Consider the needs of marginalized patients to promote equity
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.1 Research has uncovered disparities in contraceptive use in the United States.2 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).2 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.3 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.4-6 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.7 Black women reported bias and coercion in data from another study about contraception in the postpartum period.8 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.9 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.10 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.11
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.12 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.13
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).14
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.15 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.17 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.18
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.19 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.20 Patients everywhere are increasingly turning to social media platforms such as TikTok, Instagram, and Twitter for information—including regarding their health.21 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.22 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,23 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.24 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.25 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.3 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.26 This is consistent with health service data showing lower telehealth usage for preventive care among individuals living in marginalized areas.27 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,28 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.29 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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