Who decides women’s best interests? Examining the role of contraceptive care providers

Thursday 26 May 2022

The need for a more holistic approach to contraceptive care has been highlighted in new research by Senior Lecturer Dr Tracy Morison. Her research has found that despite good intentions, contraceptive providers often undermine patients’ agency.

Different types of long-acting reversible contraception

Long-Acting Reversible Contraception

Last updated: Wednesday 1 June 2022

The need for a more holistic approach to contraceptive care has been highlighted in new research by Senior Lecturer Dr Tracy Morison. Her research, Patient-provider power relations in counselling on long-acting reversible contraception: a discursive study of provider perspectives, has found that despite good intentions, contraceptive providers often undermine patients’ agency.

Long-Acting Reversible Contraception (LARC) is widely accepted in most public health and family planning approaches. They are highly effective methods—like the intrauterine device (IUD), injectable contraception (the jab) and implants (the rod)—that must be fitted and removed by a contraceptive provider and prevent pregnancy for extended periods. However, power imbalances between healthcare providers and patients make many women feel as though they have limited choice or are pressured into taking LARC, as Morison’s earlier study with women indicated. Despite this evidence, which supports international findings, she says there is little research on the nature and quality of patient-provider interactions, including issues of power and women’s agency. Most researchers focus on contraceptive access, leaving concerns about potential coercion, lack of patient-centredness, or uncritical LARC promotion under-explored, especially among ‘high-risk’ women who experience poor health and social outcomes.

Dr Morison’s latest study addresses this knowledge gap. Examining how providers’ perspectives of family planning and reproduction shape their recommendations to patients, she sought to identify ways to help support patients’ agency in making reproductive choices.

Contraceptive providers play a key role in counselling women on their contraceptive options, including LARC, helping them make the best decisions for their reproductive health and life circumstances. However, patients report experiencing a lack of autonomy in their interactions with contraceptive providers or feeling as though they are being subtly coerced into taking LARC. This is especially true in the case of socio-economically vulnerable populations, where population control can often be  seen by policymakers as a way of addressing social issues, like poverty or welfare dependency.

Senior Lecturer Dr Tracy Morison

Dr Morison interviewed 22 contraceptive providers from across the country and analysed their responses using a theoretical lens that explores power imbalances in social relationships. Most providers were frustrated with patients who did not follow their advice about contraception and sometimes sought to influence or control decision-making in subtle ways. Again, this echoes British and US studies which have noted this response but not explored it in depth. However, Dr Morison argues that exploring how providers make sense of their responses can help address some of the underlying issues driving them. She noted that providers seemed to be aware that restricting women’s right to choose through pressing or persuading the  into taking certain decisions is viewed in a negative light. and explained and justified restricting or controlling contraceptive decision-making by framing their actions as acting in women’s best interests, for their own good. Overall, providers attributed their actions to helping patients live up to their responsibility of looking after their sexual and reproductive health through rational decision-making and careful family planning to avoid unplanned pregnancy—a way of thinking about sexual and reproductive health called ‘sexual healthism’.

Dr Morison identified three roles that providers claimed to justify influencing, controlling, or limiting women’s contraceptive decision-making.

The first involves providers presenting themselves as a ‘promoter of responsible choices’ to explain why they persuade patients in favour of LARC, which they spoke of as pushing or selling LARC by emphasising its benefits and downplaying side-effects or other negatives. Presenting specific contraceptives as the only responsible choice can make using it seem compulsory and limit patients’ choice of contraceptives.

The second role that providers claimed was as ‘protectors’ of patients. This argument relies on the view of certain patients as being ‘at risk’ and unable to make a good decision for themselves. Here, the providers commonly described their actions of pushing patients along a particular path or restricting choices as protecting the patients from making poor, illogical, or uneducated choices. This paternalistic view often dismisses women’s concerns (beyond pregnancy prevention) and implies that providers are more capable of making choices in patients’ interests than the women themselves.

The final role providers claimed was as ‘empowerers’ of women. They argued that LARC can bring about personal empowerment—especially for poor, working-class, and young women. Reliably contracepting to delay motherhood or limit family size was seen as allowing these women to overcome adverse life circumstances. However, seeing LARC as the solution to marginalised women’s difficulties focuses on their reproductive practices instead of the structural factors limiting their choices and opportunities (e.g. lack of a living wage or access to healthcare, housing insecurity, discrimination). This approach prioritises intervening at the level of individual behaviour and inadvertently maintains inequity by not addressing broader systemic factors.

Dr Morison says these findings show that targeted counselling by providers can be justified as well-intentioned but ignores the underlying sexual healthism that promotes the middle-class, Western ideals, undermining unmarried, young, poor, or working-class women’s childbearing wishes and enabling monitoring of their reproductive practices.

“There is a clear need for capacity building, training, and guidance for providers regarding the nature of rights-based, patient-centred care and how to implement it,” Dr Morison says. She also recommends adopting a holistic approach to contraceptive care—from contraceptive policy and planning through to implementation—grounded in principles of reproductive justice. These principles are based on the view that all people should have access to noncoercive, patient-centred reproductive health counselling, and a range of contraceptive methods, alongside the right to have children free of stigma and shame.

“A holistic approach is necessary to inform person-centred care, given that, despite good intentions, the goal of supporting women’s rights can be side-lined by the power relations surrounding contraceptive care.”

One such approach is to recognise and address wider factors that affect the provision of equitable contraceptive care. These factors include the burdens on programmes, for example over-subscribed and under-resourced clinical environments, institutional targets, and policy framings.

Dr Morison says that recognising that contraceptive providers are motivated by a desire to help patients is an important step towards promoting a rigorous and nuanced discussion of patients’ agency and best interests. She believes further research in this direction will help set the course for patients to gain true agency over their reproductive choices and help realise truly rights-based, voluntary contraceptive care.