Challenging Assumptions About the Use of Contraception by U.S. Muslim Women

By Henna Budhwani and Kristine Ria Hearld

Contraception is complicated. Reproductive health scholars can comfortably weigh the protective benefits of condom use compared to the convenience of intrauterine devices. However, for most people, contraception continues to be a sensitive subject not appropriate for casual conversation – and consequently many Americans lack an adequate understanding of their contraception options. Likewise, even the best-intentioned clinicians know little about how minority communities engage with reproductive healthcare and utilize contraception. Due to these knowledge gaps, providers of contraceptive services often struggle with how to approach family planning with individuals from minority populations, particularly those belonging to highly stigmatized groups that are underrepresented in scientific research. This can be especially true for “culturally conservative” populations of clients, among whom sex itself is stigmatized and sexual health is not freely discussed in the home or the doctor’s office.

Knowledge gaps are especially prevalent about the reproductive health behaviors of Muslim women, arguably one of the most understudied populations in the United States. This dearth of research is not surprising, given that Muslim women are part of a religious minority group that experiences ongoing intersectional stigma and discrimination in American public life. Because past studied have sometimes taken advantage of minority and marginalized populations, groups such as Muslim women may be suspicious of researchers and wary of divulging personal information, particularly on sensitive topics like contraception use.

Nevertheless, good research is needed, because in its absence, pernicious assumptions can take the place of actual evidence – and myths can misinform clinicians and policymakers as well as the general public. Social scientists therefore have a pressing calling to conduct research that may ultimately dispel harmful myths and give voice to a group of women missing from academic discourse. Our work examines this set of issues, contraception use and reproductive health preferences, in Muslim women in the United States. We collected information from Muslim women themselves about their lives, and our findings refute presumptions that women in this population typically experience low bodily autonomy and high sexual risk factors.

Path-Breaking Research from the Muslim Women’s Health Project

In 2015, the Back of the Envelope mechanism at the University of Alabama at Birmingham School of Public Health funded a grant to collect exploratory data from Muslim women across the United States. Our research team developed an online survey that included measures of stigma, mental health, and contraceptive use among participants. Respondents were women who self-identified as Muslim and who were at least eighteen years old and current residents of the United States. To be sure, online surveys have limitations – for example, American Muslim women who did not have a computer in their home or did not regularly use the Internet would likely not have been exposed to the survey at all. Nevertheless, one major benefit of online surveys is their ability to engage difficult-to-reach populations, including respondents in stigmatized populations, minority enclaves, and groups fearing persecution. Data from our respondents, including participants from Muslim subgroups, were analyzed to identify notable barriers and facilitators to various kinds of contraception use – namely use of oral contraceptive pills, condoms, intrauterine devices, and reliance on withdrawal during sex.

In the United States as a whole, some national estimates suggest that 62% to 75% of women of reproductive age use contraceptives. Rates of contraception use by women in Muslim majority countries varies widely, from a low rate of use by 38.5% of reproductive-age women in Pakistan and to a high rate of use by 62.3% of such women in Indonesia. Because of these statistics, we assumed Muslim women in the United States would use contraceptives at a higher rate than their counterparts in Muslim majority countries, but at a lower rate than other women in the wider-population of Americans.

Results from our survey showed that our hypotheses were wrong. We found that almost 80% of eligible Muslim respondents used some form of contraception. As we delved further into characteristics of our sample, we realized that the women who responded to the survey tended to be highly educated (over half had completed graduate or professional school) and had relatively high incomes (43% had a household income of over $100,000 annually). They also had high rates of health insurance coverage, given that fewer than six percent were uninsured. A deeper investigation through multivariate analysis showed that education and income were more important to understanding contraception use than religion, ethnicity, or even immigrant status (whether a respondent was born in the United States or elsewhere).

