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Published in final edited form as: Womens Reprod Health (Phila). 2023 Nov 30;11(3):491–508. doi: 10.1080/23293691.2023.2285271

Exploring Contraceptive Experiences of Abortion-Fund Clients in the Rocky Mountain Region of the United States from a Reproductive Justice Lens

Celina M Doria a, Jessica L Liddell b,*, Alex Buscaglia c, Lauren Buxbaum b, Stephanie Gliko b
PMCID: PMC11583371  NIHMSID: NIHMS1978225  PMID: 39584043

Abstract

Objective:

This study focuses on the contraceptive experiences of abortion fund applicants to draw attention to various elements that restrict the realization of reproductive justice in the Rocky Mountain Region of the United States.

Methods:

This study uses qualitative data from 830 applications to an abortion fund submitted between 2013 and 2022.

Results:

Our findings highlight a range of experiences, from contraceptive failure and side effects, to diminished access and reproductive coercion.

Conclusion:

Abortion fund applicants described individual, interpersonal, and structural factors that shaped their access to contraception. This study calls for various interventions, including implementing comprehensive sex education, to ensure reproductive justice.

Keywords: abortion, contraception, abortion fund, reproductive justice

Introduction

Access to abortion and contraception are two tools for individuals to decide if and when they want to parent children, and are essential components of reproductive justice (Ross & Solinger, 2017). Despite how crucial contraception and abortion are to exercising full control over one’s life, many barriers to meaningful access exist. From contraceptive failure and dissatisfaction, to limited access to desired contraceptives, many people experience numerous barriers to contraceptive care. As the influential Turnaway Study has described, many of these difficulties in accessing contraception overlap with access to abortion care, often leaving pregnant people with no choice other than to navigate the negative financial, physical and emotional health, and social outcomes of carrying an unwanted pregnancy to term (Foster, 2020). Marginalized individuals–particularly poor people and people of color–face increased barriers to accessing reproductive healthcare, limiting their bodily autonomy. Such barriers to accessing reproductive healthcare are compounded by rural location, further deepening existing healthcare disparities for individuals in rural regions (Kreizter et al., 2021). In this article, we explore the contraceptive experiences of abortion fund clients in the Rocky Mountain Region, a rural region of the United States, to highlight the various structural barriers that constrict the realization of reproductive justice. [1]

Background

In the United States, nearly 45 percent of pregnancies are unintended (Finer & Zolna, 2016). Research has shown that unintended pregnancies are often the result of structural barriers and inequalities, such as poverty and systemic racism (Auerbach et al., 2023; Foster, 2020; Ross & Solinger, 2017). Indeed, low-income individuals in the United States are five times more likely to experience an unintended pregnancy than higher income individuals (Finer & Zolna, 2016). Furthermore, people of color, young people, and people without a high school degree are also more likely to experience unintended pregnancies (Finer & Zolna, 2016). Marginalized individuals are also the least likely to have access to reproductive health services, including abortion and contraception, further increasing rates of unintended pregnancies.

There exist numerous barriers to abortion and contraception access in the Rocky Mountain Region. Rural location, for example, is a critical factor shaping access to reproductive healthcare. In a rural state like Montana, there are only 36 health centers that serve nearly 200,000 reproductive-aged individuals, leaving nearly 33 percent of these individuals without access to needed reproductive health services (Power to Decide, 2022). Similarly, Wyoming has just 14 health centers, leaving 31 percent of reproductive-aged individuals without access to care (Power to Decide, 2022). Even in a state like Colorado, where reproductive health services are generally more accessible, 20 counties are without a single health center (Power to Decide, 2022). Contraception accessibility is also limited by rural location. It is estimated that nearly 19 million women of reproductive age in the United States live in what are known as “contraception deserts,” or areas with limited to no family planning resources (Axelson et al., 2022; Krietzer et al., 2021). Krietzer et al. (2021) deepen this notion of contraception deserts by noting that these areas not only lack access to reproductive health care, but are also often marked by concentrated disadvantage, “where populations who are already made vulnerable due to socioeconomic and racial inequalities are isolated from a geography of opportunity” (p. 278). Thus, people of color and low-income individuals are more likely to live in contraception deserts, limiting their access to reproductive healthcare and bodily autonomy.

Another central barrier to reproductive healthcare is affordability. Abortion care, for example, can cost anywhere from $250 to more than $1000 depending on the clinic, procedure, and gestational age (Roberts et al., 2014; Upadhyay et al., 2021). This steep price tag is compounded by the fact that many states do not allow Medicaid dollars to cover abortion care (Donovan, 2017). Similarly, health insurance coverage and limited financial resources also represent barriers to contraception access in the United States (Culwell & Feinglass, 2007). For example, a study by Culwell and Feinglass (2007) found that “lack of health insurance was associated with 20–40% reductions in the likelihood of prescription contraceptive use” among nearly all 27,000 women in their sample, regardless of socioeconomic status, marital status, age, and race (p. 229). Thus, the considerable financial burden associated with abortion and contraception, compounded by restrictions on health insurance coverage, contribute to the persistent challenges faced in accessing comprehensive reproductive healthcare.

