Looking back while moving forward: a justice-based, intersectional approach to research on contraception and disability

Contraceptive and Pregnancy Decision-Making Autonomy and Health Care Experiences Among Women With Intellectual Disabilities

BACKGROUND

There is currently limited research exploring the extent to which women with an intellectual disability experience autonomy over contraception, pregnancy timing and pregnancy outcome decisions. Previous studies have highlighted inequities in sexual and reproductive health outcomes. However, barriers and facilitators of reproductive autonomy for women with an intellectual disability across the reproductive journey, including health care experiences, are poorly described; this is the focus of the current study.

METHODS

Ten women with intellectual disabilities participated in focus groups or individual interviews where they discussed their experiences of accessing sexual and reproductive health services and making reproductive health decisions. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes elucidate how a lack of sexual and reproductive health information and violence impacted many participants' ability to control timing of conception and make informed pregnancy outcome decisions. The first theme describes contraceptive literacy as a barrier to reproductive autonomy. Most participants received no contraception or reproductive health education prior to their first pregnancy. While most women were aware of common forms of contraception and pregnancy options, their contraceptive knowledge was incomplete or incorrect. The second theme explores how most participants experienced agency over pregnancy outcome decisions, though informed decision-making was hampered by reproductive coercion and abuse, delayed pregnancy detection and insufficient information about all pregnancy options. The third theme identifies health professionals as pivotal in empowering reproductive agency and facilitating informed decision-making.

CONCLUSIONS

Women with intellectual disabilities demonstrate the willingness and the ability to make informed and autonomous reproductive health decisions when appropriately supported with care and information. However, they face reproductive coercion and abuse and are often required to overcome numerous systemic challenges to assert their reproductive rights. Significant efforts are needed to better understand and address barriers to informed reproductive decision-making.

Preconception health risks by presence and type of disability among U.S. women

BACKGROUND

Poor preconception health may contribute to adverse perinatal outcomes among women with disabilities. While prior research has found higher prevalence of preconception health risks among women with versus without disabilities, existing U.S. studies have not assessed how preconception health risks may differ by disability type. Understanding such differences is relevant for informing and targeting efforts to improve health opportunities and optimize pregnancy outcomes.

OBJECTIVE

This cross-sectional study examined preconception health in relation to disability type among reproductive-age women in the United States.

METHODS

We analyzed 2016-2019 data from the Behavioral Risk Factor Surveillance System to estimate the prevalence of 19 preconception health risk among non-pregnant women 18-44 years of age. We used modified Poisson regression to compare women with different types of disability to non-disabled women. Disability categories included: 1) hearing difficulty only; 2) vision difficulty only; 3) physical/mobility difficulty only; 4) cognitive difficulty only; 5) multiple or complex disabilities (including limitations in self-care or independent living activities). Multivariable analyses adjusted for other sociodemographic characteristics such as age and marital status.

RESULTS

Women with each disability type experienced a higher prevalence of indicators associated with poor preconception health compared to women with no disabilities. The number and extent of health risks varied substantially by disability type. Women with cognitive disabilities and women with multiple or complex disabilities experienced the greatest risk.

CONCLUSIONS

Addressing the specific preconception health risks experienced by women with different types of disabilities may help reduce adverse perinatal outcomes for disabled women and their infants.

Pregnant racialised migrants and the ubiquitous border: The hostile environment as a technology of stratified reproduction

This article explores the impact of the 'hostile environment' on racialised migrant women's experiences of pregnancy and childbirth in England, arguing that the 'hostile environment' functions as a technology of 'stratified reproduction.' First coined by Shellee Colen, the concept of stratified reproduction describes the dynamic by which some individuals and groups may be supported in their reproductive activities, while others are disempowered and discouraged. This paper locates the stratified reproduction produced by the 'hostile environment' as intertwined with wider gendered and racialised discourses around British citizenship which have been 'designed to fail' racialised residents of the UK. Drawing on interviews with racialised migrant mothers in the north of England, this paper analyses how the proliferation and intensification of immigration controls interacts with gender, race, class, and other social regimes to differentially allocate the resources necessary for a safe and healthy pregnancy and childbirth, and how this is experienced materially by pregnant migrants.

