Reproductive Well-Being: A Framework for Expanding Contraceptive Access

Currently, more than 19 million women eligible for publicly funded contraception live in counties where they lack reasonable access to the full range of birth control methods. Around 1.2 million of these 19 million women live in counties without a single health center offering the full range of methods, compounding burden and inhibiting reproductive autonomy. These “contraceptive deserts” are defined as counties where the number of health centers offering the full range of methods is not enough to meet the needs of the county’s estimated number of people eligible for publicly funded contraception, defined as at least one health center for every 1000 people in need of publicly funded contraception. This calculation is based upon ratios developed by Richard Cooper, MD, of the University of Pennsylvania Wharton School, one of the leading physician utilization and supply experts in the United States.¹

Access to the full range of contraceptive methods is critical given what is known about pregnancy desires and trends in contraceptive use over time. Most single young women (aged 18–29 years) report they do not want to get pregnant at this point in their lives, yet nearly half of these women are not using contraception reliably or at all.²

The ability to choose from among the full range of contraceptive methods encourages consistent and effective contraceptive use and leads to positive health, social, and economic outcomes. People who are satisfied with their current method are less likely to use the method inconsistently or incorrectly.³ Using a method correctly allows people to avoid pregnancies that they do not want and to appropriately plan and space the pregnancies that they do want, reducing the risk of low birth weight and premature birth.⁴ Contraceptive use enables people to achieve their educational and career goals and to support themselves and their families.⁵ Perhaps most importantly, all people should have the right to choose the contraceptive methods they prefer—or no method at all. Protecting this right guards against explicit and implicit coercion within the health care system, which may occur if patients are only offered a limited selection of methods to choose from or if they feel pressured to select a particular method because of effectiveness, cost, or other factors.⁶

Despite these benefits, contraceptive access continues to be at risk because of geographic barriers, economic barriers (including the actual cost of the method as well as related costs like childcare, time off work, and transportation),⁷ policy changes such as reductions to the Title X program,⁸ and more. In the coming years, predicted shortages of health care providers able to offer contraception may exacerbate access gaps. The Association of American Medical Colleges predicts a shortage of between 46 900 and 121 900 physicians by 2032,⁹ while the Health Resources and Services Administration predicts a shortage of approximately 293 800 registered nurses and 151 500 licensed practical nurses by 2030.¹⁰ A similar shortage is anticipated in the “women’s health” workforce specifically, including a decrease in the number of obstetricians/gynecologists and an increase in demand for reproductive health care services by 2030.¹¹

Power to Decide, a national reproductive health organization, works to build awareness about these contraceptive access gaps and to address people’s immediate contraceptive needs. We posit that the misalignment between pregnancy desires and contraceptive behavior is largely attributable to systemic inequities that exist in three interconnected areas: (1) knowledge about sexual health and contraception, (2) access to quality and comprehensive contraceptive services, and (3) sense of agency in decision-making and relationships. This hypothesis led to the development of a reproductive well-being framework, which shifts the narrative from personal intentions to supporting autonomy and recognizing and eliminating systemic barriers to reproductive health. In this article, we lay out that framework, describe efforts to implement this innovative approach at the community level, and identify the benefits of wide adoption of this framework to increase contraceptive access. Widespread adoption of this framework would result in measurable system changes in sectoral policies, positions, and practices.

DEVELOPING THE FRAMEWORK

In 2017, Power to Decide convened leaders and practitioners from more than 50 national, state, and local organizations including March of Dimes, the American College of Obstetricians and Gynecologists, the Association of Maternal and Child Health Programs, National Birth Equity Collaborative, Nurse Family Partnership, and the University of California‒San Francisco, among others. The goal was to address the gap between people’s stated desires to prevent pregnancy and their contraceptive decision-making and use. As part of this effort, we conducted focus groups across a range of sectors, geographies, backgrounds, and lived experiences, including in-depth interviews with experts and providers in reproductive justice, reproductive health, and reproductive rights. In total, we spoke with more than 300 people as part of this research effort.

We heard clearly that to align one’s contraceptive behaviors with one’s pregnancy desires, including the desire not to have a child, access is critical, and it is one piece in a larger context. We have long understood that contraceptive use is influenced, in part, by individual factors, such as knowledge, attitudes, and behaviors (e.g., desires to avoid or achieve pregnancy, concerns about side effects),² as well as interpersonal influences (e.g., relationships with partners, peers).¹² In our research, we learned that many people, young people in particular, do not feel like they have the power, agency, or self-efficacy to set their intentions related to contraceptive use, pregnancy, and reproduction, largely because of systems barriers. These include organizational factors, such as the availability and accessibility of services as well as the type of services offered; community factors, such as sociocultural norms and expectations and interactions with the built environment; and societal factors, such as systems of oppression (e.g., racism in the health care system), health insurance policies, and the state policy context.

