Reproductive Decision Making

About the Authors
Acknowledgments
Introduction

Chapter 1: Reproductive Decision Making Is Important to Client Well-Being: A Call to Action

Chapter 2: A Strategy for Understanding Reproductive Decision Making

Chapter 3: Partnering with Clients in Reproductive Justice

Chapter 4: Reproductive Decision Making in a Post-truth World

Chapter 5: The Stork Is Irrelevant: Fact and Fiction in Family Planning and Reproductive Biology

Chapter 6: Putting It All Together: What to Say and How to Say It

Afterword
References
Appendix: Tools
Index

Melissa M. Bell, PhD, LSW, is an associate professor and the social work program director at Chatham University, Pittsburgh. She holds a doctorate in social work and a PhD certificate in the study of women, gender, and sexuality from the University of Pittsburgh. She is a licensed social worker in Pennsylvania with 10 years of post-MSW experience in psychiatric social work. On completion of her undergraduate degree in psychology, with a minor in women’s studies, from Indiana University of Pennsylvania, Bell attended the University of Pittsburgh, earning an MSW with a concentration in direct practice mental health. She then completed a 12-month postgraduate fellowship at Yale University in intensive clinical services. Her research focuses on family planning, the influence of politics and religion on social work practice, and emotion dysregulation in psychiatric treatment. Bell has participated in legislative action focusing on the assurance of access to emergency contraception in Pennsylvania hospital emergency rooms for survivors of sexual assault. Her research has appeared in Social Work in Public Health, Journal of Baccalaureate Social Work, Journal of the Society for Social Work and Research, Journal of Religion and Spirituality in Social Work, Social Work in Health Care, and Social Work Education: The International Journal. She has presented at several national conferences and is a content advisor on gender issues for the documentary film Journey to Normal: Women of War Come Home.

Sherie L. Edenborn, PhD, MT (ASCP), is an associate professor at Chatham University, Pittsburgh. She holds a doctorate in plant and soil science/environmental microbiology from West Virginia University, Morgantown. She received her undergraduate and master’s degrees in biology and medical technology from Clarion University of Pennsylvania and is certified as a medical technologist by the American Society for Clinical Pathology. Her research interests are interdisciplinary, including teaching biology to students in the social sciences. Edenborn regularly presents at the annual meetings of the Council on Social Work Education and the Association of Baccalaureate Social Work Program Directors and has written a paper about innovative pedagogy with Bell for the Journal of Baccalaureate Social Work. Her teaching agenda focuses on helping students find, evaluate, and understand empirical evidence and developing accessible and engaging curricula.

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Bell and Edenborn provide a toolkit for the busy social worker who feels unprepared to discuss family planning with clients. Theory-driven but eminently practical, this book explains the necessary biological and historical background and, based on case examples, shares strategies for raising the issues with clients. Social workers who wish to advance reproductive justice should read this book.

Joan C. Chrisler, PhD
Professor of Psychology, Connecticut College
Editor of Women’s Reproductive Health
Author of Reproductive Justice: A Global Concern

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This book is user-friendly and an absolutely wonderful resource. It is easy to read, thorough, and encourages discussions around reproductive health issues, an enormously important issue that should be addressed regularly with social work clients. I recommend it without hesitation for all social workers.

Scott Migdole, MSW, LCSW
Assistant Clinical Professor (Social Work) of Psychiatry
Chief Operating Officer, Yale Behavioral Health & the Yale Program on Supervision
Yale University School of Medicine

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This book not only provides a rationale for why reproductive health discussions matter and the factors that shape RDM, but offers concrete strategies and tools for social workers to approach the topic area with their clients. I especially love the case examples, which really highlight the complexity of women’s social and structural realities and the need to address reproductive goals and preferences in context.

Sonya Borrero, MD, MS
Director, Center for Women’s Health Research and Innovation,
University of Pittsburgh
Associate Professor of Medicine, University of Pittsburgh School of Medicine

Diane sat in front of my colleague and me looking devoid of emotion. She was about to be discharged to a lower level of care for treatment of bipolar disorder and substance abuse. She knew the discharge procedure well from previous episodes of treatment. We reviewed with her discharge plans, follow-up for continued dual-diagnosis care, living and transportation arrangements, and referrals for vocational training, and provided all the relevant literature and contact information. However, we did not discuss reproductive planning. She had five children but did not have custody of any of them. She had been an adolescent parent and had left school to work. Her psychiatric disorder and later substance abuse, combined with her lack of economic stability, led her to using sex to obtain drugs. That was the extent of what we knew regarding her reproductive decision making (RDM). When I asked the senior social worker on her case about the need to discuss contraception, I was told to “leave it to the physician,” and there was no further discussion. That was many years ago. Now I know that I would have another response.