Equitable Care for Patients With Disabilities: Considerations for the Gynecologic Health Care Professional

All patients deserve high-quality health care. Patients with disabilities have historically experienced discrimination in health care and subsequently detrimental health outcomes. Health care professionals often lack confidence and preparedness in treating patients with disabilities effectively. Barriers such as communication difficulties, biased assumptions, and inadequate equipment hinder comprehensive care. These barriers to care lead to health inequalities and a diminished overall quality of life for individuals with disabilities. Existing clinical guidelines for care of this underserved population are lacking. This article establishes a comprehensive educational framework and accessible reference tools for gynecologic health care professionals to enhance their ability to offer inclusive and effective care to patients with disabilities. Insights in this article stem from expert consensus among clinicians experienced in this field and ongoing dialog with community-based disability care partners. We present actionable steps to cultivate an open, adaptable, and patient-centric method to actively engage patients and to provide suitable accommodations when needed.

Contraception use among female youth with disabilities: Secondary analysis of a Canadian cross-sectional survey

BACKGROUND

Non-use of contraception among sexually active youth is an important contributor to unintended pregnancy, but contraception use among disabled youth is poorly understood.

OBJECTIVE

To compare contraception use in female youth with and without disabilities.

METHODS

We used data from the 2013-2014 Canadian Community Health Survey on sexually active 15 to 24-year-old females with (n = 831) and without (n = 2,700) a self-reported functional or activity limitation, who reported that it was important to them to avoid getting pregnant. We used log binomial regression to derive adjusted prevalence ratios (aPR) for use of any vs. no contraception, and for oral contraception, injectable contraception, condoms, other contraception methods, and dual methods separately, comparing youth with and without disabilities. Adjusted analyses controlled for age, school enrollment, household income, marital status, race/ethnicity, immigrant status, and health region.

RESULTS

There were no differences in the use of any contraception (85.4% vs. 84.2%; aPR 1.03, 95% CI 0.998-1.06), oral contraception (aPR 0.98, 95% CI 0.92-1.05), condoms (aPR 1.00, 95% CI 0.92-1.09), or dual methods (aPR 1.02, 95% CI 0.91-1.15), comparing youth with and without disabilities. Those with disabilities were more likely to use injectable contraception (aPR 2.31, 95% CI 1.59-3.38) and other contraception methods (aPR 1.54, 95% CI 1.25-1.90).

CONCLUSION

Youth at risk of unintended pregnancy had similar overall use of contraception, regardless of disability status. Future studies should examine the reasons for higher uptake of injectable contraception in youth with disabilities, with possible implications for health care provider education on access to youth-controlled methods for this group.

Centering disability visibility in reproductive health care: Dismantling barriers to achieve reproductive equity

Access to comprehensive and culturally competent reproductive health care is essential for individuals and communities to realize and achieve health and well-being, as one prefers. The disability community represents a diverse group of individuals with a wide spectrum of functional, physical, sensory, and/or neurodivergent abilities. Existing barriers to reproductive health care are a consequence of environmental and attitudinal barriers, not from the disabilities themselves. People with disabilities are also not frequently centered or included in discussions surrounding reproductive rights. This article reviews the intersection of the Disability Justice Movement and the history of discrimination in the United States against people with disabilities with a particular focus on reproductive oppression. We discuss the mechanisms of inequity and barriers to health care, including financial barriers, inaccessible medical facilities, provider discrimination and competency, and guardianship; as well as the importance of open access to contraception, menstrual health, and abortion for people with disabilities. Finally, we explore the intersection of the Disability Justice Movement and the Reproductive Justice Movement to better promote reproductive autonomy.

Perinatal Health Risks And Outcomes Among US Women With Self-Reported Disability, 2011-19

Women with disabilities experience elevated risk for adverse pregnancy outcomes. Most studies have inferred disabilities from diagnosis codes, likely undercounting disabilities. We analyzed data, including self-reported disability status, from the National Survey of Family Growth for the period 2011-19. We compared respondents with and without disabilities on these characteristics: smoking during pregnancy, delayed prenatal care, preterm birth, and low birthweight. A total of 19.5 percent of respondents who had given birth reported a disability, which is a much higher prevalence than estimates reported in US studies using diagnosis codes. Respondents with disabilities were twice as likely as those without disabilities to have smoked during pregnancy (19.0 percent versus 8.9 percent). They also had 24 percent and 29 percent higher risk for preterm birth and low birthweight, respectively. Our findings suggest that studies using diagnosis codes may represent only a small proportion of pregnancies among people with disabilities. Measurement and analysis of self-reported disability would facilitate better understanding of the full extent of disability-related disparities, per the Affordable Care Act.

