“Did I Choose a Birth Control Method Yet?”: Health Care and Women’s Contraceptive Decision-Making

Medicalization and Unintended Pregnancy

Medicalization is a continuous and complex process whereby natural life events like pregnancy, both intended and unintended, become defined and treated as medical problems (Conrad, 2007). Nearly all aspects of reproduction, including unintended pregnancies, are medicalized (Armstrong, 2003; Waggoner, 2017). How conditions like unintended pregnancy are medically defined and who is treated are often the result of external actors and social contexts (Conrad, 2005). Increasingly, scholars recognize the complexity of the term “unintended” to describe mistimed or unwanted pregnancies, instead demonstrating that women can feel a range of emotions, including joy, dread, and ambivalence about pregnancy (Higgins et al., 2012; McQuillan et al., 2011). Furthermore, women do not necessarily apply or adopt terms such as unwanted or unplanned to describe their pregnancies (Barrett & Wellings, 2002). Rather, the concept “unintended pregnancy” emerged among concerned stakeholders as a deviant form of pregnancy in the wake of unprecedented global population growth in the 1950s alongside increasing rates of births to young, unmarried women, as well as women of color and women with immigrant backgrounds (Bongaarts et al., 1990; Campbell, 1968; Roberts, 1997). Policy makers and medical establishments have historically addressed larger social problems, like population growth and poverty, with concerted efforts to limit the reproduction of socially marginalized groups through the coerced use of contraception and sterilization (Roberts, 1997; Ross & Solinger, 2017). At present, these concerns persist and this lack of reproductive autonomy often manifests as women encounter systemic health care barriers to obtaining the contraceptive of their choice, including when women prefer not to use a method at all.

Although scholars increasingly, and importantly, question the link between unintended births and alleviating the nation’s health and social ills, expanding access to birth control remains the most popular and short-term solution advocated among policy makers and health care providers to reduce unintended birth rates (Gipson et al., 2008). Claims that unintended births pose a serious risk have garnered widespread social acceptance for birth planning, especially among White, middle-class women (Waggoner, 2017). Furthermore, birth planning using contraception is now a model framework among health care professionals and organizations for reducing reproductive risk. For instance, ACOG and the CDC now recommend intrauterine devices (IUDs) and subdermal arm implants for most women, recently including sexually active adolescents and nulliparous women in their guidelines (ACOG Committee on Gynecologic Practice, & LARC Working Group, 2009; CDC, 2006). This institutionalization of contraception as both the solution and treatment for unintended pregnancy further legitimates and necessitates contraceptive interventions, and encourages action by policy makers and health care providers (CDC, 2006; ODPHP, 2014; Waggoner, 2017). Doing so, considerably broadened contraceptive markets for pharmaceutical companies who have since capitalized on the new guidelines and motivated policy makers by generating several new birth control pill varieties, IUDs, and the subdermal arm implant in the past 10 years. Manufacturers advertise many of these methods for multiple purposes, including pregnancy prevention, treatment for reproductive health conditions, and menstruation suppression (Shoupe, 2016; Watkins, 2012).

In this way, the medicalization of unintended pregnancy has aided in expanding the role of health care in women’s reproductive lives and the reach of its actors to indirectly and directly determine appropriate reproductive activities, contraceptive use, and its availability (see, for example, Armstrong, 2003; Conrad, 2007; Roberts, 1997; Waggoner, 2017). Moreover, health care contexts continue to shift as federal and state-level policies affect women’s access to contraception, and the market-based health care system continues to transform the insurance coverage and medical landscape in which women make contraceptive decisions. As such, health care contexts remain essential to explore as they influence the conditions in which most women access contraceptives. Indeed, for many women desiring treatment for health conditions or desiring contraception to prevent pregnancy, continued advancements in contraceptive technologies can greatly improve their lives by supporting their overall health and well-being, as well as help individuals achieve their fertility goals. In this way, it is not the advancement of contraception that is inherently problematic, rather, it is the process of acquiring this contraception through the health care system that poses undue challenges to women’s access.

