Contraception Utilization in Black Women via a Reproductive Justice Lens

Reproductive justice (RJ) is the human right to maintain personal bodily autonomy, to have or not have children, and to parent children in safe sustainable communities. ¹ This term was coined in June 1994 by the Women of African Descent for Reproductive Justice, a group of Black women in Chicago, Illinois, in an effort to address the needs of marginalized women of color and trans persons within the women's right movement. ¹ Previous movements were led and represented by middle class and wealthy white women. This human rights framework combined reproductive rights and social justice. ¹ RJ is also based on the United Nations' Universal Declaration of Human Rights, which is a comprehensive body of law that details the rights of individuals and the responsibilities of the government to protect those rights. As such, it recognizes that the marginalized and women of color have difficulty accessing abortion, contraception, comprehensive sex education, prevention and care for sexually transmitted infections, alternative birth options, adequate prenatal and pregnancy care, domestic violence assistance, adequate wages to support their families, and safe homes. ¹ The reproductive rights framework is largely centered on achieving women's individual reproductive freedom through the legal system and has historically focused largely on the prochoice and prolife debate, sexual education, and family planning. Whereas the RJ framework acknowledges the ways in which socioeconomic status, gender identity, and race shape one's experiences with reproductive health care and health policy.

The term “eugenics” was first coined in 1883 by Sir Frances Galton, a British polymath and naturalist, and is derived from the Greek root, “eugenes,” meaning “good in stock or hereditarily endowed with noble qualities.” ² Dr. Galton further explained eugenics, in a 1904 issue of the American Journal of Sociology, as “the science which deals with all influences that improve the inborn qualities of a race; also with those that develop them to the utmost advantage.” ² These notions influenced the progressive era of 1900–1920 and gave rise to American social reformers whose goals were to fix the social ills of the day, including urban poverty, huge number of immigrants, and the public health crises of high infant mortality and population growth. ² To address these social conditions, these reformers believed that certain racial groups were “eugenically superior,” specifically white Anglo-Saxon Protestants, and, therefore, were encouraged to reproduce at greater rates, a concept often referred to as “positive eugenics.” ² On the converse, “inferior genes” were discouraged from reproducing through the establishment of “negative eugenics” programs, such as state-mandated sterilization laws for “mental defectives,” restrictions against who could marry whom, birth control policies, harsh adoption laws, and restrictive immigration policies. ² Discussions of Black, brown, and Indigenous people—racialized communities of color (BIPOC)—and agency over their bodies as commodities in the sociohistorical context of being enslaved, add nuances to these perspectives.

Worldwide, ∼40–50% of pregnancies are unplanned and a majority are unwanted. ³ More than half of those with an unplanned pregnancy report the use of a contraceptive method 1 month before or at the time of the pregnancy. ⁴ An estimated 88.2% of all women of ages 15–44 years have used at least one form of contraception during their lifetime. ⁵ The burden of an unplanned pregnancy is not equally distributed among racial and ethnic groups in the United States with the rates of unplanned pregnancies as follows: Black (69%) and Latina women (54%) as compared with white women (40%). ⁵ Among the reasons for these differences include a lack of access to care, and differences in contraceptive failure rates among racial and ethnic groups, ⁴ as well as less of an inclination to have an abortion. With this background in mind, this article discusses the disparity in the utilization of contraception among Black women through an RJ lens.

Structural racism and discrimination are factors that have led to the highest rates of maternal and infant mortality, high teenage pregnancy rates, and the lowest rates of contraception use in Black women. ⁶ Over 100 million women make decisions about beginning or resuming contraception after childbirth annually. ⁷ The timing of contraception initiation is important since the return of menstruation and ovulation can be unpredictable in breastfeeding women. ⁷ Barriers to contraception for breastfeeding persons include provider worries of medical conditions, patient concerns, and resistance by other health care providers. ⁸ Providers themselves may be a barrier to contraceptive choice, especially among marginalized populations such as those who are homeless, imprisoned, and transgender persons, due to knowledge asymmetry and language and cultural barriers. ⁷ Other factors influencing postpartum contraceptive choice include race (with white women more frequently choosing the progestin-only pill [POP] and nonwhite women preferring long-acting methods—p-value = 0.019); previous contraceptive use (70% chose POP vs. 30% in women who were not previous contraceptive users—p-value = 0.001); and type of delivery (tubal ligation was chosen by 26% of women who had a cesarean section vs. 2% of those who delivered vaginally—p-value = 0.048). ⁸

