ENSURING EQUITABLE, ACCESSIBLE, AND HIGH QUALITY CONTRACEPTION

In the U.S. and other parts of the world, contraceptive access is under attack and at critical risk for being dismantled (Guttmacher 2024). Universal contraceptive access is essential to ensuring that everyone who wants contraception can obtain the information, methods, and services that best meet their needs – free of barriers, bias, or coercion. Equitable contraceptive access also means that people who do not want contraception, want to switch methods, or who want to discontinue contraception, should be free to make and realize that decision for any reason, without pressure, judgment, or coercion (CECA 2024).

Contraception has many important benefits. It improves health and well-being, provides health benefits of pregnancy spacing to both people capable of pregnancy and children, and reduces global pregnancy-related mortality. It also has noncontraceptive benefits, allowing some (depending on many sociopolitical factors) to pursue educational and economic opportunity and self-sufficiency (ACOG 2015, WHO 2025), as well as reductions in various health conditions and cancers (Gierisch 2013). The gap between desire for and access to contraception varies, but exists in all countries (Guttmacher 2016). By recent estimates, 257 million people with pregnancy potential have an unmet need for contraception (WHO 2023), with reasons including but not limited to:

• limited access to contraception, or cuts to universal coverage
• limited choice of methods, or poor quality of available services
• fear or experience of side-effects
• cultural or religious opposition
• weight-based or gender-based barriers

Addressing Reproductive Coercion, Violence, and Stratified Reproduction

Our ability to provide high-quality, equitable reproductive healthcare must acknowledge – and work to better understand – our medical community’s history. Reproductive Justice (RJ) includes the human right to maintain personal bodily autonomy, have children, not have children, and parent children in safe and sustainable communities. RJ principles recognize the limited choices marginalized communities face with respect to reproductive autonomy, health services, and socioeconomic opportunity, as intersecting systems of oppression impact access to care (SisterSong).

Globally, marginalized communities have been aggressively targeted by health systems and providers for differential and disproportionate contraceptive use (See Ch 1: Reproductive Health Through a Justice Lens). Over 1 in 3 U.S. patients studied report experiencing contraceptive coercion in healthcare in their lifetime (Swan 2024).

Additionally, others are denied access to contraception options if they have larger bodies without clear evidence to support this. BMI is a historically racist measurement method (AMA 2023), yet is often still used in FDA labeling and clinical care.

Historical and current experiences demand that providers recognize and address their own biases and complacency to ensure all people have autonomy to control whether and when they want contraception. Clinicians must be cognizant to provide people with a full range of contraceptive options when desired and based on stated preferences. Understanding and addressing one’s own biases is a life-long process and providers should feel empowered to acknowledge and challenge their assumptions about individuals and communities. Providers have a unique opportunity to invest in people’s experiences and preferences, rather than in a particular method or outcome. This allows for more equitable care and allows clinicians to center and support people’s needs (See Ch 2: Addressing Personal and Systemic Bias).

Improving Access

Beyond working to ensure people have universal contraceptive coverage (without copay), clinicians can improve and streamline individual access in the following ways:

• Provide contraceptive initiation, method switching, and method removal as same-day services, without separate counseling visits and/or waiting periods.
• Refill contraception without requiring visits (in the absence of medical issues).
• Use telehealth visits for contraceptive counseling and/or initiating methods including self-administered subcutaneous DMPA:
  • Video, SubQ DMPA: https://bit.ly/2CEha3b
  • Depo-subq-user-guide: https://bit.ly/2BdHnoO
• Use online pharmacy delivery to facilitate access at home.
• Initiate bridge methods by telehealth, pending a follow-up in-person visit for DMPA, IUD, implant, or permanent contraception.
• Offer evidence-based extended durations for LARCs (Ti 2020, Dethier 2002).
• Counsel about IUD self-removal to improve autonomy and minimize undesired visits.
• Dispense a full year of a contraceptive prescription, which is safe, effective, and improves continuation (Jones 2023).
• Offer take-home bags with condoms, emergency contraceptive (EC) pills, and pregnancy tests.
• Offer advance prescription of EC pills.