"It Would Have Been Nice to Have a Choice": Barriers to Contraceptive Decision-making among Women with Disabilities

INTRODUCTION

Engaging in contraceptive decisions is an important part of reproductive health for women and other people with the capacity for pregnancy. However, not all individuals capable of pregnancy have equal access to information and/or opportunities to make fully informed decisions. The goal of this study was to understand barriers women with disabilities experience around contraceptive decision-making and whether these differ based on type of disability.

METHODS

We conducted focus groups with 17 reproductive age adult women (aged 18-45 years). Focus groups were homogenous with regard to disability type and consisted of one group for each of the following disability categories: 1) physical disability, 2) intellectual and developmental disabilities, 3) blind or low vision, and 4) Deaf users of American Sign Language. Data were collected in the Portland, Oregon, metropolitan area during 2016-2017. We analyzed focus group transcripts using content analysis.

RESULTS

Barriers to informed contraceptive decision-making emerged in five main thematic areas: 1) lack of information in accessible formats, 2) incomplete information about contraceptive side effects, 3) limited clinician knowledge and relevant research specific to the care of women with disabilities, 4) taboos around discussing sexual activity, and 5) limited opportunities for shared contraceptive decision-making.

CONCLUSIONS

Women with disabilities faced numerous barriers to contraceptive decision-making. Although the barriers differed somewhat by disability type, many barriers were consistent across groups, suggesting commonalities associated with the experience of disability in the context of contraceptive decision-making. Increased attention to the reproductive health needs of people with disabilities is important for improving health care equity and quality.

Contraceptive Provision and Quality Care Measures for Insured Individuals in Massachusetts Who Are Deaf or Hard of Hearing

OBJECTIVE

To evaluate contraceptive provision and contraceptive care quality measures for individuals who are deaf or hard of hearing and compare these outcomes to those individuals who are not.

METHODS

We conducted a claims analysis with data from the 2014 Massachusetts All-Payer Claims Database. Among premenopausal enrollees aged 15-44, we determined provision of any contraception (yes or no) and provision by contraception type: prescription contraception (pills, patch, ring, injectables, or diaphragm), long-acting reversible contraceptive (LARC) devices, and permanent contraception (tubal sterilization). We compared these outcomes by deaf or hard-of-hearing status (yes or no). The odds of contraceptive provision were calculated with regression models adjusted for age, Medicaid insurance, a preventive health visit, and deaf or hard-of-hearing status. We calculated contraceptive care quality measures, per the U.S. Office of Population Health, as the percentage of enrollees who used: 1) LARC methods or 2) most effective or moderately effective methods (tubal sterilization, pills, patch, ring, injectables, or diaphragm).

RESULTS

We identified 1,171,838 enrollees at risk for pregnancy; 13,400 (1.1%) were deaf or hard of hearing. Among individuals who were deaf or hard of hearing, 31.4% were provided contraception (23.5% prescription contraception, 5.4% LARC, 0.7% tubal sterilization). Individuals who were deaf or hard of hearing were less likely to receive prescription contraception (adjusted odds ratio 0.92, 95% CI 0.88-0.96) than individuals who were not deaf or hard of hearing. The percentage of individuals who were deaf or hard of hearing who received most effective or moderately effective methods was less than that for individuals who were not (24.2% vs 26.3%, P<.001). There were no differences in provision of LARC or permanent contraception by deaf and hard-of-hearing status.

CONCLUSION

Individuals who were deaf or hard of hearing were less likely to receive prescription contraception than individuals who were not; factors underlying this pattern need to be examined. Provision of LARC or permanent contraception did not differ by deaf or hard-of-hearing status. These findings should be monitored and compared with data from states with different requirements for contraceptive coverage.

Addressing long-acting reversible contraception access, bias, and coercion: supporting adolescent and young adult reproductive autonomy

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare.

RECENT FINDINGS

Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services.

SUMMARY

Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.

Pregnancy decision-making in women with physical disabilities

BACKGROUND

Women with physical disabilities experience barriers to knowledge about pregnancy and adequate reproductive healthcare, which impedes decision-making processes and negatively impacts their pregnancy planning.

OBJECTIVE

The purpose of this study was to learn more about pregnancy decision-making in women with physical disabilities.