Essentially, our inquiry found was that when the social playing field is leveled through higher education, increased income, and full access to health insurance, contraceptive utilization increases – even among populations that are predominantly foreign-born and where people may be religious or hail from culturally conservative communities where women hold a secondary social status. Such factors are typically associated with low contraception use, but in our study, we found these factors could be counteracted by positive social conditions associated with empowerment.

Why Policymakers and Advocates Should Further Overall Improvements

When officials or advocates aim to boost contraceptive use by racial and ethnic minorities in order to reduce unintended pregnancies and sexually transmitted infections, it may be valuable to address community conditions holistically. Working patient by patient in health care settings can be helpful, but this approach is limited in scope, costly in time, and influences only the identified, targeted health behaviors. The better approach may be to expand women’s overall access to advanced educational opportunities that can lead to socioeconomic success and improved quality of life – even for women who belong to culturally conservative communities. Overall empowerment, we conclude, is the best way to increase rates of contraceptive use and ensure better life choices and opportunities for women in all communities.

Why Coverage of Prescription Contraception Matters for Men As Well As Women

Though the federal Affordable Care Act requires health insurers to cover many types of contraception, a vasectomy is not one of them.

Contraception – who should be able to use it, and the role of government in its provision – has become a contentious issue, in part due to disagreements over the Affordable Care Act mandate positing that all private insurance plans must cover prescription contraception for women. The issue is not trivial, because nationally representative surveys show that more than 10 million women in the United States use the pill as their current method to prevent pregnancy. The pill is the most popular form of reversible birth control.

Across the political spectrum, both citizens and public officials tend to understand birth control as a “women’s issue” rather than as a healthcare or social policy issue. Usually, birth control is discussed as a matter of reproductive health and rights or treated as an aspect of women’s personal responsibility for managing their own sexuality.

But where do men fit? How do they benefit from the availability and use of prescription birth control coverage? Could a better understanding of the ways prescription birth control coverage benefits heterosexual couples improve bipartisan discussions about coverage for contraception? My research provides insight into both of these questions.

Women’s Contraceptive Use and Couples’ Protection from Pregnancy

Contraception presumes the sexual involvement of couples, but surveys typically ask individual people about what method(s) they as individuals use to prevent pregnancy. By default, a woman who uses the pill for contraception also provides her partner with protection from pregnancy; and if her partner wears a condom, then both participants benefit. Contraception and condoms can be used together, but research shows that, in practice, couples in long-term relationships often move from using condoms to relying solely on prescription contraception.

Notably, interviews I conducted revealed that women who use prescription contraception for long periods of time rarely receive financial help from partners in purchasing it. Thus, although women’s birth control covers men, too, the men do not have to pay for this coverage and its benefits.

Men reap the positive effects of women’s use of prescription contraception in at least three ways: they gain protection from pregnancy without much effort; they avoid using condoms when couples transition to solely using prescription contraception, and they can spend money they might have spent on contraception on other items and pursuits.

There is also another way that men benefit from female contraceptive use that is not often mentioned. Women must deal with the downsides of whatever type of prescription birth control they use – including downsides such as physical side effects like nausea or depression and hassles like having to repeatedly refill prescriptions at the pharmacy. Their male partners are freed from such issues.

Contraceptive Use and the Unequal Burdens of Dissatisfaction

Preventing pregnancy is generally not something that couples enjoy, because it can be stressful, costly, and bothersome. Although public attention focuses on men’s dissatisfaction with condoms, much less attention is paid to women’s dissatisfaction with prescription birth control methods. My research using survey data finds that nearly 40% of women ages 23 to 44 who had ever used hormonal contraception had stopped using it at some point because they were dissatisfied.

Yet even though many women stop using a particular type of prescription contraception, they rarely stop contraception use altogether. They try various methods – different pills, or long-acting reversible contraception devices like implants and intrauterine devices – until they find something that feels right for them. As my in-depth interviews show, although many women experience dissatisfaction with side effects of particular birth control methods, they still believe that they should continue using some kind of prescription method.

