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Women’s stories of reproductive life in rural California: a qualitative study

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Women’s stories of reproductive life in rural California: a qualitative study

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Women’s Stories of Reproductive Life in Rural California: A Qualitative Study

Melissa Bird, MSW

Suzanne Dworak-Peck School of Social Work
Graduate School
University of Southern California

Doctor of Philosophy, Social Work
May 2017

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 2

“Women’s rights are human rights, and human rights are women’s rights.”
Hillary Rodham Clinton

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 3
Dedication
I dedicate this dissertation to several important key figures in my life, including my
grandmother Mary Valentine, who taught me that love is unconditional; my aunt Nancy Young,
who taught me that politics and political activism are women’s spaces; and my mother, Christina
V. Larsen, who is the bravest person I know. To my husband, James T. Kelly, and my three
children, Katelynn, Gwendelynn, and Sean: The road was bumpy but your fierce love and belief
in my purpose on Earth kept me going through it all. To my wonderful friends Matthew Denckla,
Julie Jensen Nelson, Kristen, Marci, my goddaughter Lili, our nanny Ashley, and so many others
who kept me going when I was at my best and my worst, thank you so much. To Dr. Caren Frost
for supporting me then and now, you will never know what your mentorship and friendship mean
to me. To Dr. Gretchen who is my absolute rock-solid compassionate PhD shero, thank you for
everything you have given me through this process. And finally, to Eleanor Roosevelt, whose
words of inspiration and constant reminder to do one thing every day that scares me propelled
me out of my imposter complex and forced me into a world that I never thought would have me.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 4
Acknowledgements
I would like to thank the committee members who supported my efforts in writing this
dissertation.
To my chair, mentor, and friend, Dr. Julie Cederbaum, thank you for your passionate
belief in women’s reproductive health and in my ability to tell women’s stories. Your support of
me throughout my doctoral studies has sustained me through some of the most difficult days. I
am blessed and honored to have had you as my scholar-in-chief and I will be eternally grateful
for you taking me on as your wayward student. Without your help and support along the way,
this dissertation would never have come into being.
To Dr. Suzanne Wenzel, there were moments in my first years of this program when our
passionate discussion about women’s bodies and the politics of reproductive health were all that
got me through a day. I admire the work you do so very much and it has been a true honor to
work with you on the national stage as we work to bring justice to homeless women.
To Dr. Luanne Rohrbach and Dr. Lourdes Baezconde-Garbanati, thank you for joining
this team of extraordinary women in this process. Your contribution to this work has been
invaluable. I admire your guidance and your way of providing feedback that has helped me grow
as a scholar. Thank you for taking the time and effort to support my doctoral education. It is my
sincere hope that your time on this committee has been as beneficial to you has it has been for
me.
To Ariana Ramos, thank you for bearing witness to the amazing women who were
willing to share their intimate stories with you and for being a most wonderful research assistant.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 5
I would be remiss if I did not thank the incredible men and women who work at
community health centers and Planned Parenthood clinics, tirelessly ensuring that the most
vulnerable women have access to high-quality health care in the most rural parts of California.
To my entire gang of barista feministas at Bodhi Leaf Coffee in Orange, CA. I promised
you a mention in my dissertation if you kept making the perfect rose latte. Thank you for your
continued love and support of my work. I am so happy that I can share my research with you and
that it has informed the way you look at the world.
Last, I would like to thank the brave women who took the time to participate in this
research and let their vulnerability shine through. I honor you and cannot describe the humility
with which I present your most intimate lives. To every woman who has shared with me your
deepest secrets and your darkest regrets, I see you and hold space for you in my heart. Until all
of us are free, none of us is free. Without you, none of this work would have been possible.

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Table of Contents
Dedication ........................................................................................................................................ 3
Acknowledgements ......................................................................................................................... 4
Abstract ............................................................................................................................................ 8
Chapter 1: Introduction .................................................................................................................... 9
Chapter 2: Review of the Literature .............................................................................................. 11
Introduction ............................................................................................................................. 11
Previous Research ................................................................................................................... 16
Theoretical Framework: Madonna–Whore Binary .................................................................. 17
Definition of Terms ................................................................................................................. 20
Chapter 3: Research Methods ........................................................................................................ 24
Study Purpose .......................................................................................................................... 24
Research Design ...................................................................................................................... 25
Participant Recruitment and Screening ................................................................................... 26
Data Collection ........................................................................................................................ 26
Ethical Considerations ............................................................................................................. 28
Data Coding and Analysis ....................................................................................................... 28
Summary .................................................................................................................................. 29
Chapter 4: Results .......................................................................................................................... 30
Sample Description ................................................................................................................. 30
Findings ................................................................................................................................... 31
Theme I: Experiences of Individual and Family-Level Stigma .............................................. 31
Theme II: Abortion Stigma ..................................................................................................... 34
Theme III: Religious Stigma ................................................................................................... 37
Theme IV: Information About Reproductive Health .............................................................. 42
Summary .................................................................................................................................. 48
Chapter 5: Discussion .................................................................................................................... 49
Individual and Family-Level Stigma ....................................................................................... 50
Contraception and Abortion Barriers ...................................................................................... 52
Religious Stigma ..................................................................................................................... 54
Information about Reproductive Health .................................................................................. 55
Recommendations for Policy .................................................................................................. 58
Study Limitations .................................................................................................................... 61
Conclusion ............................................................................................................................... 62
References ..................................................................................................................................... 63
Appendix A: Qualitative Survey Instrument ................................................................................. 75
Appendix B: Demographic Survey Instrument ............................................................................. 78
Appendix C: Code List .................................................................................................................. 81
Contraception Code List .......................................................................................................... 81
Abortion Code List .................................................................................................................. 81
Challenges Code List ............................................................................................................... 82
Appendix D: Chart of Analytic Process ........................................................................................ 83
Appendix E: Process Memos ......................................................................................................... 86
Appendix F: Final Codebook ........................................................................................................ 87
Contraception .......................................................................................................................... 87
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 7
Abortion ................................................................................................................................... 87
Predominant Challenges .......................................................................................................... 88

