Factors that influence sexual and reproductive health and rights (SRHR) are many, interrelated, and operate at various levels (1). Researchers have demonstrated that factors such as the economic status, residence, agency, sociocultural and gender norms, and the affordability, accessibility, and acceptability of reproductive health care services influences sexual and reproductive health decision-making, experiences, service use, and outcomes (1)(2)(3). Furthermore, from the psychology literature, cognitive factors such as past experience and biases (4,5) have emerged as important influences on decision-making. As an example, medical mistrust on the part of the patient, resulting from an experience of poor-quality healthcare and/or the expectation of poor treatment by healthcare professionals has led to lower engagement with medical services among Black women in the United States (US) (6).Evidence on the factors that influence the sexual and reproductive experience of Black women is growing (7)(8)(9) but few studies have applied a reproductive justice framework to their analyses (10) and few have assessed how social realities might constrain or influence Black women's decision-making and family planning agency (11). Understanding the social reality is especially important as Black women in the United States, navigate a complex array of structural barriers related to their race and gender. Black women experience the highest rates of poverty (12), have lower access to comprehensive sexual health information (13), lower access to reproductive healthcare services (14), and have a well-established history of poor sexual and reproductive health experiences (15).Many of the structural barriers shaping Black women' s lives are embedded in the environments where they reside. Nearly 60 % of the Black population in the United States resides in southern states (Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and District of Columbia) ( 16)-a region considered a hostile reproductive health environment. The south contains the highest concentration of counties without a single obstetrician or birthing center (17), faces severe shortages in obstetricians and gynecologists (18), requires their sex education programs stress abstinence (19), and enforces some of the most restrictive abortion policies, including total or near total abortion bans, prohibitions on telemedicine for abortion, and six-week gestational limits (20). Compounding these barriers, many southern states have not expanded public health insurance under the Affordable Care Act, leaving many low-income populations uninsured and facing high out-ofpocket costs for contraception (21) At the same time, the legacy of redlining and chronic underinvestment in schools in predominantly Black neighborhoods has produced enduring inequities in education, employment, and economic security (22,23). These structural disadvantages directly undermine factorssuch as higher educational attainment and stable employment-that research identifies as critical to women's autonomy in healthcare decision-making (24).Aside from structural barriers, Black women in the United States have been subject to decades of negative portrayals of Black motherhood. Harmful rhetoric of Black mothers as "welfare queens" (25) and "crack mothers" (26), individuals who intentionally have children and misuse or abuse social systems, led to Black mothers being viewed as a drain on society and as unfit parents (26,27). While anti-abortion campaigns stating that "the most dangerous place for an African American is in the womb" weaponized abortion use within the Black community (28). The impact of these narratives lives on, as Black women are consistently subjected to surveillance and scrutiny (29,30) and uniquely discriminated against (31). As a result, Black women face a constrained landscape for reproductive decision-making and agency, shaped not by individual choice but by the cumulative weight of systematic inequality and discrimination.In this paper, we use qualitative data collected from Black women living in two southern states-Georgia and North Carolina-two states with a large concentration of Black women and a mix of supportive and restrictive reproductive health policies. We aim to identify factors that influence pregnancy decision-making and family planning agency. We use a reproductive justice lens (32) to make connections between these factors and the social context as well as to showcase family planning across the full spectrum, from no children to adoption. Finally, we leverage the community-based participatory framework study approach to bring forward relevant and targeted community strategies to enhance Black women's reproductive decision-making and agency.We use narratives from a qualitative community-based participatory research study that aimed to understand the (1) reproductive health experiences and concerns of Black women living in Georgia (GA) and North Carolina (NC), (2) the range of factors influencing Black women's reproductive health decision-making, and (3) strategies that could engage and/or improve Black women's reproductive health experience.Black women from a reproductive justice organization and a nonprofit research organization (the study team) collaborated with two Black-led community organizations and a Black Research Board to conduct the parent study. Additional details on the study approach are documented elsewhere (33).All members of the study (study team, community organizations, and research board) identify as women who have sought sexual and reproductive health services. We focused on geographic settings with a larger concentration of Black women (15% and higher) and with different reproductive health environments. Approximately 15 states have a proportion of Black women that is 15% or higher. From within these states, we selected two with a similar mix of supportive and restrictive reproductive health policies (e.g., Medicaid expansion, abortion restrictions, contraceptive equity law, etc.) (34) and where the reproductive justice organization had partners who could support study implementation.The community organizations recruited participants for and conducted focus group discussions with 8-10 participants each. Focus group size was based on literature recommending 6 to 10 participants (35) and participant availability during scheduling. The study team trained community organizations in conducting focus-group discussions before the study was launched. Participants from the focus group discussions who wished to share more about their