E103: The Social Domain of Family Planning

Katie: So when you're deciding whether or not to have a baby, who's in the bedroom with you? Turns out more people than you think. Today, we're in the social domain of family planning in our series.

There's a tension I've been thinking about here. For me personally, and for most women, I think using contraception feels like a private decision. We say my body, my choice, my business. But pregnancy requires two people. So we're a sexually reproducing species. Can't do that alone.

So suddenly there are stakeholders everywhere. There's your partner's desires, maybe your mother's or your mother-in-law's desires, hopes and dreams for grandchildren. And then there are a lot of other things: your employer's leave policy, how much time do you get off. There's your church's teachings, your state laws, and your access to healthcare that you might need.

And so I think that that's an interesting dynamic about why contraception is controversial. It lets one person act autonomously in a space where society feels like it has collective claims.

I'm Katie Ward. I'm a women's health nurse practitioner. Family planning, both contraception and planning conception, has been at the center of my life's work, both as a clinician and as a professor.

And of course, I'm here today, as always, with Dr. Kirtly Parker Jones, who's a reproductive endocrinologist. And as we've mentioned, we met when she was the medical director for a family planning clinic, and she was also working providing really high-tech infertility care.

Kirtly, did you ever feel that was a conflicted place to be for you, to see people struggling with infertility while others were pregnant that maybe didn't want to be or at least it was a surprise? I feel like as a society, we sometimes have sympathy for the infertile group and not so much for the people that maybe didn't get the contraception that they needed or wanted.

Kirtly: Well, we actually pour more money for people who are underserved and underfinanced. We pour more money into their contraceptive needs than we do in their infertility needs. So financing for infertile couples is often neglected for people who are underfunded.

But anyway, in the first episode of the 7 Domains of Family Planning, I quoted the document for the United Nations that family planning is a human right. People have the right to choose when and how to build their family. And this includes support for contraception and infertility services.

So, for me, the foundation of my career has been that every child deserves to be wanted and planned for, and every person has a right to have a child if they want to.

Of course, the ethics folks would ask whether this is a positive right. You have to help people achieve that goal. So is reproduction a positive right or is it a negative right? Meaning you don't have to help them, but you can't get in their way.

There are long ethical issues that you can spend forever with the philosophers about. But having my days split between a reproductive health clinic that focused on contraception and a clinic that focused on infertility and in vitro fertilization seemed all part of the greater goal of a planned family.

So, for me, they were two different systems that I worked in, but they were all part of this whole of trying to make a family that you want or not make a family that you don't want, and make it a choice that people can live with and change their mind.

On the other hand, I might question this right to family planning and having the number of children of your choosing, from zero to however many. I wonder if that doesn't come with some responsibilities.

My husband and I considered ourselves citizens of the planet, responsible to humankind and all other kinds. And we decided when we met in the early 1970s that we would have zero to one child, specifically thinking of our social responsibilities and human pressures on resources and the planet.

That sense of responsibility is shared by many young people these days, but not by all, because now there are forces on social media telling you that you should have children. "This is for the better, for the economics." It's usually rich people telling you should have more children so they can make more money.

But you have forces that say, "Oh, for the good of society and the planet, you shouldn't have so many," and others saying, "For the good of society, you should." So we have a lot of social pressures, one way or the other, about how we're going to build our family, not just our own individual desires.

Katie: So with us today to help us think about the social domain is Jessica Sanders. Jessica Sanders is an associate professor in obstetrics and gynecology at the University of Utah in the division of family planning where she's the director of research for the ASCENT Center for Reproductive Health. Jess has a PhD in public health from the University of Utah with an emphasis in women's health. She has done a lot of really great research on family planning, and I am super excited to talk about it.

Katie: Jess, your research is just so salient to our topic today, but I want to start with how you got into this work. What was your inspiration?

Dr. Sanders: So I was interested in sexual reproductive health early on. I was in the delivery room when my mom delivered my little sister when I was 11, and I was fascinated by pregnancy and birth. Then in high school, one of my first summer jobs was as a sexual health peer educator at Planned Parenthood in Texas.

I really enjoyed talking about reproductive health in ways that removed stigma and provided information. I loved being a resource for family and friends. And I also felt really drawn to understanding population health as well as individual health. And so I found my way into public health.