Institutionalized racism, transphobia, and homophobia may compromise patient access to the full spectrum of contraceptive options available. Socioeconomic factors have also attributed to higher rates of unintended and unwanted pregnancies observed among Black and Latina women compared with white women in the United States and have influenced differences in contraceptive preferences. ⁹ Black and Latina women have reported lower rates of overall contraceptive use and prescription contraceptive use, but higher rates of condom utilization and female sterilization. ⁹ Low-income Black and Latina women may also be pressured into receiving long-acting reversible contraception due to bias, discrimination, and reproductive coercion. ⁹ There are also differences in the reliability of methods between racial and ethnic groups with Black and Latina women being more likely to choose less reliable contraceptive options, such as condoms and withdrawal methods, compared with white women, who are more likely to choose more reliable options such as the progesterone implant and intrauterine device. ⁵

Utilizing contraception after childbirth is important for birth spacing to improve the health of mothers and children. Birth lengthening of at least 18 months has been shown to reduce the risks of preterm delivery and neonatal death, and poor maternal outcomes.^10,11 Short interpregnancy intervals (IPIs) have also been associated with social vulnerability. ¹² Furthermore, non-Hispanic Black women may have a greater occurrence of shortened (i.e., <6 months) IPI (i.e., the time between the end of one pregnancy and conception of the next) than non-Hispanic white women. This is a risk factor for preterm birth even when controlling for maternal education, parity, and previous preterm birth. ¹³ Preterm birth can make direct breastfeeding and human milk feeding more challenging and there are known racial disparities in the provision of human milk for preterm infants.^14–17

Most women plan to use contraception after giving birth. In a cross-sectional convenience sample of 100 breastfeeding women, the authors noted that many women (up to 91%) intended to use contraception postpartum. Only 21% of women, however, considered the effects of contraceptive method on breastfeeding. Intention of contraception was primarily based on convenience. ¹⁶ Another contraceptive option that may not be as familiar to patients is the lactational amenorrhea method (LAM). When used properly, as per the recommendations of the Bellagio Consensus Conference in 1988 on LAM, the risk of pregnancy in fully breastfeeding women who remain amenorrheic is less than 2% in the first 6 months after delivery. ⁸ Its practice requires mothers and infants to breastfeed without restriction of time or convenience for optimum suppression of ovulation. Women returning to work and expressing milk frequently probably achieved the same ovulation suppression, but research is lacking.

The effectiveness of the LAM method is as real today as it was when slaveholders previously realized previously that it allowed for pregnancy spacing by ∼2 years, thereby decreasing the number of potential future slaves available to them. ¹⁷ Slaveholders, thus, began the practice of removing infants from their mothers to make the women more available for childbearing. ¹⁷ Although the slaveholders' abuse of this knowledge was a miscarriage of justice, there is no reason for women not to be aware of the effectiveness of LAM today. It is unclear how often Black women are informed of LAM as an option for contraception. It is possible that through implicit bias, it is assumed that Black women will not breastfeed to the level necessary to assure an anovulatory status, and thus avoid an undesired pregnancy, although this has not been well researched. The option to combine LAM with a nonhormonal contraceptive method (such as an intrauterine device without hormones or barrier method) may be a welcome alternative, which would not run the risk of suppression of milk production that sometimes accompanies the hormonal methods that Black mothers are most often encouraged to use. ⁹

Structural competence and cultural sensitivity and humility must be utilized in counseling women about contraceptive choices in the context of their breastfeeding goals. As concluded by Brownell et al. in a systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation, it is important that “potential breastfeeding risks associated with early (<6 weeks) postpartum [LARC] use be disclosed to allow for a fully informed consent and decision-making process.” ¹⁸ Where additional support may be needed for initiation and continuation of breastfeeding, Black women should be counseled about all contraceptive options, particularly avoiding reproductive coercion while giving consideration to the impact of racialization, racism, and bias on their reproductive and breastfeeding outcomes. Given the individual and public health benefits of breastfeeding and the impact those benefits can have in helping Black birthing persons and children achieve health equity, it is important for obstetric and pediatric health care providers to play their part in encouraging and supporting breastfeeding.