Medicalization and Contraceptive Decision-Making

Despite efforts that encourage women’s contraceptive use and address access barriers, unintended pregnancies persist, especially among young, low socioeconomic status (SES), and unmarried women (see, for example, Finer & Zolna, 2016). Consequently, a vast body of research seeks to understand women’s contraceptive use and decisions, especially why they choose some methods over others, inconsistently contracept, or do not contracept at all (Borrero et al., 2014; Daniels et al., 2014; Higgins et al., 2012; McQuillan et al., 2011).

However, childbearing decisions and whether to use contraception to prevent pregnancies, are contextual, complex, and diverse (Borrero et al., 2014; Higgins et al., 2012; McQuillan et al., 2011). The health care system and its many actors add to this complexity. At the most basic level, encouraging women to use contraception and then requiring that they access most forms from health care providers creates inherent barriers. For instance, women are exposed to external forces within health care, such as insurance and pharmaceutical company policies and profit goals, as well as political and public health initiatives whose incentives may not align with women’s desires or effectively address women’s access issues (Conrad, 2005; Gubrium et al., 2016; Higgins, 2014). Scholars have identified many prominent barriers, such as systemic access issues, provider knowledge or bias, and interpersonal interactions between patients and providers (Dehlendorf et al., 2013; Dehlendorf, Levy, et al., 2010; Gomez et al., 2018; Gomez & Wapman, 2017; Kimport, 2018b; Kimport et al., 2017; Littlejohn & Kimport, 2017; Mann et al., 2019). Understanding how these barriers then implicitly and explicitly affect women’s experiences obtaining contraception, as we do in this article, further elucidates the complex conditions in which women make their contraceptive decisions and the challenges they face in achieving reproductive autonomy.

Indeed, despite the 2010 Patient Protection and Affordable Care Act (ACA), women continue to encounter structural barriers that affect their access to, and decisions about, contraception, such as limited appointment times; long waitlists for available providers, especially providers accepting public insurance; geographic access issues; and other tertiary concerns arising out of the obligation to seek medical care, such as coordinating child care, child care costs, and transportation (ACOG Committee on Health Care for Underserved Women, 2015; Goodman et al., 2008; Politi, Estlund, et al., 2016; Politi, Sonfield, & Madden, 2016; Secura et al., 2010; Weisman et al., 2002). These structural barriers are particularly difficult for lower resourced women to navigate but can create unnecessary gaps in all women’s contraceptive coverage (ACOG Committee on Health Care for Underserved Women, 2015).

Health communication also influences women’s contraceptive use. Patient–provider interactions are linked to health outcomes, potentially creating barriers to care, in general, and women’s desired contraceptives, in particular (Dehlendorf et al., 2013). Women’s initiation of contraception and improvement in overall method knowledge are significantly associated with extensive provider counseling (Harper et al., 2010). However, some health care providers lack accurate knowledge about contraception or hold biases about certain methods that can affect the quality of contraceptive counseling and deny women access to a full range of birth control (Dehlendorf, Levy, et al., 2010; Kimport, 2018b; Kimport et al., 2017). These communication barriers are often a result of provider assumptions about patients and subjective criteria used to guide contraceptive counseling (Kimport et al., 2017; Littlejohn & Kimport, 2017). Clinics may further deter contraceptive use by delaying its initiation for menses, required laboratory tests, or obligating women attend multiple appointments before prescribing contraception (Bergin et al., 2012; Leeman, 2007). Beyond identifying provider counseling and clinic policies as barriers, however, understanding how they then shape women’s decision-making experiences is essential to constructing solutions to such barriers.

