Today in the United States we see a resurgence of the discussion around our country’s oldest problem: racism. Whether we’re talking about how communities of color are being over-policed and disproportionately imprisoned, or the continuation of economic inequality, it’s clear that institutional racism is an unyielding problem in our society. It is also our shame as a nation, and this shame prevents us from tackling the problem head on.
We in the family planning community have our own complicated history with racism, including:
- Forced sterilization of women with mental illnesses, poor women, women of color, and Hispanic immigrant women—as recently as the 1970s.
- Experimentation without informed consent on Puerto Rican women in the development of the oral contraceptive.
- Coercion of poor women, who in the U.S. are disproportionately women of color, to use long-acting contraceptives (LARC) like Norplant and Depo-Provera in order to receive social assistance.
While most current policies are not intentionally targeting poor women and women of color, this legacy has formed a collective memory in many communities. Our patients from these communities may fear that modern family planning programs are a form of genocide.
History is alive
This collective memory may explain why, on average, black women report lower use of contraception compared to whites, and lower use of modern contraceptives including IUDs and implants. It may also affect some women’s preferences for avoiding methods that change menstruation or require a visit with a provider to stop using them.
It is not just patient behaviors stemming from historical racism that drive these differences in reproductive health care outcomes: we too contribute, in our roles as health care providers. In our enthusiasm to provide access to contraception to women whom we feel need it most, we may unwittingly continue the legacy of differential treatment, care, and counseling regarding family planning.
Here’s a current example. Some family planning programs have started using percentage of contraceptive patients initiating LARC as an indicator of quality of care. This may seem like a benign policy and—from a biomedical perspective—a good one, since LARCs are the most effective methods. But most family planning clinics are located in communities with concentrations of low-income women and women of color. That means we as providers may be perceived as targeting these women to use LARC, and possibly even pushing it, because we are being incentivized to increase the percent of women initiating LARC. If the incentive were to give unbiased, complete contraceptive counseling and then give the method that the patient desires, this quality indicator would feel very different.
Unconscious biases: you have them
Indeed, studies have shown that we providers, when presented with patients with varying combinations of apparent education, income level, and race/ethnicity, are more likely to recommend IUDs to poor women and women of color compared to wealthier women and white women.
This reality of our unconscious biases may be the reason that studies show black women tend to rate their quality of family planning care as low. The same study showed that black women felt pressured by their providers to use contraception, and other studies have shown they felt pressured to limit their reproductive potential.
Breaking the cycle
If women do not feel comfortable receiving care from us, they will not seek out needed health care, leading to a continuation of poor reproductive and other health outcomes. So how do we as providers break this vicious cycle? By doing three things:
Learn about and acknowledge our history of reproductive abuse in family planning. While painful, without this education for our current and future family planning leaders, we will continue to make the same mistakes.
Never allow group statistics to determine how we treat an individual patient. This phenomenon is called statistical discrimination. For example, while it is true on average that women of color have higher rates of unintended pregnancies and contraceptive misuse, we should not allow that fact to creep into individual interactions with our patients. This is the doorway that our unconscious biases and stereotypes creep through, and we then fail to provide patient-centered care. Remaining open and curious about each individual patient's experience helps to avoid statistical discrimination.
Take a lesson from our reproductive justice colleagues: trust your patient. Even if it seems like a decision you would not make for yourself if you were in her shoes, remember that you do not have all the information she does—she’s the expert on her life. Let’s also remember our oath to be caring, empathic, and supportive medical providers and empower our patients to make their own decisions.
So many of us providers are in this for the right reasons: we want to be the people who help patients achieve their health and overall life goals. Like our painful but critically important national conversation about race and equity, health care providers are due for some of the same hard and fruitful reflections and conversations. Let’s take these steps to ensure that patients of color and poor patients achieve true reproductive health equity within our generation.
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