Key points

Introduction

Contraception serves a critical role in a patient’s ability to self-determine whether and/or when to become pregnant. If someone is able to control their ability to become pregnant, they can then go on to create the families and communities that best fit their needs and dreams. Clinicians who provide contraception can assist patients in their reproductive freedom or can be gatekeepers to needed care. There is historic context to birth control that stems from a history of reproductive control in the United States that informs which citizens should and should not become pregnant.

This article briefly reviews the context of contraceptive counseling within the history of coercive practices. Through that, the authors enforce the importance of patient-centered counseling and shared decision-making in contraceptive counseling. This article also considers how to approach a contraceptive counseling visit and special circumstances of contraceptive use that may require special attention.

Historic overview

“Eugenics without birth control seems to us a house built upon the sands. It is at the mercy of the rising stream of the unfit,” said Margaret Sanger. “Only upon a free, self-determining motherhood can rest any unshakable structure of racial betterment.”

Sanger, like many other proponents of the early birth control movement in the United States, utilized the ideals of the eugenics movement to help create the political capital needed to push the development of birth control over the finish line. Eugenics holds birth control as one tool to solve socioeconomic inequality by preventing the procreation of the “unfit.” From the perspective of the medical-industrial complex within the United States, birth control has been consistently utilized as a means of scientifically colonizing fertility to reduce the population growth of those deemed a drain on society.

The forced sterilization of thousands of individuals in prisons and state psychiatric institutions as well as those within the disabled, low-income, Indigenous, Black, and immigrant communities has been well documented and identified in Immigration and Customs Enforcement (ICE) detention centers as recently as 2020. Individuals from marginalized communities have been routinely experimented on for the sake of the development of various contraceptive methods and disproportionately targeted for their use. ^, In the 1950s, the first birth control pill was tested on patients in a psychiatric hospital. ^, Several decades later, Depo Provera was tested on thousands of majority Black patients in Atlanta, Georgia, without proper informed consent. In the 1960s, the Population Council—dominated by men with eugenicist beliefs—established the development of the intra-uterine device (IUD) as a technological solution suitable to help control “overpopulation” of the “masses” in the Global South. To the Population Council, in contrast to white middle-class married women in the Global North, women of the Global South were an aggregate deindividualized and ultimately dehumanized population that required reproductive control by others. In 1990, an editorial in The Philadelphia Inquirer suggested that Norplant—the original arm implant—be used to solve the poverty within Black communities. This was followed by the introduction of dozens of legislative proposals incentivizing welfare recipients to obtain Norplant, as well judges giving women convicted of child abuse or drug abuse during pregnancy the option between Norplant and jail time.

The societal interest in pushing use of highly effective long-acting reversible contraceptive (LARC) methods in certain communities has continued. Beginning in the early 2000s, a reinvigorated enthusiasm surrounding LARC efficacy led to a shift toward the tiered-effectiveness approach of contraceptive counseling. This way of counseling recommends methods with the lowest failure rates first and foremost, often with accompanying visual aids emphasizing LARCs as the “best” methods at the proverbial top of the food chain. The tiered-effectiveness counseling model gained popularity and was endorsed by the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG). In turn, patients perceive this push toward selecting LARC. ^, In one survey of current LARC users, 26% reported feeling high pressure to obtain and 11% to maintain their LARC methods.

Accompanying this provider-driven push toward LARC insertion is provider-driven barriers to removal. Patients report that their requests for LARC removal due to side effects may be met with clinician minimization of symptom severity and recommendations to continue regardless of these concerns. When providers were surveyed and met with hypothetical request for LARC removal, about half stated that they would defer removal until a later time, with some only willing to proceed with removal if the hypothetical patient agreed to another contraceptive method. In one survey, 26% of patients reported at least one barrier that prevented LARC removal at their time of request—often, clinicians recommending that patients think about their options more or start another method—which led to delays ranging from 1 week to as long as 6 months. Patients also frequently cited absence of Medicaid coverage for removal before a specified time interval after placement as a significant barrier. People of color, those using public insurance, or those with a history of either prior birth or abortion were disproportionately impacted by these delays.

Inherent within the history and presence of coercive contraceptive practices is the motivation—whether intentional or subliminal—to prevent unintended pregnancy among marginalized groups and the associated sequelae on an individual and societal level. Many clinicians believe that they are “helping” patients by advocating for use of effective contraception. ^, In qualitative studies of obstetrician-gynecologists (OBGYNs) and their contraceptive counseling practices, physicians reported an inherent responsibility to recommend highly effective methods to “at risk” or “underserved” patient populations. ^, Some mentioned recommending LARCs with the explicit intention to prevent future unintended pregnancies, to “empower” patients to improve their educational or economic prospects, and to protect patients from having multiple abortions, suggesting that abortion stigma also motivates coercive contraceptive practices. OBGYNs discuss feeling frustration with patients who do not listen to their “evidence-based” recommendations and decline LARCs or contraception altogether, particularly when immediately postabortion or postpartum. ^,

The ideology of the tiered-effectiveness model of contraceptive counseling is reminiscent of its eugenicist forefathers. It fails to address the institutions and structures that contribute to systemic inequities and instead sees unintended pregnancies among certain socioeconomic groups as the source of disparities. Ultimately, it is rooted in medical paternalism, white supremacy, classism, oppression, and the underlying assumption that certain individuals cannot be trusted to control their own fertility (for suggestions for further reading, see Table 1 ).

