Patient-provider power relations in counselling on long-acting reversible contraception: a discursive study of provider perspectives

Abstract

Contraceptive providers play an essential role in shaping contraceptive decision-making and care, with the potential to constrain patients’ agency. This is a particular concern given the rising hegemony of Long-Acting Reversible Contraception (LARC) and growing evidence of negative patient experiences of LARC promotion and provision. Despite this evidence, little research has considered health providers' perspectives. Drawing on interviews with 22 contraceptive health providers in Aotearoa New Zealand, this paper explored their professional identity construction, focusing on meaning-making in instances of conflict between providers' and patients' priorities and agendas. Guided by feminist poststructuralist theory, the discursive analysis highlights common rhetorical strategies used by participants to (1) justify the use of coercive practices to encourage LARC uptake, and (2) in turn, negotiate positive identities. Findings show how participants grapple with the reproductive politics structuring contraceptive care, including established understandings of the purpose of (long-acting) contraception and contraceptive providers' roles vis-à-vis provision and promotion. The findings point to limitations on contraceptive agency, despite the unanimous endorsement of rights-based voluntary care. Extending the critical literature on LARC and contributing to the under-researched area of contraceptive coercion and agency, the findings of this study have important implications for the delivery of contraceptive care.

Keywords:

• Long-acting reversible contraception
• healthcare providers
• contraceptive counselling
• agency
• critical discursive analysis
• decision-making

Introduction

The emergence of second-generation (redeveloped) Long-Acting Reversible Contraception (LARC)¹ in the early 2000s marked the beginning of an ‘era of LARC hegemony’ (Brian, Grzanka, and Mann 2020, 1). Steadily growing acceptance of the methods propelled promotion efforts worldwide and, today, a LARC-first approach is widely adopted in public health and family planning (Holt et al. 2020). There is, however, growing evidence of negative patient experiences, raising questions regarding patients' contraceptive agency (Morison and Eagar 2021). Women in various contexts report feeling dismissed or overlooked in decision-making, and pressured or otherwise directed toward LARC (Amico et al. 2016; Brandi et al. 2018; Gómez and Wapman 2017; Higgins, Kramer, and Ryder 2016; Mann et al. 2019).

Despite this evidence, very little research considers issues of power and agency in LARC promotion and provision, including contraceptive providers' roles. There is almost no critical consideration of providers’ perspectives (Morison and Eagar 2021). This is a significant omission, because how providers understand and consequently carry out their roles and responsibilities directly impacts patients’ decision-making and agency (Stevens 2015). To address this critical gap, I investigated how contraceptive providers in Aotearoa (New Zealand) understand and construct their professional identities. The focus in this article is on how they make sense of their roles and responsibilities in instances of conflict between providers' and patients' priorities, agendas, or ideas of what is (medically or otherwise) best for women. The findings offer novel, much-needed insights into how providers grapple with the broader socio-cultural meanings and politics structuring contraceptive care. These findings contribute to scholarship on contraceptive coercion and agency and extend the critical literature on LARC by showing how women's² contraceptive agency can be limited, with important implications for contraceptive care.

Contraceptive coercion and agency in the LARC hegemony

With a greater emphasis on population-based outcomes in recent years, urgency, efficiency, cost-effectiveness and outcomes have come to dominate global health policy and clinical practice (Brian, Grzanka, and Mann 2020). For example, in Aotearoa, LARC is frequently advocated as the most efficient, low-cost method of reducing unwanted pregnancy and abortion rates and remedying associated economic and social costs (Mcginn, Mount, and Fulcher 2021). Widespread promotion of the most effective, cost-efficient modern methods has contributed to a LARC hegemony in which providers are required to prioritise LARC and increase uptake (Brandi and Fuentes 2020). This LARC-first approach has been criticised by reproductive justice scholar-advocates for undermining patient-centred contraceptive care by minimising patients' options and potentially encouraging coercion (Holt et al. 2020; Mann, Chen, and Johnson 2021).

Indeed, qualitative research with patients points to power differentials in contraceptive consultations, characterised by limited patient engagement and subtle or overt pressuring of patients, especially socially marginalised women, to use/not use LARC (Amico et al. 2016; Brandi et al. 2018; Gómez and Wapman 2017; Waller, Tholander, and Nilsson 2017; Yirgu et al. 2020; Higgins, Kramer, and Ryder 2016). These findings are supported by the few critical qualitative studies with providers from a range of contexts that show how women’s contraceptive agency is restricted. The participants report prioritising high-efficacy methods, especially when counselling young women (Biggs et al. 2020), women of colour, or poor women, who may be ‘non-compliant’ (Mann 2022). They describe attempting to prevent ‘premature’ IUD removal (Biggs et al. 2020; Isley et al. 2019; Kaneshiro et al. 2020; Mann, Chen, and Johnson 2021) and ‘manoeuvre’ women toward LARC to prevent further conceptions or abortions (Purcell et al. 2016; Mann 2022; Senderowicz 2019) using foreclosed or directive counselling and by minimising side effects (Biggs et al. 2020). Such practices are concerning since these technologies are provider-dependent and grant clinicians a high degree of control in a context where they as medical experts already wield significant power (Mann and Grzanka 2018).

