Reproductive justice: A radical framework for researching sexual and reproductive issues in psychology

Exploring women's motivations to freebirth and their experience of maternity care: A systematic qualitative evidence synthesis

BACKGROUND

Freebirth is currently defined as the deliberate decision to give birth without a regulated healthcare professional. Previous reviews have identified factors influencing women's decision to freebirth, yet there is limited evidence on what is the care experience for women who opt to freebirth.

AIM

To synthesise the qualitative evidence on women's motivations to freebirth and their experience of maternity care when deciding to freebirth.

METHODS

We conducted a qualitative evidence synthesis using a sensitive search strategy in May 2022 and August 2023. Twenty-two publications between 2008 and 2023 and from ten different high-income countries were included. Thematic synthesis, underpinned by a feminist standpoint, was used to analyse the data.

FINDINGS

Three main analytical themes were developed in response to each of the review questions. 'A quest for a safer birth' describes the factors influencing women's decision to freebirth. 'Powerful and powerless midwives' describes women's perceptions of their care providers (mostly midwives) and how these perceptions influenced their decision to freebirth. 'Rites of self-protection' describes women's care experiences and self-care practices in the pregnancy leading to freebirth DISCUSSION: Freebirth was rarely women's primary choice but the result of structural and relational barriers to access wanted care. Self-care in the form of freebirth helped women to achieve a positive birth experience and to protect their reproductive self-determination.

CONCLUSION

A new woman-centred definition of freebirth is proposed as the practice to self-care during birth in contexts where emergency maternity care is readily available.

Gender-inclusive language in midwifery and perinatal services: A guide and argument for justice

Effective communication in relation to pregnancy and birth is crucial to quality care. A recent focus in reproductive healthcare on "sexed language" reflects an ideology of unchangeable sex binary and fear of erasure, from both cisgender women and the profession of midwifery. In this paper, we highlight how privileging sexed language causes harm to all who birth-including pregnant trans, gender diverse, and non-binary people-and is, therefore, unethical and incompatible with the principles of midwifery. We show how this argument, which conflates midwifery with essentialist thinking, is unstable, and perpetuates and misappropriates midwifery's marginalized status. We also explore how sex and gender essentialism can be understood as colonialist, heteropatriarchal, and universalist, and therefore, reinforcing of these harmful principles. Midwifery has both the opportunity and duty to uphold reproductive justice. Midwifery can be a leader in the decolonization of childbirth and in defending the rights of all childbearing people, the majority of whom are cisgender women. As the systemwide use of inclusive language is central to this commitment, we offer guidance in relation to how inclusive language in perinatal and midwifery services may be realized.

Ethical inclusion: Risks and benefits of research from the perspective of perinatal people with opioid use disorders who have experienced incarceration

BACKGROUND

Research ethics guidelines and emphasis on representation in research guide the inclusion of marginalized groups, including people with perinatal opioid use disorders (OUD) and people experiencing incarceration in the United States. However, insights from participants regarding the risks and benefits of participation are not adequately considered. The aim of this study was to examine the risks and benefits of research participation from the perspective of pregnant/postpartum people with OUD who have experienced incarceration.

DESIGN

We recruited people who had experience with perinatal incarceration and were either currently pregnant or postpartum, and at least 18 years old. All participants met the clinical criteria for OUD. Our study did not have exclusion criteria based on gender, race, or ethnicity.

SETTING

Participants were either currently incarcerated at the North Carolina Correctional Institute for Women in Raleigh, North Carolina, United States or had previously experienced perinatal incarceration and were recruited from a perinatal substance use disorder treatment program located in North Carolina.

PARTICIPANTS

Between 9/2021-4/2022, we completed 12 interviews with pregnant/postpartum people with OUD, approximately half who were currently incarcerated and half with a recent history of perinatal incarceration.

INTERVENTION/MEASUREMENT

Interviews were conducted via Webex phone or video. The interviews followed a scripted interview guide and lasted one hour on average. Interview transcripts were analyzed using the Rigorous and Accelerated Data Reduction technique to produce an overarching thematic framework.

FINDINGS

Our analysis identified benefits, including the personal advantage of self-expression, helping others and contributing to change, and financial incentives. Risks included stigma and breach of confidentiality, misunderstanding of the distinction between research and advocacy, and limited ability to share their whole experience.

CONCLUSIONS

Participant-identified benefits of research mirrored those from other marginalized populations, though participant-identified risks were novel and nuanced. Recruitment and consent should move beyond normative research ethics committees protocol language to consider the perspectives of participants.