Many considerations should be included in helping our clients achieve their reproductive goals. Increasing access to fertility treatments and addressing forced marriage could be considerations, for example. Out of the many reproductive health concerns that our clients could face, this book is focused more on unintended pregnancy. As practicing social workers, many of us have witnessed how unintended pregnancy can limit the opportunities that our clients may have and interfere with the ability of some clients to take medications and acquire intensive treatment. We also often realize that many of the populations that tend to be in contact with social workers experience higher rates of unintended pregnancy than the general public. However, the social work profession as a whole tends to do little in providing information about RDM despite the fact that the decision to have children is one of the most impactful choices that people can make. I began to question why there seemed to be so little attention to RDM when I worked as a direct practice social worker.

Certainly, there are time constraints. I know that many social workers may feel as though we are attending to problems that need our immediate attention and do not have the time to focus on prevention or reproductive health. As I transitioned into academics, I began to focus my scholarly efforts on what I had observed and experienced as a social worker practicing in the community and the psychiatric field. I also had worked for two years as an advocate for a state-level Compassionate Assistance for Rape Emergencies bill (including access to emergency contraception for rape survivors who are receiving emergency room treatment) and was troubled by policy-level issues. Using social cognitive theory helped me understand the barriers that social workers encounter in providing family planning information to their clients. I discovered that a lack of supportive agency policies and of initial and continuing education was a significant barrier. However, the results of my research did not suggest that social workers were unaware of the problem of unintended pregnancy, ignoring it, or morally opposed to discussing family planning. Instead, there was a common theme of frustration and a lack of knowledge of what to say and when. There also was an overwhelming feeling that social workers could not make a difference and did not know where to turn for assistance in discussing issues of sexuality either at work or in the community. Many felt as though pregnancy was being addressed only after the threat of unintended pregnancy. Studies suggest that, in the United States, discussing contraception tends to happen after sexual intercourse, rather than before (Beckett et al., 2010).

Despite statements from the National Association of Social Workers (NASW) supporting the notion that social workers have a professional role in providing family planning information (NASW, 2018), the national reproductive health goals of Healthy People 2020 (U.S. Department of Health and Human Services [HHS], 2010) and numerous social services programs that aim to help reduce instances of unintended pregnancy, many social workers still express a lack of understanding regarding how they should discuss RDM with their clients. The current research supports the need for social workers in community agencies to be part of the solution by addressing RDM early and often (Hock-Long, Whittaker, & Herceg-Baron, 2010). A study by Borrero et al. (2015) suggests that women do not always recognize that they have control over becoming pregnant. Many women in the study were not aware of the benefits of planning a pregnancy as opposed to a pregnancy occurring without an intention to have a child. Others are in situations that do not support their self-determination. Furthermore, women who did state a preference to avoid a pregnancy often did not use contraception in a manner that matched this desire (Borrero et al., 2015). Several health models indicate the importance of referents, including social workers, in influencing client behavior (Maville & Huerta, 2008). Taken together, these factors indicate a need to address barriers that social workers seem to be facing in their professional roles.

The idea for a social worker’s guide to help clients navigate RDM has been on my mind for several years. I am hoping that this practice book will act as a starting point in tackling barriers that social workers encounter in providing RDM strategies and information. It is not intended to be a lengthy review of every aspect of RDM. This book was instead written to be an easy-to-use guide for the busy social worker who is working with clients who may potentially be at risk of unintended pregnancy. This book is different from other books related to family planning in that it relies on, and is organized around, social cognitive theory and the theory of planned behavior, which will allow for greater understanding of social workers’ behavior in providing RDM assistance. Research has demonstrated that social cognitive theories in general are effective in predicting the behaviors or the underlying intentions of clinicians (Godin, Bélanger-Gravel, Eccles, & Grimshaw, 2008). Using Bandura’s (1986) social cognitive theory, the that for successful interventions, social workers need to (a) view the provision of family planning information as relevant to their clients and as part of their professional role, (b) feel confident and capable in providing the information, (c) feel positive about providing the information, (d) be aware of family planning information and how to provide the information, and (e) feel that their environment supports their attempts to address unintended pregnancy.

One of this book’s strengths is that it is an interdisciplinary collaboration. I am fortunate to have a colleague, with whom I have worked previously, help me write this book. She is an associate professor of biology. Our research together has focused on developing an innovative curriculum for teaching biology to social workers. Part of what makes her an incredible teacher is that she deeply understands the connection between various disciplines and can teach information in a manner that is highly attainable for people who do not have the same background that she does. She appreciates social work, takes a holistic approach to the world, and invests in promoting programs that improve society. She is also very familiar with strategies to critically evaluate and use online resources. For example, she provides guidelines for vetting online resources so students in her classes can aggregate, organize, and use information to solve real-world problems. One advantage of this process is that the documents that the students create can always be updated and can thus be relevant well beyond the end of the course she is teaching. We have applied these principles to this book. Given the changing policies and technology related to reproductive health, the ability to evaluate and use online resources is incredibly important. Thus, each chapter includes links that allow the reader to remain well versed on current information and to evaluate resources to prevent this work from becoming stagnant.