I worked as the data steward for the Utah Pregnancy Risk Assessment Monitoring System, or PRAMS, at the health department, and then dedicated my PhD research to examining decision-making and experiences with infertility. So I always viewed reproductive health as a spectrum that influenced every aspect of people's lives. And I continue to be interested in how people make decisions about sex, relationships, and family formation, and also how factors beyond biology, such as community, culture, and policy, inform these decisions.

Katie: You are so the perfect person for this social domain.

Kirtly: Exactly.

Katie: You study it top to bottom.

Dr. Sanders: I feel really lucky to get to do the work that I'm doing.

Katie: Will you tell us a little bit about the ASCENT Center just so listeners know what that resource is?

Dr. Sanders: So the ASCENT Center is a multidisciplinary center based at the University of Utah focused on improving sexual and reproductive health across Utah and the Mountain West. So we serve as a regional hub for providers, public health professionals, policymakers, and patients.

At its core, ASCENT is about making sure that people have access to the reproductive and sexual health care they need, and when they need it, as well as that the systems around them support their efforts in making these important decisions that impact so many domains of their health and their life.

Katie: Well, let's get into the social domain. I tend to think of it as concentric circles. I mean, you could think about it from any direction, I guess. But as I was kind of framing what I wanted to talk to you two about today, I was kind of thinking about it that way, with the individual at the center, and then the partnership around that, and the community beyond that, and then laws and policies, and structural forces. So that was kind of the framework I was working on.

I realized as I was going through your profile on Google Scholar, Jess, that you have done work that touches all of those. I don't know if that was an intentional thing or it just happened that way.

But let's start with the individual, because that's where I'm meeting people. I'm in the clinic and I'm asking people about their pregnancy desires, and their method preferences, and their side effects, and whether it's working. I'm thinking about preventing pregnancy, or achieving pregnancy, or infections.

But you have done this really interesting work that I was hoping you'd tell us a little bit about with the paper that you did on sexual functioning and poverty, and how some of those things that people are dealing with individually impact their sex life. And I would love for you to just tell us a little bit about that.

Dr. Sanders: Yeah, happy to. So these data come from the HER Salt Lake data, which I'll share a little bit more about later on. But one of the things that our research demonstrated was that economic insecurity directly affects people's sexual well-being. So it's not just about access to contraception or healthcare. When people are worried about rent, food, transportation, child care, people's experiences of sex also change. It can become more stressful, less pleasurable, and less autonomous.

And so, in that paper, we found that when people had fewer economic resources, they were more likely to report worse sexual satisfaction during those times and more negative experiences with their contraception as well. Not because the methods that they were using were inherently bad, but because the stress and instability shape how people's bodies feel and how decisions are made.

So when we talk about choice, we have to kind of be honest and say, "Choices aren't made in a vacuum." And certainly poverty is something that people experience really deeply and it affects these very basic human parts of us, like desire and pleasure, as well as how people use their contraceptive methods, as well as their ability to switch and discontinue if something's not working for them.

Kirtly: We did some interesting . . . And for some years, I wasn't a sex counselor, but I certainly did a fair amount of sex therapy with my patients and my infertility patients, who were also profoundly affected by their infertility processes in terms of their appreciation of their intimate life.

For women to have an orgasm, they have to have an empty brain. Men are often much more goal-oriented. Now, this doesn't mean it's all men because men can also have difficulties with their sexual functioning if there's something on their mind. But for women, you have to have an empty brain to have an orgasm. And if your brain is filled with many other things, it's hard to turn off.

Even the most wonderful partner may have a hard time turning off the fact that your baby is crying and the 2-year-old is crying, and maybe you don't have gas in the car to get to work tomorrow. All the kinds of things that make for a very occupied brain to be sexually in the moment, in the act, to have an orgasm, you have to be shutting everything else off.

Katie: Yeah. I wish I could say this was my phrase. It's another educator in the space. But she says that an orgasm is not something you have. It's a place where you go. And I think about that a lot. It's a place where you go or you let yourself go.

Dr. Sanders: It's really interesting, actually, in some of the qualitative work that we did around sexual satisfaction, many people reported that that ability to let go was a way that contraception benefited their sex life. And that was something that came . . . This narrative around letting go, I think, is really prevalent.

