Reproductive Autonomy in Appalachia: An Investigation into Perceived Contraceptive Pressure

Abstract

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants (N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent’s partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

Keywords

Appalachia contraception reproductive autonomy reproductive coercion reproductive justice rural social services

Reproductive autonomy is “having the power to decide about and control matters associated with contraceptive use, pregnancy, and childbearing” (Upadhyay et al., 2014, p. 20), without interference from violence, coercion, or pressure. However, the reproductive autonomy of persons who can give birth can be impeded through nuanced forms of interpersonal violence, power dynamics, and pressure, including by healthcare providers (e.g., paternalization), romantic partners, and family members. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities (Asian Communities for Reproductive Justice [ACRJ], 2005). Studies have shown a lack of reproductive autonomy to be associated with negative health consequences, such as unintended pregnancies, unsafe abortions, choosing to limit contact with healthcare in the future, and increased risk of homicide (Bagwell-Gray et al., 2021; Galli, 2011; Gomez & Wapman, 2017; Miller et al., 2010).

Contraceptive pressure interferes with the reproductive autonomy of persons who can give birth, and examples include the denial of wanted contraceptive methods or disregarding a person’s choice to not use contraception (Senderowicz, 2019). For the purposes of this study, we investigate contraceptive pressure in terms of pressure reported by participants regarding birth control, including experiences of pressure to use birth control and pressure not to use birth control. We then examine four interpersonal sources of pressure (i.e., healthcare providers, family members, romantic partners, and religious communities). Since we examined respondents’ perceptions of their experiences, we refer to this as perceived contraceptive pressure. While health disparities in Appalachia have been well researched in some regards, there exists a dearth of information related to reproductive health. Therefore, the focus of this paper is to investigate perceived contraceptive pressure in the Appalachian region.

Disparities in Contraception Use

According to the 2017–2019 National Survey of Family Growth, approximately 65% of U.S. women ages 15–49 currently use contraception (Daniels & Abma, 2020). Women report female sterilization as the most common contraceptive method (18.1%), followed by the oral contraceptive pill (14.0%), long-acting reversible contraceptives (LARCs) (10.4%), and the male condom (8.4%). Differences in contraceptive use based on demographic factors such as race/ethnicity, age, and education were evident in the survey. For example, incidence of female sterilization increased with age yet decreased with higher education, ranging from 39.9% among women without a high school degree or GED to 12.1% of women with a bachelor’s degree or higher. The use of the pill varied by race and ethnicity, with White women using it more prevalently (17.8%) than Latinas (7.9%) or non-Hispanic Black women (8.1%).

When examining contraceptive use between those living in rural versus urban areas, both groups demonstrated a similar rate of contraception use overall (79%) yet differences emerged among the type of contraceptive method chosen (Daniels et al., 2018). Women living in urban areas had higher rates of less effective methods (e.g., condom, withdrawal) and lower rates of the most effective methods (e.g., sterilization or intrauterine device [IUD]) when compared with women living in rural regions (Daniels et al., 2018). A study by Geske et al. (2016) investigating contraceptive use in adolescents found no differences in the overall use of contraception between rural and urban residents; however, participants residing in rural areas reported more barriers to obtaining contraception.

Religiosity is a variable that has been investigated in the literature; however, more research is needed to better understand the nuances of its possible influence on contraceptive use. In the 2002 National Survey of Family Growth, similar patterns of contraceptive method choice were found between the nationally representative overall sample of U.S. women (N = 7,635) and the U.S. Roman Catholic subset (N = 2,250; Ohlendorf & Fehring, 2007). Yet, the same study also found that Roman Catholic women who reported frequent church attendance were 38% more likely to be sterilized than Roman Catholic women with low church attendance. In addition, Roman Catholic women who reported their religion as very important were 68% more likely to be sterilized than Roman Catholic women who reported religion as not very important (Ohlendorf & Fehring, 2007). Looking at state-level data, conservative religious beliefs strongly predict U.S. teen birth rates, even when controlling for income (Strayhorn & Strayhorn, 2009). One possible reason for this correlation may be lower rates of contraceptive use in this population (Strayhorn & Strayhorn, 2009).

Differences in contraceptive choice may, in part, reflect varying perspectives women hold regarding contraception. For example, while LARCs may be considered by some as a way to eliminate frequent consideration of contraception, others may see LARCs as invasive (Gomez et al., 2018). A survey of Latinas in New York City (N = 288) found no correlation between religiosity and beliefs about safety or efficacy of contraceptives (Venkat et al., 2008).

However, differences in views based on race and ethnicity have been found by others (Edelman et al., 2007; Jackson et al., 2015; Rocca & Harper, 2012). For example, findings from one study (N = 1783) suggest Latina, non-Hispanic Black, and Asian Pacific Islander women are more likely than non-Hispanic White women to prefer contraceptive methods that they could stop at any time and that did not alter the menstrual period (Jackson et al., 2015). While racial and ethnic differences in attitudes toward contraception and pregnancy may play a role, they only partly explain disparities in choice of contraceptive method (Rocca & Harper, 2012). More research is needed to investigate variables that may account for disparities in methods of contraceptive use.