In the few studies with providers, participants allude to tensions or dilemmas they experience vis-a-vis their roles and objectives in contraceptive counselling (Isley et al. 2019; Purcell et al. 2016; Sandle and Tuohy 2017; Stevens 2018). For example, US providers recounted feeling torn between ensuring autonomous decision-making and promoting high-efficacy methods (Biggs et al. 2020), and UK providers reported ‘tensions between the facilitation of “choice” and the perceived role of [ensuring] contraceptive uptake at abortion' (Purcell et al. 2016, 171). These dilemmatic experiences stem from broader, sometimes competing understandings of family planning and contraceptive care. They point to a deeper tension within the LARC hegemony: whether women or LARC are/should be prioritised in family planning policies and strategies (Gómez, Fuentes, and Allina 2014).

LARC promotion is typically depicted as producing a win-win outcome: supporting women's rights and addressing social problems associated with unintended pregnancy (Gómez, Fuentes, and Allina 2014; Stevens 2015). However, this depiction rests on an over-simplified view of contraception as necessarily beneficial to women, which history and current research clearly refute (Gómez and Wapman 2017). Conflicts between women's empowerment and public health goals raise questions about women’s best interests and who determines these. Investigating how this tension manifests in providers' accounts of their work provides insights into how they negotiate the wider meanings and politics that shape understandings what family planning’s purpose is and how it should be achieved. This was the objective of the study, which I turn to next.

Study background

In a context in which there is a delicate balance between ensuring access and agency in contraceptive care, much of the scholarly attention in Aotearoa has been on access issues. This is warranted as there certainly are access barriers related to broader health system challenges and health inequities that disadvantage marginalised women (e.g. associated costs, skilled worker shortages) (Lawton et al. 2016; Mcginn, Mount, and Fulcher 2021). However, a concurrent focus on agency is lacking. Concerns about uncritical LARC promotion have gone unexplored, including the potential for rationing, statistical discrimination, and coercion due to focusing on a 'target population' of 'women at higher risk of unplanned pregnancy and poor health and social outcomes'—generally young, Māori, and Pasifika women (Mcginn, Mount, and Fulcher 2021). This study is motivated by the need for research on power and agency in LARC promotion and provision in Aotearoa.

Materials and methods

This article draws on an analysis of 22 semi-structured interviews with contraceptive providers recruited via email invitations and electronic or physical advertisements distributed by relevant healthcare organisations. Participant characteristics are detailed in Table 1. Providers participated in an in-person (n = 19) or telephonic (n = 3) interview about general contraceptive care practices and experiences (counselling; methods most/least recommended, to whom, and why) and LARC provision (type most/least recommended, to whom, and why; eligibility criteria; memorable cases).

Table 1. Interviewee characteristics.

	N (22 total)
Self-identified gender
Female	19
Male	3
Ethnicity
Māori (Indigenous)	4
Pākeha (of Settler descent)	12
Tauiwi (Resident/Immigrant)	6
Provider type
Registered Nurses	7
Specialist gynaecologist	5
Midwives/Maternity caregivers	4
Nurse practitioners	3
Community health /social workers	2
General Practitioner	1
Healthcare setting
Public hospital	7
Women’s health centre	2
Sexual Health Clinic	1
Non-governmental organisation	3
Youth-oriented service	4

Data analysis was guided by poststructuralist feminist theory, which draws attention to the political dimension of subjectivity construction. I used a form of critical discursive analysis that connects the micro-politics of self-making in the immediate context (i.e. interviews) with prevailing social meanings (discourses) and macro-politics in the broader context (Morison and Macleod 2013). The method illuminates speakers' identity work achieved in and through talk: how they maintain ‘positive social value’ (Bamberg 2004, 221) and avoid ‘trouble’ presented by negatively valued identities (Morison and Macleod 2013).