Abortion funds have emerged to offset these institutional gaps and barriers, helping pregnant people better meet their reproductive desires. Abortion funds assist people in removing financial and logistical barriers to abortion access by assisting with clinic, travel, and lodging costs, in addition to providing informational resources (Ely et al., 2016). Some abortion funds work directly with clinics to pay for abortion procedures and any tests that may be required, while other funds provide practical assistance directly to the pregnant person to support other needs like transportation and childcare costs (NNAF, 2023). Some funds provide both types of support. Abortion funds generally support people within their local region, while others provide national and international support. According to the National Network of Abortion Funds (NNAF)–a membership organization that supports abortion funds in the United States–there are over 90 abortion funds that operate across the country, yet the large majority of these funds are located in the midwestern, southern, and eastern United States (NNAF, 2023). Although some people in the upper Rocky Mountain region (including the states of Idaho, Montana, and Wyoming) can obtain abortion funding from national organizations, there are only three local abortion funds. Such funds have become increasingly important in these rural states where many people lack access to reproductive healthcare services.

Conceptual Framework

This article situates the contraceptive experiences of abortion fund applicants within the framework of reproductive justice. Coined by Black women in the 1990s, reproductive justice is understood as an intersectional framework that advances the right to have children, to not have children, and to raise children with safety and dignity (Sister Song, 2022; Ross & Solinger, 2017). Drawing upon frameworks of human rights and social justice, the praxis of reproductive justice underscores the broader social and structural conditions that shape sexual and reproductive autonomy. Understanding the contraceptive experiences of abortion fund applicants in the Rocky Mountain Region requires a holistic understanding of the various structural factors that shape reproductive autonomy. We turn to the reproductive justice framework to highlight the multifaceted nature of contraceptive experiences and to underscore multisector implications.

Current Study

In this article, we explore the contraceptive experiences of abortion fund clients in the Rocky Mountain region of the United States. Abortion fund applicants are an important and unique population to explore, as they are often multiply marginalized (e.g., low-income women of color without health insurance) and lack access to the full spectrum of sexual and reproductive health services. A growing body of research has begun to explore abortion fund data, highlighting, for example, the demographic characteristics of applicants (Ely et al., 2017; Leyser-Whalen et al., 2021; Rice et al., 2021), distance traveled for care (Ely et al., 2017), and funds effect on pregnancy outcomes (Morgan & Parnell, 2002); yet, no literature to date has explored the contraceptive experiences of abortion fund applicants. This study is motivated by the following research questions: (1) What are the contraceptive experiences of abortion fund clients in the rural Rocky Mountain Region?; and (2) What do these contraceptive experiences tell us about broader reproductive politics in this region? Drawing on 830 intake applications from a rural abortion fund in the Rocky Mountain region of the United States, we identify four central themes regarding the contraceptive experiences of abortion fund clients: (1) contraceptive failure; (2) negative side effects of contraceptives; (3) lack of access to contraceptives; and (4) reproductive coercion and relationship factors. The contraceptive experiences of abortion fund applicants underscore the numerous structural barriers they face when accessing care. More so, when read through the lens of the Reproductive Justice framework, the contraceptive experiences of abortion fund applicants reveal deeper reproductive politics surrounding bodily autonomy and reproductive healthcare for people in the Rocky Mountain Region and beyond.

Methods

Research Design

Our research design was informed by a reproductive justice lens. Reproductive justice advocates have long emphasized the importance of having a broad understanding of the structural factors that shape access to and experiences of bodily autonomy (Combahee River Collective, 1983; Price, 2010; Ross, 2006; Sistersong, 2022). As mentioned above, reproductive justice is more than a theory; it is a dynamic praxis that can and should be applied to reproductive health research design (Eaton & Stephens, 2020). Indeed, incorporating reproductive justice into research design calls for explicit attention to the experiences of marginalized people of color, and analyses of power, privilege, and oppression (Eaton & Stephens, 2020). Consistent with the reproductive justice framework, we explore the various factors that shape the contraceptive experiences of marginalized pregnant people in the rural United States. Further following this framework, we strove to go beyond simply noting disparities, but to also place these individual experiences of inadequate reproductive healthcare within the broader context of political, social, and economic injustice.