METHODS

We conducted a qualitative study utilizing semi-structured interviews with women with physical disabilities. We asked questions regarding pregnancy, parenting, reproductive health, relationships and interactions with the healthcare system. We utilized interview transcripts and notes to form a codebook regarding pregnancy and parenting decision-making, knowledge, and fears. We then organized codes into themes based on pre-existing literature regarding fertility and conceptualization of the self.

RESULTS

We completed and analyzed 16 interviews. Themes overall reflected the participants grappling with their own baseline assumptions that they were infertile, as well as managing similar assumptions from others. However, many of the participants recall an exact point where they began to contemplate the fact that having children was possible for them. Finally, disability-related parenting challenges are considered very early in pregnancy decision-making process.

CONCLUSIONS

Women with physical disabilities experience barriers to contemplating pregnancy including inadequate information on pregnancy and reproductive healthcare that affects their decision-making regarding pregnancy and parenting. All healthcare providers should talk to patients with disabilities about family planning and address possible barriers to contemplating pregnancy.

Abortion at the edges: Politics, practices, performances

This article provides a brief overview of the state of discourse, politics and provision of abortion in the Anglophone West, including developments in the wake of the COVID-19 pandemic. It then surveys three promising directions for feminist abortion scholarship. The first is work inspired by the Reproductive Justice Movement, that points to the intersectional axes of inequality that shape abortion discourse and position us in relation to reproductive choice and access issues. The second is work that examines the particularity of the constitution of the aborting body, reflecting the particularity of the pregnant body. This is a specific body, with a specific history; abortion discourse draws from and makes a significant contribution to the meaning and lived experience of this body. The third area of scholarship we highlight is that which seeks to amplify the meaning of abortion as a social good. Much abortion scholarship is attuned to a critique of negative aspects of abortion-from its representation in popular culture to restrictive law and access issues. This is critical work but/and the performative nature of abortion scholarship, like all discourse, means that it can amplify the association of negativity with abortion. The article concludes by introducing the articles contained in the special section of Women's Studies International Forum, 'Abortion at the edges: Politics, practices, performances'.

Pregnancy Intendedness by Maternal Disability Status and Type in the United States

CONTEXT

Societal views about sexuality and parenting among people with disabilities may limit these individuals' access to sex education and the full range of reproductive health services, and put them at increased risk for -unintended pregnancies. To date, however, no national population-based studies have examined pregnancy -intendedness among U.S. women with disabilities.

METHODS

Cross-sectional analyses of data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth were conducted; the sample included 5,861 pregnancies reported by 3,089 women. The proportion of pregnancies described as unintended was calculated for women with any type of disability, women with each of five types of disabilities and women with no disabilities. Multivariate logistic regression analyses were conducted to examine the relationship of disability status and type with pregnancy intendedness while adjusting for covariates.

RESULTS

A higher proportion of pregnancies were unintended among women with disabilities than among women without disabilities (53% vs. 36%). Women with independent living disability had the highest proportion of unintended pregnancies (62%). In regression analyses, the odds that a pregnancy was unintended were greater among women with any type of disability than among women without disabilities (odds ratio, 1.4), and were also elevated among women with hearing disability, cognitive disability or independent living disability (1.5-1.9).

CONCLUSIONS

Further research is needed to understand differences in unintended pregnancy by type and extent of disability. People with disabilities should be fully included in sex education, and their routine care should incorporate discussion of reproductive planning.

Ensuring the Reproductive Rights of Women with Intellectual Disability

BACKGROUND

Women with intellectual disability experience disparities in sexual and reproductive health care services.

METHODS

To explore perceptions of caring for persons with disability, including individuals with intellectual disability, we conducted open-ended individual interviews with 20 practicing physicians and three video-based focus group interviews with an additional 22 practicing physicians, which reached data saturation. Interviews were transcribed verbatim. We used conventional content analysis methods to analyse transcripts.

RESULT

Physicians indicated that intellectual disability can pose challenges to providing sexual and reproductive health care. Observations coalesced around four themes: (1) communication; (2) routine preventive care; (3) contraception and sterilization; and (4) conception and parenthood. Observations raised concerns about equity of access to reproductive care for women with intellectual disability.

CONCLUSIONS

In our sample of physicians, we found attitudes that might compromise reproductive care for women with intellectual disability, suggesting that gaps remain in ensuring reproductive rights of women with intellectual disability.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.