The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

mHealth technologies for pregnancy prevention: A challenge for patient-centred contraceptive counselling in Dutch general practice

BACKGROUND

A general practitioner (GP) standardly provides contraceptive counselling and care in the Netherlands. Recent years have seen the rise of mobile health technologies that aim to prevent pregnancy based on fertility awareness-based methods (FABMs). We lack high-quality evidence of these methods' effectiveness and clarity on how healthcare professionals include them in contraceptive counselling.

OBJECTIVES

To analyse how Dutch healthcare professionals include pregnancy-prevention mobile health technologies (mHealth contraception) in contraceptive counselling and to propose practice recommendations based on our findings.

METHODS

We used ethnographic methods, including semi-structured interviews with nine professionals who were recruited using purposive sampling, 10 observations of contraceptive counselling by four professionals, six observations of teaching sessions in medical training on contraception and reproductive health, one national clinical guideline, and seven Dutch patient decision aids. Data were collected between 2018 and 2021 and analysed inductively using praxiographic and thematic analysis.

RESULTS

In contraceptive counselling and care, professionals tended to blend two approaches: 1) individual patient-tailored treatment and 2) risk minimisation. When interviewed about mHealth contraception, most professionals prioritised risk minimisation and forewent tailored treatment. Some did not consider mHealth contraception or FABMs as contraceptives or deemed them inferior methods.

CONCLUSION

To minimise risk of unintended pregnancy, professionals hesitated to include mHealth contraception or other FABMs in contraceptive consultations. This may hamper adequate patient-centred counselling for patients with preference for mHealth contraception.Based on these results, we proposed recommendations that foster a patient-tailored approach to mHealth contraceptives.

Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study

OBJECTIVE

To examine the uptake of postnatal contraception (PNC) and experiences of PNC care across a geographical region of England.

DESIGN

Cross-sectional online survey.

SETTING

The North East and North Cumbria Integrated Care System (ICS).

POPULATION

Women who had completed a pregnancy in the previous 3 years.

METHODS

The uptake of PNC by accessed method(s) and the availability of preferred method(s) is described, and adjusted odds ratios are reported for group differences in uptake by characteristics of interest.

MAIN OUTCOME MEASURES

Uptake of medically prescribed/administered contraception and uptake of long-acting reversible contraception (LARC) during the postnatal period, and access to preferred PNC methods.

RESULTS

Although almost half of respondents (47.1%; n = 1178) reinitiated some form of sexual activity during the postnatal period, only 38.7% (n = 969) of respondents accessed a medically prescribed/administered contraceptive method postnatally, and only 15.5% (n = 389) of respondents accessed a LARC. It is a matter of concern that 18.8% (n = 451) of respondents indicated that they were unable to access their preferred PNC. In multivariate analysis, younger age, lower household income, higher multiparity, operative delivery, unplanned pregnancy and not breastfeeding were significant predictors of higher PNC uptake.

CONCLUSIONS

The uptake of PNC in this cohort was low, with almost a fifth of women unable to access their preferred method. However, there was some evidence that women belonging to groups perceived to be at risk of rapid repeat pregnancy were more likely to access reliable PNC methods.

Long-acting reversible contraception: Targeting those judged to be unfit for parenthood in the United States and the United Kingdom

There is a long history of regarding marginalised groups as unfit to parent and of eugenic policies targeting those with 'undesirable' bodily conditions or behaviours. This is part of a broader pattern of stratified reproduction - structural conditions that enable or discourage certain groups from reproducing - that often brings about and exacerbates injustices. This paper critically assesses the US and UK social and medical literature on applying pressure to marginalised groups, or those who have behaved 'irresponsibly', to use long-acting reversible contraception (LARC). Targeting young people for LARC fails to recognise that social inequality is the context for teenage pregnancy, not the result of it. Provider pressure on women of colour to use LARC is linked to institutional racism, whilst policy for those with physical and intellectual disabilities is shaped by disability discrimination. Other groups to be targeted include so-called 'welfare mothers', substance users, those who have had children put into care and offenders. Particularly controversial are cases in which LARC has been ordered by courts. LARC policy incorporating these kind of discriminatory practices needs to stop; future policy should focus on person-centred care that bolsters reproductive justice.

Interference with and abuses of sexual and reproductive health and rights: a new proposal for classification and terminology

There has been overuse of the term 'reproductive coercion', with a potential for confusion and weakening of messaging. This opinion paper proposes a classification for the many and varied types of interference with, and abuse of, sexual and reproductive health and rights. It also stresses the need for accurate portrayal of behaviours, however uncomfortable this may be for survivors or perpetrators. There are a range of abuses including denial of access to services, control, pressure, threats, coercion and violence. Violence may consist of neglect, mistreatment, exploitation or sexual assault. Abuses are categorised sociologically, according to micro, meso and macro levels of influence. Many types of behaviour at meso and macro level contain elements of racism. It is concluded that the term reproductive coercion and abuse should refer only to micro level behaviour. Healthcare professionals should ascertain that no practices that could be considered abusive are taking place in their workplace.