The recent global pandemic has highlighted health inequities across the world. Despite rapid medical and social advances in recent years, inequities related to reproductive choices and rights remain, especially for women in marginalised sectors of society.
Dr Tracy Morison, a health psychologist at Massey University in New Zealand, focuses on the complexities around contraception choice and uptake.
Read the original article: https://doi.org/10.1111/spc3.12605
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Hello and welcome to Research Pod. Thank you for listening and joining us today.
In this podcast we are exploring the research of Dr Tracy Morison, a health psychologist at Massey University in New Zealand. Her most recent study focuses on the complexities around contraception choice and uptake, especially increasingly popular long-acting methods (like the contraceptive implant and intrauterine devices like Mirena and Jadelle).
The findings highlight how inequity of contraceptive care disproportionately affects marginalised groups of women, from ethnic minorities and poorer socio-economic backgrounds. The research demonstrates the need for social scientists’ analyses to include the wider social and political environments that surround the women making choices about their reproductive health.
The recent global pandemic has shown that poor health affects us all, but not equally. Those hardest hit have been poor women, who are often frontline workers, unpaid caregivers, or in precarious employment, and often struggle to access quality healthcare and education. This drives home the importance of equal access to resources, justice, privileges, and opportunities to stay well. Despite rapid medical and social advances in recent years, inequities related to reproductive choices and rights remain, especially for women in marginalised sectors of society.
Sexuality and reproduction have long been very politically charged subjects, which are often debated in the media. Typically, social scientists researching this area have focused on understanding individuals’ experiences; for instance, their attitudes toward contraception use. Often the root causes of these reproductive health issues are neglected. They may be driven by underlying social factors, such as coercive or violent sexual partners and social stigma. To fully address issues related to sexuality and reproduction, social scientists must investigate the social and political contexts that surround the people making the choices.
The need to look beyond the individual choice and thinking, can be demonstrated by the problem of high maternal mortality rates in South Africa. More than a quarter of avoidable deaths among pregnant South African women are due to unsafe abortions. However, abortion has been legal in South Africa since 1996. So why are so many women opting for unsafe, illegal abortions? To answer this question, and others like it, Dr Tracy Morison of Massey University, New Zealand, argues that we need to move past the simplistic ideas we hear in the media and public discussions that suggest women are simply ignorant, uninformed, or irresponsible
In seeking to tackle the problem of preventable maternal deaths, researchers often only focus on individual choices, and miss some of the key societal factors that discourage women from using public abortion services. These include stigma and social judgement around unplanned or teenage pregnancy or abortion. The fear of such negative responses from healthcare providers and community members deters women from using safe, legal services.
They may also not have the finances or freedom to get to these facilities. In these scenarios, which might not be mutually exclusive, women might use private but dangerous ‘backstreet’ abortion services.
We could ask what good is the right to abortion, if you cannot access the services that right provides? This is the problem that Dr Morison seeks to address in her work, which highlights how reproductive issues, and the choices available to people, are shaped by the social and political landscape, including inequity and widespread discrimination stemming from racism, sexism, ageism classism.
To do this she uses a research approach called the Reproductive Justice Framework. It enables researchers to highlight multiple, interconnecting imbalances of power that can impact upon people’s reproductive lives. As a result, it helps to expose underlying inequities and highlight where social change is needed.
The term ‘reproductive justice’ was coined in the USA in the 1990s by women of colour. It arose as a movement for women and other marginalise people whose needs and interests were not being met by the mainstream women’s movement, which focused mainly on the right to contraception and abortion. While this was a concern for them, African American women and other women of colour were facing much more pressing challenges such as coercive contraception, forced sterilisation, or the removal of their children by the state based on the view that they were undesirable reproducers or unfit parents. The initial focus on the unique challenges of women of colour has since expanded to consider the struggles faced by other marginalised groups.
Reproductive Justice advocates argue for a bigger picture than simply access to rights, asking critical questions such as: How can poor women visit abortion services if they are working multiple jobs? Or, access contraception services, if they need to spend time and money to travel there? How might young people in small communities or conservative spaces access contraception confidentially and without judgement? Therefore, the Reproductive Justice framework has a dual focus of (1) supporting the individuals’ right to make their own choices and (2) the state’s obligation to ensure suitable conditions for people can make the choices they want.
Importantly, the reproductive justice framework also highlights how people’s reproductive lives continue to be impacted by the after-effects of historical power imbalances evident in colonisation, slavery, and population control programmes. For instance, research shows that healthcare providers are more likely to subtly or not so subtly pressure Black women in contraceptive counselling than other patients, to direct them to use long-acting methods, or discourage them from having more children.