Pressure in Contraception Use

Given their role as experts, healthcare providers control access to prescriptive contraceptives and broadly serve as contraceptive gatekeepers. Moreover, many providers control the presentation of information during contraceptive counseling, and patients may accept providers’ recommendations due to a willingness to defer to their expertise (Gurnah et al., 2011). Moreover, evidence also suggests physicians’ recommendations for contraception may vary based on a patient’s demographic factors, including race, ethnicity, age, and socioeconomic status (SES; Berlan et al., 2016; Dehlendorf et al., 2010). For example, Berlan et al. (2016) found that beliefs and attitudes held by pediatricians regarding adolescent IUD use influenced whether they discussed IUDs in routine contraception counseling with this age group, including beliefs based on outdated knowledge. Dehlendorf et al. (2010) found that healthcare providers were less likely to recommend intrauterine contraception (IUCs) to White patients of low SES than to high SES White patients, although SES was found to have no significant influence among IUC recommendations to Latina and Black patients. In addition, healthcare providers were more likely to recommend IUCs to low SES Latina and Black patients than to low SES White patients.

In a qualitative study with women of minority ethnic backgrounds (N = 30), participants differentiated between providers who were firm in recommending birth control and providers they felt were coercive or overbearing in birth control counseling (Yee & Simon, 2011). Coercive undertones were reported primarily for two categories of women: women who desired sterilization yet felt they had to fight for their postpartum tubal ligation, and women who felt coerced to select a particular contraceptive method (Yee & Simon, 2011). In addition, two African American participants reported coercive experiences in interactions with providers that they believed were influenced by racism (Yee & Simon, 2011).

Sterilization has a complex history in the United States as it pertains to reproductive autonomy, as some women have been sterilized without their knowledge or consent, while others have been prohibited from obtaining the procedure (American College of Obstetricians and Gynecologists [ACOG], 2017). For example, women report denials of sterilization requests by healthcare providers due to being “too young,” even when in their 30s (Potter et al., 2012, p. 232; Yee & Simon, 2011). In addition, at least 148 women incarcerated in California prisons were sterilized between 2006 and 2010 without the required state approvals with some women reporting being coerced into agreeing to the procedure (Johnson, 2013).

However, pressure can come from sources other than healthcare providers, and there is a large body of literature investigating pressure and coercion perpetrated by intimate partners. Coercive behaviors committed by an intimate partner may include pressure to have sex without a condom, throwing contraceptive methods in the trash, and preventing a partner from obtaining birth control or refills (Grace & Anderson, 2018; Upadhyay et al., 2014). Almost one-third of a sample of low-income women in Pennsylvania (N = 66) reported pressure from a male partner that included verbal and emotional pressure to get pregnant as well as overt birth control sabotage (Borrero et al., 2015). In a qualitative study by Holliday et al. (2018), White women reported birth control sabotage and more physical experiences of intimate partner violence (IPV), while Black women were more likely to report condom refusal and male-dominated contraceptive decision-making.

A systematic review of the literature investigating reproductive coercion, defined in the study as behavior perpetrated by male intimate partners that interferes with the decision-making of a woman with regards to her reproductive health, found birth control sabotage was most prevalent in non-Hispanic Black women (Grace & Anderson, 2018). The review also found reproductive coercion disproportionately impacted women experiencing IPV, multiracial women, and women of lower SES; however, the majority of the extant literature was descriptive (Grace & Anderson, 2018). A recent study in Texas investigating reproductive coercion and IPV victimization in a racially diverse sample of female-identified individuals (28.9% White/non-Hispanic, 32.7% Latinx/Hispanic, 25.7% Black/African American, 4.6% Asian/Pacific-Islander, and 8.1% more than one race) aged 19–22 years found 10% of the entire sample had experienced pregnancy coercion and 3.3% has experienced birth control sabotage in their lifetime (Muñoz et al., 2023). Participants who had experienced reproductive coercion were more likely to report physical or sexual, but not psychological, IPV as compared with those who did not experience reproductive coercion. In addition, Hispanic and Latinx participants had a significantly higher prevalence of reproductive coercion when compared with White/non-Hispanic participants (Muñoz et al., 2023).

Fewer studies have explored additional interpersonal sources of pressure regarding contraception. Pressure experienced from family members was typically discussed in international settings (Grace & Fleming, 2016; Gupta et al., 2012); however, studies based on U.S. samples show women experience pressure from their families as well as from their partner’s family (Coggins & Bullock, 2003; Paterno et al., 2021). Women in a domestic violence shelter reported pressure from their family members to avoid pregnancy while also discouraging the use of birth control; the reliance on superstitious methods to avoid pregnancy was promoted instead (Coggins & Bullock, 2003).

