Elsevier

Contraception

Volume 96, Issue 4, October 2017, Pages 221-226
Contraception

Original research article
Under (implicit) pressure: young Black and Latina women's perceptions of contraceptive care

https://doi.org/10.1016/j.contraception.2017.07.007Get rights and content

Abstract

Objective

To understand the ways in which young women of color experienced pressure from healthcare providers during contraceptive care, including the impact of these encounters on contraceptive decision making and reproductive autonomy.

Methods

Data were drawn from a qualitative study of contraceptive decision making, which included 38 young (age 18–24) Latina and Black women recruited using community-based and online strategies. We analyzed in-depth interview data from a subsample of 27 young women who described experiencing pressure from healthcare providers during contraceptive care. We conducted a thematic analysis of coded data using a cross-case analytic approach.

Results

Our analysis revealed that the pressure experienced by our participants was typically subtle and constrained reproductive autonomy to varying degrees. We termed this phenomenon implicit pressure owing to the under-the-surface nature of these experiences — that is, participants perceived an implied outcome regarding contraceptive use favored by their providers. Participants felt implicitly pressured when providers appeared to prefer certain methods based on imbalanced provision of information, tone of voice and affect, and minimization of or failure to describe potential side effects. Some participants accepted their providers' contraceptive suggestions as a way to end counseling encounters — methods they rapidly discontinued. Experiences of implicit pressure were longitudinally impactful, with some participants curtailing future healthcare access and contraceptive use because of negative clinical encounters.

Conclusions

Practices that implicitly pressure women in contraceptive counseling can infringe upon reproductive autonomy and reinforce health inequities when they engender mistrust of healthcare, providers and contraception.

Implications

This study underscores the importance of high-quality contraceptive care for young women of color. Adverse healthcare experiences during adolescence and young adulthood can negatively impact future health-seeking behavior, with important implications for health throughout the life course. Patient-centered approaches may positively affect patients' experiences while continuing to facilitate contraceptive discussions.

Introduction

There is longstanding recognition that healthcare disparities — differences in quality of healthcare experienced by members of minority groups — are a barrier to improving health, particularly for racial/ethnic minorities [1], [2], [3]. A small body of research has described practices perpetuating healthcare disparities in family planning settings [4], [5], [6], [7], as well as women's perceptions of discrimination, coercion and bias in contraceptive counseling [8], [9], [10], [11]. Moreover, qualitative research has surfaced important insights into the ways that providers' beliefs — implicit or explicit — about appropriate childbearing can impact healthcare provision [12], [13], [14]. The most recent national data indicate that Black, Latina, young and low-income women experience the highest rates of unintended pregnancy in the United States [15]. At face value, these differences in population-level rates of unintended pregnancy by race/ethnicity, income level and age may provide justification for differential interventions for “at-risk” populations. Such approaches neglect the highly personal nature of contraceptive decision making and the long history of reproductive oppression impacting these same groups [16], [17].

Indeed, the role of family planning providers in promoting and constraining reproductive autonomy has been the subject of increasing focus in recent years [9], [13], [17], [18]. In particular, the benefits and limitations of various methods of contraceptive counseling, including directive, informed choice and shared decision-making approaches, have been highlighted [19], [20]. With the rise of patient-centered care, some scholars argue that preference-sensitive decisions, such as contraceptive method choice, require counseling that is engaged, nondirective and interactive and that acknowledges patients' preferences and priorities [20], [21]. Notably, two studies found an association between non-patient-centered care and earlier contraceptive discontinuation [22], [23]. Given the high levels of contraceptive discontinuation and dissatisfaction in the United States, interventions and practices that support patients in accessing and using methods that best fit their situations are critically important [24].

Despite the well-established tensions between contraceptive counseling approaches and respect for reproductive autonomy, scant research examines young women of color's experiences with family planning care within this context. Accordingly, the objective of the present qualitative analysis was to understand the impact of feeling pressured during contraceptive care on contraceptive decision making and reproductive autonomy among young Black and Latina women.

Section snippets

Methods

This analysis drew on qualitative data collected in 2013 regarding contraceptive decision making and attitudes toward intrauterine devices (IUDs) among 38 young Black and Latina women in the San Francisco Bay Area. Women were eligible to participate in the study if they were between the ages of 18 and 24; identified as Black, African–American, Latina or Hispanic; had vaginal sex in the last 3 months and were not pregnant or trying to conceive. We recruited participants via Craigslist and flyers

Results

The majority of women in the study (71%) recounted experiences of pressure in contraceptive care. Demographics for both the full sample (n=38) and analytic subsample (n=27) experiencing pressure are presented in Table 1. While the subsample was demographically similar to the full sample, all participants with children (n=11) relayed experiences of pressure. Among the subsample, the mean age was 21.7 years (range 18–24). Fifteen participants identified as Latina or Hispanic, and 13 identified as

Discussion

In our sample of 38 young Latina and Black women, the majority had experienced pressure from a healthcare provider regarding contraception. While a number of our participants agreed to providers' directive recommendations, several discontinued these methods shortly after their appointments if they felt pressured, did not receive enough information about side effects or only initiated the method as means of interrupting directive counseling. Notably, the maximum age of study participants was 24

Acknowledgments

This work was supported by an individual investigator grant from the Office of Sponsored Research and Programs at San Francisco State University. We gratefully acknowledge Stephanie Arteaga, Kelly Bermudes, Vanessa Cardona, Airial Clark and Vanessa Torres for their work facilitating data collection, recruiting and interviewing participants, and cleaning the data. Additionally, we thank Jennet Arcara, Stephanie Arteaga, Lauren Caton, Maggie Downey, Bridget Freihart, Alvaro Gómez, Elizabeth

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