Despite the many advantages of using this approach, there has been little engagement in mainstream social sciences, especially psychology. This may be due to psychologists finding it challenging to depart from the traditional approach that focuses on individuals to include a broader consideration of social conditions, including societal power imbalances.
Dr Morison strongly believes in the benefits of using this framework to expand learnings and tackle social injustice. An area where this approach could be applied effectively is the use of long-acting reversible contraceptives. Contraception has empowered many women across the world, but at the same time it has also served to oppress and control others, when administered without their knowledge or consent. This is known as the contraceptive paradox. The mid-1990s saw a major shift in global thinking on family planning and women’s rights, with freely chosen contraception highlighted as essential for women to take control of their fertility, and their lives.
Alarm has been raised that the freedom to choose could be compromised by the increased popularity and indiscriminate promotion of a new generation of long-acting reversible contraceptives or LARCS, that include Intrauterine devices, implants, and injectable contraceptives. While they are safe, relatively affordable, and allow women the freedom to ‘fit and forget’, they must also be administered or removed by a healthcare provider. This means that control is not fully in women’s hands and can create coercive situations if a healthcare provider doesn’t trust or respect a woman’s ability to decide when to stop/reverse a LARC method.
Because LARCS are widely seen as an ideal choice for those from ‘at risk’ populations, they have been targeted at young and socially vulnerable women. Worryingly, a result has been that well-meaning healthcare providers have been found to use forms of counselling that direct patients to LARC use or don’t provide a full range of choices.
Researchers have therefore been concerned about women’s freedom to make choices about contraception. However, focusing on individual choice overlooks the social spaces in which choices are made. A recent study of contraceptive services in sub-Saharan Africa demonstrates how there can be problems with the system, rather than individual behaviours.
Patients and healthcare providers at family planning clinics were interviewed about attitudes towards, and access to, LARCs. Their accounts suggest that, despite the good intentions of healthcare providers, women’s decisions were not always as made freely and, in fact, in some instances subtle coercion had taken place. For instance, the women were told they could have LARC devices removed whenever they wished, but healthcare providers expressed reluctance and sometimes refused to do so.
Interviews with the healthcare providers indicate that this was related to pressure from the government to meet targets to decrease rates of unplanned pregnancy. Focusing on individual choice would have only given a partial view and overemphasised the responsibility and power that women have in the process – especially when some things are outside of her control.
Using the Reproductive Justice Framework to consider the wider social issues that may affect contraceptive usage, Dr Morison and her colleagues conducted a study of contraceptive consultations in New Zealand and South Africa.
Interviews with patients suggest that the balance of power sways toward healthcare providers due to the expert knowledge they hold. Patients’ experiences and concerns are given far less weight and sometimes even ignored or dismissed. Many women reported doctors and nurses directing decision-making in this way. Many women felt powerless to refuse professional orders or unquestioningly complied believing that the expert knows best.
This lack of power was more pronounced for women from marginalised sectors of society. Younger participants and those who were indigenous or Black recounted instances where their choices had been limited or their preferences and experiences were not even considered. For example, an African participant reported that she was given a contraceptive injection when discharged from hospital without her informed consent, simply because she was a teenage mother. Similarly, a young Māori participant disclosed that she wasn’t given a choice about the type of contraceptive she wanted to use but was prescribed a LARC, purely on the basis that – as a Māori teenager who had just left school – she was at high risk of unintended pregnancy.
From the healthcare providers’ perspectives, there was a clear tension in their accounts between competing responsibilities: to honour patient’s freedom to choose versus preventing unplanned pregnancy by ‘getting’ women to use and stay on the most effective contraceptive possible. Some disclosed that they themselves at times felt obliged to persuade women to take their advice to “sell” or “push” certain methods, especially LARCs, believing that this was in the patients’ best interests. The question is how this tension is resolved and how this might impact on women.
The findings highlight how power imbalances in contraceptive counselling sometimes restricted women’s contraceptive choices. It also suggests that choices are often shaped by healthcare providers values and beliefs rather than women’s needs, preferences, or unique circumstances, especially if they are young, of colour, and poor.
Historically long-acting reversible contraceptives have been used a source of oppression towards groups of women who are deemed as socially undesirable reproducers. Using the Framework within this study has helped to uncover the subtle ways in which contraception is still restricted, specifically for marginalised groups of women.
Dr Morison’s research highlights that lives are not lived in a social and political vacuum. Oppression such as sexism, racism, classism, and ageism has been shown to have an impact on women’s contraceptive choices. It is important that other social psychologists adopt the Reproductive Justice framework within their analysis, especially around the area of sexuality and reproduction. It is imperative that women can make sexual and reproductive choices that are free from the limitations brought about by discrimination, which is still present throughout our societies.
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