The stakeholder group used this feedback to create the reproductive well-being framework, which aims to design systems of support that surround individuals and help them align their reproductive desires with their actions. This framework is intersectional in nature, touching all levels of the socio-ecological model while also illustrating the complexities of personal, community, and institutional factors (Figure A, available as a supplement to the online version of this article at https://ajph.org). Reproductive well-being means that all people have equitable access to the information, services, systems, and support they need to have control over their bodies, and to make their own decisions related to sexuality and reproduction throughout their lives. In a culture of reproductive well-being, all people are

• 1.Respected: People are seen, heard, and understood by their provider, family, and society. They are trusted to be able to make the decision that is best for them. Their unique experiences, beliefs, and cultures, as well as the complexity of their decisions, are respected.
• 2.Autonomous: Decision-making power sits with the individual. Providers prioritize shared decision-making, even when a patient’s decision may feel counter to their own training or beliefs, or when the system they work in makes that difficult.
• 3.In control: People receive access to all the information and options available so they can make informed decisions. They can create a healthy future for themselves and a healthy start for the next generation if they choose to have or raise children.
• 4.Surrounded by communities and systems of support: Reproductive well-being is an essential component of overall health and well-being, not only in the health care system but also in society in general. It is understood, discussed openly, and pursued by all.

The stakeholder group identified four key systems-level domains that serve as “levers” to achieve reproductive well-being at the place-based level: (1) policy, (2) education and communication, (3) health care and social services delivery, and (4) health equity. We also developed an implementation toolkit that identifies key actions communities can take to catalyze change in each of these domains. The implementation of the actions within this toolkit, as well as the integration of the reproductive well-being framework in the field’s approach to clinical practice, programs, research, and policy, will support the design and maintenance of more holistic service systems that reflect the realities of complex decisions and circumstances people face related to reproductive well-being, including contraceptive access.

PLACE-BASED IMPLEMENTATION TO INCREASE ACCESS

Power to Decide understands that communities themselves are best positioned to determine the specific approach for increasing reproductive well-being where they live. As such, we support various place-based reproductive well-being initiatives, outlined here, to increase contraceptive access through strategies across the four domains (policy, education and communication, health care and social services delivery, and health equity). We use a reproductive well-being assessment tool to assess contraceptive access and other key reproductive well-being indicators within the domains at baseline and annually throughout the project period.

All Access Eastern Kentucky

Since 2017, Power to Decide has worked in partnership with Kentucky Health Justice Network and Appalshop to implement a contraceptive access initiative in a 10-county region in eastern Kentucky. The goal is to build a sustainable policy, services, and program environment so that all people have awareness of and access to the full range of contraceptive methods.

Within the policy domain, the team has developed a state-specific online advocacy training to build stakeholders’ capacity to advocate for policies that increase contraceptive access. Within the education and communication domain, the team trained youth participants to develop and disseminate media pieces about contraceptive access and health care services in the region to influence change in the health care system as well as change norms across the region. Within the health care and social service delivery domain, the team partnered with clinics to provide training, disseminate Bedsider educational materials, and increase best practices in contraceptive services delivery. Finally, within the health equity domain, the team contributed to the knowledge base on contraceptive access in rural communities.

Evaluation efforts indicate an increase in the number of clinical providers in the region certified in One Key Question, a pregnancy desire screening tool that is recognized as a promising practice by medical and public health groups such as the American College of Obstetricians and Gynecologists, the American Public Health Association, the American Medical Association, and the Association of Maternal and Child Health Programs, and an increase in the number of best practices for youth-friendly contraceptive care at partner clinics.

Shared Learning Collaborative

In 2020, Power to Decide launched a place-based reproductive well-being shared learning collaborative to improve reproductive well-being, disseminate lessons learned, and build the evidence base at the community level. We currently work with seven communities across the country: Detroit, Michigan; Omaha, Nebraska; Syracuse, New York; Austin, Texas; Oklahoma City, Oklahoma; Harrisonburg, Virginia; and the Commonwealth of the Northern Marianna Islands. Each multisectoral team completed a reproductive well-being assessment, identifying best practices within the key domains to increase contraceptive access and enhance reproductive well-being in their communities. Implementation activities range from offering free provider education and training to advocating for policy change to hosting social media campaigns. Teams complete the reproductive well-being assessment annually to measure progress over time in the four domains.

MEASURING REPRODUCTIVE WELL-BEING

During the early stages of the reproductive well-being work, an expert measurement group was convened to discuss measurement considerations for the framework, as well as the future development of a reproductive well-being index. The index will include (1) both population and individual measures, (2) domains identified by the expert measurement group as critical to measuring this complex topic, and (3) existing data along with gaps related to measuring reproductive well-being, including contraceptive access. In short, the tool will measure social determinants of health as well as other factors that influence a person’s ability to achieve reproductive well-being. Development and adoption of a such a reproductive well-being index could fundamentally shift the way the sexual and reproductive health field approaches priority setting, measurement, outcome indicators, and more.

ENCULTURATING THE REPRODUCTIVE WELL-BEING NARRATIVE

Power to Decide envisions a culture in which there is a system of support that makes it possible for every person—no matter who they are or where they live—to achieve reproductive well-being. In such a culture, all people have equitable access to the information, services, systems, and support they need to have control over their bodies and to make their own decisions related to sexuality and reproduction throughout their lives. Certainly, access to contraception does not equate to the totality of reproductive well-being; however, reproductive well-being cannot be achieved without practical, equitable access to contraception. The ability to identify one’s own pregnancy desires and to use contraception to achieve those desires is fundamental to feeling respected, autonomous, in control, and supported.

Expanding contraceptive access requires innovation and a collective commitment to address the broader inequities and social determinants of health that stand between many people and their overall well-being. The reproductive well-being framework leverages institutional, policy, and practice change to build and scale a system of support that increases access to contraception and makes reproductive well-being possible for every person. Transforming reproductive well-being from an aspiration to reality will require everyone to support a paradigm shift to a culture that values people’s empowerment, agency, and autonomy for their own reproductive well-being. Join the reproductive well-being movement.