A key tenant of reproductive justice is the importance of identity and its intersection with privilege and access to resources (Combahee River Collective, 1983; Crenshaw, 1989; Price, 2010; Ross, 2006; Sistersong, 2006). Attention to identity in research is consistent with this focus and some scholars have critiqued any research where researchers do not analyze their own intersectional positionality (Kovach, 2010; Strega & Brown, 2015). As part of this framework, we paid particular attention to each researcher’s positionality. The research team has a broad set of skills and experiences, which allowed for diverse perspectives to inform the analysis and interpretation of this study. The team included social work, public health, and psychology faculty members and students from three different universities. The team also included two current board members of the abortion fund in this study, one volunteer for the fund, and three researchers who are unaffiliated with the abortion fund. We discussed our theoretical and philosophical orientations towards this research and engaged in reflection on how our own identities impacted our analysis throughout the research process.

Setting and Sample

This analysis draws on qualitative data collected from 830 abortion fund applications, submitted between 2013 and June of 2022. Due to the relative lack of scholarship on abortion funds in general (Liddell et al., Under Review), the research team was interested in exploring the experiences of abortion fund applicants, particularly those in the Rocky Mountain West who are underrepresented in the literature. The abortion fund provided the deidentified data to the research team. Applicant qualitative responses involved short text descriptions of why they were seeking assistance from the abortion fund, and ranged in length from one sentence to longer paragraphs. The abortion fund shared de-identified data of the applicants, including basic demographic information, the amount each applicant was funded, and their qualitative responses to the intake questionnaire. This particular abortion fund is located in the northern Rocky Mountain Region of the United States and is the only statewide fund, supporting individuals throughout the region. According to the demographic data of applicants, this fund primarily supported residents of Montana, Idaho, North Dakota, South Dakota, and Wyoming. The fund provides various services such as information and education on what to expect during and after an abortion procedure, information on legal contexts surrounding abortion, financial and travel support, and emotional support. This study was deemed exempt from IRB review by the University of Montana’s IRB and was approved by the board of the abortion fund.

Our understanding of participant characteristics is limited to the demographic questions asked as part of the abortion fund intake application. The abortion fund was also committed to providing equitable and nonjudgmental care, and therefore did not require applicants to answer any demographic questions to receive services. Of the demographic questions asked, a large majority of applicants (88%) (n=731) reported their age. The applicants ranged in age from 16 to 45 years old, with the majority (68%) (n=570) between age 18 and 34. Almost half of applicants (45%) (n=381) did not report their race/ethnicity; among those who did, 39% (n=320) identified as White, 7% (n=54) as American Indian/Alaska Native, 5% (n=42) as Latinx, and 3% (n=21) as Black. Around half of applicants (41%) (n=344) did not report their educational status; however, among those who did, 22% (n=184) reported having either a GED or high school degree and 22% (n=185) an associate’s degree or some college. A third of applicants (35%) (n=289) reported having other children, 30% (n=253) reported having no children, and 32% (n=269) did not respond.

Data Analysis

A thematic analysis approach was used to analyze application data findings. Thematic analysis involves a process of searching across a qualitative dataset to identify and analyze repeated patterns, and entails interpretation in the process of generating codes and constructing themes (Braun & Clarke, 2006; Kiger & Varpio, 2020). Thematic analysis is a flexible method of qualitative data analysis that uses both deductive and inductive approaches (Braun & Clarke, 2006). Our research team used an iterative coding approach where an initial coding scheme was created after reviewing a sample of applicant data. Later, the initial codes were adapted into more specialized sub-themes that emerged through the coding process. For example, the broad theme “contraceptive experiences” was broken down into “contraceptive failure,” “side effects,” and “unable to afford contraceptives,” among others. Our deductive analysis was guided by the theoretical lens of reproductive justice. Therefore, when identifying patterns and themes related to contraceptive experiences, we were particularly attuned to structural barriers to reproductive healthcare, intersections between rurality, class, and race, and issues of bodily autonomy.

The data were coded by a team of six researchers using NVivo software. Memos were used by each researcher throughout data analysis to document their coding process and to identify potential new codes and other methodological questions. Although dual-coding 20% is generally considered the gold standard for dual-coding in large datasets, we dual-coded 30% of qualitative responses to assess inter-rater reliability and ensure the high rigor of our coding process (Syed, & Nelson, 2015).

Findings

Our analysis of intake applications highlights four central themes regarding the contraceptive experiences of abortion fund clients: (1) contraceptive failure; (2) negative side effects of contraceptives; (3) lack of access to contraceptives; and (4) reproductive coercion and relationship factors. Taken together, these findings reveal deeper reproductive politics that shape access to reproductive autonomy within the Rocky Mountain Region.

“I always have safe sex, but sometimes condoms break and can change your life forever:” Contraceptive failure

Many individuals applying for aid from the abortion fund mentioned contraceptive failure as the primary cause of their unintended pregnancy. Most women explained that they became pregnant despite using some form of contraception. Numerous intake applications shared similar refrains: “I found out that I am pregnant even though I am on birth control;” “I was on birth control, and it failed;” “This was a surprise to be pregnant because I am on birth control.” Like many applicants, a 22-year-old woman shared her story of contraceptive failure:

I was not planning to get pregnant. I am even on the Nuva ring and have no idea how I got pregnant with it in. I have been in the process of hopefully getting my tubes tied, but with being so young still I haven’t got the chance to. I use my birth control continuously and switch it every month.

