Socioeconomic and Racial/Ethnic Inequalities in Infertility Prevalence, Help-Seeking, and Help Received Since 1995.

BACKGROUND: In the United States, infertility and treatment for infertility are marked by racial/ethnic and socioeconomic inequalities. Simultaneously, biomedical advances and increased public health attention toward preventing and addressing infertility have grown. It is not known, however, whether the racial/ethnic and socioeconomic inequalities observed in infertility prevalence, help-seeking, or help received have changed over time. METHODS: Using National Survey of Family Growth data (1995 through 2017-2019 cycles), this study applied multivariable logistic regression with interaction terms to investigate whether and how racial/ethnic and socioeconomic inequalities in 1) the prevalence of infertility, 2) ever seeking help to become pregnant, and 3) use of common types of medical help (advice, testing, medication for ovulation, surgery for blocked tubes, and artificial insemination) have changed over time. RESULTS: The results showed persisting, rather than narrowing or increasing, inequalities in the prevalence of infertility and help-seeking overall. The results showed persisting racial/ethnic inequalities in testing, ovulation medication use, and surgery for blocked tubes. By contrast, the results showed widening socioeconomic inequalities in testing and narrowing inequalities in the use of ovulation medications. CONCLUSIONS: There is little evidence to suggest policy interventions, biomedical advances, or increased public health awareness has narrowed inequalities in infertility prevalence, treatment seeking, or use of specific treatments.

Beyond knowledge: Introducing embodied aversion through the case of contraception.

Family planning programs have largely operated at the individual level, seeking to enhance individuals' knowledge of, change attitudes towards, and improve consistent use of efficacious contraception. Social science research has added to these efforts by emphasizing the structural influences that shape individuals' contraceptive attitudes, beliefs, and behaviors. Such work highlights the importance of embodied knowledge which is informed by social contexts and provides individuals with a sense of assuredness in knowing which contraception works well for them (and within their bodies). However, through qualitative analysis of in-depth interviews with 59 self-identified women conducted from 2017 to 2018 across the state of Delaware in the United States, we argue that there is a powerful facet of contraceptive decision-making that lies beyond articulatable, conscious knowledge, which we name "embodied aversion." We draw on affect theory and stigma theory to introduce embodied aversion as an influential feeling and orientation away from implantable and insertable contraceptive methods that arises from internalized stigma around the reproductive body. Embodied aversion overpowers conscious understanding of contraceptive benefits like efficacy, ease of use, and longevity. Our research presents embodied aversion as a missing piece of contraceptive understanding that we argue is vital in more fully conceptualizing experiential dimensions of contraceptive use. Doing so enhances patient-centered care, shared decision-making, and reproductive autonomy.

Intersections between culture, contraception, knowledge and the body in the USA.

Women's contraceptive use is a central feature of US culture around reproduction as evinced by high usage rates and nationwide public health efforts to further increase its use. Paradoxically, women know little about contraception within its biomedical framing, and successive public health-related educational campaigns have produced only moderate knowledge gains. Drawing on 86 in-depth interviews with a diverse sample of reproductive-age women, we set out to understand this persistent learning lag. In doing so, we found that women's limited contraceptive knowledge extended beyond simply being uneducated about various methods. Rather, these learning lags can be attributed to many women's lack of knowledge or misunderstandings about their anatomical bodies and reproductive processes. Employing feminist perspectives, we argue that these misunderstandings derive from factors beyond individual women's control. Indeed, they are rooted in cultural norms that stifle and stigmatise women's reproductive learning. Traditional public health efforts may inevitably fail to overcome these cultural barriers, perpetuating women's gaps in knowledge. Recognising the cultural dimensions of contraceptive knowledge and education reveals how critical action is needed around sexuality education in the USA as well as the limitations of on-going educational efforts.

Comparing methods of long-acting reversible contraception: A qualitative study of Delaware women's perceptions of intrauterine devices and the implant.