Given the significance of health communication on women’s experiences and outcomes, great efforts have been made to improve the patient–provider interaction. Patient-centered care is a popular recommendation where patients ultimately guide conversation and health care decisions (Dehlendorf et al., 2013; Stewart et al., 2000). Such efforts can be successful when recognizing that women’s preferences for interaction and communication styles vary widely, often dependent on their age, past experiences, race/ethnicity, and language. Dehlendorf and colleagues (2013) found that, in addition to patient-led approaches, direct communication about needs and goals in care may improve interactions as does empathetic care and motivational interviewing techniques. They recommend patient-specific, nondirective counseling strategies that encourage open communication and offer a full range of contraceptive options and information. However, given constraints found within the health care system, such as short appointment times, inconsistent provider training around contraception, provider biases, and other structural barriers, such as insurance coverage, serve to undermine the patient–provider relationship.

Moreover, public health initiatives and professional guidance around pregnancy risk influence providers’ contraceptive counseling strategies in ways that may encourage greater use of IUDs and the implant, often at the expense of honoring women’s contraceptive preferences and needs (Gomez et al., 2014). Consequently, rather than utilize nondirective counseling practices, providers may use targeted counseling, especially for women whom researchers identify as experiencing greater rates of unintended pregnancy, such as low-income women, young women, unmarried women, and women of color. Providers are more likely, for instance, to encourage women of color to use IUDs, the implant, or sterilization, relative to White women (Borrero et al., 2009; Dehlendorf, Ruskin, et al., 2010; Gomez et al., 2018; Mann & Grzanka, 2018). Moreover, Black and Latina patients have identified an implicit pressure to accept contraceptive methods favored by their providers (Gomez & Wapman, 2017). In yet other cases, providers may downplay side effects or discourage women’s contraceptive desistance, citing pregnancy risk as their justification (Amico et al., 2017; Littlejohn, 2013). Women who feel pressured or who feel their desires are not honored are more likely to discontinue their contraceptive method and, in some cases, limit their future encounters with health care personnel (Gomez & Wapman, 2017; Littlejohn, 2013). Ironically, desisting from contraceptive use increases the likelihood of an unintended pregnancy and merely reinforces providers’ assumptions that some women are at greater risk for unplanned births. This implicates women’s individual decision-making rather than fully understanding the role providers and health care structures play in shaping such decisions.

Exploring women’s efforts to access contraception both identifies their barriers to contraceptive use and elucidates health care contexts as a critical factor in women’s decision-making and experiences. Existing research has insightfully begun to demonstrate and expose barriers to women’s contraceptive access within health care contexts, particularly focusing on provider–patient interactions and systemic access issues such as cost. In addition, other scholars have importantly raised concerns about reproductive and bodily autonomy associated with such barriers (Gomez et al., 2018). However, more empirical work is needed to explore women’s experiences accessing contraception within these health care settings, as doing so offers more context to known barriers and demonstrates their role in women’s decision-making. These insights inform opportunities to ensure women’s reproductive autonomy as they make decisions, support contraceptive equity, and, crucially, improve contraceptive interventions and related policies.

Insurance

Women’s insurance greatly affects their experiences acquiring contraception because for each participant it predetermines under what conditions which methods are available. One woman reflects on why she was recently unable to obtain her desired name-brand birth control pill saying,

I wanted a low hormone [method] and everything like that and [my doctor] suggested whatever Medicaid could cover. And see that’s another thing. Not only do I have to go within whatever my Medicaid would cover for doctors, but I had to go with whatever Medicaid can cover for contraception . . . So I guess he initiated what my other options were because the kind that I wanted wasn’t Medicaid approved.

Here, we see that while women can be active consumers of contraception, they do so within a much larger system driven by forces that often do not center their needs (Conrad, 2007). Indeed, one third of pill users in this study referred to insurance as having limited their contraceptive options. In several cases, providers for commercially insured women willingly prescribed the desired brand pill only to have the pharmacist inform the women that these methods were not actually covered by insurance.

It is common practice for both commercial and public insurance to restrict which providers and contraceptive coverage women receive (Snyder et al., 2018). Such insurance-related barriers are further compounded for women on Medicaid due to the strict income-based eligibility guidelines and complex bureaucratic requirements to maintain coverage. The above participant continues saying,

[M]y medical care has been so scattered between moving and I made too much money . . . so my Medicaid gets cancelled . . . And one other time where it had just lapsed so it’s been an issue.

