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OriginalresearcharticleAnexplorationofperceivedcontraceptivecoercionatthetimeofabortionKristynBrandi,1,ElisabethWoodhams,KatharineO.
White,PoojaK.
Mehta2DepartmentofObstetricsandGynecology,BostonMedicalCenter/BostonUniversitySchoolofMedicine,850HarrisonAvenueYACC-5,Boston,MA,USA02118Received28June2017;revised5December2017;accepted8December2017AbstractObjective:Toexplorepatientexperiencesofcontraceptivecoercionbyhealthcareprovidersattimeofabortion.
StudyDesign:WeconductedaqualitativestudyofEnglish-speakingwomenseekingabortionservicesatahospital-basedclinic.
WeusedtheIntegratedBehavioralModelandtheReproductiveAutonomyScaletoinformoursemi-structuredinterviewguide;theScaleprovidesaframeworkofreproductivecoercionasalackofautonomyorpowertodecideaboutandcontroldecisionsrelatingtoreproduction.
Weenrolledparticipantsuntilthematicsaturationwasachieved.
TwocodersusedmodifiedgroundedtheorytoanalyzetranscribedinterviewswithNvivo11.
0(Κ=0.
81).
Results:The31womenweinterviewedfromJune2016toMarch2017wereallinthefirsttrimester,andpredominantlyyoung(meanage27±5years),non-HispanicBlack(52%)andMedicaid-insured(68%).
Someparticipants(42%)reportedfeeling"pressured"intochoosingsomeformofcontraception.
Asubsetofparticipants(26%)voicedthatprovidersseemedtopreferLARCmethodsorwere"pushing"aspecificmethod.
Severalparticipantsperceivedpressuretochooseanymethodduetoproviders'preferencetopreventrepeatabortions.
Conversely,participantswhowereofferedarangeofmethodsthroughtheuseofdecisionaidsandwhoweregiventimetodeliberatedemonstratedmorereproductiveautonomy.
Conclusions:Almosthalfofparticipantsperceivedaformofcoercionaroundtheircontraceptivecounseling.
Coercionmanifestedinperceivedproviderpreferenceforspecificmethodsorimmediateinitiationofamethod.
Participantnarrativesinvolvingdecisionaidstoofferarangeofmethodsandtimefordeliberationdemonstratedgreaterreproductiveautonomyandlesscoercion.
Abortionstigmamaymediatepotentiallycoerciveinteractionsbetweenpatientsandproviders.
Implications:Thisqualitativestudyexploredcontraceptivecoercionatthetimeofabortion.
Findingshighlightedproviderpressuretoinitiatecontraception,LARCpreference,andabortionstigma.
Offeringmanymethodsandopportunityfordeliberationsupportedautonomyandsatisfaction.
Findingsinformongoingeffortstoimprovecontraceptivecounselingandpromotereproductiveautonomy,whileaddressingunintendedpregnancies.
PublishedbyElsevierInc.
Keywords:Coercion;Contraception;Abortion;Qualitative;Counseling;Shared-decisionmaking1.
IntroductionReproductiveautonomyisdefinedasone'sabilitytomakestrategicdecisionsaboutwhetherornottobecomepregnant[1].
Currentliteratureonreproductiveautonomyprovidesaframeworkforunderstandingcontributingfactorssuchasself-efficacy,decision-makingpower,communication,andanindividual'smanagementofcoercion[1].
Contraceptivecoercionisoneformofreproductivecoercion,andreferstoanybehaviorthatinterfereswithcontraceptionuseinanattempttoeitherpromoteordiscouragepregnancy[1,2].
Contraceptivecoercionisassociatedwithunintendedpreg-nancy,sexuallytransmittedinfectionsandintimatepartnerviolence[2,3].
Unintendedpregnanciesresultingfromcontra-ceptivecoercionareassociatedwithdepressionandlowbirthweight[4].
Professionalguidanceforreproductivehealthprovidersiteratestheimportanceofidentifyingmethodsconcordantwithpatientpreferences[5–7]whilealsoemphasizinghighefficacyofspecificLARCmethods[6–8].
Novelframeworksforcontraceptivecounselingemphasizepatient-centeredcare,shareddecisionmaking,andinformedconsenttoimprovewomen'sautonomyandminimizecoercionwhilestilladdressingunintendedpregnancy[9].
Contraceptionxx(2017)xxx–xxxCorrespondingauthor.
Tel.
:+16092043299.
E-mailaddresses:Kristyn.
Brandi@gmail.
com(K.
Brandi),Elisabeth.
Woodhams@bmc.
org(E.
Woodhams),Katharine.
White@bmc.
org(K.
O.
White),pmehta@lsuhsc.
edu(P.
K.
Mehta).
1Currentaffiliation:DepartmentofObstetricsandGynecology,Harbor-UCLAMedicalCenter,Torrance,CA,USA90509.
2Currentaffiliation:DepartmentofObstetricsandGynecology,SchoolofMedicine;PrograminHealthPolicyandSystemsManagement,SchoolofPublicHealth;LouisianaStateUniversityHealthSciencesCenter,NewOrleans,LA70112.
https://doi.
org/10.
1016/j.
contraception.
2017.
12.
0090010-7824/PublishedbyElsevierInc.
Insurveysofwomenseekingabortionservices,onlyhalfdesiretoreceivecontraceptiveservicesatthattimeandsomewomenreportpressurefromproviderstochooseabirthcontrolmethodduringtheirabortion[10,11].
Limitedresearchexistsregardinghowprovidersmaycontributetocontraceptivecoercioninhealthcareinteractions.
Weconductedaqualitativestudytoexplorewomen'sperceptionsofcontra-ceptivecoercionbyprovidersatthetimeofabortion.