Policy and practices shaping the delivery of health services to pregnant adolescents in informal urban settlements in Kenya

In Kenya, the pregnancy rate of 15% among adolescents aged 15-19 years is alarmingly high. Adolescent girls living in informal urban settlements are exposed to rapid socio-economic transitions and multiple intersecting health risks and may be particularly disadvantaged in accessing sexual reproductive health services. Understanding vulnerabilities and service-seeking behaviours from different perspectives is important in order to support the development and implementation of progressive policies and services that meet adolescents' unique needs within urban informal settlements. This study explored policy makers, community health service providers' and community members' perceptions of access to, and delivery of, sexual reproductive health services for pregnant adolescents in one informal urban settlement in Nairobi. We employed qualitative methods with respondents throughout the health system, purposively sampled by gender and diversity of roles. We conducted focus group discussions with community members (n = 2 female-only; n = 2 male-only), key informant interviews with policy makers (n = 8), traditional birth attendants (n = 12), community health volunteers (CHVs) (n = 11), a nutritionist (n = 1), social workers (n = 2) and clinical officers (n = 2). We analysed the data using thematic analysis. Government policies and strategies on sexual and reproductive health for adolescents exist in Kenya and there are examples of innovative and inclusive practice within facilities. Key factors that support the provision of services to pregnant adolescents include devolved governance, and effective collaboration and partnerships, including with CHVs. However, inadequate financing and medical supplies, human resource shortages and stigmatizing attitudes from health providers and communities, mean that pregnant adolescents from informal urban settlements often miss out on critical services. The provision of quality, youth-friendly reproductive health services for this group requires policies and practice that seek to achieve reproductive justice through centring the needs and realities of pregnant adolescents, acknowledging the complex and intersecting social inequities they face.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

BARRIERS TO REPORTING AND LACK OF EQUITABLE SUPPORT: ABORTION ACCESS FOR ADULTS WITH AUTISM EXPERIENCING RAPE-RELATED PREGNANCY POST-ROE

Following the overturning of Roe v. Wade, individuals with autism experience unique barriers to accessing abortion for rape-related pregnancies in states restricting reproductive health care. Barriers to reporting rape include inadequate sex education which contributes to a lack of information about sexual violence (SV), difficulties labeling and recognizing SV, and potential difficulties navigating the role of a caregiver or conservator when reporting SV. Individuals with autism often experience a lack of equitable support from formal SV support services. Both barriers to reporting and lack of equitable support from formal SV support services reflect that individuals with autism are marginalized and often overlooked when receiving sexual and reproductive health care. Suggestions are provided for sexuality educators, SV support services, police, healthcare providers and policymakers, for better supporting individuals with autism experiencing rape-related pregnancy in states with abortion restrictions.

Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action

OBJECTIVE (STUDY QUESTION)

To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States.

DATA SOURCES/STUDY SETTING

Data were collected from six groups of system actors via online focus groups.

STUDY DESIGN

This is a qualitative multilevel study using the iceberg systems thinking framework.

DATA COLLECTION/EXTRACTION METHODS

Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas.

PRINCIPAL FINDINGS

Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders.

CONCLUSIONS

By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Sterilized and Satisfied: Outcomes of Childfree Sterilization Obtainment and Denials

As more women choose to forgo motherhood, childfree women and people assigned female at birth (AFAB) are important to study, particularly given pronatalist ideals that can make the choice not to have children difficult to exercise. Although temporary contraception prevents motherhood, physicians sometimes discourage or deny women access to more permanent options, including sterilization, due to their belief that childfree women and those AFAB will regret their decision. From a reproductive justice framework, we examined psychological outcomes of sterilization approval and denials among a sample of 154 childfree women and nonbinary people AFAB who sought and either obtained or were denied sterilization. Participants completed measures of psychological well-being, self-esteem, and sexual quality of life. Childfree participants who obtained sterilization reported higher self-esteem, better sexual quality, and higher well-being than childfree individuals who were denied the procedure. Neither age nor time since making the sterilization request accounted for the differences between the groups in terms of sexual quality of life and psychological well-being. Collectively, these findings offer the first empirical evidence of the potential outcomes among childfree women seeking sterilization.

Applying a Reproductive Justice Lens to Enhance Research Engagement Among Systematically Underrepresented Childbearing Women

BACKGROUND

Historically, childbearing women from diverse and systematically hard-to-reach populations have been excluded from nursing research. This practice limits the generalizability of findings. Maximizing research strategies to meet the unique needs of these populations must be a priority.

OBJECTIVES

The aim of this study was to provide methodological context for the comprehensive application of reproductive justice strategies to guide research methods and promote engagement of underrepresented childbearing women while decreasing systemic bias.