Despite her consistent use of birth control, she ended up pregnant. More so, this applicant expressed the challenges she has faced in meeting her desire for tubal ligation, further highlighting her constricted reproductive autonomy. With two young children, unstable finances, and limited family support, this applicant turned to the abortion fund for support with terminating her pregnancy.

Other women attributed the contraceptive failure to improper use. As one applicant explained, “Although I was on birth control pills, I must have missed a day or not taken it at the right time.” Similarly, other applicants believed that their contraceptive method failed due to “improper absorption” due to antibiotics or other health concerns. As a 25-year-old woman explained: “I actively take a daily birth control pill, but believe my pregnancy was the result of a stomach flu (and improper absorption) and I regret not utilizing a back-up method of birth control.”

Condom failure and emergency contraception failure were two other common experiences shared by abortion fund clients. One unemployed 23-year-old explained: “I am on birth control and use condoms every time I have sex. My boyfriend and I had sex, and the condom broke without us knowing it, I thought I would be okay, but I took a pregnancy test today and found out I am pregnant.” Another 39-year-old woman shared a similar experience: “I am meticulous in making sure I won’t get pregnant. I cannot take hormone-based birth control. We did use condoms. One incident resulted in the condom being lodged inside me. I took a plan B but still have two positive pregnancy tests.” Despite using various forms of contraception, these women still experienced unplanned pregnancies. One 17-year-old high school student summarized her feelings about her unintended pregnancy: “What happened was a complete freak accident, I always have safe sex, but sometimes condoms break and can change your life forever.”

“It messes with my system too much:” Negative side effects of contraceptives

Many other women experienced negative side effects which prevented them from regularly using contraceptives. For example, many women shared that they were unable to stay on birth control because “it made me feel terrible” or because “it messes with my system too much and it was hard to handle.” As one 30-year-old woman explained: “I have severe reactions to most medications, pill-form, and shot-form birth-control being included in the ‘my body rejects most’ list. We used protection but accidents happen.”

From unpredictable mood swings and mental health impacts to physical pain and uncomfortable side effects, some women described more severe health concerns related to use of contraceptives, leading them to forego contraceptives altogether. As one applicant shared: “Hormonal birth control is not an option as I suffer major depression and suicidal thoughts.” Similarly, another woman noted the negative impact hormonal birth control had on her mental health: “I was using birth control (hormonal pill). In May, I ran out of refills on my prescription and chose not to set an appointment to get another prescription because I was having a hard time with mood swings while on it. My partner and I used condoms after that and I missed my next period.”

Other applicants described physical health concerns that limited their ability and desire to use contraceptives. One 28-year-old food service worker explained her inability to continue using various forms of contraception due to difficult side effects:

I’ve spent quite a bit of this year looking for a birth control option that worked for me. I tried an IUD but was in so much pain I had it removed. I went on a low hormone, progesterone only pill (Lyza), due to some issues with blood pressure, as well as the fact that previous birth control pills had some mood effects that I couldn’t handle. I’ve been on Lyza since February, and as my work schedule changed, I found that the early morning brain fog led to a missed pill. My next period was late, so I took a test, it came up positive.

Another 38-year-old applicant shared an upsetting experience related to side effects from hormonal birth control:

This pregnancy was a very scary surprise…Recently my doctor advised me to stop taking the birth control I was on. The birth control was causing strange hormonal issues that lead to a lump in my left breast. After getting a mammogram, the radiologist informed me that I needed to have an ultrasound and biopsy…After a week of waiting I was cleared. The lump was merely hormonal and nothing to worry about. It took two months for my period to regulate again. In the small window of time before I was to start my birth control again, I must have gotten pregnant.”

In addition to challenges with hormonal birth control, this applicant’s experience also highlights the numerous other reproductive health procedures and costs that people must navigate.

Some applicants who were using contraceptives reported having irregular periods or missed periods altogether. For some women, this irregularity often led to delayed detection of the pregnancy. As one 19-year-old student succinctly commented: “I was on birth control and thought that was the reason for my missed periods and did not foresee getting pregnant.” Similarly, another 27-year-old woman explained: “The doctor said my period would not be normal for a while. I was on birth control. My periods were never normal...so I figured my period was just being missed.” A 22-year-old college student recounted her experience of detecting her pregnancy despite missing her period due to birth control:

I found out a few weeks ago that I was pregnant. I was on birth control when my boyfriend and I had sex, so I thought that I was safe. But with this birth control I don’t get my period for three months at a time. At about four weeks after the first time we had sex I felt terrible cramping and figured it was normal because that would be around the time I would get my period if I wasn’t on birth control…After I was puking and couldn’t keep food down, I decided to take a pregnancy test…I took four tests and they came out positive…A few days later I went to the doctor and took a pregnancy test and she estimated I was 7 1/2 weeks pregnant. I made an appointment [two weeks later] for a medical abortion because that was the earliest they could get me in. At that point I will be 9 1/2 weeks pregnant.