reproductive health experience were invited to complete an in-depth interview with a member of the study team. Data was collected between May 2019 and January 2020.To participate in the study, people had to be between the ages 18-49, speak English, self-identify as Black or African American, and live in Georgia or North Carolina for at least 2 years. Participants with a range of educational and economic backgrounds were recruited from urban and suburban centers, through social media, flyers distributed at health clinics, other community organizations, and other spaces where Black women in the community could be reached. Interested participants were screened by telephone to assess their eligibility to participate in the study. To allow the community partner to schedule focus group discussions at a time that works for participants as well as create age-specific focus group discussions, eligible participants were asked to complete a short demographic survey over the phone and to provide days and times when they could participate in a focus group discussion. Recruitment activities were the same in each state. Focus group discussions were divided into three age groups; two younger (18)(19)(20)(21)(22)(23)(24), one older ; and three mixed . In-depth interviews were conducted with women across the age groups. Recruitment concluded when the study team determined, through transcript review, that we had met thematic saturation.Focus group discussions covered related to sex education, family and sexual health care (e.g., the in-depth interviews focused on healthcare decision-making. These were based on a of the sexual and reproductive health literature and through with the Research We a to to each As an focus group participants were of Black (e.g., same single and and to when this on the participants partners conducting the focus group were trained to each more about the are some of the with the are the of Black women this and other concerns related to this that have not been Participants were to on each and to their and/or community in-depth participants were asked about their and past reproductive health with about their health and more about their reproductive were asked to on their reproductive health concerns they have with their reproductive and experiences with reproductive health such as participants to and they as While the of the we that and gender Black individuals be or by the factors that emerged in this study. participants that they were in same sex during discussions, a few participants family of group discussions and interviews were and for participants for in a focus group and an they an in-depth The study was and by an the the parent study, the research team a and to the in the interview was from based on concerns for data The study team a based on the interview and from the sexual and reproductive health focus group transcript and two interview were by two members of the study team and were by the study team. To with their and across the study team at time including before they were with community and community study team member an from and The during interviews and focus group and were during thematic were to larger members (the study team, research and community and the and that emerged from the or were during community with the of the data and in how to to the study team members and have experience and qualitative data related to sexual and reproductive including in and experience conducting this paper, we a thematic to identify from within the healthcare and family We by the full range of sexual and reproductive health experiences such as abortion, across the three We from each of these experiences related to reproductive justice to have a and to not have a . this study, these were as pregnancy to pregnancy decision-making related to and family planning agency to and family planning We these to create that various influences on pregnancy pregnancy decision-making, and family planning agency. the reproductive justice framework is that factors operate across levels and in or more one could a we based on structural or an for the reproductive health decision-making, family planning agency, or pregnancy As an economic were most relevant to the that structural barriers that family planning the we for that emerged based on the education, insurance status, and state. were based on the research The qualitative data was the from focus group discussions and interviews are by and participant group in the of focus group women in the from North Carolina and from focus group discussions, in Georgia and 2 in North Carolina were and a of participants from Georgia and from an in-depth focus group discussions in-depth interviews Participants in education, from high or to of the participants a participants being full of the participants had health insurance and to had insurance through a or in from to but the age in states was years. participants on their pregnancy history but of who had pregnancy emerged from the influences on pregnancy decision-making, and family planning agency. and factors were as for pregnancy and decision-making and economic factors family planning agency. The to the and community strategies that could improve decision-making and agency among Black in were by education, or insurance we by group for the social and with younger participants a negative influence of social and factors on pregnancy and decision-making. are by from focus group discussions and in-depth interviews in the social context Black pregnancy and decision-making. their social and participants at the community and and experiences of as single was as a community and that pregnancy decision-making. was within their and at a as the for Black for this was portrayals of Black a no the has a or the that their is to is that Black is single and and at were viewed by Participants that single into of partners in more for economic and negative about participants pregnancy as a for Black women based on their that not within the context of a or stable negative in younger no to experience economic the of or as a for pregnancy and a for family a larger of security or be in a more or to and that for the women and with the single participants that within the community led some Black women to from their for no to when they a for no to have to their for no and to To this some the services that with their family planning such as abortion of with that the society viewed Black as and The that Black were not within society was and a of when with community participants that a community more and for Black the by the that women's