Reproductive Autonomy in Appalachia

Reproductive health and reproductive decision-making are understudied in Appalachia, despite known health disparities experienced in the region (Driscoll & Ely, 2019; Ely et al., 2020). Appalachia spans 13 states from southern New York to northern Mississippi and includes 25 million residents (ARC, n.d.). With only a few large metropolitan areas, most of the region is rural, often under-resourced, and it encapsulates some of the most economically disadvantaged zip codes in the United States (Driscoll & Ely, 2019; Ely et al., 2020). The median household income is lower than the median income for the overall U.S. (i.e., $51,916 vs. $62,843), and there is less racial and ethnic diversity than in the overall U.S. population (i.e., 80.7% White only in Appalachia vs. 60.1% White only in the United States; Pollard & Jacobsen, 2021). Regional strengths include a rich, shared culture and propensity for self-reliance; however, health disparities (e.g., elevated rates of cancer, heart disease, chronic obstructive pulmonary disease, injury, infant mortality, strokes and diabetes) prevail in the Appalachian region (Ely et al., 2020; Marshall et al., 2017).

Regional disparities may exist that put vulnerable groups at increased risk of pressure regarding contraceptive decision-making. Appalachian counties have been shown to have significantly higher rates of IPV-related hospitalizations associated with IPV compared to non-Appalachian counties; however, it is unclear whether this is due to a higher prevalence of IPV, more severe IPV, or an overutilization of emergency services due to fewer resources in rural areas (Davidov et al., 2017). In one study specific to Appalachia, cost was shown to be a significant barrier to utilization of LARCs in an Appalachian sample with private insurance (Broecker et al., 2016). In another study of 400 Appalachian, drug-using women recruited from rural jails, almost 12% of the sample reported not using condoms because a partner did not want to, and they were less likely to report condom use if they also had a partner who got violent, angry, and suspicious (Ely et al., 2020). In Wright et al.’s study (2018) of rural university women and men (N = 468) attending a rural university located in the southeast, several predictive factors for reproductive autonomy were found. These included having a shorter distance to a healthcare provider, using birth control, engaging in less religious activity, and being non-Christian. More research is needed to understand the history and cultural influences on reproductive autonomy for those living in Appalachia.

Guiding Framework: Reproductive Justice

Reproductive justice moves beyond the limited discourse of “choice” that often surrounds the reproductive health debate by recognizing the connection of reproductive rights to other social issues (e.g., poverty, immigration, welfare reform, prisoners’ rights, environmental justice) that may negatively impact the choices available (Price, 2010; Ross & Solinger, 2017). The reproductive justice framework, originally developed by Black women to better encompass the reproductive health and parenting concerns pertinent to people of color, emerged from the international human rights and social justice movements (Price, 2010; Ross & Solinger, 2017). Reproductive justice has three core values: the right to have children, the right not to have children, and the right to parent children peacefully and safely, with the ability to freely exercise these rights without pressure (Price, 2010). Reproductive justice is a theory, praxis, and intersectional social movement useful for guiding research that is intended to bring social justice to health care (Gómez et al., 2020). As noted within the reproductive justice framework, bodily autonomy is central to the achievement of life-course goals, and the attainment of personal potential; moreover, the reproductive justice framework focuses on structural power imbalances that may limit reproductive autonomy within entire communities (ACRJ, 2005; Ross & Solinger, 2017).

Our research is framed in a reproductive justice lens as we focus on coercive interpersonal forces that may impede the reproductive autonomy through applying reproductive pressure toward those who can give birth. By investigating the Appalachian region, our findings may speak to more macro-level cultural issues in the area that limit reproductive autonomy. Within the reproductive justice framework, people have the right to have children and not to have children; therefore, our investigation included pressure to use birth control as well as pressure not to use birth control. We hope our findings will help address coercive forces that impede reproductive autonomy and increase social justice in reproductive health for those residing in the Appalachia region.

Study Purpose

There exists a dearth of information related to Appalachian reproductive health, as well as a need to better understand the cultural influences on reproductive autonomy for those living in Appalachia. Utilizing a reproductive justice framework, the purpose of this study was to examine perceptions of contraceptive pressure in a sample of women residing in the Appalachian region. The following research questions were addressed:

(1) What is the prevalence of contraceptive pressure in this Appalachian sample?

(2) Who is at increased risk of experiencing contraceptive pressure?

(3) From what sources do persons report experiencing contraceptive pressure from?

Methods

Participants and Procedure

The sample for this study was recruited through targeted Facebook advertising (e.g., ads in groups oriented toward Appalachian identity or interests, and/or targeted to those living in Appalachian zip codes). Interested participants could click on a survey link with the advertisement, which took them out of Facebook and into the secure REDCap electronic survey platform (Harris et al., 2009). Eligibility criteria included the following: self-identify as a woman or female to male transgender person between the ages of 18–50, and currently residing in an Appalachian zip code. Respondents who provided an email address upon survey completion were compensated with a $10 retail gift card. Data collection occurred in December 2019 and all procedures were approved by the Institutional Review Board of the University at Buffalo.

