Abstract
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Several sociodemographic variables were also collected and indicate that the sample was comprised largely of African American women (80.2%) and that more than 60% of the sample had acquired a high school degree/GED, or less. An impressive percentage reported having experienced childhood physical violence (49.6%), adult physical violence (45.3%), recent intimate partner violence (34.3%), and overall reproductive coercion (33.3%). The majority (59.3%) of women were classified as having “normal/low” self-esteem at baseline.
In summary, the question driving this investigation seems to be “which of the collected variables, when considered in meaningful groups, best explain women's tendency to participate in ineffective or effective contraceptive use?” Effective contraception use was defined by the following over the follow-up period: consistent use of pills, condoms, adherence to Depo-Provera, the patch, vaginal ring, or use of an IUD or Implanon over the course of the follow-up period.
The adjusted model indicated that childhood sexual violence and low self-esteem are significantly related to ineffective contraceptive use; the authors cite the need for trauma-informed approaches and screening related to childhood sexual violence and “interventions to increase self-esteem.” Although these results are not surprising, they raise interesting questions related to self-esteem and its power and place in female decision-making over the life course.
This particular sample was lower socioeconomic status, 22.5 years old on average, and not seeking pregnancy with conscious intent. Despite the latter, 93 (36%) of 258 women were classified as ineffective subscribers to contraceptive use. In other words, they were health-motivated enough to access a family planning clinic, yet at follow-up were either inconsistently using pills or condoms, relying on the withdrawal method, or using nothing at all.
This signals a potential contradiction between intent and behavior in crucial moments. The authors provide apt explanation, “In fact, we found that women reporting low self-esteem in this study were less likely to report that they were certain about their ability to refuse a sexual advance by their partner, their ability to have a sexual encounter without feeling obligated to have intercourse, and their ability to promote the use of condoms with a sexual partner.”
As a researcher focused on women's mental health after childbirth, this breakdown in the ability to promote one's own self-interest (i.e., preventing an unwanted pregnancy) is reminiscent of behavior observed in the postpartum period. Recent research indicates that, regardless of socioeconomic status, women often struggle to prioritize their own needs in the context of new motherhood. 1,2 In a relatively mid- to high-income group of new mothers, Barkin and Wisner 2 observed that although women could often communicate the importance of attending to their own needs, they encountered both internal and external obstacles in the execution of related self-care behaviors.
Numerous obstacles to self-care within the context of family life have also been noted in low-income women in the southeastern United States. 3 Although applications and barriers to self-care have not yet been examined in mothers of older children, the research team hypothesizes that a similar struggle exists throughout the course of motherhood. Meaning that even when further along in motherhood, women are still grappling with the idea of promoting their own needs.
Nelson et al. describe low self-esteem as a modifiable factor in the effort to prevent unplanned pregnancy. This leads to the rather loaded question, “what factors impact female self-esteem across the lifecourse?” Certainly, in the Nelson et al. study, the exposure to all forms of childhood violence represents a vulnerability that is complex and difficult to address. However, women's tendency to place their needs on the backburner at key junctures in time is not owned exclusively by low-income, young, urban women. Anonymous surveys have indicated that 27%–50% of females in college have participated in “coerced sexual activity,” 4,5 and in new motherhood, extreme cases of female self-neglect (in relatively advantaged women) include lapses in personal hygiene, “forgetting” to eat, and an unwillingness to leave one's child in the hands of capable family members, including the infant's father. 2
In the effort to understand female self-esteem and decision-making more comprehensively, we need to consider both the immediate environment (i.e, Was the woman subject to childhood violence? Community violence? Did she have mentors? Family support?) and also pervasive societal messaging.
Despite advances in thinking, women in general may still feel fortunate to receive male attention 5 and that might help to explain some women's reluctance to insist on condom use during sexual encounters. Why might a woman feel fortunate? Part of the answer is tied to reproductive window. Women have a “deadline,” per say, to find a partner and have children, whereas men do not. This represents a disadvantage in leverage in dating and sexual encounters that is dictated by biology—an unmodifiable factor. Norris et al. 6 describe women as “walking a cognitive tightrope” as they have to consider both relationship-building goals and their own protection.
Other reasoning likely includes society's valuation of men and women. The Institute for Women's Policy Research indicates that although women represent almost half of the U.S. workforce and are the breadwinners in 4 out of 10 families, on average, they earn 80 cents for every dollar earned by men. 7 This disparity in compensation persists across occupational type. 7 Despite the fact that more African American women earn college degrees (65%) than same-race men (35%), 8 the median annual earnings for black women in 2015 was $36,212 versus $41,094 for men. 9 The gap in compensation is much wider when comparing white women's earnings with white men's. 9
As health professionals, we also send important messages, whether wittingly or unwittingly. An example of this occurs after childbirth, where women receive one standard follow-up visit often after a cesarean section or a difficult labor. In contrast, the infant receives seven standard well-child visits across the first year of life. This sends a message to the woman: your needs are not a priority.
There are both advocates, such as U.S. Representative Katherine M. Clark from Massachusetts, 10 and detractors for perinatal depression screening, and the debate will likely continue. 11 However, regardless of whether mental health screening precipitates treatment engagement, it sends an important signal to the women regarding the importance of their health and life satisfaction in the context of family life. It puts her needs on the map.
In response to a lack of public health marketing for their Women's Health and Birth Control Program, the Georgia Department of Public Health's North Central Health District recently adopted the slogan, “Birth Control. Because you have other plans.” This message of empowerment, intended to reach the teen and young adult population, can be seen on billboards, local transit authority buses, and on their website as a rolling header. 12 Anita Barkin, Director of Nursing and Clinical Services, describes a “dramatic increase in requests for Long Acting Reversible Contraception (LARC)” as a result.
Another important message about gender ranking is received through the church. Although it is African American women who represent the majority of the constituency in black churches (estimated at 66–88%), 13 men still hold the bulk of the leadership roles. 13 Black and white women alike who manage to work their way into pastoral roles face obstacles such as smaller congregations, less organizational support, and fewer paid staff. 13
It makes sense that if women do not feel equal to men in general, they may have difficulty promoting their own agenda (i.e., having sex without getting pregnant) during intercourse. It also makes sense that this power dynamic is exaggerated where women have preexisting low self-esteem and/or have been subjected to childhood violence.