OBJECTIVE: To distinguish Delaware women's perceptions of the intrauterine device (IUD) relative to the subdermal arm implant (implant) as well as to compare their perceptions of various IUD types. STUDY DESIGN: In this qualitative study, we conducted in-depth interviews with 86 self-identified women between 16 and 44 years old who resided in the state of Delaware. We used quota sampling to ensure a diversity of perspectives using age, socioeconomic status, race/ethnicity, and county of residence to do so. We analyzed the data for content and themes using deductive and inductive techniques. RESULTS: Of the 47 participants who would use long-acting reversible contraception (LARC), 36 favored IUDs over the implant, and 11 felt more comfortable with the implant. Participants' perceptions were primarily influenced by device side effects, body placement, and the removal process. Those favoring a specific IUD prioritized the presence of exogenous hormones, device size, and maximum duration of use. Thirty-nine women would not use IUDs or the implant, citing safety risks and the availability of "simpler" methods. CONCLUSIONS: Clinicians often use tier-based descriptions when counseling patients about contraception, particularly when emphasizing the similar efficacy levels of LARC devices. Participants in our study did not perceive LARC as a homogeneous category; rather, they consistently differentiated between IUDs and implants as well as between IUD types. Such findings demonstrate the need to understand which device features inform these distinct preferences and how providers' contraceptive counseling practices can be adjusted in response. IMPLICATIONS: Given these findings, scholars should compare and further distinguish across methods, including IUDs, whenever possible. The findings also reinforce the benefits of stocking a variety of LARC devices at clinic and practice sites and encouraging provider counseling that emphasizes method-specific concerns and features. Doing so centers users' needs and preferences.

"Did I Choose a Birth Control Method Yet?": Health Care and Women's Contraceptive Decision-Making.

In the United States, unintended pregnancy is medicalized, having been labeled a health problem and "treated" with contraception. Scholars find women's access to contraception is simultaneously facilitated and constrained by health care system actors and its structure. Yet, beyond naming these barriers, less research centers women's experiences making contraceptive decisions as they encounter such barriers. Through in-depth, semi-structured interviews with 86 diverse, self-identified women, this study explores how the medicalization of unintended pregnancy has influenced women's contraceptive access and decision-making. We highlight the breadth of such influence across multiple contraceptive types and health care contexts; namely, we find the two most salient forces shaping women's contraceptive decisions to be their insurance coverage and providers' contraceptive counseling. Within these two categories, we offer crucial nuance to demonstrate how these oft-cited barriers implicitly and explicitly influence women's decisions. Paradoxically, it is the health care system, itself, that both offers yet constrains women's contraceptive decisions.

The limitations of patient-centered care: The case of early long-acting reversible contraception (LARC) removal.

Patient-centered care (PCC) is frequently recommended to improve healthcare outcomes in the United States. Despite its purported benefits, little research explores how and to what extent providers implement this model in their care. We examine such processes through the case of contraception, specifically, "early" removals of long-acting reversible contraception (LARC). In-depth interviews with 51 healthcare providers reveal that while providers describe embracing patient-centeredness when considering patients' early LARC removal requests, their implementation ironically sidelines patient preferences and needs. Rather than be responsive to patients' requests, all providers in the study resist early LARC removal by: withholding information about self-removal of intrauterine devices (IUDs); negotiating with patients to keep their device longer; setting subjective timelines to prolong LARC use; and/or engaging in delay tactics to wear down patients' resolve for removal. Furthermore, beyond simply resisting LARC removal requests using these strategies, providers purposively employ tenets of PCC to sway patients away from removal. In other words, providers utilize PCC as a means to undermine it. Understanding how providers implement patient-centered care reveals the challenges to doing so, even in cases like early LARC removal where providers indicate patient-centeredness is a priority. It also elucidates the need for enhanced training, specificity, and institutionalization around patient-centered models of care; informs interventions that promote LARC use among patients; as well as offers opportunities for improving patient-provider exchanges generally.