Person-centered counseling

What does person-centered contraceptive counseling (PCCC) truly look like? Many clinicians might believe that they are providing counseling in a person-centered manner, but this may not be successfully achieved in practice. First, it is critical that as a community all reproductive health care providers acknowledge and reflect on the history of coercive family planning practices as previously outlined. It is salient that clinicians take steps to move beyond the confines of basic medical school education on social determinants of health and instead develop a deeper understanding of structural competency and critical race theory (CRT). ^, Structural competency emphasizes recognition of the “upstream” structural and systemic forces and policies that contribute to “downstream” inequities. ^, Similarly, CRT recognizes that race was socially constructed to create a hierarchy of power that is embedded within the world as we know it. For example, rather than attributing an individual’s poverty to their unintended pregnancy, one could recognize the interacting structures of capitalism, white supremacy, and mass incarceration within America. In addition, the field of family planning should prioritize participatory action research in which the knowledge, perspectives, and expertise of marginalized communities are centered and valued in research development, implementation, and evaluation—rather than incorporated as an afterthought or simply excluded completely. Addressing reproductive injustices requires a shift toward meaningful actions that confront intersecting systemic oppressions through an antiracist lens, in partnership with communities.

The latest ACOG guidelines do depart from the tiered-effectiveness approach and recommend “prioritizing patient values, preferences, and lived experiences” during contraceptive counseling through a reproductive justice lens. Created by Black women within the SisterSong Collective, the reproductive justice framework is grounded in the fundamental human right to have children, to not have children, and to parent children in safe and sustainable communities. To put this into practice, clinicians must respect an individual’s values and needs within the broader context of their lives as the guidance for all clinical decisions. This requires intentionally dismantling hierarchy and white supremacy and removing their own biases, intentions, and priorities from the equation, such as this often-ingrained desire to prevent unintended pregnancies. “Unintended pregnancy” does not need to be universally and unequivocally considered to a negative outcome for all patients and its prevention should not supersede an individual’s bodily autonomy. Pregnancy within the context of a person’s entire life is multidimensional and nuanced, and its intendedness is not the only factor that would make a pregnancy be acceptable or unacceptable to a person. In the same vein, providers must recognize that efficacy is only one element of a contraceptive method to consider among things like side effects, ease of initiating and stopping, privacy, context of one’s family, peer, partner relationships, and involvement in the medical system.

Using the Person-Centered Contraceptive Care Framework, a genuinely person-centered approach should utilize principles of outreach and trust-building, access, quality, and follow-up support. This means facilitating shared dialogue between communities and health care institutions to create authentic relationships built on mutual trust, understanding, and respect. This means creating services that are flexible, affordable, and navigable for all, such as assistance with transportation and childcare, access to telemedicine, same-day access to all methods, and barrier-free LARC removal. This means noncoercive counseling by providers who are committed to actively dismantling reproductive oppression and specifically trained to elicit and respond to patients’ needs and values, and robust options for ongoing support and communication with patients to respond to questions or concerns. This also means utilizing quality improvement systems that incorporate patient experience, such as the PCCC, to evaluate the quality of contraceptive care and proactively respond to feedback to ensure continued alignment with principles of reproductive justice.

There is no simple way to ensure PCCC—it requires a conscious, intentional, and daily effort on the part of health care providers to actively dismantle a hierarchical system of oppression and shape a more equitable future.

Typical counseling

Implementation of the person-centered contraceptive care framework in practice starts with a conversation between provider and patient. It is the role of the provider to elicit from the patient what their goals, priorities, and preferences are for contraception in their reproductive present and future. The direction of the counseling content should be tailored to address the patient’s goals and preferences outlined by the patient. Proposed models for counseling, such as the tiered effectiveness, should only be utilized when in alignment with these preferences (for a list of priorities during a contraceptive counseling encounter and sample questions to utilize, see Table 2 ).

Table 2

Patient counseling considerations

Understanding Patient Goals and Preferences	Addressing Lifestyle and Routine	Evaluating Medical History and Comorbid Conditions	Prior Experience
What are your primary reasons for seeking contraception? What are your short and long-term reproductive goals? Are there any specific methods that you are most interested in learning more about?	How comfortable are you with taking medication daily, weekly or monthly? Do you have any lifestyle or routine concerns that you want to take into consideration when choosing a method (ie, frequent travel, irregular work schedule).	What medical conditions do you have?	Have you had any past experiences with contraception that you would like to discuss?

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