Notably, these coverage gaps affected almost all Medicaid-covered participants at various points. For many low SES women who qualify for Medicaid, the process of obtaining and maintaining coverage can result in delays to care as well as limit access to their desired contraception (Leyser-Whalen & Berenson, 2013; Ostrach & Cheyney, 2014). In other words, continuous and satisfactory contraceptive access is not guaranteed despite the U.S. Medicaid insurance program.

Women may also lose the ability to choose their method when insurance providers change which contraceptives they cover or when women change insurers whose coverage varies from their previous carrier. These issues are particularly typical with pill formulations—the most common method used in the United States (Daniels et al., 2014). A participant explains,

[My insurance] actually used to cover [my pill] completely and I just changed my insurance and it actually doesn’t and they offered like a different kind of contraceptive, but I opted to just kind of pay the difference and stay on the same one because I knew that it worked for me and my body . . . It was still just birth control, but it was like two different brands or kinds with like different things in them, so the one that I’m on I have been on for like a long time and it worked well for me. And the one they suggested was like a different . . . so I didn’t want to switch it up because my body was like used to the one that I was on . . . But it was like pretty much the cheapest birth control you could like get was the only one that they would cover . . . So yeah, I don’t know all the rules and details. But it just kind of sucks.

This participant is disappointed that her previous pill variety is no longer available and raises important concerns about side effects from different formulations—so much so that she decides to pay out of pocket to keep her current method. In this way, insurance coverage not only affects whether a woman has access to birth control, but also which variety. These access issues can affect the quality of life for women worried about side effects, health risks, and the medical benefits associated with contraception—concerns most birth control pill users hold, including those in our study (Geampana, 2019; Littlejohn, 2013). Importantly, this participant expresses a lack of knowledge about how insurance works, which can shape how patients respond to such barriers and understand their options. In fact, few women in our study understood how and why their insurance covered some methods and not others, and were unaware of how to go about navigating these issues. Moreover, women who experience side effects or fear them are more likely to desist from their method (Littlejohn, 2013). As such, formulary changes may especially impact lower resourced women who cannot pay out of pocket for a contraceptive they feel safe and comfortable using or for women who are simply unaware of that option (Bessett et al., 2015).

Indeed, the above participant overcomes her insurance coverage change because she can afford to pay for her method outside of insurance, an option lower SES women like the participant below do not always have (see, for example, Bessett et al., 2015). This woman works for an employer with a religious exemption that permits the company to exclude contraceptive coverage as a part of their employer-based insurance plan. As a result, she desists from one method while waiting to acquire a less expensive one. She explains,

And the reason why I stopped using [the Nuvaring] ⁶ was because [my employer] doesn’t cover birth control . . . they was like, “Yeah, your insurance doesn’t cover it.” [My coworker] told me the birth control pills are a lot cheaper, so she pays for the birth control pills [out of pocket] and that’s why I went back to birth control pills.

This woman went without contraception until she could get an appointment with her health care provider and change to the pill—a less costly, but less desirable method. While the religious exemption only affected one participant, more employers can now qualify for it after a recent Supreme Court ruling that significantly expanded the type of corporations that can claim such an exemption (see, for example, Higgins & Mangan, 2020). While this is an insurance-initiated barrier, it is exacerbated by this participant’s inability to then pay out of pocket for her desired method, which forces her to choose the pill over the Nuvaring. Moreover, because the birth control pill requires a provider’s prescription, she must wait for an appointment because, unlike in other countries, U.S. patients cannot purchase the pill over the counter. This requirement created delays for this participant and is an access issue for all U.S. women regardless of their insurance type and despite the contraceptive coverage mandate of the ACA (Potter et al., 2010; Trussell et al., 1993).

