find the best OCP for a particular patient. 

As long as the provider and patient continue to work together through shared decision-making, many women will be able to satisfactorily find a reliable form of contraception while also taking advantage of the many non-contraceptive benefits that pills offer.

is a clinical assistant professor at Michigan Medicine, University of Michigan, Ann Arbor.

is a fourth-year medical student at the University of Michigan Medical School, Ann Arbor.

1. National Center for Health Statistics. National Survey of Family Growth 2015-2017. 

https://www.cdc.gov/nchs/nsfg/nsfg_2015_2017_puf.htm

2. David PS, Boatwright EA, Tozer BS, et al. Hormonal contraception update. 

3. Trussell J. Contraceptive failure in the United States. 

4. Broome M, Fotherby K. Clinical experience with the progestogen-only pill. 

5. Sheth A, Jain U, Sharma S, et al. A randomized, double-blind study of two combined and two progestogen-only oral contraceptives. 

6. Korver T. A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 μg/day or levonorgestrel 30 μg/day. 

7. Vessey MP, Lawless M, Yeates D, McPherson K. Progestogen-only oral contraception. Findings in a large prospective study with special reference to effectiveness. 

8. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. 

9. Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. 

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

10. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility for Contraceptive Use, 2016. 

11. Grossman D, Fernandez L, Hopkins K, Amastae J, Garcia SG, Potter JE. Accuracy of self-screening for contraindications to combined oral contraceptive use. 

12. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: A model for clinical practice. 

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21. Thorneycroft IH. Update on androgenicity. 

22. Stanczyk FZ. All progestins are not created equal. 

23. Palacios S, Regidor PA, Colli E, et al. Oestrogen-free oral contraception with a 4 micrograms drospirenone-only pill: new data and a review of the literature. 

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24. Barr NG. Managing adverse effects of hormonal contraceptives. 

25. Cedars MI. Triphasic oral contraceptives: Review and comparison of various regimens. 

26. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. 

27. Ahrendt HJ, Karckt U, Pichl T, Mueller T, Ernst U. The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: Results from two studies on oestrogen-related symptoms and dysmenorrhoea. 

28. Lethaby A, Wise MR, Weterings MAJ, Rodriguez MB, Brown J. Combined hormonal contraceptives for heavy menstrual bleeding. In 

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30. Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. 

31. Zorbas KA, Economopoulos KP, Vlahos NF. Continuous versus cyclic oral contraceptives for the treatment of endometriosis: a systematic review. In 

Oral contraceptive pills are a popular choice for many; providers should understand the options to guide patients effectively.

Choosing the right pill

Fertility awareness-based contraceptive methods (FABM) are behavioral methods of contraception that are used by approximately 2.2% to 3.2% of sexually active women.

 This low usage rate may be due to provider and patient knowledge and beliefs. One concern providers may have is that the typical use efficacy rate is lower than for other contraceptive methods. In addition, providers may be uncomfortablen counseling patients about appropriate usage.

Women who use FABM may choose it because they have values and/or beliefs that are aligned with using non-pharmacologic contraception. However, we must consider that the best form of contraception is the one the patient feels works for her. Given that FABM may be used as a contraceptive, and that there are patients who will choose it, ob/gyns must be familiar with it and ready to counsel about its use.

Nonjudgmental and open conversation with patients about their priorities is critical to all contraceptive counseling, particularly when discussing FABM. Generally, FABM is most suitable for patients who have regular menses (although some methods, such as TwoDay

, may not require this) and for whom variance in efficacy of a method-and therefore the real possibility of an unplanned pregnancy-is acceptable.

As such, an important part of counseling is reviewing medical comorbidities, obstetric history, and current medications so that the patient understands the risks of unplanned pregnancy to their health and the health of the fetus. Given that FABM requires abstinence or use of barrier methods on certain days, the ability to have open communication with a partner is paramount. Considering this, FABM may work best for patients whose partner(s) is highly motivated to avoid pregnancy and willing to avoid unprotected sex on certain days.

Thirty-six percent of women in the United States suffer sexual violence and coercion

; behavioral methods cannot protect against pregnancy in these cases. In addition, FABM does not offer protection against sexually transmitted infections.

It is important to note that studies of FABM effectiveness vary in quality, which makes it difficult to compare efficacy between specific methods.

 Overall, FABM collectively has a 15% typical-use first-year failure rate, but it can vary as much as 2% to 23%.

 There are many factors that impact effectiveness of FABM.

These include the ability of the provider to adequately counsel on how to use the method and the ability of the patient to follow and use the method instructions appropriately.

 Given that most studies show high first-year discontinuation rates for FABM,

 shared decision-making and clear instructions on how to properly use each technique are critical to successful patient use. Table 1 summarizes the methods and key requirements for each method.

Patients who choose FABM over other methods are likely doing so for reasons beyond its efficacy. It is well-studied that contraceptive counseling and recommendations should be patient-centered.

 If a patient is aware that FABM has variable efficacy rates, has been counseled on the factors that make a good FABM candidate, and accepts the risk of unintended pregnancy, there is no reason a clinician should be uncomfortable with aiding her in using that method.  

Advantages to FABM include little to no financial investment, few if any medical contraindications to use, no medications or devices needed, and possible alliance with religious and cultural beliefs about family planning.

In addition, many patients may choose to educate themselves about and use behavioral methods in the time leading up to planning a pregnancy. This is because these methods require more awareness of the body and the fertile time, which helps a patient to prevent pregnancy and also to become pregnant when she is ready.

Behavioral methods of contraception are used by less than 3.2% of sexually active women; careful counseling could change that.

Charisse Loder, MD, MSc

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