Measures

Demographic variables

This study examined race/ethnicity, annual household income, level of education, place of residence (rural/urban), religion, possession of health insurance, and history of IPV. Participants were asked what racial/ethnic background(s) they identified with and were able to select one or more of the following options: Black/African American, Asian/Pacific Islander, White/Caucasian, Latina/o/x, or Native American/American Indian. Due to the small percentage of participants of color (i.e., 10%), a new category was created for all respondents of color for the purposes of statistical analysis and included all participants that did not state they were White/Caucasian only. Regarding annual household income, respondents were asked for their household annual income before taxes for 2018 from all sources (e.g., disability, wages, social security). Education was coded as a categorical variable and respondents were asked for the highest level of education completed. The possession of health insurance was coded dichotomously as yes or no.

The 2013 Rural–Urban Continuum Codes set by the U.S. Department of Agriculture (USDA) classify metropolitan counties by the population size of their metro area and nonmetropolitan counties by the degree of urbanization and their adjacency to a metro area, distinguishing nine different categorizations (USDA, 2020). For regression analyses, some categories were combined and are listed in Table 2.

Regarding religion, participants were asked for the religious group they most closely identified with. Respondents selected from the following options: Protestant (e.g., Baptist, Lutheran, Methodist, Pentecostal), Catholic, Buddhist, Hindu, Jewish, Mormon, Muslim, Shinto, Native American Church, Traditional Native American, Christian (non-denominational or not specified), other, or N/A. For regression analyses, categories with 10 or fewer respondents were added to the Other category.

Regarding history of IPV, responses to the following two questions were combined to create one IPV history variable: (1) in your current relationship, have you ever been harmed or felt afraid of your partner and (2) in a previous relationship, have you ever been harmed or felt afraid of your partner. Respondents who reported yes to either of those questions were coded as having a history of IPV.

Pressure-related variables

Participants were asked about their perceptions of contraceptive pressure in three different circumstances; however, “pressure” was not defined for participants: (1) have you ever felt pressure to become sterilized (i.e., use a permanent method to prevent becoming pregnant); (2) have you ever felt pressure to use birth control; and (3) have you ever felt pressure NOT to use birth control.

Sources of pressure

Respondents that answered yes to perceived pressure to use birth control were subsequently asked if the pressure was from (1) healthcare provider (doctor, nurse, etc.), (2) partner, (3) family, or (4) religious community. Participants could respond yes, no, or don’t know to each, allowing respondents to report perceived pressure from more than one source. Respondents that answered yes to perceived pressure not to use birth control were asked the same subsequent questions. The survey did not include a question inquiring as to the source of the perceived pressure to be sterilized.

Analysis

Researchers employed Statistical Package for the Social Sciences (SPSS) version 27 (IBM Corporation, 2020) to compute univariate statistics, odds ratios, binomial logistic regressions, and Pearson’s chi-square. Chi-square tests were run on demographic variables (i.e., race/ethnicity, income, education, place of residence, health insurance, religious affiliation, IPV history) to identify significant predictor variables (Pearson’s correlations with p ≤ .05 were deemed significant). A binomial logistic regression was then conducted with the predictor variables for each dependent variable: (1) pressure to be sterilized; (2) pressure to use birth control; and (3) pressure NOT to use birth control. Missing data were treated by listwise deletion, and removed from analysis (Cheema, 2014). Per Enders (2010), missing data were also treated by multiple imputation but no statistically significant differences between the results of the two methods were found.

Results

Demographics of Overall Sample

The sample for this study (N = 632) was less racially and ethnically diverse than the Appalachian region overall (i.e., 90.0% White only vs. 81.0% White only), with a slightly younger mean age (i.e., 33.7 vs. 41.3; Pollard & Jacobsen, 2021). In terms of education, only 2.4% had not graduated high school and almost half of the sample had obtained a bachelor’s degree or higher (46.2%). One-fourth of the sample (25.0%) did not have any children currently living in their household; the number of children currently in the household ranged from 0 to 7, with the mean number of children M = 1.51 (standard deviation = 1.32). In reporting the previous year’s annual household income, the largest percentage of respondents (26.4%) reported between $30k and $49k and only 9.8% reported less than $15k. Almost 90% of respondents reported that they had health insurance and 20.4% of those had Medicaid. Regarding IPV, 12.3% of respondents reported currently being in a relationship where they had either been harmed or felt afraid of their partner, and 49.2% reported having been harmed or feeling afraid of a previous partner. In this sample, 58.0% of respondents reported currently using birth control which is slightly lower than the national average of 65.3% (Daniels & Abma, 2020). See Table 1 for full descriptive analysis.

Table 1.

Sample Characteristics.

Variable	n	M	%	SD
Race and ethnicity	632
Participants of color	63		10.0
Asian/Pacific Islander	5		.8
Black/African American	22		3.5
Latina/o/x	6		1.0
Native American/American Indian	9		1.4
Multiracial/ethnic	21		3.3
White/Caucasian	569		90.0
Age	611	33.67		6.61
Annual household income	625
0–$14,999	61		9.8
$15,000–$29,000	98		15.7
$30,000–$49,000	165		26.4
$50,000–$69,000	154		24.6
$70,000 and greater	147		23.5
Education	627
High school graduate or below	90		14.4
Associate’s degree or trade school	93		14.8
Some college	154		24.6
Bachelor’s degree	153		24.4
Graduate degree or some graduate school	137		21.8
Health insurance	631
Has health insurance	564		89.4
Medicaid	115		20.4
Medicare	54		9.6
From my job	213		37.8
From my partner’s job	120		21.3
Other	62		11.0
Current IPV	77		12.3
Previous IPV	307		49.2

IPV = intimate partner violence; M = mean; n = number in sample; SD = standard deviation.