When I first started the journey to further understand the barriers that social workers face in providing family planning information, I was using my own anecdotal experiences as a social worker. After several years of research and inquiry, I am pleased to be taking the next step in creating a book with a colleague that I hope will be a useful guide for practicing social workers. The ultimate goal of this book is to improve the lives of our clients by providing more tools to navigate RDM. I hope the experiences that you have had and the information presented in this book will help convince you that this is an important issue, if you do not believe that already. Together, we have the power to make a difference.

HOW TO USE THIS BOOK

We developed this book with the idea of providing tools and strategies to help social workers and their clients negotiate RDM. The book as a whole, is like a toolbox, with each chapter providing background information and strategies that focus on core issues that are essential for effective RDM. To help connect the theoretical foundations to the actual practice of working with clients, we also have included scenarios that were developed based on circumstances shared in the research and situations that social workers have reported. We have changed details to protect confidentiality as needed.

We hope that we have been able to speak to the challenges that social workers and clients face while respecting the dignity of the individuals in the scenarios. It should be noted that gender pronoun usage in this book is based on an arguably limited gender binary. That is not to exclude the RDM of those who do not identify as either male or female; rather, these pronouns are aligned with much of the policy and research referenced in this book. We recognize the need for competent reproductive care for all, regardless of gender identity. Furthermore, NASW (2017) has stated the specific need “to provide safe, competent, non-judgmental, and confidential reproductive health services to trans women and trans men who may be in need of services that do not align with their current gender identification and expression” (p. 272).

Overall, we have tried to focus on providing tools and strategies, while connecting the topics to the lives of individuals, families, and communities. An emphasis has been put on the relevance to the social work profession and developing self-efficacy among practicing social workers. We hope that you find this approach useful.

CHAPTER DESCRIPTIONS

Chapter 1 highlights the importance of RDM to social work practice. The chapter focuses on the social work ethic of self-determination of the client and on professional obligation coupled with client risk. It also addresses gaps in interventions concerning RDM, such as those involving parents and medical professionals. Before we can take steps toward helping clients with RDM, it is helpful to understand the gaps and barriers that we may be facing. The chapter concludes with a validated measure, the Reproductive Counseling Obstacle Scale (RCOS), which is intended to be used as a tool for social workers and social service providers to help identify barriers in discussing RDM with clients (M. M. Bell & Newhill, 2017).

Chapter 2 begins with an introduction to a modified version of Ajzen’s (1991) theory of planned behavior, which has been used to understand health behavior decision making within public health. We discuss how the theory could be applied to understanding client RDM. Case studies are used to illustrate the use of the theory with clients. We hope that providing this model will increase self-efficacy in discussing reproductive options with clients and place such discussions within a public health framework, thus shaping, or reshaping, attitudes about providing this information. As provided in this book, the theory of planned behavior is intended to offer a strategy that will further allow social workers to take action in assisting their clients with RDM.

Chapter 3 uses a reproductive justice framework to approach clients and advocate for policy change around issues related to RDM. Reproductive justice is a good fit with social work practice and social work ethics and connects to the goals of this book. This chapter provides current reproductive justice objectives and examples of historical U.S. reproductive policy with a focus on the outcome of those policies on individuals, families, and societies. Lessons that can be gathered from these examples are also included. This chapter aims to connect social work direct practice and advocacy to reproductive justice while building on the theory of planned behavior. Tools to promote policy advocacy are included.

Chapter 4 focuses on the role that beliefs, facts, and opinions play in RDM. The section ends with tools that can be used to evaluate resources, including those online, to help social workers and their clients use online materials and those published otherwise. Although people have access to exorbitant amounts of information, many do not know how to critically evaluate the material that they find. Policies, methods, and technologies change. Our goal is to help social workers and their clients evaluate the timeliness, relevance, objectivity, and quality of resources for use in a dynamic society. Access is key as well. If clients believe that family planning methods are out of reach due to cost or are inaccessible for other reasons, they will be less likely to pursue the method under consideration. Information about where social workers and their clients can obtain family planning is provided.

Chapter 5 focuses on increasing social workers’ confidence and comfort in providing reproductive-planning information. It also includes additional resources that social workers can use to provide relevant and accurate information about reproductive biology to their clients. Specifically, the chapter covers family planning methods, including who should use them, their effectiveness, and body literacy. Common myths are also addressed. Links to high-quality and timely online informational sites used across various cultures and countries are provided.

In the last chapter, strategies to address reproductive counseling are discussed and connected to earlier portions of the book. Social workers and other social service providers work with very diverse populations, each with unique strengths and challenges. Patient-centered approaches to clients that place client self-determination at the forefront are emphasized. This chapter presents programs and best practices that have been found to be effective and incorporates scenarios and tools from earlier in the book.