"We're a Little Biased": Medicine and the Management of Bias through the Case of Contraception.

There is a wealth of literature demonstrating the presence of bias throughout the American health care system. Despite acknowledging such presence, however, little is known about how bias functions within medical encounters, particularly how providers grapple with bias in their patient counseling and decision-making. We explore such processes through the case of contraceptive counseling, a highly raced, classed, and gendered context. In-depth interviews with 51 health care providers reveal that providers use four primary strategies to navigate and minimize bias in their care-using scientific rationale, employing "safe" biases, standardizing counseling, and implementing patient-centered care. Paradoxically, using these strategies can exacerbate rather than resolve bias. Understanding these bias management strategies reveals provider-held biases, how they manifest within appointments, and the potential consequences for patients' health autonomy. Such knowledge informs interventions that promote contraceptive use among women in the United States, addresses bias in health care broadly, and thus ultimately helps combat health disparities.

Contextualizing barriers to long-acting reversible contraception in Delaware.

OBJECTIVE: We conducted this study to examine barriers to long-acting reversible contraception (LARC) that persist in the context of a large-scale LARC program, Delaware Contraceptive Access Now (Del-CAN), that has actively endeavored to remove such barriers. STUDY DESIGN: In 2016-2017, we conducted in-depth interviews with 86 self-identified women of reproductive age, diverse along the lines of age, race, and class, in the state of Delaware on their attitudes, beliefs, and behaviors regarding contraception. We analyzed the interviews using an inductive coding process. RESULTS: We found that, even in the midst of Del-CAN's efforts, meso and macro-level contexts, including provider-patient communication and clinic/practice structures, reinforced LARC barriers related to knowledge, access, and side effects. CONCLUSIONS: The multi-level contexts and nuances we illuminate in our study currently fall outside the purview of well-intentioned, large-scale initiatives such as Del-CAN, that attempt to address and ameliorate oft-researched barriers. Thus, these barriers persist within provider-patient interactions and clinic/practice policies and structures. IMPLICATIONS: The evaluated LARC-based intervention, Del-CAN, cannot fully address issues around provider autonomy, inadequate provider-patient communication, or practice-specific policies and criteria. In order for this intervention, and others like it, to be successful, they must be aware of and prepared to address such dimensions in their efforts.

"This is what the truth is": Provider-patient interactions serving as barriers to contraception.

Contraception is a vital component of women's reproductive health, but not all women use it consistently and effectively. Many studies explore individual-level barriers to contraceptive use, yet interactional barriers are important to understand since contraception is primarily obtained through provider-patient interactions. Thus, through interviews with 86 women and 51 providers in the United States, we employ a framework of biomedicalization to study how such interactions, including the knowledge bases that inform them, shape women's contraceptive decision-making. We find that when women's embodied knowledge and providers' biomedical knowledge differ, providers' preferences supersede women's. Providers, however, overlook this hierarchy, instead viewing their relationships with patients as empowering equal partnerships. This pattern precludes women from achieving their desired contraceptive method and highlights the process through which women's concerns become barriers to contraceptive use. Moreover, these findings reflect how provider-patient hierarchies continue to thrive despite purported patient-centered care models.

"Power of Mom": A Mixed Methods Investigation of Mothers' Influence on Women's Contraceptive Attitudes and Behaviors.

