Health care provider bias in the Appalachian region: The frequency and impact of contraceptive coercion

Abstract

Objective To investigate the frequency and impact of contraceptive coercion in the Appalachian region of the United States. Data Sources and Study Setting In fall 2019, we collected primary survey data with participants in the Appalachian region. Study Design We conducted an online survey including patient‐centered measures of contraceptive care and behavior. Data Collection/Extraction Methods We used social media advertisements to recruit Appalachians of reproductive age who were assigned female at birth (N = 622). After exploring the frequency of upward coercion (pressure to use contraception) and downward coercion (pressure not to use contraception), we ran chi‐square and logistic regression analyses to explore the relationships between contraceptive coercion and preferred contraceptive use. Principal Findings Approximately one in four (23%, n = 143) participants reported that they were not using their preferred contraceptive method. More than one‐third of participants (37.0%, n = 230) reported ever experiencing coercion in their contraceptive care, with 15.8% reporting downward coercion and 29.6% reporting upward coercion. Chi‐square tests indicated that downward (χ2(1) = 23.337, p < 0.001) and upward coercion (χ2(1) = 24.481, p < 0.001) were both associated with a decreased likelihood of using the preferred contraceptive method. These relationships remained significant when controlling for sociodemographic factors in a logistic regression model (downward coercion: Marginal effect = −0.169, p = 0.001; upward coercion: Marginal effect = −0.121, p = 0.002). Conclusions This study utilized novel person‐centered measures to investigate contraceptive coercion in the Appalachian region. Findings highlight the negative impact of contraceptive coercion on patients' reproductive autonomy. Promoting contraceptive access, in Appalachia and beyond, requires comprehensive and unbiased contraceptive care.

Healthcare Provider-Based Contraceptive Coercion: Understanding U.S. Patient Experiences and Describing Implications for Measurement

“…In our online survey, participants responded to open- and closed-ended questions about their health and contraceptive care. Based on theoretical conceptualizations of upward and downward contraceptive coercion [ 11 , 15 ] and our previous research interviewing stakeholders about regional family planning needs [ 19 ], we developed the five-item Coercion in Contraceptive Care Checklist. Figure 1 displays the items measuring the targeted aspects of contraceptive coercion dichotomously (0 = no, 1 = yes).…”

“…For example, discouraging or refusing a wanted permanent contraception procedure, as documented in several studies [ 9 , 12 , 13 , 14 ], are examples of downward coercion. Conversely, upward coercion involves pressure from a healthcare provider to use contraception [ 11 , 15 ]. Forcible sterilization, as well as the promotion of or refusal to remove LARC methods, are examples of upward coercion.…”

“…One of the few existing quantitative studies of contraceptive coercion focused specifically on the Appalachian region of the United States, finding that 37% of Appalachian women of reproductive age had ever experienced contraceptive coercion [ 15 ]. This study found that experiences of contraceptive coercion may undermine patients’ reproductive autonomy through a decreased likelihood of using their preferred contraceptive method(s) [ 15 ]. However, given the regional focus of this previous study, these findings may not reflect the experiences of patients across the country.…”

“…In this study, we begin to fill this gap in the first exploration of patients’ perceptions of contraceptive coercion in a national sample. Building on scholars’ theoretical descriptions of contraceptive coercion [ 11 , 15 ] and the emerging literature on the topic, we detail nuances in patients’ experiences of coercion in contraceptive care, debut and test a novel measure of contraceptive coercion, and make recommendations for future measurement of the construct.…”

Contraceptive Behavior in Appalachia: Exploring Use, Nonuse, and Contraceptive Attitudes

“…Additional evidence suggests people seeking contraception in Appalachia experience coercion related to their care. Swan et al [9] found that more than one-third of Appalachian women reported health care provider coercion related to their contraceptive method in a recent study, including both pressure to use and not use contraception.…”