Although this applicant was still able to detect her pregnancy fairly early, other women with irregular periods experienced delayed pregnancy detection. One unemployed 25-year-old woman shared her story:

My period became erratic in late July. I went to a gynecologist and actually had a

pregnancy test ran then and was told it was negative, they switched my birth control and

assured that some spotting may happen in the first few months and was fine. This week I

find out that I am now 25 weeks pregnant and showed little to no signs through the

months. I gained 6 pounds and that was really the only sign which is when I went to a

local clinic and got a checkup. I was then given the result that I am pregnant.

As these stories highlight, negative side effects of contraception, including various physical and mental health impacts, impeded women’s use of desired contraceptive methods, and sometimes led to delayed abortion care.

“I wasn’t able to afford birth control which is why I ended up pregnant:” Lack of access to contraceptives

For many applicants, inability to access contraception led to unwanted pregnancies. Many noted that they were simply unable to afford contraceptives. As one 32-year-old unemployed woman succinctly explained, “I wasn’t able to afford birth control which is why I ended up pregnant.” Similarly, another applicant noted: “I wasn’t able to afford my birth control and ran out. So, a couple weeks later I found out I was pregnant.” Many of these women who could not afford contraceptives faced additional financial barriers that amplified their desire to terminate their pregnancies. A 22-year-old applicant described how unemployment and an upcoming move strained her finances and limited her ability to afford both contraception and abortion care:

I need this abortion because I am not okay with being a mother. I got pregnant once before last year and thought I was ready. I had a miscarriage during that pregnancy, and it really affected me mentally. I wanted to get an IUD, but I could not afford one at the time. I took the pill and missed one or two here and there. Now I’m here. I am losing my employment [soon] and will be moving cross country. I am trying to save my money as much as I can for that move.

For others, health insurance played a critical role in restricting access to contraception. One 23-year-old college student explained: “My insurance stopped paying for my birth control and it was such a mess trying to get them to pay, so I gave up because I don’t have time to go back and forth with doctors and insurance every day.” In many cases, insurance covered neither access to birth control nor abortion care, further limiting access to desired forms of family planning. A 22-year-old barista detailed:

I am currently working about 8 hours a week if my schedule permits and paying for myself almost completely. I have Blue Cross Blue Shield through my parents, and they won’t even cover birth control. I’m really concerned about paying [for the abortion] because even with all the saving I’ve done and can do, I don’t think I’ll have any more than $300 at the time of the appointment.

Similarly, other applicants described barriers to accessing contraceptives due to negative interactions and miscommunications with healthcare providers and pharmacies. One applicant shared: “I had scheduled an appointment for birth control, I sat there for two hours and then the doctor refused me.” Another 34-year-old applicant recounted a similar experience with healthcare providers which did not allow for her to achieve her desired family planning method: “I tried twice to get my tubes tied but no one would call me back and my doctors didn’t do much to help.” Interactions with healthcare providers were sometimes further complicated by issues with pharmacies. As one 20-year-old food service worker noted: “I had an appointment set up to get back on birth control after my doctor wouldn’t refill my prescription and wouldn’t answer faxes from the pharmacy.” Another 21-year-old woman also described having her family planning desires limited by miscommunication with healthcare providers and pharmacies: “I decided to get on birth control again but [the clinic] never sent [the prescription] to my pharmacy and when I called, [the pharmacy] said they would take care of it, but they never did.”

More recently, the COVID-19 pandemic created additional barriers to accessing needed contraceptives and family planning methods at local clinics. As one unemployed 20-year-old woman explained, “[clinics] were not doing birth control procedures. I ended up getting pregnant again shortly after giving birth.” Similarly, a 26-year-old mother of three experienced delayed family planning care due to her doctor contracting COVID-19:

I am scheduled to have a tubal removal [in a month] and I have unexpectedly found out I’m pregnant. Things are tough right now…and neither [my husband or I] want or can afford any more kids. I was supposed to have surgery to get my tubes out [four months ago], but my doctor caught COVID and the soonest I could get back in is [a month from now]. I have 3 other children at home, so money is very tight right now.

These experiences highlight the difficulty many women had in accessing their desired form of contraception and the role of institutional barriers, such as health insurance or negative interactions with providers and pharmacies, in perpetuating such inaccessibility.

