Black Women in the United States Experience Limited Contraceptive Access

Language Surrounding the Issue

In describing this issue, ‘women’ refers to cisgender females. While it is recognized that other populations, such as transgender men and nonbinary people, may use contraceptives, the references cited in this assignment do not explicitly include all people with uteruses. Therefore, this discussion cannot be applied beyond cisgender females. Furthermore, black and white races, as used in this text, are defined as people identifying as Black or of African descent, or as white or of European descent, respectively.

Description of the Issue

Access to contraception is a public health issue that many people with uteruses encounter. As summarized by the Committee on Health Care for Underserved Women (2015), some key barriers to universal contraception access are knowledge deficits, restrictive legislation, cost and insurance coverage, religious objection, and healthcare inequities. It is important to address this issue so that less unintended pregnancies occur, avoiding the emotional and physical burden that accompanies the decision to abort or birth. Furthermore, providing universal access to contraception supports people with uteruses in prioritizing their families, careers, and overall well-being.

Importance of the Issue

It is of utmost importance to address the barriers to universal contraception access in order to work toward providing equitable health care to all people. At present, “minority and low SES [socioeconomic status] women are less likely to use contraception overall, use different contraceptive methods, and have higher rates of contraceptive failure than white and higher SES women” (Dehlendorf, Rodriguez, et al., 2010). This leads to a second reason for addressing this public health issue: providing equal access to contraception means that accessibility and affordability must be prioritized for minorities and low SES women. Out-of-pocket cost is a main factor contributing to the cost barrier to equal contraceptive access, especially as women pay for insurance-covered contraceptives 60% out-of-pocket, as compared to the general out-of-pocket cost for noncontraceptive drugs at 33% (Phillips et al., 2004). Finally, contraceptive use decreases the risk of unintended pregnancy (Peipert et al., 2012). Among Black women, 69% of pregnancies were unintended, as compared to 40% among white women (Finer & Henshaw, 2006). Similarly, among low-income women, 62% of pregnancies were unintended, as compared to 38% among women over 200% of the Federal Poverty Level (Mosher et al., 2004). Unintended pregnancies are important to decrease because they increase the risk of psychosocial distress and are associated with low SES, thus placing a financial burden on those who cannot afford it (Yazdkhasti et al., 2015). Therefore, universal contraception access would diminish the inequity surrounding populations with the most unintended pregnancies.

Patterns in the Issue

Black women in the United States (US) have long faced issues with their sexual and reproductive health, stemming from the continual racism inflicted on Black people since the colonial era (Prather et al., 2018). Specifically, related to contraceptive access, such issues include pressure to use contraceptives (Becker & Tsui, 2008) and limit child-bearing (Downing et al., 2007). Moreover, it is reported that low-income Black women had 3.1 times the odds of being recommended intrauterine contraceptive use compared to low-income white women (Dehlendorf, Ruskin, et al., 2010), while Black women are also more likely than white women to use less effective contraceptive methods, such as Depo-Provera and condoms (Frost & Darroch, 2008; Mosher et al., 2004). It is also proven that Black women more often experience unintended pregnancies than white women (Finer & Henshaw, 2006; Kim et al., 2016). According to Kim et al. (2016), Black women had 2.54 times the odds of unintended pregnancy compared to white women between 2006-2010. In summary, Black women in the US are shown to use less effective contraceptive methods, despite society’s efforts to simultaneously encourage them to use more effective methods and discourage them from reproducing. The intended goal of achieving equitable access to contraceptives for Black women would be to give the demographic the opportunity to have control over their bodies and trajectory of their lives.

Importance of Cultural Humility

Cultural humility is the continual practice of self-evaluation, challenging power imbalances, and building mutually beneficial community partnerships (Tervalon & Murray-Garcia, 1998). Thus, when considering the culture of Black women, who disproportionately encounter challenges accessing contraceptives, it is essential to recognize the historical disparities Black people continually confront (Hammonds & Reverby, 2019). In particular, Black women have been forcefully sterilized post-Cesarean section as an ultimatum to being denied welfare benefits or medical care and as hysterectomy practice for medical students (Wade, 2011). Therefore, failing to recognize past wrongdoings could lose the trust of this community, as it is already historically unsteady. While Black women are less likely than white women to use contraceptives, this difference cannot be entirely explained by SES or healthcare access, so public health professionals must explore other strategies when approaching the issue (Grady et al., 2015). It can be recommended that these non-Black professionals apologize to Black women for the violations they and their ancestors have felt or experienced, then proceed with respectfully timed questions about their feelings toward contraceptive methods and information on effective methods (Rocca & Harper, 2012). It is also important for an apology to be made at the institutional level of such public health organizations to set the precedent that a collective effort is being made in support of Black women’s access to contraceptives. With these strategies, the goal is to further understand how to aid Black women in increasing their access to contraceptives to, in turn, decrease their risk of unintended pregnancies and allow for them to have more equitable opportunities.