Bureaucratic timelines built into insurance policies may also shape women’s contraceptive experiences and decisions. Sterilization procedures are relatively common in the United States among women no longer desiring children (Daniels et al., 2014). However, Medicaid stipulates that women must be at least 21 years-old prior to obtaining a tubal ligation or Essure, a requirement that burdens younger, particularly low SES mothers desiring the procedure (Leyser-Whalen & Berenson, 2013). In addition, although private and commercial insurers also cover sterilization fees, Medicaid requires that patients consent to the procedure 30 days prior to giving birth, while no such time restrictions are present within private insurance policies. This differentiation creates a two-tiered system that does not allow for equitable access to sterilization (King & Meyer, 1997; Leyser-Whalen & Berenson, 2013). Here, one participant describes how the rigidity of this policy could not accommodate the premature birth of her son and disqualifies her for sterilization coverage through her public insurer:

I wanted [sterilization] when I had my last son. I have Medicaid and they would have covered it . . . but . . . it was not 30 days, so they told me that if they did [the procedure] right after I gave birth . . . I would have to pay. Medicaid would not cover it. So of course I wasn’t going to get it done then. And they said, “Well, we could make the appointment for another few weeks after you recuperate” . . . I had C-sections. But still, I was just scared . . . I wanted them to do it when I had the baby and while they were already down there, had me open. And he just came a little bit earlier than he was supposed to, so it didn’t work out.

The insurance restrictions serve as a barrier to this woman receiving her contraceptive method of choice. Unable to complete the procedure immediately following childbirth, she elects not to return for a subsequent procedural appointment out of fear, thereby not only forgoing sterilization, but also forgoing an alternative contraceptive. Denying these procedures can have grave consequences for women’s reproductive lives as women who are denied sterilization are more likely to become unintentionally pregnant within the year following that denial (Thurman & Janecek, 2010).

Recent ACA cost-sharing measures can reduce out-of-pocket expenses for women (Snyder et al., 2018); however, while insurance is understood to be a barrier for some women, our findings reveal the breadth and significance of this barrier across and among women, in general. Moreover, understanding how these barriers shape women’s contraceptive decision-making also reveals the complexity of women’s contraceptive needs and the role that actors within the health care system play in shaping women’s contraceptive outcomes. Given the seriousness of side effects or the permanency of some methods, switching methods or delaying access unnecessarily increases barriers and disincentives for women pursuing health goals around fertility management and fundamentally influences the decisions they are able to make about contraception.

Patient–Provider Health Communication

While nearly all participants experience insurance or other similarly cost-related issues while accessing contraception, most participants also cite provider–patient communication as integral to their experiences and contraceptive decisions. Indeed, researchers link this dialogue to patient health outcomes, noting that poor communication can lead to numerous barriers to care, in general, and women’s desired contraceptives, in particular (Dehlendorf et al., 2013).

Importantly, we identify several external factors, such as provider training, public health initiatives, and clinic policies, which informed the substance and style of provider communication with women and their subsequent patient experience. For instance, well-meaning clinic protocols can impact the substance and quality of individual provider–patient interactions in profound ways. Notably, more than 30 states now train their health care providers to ask the “one key question” in every appointment for women aged 18 to 50 years to reduce unintended pregnancy risk using contraception—“Would you like to become pregnant in the next year?” (Power to Decide, 2019). The training urges providers to counsel women not desiring pregnancy about contraception even if the appointment is not related to reproductive health. A woman recounts her experience with this new approach at a recent appointment saying,

Every time I would go in there and they would try to get me . . . to choose . . . which one to pick . . . and I would just tell them, “No, I want to just wait” . . . I was uncomfortable because I’m like, “Why are you trying to force me to do something that—I didn’t even come here to complain about” . . . “You’re just throwing these out here” . . . And I appreciate it because it’s knowledge, but I didn’t come here for that. I came here for like a hurt hand and you’re asking me, “Did [I] choose a birth control method yet?”