“I feel this is a violation of my autonomy, choice, boundaries, and trust:” Reproductive coercion and relationship factors

Finally, some applicants mentioned forms of reproductive coercion and relationship factors that restricted them from utilizing desired contraceptives, including parents restricting access to birth control and abusive partners refusing to use agreed-upon contraceptive methods. For example, a 17-year-old high school student explained:

My boyfriend and I have been together for a year, and we just decided to have intercourse and the condom broke. My mother will not put me on birth control, and I’ve had many conversations with her about it. My mother has no idea what’s happening, so I’ve been talking to my friend’s mom who recently has experienced an abortion, so she is helping me through it. I don’t feel comfortable telling my mother and things will go very wrong if I do. I would be traveling from [another state] to get this abortion done, and I feel it’s the right thing for me to do so my mother won’t do any harm.

While coercive experiences with parents were less common, many other applicants shared stories of abusive partners and reproductive coercion, highlighting the ways in which their reproductive autonomy was violated. For example, one 22-year-old gig worker shared: “I was in a relationship with a man who was trapping me in the place he lived and physically abusing me and not allowing us to use protection, because if I would bring it up, he would accuse me of cheating.” Another 26-year-old applicant shared her experience of reproductive coercion:

I am not on birth control due to side effects. I told my partner this and requested we use a condom and pull out. He slipped the condom off without me noticing and failed to pull out. He says he wants a kid, and he hasn’t been with a woman in a while. He ‘had to take his chance while he could.’ I feel this is a violation of my autonomy, choice, boundaries, and trust. I have been used.

A 17-year-old explained her desperation to have an abortion after her partner disregarded her reproductive desires:

Like many girls these days I got rough start sexually. Made a lot of bad choices in partners and got hurt a lot. But I was always very careful…[then] I met…a really wonderful guy. So, even though I had to stop my birth control due to it causing extreme emotional highs and lows, I still let him have intercourse with me, without a condom. Before I knew it, he wasn’t pulling out anymore. I wouldn’t say anything as I was too worried to confront him about it or ask him to [stop]. Now here I am 3 months later and 5 weeks pregnant. Like I said, I never thought I would be here. I always thought I would be smarter. But here I am in desperate need of help. I am scared walking through this alone and figuring out my next step.

These stories illustrate the various forms of reproductive coercion that some clients faced, from having their partners refuse to use condoms to failing to use an agreed-upon contraceptive method. For these women, such experiences only deepened their desire to end their pregnancies. As one woman noted: “I do not want to stay in a relationship with this man, but I don’t know what else to do if I have this child, because I can’t do it alone.” For these abortion fund clients, the decision to have an abortion returned some form of bodily autonomy and choice.

Discussion

Our study highlights the complex and varied contraceptive experiences of women and pregnant people in the Rocky Mountain Region, calling attention to the numerous barriers that exist to accessing desired family planning methods. The contraceptive experiences of abortion fund applicants, when viewed through the Reproductive Justice framework, shed light on the underlying dynamics of reproductive politics concerning bodily autonomy and access to reproductive healthcare. The term reproductive politics refers to the power dynamics embedded within reproductive autonomy, drawing our attention to “who has power over matters of sex-and-pregnancy and its consequences” (Solinger, 2019, p. 6). First, our findings underscore the various intersecting structural barriers that further disadvantage marginalized pregnant people seeking reproductive healthcare in the Rocky Mountain Region. Second, the contraceptive experiences of these abortion fund clients reveal deeper social norms and stigmas surrounding unintended pregnancies. Together, our findings highlight the various dynamics that restrict the realization of reproductive justice for pregnant people in this region of the United States.

The findings of this study clearly highlight the structural barriers that abortion fund applicants face when seeking reproductive healthcare. From unstable finances and lack of insurance to negative interactions with healthcare providers and coercive relationships, the applicants in this study faced a range of barriers to reproductive autonomy. When situated within the framework of reproductive justice, we can understand these barriers as a product of reproductive politics and power that differentially impacts marginalized women and people. Although little research has explored the demographic factors of abortion fund clients, some research suggests that low-income individuals, adolescents, and people in rural areas are more likely to request aid from abortion funds (Ely et al., 2017; Leyser-Whalen, Torres & Gonzales, 2021; Rice et al., 2021). The applicants in this study, like many other abortion fund clients, navigate intersecting injustices, with a majority experiencing low income, limited education, unemployment, and poverty. Moreover, although many applicants did not report their racial and ethnic identity, our sample reflects a diverse population of people of color. For example, of the applicants who reported their race/ethnicity, 5% identified as Indigenous, whereas only 2% of the population of the United States identifies as Indigenous (U.S. Department of Health & Human Services, 2023). As reproductive justice advocates have long noted, women of color have and continue to face disproportionate reproductive injustices (Ross & Solinger, 2017).

