Although many women with intellectual and developmental disabilities are sexually active, the specific reproductive health needs of this population have gone largely unstudied. In this issue of Perspectives on Sexual and Reproductive Health, Hillary K. Brown and colleagues examine the provision of postpartum contraceptive care to Ontario residents with intellectual and developmental disabilities who gave birth in 2002–2014 (page 93). Using population‐based data covering nearly 40,000 births, the analysts find that women with intellectual and developmental disabilities were provided with nonbarrier contraceptives—both permanent methods and reversible ones (particularly implants)—at higher rates than were other women. As the authors note, for some women with intellectual and developmental disabilities, nonbarrier methods may be the most appropriate contraceptives, but the findings raise questions as to why women with these disabilities are more frequently than others given methods that are irreversible or may have side effects. In particular, Brown and colleagues recommend that qualitative research explore how such women “perceive their participation in contraceptive decision making, as well as their knowledge, needs and satisfaction related to currently available options.”

Also in This Issue

• The contraceptive mandate of the Affordable Care Act has expanded the number of Americans who have access to contraceptive care without cost sharing. Nevertheless, not all those seeking contraceptive services have insurance or use the coverage they have. In a 2016 survey of a nationally representative sample of clients seeking contraceptive care at Title X–funded clinics, Megan L. Kavanaugh and colleagues found that nearly one in three lacked insurance, and nearly one in five who had coverage did not plan to use it for their clinic visit (page 101). Those who did not plan to use their insurance cited a variety of reasons—largely that the service they were seeking was not covered or they had concerns about confidentiality. The proportion of clients who have coverage and the proportion planning to use it varied among demographic and socioeconomic groups. Kavanaugh and her coauthors warn that if efforts to dismantle or weaken the Affordable Care Act eliminate contraceptive coverage, they could both reduce access to care and intensify the demand on the Title X system.

• Quantitative research has documented structural barriers that impede women's access to long‐acting reversible contraceptive (LARC) methods—high up‐front costs, inadequate provider training and reimbursement challenges. Elizabeth Janiak and colleagues have taken a qualitative approach to examining a related question: how providers view, and manage, the process of providing these methods (page 111). In focus group discussions with staff at Massachusetts community health centers in 2014–2015, the researchers learned that even within facilities, protocols and practices vary, and the pathway to care is often dependent on the provider's “idiosyncratic” approach. In fact, whereas professional recommendations favor provision of LARC methods on the day they are requested, participants generally did not consider same‐day provision feasible. Counseling protocols, insurance verification procedures and challenges regarding supplies were mentioned as sources of delay. As the authors put it, improving LARC method access for women attending these centers will require “multipronged, structured interventions to support the design and implementation of standardized, evidence‐based” care.

• It seems reasonable to suppose that women's perceptions of their biological capacity to conceive—their fecundity—may influence their contraceptive decision making, but the relationship has not received a great deal of research attention. Alison Gemmill takes an important step forward by examining this relationship among sexually active 25–30‐year‐old women who are part of the National Longitudinal Survey of Youth 1997 cohort (page 119). In this nationally representative sample, Gemmill finds that women who considered themselves only somewhat or not very likely to conceive were significantly more likely to forgo contraceptive use within the next year than were those who thought that pregnancy was very likely. The associations were generally similar in analyses controlling for objective measures of subfecundity, suggesting, Gemmill observes, that “fecundity risk perceptions … merit attention as possible factors in unintended pregnancy risk.” Future areas of research, she suggests, include assessing links between behaviors stemming from fecundity perceptions and unintended pregnancy, and examining the accuracy of women's fecundity perceptions.

• Women who have had an unintended birth are known to be at risk of having another—but not, it seems, because of their postpartum contraceptive behavior. On the contrary, in analyses of data from the 2011–2015 rounds of the National Survey of Family Growth (page 129), Karen Benjamin Guzzo and colleagues find that women who had an unintended birth were more likely to practice contraception postpartum, began using a method sooner and tended to choose more effective methods than those who had an intended birth. Notably, compared with women who had intended to give birth, those with unintended births had nearly twice as high odds of subsequently choosing a highly effective method, rather than no method. In the authors’ words, the results “demonstrate the importance of understanding contraceptive decision making as part of a series of linked reproductive outcomes,” but also raise questions about how patterns of contraceptive use are related to reproductive experiences and how postpartum care can help address disparities in access to and use of contraceptives.

• The prevalence of reliance on sterilization has been fairly stable among U.S. women, but the prevalence of desire for reversal of the procedure has grown, Mieke C.W. Eeckhaut and colleagues report (page 139). Moreover, the researchers find in analyses of data from the 1995, 2002 and 2006–2010 cycles of the National Survey of Family Growth, the risk of desire for reversal is negatively related to educational attainment, and the gap between the most highly educated women and those with the least schooling has grown markedly. In the latest survey, an estimated 15% of sterilized women who had less than a high school education desired reversal, compared with 3% of those with a college degree. The authors consider these trends surprising, given that expanded insurance coverage of—and, therefore, presumably increased access to—reversible methods might have been expected to result in less reliance on permanent contraception. While they acknowledge that “some desire for reversal is inevitable,” Eeckhaut and colleagues encourage further investigation of its correlates.

• A 2007 Perspectives article by Jenny A. Higgins and Jennifer S. Hirsch described what the authors called the “pleasure deficit”—the lack of acknowledgment in sexual and reproductive health research that people's enjoyment of sexual activity may have something to do with “risky” sexual behavior. As part of the journal's 50th‐year retrospective, we spoke with Higgins about the motivations for writing that article and whether the deficit has been reduced in the years since. She told us that she sees some improvement, but not enough; still, she is optimistic that the next generation of researchers is “light‐years ahead” of hers and will help fill the gap. The interview originally appeared on our anniversary blog, [email protected] (https://www.guttmacher.org/perspectives50), and it is reproduced in this issue (page 147).

The Editors