Identity work is enabled and restricted by broader social meanings or socially established ways of speaking about a topic, i.e. discourses, that offer various possibilities for identity work (e.g. women's rights or public health discourses). Discourses thereby act as 'discursive resources' available for speakers to use in presenting themselves/others in various ways by taking up positions within them. Positions can be either positive (e.g. patient-centred, ethical provider) or negative (e.g. coercive, biased provider) (Morison and Macleod 2013). The possibility of occupying a socially undesirable position or 'spoiled identity' creates 'identity trouble' for speakers, which can be averted through rhetorical strategies called 'repair work' (e.g. justifying, explaining, counter positioning) (Bamberg 2004).

In this study, analysis involves iteratively: (1) identifying discourses by searching across and within transcripts and coding patterned language use (e.g. recurring words/phrases, imagery, metaphors etc); and (2) considering each discourse contextually (i.e. a particular instance in an account) to explore how it is ‘put to work’ in various rhetorical strategies (e.g. justifying, excusing) (Morison and Macleod 2013). The analysis focuses on repair work arising in talk about contraceptive counselling.

Findings

Most contraception providers are motivated by providing patients with good care, as Mann (2022) highlights. This intention was reflected in participants' unanimous endorsement support of patient choice in contraceptive decision-making, echoing their international colleagues in the studies discussed above. Nevertheless, they too expressed frustration, concern and worry about patients who do not comply with their advice, or when they are unable to ‘get’ patients to use/keep using high-efficacy contraceptives. This was especially evident in talk about targets for decreasing unintended pregnancy, teenage pregnancy, and (repeat) abortion rates as indicators of successful practice. Participants spoke of situations warranting professional intervention or influence by presenting information to patients in particular ways or steering them along a particular course. Essentially, such talk renders (particular) women's rights conditional or contingent on provider endorsement and cooperation.

Providers were not unaware that such talk may open them to the spoiled identity of biased, controlling, or coercive provider, as evidenced by the repair work in their accounts. The repair work was supported by a sexual healthism discourse, which functioned as a central discursive resource for negotiating a positive social identity as a good contraceptive provider. This discourse is underpinned by a neoliberal worldview that valorises the rational, responsible, and self-regulating modern citizen (Epstein and Mamo 2017; Brian, Grzanka, and Mann 2020). It holds individuals morally responsible for self-optimisation through rational choice-making and careful pregnancy planning (Downey et al. 2017). Within this self-regulatory process, responsible contraceptive use features as a means of exercising "personal responsibility, bodily scrutiny, and risk reduction" (Epstein and Mamo 2017, 181). This is exemplified by the notion of ‘family planning’, also strongly upheld in the public health discourse, which foregrounds timing, planning, and rational choice as enabling a valued reproductive trajectory as part of an ideal life course (Morison and Macleod 2015).

Sexual healthism discourse therefore complements and supports the well-established public health discourse and, as demonstrated further below, functions as a powerful discursive resource in providers’ talk. In the analysis that follows I present three common rhetorical strategies and demonstrate how each works to construct positive provider identities as (i) promoter of responsible choices, (ii) protector, and (iii) empowerer, using anonymised quotes as exemplars. These positive identities all present the provider as benevolent, placing them in the relatively powerful position of helping patients, and can thus be linked to the clinical paternalism common in medical interactions (Stevens 2015).

Provider as promoter of responsible choices

The first rhetorical strategy involves positioning providers as acting to ensure patients make responsible contraceptive decisions in line with the dictates of sexual healthism. The strategy commonly occurs in accounts about promoting LARC, directive counselling, or persuading patients to follow provider recommendations and wards off any trouble associated with these practices. For example, in the following extract Kaia (nurse) describes how she tries to persuade patients to use/keep using LARC. Her disclosure could lead to her being seen as manipulative or pushy and as limiting patients’ choices.

So, selling (…) trying to sell more of the pros about it than the cons, you know? I mean, obviously, as nurses, we have to discuss the side effects and all that kind of stuff, but not making it sound like it's a real horrible thing for any of them. […] I'm always trying to be real open and honest, but you know, try and push more of a long-term contraception.

In this account, there is an overarching tension between promoting LARC and ensuring full informed choice, but ultimately the provider's role is one of 'selling' or trying to 'push more long-term contraception'. The language of persuasion ('push') and sales ('sell') used here was common, and echoes US providers' descriptions of trying to ‘sell’ the intrauterine device to patients while struggling not to pressure them (Amico et al. 2017). Similarly, promoting LARC by emphasising its positive features mirrors international findings of providers minimising or normalising the negatives of contraceptives to encourage uptake and adherence (Meier et al. 2021; Stevens 2018; Yirgu et al. 2020).