Among the numerous structural barriers encountered by the abortion fund applicants in this study, residing in rural areas emerged as a prominent barrier to reproductive healthcare. The Rocky Mountain Region can be considered a “contraceptive desert,” where there is limited access to contraceptive care (Krietzer et al., 2021). Krietzer et al. explain that contraceptive accessibility is shaped by both spatial and nonspatial elements. Thus, while rural location and limited number of health centers play a critical role in spatial access to contraception, other nonspatial factors also limit access to desired contraceptive care. For example, women in our study described nonspatial factors that interfered with their access to contraception, including unaffordability of contraceptives, unemployment, and lack of health insurance. The reproductive justice framework explicitly acknowledges the ways in which various structural factors intersect to limit reproductive autonomy. As Loretta Ross and Rickie Solinger (2017) succinctly explain: “if a person becomes unintentionally pregnant because she cannot get effective, affordable contraception, this can be considered a violation of her right to health and life, equality, and nondiscriminatory access to reproductive health care” (p. 150).

These barriers to contraception access are further compounded by negative interactions with healthcare providers. For example, applicants in our study mentioned being denied access to desired contraceptive methods, including long-acting reversible contraception (LARC) methods and tubal ligation. Indeed, various applicants ranging in age from 22 to 34 years old wished for tubal ligation but were unable to access the procedure. As one applicant mentioned: “no one would call me back and my doctors didn’t do much to help.” Such experiences can be conceptualized as a form of downward contraceptive coercion, whereby healthcare providers pressure patients to not use contraception (Senderowicz, 2019; Swan et al., 2023). These experiences of contraception coercion are part of a broader history of reproductive injustices faced by marginalized women in the United States. As mentioned, our sample of abortion fund applicants are multiply marginalized, facing limited access to reproductive healthcare. Historically, marginalized women–particularly women of color and poor women–were pressured and coerced into utilizing long-acting reversible contraception (LARC), which were routinely administered without their consent (Roberts, 2014; Solinger, 2013). Similarly, tens of thousands of marginalized women were involuntarily sterilized during the 1900s, which hindered bodily autonomy and reproductive justice (Harris & Wolfe, 2014; Lawrence, 2000). These histories of reproductive injustices have shaped current contraceptive practices whereby marginalized women, particularly women of color, are disproportionately offered LARC methods, which is sometimes the result of healthcare providers’ implicit biases (Kathawa & Arora, 2020). Such ongoing reproductive injustices reinforce reproductive health disparities among marginalized women, while restricting their reproductive autonomy.

In addition to these structural barriers, our findings underscore another element of reproductive politics – the social norms and stigmas that emphasize unintended pregnancies as personal failures, rather than the result of structural inequities in reproductive healthcare. This stigma surrounding unintended pregnancies also reinforces the notion that it is a woman’s sole responsibility to prevent pregnancy, often through the use of contraception or even abstinence (Auerbach et al., 2023; Smith et al., 2016). As noted in our findings, many abortion fund applicants often felt the need to justify their contraceptive decisions that led to their unintended pregnancies. This was especially evident when applicants cited their experiences of contraceptive failure and negative side effects. For example, many women emphasized their feelings of shock, and sometimes shame, that they got pregnant despite actively using a birth control method, such as the Nuva Ring. Similarly, others made clear that they were not able to be on birth control due to uncomfortable side effects, which justified their unwanted pregnancy. The narratives of reproductive coercion shared by applicants further illustrate the complex dynamics of reproductive politics that shape reproductive autonomy. Let’s return, for instance, to the intake application of a 17-year-old who experienced reproductive coercion. She explains how her partner at the time did not respect her desired contraceptive methods and how she was too afraid to tell him otherwise. She goes on to share: “Now here I am 3 months later and 5 weeks pregnant. Like I said, I never thought I would be here. I always thought I would be smarter.” Despite navigating a coercive relationship, this applicant placed blame on herself for becoming pregnant, reinforcing social norms regarding unintended pregnancies.

Taken together, these structural barriers and stigmas faced by abortion fund applicants reveal the reproductive politics that continue to impact marginalized women and people’s access to reproductive justice. Such disparate access to reproductive healthcare – compounded by social norms regarding unintended pregnancies – ultimately results in women’s reproduction becoming rooted in racialized, gendered, and classed notions of worthy and unworthy mothers (Bell, 2014; Colen, 1995; A. Davis, 2003; Roberts, 2014). By recognizing and challenging these dynamics, we can work towards fostering a reproductive healthcare system that is equitable, inclusive, and upholds the principles of bodily autonomy and reproductive justice.