During her visit, the physician inquired about the participant’s interest in contraception due to standard clinic policy but doing so signals that this patient’s preferred method, condoms, is not a qualified choice. The participant describes how this assumption affects her experience at multiple appointments where the focus is on contraception rather than her presenting health needs. Consistent with other research, as an African American woman, she and several other participants who described similar experiences may have felt especially pressured by providers to choose from the most effective methods available because of unfounded stereotypes around hypersexuality and hyperfertility (Dehlendorf, Ruskin, et al., 2010; Gomez & Wapman, 2017). This case demonstrates that patient–provider interactions not only affect women’s experiences obtaining contraception, but also their health care quality more broadly. In addition, women who sought care from clinics specializing in family planning or who received Title X funding, which disproportionately serve low SES women and racial minorities, appeared more likely to receive this intentional style of contraceptive counseling at each visit relative to women who sought care at general family practice clinics or private clinics.

Clinic protocols around scheduling also affect the quality and substance of patient–provider interactions. Most participants reflected this problem, describing how they felt that their providers were too overburdened or rushed to offer adequate counsel about contraceptive methods because appointment times were simply too short or other patients were waiting. Some women recalled having fewer than 10 minutes with their provider each year, expressing how this limited their ability to enact contraceptive decisions. For instance, one participant sought to change from an estrogen combination pill to a longer acting, progesterone-only method because her mother and aunt were recently diagnosed with breast cancer. She shares,

It felt like I was on a factory assembly line where I had like five minutes with [my doctor] . . . like I had asked her in the past about my concerns about having been on the pill for so long and her response was essentially, “Ah, if it’s not broke, don’t fix it.” And she didn’t even like entertain a conversation . . . And five minutes later I was dressed and out of the office.

This narrative speaks to ways punctuated appointment times and overburdened providers undermine women’s contraceptive decisions by failing to host conversations about methods. The participant stayed on the pill, having left the appointment with neither a new method nor an answer to her legitimate health questions. Following the appointment, she elected to change doctors, citing concerns not just about remaining on the pill, but also about how that method had been found to pose health risks, such as strokes, for older women like herself. Notably, she enjoys the privilege of a high-quality, commercial insurance that allows the flexibility to change providers, where women with more restrictive or publicly funded policies cannot as readily navigate contraceptive barriers using these strategies.

While policies can be influential, providers’ medical training forms the basis of their clinical knowledge and often determines their contraceptive counseling approaches. For many of the participants, providers asserted this knowledge in ways that undermined the women’s own knowledge, appointment experience, and subsequent decision-making. More than a dozen participants recalled instances where they felt their providers did not trust their contraceptive decisions (Kimport, 2018b; Stevens, 2018). One woman reflects on an appointment where she sought an IUD, saying,

I wanted something non-hormonal and it was long-term. It was the copper IUD . . . I had to fight for that because I didn’t have children and providers did not want to give you an IUD without having kids . . . I knew that’s what I wanted and there were a couple of doctors that wouldn’t give it to me . . . I was serious that I didn’t want to be pregnant and I wanted the IUD . . . I told them . . .“Well, there’s no chance that I want kids. So it’s okay. I’m willing to take that risk.” And they still said, “No, we’d rather you use something else because you don’t have kids.”

Such experiences imply that providers, rather than women, can veto and ultimately make contraceptive decisions. As we see in the above case, this holds true even in circumstances where women are knowledgeable about contraceptive methods, challenging providers who may operate on outdated medical paradigms.

Despite rigorous medical training, providers, themselves, often lack sufficient knowledge about contraception to adequately counsel their patients; yet, because of their authority to prescribe within this medicalized context, women’s choice can be easily undermined. This participant seeks out her provider to initiate contraception, however, she feels her provider’s explanations about various methods are inadequate. Consequently, she feels unable to choose a method at her appointment and, instead, undertakes contraceptive research on the internet to supplement her provider’s counseling prior to deciding. She explains,

I can spend two hours scouring the Internet and trying to get the information. You shouldn’t have to do that . . . [b]ecause even some of that stuff I would ask my doctor and . . . they couldn’t tell me the ins and outs . . .