OBJECTIVES: Unintended pregnancy is an individual and public health problem with significant social and economic consequences. The literature has established that parents, especially mothers, play an important role in shaping the contraceptive attitudes and behaviors of young women and could therefore affect the likelihood of their daughter experiencing an unintended pregnancy. However, research has yet to fully explore the nuances of how mothers influence their daughters with respect to contraception. METHODS: We conducted a mixed methods study to explore the impact of mothers on women's contraceptive attitudes and behaviors. In-depth interviews were conducted with 86 women of reproductive age to identify potential patterns and explore the nature of mothers' influences. We then analyzed medical and prescription claims for a cohort of 9813 pairs of women (mother-daughter proxies) enrolled in Medicaid, to determine if such patterns of contraceptive use held in a larger sample. RESULTS: In-depth interviews reveal how and why mothers shape women's contraceptive attitudes and behaviors, particularly highlighting the nuances of communication, knowledge, and relationships. The statistical claims data supported such findings on a broader scale. For instance, across several types of contraceptives, including oral, injectable, and long-acting reversible contraceptives (LARCs), young women were significantly more likely to use a particular method if an older woman in the household (mother proxy) also used that method (AOR (95% CI) 1.99 (1.67-2.37), 2.06 (1.58-2.68) and 2.83 (1.64-4.88) respectively). CONCLUSIONS FOR PRACTICE: This study fills a gap in the literature regarding the nuanced ways in which mothers influence women's contraceptive behavior. In turn, it supports the importance of familial context-especially the influence of mothers-in contraception decision-making and suggests that interventions aimed at improving access to and uptake of effective methods of contraception consider this context in their design and implementation.

The gas that fuels the engine: Individuals' motivations for medicalisation.

It is well established that the drivers of medicalisation have shifted alongside changes in the institution of medicine. The process of medicalisation is no longer incited by macro processes of institutional prestige or control; rather, individual patients/consumers are pushing the process forward. The present study complicates this neat transition and examines the relationship between structure and agency using the case of assisted reproductive technology (ART), specifically the medicalisation of lesbian reproduction in the US. I explore individuals' influence on and motivations towards medicalisation through 24 in-depth interviews with women in same-sex relationships who had ever attempted to become pregnant. In centring on their experiences, I find that while individual consumers may now propel medicalisation forward, oftentimes consumers' motivations for doing so reside in the prestige and control of medicine. In other words, consumers now seek medicalisation precisely because of the process's previous institutional drivers. In exploring what fuels the engine of medicalisation, the findings reveal its nuance and complexity.

The margins of medicalization: Diversity and context through the case of infertility.

There is a prolific literature on medicalization. While that research highlights numerous effects of the process, it is just beginning to explore medicalization's complexity. In an effort to understand medicalization as a diverse, contextual process, I utilize the case of infertility in the U.S., a highly stratified, medicalized condition. I interviewed 95 individuals among those at the margins of mainstream understandings of reproduction-women of low socioeconomic status, men who were part of an infertile couple, and women in same-sex relationships who were accessing medical treatment to assist in conception-and compared their experiences to 17 straight women of high socioeconomic status who are at the center of reproductive care. Through such comparison, I examine the gender, class, and sexuality dimensions of inequality in medicalization. Ultimately, medicalization excludes, but it does so differentially and with different effects depending on an individual's social location. Such findings demonstrate that medicalization is not a fixed, universal process. It is fluid and relational and shifts depending on context.

'I don't consider a cup performance; I consider it a test': masculinity and the medicalisation of infertility.

Researchers have deemed medicalisation a 'gendered' theory, yet the incorporation of men and masculinity in medicalisation literature is sparse. Recently, however, medicalisation scholarship has begun studying men. This burgeoning literature heavily emphasises sexuality and is beginning to focus on medicalised masculinities in which traits associated with masculinity are deemed a health risk. Such research has demonstrated how masculinities shape men's lived experiences of health, but how does health itself shape masculinity? I explore this question using the case of infertility. Through thirty in-depth interviews, I find that men use medicine as a way to achieve rather than diminish their sense of masculinity in the feminised context of reproduction. By perpetuating the stereotype that infertility is a woman's problem, the medical establishment has caused men to not necessarily see themselves as infertile. Additionally, even if men do claim the infertility status, they do not perceive it as negative. The legitimating effects of medicalisation objectify the ailment and separate its connection with sexuality. In centring men's voices, the study not only reveals men as active players in the reproductive process, but also incorporates them into understandings of medicalisation.