Prevalence of Contraceptive Pressure

From the overall sample, 35.6% (n = 225) reported pressure to use birth control, 22.5% (n = 142) reported pressure not to use birth control, and 22.3% (n = 141) reported pressure to become sterilized (see Table 2). In total, approximately half of the respondents (49.5%) reported experiencing at least one of the three types of pressure regarding contraception included in this study. Of those who reported pressure, 54.3% reported experiencing one type of pressure, 35.5% reported experiencing two types of pressure, and 10.2% reported experiencing all three types of pressure.

Table 2.

Characteristics of Women Regarding Pressure.

	Perceived Pressure to Become Sterilizedn (%)	Perceived Pressure to use Birth Controln (%)	Perceived Pressure NOT to use Birth Controln (%)	Did not Perceive any Pressuren (%)
Total number of respondents	141 (22.3)	225 (35.6)	142 (22.5)	300 (47.5)
Race/ethnicity
Participants of color	23 (16.3)	30 (13.3)	18 (12.7)	21 (7.0)
White/Caucasian (not Hispanic)	118 (83.7)	195 (86.7)	124 (87.3)	279 (93.0)
Annual household income
0–$14,999	12 (8.6)	16 (7.1)	19 (13.5)	29 (9.8)
$15,000–$29,000	23 (16.4)	39 (17.4)	25 (17.7)	39 (13.2)
$30,000–$49,000	45 (32.1)	76 (33.9)	46 (32.6)	60 (20.3)
$50,000–$69,000	41 (29.3)	56 (25)	36 (25.5)	75 (25.3)
$70,000 and greater	19 (13.6)	37 (16.5)	15 (10.6)	93 (31.4)
Education
High school graduate or below	27 (19.4)	31 (13.9)	23 (16.5)	44 (14.7)
Associate’s degree or trade school	24 (17.2)	37 (16.6)	29 (20.8)	40 (13.4)
Some college	53 (38.1)	74 (33.2)	34 (24.3)	55 (18.4)
Bachelor’s degree	20 (14.4)	45 (20.2)	31 (22.1)	82 (27.4)
Graduate degree or some graduate school	15 (10.8)	36 (16.1)	23 (16.4)	78 (26.1)
Place of residence (rural/urban)
Metro of 250,000 or more	44 (32.4)	70 (31.9)	46 (32.8)	99 (33.0)
Metro of fewer than 250,000	16 (11.8)	32 (14.6)	15 (10.7)	52 (17.3)
Urban of 20,000 or more	13 (9.6)	29 (13.2)	18 (12.9)	43 (14.3)
Urban of 2,500–19,999 adjacent to metro	11 (8.1)	17 (7.8)	7 (5.0)	38 (12.7)
Urban of 2,500–19,999 not adjacent to metro	42 (30.9)	49 (22.4)	41 (29.3)	34 (11.3)
Rural or less than 2,500	10 (7.3)	22 (10)	13 (9.3)	34 (11.3)
Health insurance
Yes	120 (85.1)	195 (86.7)	127 (89.4)	274 (91.3)
Medicaid	42 (29.8)	47 (24.1)	39 (30.7)	40 (14.6)
Religion
Protestant	35 (25.5)	64 (29.2)	34 (24.5)	107 (36.5)
Catholic	25 (18.2)	31 (14.2)	29 (20.9)	21 (7.2)
Christian (non-denominational or not specified)	39 (28.5)	59 (26.9)	26 (18.7)	77 (26.3)
Other	16 (11.6)	30 (13.7)	19 (13.6)	23 (7.8)
N/A	22 (16.1)	35 (16.0)	31 (22.3)	65 (22.2)
IPV history	101 (71.6)	131 (58.5)	93 (65.5)	128 (42.7)
Undergone sterilization	21 (14.9)	15 (6.7)	14 (9.9)	28 (9.3)
Currently using birth control	86 (61.0)	121 (53.8)	93 (65.5)	174 (58.0)

IPV = intimate partner violence

Who is at Increased Risk for Experiencing Pressure

Table 2 displays the comparison of characteristics for individuals who perceived pressure to become sterilized, who perceived pressure to use birth control, who perceived pressure not to use birth control, and those who reported not experiencing any of the three forms of pressure.

Perceived pressure to become sterilized

Individuals who perceived pressure to become sterilized and those who reported no pressure to become sterilized were statistically significantly different in the following variables: race and ethnicity, place of residence, education, income, religious affiliation, and IPV history. These variables were then utilized in the binomial logistic regression and statistically significant relationships were found with IPV history, religious affiliation, place of residence, and education. Since no significant relationships were found with income or race and ethnicity, these variables were dropped from the final model.

