Patient distrust and poor access are hampering federal efforts to overhaul family planning

Patient distrust and poor access are hampering federal efforts to overhaul family planning

Two years ago, Sherika Trader was denied a tubal ligation after an emergency C-section at a Mississippi hospital. Trader, now 33, was told she needed a second child or a husband's permission to have her fallopian tubes tied, even though she wasn't married.

Jasmin Shepherd had heavy menstrual cycles because she was prescribed birth control pills after giving birth to her son 13 years ago. The symptoms continued even after she stopped taking the medication. Last year, a doctor in Jackson responded by offering 33-year-old Shepherd a hysterectomy, which she didn't want.

The experiences left the women feeling like the providers were acting like “robots” or, worse, feeling stereotyped. Black women already face significant barriers to accessing health care, including provider shortages and racial biases rooted in the medical system.

But with contraception dealing with deeply personal patient preferences, they also must contend with providers who dismiss their concerns. Decisions about whether – or when – to have a child and how to prevent pregnancy are not as standardized as treatment for other conditions. Yet providers give prescriptions or recommendations without considering a patient's specific circumstances, Shepherd said.

Late last year, the White House made new recommendations for a federal program that would provide funding for free contraceptives, health exams and certain cancer screenings. Health officials want to regain the trust of patients like Trader and Shepherd who feel their doctors don't always listen to them. The goal of the Title X program, which provides grants to states and other groups for family planning, is to let patients dictate the care they want, he said Jessica Marcella who is the deputy assistant secretary for population affairs at the U.S. Department of Health and Human Services and oversees the Title X program.

“Our belief and that of family planning is that it is important that you respect a client’s interests, needs and values,” she said. Providers shouldn't force patients to take a birth control method because it's more effective, she said, or deny them a particular method because they think a patient will want to have more children.

“What we don’t want is a provider causing trauma or unintentionally causing harm,” Marcella said.

In Mississippi, efforts to implement this approach began with a change in how Title The Biden administration's decision this year to award the $4.5 million grant to Converge marks the first time in four decades that the Mississippi Department of Health has not received the federal family planning grant.

Converge does not provide family planning services. Instead, the group funds a network of clinics across the state, organizes provider training, helps clinics overcome technological challenges and keeps them stocked with supplies. For example, when a provider had trouble printing a patient survey about their contraceptive preferences, Jamie Bardwell, co-founder and co-director of Converge, sent a wireless printer to the clinic.

But in the South, attempts to change the culture of family planning face obstacles old and new. Some are deeply rooted in the medical system, such as the bias that black women and other women of color have long faced. Additionally, contraceptive supplies are limited in the conservative South, and the Supreme Court's June decision, Roe v. Repealing Wade has led to restrictions on abortion access across much of the region.

Black women often feel disrespected and dismissed by their providers, said Kelsey Holt, an associate professor of family and community medicine at the University of California-San Francisco. She is co-author of a Study 2022 in the magazine Contraception, which interviewed dozens of black women in Mississippi about their experiences using contraceptives.

Women told researchers they had difficulty getting appointments, faced long wait times and had to put up with condescending behavior. Many of the women said providers did not inform them about alternatives to the contraceptive Depo-Provera, a progestin injection given once every three months, despite the known side effects and the availability of other, more appropriate options.

After the Supreme Court decision and the closure of abortion clinics across the South, trying to undo decades of such harm — and overhaul the way providers deliver family planning care — became even more difficult. Suddenly, women in Mississippi, Alabama and about a dozen other states could no longer get abortions.

“An important service has been suspended,” said Usha Ranji, deputy director of women’s health policy at KFF. Title X funds cannot be used — and have never been used — to pay for abortions. But, she said, clinics can no longer offer abortion as an option, affecting their ability to provide comprehensive counseling, a key requirement of the Title X program.

Many Mississippi residents cannot afford to travel across state lines to terminate an unwanted pregnancy. 2020, 84% of Title X clients in the US had incomes at or below 200% of the federal poverty level, and 39% were uninsured. Even Mississippi women with the ability to travel will face hurdles in nearby states like Georgia and Florida, which have not outright banned abortion but have limited access.

Even before the Supreme Court's decision, access to family planning in Mississippi was fraught with hurdles and judgments.

When Mia, who did not want to use her last name for fear of legal and social repercussions, became pregnant for the second time in 2017, she called the local health department in Hattiesburg to seek advice about an abortion. She had a daughter and was neither financially nor mentally prepared to have another child. The health department contact sent Mia to a religious anti-abortion center.

“I felt judged,” Mia said of the call. She eventually terminated the pregnancy in Jackson, about 90 miles away, at the state's only abortion clinic. which closed in July. “In the end, I did what was best for me,” said Mia, who had a son a few years after the abortion.

The loss of abortion care in Mississippi increases pressure on family planning providers to earn the trust of their patients, said Danielle Lampton, who is also co-founder of Converge. Patient-centered care is the “backbone of what we do,” Lampton said.

Both Trader and Shepherd serve on Converge's Patient Experience Council and occasionally receive grants to provide their perspectives to the nonprofit.

Providers should not force or pressure low-income patients to use long-term contraception, such as an intrauterine device, to protect themselves from pregnancy, Dr. Christine Dehlendorf, a family physician and researcher at UCSF who advises Converge.

Pressuring Black women to use IUDs, implants and other long-term contraceptives is reminiscent of a history of Black women being sterilized against their consent, she said. Even today, Studies show that providers are more likely to pressure women of color to limit the size of their families and recommend IUDs. These women also have a harder time finding a provider to remove the devices and obtaining insurance to cover the removal costs, Dehlendorf said.

Too often, Wyconda Thomas, a family nurse practitioner near the Arkansas border, encounters patients who are skeptical about contraception because of bad experiences. Many of her patients continued the Depo-Provera shots even after gaining an unsafe amount of weight — a known side effect — because they were not offered other options.

Even when patients come to us for another reason, Thomas talks to them about family planning “every chance he gets,” she said. Four years ago, Thomas opened Healthy Living Family Medical Center in Gunnison, an 80% black town of 300 residents. The clinic receives Title X funding through Converge. Nevertheless, Thomas does not force contraception on patients - she respects their decision not to use a pill, a patch or an implant.

But Title

“My job for them is to help them understand that there are more methods and that there is no method at all,” Thomas said. “And that’s a whole visit in itself.”

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