METHODS

In this article, we use a reproductive justice lens to characterize and define strategies for enhancing ethical and equitable engagement in research involving childbearing women who are often systematically underrepresented using a case study approach. Using a specific case study exemplar, the core tenets of reproductive justice are outlined and affirm the need to advance research strategies that create ethical engagement of diverse populations, transform oppressive social structures, and shift research paradigms so research objectives intentionally highlight the strengths and resiliency inherent to the targeted communities.

RESULTS

We begin by describing parallels between the tenets of reproductive justice and the ethical principles of research (i.e., respect for persons, beneficence, and justice). We then apply these tenets to conceptualization, implementation (recruitment, data management, and retention), and dissemination of research conducted with childbearing women from diverse backgrounds who are systemically underrepresented. We highlight our successful research strategies from our case study example of women with histories of incarceration.

DISCUSSION

To date, outcomes from our research indicate the need for multilevel strategies with a focus on respectful, inclusive participant and key community partner engagement; the time investment in local communities to promote equitable collaboration; encouragement of the patient's autonomous right to self-determination; and mitigation of power imbalances. Nurse researchers are well positioned to advance research justice at the intersection of reproductive justice and ethics to fully engage diverse populations in advancing health equity to support the best health outcomes.

Refugee women's pregnancy and childbirth experiences in the US: Examining context through a reproductive justice framework

Maternal health in the United States is an area of immediate concern. The compounded disadvantages and unique global positions of refugee women highlight the need for research that explores the experiences of refugee women during pregnancy and childbirth. The present study examines how contextual factors shape pregnancy and childbirth experiences for Syrian, Afghan, Congolese, and Karen women living in Clarkston, Georgia, US. Qualitative data were collected via focus groups facilitated by community interpreters. We used a reproductive justice framework to center women's desires, needs, and experiences, and to highlight the importance of structural factors in the findings and analysis of this study. Using codebook thematic analysis, three themes were developed: (1) isolation and alienated knowledge, (2) gendered disparities and structural inequities, and (3) community support and precarity. The findings reflect both the diversity and constancy of women's experiences and highlight how the context of the US impacts women's ability to exercise agency during pregnancy and childbirth. Systemic change is needed to improve women's access to tools that increase their capacity to exercise agency both during pregnancy and childbirth, and beyond.

"She told me no, that you cannot change": Understanding provider refusal to remove contraceptive implants

Enthusiasm for long-acting reversible contraception (LARC) is growing among donors and NGOs throughout the global reproductive health field. There is an emerging concern, however, that the push to insert these methods has not been accompanied by a commensurate push for access to method removal. We use data from 17 focus group discussions with women of reproductive age in an anonymized African setting to understand how users approach providers to request method removal, and how they understand whether or not such a request will be granted. Focus group participants described how providers took on a gatekeeping role to removal services, adjudicating which requests for LARC removal they deemed legitimate enough to be granted. Participants reported that providers often did not consider a simple desire to discontinue the method to be a good enough reason to remove LARC, nor the experience of painful side-effects. Respondents discussed the deployment of what we call legitimating practices, in which they marshalled social support, medical evidence, and other resources to convince providers that their request for removal was indeed serious enough to be honored. This analysis examines the starkly gendered nature of contraceptive coercion, in which women are expected to bear the brunt of contraceptive side-effects, while men are expected to tolerate no inconvenience at all, even vicarious. This evidence of contraceptive coercion and medical misogyny demonstrates the need to center contraceptive autonomy not only at the time of method provision, but at the time of desired discontinuation as well.

Do Black birthing persons prefer a Black health care provider during birth? Race concordance in birth

BACKGROUND

For many years in the United States, there has been an active discussion about whether race concordance between care providers and patients contributes to better health outcomes. Although beneficial provider-patient communication effects have been associated with concordance, there is minimal evidence for concordance benefits to health outcomes.

METHODS

A cross-sectional survey was conducted including 200 Black mothers who had given birth within the last 2 years asking about the perceived racial identity of their birth health provider, whether they preferred to have Black women providers, and the intersection between race and gender concordance on birth outcomes. In addition to race and gender concordance, other variables were tested for their impact on birth satisfaction including respect, trust for the care provider, perceived competence, care provider empathy, and inclusive communication.

RESULTS

Forty-one percent of the mothers in this study were assisted in birth by a Black woman provider. Although patient-provider concordance did not result in measurable health outcomes, it is clear that compared to other studies of birth satisfaction among Black birthing persons, this study showed relatively higher levels of satisfaction, perceived trust, empathy, perceived provider competence, inclusive communication, and equal respect for both concordant and discordant care providers.

CONCLUSIONS

Although many participants showed a preference for race concordance, participants equally valued respect, competence, and trust with their care providers. Further community-based research needs to be conducted to examine whether race, gender, and cultural concordance results in other beneficial health outcomes.