Improving contraceptive care for marginalized populations

Contemporary OB/GYN JournalVol 67 No 09
Volume 67
Issue 09

Consider the needs of marginalized patients to promote equity

View as PDF

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.

How to approach contraceptive counseling

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

TABLE. Patient-Centered Approach to Contraceptive Counseling

TABLE. Patient-Centered Approach to Contraceptive Counseling14

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.

Creating an open dialogue

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.


1.Hall JM, Stevens PE, Meleis AI. Marginalization: a guiding concept for valuing diversity in nursing knowledge development. ANS Adv Nurs Sci. 1994;16(4):23-41. doi:10.1097/00012272-199406000-00005

2.Dehlendorf C, Rodriguez MI, Levy K, Borrero S, Steinauer J. Disparities in family planning. Am J Obstet Gynecol. 2010;202(3):214-220. doi:10.1016/j.ajog.2009.08.022

3.Sundstrom B, DeMaria AL, Ferrara M, Meier S, Billings D. "The closer, the better:" The role of telehealth in increasing contraceptive access among women in rural South Carolina. Matern Child Health J. 2019;23(9):1196-1205. doi:10.1007/s10995-019-02750-3

4.Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005;95(7):1128-1138. doi:10.2105/AJPH.2004.041608

5.Committee Opinion No. 695: Sterilization of Women: Ethical Issues and Considerations. Obstet Gynecol. 2017;129(4):e109-e116. doi:10.1097/AOG.0000000000002023

6.American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 208: benefits and risks of sterilization. Obstet Gynecol. 2019;133(3):e194-e207. doi:10.1097/AOG.0000000000003111

7.Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016;106(11):1932-1937. doi:10.2105/AJPH.2016.303393

8.Yee LM, Simon MA. Perceptions of coercion, discrimination and other negative experiences in postpartum contraceptive counseling for low-income minority women. J Health Care Poor Underserved. 2011;22(4):1387-1400. doi:10.1353/hpu.2011.0144

9.Ross LJ, Solinger R. Reproductive Justice: An Introduction. University of California Press; 2017.

10.American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, Contraceptive Equity Expert Work Group, and Committee on Ethics. Patient-centered contraceptive counseling: ACOG Committee Statement Number 1. Obstet Gynecol. 2022;139(2):350-353. doi:10.1097/AOG.0000000000004659

11.Preliminary information, Implicit Association Test. Project Implicit. Accessed July 15, 2022.

12.Gonzalez CM, Lypson ML, Sukhera J. Twelve tips for teaching implicit bias recognition and management. Med Teach. 2021;43(12):1368-1373. doi:10.1080/0142159X.2021.1879378

13.Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health. 2019;18(1):174. doi:10.1186/s12939-019-1082-3

14.Dehlendorf C, Fox E, Sobel L, Borrero S. Patient-centered contraceptive counseling: evidence to inform practice. Curr Obstet Gynecol Rep. 2016;5:55-63. doi:10.1007/s13669-016-0139-1

15.Crenshaw K. Demarginalizing the intersection of race and sex: a Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Leg Forum.1989(1):139-167.

16.McNicholas C, Madden T, Secura G, Peipert JF. The contraceptive CHOICE project round up: what we did and what we learned. Clin Obstet Gynecol. 2014;57(4):635-643. doi:10.1097/GRF.0000000000000070

17.Gubrium AC, Mann ES, Borrero S, et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Am J Public Health. 2016;106(1):18-19. doi:10.2105/AJPH.2015.302900

18.Moniz MH, Spector-Bagdady K, Heisler M, Harris LH. Inpatient postpartum long-acting reversible contraception: care that promotes reproductive justice. Obstet Gynecol. 2017;130(4):783-787. doi:10.1097/AOG.0000000000002262

19.Romero L, Mendoza ZV, Croft L, et al. The role of public-private partnerships to increase access to contraception in an emergency response setting: the Zika Contraception Access Network program. J Womens Health (Larchmt). 2020;29(11):1372-1380. doi:10.1089/jwh.2020.8813

20.Powell R, Rosenthal J, August EM, et al. Ante La Duda, Pregunta: a social marketing campaign to improve contraceptive access during a public health emergency. Health Commun. 2022;37(2):177-184. doi:10.1080/10410236.2020.1828534

21.Merz AA, Gutiérrez-Sacristán A, Bartz D, et al. Population attitudes toward contraceptive methods over time on a social media platform. Am J Obstet Gynecol. 2021;224(6):597.e1-597.e14. doi:10.1016/j.ajog.2020.11.042

22.Lathrop E, Romero L, Hurst S, et al. The Zika Contraception Access Network: a feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreak. Lancet Public Health. 2018;3(2):e91-e99. doi:10.1016/S2468-2667(18)30001-X

23.Dalton VK, Moniz MH, Bailey MJ, et al. Trends in birth rates after elimination of cost sharing for contraception by the Patient Protection and Affordable Care Act. JAMA Netw Open. 2020;3(11):e2024398. doi:10.1001/jamanetworkopen.2020.24398

24.Birth control benefits. Accessed April 28, 2022.

25.Zapata LB, Curtis KM, Steiner RJ, et al. COVID-19 and family planning service delivery: findings from a survey of US physicians. Prev Med. 2021;150:106664. doi:10.1016/j.ypmed.2021.106664

26.Hill BJ, Lock L, Anderson B. Racial and ethnic differences in family planning telehealth use during the onset of the COVID-19 response in Arkansas, Kansas, Missouri, and Oklahoma. Contraception. 2021;104(3):262-264. doi:10.1016/j.contraception.2021.05.016

27.Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e2024984. doi:10.1001/jamanetworkopen.2020.24984

28.Lopez AM, Lam K, Thota R. Barriers and facilitators to telemedicine: can you hear me now? Am Soc Clin Oncol Educ Book. 2021;41:25-36. doi:10.1200/EDBK_320827

29.List of telehealth services. Centers for Medicare & Medicaid Services. Accessed April 28, 2022.

Recent Videos
The significance of the Supreme Court upholding mifepristone access | Image Credit:
Understanding combined oral contraceptives and breast cancer risk | Image Credit:
Deciding the best treatment for uterine fibroids | Image Credit:
What's new in endometrium care? | Image Credit:
New algorithm to identify benign lesions developed | Image Credit:
Related Content
© 2024 MJH Life Sciences

All rights reserved.