The overall resultant model for perceived pressure to become sterilized was significant (χ² (14) = 76.830, p < .001). Respondents who had a history of IPV were 2.27 times (confidence interval [CI]: 1.44–3.59) more likely to perceive pressure to be sterilized than respondents who did not report a history of IPV. Respondents who reported their religious affiliation as Catholic were 3.17 times (CI: 1.49–6.78) more likely to perceive pressure to be sterilized than respondents who reported no religious affiliation. Compared to those residing in an urban population of 2,500 to 19,999 not adjacent to a metro area, respondents living in a metro of fewer than 250,000 (odds ratio [OR] = 0.37, CI: 0.18–0.76), respondents living in an urban area of 20,000 or more (OR = 0.30, CI: 0.14–0.66), respondents living in an urban area 2,500–19,000 adjacent to metro (OR = 0.40, CI: 0.17–0.91), and respondents living in a rural area of less than 2,500 (OR = 0.36, CI: 0.16–0.83) were less likely to perceive pressure to be sterilized. Compared to respondents with at least some graduate education, those with a high school degree or below (OR = 2.49, CI: 1.17–5.32) and those with at least some college education (OR = 3.51, CI: 1.77–6.96) were more likely to perceive pressure.

Perceived pressure to use birth control

Respondents who perceived pressure to use birth control were statistically significantly different compared with respondents who reported no perceived pressure to use birth control in terms of race and ethnicity, education, income, religious affiliation, and IPV history. These variables were utilized in a binomial logistic regression and significant relationships were found with education, income, and religious affiliation. IPV history and race/ethnicity were dropped from analysis and the resultant model for perceived pressure to use birth control was significant (χ² (12) = 42.514, p < .001).

Respondents who reported their religious affiliation as Catholic (OR = 2.63, CI: 1.35–5.15), Christian (non-denominational or not specified) (OR = 1.84, CI: 1.08–3.14), or Other (OR = 2.16, CI: 1.13–4.14) were more likely to perceive pressure than respondents who reported no religious affiliation. Respondents who reported having some college education were 2.16 times (CI: 1.26–3.70) more likely to perceive pressure than respondents who reported at least some graduate education. Respondents who reported their income in the $30k–$49k range were 2.32 times (CI: 1.37–3.92) more likely to perceive pressure than respondents who reported making over $69k.

Perceived pressure not to use birth control

Respondents who perceived pressure not to use birth control were statistically significantly different compared to respondents who reported no perceived pressure in terms of place of residence, income, religious affiliation, and IPV history. These variables were then utilized in a binomial logistic regression and significant relationships were found with three of the variables: income, religious affiliation, and IPV history. The resultant model for perceived pressure not to use birth control was significant (χ² (14) = 62.162, p < .001).

Respondents who had a history of IPV were 1.69 times (CI: 1.10–2.59) more likely to perceive pressure not to use birth control than those respondents who did not report a history of IPV. Respondents who reported their religious affiliation as Catholic were 2.69 times (CI: 1.32–5.49) more likely to perceive pressure than respondents who reported no religious affiliation. Respondents in the lowest three income brackets were all more likely to perceive pressure not to use birth control than respondents whose annual household income was over $69k, with those whose annual household income was less than $15k being 3.69 times (CI: 1.62–8.40) more likely to perceive pressure.

Sources of Perceived Contraceptive Pressure

For participants who perceived pressure to use birth control, 67.4% perceived pressure from their healthcare provider, 58.3% perceived pressure from their family, 51.6% perceived pressure from their partner, and 14.5% perceived pressure from their religious community. Of those perceiving pressure, 1.8% did not select any of the provided sources, 32.6% selected only one of the provided sources, 42.7% selected two options, 19.3% selected three options, and 3.7% selected all four of the provided options.

For participants that reported perceived pressure not to use birth control, 51.1% perceived pressure from their partner, 44.7% perceived pressure from their religious community, 37.9% perceived pressure from their family, and 27% perceived pressure from their healthcare provider. Of those reporting pressure, 4.3% did not select any of the provided sources, 53.6% selected only one of the provided sources, 28.3% selected two options, 8% selected three options, and 5.8% selected all four of the provided options.

The survey only included a question inquiring as to the source of the perceived pressure for those perceiving pressure to use birth control and those perceiving pressure not to use birth control; there was no question asking about sources of perceived pressure to be sterilized.

Discussion

Findings from this study shed light on the reproductive autonomy of women in an Appalachian sample, specifically exploring experiences of contraceptive pressure. Approximately half of all respondents (49.5%) reported at least one type of pressure targeting contraceptive decision-making. The most common pressure reported was pressure to use birth control (35.6%), followed by pressure not to use birth control (22.5%) and pressure to become sterilized (22.3%). Almost one-fourth of all respondents (23.3%) reported experiencing at least two types of pressure, and 12% experienced the conflicting pressures to use birth control and not to use birth control.

The most common source of perceived pressure to use birth control was from the healthcare provider (67.4%), followed by the respondent’s family (58.3%), partner (51.6%), and religious community (14.5%). Pressure from a healthcare provider to use contraception is in line with extant literature, where women report coercion or pressure by their healthcare provider in the contraceptive decision-making process (Potter et al., 2012; Yee & Simon, 2011). While our survey was not designed to elicit qualitative responses regarding contraceptive pressure, exploring these experiences in an Appalachian population is critically needed to enrich our understanding of this common phenomena.

