Authors: Rhea Manohar, MPH; Leah Liszak; Dr. Divya Krishnan on behalf of AMWA’s Gender Equity Task Force
When a group of Congolese refugee women began visiting a community clinic for regular check-ups and catch-up vaccines, the medical team quickly realized that health care needed to be about more than just immunizations. These women were entering a new system of care, one that often assumed a universal understanding of contraception and family planning regardless of a patient’s background. Yet, their lived realities were far more complex.
In their communities, reproductive decision-making was often not their own, but a joint one or male-centric. From the practitioners’ initial lens, men were seen as the ones who “owned” fertility choices. Yet as the medical team sat with them and listened to their stories, the real truth emerged: being a mother and having children was often deeply rooted in their cultural identity. For some women, having children served as their primary purpose within the family unit. Others had competing internal views on prioritizing personal benefits of decreasing pregnancy and childrearing-related burdens versus the perception of their role in the eyes of their male partners and the broader community.
The clinic began to reframe these visits, creating space for women’s voices to guide the conversation. After requesting the family to step out for routine women’s health conversation, the buried truth finally was uncovered. The medical team asked:
- Do you want to have more children?
- Do you feel ready for another pregnancy?
- Have you heard of birth control options?
These questions, simple yet profound, gave women the chance to name their desires—often for the first time without fears of judgement. This practice of active listening was as essential as any clinical guideline. It wasn’t about giving a lecture; it was about hearing a woman’s own words and building care around them based on their culture, personal values, and future planning. These conversations—driven by the physician’s curiosity and desire to better understand the needs of their patients—continue to return the lost autonomy that these women have desired for generations.
The options were laid out clearly but respectfully taking into account apprehensions about partner awareness of the contraception. For many, Depo-Provera injections given alongside catch-up vaccines was the best choice, because of their inconspicuous nature. When it came to IUDs, cultural concerns often surfaced—“my husband is going to feel it”—revealing the need to talk through relational dynamics alongside medical facts. Younger women often gravitated toward the Nexplanon implant, drawn to its discretion and long-acting nature. A few considered oral contraceptives when their own feelings of not wanting to grow their family were shared by their partner.
What became clear in these conversations is that contraception is not just about physiology—it’s about identity, partnership, autonomy, and culture. Physicians cannot prescribe effectively if we do not also listen. Our role is not to push one method over another, but to equip women with information, respect their context, and support their choices.
Part of this support includes education about health risks that may not be obvious. Back-to-back pregnancies—those occurring less than 18 months apart—carry higher risks: preterm labor, maternal anemia, uterine rupture, and newborn complications such as low birth weight (Conde-Agudelo et al., 2006; ACOG, 2019). The World Health Organization (WHO) and American College of Obstetricians and Gynecologists (ACOG) both recommend spacing pregnancies at least 18–24 months apart to allow a woman’s body to heal and restore nutrient stores (WHO, 2007; ACOG, 2019). Refugee women on average have polarizing maternal ages, some seen in teenage years and others in their 4th decade of life. Which presents its own risks such as chromosomal abnormalities, birth defects, complications, etc. (Agbemenu, K et al., 2019).
But telling a woman “back-to-back pregnancies are dangerous” is rarely effective. A culturally sensitive approach reframes the message: “Your body needs time to heal between pregnancies—resting your womb now helps protect you and your next baby.” It’s a shift from prescriptive to supportive, from directive to collaborative.
Cultural sensitivity in contraception counseling means more than offering a menu of methods. It requires sitting down, listening deeply, and holding space for ambivalence, fears, or competing family expectations. It means affirming that each woman’s voice matters most in decisions about her reproductive health.
Physicians can help by:
- Practicing active listening, ensuring patients feel heard rather than lectured.
- Framing choices in culturally meaningful ways, connecting health recommendations to women’s own values and goals.
- Balancing evidence with empathy, grounding education in medical facts while respecting cultural narratives.
- Empowering autonomy, making sure women leave the clinic not only with a method, but with confidence that the decision was truly theirs.
At its heart, contraception counseling is about far more than preventing pregnancy. Culturally sensitive contraceptive counseling means creating space for women to articulate their desires, balancing respect for tradition with evidence-based care. For refugee and immigrant populations in particular, it is critical to recognize the weight of cultural norms while offering education that highlights maternal safety and reproductive autonomy.
When we ask—not assume—what women want, we shift the narrative. We move from a history of paternalism toward a practice of partnership. And in doing so, we affirm that contraception is not just about preventing pregnancy, but about safeguarding women’s health, dignity, and choice.
References:
- American College of Obstetricians and Gynecologists. (2019). Interpregnancy care: ACOG Obstetric Care Consensus No. 8. Obstetrics & Gynecology, 133(1), e51–e72. https://doi.org/10.1097/AOG.0000000000003013
- Conde-Agudelo, A., Rosas-Bermúdez, A., Kafury-Goeta, A. C. (2006). Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. JAMA, 295(15), 1809–1823. https://doi.org/10.1001/jama.295.15.1809
- World Health Organization. (2007). Report of a WHO technical consultation on birth spacing. Geneva: WHO. https://apps.who.int/iris/handle/10665/69855
- Agbemenu, K., Auerbach, S., Murshid, N. S., Shelton, J., & Amutah-Onukagha, N. (2019). Reproductive Health Outcomes in African Refugee Women: A Comparative Study. Journal of women’s health (2002), 28(6), 785–793. https://doi.org/10.1089/jwh.2018.7314
About the Authors
Rhea Manohar, MPH, MS3
Rhea Manohar is a third year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology, Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed and implemented hands-on workshops to further reproductive health issues and bolstered medical students abilities to navigate physician-patient communication. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force and Reproductive Health Coalition within the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.
Leah Liszak, MS3
Leah Liszak is a third year medical student from St. George’s University. She has a Bachelors of Science in Biomedical Science from Oakland University in Auburn Hills, Michigan. She served as the SMILEs Orphanage Home Coordinator of the St. George’s University Humanism Service Organization in St. George, Grenada where she fostered impactful relationships with at-risk female youth and developed seminars to educate, encourage, and engage their personal growth. She is also a member of the Gender Equity Task Force with the American Medical Women’s Association. When she is not pursuing medicine, you can find her enjoying time with friends and family, working towards athletic pursuits in the gym, and testing new pastry recipes.
Divya Krishnan, MD
Dr. Divya Krishnan obtained a medical degree with honours at the University of Medicine and Health Sciences, St. Kitts. She is passionate about preventative medicine and community medicine. She believes that we can only begin to move towards good health for all patients, with health equity and consistent community education led by healthcare workers. When not working in the medical world, she spends her spare time learning outdoors (hiking, rock climbing, gardening), learning indoors through reading books, and studying to brainstorm creative ideas for how to improve her practice as a whole- for her patients and for her co-workers.