Who Decides Women’s Best Interests? Examining patient-provider power relations in counselling on long-acting reversible contraception

By Tracy Morison

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Long-acting reversible contraception (LARC) is widely accepted in most public health and family planning approaches. However, power imbalances between healthcare providers and patients make many women feel as though they are coerced into taking LARC. There is little research that considers the nature and quality of patient-provider interactions, including issues of power and women’s agency, as most scholarship in the field focuses on access. Concerns about the potential for coercion, lack of patient-centeredness, or uncritical LARC promotion are therefore under-explored, especially among ‘high-risk’ women who experience poor health and social outcomes. This study takes a much-needed look at how providers’ perspectives influence their recommendations to patients and the changes that must be implemented to help patients regain autonomy over their reproductive choices.

Long-acting reversible contraception (LARC) is a widely accepted approach to family planning and contraception. Contraceptive providers play a key role in counselling women1 on their contraceptive options, including LARC, and in helping them make the best decisions for their reproductive health and life circumstances. However, many 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 socioeconomically vulnerable populations, where population control is also seen by policymakers as a way of addressing social issues like poverty or welfare dependency.

In my new study published in Culture, Health & Sexuality, I examined contraceptive care providers’ accounts of their experiences of offering contraceptive care in Aotearoa, New Zealand. I focused on how contraceptive providers’ preconceived notions about reproduction shape their recommendations to patients in reproductive counselling.

As a part of the study, I interviewed 22 contraceptive providers from Aotearoa (New Zealand) and analysed their responses using a feminist poststructuralist lens to explores power relations in contraceptive care. I found that many 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. However, providers seemed to be aware that restricting women’s right to choose is viewed in a negative light. To pre-empt or respond to criticism related to pressing or persuading patients into taking unwanted decisions, many providers explained and justified restricting or controlling contraceptive decision-making.

Overall, providers presented their actions as being in their patients’ best interests, thereby portraying themselves in a positive light. Contraceptive 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’.

I 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 LARC 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 good decisions 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 is a paternalistic view that often dismisses women’s concerns (beyond pregnancy prevention) and implies that providers are more capable of making choices in their patients’ interests than the women themselves.

The final role providers claimed 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. Seeing LARC as the solution to marginalised women’s difficulties focuses on their reproductive practices instead of the structural factors that limit 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.

What do these findings imply? I argue 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. Provider training is not the whole answer, however. I also recommend 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 a person-centred framework that was designed by Holt and colleagues in the USA, which offers a guide for all those involved in contraceptive care to recognise and address wider factors that affect the provision of equitable contraceptive care“. These factors include the burdens on programmes (e.g., over-subscribed and under-resourced clinical environments, institutional targets) and policy framings (e.g., policy overly focused on individual risk management).

Accepting that contraceptive providers are motivated by a desire to help patients is an important step toward promoting a rigorous and nuanced discussion of patients’ agency and best interests. 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.

1Note: Not all contraceptive users are cisgender women. I focus on this group here because it is the largest group requiring contraceptive care and upon which reproductive politics has historically centred.

Acknowledgement: This work was funded by the Royal Society of New Zealand Marsden Fund (Grant MAU1815). My collaborators on the project are Jade Le Grice (University of Auckland), Catriona Macleod, and Yanela Ndabula (Rhodes University).

About the Author: Tracy Morison is ISCHP’s treasurer and former blog editor. Since 2016, she has taught critical health psychology in the School of Psychology at Massey University (New Zealand). She is an honorary research associate of the Critical Studies in Sexualities and Reproduction programme at Rhodes University (South Africa) where she obtained her Ph.D. and Editor for Feminism & Psychology journal. Tracy’s research is situated at the intersection of critical health psychology, feminism, and social psychology and explores how the socio-political context shapes and constrains sexual and reproductive decision-making, relations, and practices. A key focus in her work is on gender, sexualities, and their interrelationship with other social locations. She draws on feminist and other critical theories and in-depth qualitative methodologies to illuminate the multiple, complex processes in which sexualities and reproduction are embedded.

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