Organizational Components of Structure

Black women as a demographic are not the only group intertwined with this reproductive health inequity, as many organizations advocate for contraceptive equity, including In Our Own Voice: National Black Women’s Reproductive Justice Agenda. To call attention to the issue, this organization has a website detailing their reproductive justice goals and consisting of numerous fact sheets, blog posts, and relevant news articles (In Our Own Voice: National Black Women’s Reproductive Justice Agenda, n.d.). In the fact sheet entitled, Contraceptive Equity for Black Women, the organization highlights that although the Patient Protection and Affordable Care Act (ACA) is designed to ensure coverage of all contraceptive types under private insurance, there are variations in contraceptive methods by SES and race or ethnicity (Howell et al., 2020). Moreover, the organization pulls in newspaper content, such as reports on Free the Pill, which supports over-the-counter (OTC) birth control pills in response to the barriers Black women and other marginalized demographics face (Lynn, 2022). By linking news articles like this, the organization provides informative content to their followers about how their partners and other external organizations are also promoting reproductive justice. With a vast social media presence and both national and state roots, In Our Own Voice: National Black Women’s Reproductive Justice Agenda is ensuring Black women’s call for contraceptive equity is heard.

On the other side of this issue are the companies that produce and profit off intrauterine devices (IUDs). Such companies include Bayer Healthcare Pharmaceuticals, which manufactures three of the five Food and Drug Administration (FDA) approved IUDs (i.e., Mirena, Skyla, Kyleena) (Intrauterine Devices (IUDs): Access for Women in the U.S., 2020), and earns $900 million annually from its IUD sales (Wilhelm, 2017). As mentioned earlier, IUDs are often recommended to low-income Black women in efforts to decrease their reproduction (Dehlendorf, Rodriguez, et al., 2010). This can be traced to eugenics, which is the control of reproduction for desirable, white traits to dominate. Thus, racism appears to instigate these long-acting reversible contraceptive (LARC) recommendations for Black women, and although Bayer and other IUD manufacturers do not actively support this inequity, they certainly stand to benefit from it financially.

Perpetuating the Issue

The ACA was enacted in 2010 with goals of making health care and insurance more affordable, and expanding Medicaid coverage (About the Affordable Care Act, 2022). However, the US healthcare system, with its mixture of private and public, and for-profit and nonprofit insurers (Tikkanen et al., 2020), still fails to support the 8.0% of its uninsured citizens (Lee et al., 2022). Universal health coverage (UHC) is defined by the World Bank as “ensuring that people have access to the health care they need without suffering financial hardship” (Universal Health Coverage, 2022). Since Medicaid covers family planning services, Medicaid expansion is essential to providing reproductive health services to low-income individuals nation-wide (Taylor & Bernstein, 2021). Furthermore, if the US adapted UHC to diminish inequity, Black people – 11.4% of whom are uninsured (Tolbert et al., 2020) – would likely experience barriers to health care and contraceptive access less frequently.

Beyond the US healthcare system, the American Medical Association (AMA) also fails to adequately address the disparity in contraceptive access, although it has one of the largest lobbying expenditures (Wouters, 2020). While the organization has created a plan to uphold racial justice and health equity (Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, 2021), it is unclear what is actively being done and what is resulting. For instance, the contents of equity trainings and their effectiveness on the practice of health professionals is not reported. Moreover, the AMA published an article acknowledging the racial disparity in contraceptive access, but has not broached the subject since publication in 2014 (Payne & Fanarjian, 2014). It would be of great value for the AMA to follow up on their acknowledgement of the disparity by conducting their own investigation on the types of contraceptives being prescribed across demographics to determine next steps in addressing the inequity. Overall, by not providing UHC and the AMA’s failure to hold the system accountable, the US healthcare system perpetuates the limited access to contraception that Black women experience.

Underlying Racism

Whereas the observed issue is that Black women are limited in their access to contraceptives, racism is the underlying factor. Bailey et al. (2017) explains that the racial hierarchy has historically led to minority segregation, which has resulted in lower SES associated with Black-dominant neighborhoods. With socioeconomic disadvantages, healthcare facilities in these areas are of lower quality and less appealing to job-seeking healthcare practitioners, continually hindering Black people from receiving equitable care (Bailey et al., 2017). Due to this systematic oppression, witnessing the association between Black individuals and low SES allows for the belief that Black people are also intellectually and morally inferior (Bailey et al., 2017). Therefore, it is likely that non-Black healthcare professionals implicitly believe that Black people are irresponsible and unable to adhere to treatment plans, so they strongly recommend LARCs for Black women because they do not rely on the individual to remember to use contraception daily or even during each sexual encounter. In conclusion, if racism failed to permeate US society, perhaps Black women would not be met with the disproportionate difficulty in accessing contraception. However, with the reality being that structural racism in the US does exist, more must be done, starting at the institutional level, to challenge this inequity.

References

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