were not had younger participant on how that Black pregnancy was into Black women that a of we in Black women as is for Black women more people about their or these other to to the or about Black women to more to from Finally, experiences, with within and across about the poor care and treatment Black women during pregnancy and as well as of high rates in the states, pregnancy was especially for younger participants that their negative and the negative experience of other Black women within medical such as and their to impact of experiences and of medical were by concerns about in a surveillance of Black an and against Black as Participants that these concerns were when pregnancy a and to and The impact of this on pregnancy for was across age pregnancy and decision-making, participants that health systems, economic and policies their family planning with the health Participants how past with healthcare their of autonomy and their to make reproductive healthcare services and participants related a of being by and the medical and treatment that was of this when participants the high and poor treatment of reproductive such as and within the Black participants that discussions that their reproductive such as of Black women from and no one about we for been to a of not be to have family planning or how to is to have that that of Carolina, with about to pregnancy and/or their not be or into As one participant (the be to to have to but and we are to into that was that we is We people to to we with Carolina, details about contraceptive from their healthcare more and about the as well as into and be most that they to the from and/or poor experience with an led to the without a contraceptive they not to a to and/or were no and insurance were as a and to family planning influencing agency. insurance was as to family planning women to or Participants with insurance were to pregnancy abortion and participants the of insurance including that some family planning services were not covered or were Participants with health insurance and no insurance were especially to the of people in their community with health who without insurance for of time, or have no insurance at about health insurance were to that many of the to and in the community were no insurance and that insurance in these could health insurance of was not considered was for family planning at as more the of insurance participants to their over to health or that services for or on a insurance some participants were into one a participant with no insurance at the time of being to a pregnancy to a pregnancy center for a pregnancy to the across and insurance as a within Black that these in or no engagement with family planning services. in to insurance participants that with they had to health services a discussions abortion, and contraception participants their to services they not have the Participants the high of service that could to a were their and other Black women's for who not to have an to the of abortion and contraceptive such as were was a of time where was to with at the and we understand to and a a The of that is was no Carolina, not to have children at a in time or policies to access or engage with family planning services such as participants abortion in the larger context of reproductive (1) the of as are and (2) the impact of the on Black and (3) a about the of to Black women's especially in the Georgia focus group discussions, were to that abortion At the time of the study, the of Georgia had a to abortion services in the of The a range of among from to participants as an to of family for Black women with no for or who face While to were as and such as their and was as more for Black To or a the family is subject to considered has a impact on Black against their As one participant when through they have to through in the in the African American we that a of people and have been or have some of or against have a a or in that has of that from for most Black that they have to against a Carolina, of the factors that pregnancy decision-making and family planning agency were with and community strategies to their participants that were were more focused on they or the Black community could to improve reproductive decision-making and the individual participants a Black as a to enhance the decision-making and agency. Black were as more and to family planning While was that this was especially in and more participants that the of and to a Black were the community participants the for more within the Black community to pregnancy and decision-making as well as with that spaces a of the and by who not to have children or who are to have we to more about the Black women Black women who to have to be but for a that to have a and a of women who are Participants the to use the to Black women in their with more information on (1) reproductive health and the for (2) supportive health services such as for and (3) services such as they Black women more to their family planning as well as on Black for the society their children are being participants that the community a and for Black and on how to to their children about information might some of the and negative Black participants the community for different and portrayals of Black to of Black women Black women and of Black without children and family Participants that these portrayals within the Black community about the full of pregnancy the of or this spectrum, they could of a range of family planning and family including abortion and the focus group discussions, participants that of Black could in the community to about Black pregnancy and single the participants at during the discussion. As an participants their about single being during the focus group discussions and against the a in Black family the different that family members in and that the of a single parent on a family as a to a that for for and not that when that to be or study on pregnancy pregnancy decision-making, and family planning agency the experiences and of a of Black women in two southern From qualitative we and structural factors pregnancy and decision-making and family planning agency. of Black pregnancy in to of Black women led some to constrain their family planning and/or from their family planning poor pregnancy and outcomes (e.g., high rates of for Black women the related to some to to the on medical and the resulting by Black women that mistrust of the medical Black women's decision-making pregnancy this by that some Black women to pregnancy of this on single norms, economic and lower from the study the stress