Discussions that focus only on the benefits that prescription contraceptive coverage provides to women hide the ways that prescription birth control is very much like other medications – it can cause unpleasant and consequential side effects. By persisting despite dissatisfactions in their search for effective ways to prevent pregnancy, women provide tangible benefits for their partners, who get to avoid pregnancy without sharing such costs.

Even when women find it difficult or unpleasant to use certain methods, they cannot always count on getting male partners to wear condoms – or otherwise take responsibility for the couple’s contraception. This may explain why data from nationally representative surveys show that women who experience dissatisfaction with contraception are at higher risk of unintended pregnancy. When the burden of responsibility for birth control is too great, male partners cannot be counted on to pick up the slack.

What Does the Full Picture Mean for Debates about Contraception Coverage?

Recognizing that men as well as women benefit from prescription birth control coverage is crucial for appropriately evaluating the costs of rolling back the Affordable Care Act mandate for prescription contraception coverage. A nationally representative survey shows that only a very small percentage of people recognize that married women are the most likely to use prescription birth control. This may be because many of us are conditioned to see birth control as something affecting women rather than couples.

Public debates might very well change if more Americans understood all the ways that women, men, and society at large benefit from women’s access to prescription birth control – and their willingness to use it despite dissatisfaction. Too often, pundits and partisan debates treat contractive coverage as simply a women’s issue or benefit.

But if women, especially married women or women in long-term relationships, lose access to the most popular form of reversible contraception, so will men. Both men and women will experience new frustrations and costs.

Paid Maternity Leave: A Policy Imperative

Living in a country so focused on the reproductive behaviors of women, from contraception to abortion, it seems preposterous that despite the myriad policy imperatives that want to control women’s fertility, there is no federal policy that supports our decision to give birth by granting us paid maternity leave.

Maternity Leave in America: Where are we at?This policy gap is even more significant given that the USA is the only industrialized nation not to mandate paid maternity leave and is one of only a handful of countries globally that does not. The countries that are members of the Organization for Economic Cooperation and Development (OECD) average 18 weeks of paid maternity leave. Maternity leave is a social, economic and health policy that has broad and significant impacts for individuals, families, organizations and nations.

(For reasons of brevity and simplicity I am deliberately focusing on maternity leave but it is important to note that many national and organizational ‘maternity’ leave polices are subsumed within parental policies that apply to both mothers and fathers).

Family and Medical Leave

In the USA, the primary policy related to maternity leave is the Family and Medical Leave Act (FMLA) which puts various kinds of family-related leaves into one unpaid 3 month pot which includes leave for caring for a parent and leave for caring for an child. However, New Jersey, Rhode Island and California provide state-funded paid family and medical leave that includes pregnancy and childbirth. These policies are paid for by employee-paid payroll taxes and distributed through disability programs – with ‘disability’ being an unfortunate, if economically useful, way of categorizing pregnancy and birth.

If they do not work for one of the top law firms of the Vault 100 or a Fortune 500 corporation that competes for top talent and grant paid maternity leave to attract and retain employees, women are generally out of luck. If you are a woman with a ‘regular’ job, what do you do when you get pregnant or have just given birth? You have to take upaid leave at a time when your expenses have increased. Thus many women return to work within weeks of birth. Though some women try to continue to breastfeed, not many workplaces allow for convenient pumping and so women find themselves having to wean their infants because of workplace conditions in addition to their ‘early’ return to the paid workforce.

Many feminist activists do not want to ‘provoke’ a paid maternity leave policy because they think it makes women stand out as needing different (special) treatment than men. The fact is we are different from men and therefore need different policies related to our health and well-being. We incubate human beings for 9 months. We also have breasts that can be the sole nutritional source for infants for more than 6 months. This highly differentiates women’s parenting roles from that of males, regardless of how egalitarian a construct we may consider parenting to be.

Gender and Class Differences

In order for women to get the policies we want, we should acknowledge the difference, own the power in that difference, and demand what we need to take care of the next generation. The absence of child benefits, dearth of subsidized high-quality childcare, costly access to healthcare, low-performing public schools and high tuition costs for tertiary education are evidence of a government that talks about supporting families while neglecting the policies that would do so.