The potential trouble associated with these practices is repaired in Kaia's account through the denial of deception, self-positioning as 'open and honest' instead, and depiction of respecting patient rights as a given ('obviously'). Kaia implies, therefore, that her actions are for the patient. This repair strategy is more overt in instances where participants draw on the constructions of ‘unplanned’ pregnancy as a potential cause of personal and societal harm, underpinned by the sexual healthism discourse (Epstein and Mamo 2017). This construction helps to justify placing limitations on patient choice in the interest of mitigating harm. For instance, in the following extract that features talk of ‘pushing’ patients through directive/biased counselling or persuasion, part of a discussion about responding to patient requests to reverse a LARC:

…some women have just had enough, and then they don't want to [continue]. I think if you think you can push them a little bit, they (.) I'd often say, "Well, we'll give you a set time. If things aren't better by that point…" […] I suppose what we don't like seeing is women who get to the mid-to late-teens; they've tried everything and say that nothing works. I think then you've got to try and say to them, "Which causes the least problems? You can't just not use anything" (Janet, gynaecologist).

Here repair work anticipates being positioned as biased, forceful or manipulative for 'pushing' patients to persevere with an unwanted method causing 'problems'. Pushing is reframed as gentle persuasion through softening language ('a little bit'), alongside the depiction of negotiation and compromise (removal if 'things aren't better'). Janet thereby positions herself as reasonable, trying to balance her goal of continuation with the patient's wishes. Nevertheless, echoing findings in the USA (Mann 2022; Mann, Chen, and Johnson 2021), pregnancy prevention is ultimately prioritised above patients' concerns, as indicated by the contraceptive imperative ‘you can't just not use anything’, invoked in response to requesting reversal or to stop contracepting.

The problematisation of unintended pregnancy, informed by the sexual healthism discourse, is implicit in Janet’s instruction to choose a method with the 'least problems'. This construction presents contraception as 'a necessary evil' (Wigginton et al. 2016) with side effects and other difficulties as ‘the “price” of pregnancy avoidance’ (Stevens 2018). The construction of ‘compulsory contraception’ is common among providers (Stevens 2018; Mann 2022) and was echoed by all participants. It renders women's wellbeing, preferences, experiences and concerns subordinate to their reproductive capacities (Mann and Grzanka 2018); the former potentially become barriers to be surmounted or circumvented in consultations to ensure contraceptive uptake and ongoing use. Women's concerns and rights are secondary to the goal of averting unintended pregnancy.

Furthermore, preventing unintended pregnancy is constructed as also (needing to be) a patient's main priority, despite evidence suggesting a more complex relationship between pregnancy intention and contraceptive use (Mann, Chen, and Johnson 2021). Drawing on the sexual healthism discourse, that valorises contraceptive use as responsible and personally empowering, the ‘choice’ to use (long-acting) contraception is rendered the only genuinely responsible and viable option. Non-use is construed as unreasonable. Accordingly, contraceptive agency is constrained within a logic of 'agency without choice' (Mann and Grzanka 2018, 334). Hence, Janet’s assertion that contraception is compulsory leaves patients only with a choice between methods that cause them “the least problems”. This lends support to findings from a recent US study in which clinicians “emphasized their belief in facilitating free choice” but still presented contraceptive use as compulsory for women, especially those deemed ‘at risk’ (Mann 2022, unpaginated). Not only is contraceptive use here represented as obligatory rather than simply an entitlement (Wigginton et al. 2016) but using persuasive tactics to ensure contraceptive use is rendered justifiable. Providers can position themselves as rightly ensuring women take up their obligation. Rather than being biased, pushy or manipulative, such tactics are cast as positive and protecting patients’ best interests, as discussed next.

Provider as protector

The second rhetorical strategy involves justifying directive counselling or providers' gatekeeping practices as acting in patients' best interests. This strategy rests upon the sexual healthism discourse's construction of women as requiring protection from the undesirable consequences of individual action, in this case, ‘unplanned’ pregnancy (Epstein and Mamo 2017). Accordingly, providers frequently described their role as one of protecting patients from making poor choices. For example, Ellen (gynaecologist) stated that seeking reversal of a long-acting method is ‘their [a patient's] choice… totally up to them’ but also required ‘a valid reason’ before she would carry out such a request. As this example shows, participants commonly supported women’s choice, yet simultaneously supported provider intervention, gatekeeping, or exerting a degree of control. Providers justified retaining control over decision-making by depicting (certain) patients as likely to ignore advice or take risks for reasons they deemed not ‘valid’ (i.e. illogical or unsound). In determining what constitutes ‘a valid reason’, providers typically prioritise medical knowledge and biomedical factors over patients’ embodied knowledge and lived experience (Berndt and Bell 2021). Like Ellen, they positioned themselves as the rational arbiters of patients’ reasoning, more capable of making choices in their patients' interests than the women themselves. Accordingly, they negotiated a positive identity as the protectors of vulnerable, ill-informed or uneducated patients and justified efforts to ensure the (continued) use of high-efficacy methods.

The provider-as-protector position is reinforced by risk rhetoric, which (as indicated above) is characteristic of both sexual healthism and public health discourses. Risk rhetoric was evident in depictions of women as vulnerable to risk and needing protection due to their age, class, ethnicity/race, or other characteristics. For example, discussing counselling young women, Lou (midwife) said:

… you feel their vulnerability, and you want to protect them. You have to be careful of your own agenda, don't you? […] Whose responsibility is it really? It's the woman's responsibility, and our responsibility is to inform her and make it as accessible as possible. It's her decision, and even though you might really feel: "Oh, please, please make a decision that's going to protect you".

Lou's reflection here demonstrates awareness of a dilemma between the provider's ‘agenda’ (getting the patient to choose ‘good’ contraception) and the patients' right to choose ('her decision'). The limited capacity to influence “vulnerable” patients’ decision-making is constructed as a source of apprehension, implying that young women cannot necessarily be trusted to choose suitable (high efficacy) contraception, invoking familiar constructions of young people as risk-prone and unreliable (Mann, Chen, and Johnson 2021). Meanwhile, Lou positions herself as benevolent: aware of and concerned about young patients' 'vulnerability', and as both motivated by and better able to act in their best interests.

Positioning certain women as unable to be relied on to manage their fertility renders them ideal LARC candidates. For instance, community health worker Joan described LARC as ideal for ‘young women or women who are in vulnerable positions’ and midwife Sue explained that at her workplace 'high-risk women' are the ‘target audience’ for intrauterine devices. Such claims echo broader LARC promotion efforts, underpinned by the sexual healthism discourse, in which those operating outside of the normative model of sexual citizenship may be positioned as risky or troubling (Brian, Grzanka, and Mann 2020; Downey et al. 2017). Lou's extract illustrates how being positioned as vulnerable or at-risk calls into question a patient's ability to act rationally, reasonably, and in her own best interests. This was evident in talk about ‘high-risk’, ‘at-risk’, or ‘vulnerable’ women who were depicted as being at greater risk of unintended pregnancy.

Supported by risk rhetoric, the provider-as-protector position helps justify and avert trouble associated with practices like restricting ‘at-risk’ women's decision-making or pressing them to use certain contraceptives. For example, Renee (nurse) recounted the difficulty of allowing ‘higher risk’ patients time to deliberate during contraceptive decision-making as per patient-centred care ideals:

We have drop-in clinics every day during the week, so it's definitely possible for someone to go away and have a think about it and come back. There's just some apprehension about (.) that for someone higher RISK—because, you know, we find that sometimes you just get the one chance ((laughs))—depending on risk factors, whether you'd want to let them go without anything or not is something [inaudible] that time.

The "apprehension" described here is related to the likelihood of ‘higher risk’ patients leaving without contraception, contravening the contraceptive imperative of sexual healthism. These patients are positioned as unreliable and hard to reach, being both at risk and risky. Curtailing at-risk/risky patients' time for deliberation by requiring an immediate decision is justified because they cannot be counted on to return after a provider has 'let them go'. Risk rhetoric thus helps render what could otherwise be construed as rushing or pressuring a patient as warranted and even benevolent.

Risk rhetoric also creates a sense of urgency, as evident in Renee's claim of having only 'the one chance' to ensure high-risk patients' contraceptive uptake. Likewise, several participants maintained that immediate action is needed to ensure certain patients make a contraceptive decision. Many others referred to potential missed opportunities to provide contraception to young women and 'at-risk' patients. They spoke of needing to 'strike while the iron is hot' (Lou, midwife) or 'take the opportunity when it presents' (Sue, nurse practitioner), and of 'using an opportunity… and seizing the moment' (Lou, midwife), for instance, in pre-abortion or antenatal care or even in consultations unrelated to reproductive health.

While constructions of risk are frequently couched in medico-scientific rhetoric, and thus granted a gloss of neutrality, they are not unbiased but rely on the logic of the sexual healthism discourse to distinguish responsible/healthy subjects from irresponsible/unhealthy subjects, all of whom are racialised, classed, and gendered (Manzer and Bell 2021). In the data for this study, risk was often synonymous with 'low income' and ethnic minority women. For example, Gavin (gynaecologist), also raised the issue of high-risk patients leaving a consultation without choosing contraception. He stated: 'It's not so common for European women to go away with no contraception. Pacific Island women, Māori women, yeah, they might, and they're kind of the highest risk group, really'. Such claims evoke normative understandings of Indigenous and women of colour's reproductive capacity as risky, rendering them not entirely capable or trustworthy of making appropriate reproductive decisions. This, in turn, validates the provider-as-protector position and justifies limitations on minority women's choice-making, profiling patients, or taking targeted approaches.

Young women were frequently positioned in similar ways, and often more explicitly. In fact, like Mann, Chen, and Johnson (2021, 34), I noted “spontaneous and often disparaging accounts of adolescent patients”. In such portrayals, risk rhetoric functioned to depict young women as not only at-risk but a risk to themselves, others and larger society. This construction relies on the pervasive association of risk with youth sexuality, as evident in the following extract. Here, Gavin (gynaecologist) explains his rationale for prescribing a particular LARC method (Mirena IUD) based on assumptions about a young patient's risky lifestyle practices.

So, [the Mirena is better than the copper intrauterine device] for those who are maybe fluid in their relationships. You know what I mean? When they're not in a committed relationship… I had this lovely lady a while ago, a young girl, and I asked my standard question: "Are you in a committed relationship?" She said, "Yeah, yeah, yeah". So, I thought I had better just ask how long your committed relationship is, and she said, "six weeks"! ((laugh)) […] So, the copper coil might have been brilliant for her, but a Mirena would be safer for her, for protecting her against life and from herself.

Gavin's argument about 'risky' sexual practices (non-monogamous sex/multiple partners) was warranted by reference to the case of 'a young girl'. He drew on similar arguments to those used to justify the LARC-first approach for young women: these women need provider-administered methods because they are less reliable and more likely to engage in risky practices than older women. This argument relies heavily on the common adultist view of young people as inherently less capable, intelligent and responsible than adults, and so prone to making poor choices that oppose social norms and their own best interests (Mann, Chen, and Johnson 2021). Accordingly, in the extract above, the patient is deemed an unreliable judge of safe sexual practice, confirmed by her ostensibly laughable understanding of a 'committed relationship'.

Gavin ultimately positions the patient as needing LARC as protection not only from the risk of sexually transmitted infections but 'from herself'. Accordingly, his mistrust and recommendation of an intrauterine device are justified. This extract illustrates how risk rhetoric works not only to position certain patients as ideal LARC candidates, but also to position providers as best placed to act or choose on their behalf. It demonstrates also how those who do not/cannot adhere to the ideals of the Western childbearing subject— young, poor, and ethnic minority women—were positioned as irrational and irresponsible, acting against their best interests, and needing to be protected from themselves by knowledgeable, supposedly impartial experts. Thus, as Brian, Grzanka, and Mann (2020) also argue, constructions of the potentially 'non-compliant' patient subtly draw on long-standing racist, adultist, sexist and classist logic to position some patients as inherently irresponsible and to temporally restrict 'choice'.

Provider as empowerer

The final strategy involved portraying the provider’s role as empowering women through contraceptive provision. This strategy relies on the sexual healthism discourse's strong association between contraception, especially LARCs, personal empowerment, and responsible self-governance (Brian, Grzanka, and Mann 2020; Mann and Grzanka 2018). Overall, participants unquestioningly reiterated the construction of LARC as wholly liberatory and beneficial to women. This construction was especially evident when explaining preferences for or promotion of LARC. Erika (midwife), for example, explained her 'passion' for promoting LARC as stemming from the desire to empower women, as in the following extract where she explains why she is a 'big pusher' of LARC.

Witnessing repeat teenage pregnancies, personally, made me then feel like (.) I started to advocate for really reliable contraception more and more. Then, my own personal experience of having reliable reversible contraception meant that I experienced first-hand how nice it is not to worry and have something where you're fully in control […] You can have much more of a sense about your future and the choices that you make in your future. […]

I did have one case where a woman went to a—I'm sure you've heard stories like this—to a local Māori health provider for an implant. She had two children that were whāngai [sent to be fostered] from her partner's family, and she had a six-week-old baby. She went for the implant. They asked her whether she was breastfeeding, and she said yes, so they didn't do a pregnancy test. They put the implant in, and then, of course, […] she was pregnant. […] the advice [from the provider] was, "Nope, just leave it and then you've got really good contraception once you have this baby". So that's what she did. That's what they suggest in the [Pacific] Islands as well. It doesn't interfere with pregnancy at all, and then once the baby is delivered, it is active. […] So, she basically had like four children under four or something crazy!

Recommending LARC to (certain) women is rendered here as acting in their interests because these methods are highly effective and, consequently, empowering. As a 'really reliable' contraceptive, LARC is depicted as freeing women from worry, chance and fate by providing certainty and enabling them to be 'fully in control' of future choices. This construction rests on LARC promotion discourse, which leverages the logic of empowerment to advance sexual healthism: generating the ideal reproductive subject who uses 'really reliable' contraception to plan responsibly (Boydell and Dow 2021). While reliable contraception certainly is valuable, the emphasis on efficacy in Erika's account reiterates the typical, largely unquestioned construction of preventing unplanned pregnancy as the goal of contraceptive decision-making and a goal that is shared by all women.