and with that this stress and pregnancy and pregnancy decision-making from participants a more impact of partner on pregnancy or These could be to in applied and/or in the study women in study that living in a context where Black people are more to be and their a of children and that when some Black women were While literature the impact of during pregnancy and birthing to the literature by that the pregnancy that from experiences of before pregnancy and study, participants and for Black their children to some of the is in with a in the literature that African have to their children for and the of these that strategies such as a for Black could be in the pregnancy to Black women who are a family in pregnancy or research identifies as a that how to such as African American a relevant to Black and from the of of and could be in community settings to the some Black women pregnancy of Finally, for community spaces to health information could be to and/or support for has been for other health in the Black community and could be for this between and Black in the United States are well from the for American that Black women Black are in in health insurance and face higher uninsured rates their Finally, North Carolina and Georgia have and that the this is no that and in health insurance emerged in study as structural factors shaping family planning agency. While health insurance support family planning agency, policies that of reproductive health services or services as Black women to to access constrained this and in some women being to in were by to in reproductive health environments across the two The two southern states have abortion restrictions, for have Medicaid expansion, and contraceptive equity that not of contraception on the influence of factors on abortion Participants viewed these as they are in spaces where many Black women live and they access to a service that could women their family size or While is the impact of economic and factors on family planning study bring the of Black women who not to have who might and who are with into Black women's pregnancy decision-making is not to their social a reality where Black pregnancy is and and where medical could be or factors the impact on insurance and health service (e.g., abortion and abortion have on a population that is more to abortion and contraception services to in the of pregnancy or on pregnancy and decision-making and family planning agency. As an abortion, and people who not these to and to some not services such as abortion to these are with factors such as insurance or restrictive agency. on the some Black women other qualitative and that the social and We to the literature by the of factors such as and that is an important for Black study some community into could have a impact on Black pregnancy pregnancy decision-making, and family planning and are among the narratives in study that the context within pregnancy decision-making These narratives emerged at the community and society narratives and their such as the negative of Black in the more and to such as about the use of reproductive in and social While was of the of these and against negative narratives related to the to not have children as well as the of single Black parents being the family in Black and for different and more and narratives as well as are among the that be to in and that support for different narratives for organizations that use these strategies to reproductive and that operate public to Black women across the to of Black and to Black women in a range of family planning from to to in discussions of reproductive participants the of within the on approach that has been to African American women about reproductive health be to to narratives pregnancy and family planning in Black The of these and the Black is to support Black women's autonomy in their sexual and reproductive the for more spaces where health information could be with Black services at community-based organizations that center Black people and access to sexual and reproductive health care could be or organizations (1) health information and health ( (2) provide spaces for Black women to and share and (3) and community to for within larger from this qualitative study are and to on medical research studies could the impact of (1) policies and/or programs on in family planning and (2) race in family planning on Black women's pregnancy and family planning agency. these studies could to understand of and are in of race or qualitative studies on pregnancy and family planning agency with Black women living in different geographic and the through the factors influence pregnancy pregnancy decision-making, and family planning agency. We that with participant for pregnancy decision-making and family planning agency within the Black of these programs could be conducted to assess (1) in sexual health and and (2) these programs could be across other community this study not to to abortion of on abortion in health insurance could use these to Black women's of such as to to Black women's and to how insurance family planning agency within this the of Black women recruited from clinics, community and living in the experiences of Black women living in as well as Black women with higher is from factors to these be from some of the factors that emerged in analyses not or influence at a on these of we from the literature that experiences of in the across and and that reproductive birthing are not for Black women with higher education or higher While we the that were of the most to not participants directly about the factors that pregnancy and family could have produced and/or factors covered in this We were to pregnancy from participants who in a focus group discussion. of the three participants without pregnancy history could not be from Finally, were with and by community members community organizations, and reproductive justice they were not with have the study by that the to the qualitative data participant from Black women in two southern states to the many factors that influence pregnancy pregnancy decision-making, and family planning agency. the important of community norms, negative medical with economic and These for to narratives Black pregnancy as well as for in and sexual and reproductive health studies qualitative research on pregnancy and family planning agency with Black women in different geographic and to the through the factors etc.) influence pregnancy pregnancy decision-making, and family planning agency.
Thompson et al. (Mon,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: