Choice: Anu Manchikanti Gómez conducts research to advance reproductive self-determination

May 15, 2020

Anu Manchikanti GomezExperiences of sexuality and reproductive health are both deeply personal and nearly universal; Associate Professor Anu Manchikanti Gómez’s work explores the intersection between individual decisions, medical systems, and social structures. 

Her interest in maternal health and reproductive decision-making is rooted in her upbringing. In her Kentucky high school, she explains, “I'm pretty sure we were supposed to have abstinence-only sex ed, but I just didn't have anything.” And during childhood trips to visit family in India, she heard how her grandmother had given birth 16 times, but only eight of those children survived to age five. These lived experiences, among others, drove Gómez’s curiosity in understanding the layers of influence that play out in people’s sexual and reproductive lives.

Today Gómez leads the Sexual Health and Reproductive Equity (SHARE) Program, whose mission is “conducting rigorous research to advance the understanding of what it takes for individuals to have the families they envision, to realize reproductive self-determination, and to experience healthy sexuality.” She was honored in 2017 by the Bill & Melinda Gates Institute for Population and Reproductive Health at the John Hopkins Bloomberg School of Public Health as part of the “120 Under 40: The New Generation of Family Planning Leaders” program. She was also the recipient of the 2017 Outstanding Young Professional Award from the Sexual and Reproductive Health Section of the American Public Health Association.

A key area of Gómez’s work focuses on lived experiences of contraceptive use. In contrast to the dominant discourse around contraception that focuses on method effectiveness, Gómez’s work holistically considers the range of factors that come into play as people choose and use  — or don't use — methods, particularly long-acting reversible contraceptives (LARCs) like IUDs and implants. Focusing solely on method effectiveness implies that is the most important metric and therefore implies that IUDs and implants are therefore the gold standard. Through rigorous, mixed-methods research focused on people's preferences rather than method characteristics, Gómez aims to bring a more nuanced understanding of the factors that influence decision-making. 

In one of Gomez’s studies with Black and Latina, young cisgender women in the Bay Area, one of the strongest themes that emerged was that people wanted agency over their contraception. Internal contraception, like intrauterine devices, was perceived as more invasive, even among those who had previously used it. Access to health care was a significant factor as well, with a number of the women expressing concern about their access to insurance when it came time to remove the device. Patients who reported negative and judgemental care related to contraception — from dismissal of side effects to outright refusal to remove a device — were significantly more likely to prefer methods that did not require interaction with a health care provider. The study results, published in an article entitled “‘It would have control over me instead of me having control’: intrauterine devices and the meaning of reproductive freedom”1 highlight what Gómez calls “the contraception paradox — that contraception can be both a source of empowerment and agency for women who wish to control their fertility and a source of oppression for women deemed socially undesirable reproducers.”

Gómez’s other work also reframes dominant paradigms around family planning by centering the lived experiences of groups at the greatest risk of reproductive oppression. “It's Not Planned, But Is It Okay? The Acceptability of Unplanned Pregnancy Among Young People”2 reframes the standard categories of “planned” and “unplanned” pregnancies into “acceptable” and “unacceptable.” This alternative categorization highlights how individuals most affected by social inequality have the least opportunity to formulate, actualize, and realize their pregnancy desires, rendering some pregnancies as “unplanned” because social conditions do not support reproductive self-determination. “‘Is That A Method of Birth Control?’ A Qualitative Exploration of Young Women’s Use of Withdrawal’”3 examines an under-studied practice and provides recommendations for including it in provider-patient conversations around contraception. An upcoming study will focus on how COVID-19 (and the related recession) is changing people’s preferences around pregnancy and timing, with a focus on how low-income workers make decisions with the added constraints of shelter in place, job loss, and other stressors.

Gómez has also received acclaim for her work on the rollout of pharmacist-prescribed contraception in California. Since 2016, California pharmacists have been authorized to prescribe short-term, hormonal contraception. Gomez’s 2017 study4, published in JAMA, revealed that only 11% of pharmacies engaged in the practice. In another study5, she explored facilitators and barriers to implementing pharmacist-prescribed contraception. These data revealed that pharmacists were aware of the role that they could play in reducing healthcare costs and increasing community access by prescribing contraception. However, the primary barriers to offering this service were logistical: the physical layout of stores was not conducive to private consultations; staffing levels did not allow time for extended conversations; and pharmacies and insurers are not set up to bill for consultations. 

Gómez is currently engaged in an ongoing study of the implementation of pharmacist-prescribed contraception in Tulare County in the Central Valley. Under a grant from the Robert Wood Johnson Foundation Interdisciplinary Research Leaders Program, Gómez is now partnering with ACT for Women and Girls, a Visalia-based reproductive justice organization, and UCSD, to examine community members’ needs and preferences around pharmacist prescribing of contraception in a region where contraceptive access in rural areas can be difficult. This study will identify strategies to support more pharmacies in offering this service, in ways that align with community needs. And by working closely with a community partner in a collaborative effort, study findings and community solutions will go hand-in-hand.

Community partnership is a hallmark of Gómez’s ongoing research. In another project, Gómez is partnering with SisterWeb, a nonprofit that aims to provide culturally competent birth and postpartum care to communities that experience higher risks of preterm birth and other adverse outcomes. The SHARE Program is working closely with SisterWeb to conduct a collaborative evaluation that identifies strategies for successful implementation of community doula care programs. By interviewing clients, doulas, mentors, and labor and delivery care providers, the project aims to build a holistic picture of successes and barriers in implementing the program. 

Gómez stresses that research and evaluation conducted in close partnership with community organization is not the typical approach, where the “objective outsider helicopters in, doesn’t really understand the community very well, and never shares back the findings.” Rather, community partnership constitutes a paradigm in which “we're trying to really center equity and justice in knowledge production. You can't do that if the only people who are really making the decisions about what we study, how we do research, and what data mean are those who are already in positions of power and privilege in academia.”

Given the sample size for San Francisco’s community doula program, it’s unlikely that the study will be able to measure the impact of community doula care on birth outcomes like cesarean section rates or preterm birth. However, they will be able to assess the effect of doula support on experiences of birth and engagement with prenatal and postpartum care. And while Gómez is a strong believer in doulas’ ability to support clients in better birth experiences, she is circumspect about doulas’ ability to counterbalance bias in healthcare systems. 

“The reason those risks to maternal health in the Black community exist are because of racism and the historical, ongoing trauma that's faced by Black people in the United States. To say that a doula from the same community can interrupt that is very powerful. But while doulas can push for better care for their clients, they didn’t create these broken systems, and we shouldn’t put the burden of fixing them on their backs.”

With other pilot programs for doula care springing up around the state, Gómez hopes to be able to expand the scope of her inquiry in a way that would yield more information about maternal and infant health outcomes, as well as the feasibility of MediCal reimbursements for doulas.

All of Gómez’s work plays out against the backdrop of the political landscape around reproductive health care. Revisions to the Title X program, the federal family planning program for low-income individuals, have led to an erosion of access to high-quality reproductive healthcare in under-resourced communities. A current Supreme Court case stands to reduce access to contraception through employer-sponsored health insurance, and access to abortion is under threat both from state laws and from another Supreme Court case. 

Gómez’s work is vital under any circumstances, but particularly so in today’s political climate, where it is more important than ever to prioritize the experiences and needs of under-resourced communities and ensure access to high-quality, affordable care that supports all people in self-determining if, when, and how they want to become pregnant.

 1.Gómez AM, Mann ES, Torres V. (2018). "‘It Would Have Control Over Me Instead of Me Having Control’: Intrauterine Devices and the Meaning of Reproductive Freedom.(link is external)" Critical Public Health 28(2): 190-200.https://www.tandfonline.com/doi/full/10.1080/09581596.2017.1343935

2. Gómez AM, Arteaga S, Ingraham N, Arcara J*, Villaseñor EV. (2018). "It’s Not Planned, but Is It Okay? The Acceptability of Unplanned Pregnancy Among Young People." Women's Health Issues 28(5): 408-414. https://doi.org/10.1016/j.whi.2018.07.001

3. Arteaga S*, Gómez AM. (2016). “`Is That a Method of Birth Control?’ A Qualitative Exploration of Young Women’s Use of Withdrawal.” Journal of Sex Research 53(4-5): 626-632.

4. Gómez AM. (2017). "Availability of Pharmacist-Prescribed Contraception in California, 2017. JAMA 318(22):2253-2254

5. Anu Manchikanti Gomez, Colleen McCullough, Rafaela Fadda, Brittany Ganguly, Elena Gustafson, Nicolette Severson & Jacob Tomlitz (2020) Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies, Women & Health, 60:3, 249-259, DOI: 10.1080/03630242.2019.1635561