The construction of LARC as empowering also allows Erika to present LARC as a means of addressing the social position of marginalised women (teenagers, Pacific Island and Māori women). These women were frequently described as having repeated unplanned pregnancies or multiple children that they cannot afford or care for adequately. As Erika’s comments show, LARC was thus considered especially useful to these socially marginalised women, allowing them to plan and space births appropriately. This depiction of LARC is informed by the equation of empowerment with achieving personal autonomy and self-actualisation through self-regulation (Brian, Grzanka, and Mann 2020). This rendition of empowerment rests on individual action. To overcome the adverse circumstances of their lives and attain the ideal (middle-class) conditions for mothering, women must reliably contracept to delay motherhood or limit family size (Downey et al. 2017). The implication that contraception is a solution for marginalised women’s difficulties, 'neglects the structural factors that put these women in such difficult, marginalised positions in the first place' (Manzer and Bell 2021, 127).

This logic potentially makes women culpable for the social problems ostensibly caused by high unintended pregnancy rates. Erika's description (above) of her patient having 'four children under four or something crazy' evokes the impoverished Māori mother with multiple children. This stereotypical figure also commonly features in the data in other discussions about the need for or benefit of LARC. Responsibility consequently shifts from collective solutions (e.g. affordable childcare, adequate social safety-nets) to individual women (e.g. not having more children than one can afford/care for) (Bertotti and Miner 2019). This narrow, individualised depiction of unintended pregnancy (as the cause of social inequities and resolvable by contraception) reinforces the over-privileging of contraceptive efficacy and the positioning of women deemed 'high risk' for unintended pregnancy as ideal LARC candidates.

Throughout this study, notions of risk were subtly intertwined with class- and race-based norms. However, as Erika's account shows, participants usually avoided explicitly raced and classed language in interviews and informal chat, using coded language instead. In Erika's account, referring to a 'Māori health provider', 'the Islands', and 'whāngai' (the Māori word for fostering) invokes shared understandings of racial and class-based tropes that work to position Māori and Pacific Islander women as the ideal beneficiaries of LARC. Other participants used Māori words and referred to 'culture', 'gang involvement or 'low resource' as coded language, which minimises the appearance of bias, allowing participants 'to safely express race-, class-, or gender-based beliefs about patients and their behaviours’ (Manzer and Bell 2021, 126). Accordingly, trouble associated with profiling or singling out specific groups can be as targeted LARC promotion is portrayed as empowering marginalised women.

Discussion

My aim in this article has been to investigate an unexplored tension in provider talk that has been alluded to in other studies (Berndt and Bell 2021; Purcell et al. 2016; Rubin, Davis, and McKee 2012). This tension manifests as a mix of overt support for patients’ rights and an ongoing paternalism, reflecting a wider overarching tension in family planning politics (Stevens 2015). Despite their support for patient-centred care and reproductive choice, participants constructed the provider's primary role as preventing unintended pregnancy by ‘getting’ patients to use high-efficacy contraception. The sexual healthism discourse that underpins this construction foregrounds contraceptive efficacy and preventing ‘unplanned’ pregnancy (Epstein and Mamo 2017; Brian, Grzanka, and Mann 2020).

The dominance of this discourse is shown by its prominence in provider talk. It powerful support to powerfully supports justificatory rhetorical work featuring notions of risk aversion and normative childbearing and motherhood ideals that helped participants construct positive identities as promoters of responsible choices, protectors, and empowerers. This rhetorical work occurs in a discursive context already marked by historical paternalism and asymmetrical patient-provider power relations (Holt et al. 2020). Sexual healthism discourse, therefore, helps maintain and normalise the status quo so that it remains largely undetected, perpetuating medical paternalism, and justifying power imbalances. My analysis has shown how this discourse is drawn on in ways that represent women's rights as having been considered, allowing participants to position themselves as acting in women's interests even when describing practices that could be seen as coercive or rights violations. Via such strategies, contraception providers uphold the right to reproductive choice in principle, while effectively rendering this right provisional or conditional. This, in conjunction with benevolent provider positioning, can mask unequal power relations that are historically normalised in medicine. Indeed, like the providers in a recent US study, participants in this study generally discounted hierarchal power relations, 'instead viewing their relationships with patients as empowering equal partnerships' (Berndt and Bell 2021, 613). Thus, despite their expressed intentions, participants may inadvertently support contraceptive coercion.