The most common source of pressure not to use birth control was the respondent’s partner (51.1%), followed by the religious community (44.7%), family (37.9%), and healthcare provider (27%). Of the women reporting pressure not to use birth control, we found a higher prevalence of IPV (65.5%) compared to those who did not perceive this pressure (49.2%). These results are similar to findings from Appalachian women recruited from rural jails which indicate that lack of condom use is influenced by partner preference and partner propensity toward violent or aggressive behavior (Ely et al., 2020). A strong association between IPV and pressure is known in the larger reproductive coercion literature, as contraceptive control is a method to exert control over a partner. Abusive partners may view contraception as enabling their partner to cheat and discourage its use for this reason, not out of a desire for children (Coggins & Bullock, 2003). Over half of all respondents (52.8%) reported a history of IPV, with 12.3% reporting currently being in a relationship where they had been harmed or felt afraid of their partner and 49.2% reporting having a previous relationship where they had been harmed or felt afraid of their partner. These rates are alarmingly greater than national estimates, although definitions of IPV vary from study to study (Smith et al., 2018). Additional cause for concern exists as rural women have reported higher IPV prevalence rates and significantly greater severity and greater frequency of physical abuse than those living in urban areas, with less access to resources (Peek-Asa et al., 2011). This suggests a need for interventions targeting IPV and greater access to resources in the Appalachian region. Interventions targeted toward Appalachian women with risky partnerships may be especially warranted and have been previously recommended (Ely et al., 2020).

Our findings demonstrate that pressure from religious communities and family members was also experienced to a significant degree, and further investigation of both sources of pressure is needed. It is interesting to note that family members were reported to apply pressure to use birth control as well as not to use birth control. In addition, religious affiliation was found to be associated with pressure of all three types: to be sterilized, to use birth control, and not to use birth control. Research may need to nuance the exploration of the impact of religion on contraceptive use in terms of the influence of religious doctrine and the influence of the religious community. In our survey, we used the term “religious community” and interpreted the term at the interpersonal level; however, participants may have interpreted the term differently.

Statistically significant relationships between race/ethnicity and perceived pressure to be sterilized and perceived pressure to use birth control were initially discovered but disappeared once accounting for other variables, including income and education. This was an interesting finding but may be a result of the stronger influence of the structural factors related to race/ethnicity (i.e., income and education) as opposed to race/ethnicity itself. Results may also reflect the small percentage of participants of color in the sample, as well as the grouping of all participants of color into one category. Future research into this population may want to oversample people of color in Appalachia or conduct qualitative investigation to further explore this area.

Furthermore, applied pressure might not necessarily impact contraceptive decision-making. For example, while the percentage of women reporting female sterilization was almost twice as high among those who perceived sterilization pressure compared to those who did not, the proportion of respondents who perceived pressure not to use birth control had a higher percentage of current birth control use (65.5%) compared to those reporting no perception of pressure (58.0%). This inconsistency could be related to the source of contraceptive pressure. More work is needed to tease apart the association between experiencing contraceptive pressure and the resulting contraceptive behavior. Regardless, the high prevalence of contraceptive pressure found in our sample is concerning and speaks to a critical infringement on reproductive autonomy that warrants further attention and urgent intervention.

Implications for Practice and Policy

Study findings can help inform Appalachian healthcare and other social service providers of the potential likelihood their clients are experiencing contraceptive pressure and the potential sources. Provider education on contraceptive counseling, and reproductive autonomy more generally, is indicated to ensure the patient and their needs are centered. Routine inclusion of screening for IPV may prompt a provider to discuss contraceptive pressure, and screening for contraceptive pressure may also present an opportunity to screen for IPV. Healthcare providers should include screening for pressure or coercion, with conversations regarding prevention of coercion or assistance with hidden forms of birth control when indicated, utilizing a trauma-informed care approach (Clark et al., 2014; Fay & Yee, 2018). Women who experience pressure in their reproductive health perpetrated by male intimate partners are more likely to seek care from a healthcare professional, allowing for opportunities for intervention (Grace & Anderson, 2018; Grace et al., 2022). However, reproductive coercion measures may only detect coercion committed by intimate partners and may not capture coercion or pressure from other sources, including the healthcare provider.

Therefore, clients may also benefit from reproductive justice-informed education to support their reproductive autonomy. One theme elucidated from a sample of low-income women in Pennsylvania (N = 66) regarding pregnancy intentions was that women do not always perceive that they have reproductive control (Borrero et al., 2015). As women in rural Appalachia have reported difficulty in differentiating between loving and controlling behaviors by their partner (Riffe-Snyder et al., 2021), service providers should incorporate content on healthy relationships in interactions when appropriate (Hall-Sanchez, 2016; Shannon et al., 2016). Moreover, educational efforts should take into consideration the lack of privacy in rural areas which can translate into a lack of client confidence in maintaining confidentiality (Riffe-Snyder et al., 2021; Swan & Hobbs, 2017).