2.
Materialandmethods2.
1.
ResearchdesignandrecruitmentWeapproachedallwomenundergoingabortionatanacademicmedicalcenterfromJune2016–March2017.
Eligiblewomenwereage18yearsandolder,spokeEnglish,andwereundergoingmedicalorsurgicalabortion.
Weexcludedwomenwithearlypregnancyfailureorfetaldemiseandthosereceivingcarefromtheprimaryinvestigator(KB).
Inoursetting,abortioniscoveredbyMedicaidandthegestationalagelimitforabortionis23weeksand6daysofgestation.
Patientsaretypicallyseenfortwovisits:preoper-ativeandoperativeforsurgicalabortion,andmedicationinitiationandfollowupformedicalabortion,andmayinteractwithobstetricians/gynecologists,familymedicineproviders,nursepractitioners,nurses,studentsandresidentsduringthesevisits.
Theseprovidersinitiatepostabortioncontraceptioncounselingduringthepre-abortionvisit,andcontinuecounselingorconfirmchoicesasneededonthedayoftheprocedureoratthetimeoffollowupaftermedicationabortionfollow.
Whilethereisnostandardized,universalcounselingtoolusedinoursetting,mostprovidersuseatieredeffectivenessframeworkforcontraceptivecounseling[12].
AtrainedresearchassistantapproachedeligiblewomentodiscussthestudyafterthewomenhadsignedclinicalconsentsforsurgicalabortionorafterMifepristoneadministrationformedicationabortionpatients.
Theresearchstaffscheduledinterestedpatientsforastudyvisitforconsentandtheinterviewonaseparatedateaftercompletingabortioncare.
Participantsprovidedinformedconsentverballyusingastandardizedscriptpriortotheone-hourstudyinterview.
Allparticipantsreceivedcompensationfortimeandtravel.
ThisBostonMedicalCenterInstitutionalReviewBoardapprovedthestudy.
2.
2.
StructuredinterviewguideanddatacollectionWeconductedsemi-structuredinterviewswithparticipantsinaprivate,non-clinicalsetting.
WeusedtheIntegratedBehavioralModelandtheReproductiveAutonomyScaletodevelopourinterviewguide[1,13].
TheReproductiveAutonomyScaleisavalidatedscaleusedpreviouslytomeasurefactorsandcorrelationwithreproductiveautonomy[1].
TheIntegratedBehavioralModelseekstodescribeelementstowhyapersonchoosestoperformagivenbehavior[13].
Wepilotedtheinterviewguidewithfourparticipantsandadjustedtheguideusinganiterativeprocessthroughoutdatacollection.
Weanticipatedthatwewouldneedapproximate-ly30–50interviewstoachievethematicsaturation.
Weusedpurposivesamplingtosampleasdiverseaparticipantsampleasfeasibleandbasedonongoingcodingduringstudyenrollment,achievedthematicsaturationafter31interviewswereconductedandanalyzed[14].
Allinterviewswereconductedbyonefemaleclinicalresearcher(KB)trainedinqualitativeresearchmethodology,digitallyrecorded,andtranscribedbyaprofessionaltranscrip-tionserviceunawareofresearchgoals.
Wecollectedfieldnotesduringtheinterviewprocess.
Participantswerenotcontactedaftertheresearchinterviewtoprotectprivacy.
Weimportedde-identifiedtranscriptsintoqualitativedataanalysissoftwareforanalysis(QSRInternational'sNVivo11.
0)[15].
WerecordeddemographicinformationintotheResearchElectronicDataCapture(REDcap)system[16].
2.
3.
DataanalysisWeperformedqualitativeanalysisoftranscriptsusingmodifiedgroundedtheory.
Aninitialcodedictionarywasdeveloped,informedourtheoreticalmodels.
Tworesearchers(KB,PM)codedhalfoftheinterviewsanddiscrepanciesincodingwerearbitratedwithahighlevelofinter-readerreliability(Κ=0.
81).
Theremaininginterviewswerecodedbyasingleresearcher(KB).
Weidentifiedrecurrentthemesandrepresentativeparticipantquotationsforeachtheme.
Giventhatthepurposeofqualitativeinquiryistogeneratehypothesesratherthanmakeclaimsabouttheprevalenceofspecificfindings,attentionwaspaidtotheidentificationofdistinctthemesratherthanthenumericprevalenceofthesethemes.
3.
ResultsWescreened664patientsduringthestudyperiod:348wereineligible,mostlyforlackofEnglishfluency(n=220).
Oftheremaining316eligiblewomen,109declinedparticipationand176didnotreturnforthescheduledstudyinterview.
Atotalof31womenwereenrolledandcompletedinterviews.
Partici-pantsgenerallycompletedtheirscheduledinterviewabout2weeksaftertheirmedicalorsurgicalabortion,rangingfromadaypriortotwomonthsafter.
Gestationalageatthetimeofabortionrangedfrom5weeks1dayto12weeks3days.
ParticipantbaselinecharacteristicsaresummarizedinTable1.
Anexperienceofcoercionwascodedassuchiftheparticipantexpressednegativeinteractionswiththeirpro-videraroundtheircontraceptivechoice,ifthelanguageusedaroundtheexperiencewiththeproviderwasasynonymfortheword"coercion"(ex:pressured,forced,encouraged),oriftheparticipantexperiencedconflictwiththeprovideraroundtheircontraceptivegoals.
Mostparticipants(n=18,58%)didnotspecificallyendorseexperienceofpressureorcoercion.
ThemesmostrelevanttoexperiencesofcoercionandautonomyarepresentedbelowandsummarizedwithrepresentativequotesinTable2.
2K.
Brandietal.
/Contraceptionxx(2017)xxx–xxx