These findings have implications for marginalised women. Associations of risk/riskiness with class, race/ethnicity, and age mean that socially marginalised women can be profiled and disproportionately receive directive or coercive counselling in the targeted promotion of LARC. Indeed, these possibilities are suggested in other studies with patients in Aotearoa (Morison, Ndabula, and Macleod 2022) and abroad (Downing, LaVeist, and Bullock 2007; Gómez and Wapman 2017; Bertotti, Mann, and Miner 2021). Additionally, veiled references to race and class that featured in talk mark out certain women as ideal LARC candidates. This coded language, along with sanitised risk or quantification rhetoric, revives the discursive residues of population control supporting the restriction of contraceptive agency among the least resourced or empowered women (Brian, Grzanka, and Mann 2020; Manzer and Bell 2021). Ultimately, prevailing social and reproductive inequities may be compounded.

Questions arise regarding the extent to which the practices used to promote LARC use, such as those described by participants, 'may sometimes enact a power akin to "soft sterilisation": a version of eugenics whereby the state does not have to blatantly infringe upon civil rights in order to achieve its aims' (Brian, Grzanka, and Mann 2020, 317). Again, it is essential to point out that these effects occur aside from providers' intentions and, as in studies conducted elsewhere, participants were overwhelmingly well-intentioned toward their patients. Instead, what is at issue are the unacknowledged values and assumptions of sexual healthism that underlie the practices described, and their justification.

What does this mean for how rights-based or patient-centred care might be interpreted and implemented by providers, and for women's contraceptive agency more broadly? The findings suggest that targeted or directive counselling can be justified and characterised as well-intentioned, benevolent, or even feminist, thereby obscuring the underlying sexual healthism that promotes middle-class, Western ideals, censures unmarried young, poor, or working-class women's childbearing, and enables moralising and monitoring of their reproductive practices (Downing, LaVeist, and Bullock 2007; Stevens 2015; Stevens 2018). Moreover, over-subscribed and under-resourced clinical environments, in which institutional targets dictate good practice, may do little to encourage reflection on underlying assumptions (Senderowicz 2019; Stevens 2015).

To support contraceptive agency and, more broadly, the principles of reproductive justice in contraceptive care, there is a clear need for capacity building involving reflexive discussion of provider understandings of ‘patient-centred care’ and explicit guidance regarding what constitutes such care (Mann, Chen, and Johnson 2021). Importantly, given findings regarding the constraint of marginalised women’s contraceptive agency, capacity building must promote “structural competency” via the ability to “recognize, analyze, and intervene upon the [socio-]structural factors that impact health disparities” (Downey and Gómez 2018, 215) and impede patient-centred approaches, including the tensions explored in this paper and the underlying values and assumptions of sexual healthism.

Going beyond individual-level provider training, the person-centred framework proposed by Holt et al. (2020) offers a promising approach to guide change at multiple levels of the health system, and among various stakeholders, to address the contextual factors that might inhibit the implementation of equitable patient-centred care. Underpinned by socio-ecological theory and reproductive justice principles, the framework's purpose is to advance equitable contraceptive care by illuminating the socio-structural contexts shaping contraceptive use, and offering guidance for planning and implementing contraceptive care grounded in principles of health equity. This framework can support practitioners and other stakeholders to consider and begin to address contextual factors like institutional dynamics and material constraints (e.g. over-subscribed and under-resourced clinical environments, institutional targets) and policy framings (e.g. risk-oriented policy) (Morison, Ndabula, and Macleod 2022).

A holistic approach is necessary to inform person-centred care, given that despite good intentions, the goal of supporting women's rights can be side-lined by the power relations surrounding contraceptive care. Findings from this study suggest that notions of patients' bests interests can restrict contraceptive agency by masking paternalism and coercion. Nonetheless, providers' good intentions also provide a point of entry for tackling the problematic assumptions and norms underpinning paternalistic or coercive practices. Acknowledging providers' desire to help patients is a constructive way of introducing rigorous and nuanced discussion and comprehensive guidance regarding acting in patients' interests vis-à-vis a person-centred care framework. More work is required on applying this framework and how it can assist the development of comprehensive strategies to promote environments that support contraceptive agency and truly rights-based, voluntary contraceptive care.

Acknowledgements

My thanks go to Kris Taylor for proofreading this manuscript and to reviewers for their helpful comments.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Royal Society of New Zealand under Grant MAU1815.

Notes

1 These include intrauterine devices (IUDs), subcutaneous implants, and injectable contraception.

2 Not all contraceptive users are cisgender women. I focus on this group here because it is the largest group requiring contraceptive care and upon which reproductive politics has historically centred.