Katie: Yeah. But I wanted to bring that up because I think that that's something . . . For those of us that are providers, it's important to be thinking about how much the stress of poverty is impacting people's lives down to these kinds of intimate details. It's easy to be very practically focused and maybe not going on to ask a little bit further about if they're struggling or even suffering in this aspect of their life.

But yeah, I think that is an important thing that I always want to make sure people hear, is that the freedom to not be worried about pregnancy can allow you to have a little bit of a "let go" experience in other ways. You're not stressing about that.

Well, let's talk a little bit about partnership. So moving beyond the individual and talk about partnership a little bit.

Dr. Sanders: Even though we often frame contraception and family planning as an individual responsibility, largely we know that contraceptive labor often falls to women. The reality is that for many people, it's used in the context of their relationship. In healthcare and contraception development, there are a few novel male methods that are coming down the pipe, but largely, the options that are currently available fall on women and their reproductive bodies.

Katie: And it hasn't always been that way. Before we invented birth control pills, if your options were condoms, diaphragms, or fertility awareness and abstaining, that did incorporate the partner more. But I think the pill is what really kind of changed that. Now it's something that does sit squarely on the shoulders of women, and males can make an assumption that somebody's using birth control without even knowing one way or the other.

Dr. Sanders: Yeah. And I think that that importance around having conversations that feel open and supportive are very important for many people. But many women want to make that decision on their own as well.

And also, it's important that we remember that people use contraception for a lot of different reasons, right? So some are non-contraceptive benefits like helping with acne, or menstrual regulation, or menstrual pain. But also part of it is to make sure that sex is pleasurable and nonprocreative, kind of to what we were talking about previously.

And so those partner dynamics really matter, whether people feel supported, and also making sure that whatever method they're choosing doesn't interfere with their sex life.

We've talked about pain and bleeding, loss of desire, anxiety. Those things can influence how people use and decide which methods to use. And so making sure that, as providers, we listen to those concerns as you brought up and also that we support people in making those decisions in whatever context they want that to be, if that's with a partner or without.

Kirtly: Well, in the infertility world, trying to get pregnant can certainly be a conflict if one person says yes and the other one says no. I think having a baby, if someone wants to and someone doesn't, is kind of like sex. And when there are conflicts, if a couple is going to have babies, the person who says no gets to choose. So they certainly can come to a significant sexual crossroads if not both of them are agreeing that they want to have a baby.

This is a complex relationship issue, and it's an ethical issue, and it's a legal issue. But in the more common case of both members of the couple wanting to make a baby, it's all fun for the first couple months in fertility awareness, of knowing when you're fertile, and you can just have a great time. But then over months or years, the burden of sex to a calendar can become very tiresome. We heard this a lot in our clinic. And it becomes a wedge between the couple and a barrier to intimacy.

Just as Jess has done important research about how people feel about their contraceptive methods can affect their intimate lives and their choices, there are some statistics about how trying to have children can disrupt sex lives.

And each person is unique, and a couple's issues in infertility clinic are unique squared. So you've got one person's unique drive, and another person's unique drive, and then these drives all have to meet at ovulation or their baby isn't going to happen.

So we have a reproductive psychologist in our fertility reproductive medicine center that can help couples work this out. And the American Society for Reproductive Medicine has a fact sheet just on this topic. It's called Sexual Dysfunction and Infertility. You can Google the American Society for Reproductive Medicine and Sexual Dysfunction and Infertility, and find some really great suggestions.

So in terms of the family planning business, whether when trying to not have a baby ever, or not have a baby now, or to try to have a baby now, it gets personal.

Katie: Yeah, it definitely does. I mean, I see that play out in my clinic when couples who are trying to get pregnant often come in together, but women who are looking for a contraceptive method rarely bring their partners with them. So I see that sort of difference in who's involved at that decision-making visit with me anyway, primarily. Exceptions, of course, but more often than not, the partner is not accompanying his female partner to the clinic for her IUD insertion.

Dr. Sanders: But I do think it's important for us to remember that it's part of this continuum, right? When you were talking about fertility-awareness-based methods or fertility awareness, that can be used to avoid pregnancy and to later rely on that same body knowledge to get pregnant when you want to and are ready. And so these methods can support both of those goals.

I think that there's that trend that we kind of silo care into either birth control mode or trying to conceive mode. But the reality is our lives don't always work that way. People's lives don't work that way. Kirtly, to your point about when people are trying to conceive, there are some cycles where you're not really trying to conceive because it doesn't work for you right now. Or there are sometimes when people are trying to avoid pregnancy where they might feel more open to pregnancy.

And so supporting reproductive autonomy means supporting people across that whole arc, helping and providing the education and the tools to prevent pregnancy when they want to, and achieving pregnancy when they're ready and allowing for that dynamic to shift with their lives.

Katie: So important. Well, I want to get into the HER Salt Lake findings because that's been such a wonderful project and I think it's given us such a rich database to think about the social domain of this in so many different ways. But, Jess, can you introduce us to the project, and what has come out of it, and what you've learned?

Dr. Sanders: Yeah, happy to. So, at its core, HER Salt Lake explored what happens when you bolster healthcare systems that are already in place and remove cost as a barrier to contraception, and then follow people over time.

So ASCENT in partnership with four Planned Parenthood sites removed cost as a barrier to contraception and allowed people to come back to switch or discontinue at any time for no cost. Over 11,000 individuals received no-cost care and we enrolled 4,425 individuals in a survey that they received regularly over 3 years to learn more about their experiences.

And what we learned from HER Salt Lake was far beyond method uptake or patterns, and has been a resource for other place-based contraceptive initiatives.

Some of the takeaways that I think are important for listeners to hear about are we learned that access isn't just about whether contraception is available, but it's about where, and how, and under what circumstances people can get that care.

So even within Salt Lake, the same city, access can look different depending on clinic, neighborhood, hours, staffing, and the level of trust that people have within that space.

And we found out that when people had less to navigate, so we had same-day appointments, clear expectations of no cost, they were more likely to get a method of contraception that was their first choice.

So, in this case, we saw that many people opted to select a long-acting, reversible contraception like an IUD or implant, which at the time, and oftentimes, are more expensive and harder to get for people.

We learned that same-day access mattered enormously, and finding ways to kind of decrease those conversations of, "Come back next week," or, "We don't have that method in stock," or, "You'll need prior authorization," helped people access those methods that might not have been available otherwise.

Another thing that we found out from this research was that community norms and informal networks shape how people access care as well. Many participants told us that they chose the clinics and specific methods based on word of mouth, especially from friends and sisters. And so this informal feminized healthcare network was a really important part of the work that we were doing.

With HER Salt Lake, it showed us what happens when you remove cost and access barriers in real communities. And that was able to lead us toward policies that can increase access to care.

So following HER Salt Lake, we were able to begin the Family Planning Elevated access initiative, which was a statewide access initiative. So we went outside of Salt Lake to work directly with the healthcare systems and clinics across Utah to support the same-day access, provider training, and sustainable reimbursement.

That overlap between community access and policy are somewhat inseparable. And so we needed to find ways to support clinics, have stable funding and infrastructure, and try to move the burden away from individuals. And so HER Salt Lake showed what was possible. Family Planning Elevated showed kind of what it took to make access last a bit more.

And so these projects supported the passage of a Medicaid waiver, a family planning waiver, which will cover individuals up to 185% federal poverty who would not otherwise be eligible for traditional Medicaid.

This will go into effect in 2026. So as folks are listening, hopefully people will have additional access to contraceptive care in the state at a time when that's actually becoming more challenging.

Katie: Awesome. And then bring it back around, Family Planning Elevated, I know you were going to look a little bit at people's educational achievement and sort of long-term effects. So just bringing it back around to the poverty issue, is it too soon to see any of those results or do you have anything preliminary on the impact of getting the contraceptive you want?

Dr. Sanders: We have some three-year outcomes around people's ability to stay in school programs if they were enrolled in school, as well as kind of that movement away from policy and being able to delay pregnancy was one of the key abilities to stay out of poverty. And so there were more people who were able to delay pregnancies during that three-year period.

We're actually starting to look at 5- and 10-year outcomes from this project. And so we are excited to kind of see those bigger picture evaluations. But largely, within the three years that we followed up, people had more positive trajectories both for economics, for relationship stability, and for education.

Katie: So exciting. I mean, it's just great to be able to see that research. I think that's so important for those of us that work in that space to understand that full circle of it, that people have those choices, that they're able to achieve other goals. And even digging down on that impact of the stress of poverty on your day-to-day life, I think that's . . . I'm so grateful for your research.

So I want to look at one more circle. We've kind of touched on this, these policy and structural forces. We've been through a lot in the last few years in terms of laws that are being implemented that impose challenges for people. Can you talk to us a little bit about what gives you hope and what you're worried about in the policy world for family planning?

Dr. Sanders: Yeah. So I think after the Dobbs decision, which overturned Roe v Wade's protection on abortion access federally, things returned back to the states to make that decision. But one of the things that we have seen is providers are leaving the state. So Utah no longer has Title X funds in the state, which is the only federal program that provides contraception care as well as STI screening and treatment.

And so we've seen some clinics close and we know that patients are starting to feel that reduction in providers, facing travel delays, having to travel further, as well as just uncertainty, right? I mean, I think these policies create confusion for a lot of people, patients and providers.

And so policies kind of reshape the social environments of family planning. Kind of a lot of people report not knowing what laws and policies are in place, which we know impacts how people seek care. And then there's a lot of misinformation that's also happening especially around social media, and there are these huge communication networks that things travel very fast. I think that that's something that we, as a system, are trying to navigate.

These policies, and the speed at which things move, and information is one of the reasons that researchers, and educators, and policymakers kind of all have to work together. And we can't really fix one layer without paying attention to the others, which is one of the reasons that I love the "7 Domains" approach to how we look at different health issues.

Again, I think this entire discussion we've been talking about how family planning is never just about one person or one decision, but it's really shaped by relationships, and communities, and systems. And when we ignore those layers, we miss what people may actually need.

And so the research that I do and the work that we do at ASCENT is, I think, hoping to make those forces more visible and create things that we can improve so that clinicians, and policymakers, and communities can do better, but also support each other.

Katie: I appreciate the work you do so much. It informs me as a clinician, but also as a teacher teaching the next generation of providers. And yes, I think that it really shows us the impact of society.

Your findings that you mentioned about what your friends or your family are telling you about contraception, or what their expectations are around the appropriate age to get pregnant, or the right number, those are all social influences that we tend to not notice are real forces.

And then, yeah, social media is such a structural force now. I think that's been a real change for me as a provider, is kind of hearing people . . . It's almost fascinating. People come in and they're quoting something. I'm like, "I know exactly what influencer you're listening to." Because they come in with the same words in the same tone of voice.

Dr. Sanders: And in some ways, it can be hugely helpful to have information coming from different sources. But that's just something that we're going to have to try and keep up with too.

Kirtly: So part of the issue about policy and the whole global nature of the social part of family planning is it changes from state to state, and people need to know where they can get the help that they need, even with a planned pregnancy.

But an unplanned outcome with a fetus with significant health problems, which might not be lethal at birth, but could be extremely life-limiting, how do people access the care that they need as they make very difficult decisions about their family and what it's going to look like when they have a child who's going to be so sick?

This is when they know about it as a fetus. It is our job as physicians and as counselors to help these people make decisions and know where they can get access to the care that they need.

Katie: I think the work the ASCENT Center is doing is so valuable for those of us that are trying to understand the disparities in care. And we were talking about that a little bit, that we put more money into family planning, but the emotional aspect if family planning fails or people don't have access to the contraception that they need, the sympathy sometimes doesn't follow.

It's complicated, and I think the research that the ASCENT Center does helps me figure that out and helps me be a better clinician. So I'm really grateful for that.

I think the opportunity to talk about how much . . . As we started with, how many other people are in the room when you're making those decisions about whether or not to have zero to one babies, or lots of them, and what access to contraception you have is just so important. So this has been great to have a chance to talk about this with you guys.

We are looking forward to digging deeper into some of the other domains of family planning, and we hope you'll stay with us for this whole series. You can get the "7 Domains of Women's Health" and all 7 Domains of Family Planning wherever you get your podcasts, or at womens7.com on the web.