Implications

The findings from this study suggest the need for multiple intervention strategies that address the various factors that inhibit reproductive justice for women in the Rocky Mountain Region. First, some structural barriers such as contraceptive accessibility and affordability may begin to be addressed through the implementation of over-the-counter oral contraceptives and wider access to emergency contraception. Research has shown that over-the-counter oral contraception is not only safe and effective, it is also an affordable and accessible option for many individuals (Grossman et al., 2008; Potter et al., 2011). Marginalized communities who have historically faced reproductive injustices encounter the most barriers to accessing contraceptives today. For example, Black women have a higher unmet need to contraception than white women (Troutman, Rafique, & Plowden, 2020). Similarly, women living in rural areas and without access to health insurance face additional barriers to accessing contraception (Culwell & Feinglass, 2007; Krietzer et al., 2021). Over-the-counter provision of oral contraceptives facilitates access to desired family planning methods by removing barriers such as prescription requirements and insurance use. Expanding access to such over-the-counter contraceptive methods will not only help reduce experiences of unwanted pregnancy; it will also work to ensure access to bodily autonomy in a time of ongoing constriction of reproductive rights, allowing women and pregnant people to make their own decisions about their reproductive desires. In the wake of the overturning of Roe v. Wade, nearly 18 million women and pregnant people live in states without any access to abortion care, and more live in states with restrictive policies that make abortion care virtually inaccessible (Nash & Ephross, 2022). These findings also highlight the link between holistic access to contraceptive care and abortion access, as some states that have instituted abortion bans have also begun initiating restrictions on contraceptive access (Cleland et al., 2022; Paviour, 2022).

Second, comprehensive sex education (CSE) may serve as a critical tool to support reproductive justice by addressing the norms and stigmas that influence reproductive politics. According to the Sexuality Information and Education Council of the United States, CSE broadly encompasses “sexual development, reproductive health, interpersonal relationships, affection, intimacy, body image and gender roles” (National Guidelines Taskforce, 2004). CSE varies widely throughout the United States; 25 states and the District of Columbia mandate both sex education and HIV education, while only 17 states require program content to be medically accurate (Guttmacher Institute, 2022). Furthermore, 29 states require that CSE emphasize abstinence, and only 20 states require that information on contraception be provided (Guttmacher Institute, 2022). Although the applicants in this study did not directly address CSE, we believe that improved implementation of accurate and holistic sexual health education may empower individuals to make informed and autonomous choices regarding birth control, sex, and relationships.

Such comprehensive sex education not only provides scientifically accurate knowledge about sexual and reproductive health, but it also teaches skills to enhance respectful and healthy relationships. As applicants in our study shared, reproductive coercion and relationship violence constrained their ability to meet their reproductive desires and restricted their bodily autonomy. The implementation of CSE has been found to positively impact communication skills and attitudes regarding gender equity, which contribute towards the development of healthy relationships (Goldfarb & Lieberman, 2021; Sell, Oliver, & Meiksin, 2021). Increased attention to CSE may help empower individuals and promote gender equity in relationships.

Finally, although CSE may positively impact sexual and reproductive health, there are many other factors—such as poverty, structural racism, and lack of health insurance—that contribute to the realization of sexual and reproductive rights. Thus, we advocate for an approach to CSE that emphasizes the principles of reproductive justice, helping individuals make sense of how various structural dynamics shape lived experiences of sexuality and sexual health.

Limitations and future research

Some limitations of this research include that the data were collected from applications to an abortion fund and were not intended to provide specific findings about experiences with contraceptives and barriers to access. However, despite not being asked about experiences with contraceptives, applicants frequently described their experiences with contraception, highlighting how impactful contraception is for those seeking abortion-related care. Future research would benefit from qualitative interviews explicitly asking about contraceptive experiences and barriers, in addition to quantitative data exploring methods of contraception used prior to applying for abortion fund support. There is also a concern that applicants may describe their contraceptive experiences in particular ways, hoping that they might appear to be a more desirable abortion fund applicant. We believe that, given how the question was worded and how the application was set up, applicants would not feel pressured to specifically discuss their contraceptive experiences. Although our study focused solely on the experiences of abortion fund applicants in one Rocky Mountain state, our findings are consistent with national literature on experiences of contraception and abortion across the United States.

Conclusion

This study deepens the growing literature on abortion funds in the United States by highlighting the complex and varied contraceptive experiences of women and pregnant people seeking abortion care. Specifically, by situating their contraceptive experiences within the framework of reproductive justice, we demonstrate the dynamics that shape deeper reproductive politics surrounding bodily autonomy and reproductive justice for people in the Rocky Mountain Region. First, our findings underscore the intersecting structural barriers that further disadvantage marginalized people seeking reproductive healthcare. Second, the contraceptive experiences of these abortion fund clients reveal deeper social norms and stigmas surrounding unintended pregnancies. The findings of this study suggest the need for several intervention strategies—from expanded access to over-the-counter contraception to the implementation of comprehensive sexuality education—that may reduce barriers to achieving reproductive autonomy at various levels. Now more than ever, we uplift the principles of reproductive justice to call attention to various dynamics that shape sexual and reproductive health and to consider multifaceted solutions to upholding bodily autonomy.

Footnotes

[1]

The Rocky Mountain Region, or more broadly known as the Mountain West Region, is generally considered to include the states of Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming. The abortion fund in this particular study is located in the northern portion of the Rocky Mountain Region (which contains the states of Idaho, Montana, and Wyoming).

Data Availability Statement

Due to the nature of the research and to protect participant confidentiality, supporting data is not available.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Due to the nature of the research and to protect participant confidentiality, supporting data is not available.

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