Associations between perceived discrimination and contraceptive method use: why we need better measures of discrimination in reproductive healthcare.

Discrimination has historically contributed to coercive contraceptive in the United States. We investigated associations between perceived discrimination, or the perception of unequal treatment in everyday life, and contraceptive method use among U.S. women. We analyzed population-based data from a 2013 study of U.S. women who were premenopausal, age 18-50, sexually active with a male partner in the last year and were not attempting pregnancy. Perceived discrimination was measured using the Everyday Discrimination Scale. Contraceptive method use was categorized into five method categories: permanent, highly effective reversible, moderately effective, barrier and no method. We analyzed relationships between perceived discrimination and contraceptive method use with several regression models, controlling for covariates. Among 539 women in our analytic sample, those with high perceived discrimination had lower incomes, less educational attainment and were less likely to be insured. Perceived discrimination was associated with a reduced odds of using any contraceptive method (aOR 0.43, CI 0.21-0.87, p < .001). Contraceptive method users with high perceived discrimination had an increased odds of using highly effective reversible methods versus moderately effective methods (aOR 5.28, CI 1.63-17.07 p = < .001). Women who perceived discrimination were at risk for contraceptive nonuse; however, among contraceptive users, perceived discrimination was associated with the use of more effective reversible methods.

Inpatient Postpartum Long-Acting Reversible Contraception: Care That Promotes Reproductive Justice.

Inpatient insertion of long-acting reversible contraceptives (LARC) (intrauterine devices and implants) is increasingly offered to women immediately after childbirth. Enthusiasm for this approach stems from robust safety, effectiveness, and cost-effectiveness data and responsiveness to women's needs and preferences. Although clinical evidence for immediate postpartum LARC is well-established, the ethical implications of enhancing access to this care have not been fully considered. Contraceptive policies and practices often embody a tension between fostering liberal availability and potentially coercive promotion of some methods. Historical contraceptive policies and contemporary disparities in LARC use point to the need to consider whether health policies and health care practices support all women's reproductive wishes. Immediate postpartum LARC services need to be designed and implemented with the goal of ensuring autonomy and equity in postpartum contraceptive care. To this end, these services should include strategic plans to promote universal availability, prevent coercion, and enable device removal.

Stemming the Standard-of-Care SPRAWL: Clinician Self-Interest and the Case of Electronic Fetal Monitoring.

The "best interests of the patient" standard-a complex balance between the principles of beneficence and autonomy-is the driving force of ethical clinical care. Clinicians' fear of litigation is a challenge to that ethical paradigm. But is it ever ethically appropriate for clinicians to undertake a procedure with the primary goal of protecting themselves from potential legal action? Complicating that question is the fact that tort liability is adjudicated based on what most clinicians are doing, not the scientific basis of whether they should be doing it in the first place. In a court of law, clinicians are generally judged based on the "reasonably prudent" standard: what a reasonably prudent practitioner in a similar situation would do. But this legal standard can have the effect of shifting the medical standard of care-enabling a standard-of-care sprawl where actions undertaken for the primary purpose of avoiding liability reset the standard of care against which clinicians will be adjudicated. While this problem has been recognized in the legal literature, neither current ethical models of care nor legal theory offer workable solutions. One of the best examples of the conflict between evidence-based medicine and common clinical practice is the use of electronic fetal monitoring. Despite strong evidence and professional guidelines that argue against the use of EFM for healthy pregnancies, the practice persists. One of the main reasons for this is often assumed to be physicians' concerns about liability.

Dynamics of stigma in abortion work: findings from a pilot study of the Providers Share Workshop.

Abortion is highly stigmatized in the United States. The consequences of stigma for abortion providers are not well understood, nor are there published accounts of tools to assess or alleviate its burdens. We designed The Providers Share Workshop to address this gap. Providers Share is a six-session workshop in which abortion providers meet to discuss their experiences, guided by an experienced facilitator. Seventeen workers at one US abortion clinic participated in a pilot workshop. Sessions were recorded and transcribed, and an iterative process was used to identify major themes. Participants highlighted stigma, located in cultural discourse, law, politics, communities, institutions (including the abortion clinic itself), and relationships with family, friends and patients. All faced decisions about disclosure of abortion work. Some chose silence, fearing judgment and violence, while others chose disclosure to maintain psychological consistency and be a resource to others. Either approach led to painful interpersonal disconnections. Speaking in the safe space of the Workshop fostered interpersonal connections, and appeared to serve as an effective stigma management tool. Participants reflected favorably upon the experience. We conclude that the Providers Share Workshop may alleviate some of the burdens of abortion stigma, and may be an important intervention in abortion human resources. We present a conceptual model of the dynamics of stigma in abortion work.