Intersections between culture, contraception, knowledge and the body in the USA.

Women's contraceptive use is a central feature of US culture around reproduction as evinced by high usage rates and nationwide public health efforts to further increase its use. Paradoxically, women know little about contraception within its biomedical framing, and successive public health-related educational campaigns have produced only moderate knowledge gains. Drawing on 86 in-depth interviews with a diverse sample of reproductive-age women, we set out to understand this persistent learning lag. In doing so, we found that women's limited contraceptive knowledge extended beyond simply being uneducated about various methods. Rather, these learning lags can be attributed to many women's lack of knowledge or misunderstandings about their anatomical bodies and reproductive processes. Employing feminist perspectives, we argue that these misunderstandings derive from factors beyond individual women's control. Indeed, they are rooted in cultural norms that stifle and stigmatise women's reproductive learning. Traditional public health efforts may inevitably fail to overcome these cultural barriers, perpetuating women's gaps in knowledge. Recognising the cultural dimensions of contraceptive knowledge and education reveals how critical action is needed around sexuality education in the USA as well as the limitations of on-going educational efforts.

Comparing methods of long-acting reversible contraception: A qualitative study of Delaware women's perceptions of intrauterine devices and the implant.

OBJECTIVE: To distinguish Delaware women's perceptions of the intrauterine device (IUD) relative to the subdermal arm implant (implant) as well as to compare their perceptions of various IUD types. STUDY DESIGN: In this qualitative study, we conducted in-depth interviews with 86 self-identified women between 16 and 44 years old who resided in the state of Delaware. We used quota sampling to ensure a diversity of perspectives using age, socioeconomic status, race/ethnicity, and county of residence to do so. We analyzed the data for content and themes using deductive and inductive techniques. RESULTS: Of the 47 participants who would use long-acting reversible contraception (LARC), 36 favored IUDs over the implant, and 11 felt more comfortable with the implant. Participants' perceptions were primarily influenced by device side effects, body placement, and the removal process. Those favoring a specific IUD prioritized the presence of exogenous hormones, device size, and maximum duration of use. Thirty-nine women would not use IUDs or the implant, citing safety risks and the availability of "simpler" methods. CONCLUSIONS: Clinicians often use tier-based descriptions when counseling patients about contraception, particularly when emphasizing the similar efficacy levels of LARC devices. Participants in our study did not perceive LARC as a homogeneous category; rather, they consistently differentiated between IUDs and implants as well as between IUD types. Such findings demonstrate the need to understand which device features inform these distinct preferences and how providers' contraceptive counseling practices can be adjusted in response. IMPLICATIONS: Given these findings, scholars should compare and further distinguish across methods, including IUDs, whenever possible. The findings also reinforce the benefits of stocking a variety of LARC devices at clinic and practice sites and encouraging provider counseling that emphasizes method-specific concerns and features. Doing so centers users' needs and preferences.

"Did I Choose a Birth Control Method Yet?": Health Care and Women's Contraceptive Decision-Making.

In the United States, unintended pregnancy is medicalized, having been labeled a health problem and "treated" with contraception. Scholars find women's access to contraception is simultaneously facilitated and constrained by health care system actors and its structure. Yet, beyond naming these barriers, less research centers women's experiences making contraceptive decisions as they encounter such barriers. Through in-depth, semi-structured interviews with 86 diverse, self-identified women, this study explores how the medicalization of unintended pregnancy has influenced women's contraceptive access and decision-making. We highlight the breadth of such influence across multiple contraceptive types and health care contexts; namely, we find the two most salient forces shaping women's contraceptive decisions to be their insurance coverage and providers' contraceptive counseling. Within these two categories, we offer crucial nuance to demonstrate how these oft-cited barriers implicitly and explicitly influence women's decisions. Paradoxically, it is the health care system, itself, that both offers yet constrains women's contraceptive decisions.

The limitations of patient-centered care: The case of early long-acting reversible contraception (LARC) removal.

Patient-centered care (PCC) is frequently recommended to improve healthcare outcomes in the United States. Despite its purported benefits, little research explores how and to what extent providers implement this model in their care. We examine such processes through the case of contraception, specifically, "early" removals of long-acting reversible contraception (LARC). In-depth interviews with 51 healthcare providers reveal that while providers describe embracing patient-centeredness when considering patients' early LARC removal requests, their implementation ironically sidelines patient preferences and needs. Rather than be responsive to patients' requests, all providers in the study resist early LARC removal by: withholding information about self-removal of intrauterine devices (IUDs); negotiating with patients to keep their device longer; setting subjective timelines to prolong LARC use; and/or engaging in delay tactics to wear down patients' resolve for removal. Furthermore, beyond simply resisting LARC removal requests using these strategies, providers purposively employ tenets of PCC to sway patients away from removal. In other words, providers utilize PCC as a means to undermine it. Understanding how providers implement patient-centered care reveals the challenges to doing so, even in cases like early LARC removal where providers indicate patient-centeredness is a priority. It also elucidates the need for enhanced training, specificity, and institutionalization around patient-centered models of care; informs interventions that promote LARC use among patients; as well as offers opportunities for improving patient-provider exchanges generally.

"We're a Little Biased": Medicine and the Management of Bias through the Case of Contraception.

There is a wealth of literature demonstrating the presence of bias throughout the American health care system. Despite acknowledging such presence, however, little is known about how bias functions within medical encounters, particularly how providers grapple with bias in their patient counseling and decision-making. We explore such processes through the case of contraceptive counseling, a highly raced, classed, and gendered context. In-depth interviews with 51 health care providers reveal that providers use four primary strategies to navigate and minimize bias in their care-using scientific rationale, employing "safe" biases, standardizing counseling, and implementing patient-centered care. Paradoxically, using these strategies can exacerbate rather than resolve bias. Understanding these bias management strategies reveals provider-held biases, how they manifest within appointments, and the potential consequences for patients' health autonomy. Such knowledge informs interventions that promote contraceptive use among women in the United States, addresses bias in health care broadly, and thus ultimately helps combat health disparities.

Safeguarding Children's Well-Being: Voices From Abused Mothers Navigating Their Relationships and the Civil Courts.

Battered mothers often go to great lengths to protect their children from abuse. Most of these efforts play out in private settings such as the home. After their relationships end, women's actions shift to the public sphere for judgment by the courts. Abusers' strategies utilize the courts as another tool with which to call into question and challenge their former partners' parenting. Images of "good mothers" who behave passively are favored by officials who often have incomplete understandings of the dynamics of intimate partner violence and abuse. Existing studies about justice-involved mothers insufficiently portray women's experiences managing both continued abuse from past partners as well as discriminating treatment by the courts. Semistructured interviews with 25 women in the United States who have terminated their abusive relationships reveal strategies of negotiation and resistance used to protect their children both during and after their relationships; the women also recount instances of paternalism and naïveté present in civil and criminal courts. While their male abusers seemed to receive leniency from court officials, despite, in some cases, violating judges' direct orders, the women's efforts were sometimes interpreted as recalcitrance and disobedience when they challenged unfair labels, visitation, and custody decisions. This qualitative study contextualizes women's efforts and actions taken to safeguard their children during and after their relationships to highlight women's experiences the courts overlook and misconstrue as well as what happens when women engage with the courts. Policy suggestions include ways to prevent the continued victimization of battered women by the courts, to challenge the pejorative assessment of mother's protective behaviors, and to illuminate court officials' malfeasance and toleration of fathers' tactics.