The 15^th anniversary of World Contraception Day (WCD) on September 26^th was a perfect moment to renew the commitment to increase awareness and knowledge about contraceptive methods. But the availability of safe and effective methods is not enough. Reproductive autonomy, which is defined as “having the power to decide about and control matters associated with contraceptive use, pregnancy, and childbearing,” is also a central tenet of both WCD and the Sustainable Development Goals for 2030. People must be supported in making their own decisions about their sexual and reproductive health, including if and how they become pregnant.

This year’s WCD was especially important. The COVID-19 pandemic has posed a threat to reproductive autonomy in the United States and globally, and deepened existing inequities. World Contraception Day should remind us of the necessity of securing reproductive autonomy for all, and removing the remaining barriers to achieving this as we move forward.

Structural Barriers Need Recognition

The factors that reduce people’s agency in controlling their reproduction are primarily structural. Recognizing these factors is central to removing them.

Poverty is one example of this. Women experiencing poverty may not be able to afford the contraceptive methods they prefer, or be more likely to see pregnancy as inevitable because they have reduced opportunities in education or employment. Further, they may live in a society where a woman’s identity and social inclusion are heavily dependent on motherhood, or where child marriage and adolescent pregnancy are common—which often limits a person’s reproductive autonomy.

Gender-based violence (GBV) and coercion also severely limit people’s reproductive autonomy. GBV is extremely common globally, including sexual assault and rape. More than 23 percent of women report not being able to refuse sex. Most of the violence that women experience is perpetrated by husbands or intimate partners. Further, men might not agree to use contraception, or may sabotage women’s contraceptive use – limiting or entirely eliminating the woman’s reproductive choice.

Social inequities are not the only structural barriers. Even when people use contraception correctly, every method can fail. If an unwanted pregnancy results and a person does not have access to abortion care in their country, this further limits their autonomy.

Provider biases can also infringe on people’s autonomy. For methods that rely on provider insertion/removal (i.e., IUDs, implants, sterilization), providers may not abide by the person’s wishes, or may pressure them to use specific methods that are not their preference. Low-income, women of color are more likely to be counseled on contraceptives and pressured into using contraceptives by providers than low-income white women in the United States.

Problematic Solutions and Approaches

A Demographic and Health Surveys (DHS) report on 29 African countries demonstrated the highest proportions of unintended pregnancies occur among the most low-income women. This relationship is similar in the United States, where rates are highest among low-income, women of color. Yet despite these demonstrated structural factors that influence people’s reproductive autonomy, family planning efforts have mostly focused on individual behaviors. For example, there is an increasing trend toward encouraging utilization of highly effective methods like long-acting reversible contraceptives (LARCs) in populations at “high risk” for unintended pregnancy.

Yet LARC use alone does not automatically remove structural factors that impede reproductive autonomy. For instance, recent research on LARC utilization in several African countries demonstrates the challenges that women face in having their contraceptive methods removed, motivated by provider bias and reluctance to remove the device. Preventing people from discontinuing their contraceptive methods completely disregards that person’s preferences for contraception and childbearing and is often motivated by societal notions about who should be a parent and who should not.

Many researchers also have called attention to the harm of an uncritical approach to unintended pregnancy reduction on people’s reproductive autonomy. In a joint 2019 commentary in Contraception, the authors write that “by treating high levels of unintended pregnancy as the problem motivating our scholarship, our field reinforces a conception of abortions as health system failures, valorizes more effective contraceptive methods regardless of women’s desires and contributes to the stigmatization of fertility among already-marginalized groups.”

Meeting Contraceptive Needs

Improving reproductive autonomy requires combatting racism, gender inequity, and other forms of marginalization that underlie the barriers many people face in making reproductive decisions.

The 2022 UNFPA State of the World Population Report estimates that more than 257 million women are not using safe, modern methods of contraception despite wanting to avoid pregnancy. And of these women, more than 172 million use no contraceptive method at all. When asked why the women did not use a method, the most reported reasons were concerns over side effects from contraception and infrequent sex.

Even among people who use modern forms of contraception, discontinuation is high. Side effects are a major reason for discontinuation. More than 33 percent of women who initiate a modern contraceptive discontinue it within one year, and more than 50 percent within two years. Recent research among global populations of users shows people’s lives are greatly impacted by contraceptive side effects like changes to the menstrual cycle and mood changes. An interview-based study of women in Bangladesh found side effects were not only physically limiting, but limited their ability to engage in religion, household activities, and sexual intimacy.

Despite the increasing numbers of women using modern contraceptive methods, the high prevalence of discontinuation suggest that people’s needs for contraception are not being adequately met. Cultural expectations about women bearing the burden of contraception, as well as lack of initiative for product development, also have both contributed to the lack of highly effective, reversible options for male reproductive systems. Contraceptive methods that are highly effective, reversible, with minimal to no side effects must be part of the available options. In addition, providers need to prioritize the person’s pregnancy desires and take their concerns regarding side-effects seriously.

Assessing people’s satisfaction with their method is one way to measure reproductive autonomy. Asking people about their preferences can also reveal gaps in reproductive autonomy, for example what contraceptive method they wanted to use compared to the method they actually  use. These must be monitored moving forward. Moreover, we should measure access to contraception, people’s own assessments of whether they receive the care they want, and their access to abortion care. Prioritizing people’s needs for contraception and reducing the barriers they face to their reproductive autonomy are critical to meeting the Sustainable Development Goals of 2030.

Read more:

• COVID-19 is rolling back progress in global sexual and reproductive health and rights
• Menstrual stigma often prevents people from engaging in their communities
• Women in low-to-middle-income countries face greater social stigma and pressure about being child free