Not many women can afford to take unpaid leave and the women who work for companies were paid leave is a perk are more likely to be able to afford to take an extended leave without being paid while doing so. By making work incompatible with motherhood, women are forced to make hard choices between taking care of their children and being in the workforce, and men are forced to make this choice. Leaving the workforce because of motherhood not only reduces present income, it also limits lifetime income on which pensions are calculated while maintaining and expanding the income gap throughout the lifespan.

Our social welfare policies push poor women to work and yet social norms push middle class and wealthy women to stay home. Taking care of one’s own child should not be an economic luxury. Our economic and social policies recognize childcare as a ‘job’ only if someone other than a parent is taking care of a child. If a woman is taking care of her own child, her contribution to the economy and society is not ‘officially’ acknowledged by society at large.

For women who qualify for subsidized childcare, it is counterproductive and expensive to pay so much more money for a non-parent to care for a child while being unwilling to support a woman to take care of her own child. With regard to paid maternity leave and subsidized childcare, it is clearly not just about money, but it is about values.

The Wage Gap

Maternity leave is a key factor in the gender gap in wages and employment and in the ‘family gap’ in income that exists between women with children and women without children. Forty to fifty percent  of the gender gap income can be explained by the family gap differential due to marital and parental status among women.

The absence of paid maternity leave in the USA has been perceived by feminists and public health professionals as anti-woman, anti-child and anti-family because it does not provide income for woman post-childbirth nor does it support the 6-month breast-feeding recommendations of the American Pediatric Association.

Health Outcomes

There is no coincidence in having no paid maternity leave and the poor health outcomes we have for infants/children in this country. This is not to say that this is the only policy to blame as health policies are also significant contributors to poor health outcomes in mothers, infants and children. Policy ‘obsession’ with humans in utero do not continue once children are born.

There is little regard for comprehensive sexual health education for children and adolescence and too much attention paid to contraceptive choice and abortion. Once the child is born, our social welfare and health policies leave all but the poorest of mothers to fend on their own. The poorest women qualify for Medicaid and WIC (Women, Infants and Children). This is reflected in lack of affordable, high-quality childcare, poor performing public schools, juvenile justice facilities that are full to overflowing, low high school graduation rates and college costs that leave young adults mired in debt.

The Price of Motherhood

The price of motherhood should not be so financially challenging. Is possible women in developing nations will simply choose to opt out of the motherhood game altogether? Though the fact that American women continue to give birth at such high rates despite a social welfare net that has very large holes is a social policy paradox that is not easily understood. The demographic and economic challenges of low birthrates are not so easily fixed by social policy. Doing research on this topic for an economics class on gender and family, it was really hard to find a rationale for the resistance to paid maternity leave in the USA so I’m not sure why we are stuck in some sort of policy dark age along with universal access to health care.

Where Do We Go From Here?

In 2010, Ernst and Young was listed among the top 10 family friendly companies by Working Mother Research Institute, provides new mothers with 12 weeks paid leave and 10 weeks unpaid leave. Bank ofAmerica, which was also on the top 10, gives a paid leave to either gender of 12 weeks and allows them to take a total of 26 weeks. These organizations are profit-making institutions that would not be handing out benefits if they did not make economic sense. Getting good benefits lead to staff loyalty that reduces the costs of staff turnover. Furthermore, the costs of educating and training women get recouped over time when women are retained in the workforce.

For women who are joining the workforce, paid maternity leave should be a consideration when deciding on potential employers because the economic, social, health, personal and family benefits that result from such policies contribute much to our overall well-being and that of our families and society at large.

As is the norm in the USA, paid maternity leave is a social and health policy that is attached to employment and an employer. This leaves women at the whim of the workforce. Paid maternity leave should be a federal concern and not dependent on the whims of workplace or state policies.

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