By Melinda Young
Women living in small, rural communities tied together by religion and social traditions may have difficulty accessing their preferred contraception because of both social barriers and having fewer reproductive healthcare providers near their homes.1
“We were involved with the local health department to increase maternal-child health in the area, and we realized rural communities were not paid as much attention to,” says Rachel Wright, PhD, MSW, an associate professor in the department of social work at Appalachian State University in Boone, NC.
Women in Appalachia are less likely than non-Appalachian women to have medical insurance and less likely to take preventive health measures.1
Wright was part of a comprehensive, interdisciplinary, maternal-child health leadership team that included health department members, university members, children’s advocacy center staff, substance abuse counselors, lactation specialists, and OB/GYNs.
“They wanted to increase the use of IUDs [intrauterine devices] and had a lot of resistance from women coming into the health department and also from providers,” Wright says. “So, we took a step back to find out what women actually want and what are the barriers; what experiences do they have, and how can we support their reproductive health overall?”
The leadership team focused on rural western North Carolina. The area had a high rate of teen pregnancy, high rates of sexually transmitted infections (STIs), and low levels of communication about birth control between providers and patients.
Communication about contraception after patients give birth was especially rare.
“These conversations were not happening a whole lot,” she says. “Postpartum contraception counseling was not happening. It was sporadic.”
Researchers found that women sometimes were frustrated with their contraceptive counseling because they did not believe the provider was interested in what they said.
“One woman described where she wanted to use a specific form of birth control — the sponge — and the provider was pushing her to use the pill,” Wright explains. “She had religious reasons to not use the pill, and she told her provider, who told her she was stupid. She felt bad and took the pill prescription even though she knew she would not fill it.”
Another person who worked for a physician said the doctor would not talk to unmarried women about birth control because it was against his religious beliefs, she adds.
“The role of religion was pretty apparent — either on the side of the patient or side of the provider,” she says. “It’s two kinds of extremes.”
A 35-year-old woman described wanting to be fitted for a diaphragm, but her doctor was pushing her to use Yaz and sent her home with samples of Yaz. “So, anyway, it was somewhat frustrating, but I’m a pretty stubborn person, so I just went with what I knew was right for myself,” she told investigators.1
The main town included in the study’s geographic area is Boone, which has only one OB/GYN office, Wright notes.
“We asked in the study how far they have to travel to get to a provider,” she says. “It was common they’d have to travel for more than an hour to get to a reproductive health provider.”
The health department covered a five-county area and had some kind of presence in each of the counties, but not all of them provided birth control, which meant women still had to drive long distances for care.
When they did not have access to an OB/GYN, women often sought contraceptive care from their general practitioners. Some even asked their religious leaders about their reproductive health options, including whether they should have babies and what kind of birth control they could use.
“Religious leaders were more of a counselor sounding board,” Wright says.
The study found a low use of IUDs as contraception.
“There were a few different reasons,” she explains. “Providers here, in general, were hesitant to insert them in women who had not had a pregnancy yet or who had not yet given birth. And women who wanted to get pregnant in the next few years saw IUDs as a long-term option that did not fit with their reproductive planning.”
There also were common responses of women talking about the pain of IUD insertion or negative experiences that friends and family had with that method, she adds.
Another factor in some forms of contraception, such as IUDs, is the history in North Carolina of social workers being involved in forced sterilization. That terrible history has left scars that continue to be experienced culturally, Wright says.
More than 7,000 people were sterilized, often against their will, in North Carolina during the first half of the 20th century. In one county, the head of the welfare program pushed for sterilization of young and poor women as part of a eugenics campaign, and social workers were the intermediaries in volunteering them for sterilization.2
“It was a shock to a lot of people in the health department that there was so much resistance to the IUD,” she explains. “But it was their view that outsiders were coming in, telling women what to do with their bodies and telling them what reproductive health looks like.”
Distance to a provider was more of a barrier to reproductive care access than was cost, and religion had a big influence on their reproductive healthcare decisions, she notes.
“One of the big things that came out of the study was the importance religion played even to those who were not very religious themselves,” Wright says. “They felt the impact of the religious culture around them.”
Religion hindered access to care, as in the case of the religious provider who refused to prescribe contraceptives to unmarried women. It also influenced whom women trusted for reproductive healthcare information.
“Women had deference for their faith leaders as trusted sources of information, above and beyond that of their healthcare providers,” she says. “As we’re talking about reproductive health and supporting women, we need to make sure we — as educators or clinicians at a health department — have conversations with faith-based leaders, making sure they’re educated about reproductive health and have the support they need.”
Healthcare providers who work in a community with a strong religious cultural influence should keep in mind that their patients are seeking answers from their faith leaders.
“I want women to get the support they need, and if that’s from a religious leader, I want them to have the respect they need,” Wright says. “I want religious leaders to talk about it from a perspective that respects their religious beliefs and is medically accurate in ways that women are able to make the best decision for themselves. It matters what women think. It’s their bodies.”
Often, the religious leaders were not a church pastor. It could be the young adult Bible study leader or the women’s Bible study minister. It could even be the pastor’s wife.
“The men we interviewed talked about how they knew their female congregants won’t come to them to talk about that, so they have their wives be that support. There are some gendered components to it,” Wright explains.
Another barrier is the perceived lack of anonymity. Rural communities are small, so the woman who goes to a doctor’s office for contraception may know that her nurse is her mother’s friend, she says.
“If you’re from here and you’re 20 years old, (maybe) you don’t want to go see your family doctor. Because your family doctor is like best friends with your parents, you know?” says one 44-year-old woman participating in the study.1
“There’s not that level of anonymity that you might find in an urban area,” Wright says.
Researchers found that while religion was important to the predominantly Christian, white, straight population in this region, the women still wanted to have a choice in contraception.
“They might go to their partner about it, but it was their choice,” she adds.
References
- Wright RL, Kara D, Buchanan KC, et al. The impact of rural environments on reproductive autonomy among women in Appalachia: A qualitative analysis. Int J Sex Health 2024;36:273-286.
- Rose J. A brutal chapter in North Carolina’s eugenics past. NPR. Dec. 28, 2011. https://www.npr.org/2011/12/28/144375339/a-brutal-chapter-in-north-carolinas-eugenics-past
