Context and Objectives
Access to sexual and reproductive health (SRH) care, including contraception, enables people to achieve healthy, full lives. Understanding the impact of receiving contraceptive care is key to improving health care delivery, guiding resource investments in service delivery, and shaping equitable contraceptive access policies. Especially in the current context, where equity, science, access to SRH care, and bodily autonomy are under attack by the federal government, we need rigorous, holistic measures and tools to assess this impact.
Historically, the SRH field has quantified the impact of contraceptive access using population-level measures [1], [2] (e.g., total numbers of pregnancies, pregnancy outcomes, contraceptive nonuse, adverse SRH outcomes prevented) or systems-level measures (e.g., cost savings to health systems). For example, the Office of Population Affairs has used estimates of unintended pregnancies prevented and provision of “highly effective” contraceptive methods as an indicator of program effectiveness or quality of care. Policymakers and SRH advocates also frequently cite estimates of cost savings from public funding of contraceptive care—both family planning care overall and Title X-funded care specifically—to secure, justify, and expand federal- and state-level funding of SRH services [3], [4].
While some of these impact measures have contributed to increased public investment in the delivery of contraceptive care, they have many limitations. First, these measures provide a narrow and deficit-based understanding of impact that largely focuses on the benefits of avoiding “negative” health outcomes rather than promoting and sustaining well-being. As a result, many of these existing measures imply that certain outcomes are inherently negative (e.g., contraceptive nonuse), stigmatizing these reproductive outcomes and the communities that disproportionately experience them (e.g., people living on low incomes, Black, Indigenous, Latinx, and young people). Many of these same communities face systematic discrimination that devalues their reproductive experiences and preferences. In this context, these “negative” outcome measures can reify the phenomenon of stratified reproduction [5]—in which some groups’ childbearing is censured, and others’ celebrated—and reinforce inequities in care and resources. Further, researchers have typically omitted diverse perspectives, including the lived experiences of contraceptive users, when developing conventional contraceptive impact measures. As a result, these measures may lack validity and inaccurately reflect people’s actual experiences of, preferences for, and motivations behind seeking contraceptive care.
In addition, many of these measures do not account for the myriad reasons people use contraception in addition to or beyond pregnancy prevention, such as to prevent sexually transmitted infections, manage health conditions, and enjoy sex. Indeed, many people use contraception so they can have pleasurable sex without experiencing pregnancy, but sexual well-being is often omitted from how we assess contraceptive impact [6], [7]. Finally, many existing metrics rest on the widely criticized construct of unintended pregnancy, which—among its many flaws—does not account for people’s complex attitudes toward their pregnancies and has been used in ways that contribute to stigmatizing individuals from historically marginalized communities. Indeed, over the past several decades, public health efforts to reduce unintended pregnancy [8], [9], [10] have been used to justify coercive contraceptive policies and programs that target socially marginalized communities [11], [12], [13]. In sum, the SRH field has relied on inaccurate and, in some cases, harmful impact metrics to guide contraceptive service delivery and programmatic priorities. As a result, programs and resources are likely missing their mark in helping people achieve healthy, full sexual and reproductive lives.
An updated approach to quantifying the impact of contraceptive access is needed, with outcomes and metrics that use asset-based framing [14], better align with a person-centered approach [15], [16], and, ultimately, inform programs that help advance sexual and reproductive health equity (SRHE) [17]. Several scholars and advocates have also called for and enacted this shift to better align SRH research metrics with values of human rights, reproductive justice, and SRHE [18], [19], [20], [21], [22]. This undertaking is urgent and necessary, especially given ongoing efforts by the Trump/Vance presidential administration to undermine scientific rigor, attention to equity, and diversity across axes of oppression.
This commentary calls for a shift toward key outcomes that prioritize individuals’ perspectives and needs related to contraceptive access. Specifically, we (1) describe an ongoing collaborative process to re-examine measurement approaches in this area; (2) introduce a framework and propose key outcomes that reflect the impacts of receiving contraceptive care from a more holistic, person-centered, and asset-based perspective; and (3) propose an actionable path forward to quantify the impacts of contraceptive access, with recommendations for developing and using metrics grounded in SRHE.