Gaps in contraceptive knowledge are particularly likely among providers who do not specialize in women’s health but who offer contraceptives to women as a part of their overall patient care—an issue seen by most participants seeking contraceptive care from providers not specializing in women’s health (Akers et al., 2010; Duke & Ames, 2008). As the two cases above demonstrate, provider knowledge gaps affect women’s decision-making and obligate additional labor and resources to navigate them.

Such power asymmetries between patients and providers are inherent within health care and can have particularly significant consequences for young and marginalized women’s ability to steer contraceptive appointments and decisions (Hoffman et al., 2016). A woman in her late 20s recalls,

And like one of the nurses came in and she was talking to [the doctor] and . . . she was asking me a question. And I’m like, “I can’t think because I’m naked and you’ve got the door open” . . . They had wrote me a prescription for something after I told her I didn’t want it and she still wrote me the prescription. And they were like asking me what pharmacy I wanted it to go to and I was like, “I just told you I didn’t want it.” [B]ut she still wrote the prescription . . . sometimes people think I’m younger than what I am. So she probably thought I was like even younger. So maybe she felt like she knew better than I knew.

This participant, as with a handful of younger African American and Latina participants, feels her provider is skeptical of her claim as a young (Black) woman to remain abstinent until marriage and prescribes her a birth control pill anyway—a prescription she elected not to fill. By prescribing contraception, despite the patient’s desire not to use any and instead remain abstinent, her provider effectively alienates her from her own contraceptive decision-making process where medical knowledge and treatment are valued over women’s desires. The provider’s efforts to prescribe contraception also reflect an assumption that abstinence is not a valid method. Moreover, by not filling the prescription, her provider may come to view her as a noncompliant patient, an issue that is more common among racial minority and low SES patients. Such actions also hinder the potential for a positive patient–provider relationship in the future (Gomez & Wapman, 2017; Zola, 1981). Indeed, although several typically younger White patients felt that their providers did not agree with their contraceptive choices, most White participants described trusting their providers and did not feel unduly pressured to use contraception. Certainly, White patients, in general, enjoy more positive relationships with their race-concordant providers, a likely consequence of White privilege manifesting within health care settings (Cooper-Patrick et al., 1999).

For another young participant, age may have also affected her ability to choose her desired contraceptive—a phenomenon retrospectively described by many women trying to obtain contraception from providers at a younger age. Here, this participant is a young, White woman and describes a recent appointment where her mother and provider ultimately choose a method for her, neglecting the patient’s own desire for an IUD and putting her at greater risk for an unwanted pregnancy. The participant explains,

My mother wanted me to start with the pill and my gynecologist wanted me to start with it just so I could see like—it’s just like a pill I would have to take instead of injecting something into me or putting an implant into me. They just kind of wanted to see if I could take it [for five months] . . . part of me felt like it was kind of a waste of time like a waste of like five months because I knew how I would take pills and I knew even if I had a reminder on my phone, I probably wouldn’t get up and take it. It’s just like I guess an inconvenience for me?

She leaves the appointment fearing pregnancy because she knows she already forgets to take another daily medication and is regularly having sex. When asked why she is willing to continue care with this provider even if she felt dissatisfied with the outcome, the participant explains that it was her mother’s longtime doctor, and she trusts him without question because her mother does. This loyalty speaks to the power of providers, their presumed knowledge, and the ways trust in health care, or lack thereof, can be transmitted intergenerationally, affecting women’s contraceptive experiences over the life course (Washington, 2006). It may also speak to the power of White privilege in terms of some women’s willingness to trust providers without having to question the role of race when their preferences are not enacted (Cooper-Patrick et al., 1999; Washington, 2006)

In sum, providers are still gatekeepers to contraception, even when efforts to alleviate systemic barriers and insurance coverage are made. These constraints may be felt more significantly by racial/ethnic minorities and low SES or younger women who may be more likely to encounter these issues and simultaneously lack the resources necessary to overcome them.