To assist with education regarding reproductive autonomy, coercion, or screening efforts, community health workers (CHWs), trained using reproductive justice principles, may be an additional option. CHWs have been leveraged in the Appalachian region as a cost-effective, culturally competent way to address health disparities and bridge the healthcare system-patient divide (Brandford et al., 2018; Feltner et al., 2012).

Additional policy changes should include addressing reproductive autonomy and IPV as human rights concerns (Riffe-Snyder et al., 2021). Increased state funding is needed for the myriad social support services that intersect in the lives of women experiencing IPV (e.g., domestic violence shelters, job support services, family support services, and crisis hotlines) (Hall-Sanchez, 2016), especially to increase service access in rural areas. Until funding is obtained, those with limited access to resources may benefit from community collaboration and coordinated responses among providers (Davidov et al., 2017). Although rural residents may be less supportive of government involvement in issues related to IPV (Edwards, 2015), public support for additional funding could be enhanced by providing additional context and framing of IPV as a societal-level rather than an individual-level issue (Seely & Riffe, 2021).

Limitations

Due to the small percentage, women of color were collapsed into one group, masking any between-group differences that may exist. In addition, the use of a cross-sectional survey design does not allow for temporal analysis or causal findings (Maxwell & Cole, 2007). The data are self-reported and retrospective in nature, leading to the potential for recall bias and social desirability bias (Zandwijk et al., 2015). The online survey was advertised to Facebook users, and though research suggests that Facebook is commonly used by Appalachian women (Dickson et al., 2017; Studts et al., 2021), it is possible this biased our sample. These results are not generalizable to the entire Appalachian region or to any groups outside of these study respondents. Despite the limitations present in this study, a strength of this sample includes having respondents representing all Appalachian subregions as defined by the Appalachian Regional Commission.

Future Research

To further expand on findings from this study, qualitative approaches may reveal additional sources of pressure or the extent to which perceived pressure influences women in their decision-making process. Future research should also make efforts recruit more racially and ethnically diverse samples within the Appalachian region to inform culturally tailored interventions. Research investigating scale validation and measurement of relevant constructs (e.g., reproductive pressure) with Appalachian samples (Swan et al., 2021) should continue and expand, allowing for the collection of valid and reliable data that can inform community-driven solutions for the Appalachian context. While the relationship between IPV and reproductive coercion is well established, pressure experienced from other sources (e.g., family, friends, in-laws, religious communities) warrants further exploration. In addition, this study investigated pressure as a binary construct and future research in this region may want to explore pressure as a spectrum of experiences (Senderowicz, 2019).

Conclusion

The results of this study help illuminate the prevalence of the contraceptive pressure Appalachian women experience, the source of the pressure, and which women are most at risk of experiencing contraceptive pressure. The high percentage of women who perceived pressure is disconcerting as this suggests an infringement on their reproductive autonomy, with important implications for their lives. It is critical that providers serving clients in the Appalachian region pursue education regarding contraceptive pressure, including their own potential role and the role of their organization in perpetuating contraceptive pressure. In addition, women in this area may benefit from education on their own reproductive autonomy, on healthy relationships, and how to navigate pressure in unhealthy relationships. We hope that findings from this study will enable Appalachian practitioners and policymakers to better support women’s reproductive autonomy, as well as contribute to the development of community-driven solutions to reduce pressure on contraceptive decision-making.

Footnotes

Acknowledgements

None.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: Funded by the Society of Family Planning

ORCID iD

Melody Huslage

Author Biographies

Melody Huslage, MSSW, is a PhD candidate at the University of Tennessee-Knoxville, College of Social Work. She is deeply committed to pursuing issues of social justice and diversity, equity, and inclusion, utilizing an intersectional framework. Ms. Huslage prioritizes community-engaged research to contribute in the empowerment of marginalized communities.

Gretchen E. Ely, PhD, is a Professor and the PhD program director at the University of Tennessee College of Social Work. Her research focuses on vulnerable populations and their access to reproductive health care.

Dr. Bill Nugent is a Professor in the College of Social work, University of Tennessee-Knoxville; is a former Associate Dean for Research; and a former Director of the Ph.D. Program. His main focus of research is measurement. He has recently published on the measurement foundations of meta-analysis and has also done research on the link between violent political rhetoric and mass shootings.

Samantha Auerbach, MSN, WHNP-BC, ANP-C is a sexual and reproductive health Nurse Practitioner and PhD candidate in Nursing at the University at Buffalo with interests in expanding equitable access to care and supporting reproductive autonomy. Her research focuses on attitudes toward pregnancy and contraception that impact contraceptive behavior and the role of the socio-structural context on these decisions.

Kafuli Agbemenu, PhD, MPH, RN, is an Assistant Professor in the School of Nursing at the State University of New York, University at Buffalo. Her research examines the reproductive health outcomes of marginalized groups of women, with a focus on contraceptive intention, uptake and barriers. She uses multifaceted cultural knowledge to develop community-appropriate interventions that lead to improved life trajectories.

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