Objectives: To examine whether peripartum contraceptive care quality improvement efforts are addressing or perpetuating reproductive health injustices.
Methods: We conducted a national comparative case study of inpatient postpartum contraceptive care implementation in 2017–18, using site visits with key informant interviews and a qualitative content analysis asking: 1. What are healthcare workers’ biases related to peripartum contraceptive care delivery; 2. Do care delivery processes center the needs of the most marginalized; 3. When enhancing access to contraceptive care, do healthcare workers recognize and work to dismantle systemic inequities?
Results: 78 key informants (eg, clinicians, operations staff, and hospital administrators) at 11 hospitals participated. Many interviewees demonstrated a desire to provide compassionate care, avoid paternalism, and foster autonomy. Simultaneously, we observed interviewees subscribing to an ideology of stratified reproduction, engaging in statistical discrimination, and deploying “othering” language. Despite the stated goal of patient-centeredness, care delivery processes often prioritized healthcare systems’ needs, and patients were not engaged in designing or evaluating quality improvement efforts. Finally, while many interviewees recognized structural inequities (eg, healthcare access barriers and inadequate insurance coverage) and sometimes advocated for structural solutions to address them, healthcare workers also sometimes turned to individual-level interventions, like LARC methods, as solutions to these structural-level issues.
Conclusions: Alongside enthusiasm for delivering equitable and compassionate care, there coexists bias, centering of healthcare system needs, and narrow views of structural factors impacting patients, suggesting the need to actively address and mitigate the potential for harm in initiatives seeking to enhance access to postpartum contraceptive care.
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