"There's a higher power, but He gave us a free will": socioeconomic status and the intersection of agency and fatalism in infertility.

Existing literature characterizes fatalism as a passive reaction to health in the face of powerlessness and constructs agency as a more activist perspective based in self-efficacy and control. Frequently studied together, researchers extol agency as the appropriate approach to decision-making around health, while discouraging fatalistic outlooks. Despite associating such beliefs with social classes-agency with high socioeconomic status (SES) groups and fatalism with low SES groups-there is little research that compares health beliefs across class groups. By examining the medicalized condition of infertility among women of both high and low SES, this study examines how social class shapes reactions to health and illness. Through 58 in-depth interviews with infertile women in the U.S., we reveal the complexity of fatalism and agency and the reasons behind that complexity. We first examine the commonalities among SES groups and their mutual use of fatalism. We then demonstrate the nuance and continuity between the health beliefs themselves-fatalism can be agentic and agency can be achieved through fatalism. In other words, we disrupt the binary construction of health beliefs, their conflation with social class, and the static application of health beliefs as psychological attributes, ultimately exposing the classist basis of the concepts. Doing so can result in improved patient care and reduced health inequalities.

"I think about Oprah": social class differences in sources of health information.

Health information influences an individual's health outcomes. Indeed, researchers have found that communication inequalities contribute to health inequalities. We do not have a clear understanding of why and how the communication disparities exist, however, particularly the social forces behind such differences. The qualitative nature of this article reveals the nuances of health information seeking using the case of infertility. Through 58 in-depth interviews, I demonstrate how differences in social and cultural capital between women of low and high socioeconomic status (SES) result in different ways of learning about health. Women of high SES have access to support groups, physicians, and the Internet, whereas women of low SES do not discuss their health problems with their peers, and lack access to and distrust physicians. I explore how these differences in health information shape the illness experience. I conclude with policy implications.

Diagnostic diversity: the role of social class in diagnostic experiences of infertility.

Research in the area of the sociology of diagnosis has recently expanded. Despite this development, the foundations of the social aspects of diagnoses, including race, class and gender, are relatively unexplored. Understanding such diversity is important, however, as researchers have shown that diagnoses have significant repercussions on the illness experience. This article is an effort to overcome this gap in the literature by examining class diversity in interpretations and understandings of diagnoses. Using the medicalised condition of infertility as a case example of class differences around diagnoses, I conducted 58 in-depth interviews with infertile women of various class backgrounds in the USA. By comparing the lived experiences of infertility between higher and lower class women, I explore differences in the understanding, interpretation and outcomes of diagnoses, specifically. Furthermore, among lower class women, I examine how they understand infertility outside the medical diagnostic framework. The findings reveal how interpretations and experiences of diagnoses vary depending on an individual's social location. In other words, the study demonstrates that class matters in terms of diagnoses and their understanding.

The (stalled) progress of interprofessional collaboration: the role of gender.

Researchers have demonstrated that team-based, collaborative care improves patient outcomes and fosters safer, more effective health care. Despite such positive findings, interprofessional collaboration (IPC) has been somewhat stunted in its adoption. Utilizing a socio-historical lens and employing expectation states theory, we explore potential reasons behind IPC's slow integration. More specifically, we argue that a primary mechanism hindering the achievement of the full promise of IPC stems not only from the rigid occupational status hierarchy nested within health care delivery, but also from the broader status differences between men and women--and how these societal-level disparities are exercised and perpetuated within health care delivery. For instance, we examine not only the historical differences in occupational status of the more "gendered" professions within health care delivery teams (e.g. medicine and nursing), but also the persistent under-representation of women in the physician workforce, especially in leadership positions. Doing so reveals how gender representation, or lack thereof, could potentially lead to ineffective, mismanaged and segmented interprofessional care. Implications and potential solutions are discussed.