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 8
Abstract
Reproductive health care is a complicated component of women’s lives that is affected by
inadequate resources and stigmatization. Limited qualitative research about reproductive health
care has included the voices of women who live in rural areas. This research sought to
understand how rural women access reproductive health care in their communities and how
religion, culture, and policy influence how women think about their reproductive health care.
Sixty-eight in-depth, semi-structured interviews were conducted with women aged 18–44 who
were accessing reproductive health care services in three clinic settings in two rural California
counties. Deductive analysis of interview data revealed that ideological, individual, and
structural issues play a direct role in how women access reproductive health care and exposed
four main themes about how women experience individual stigma, abortion, reproductive choice
stigma, and access to reproductive health. Stigma and judgment about women’s health care
choices are not just limited to abortion. This research uncovered deep stigmatization governing
the use of contraception and the role judgment plays in the use of prevention measures in
women’s health. Understanding the lived experiences of rural women plays a critical role in the
preservation and expansion of reproductive health care in America. The current study provides
context about how women navigate the world of reproductive health and offers recommendations
for policy and practice.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 9
Chapter 1: Introduction
Despite policies implemented to improve access to comprehensive reproductive health
care services (i.e., abortion and contraception), considerable political and financial factors
influence rural health systems, often leaving women in rural areas with fewer resources than
women in urban areas (O’Donnell, 2014). Access to reproductive health services can
substantially improve public health outcomes. Planning and spacing births reduces a woman’s
need for public assistance, allows women to strengthen their family’s economic stability, and is
linked to improved health outcomes for both mother and child (Frost, Zolna, & Frohwirth, 2013;
Sonfield, Hasstedt, Kavanaugh, & Anderson, 2013). Thus lack of access to comprehensive
reproductive health care services puts women in rural areas at an extreme disadvantage.
Addressing the reproductive health care needs of women in rural California requires an
understanding of multiple factors, including political climate, socioeconomic status, binational
community, and access to health services.
Policy decisions at organizational, city, county, state, and federal levels dictate
availability of health care services in a community. Current policy formation and the policy
domination of women’s reproductive health create gender-specific structures that perpetuate
control over women’s bodies (Bird, 2016). Specifically, policy changes in socially conservative
areas have created barriers to the provision of reproductive health care (Sonfield, 2017). Women
in rural areas experience some of the greatest barriers to contraceptive care because of several
factors, including lack of access to contraceptive coverage and specialized reproductive health
centers that can meet their contraceptive needs.
One of the most pressing requirements in the realm of sexual and reproductive health is
to communicate information about the economic, social, and political needs of women to policy
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 10
makers and program leaders in an effective way. More in-depth research that explores women’s
reproductive health experiences would raise the priority of improving services for women in
rural areas, thus reversing the legislative trend of limiting access to resources for women of
childbearing age. Qualitative research that explores the knowledge, beliefs, and experiences of
rural women leads to a more nuanced understanding of the lived experiences of women, which
can influence organizations and policy makers to expand reproductive justice and opportunity
regardless of circumstance. Despite the known limits of resources in these areas, access to
reproductive health services in rural areas remains understudied. Further, because high rates of
poverty and uninsured pose barriers to health care along the border region (National Rural Health
Association, 2010), research that includes Hispanic women is critical to understanding health
care and health care access issues for rural women, particularly those in border communities.
Further, little qualitative research has focused on how women, especially Hispanic women,
experience reproductive health services in the United States. The current study sought to deepen
our understanding of women’s experiences in two rural California communities, with a focus on
the following specific aims:
1. To understand how women in rural California access reproductive health care.
2. To explore how religious, social, political, and cultural experiences influence how women in
rural California think about their reproductive health care and how these factors have
affected their service use.
3. To use women’s voices to help identify structural and policy changes that would facilitate
increased acceptability of and better access to reproductive health care services.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 11
Chapter 2: Review of the Literature
Introduction
Geographic and demographic characteristics. Imperial County is located in the far
southeast corner of California, bordering Arizona and Mexico. The 2014 population estimate of
the county was 179,091 (U.S. Census Bureau, 2015). The economy of Imperial County is heavily
agricultural due to irrigation supplied by the Colorado River (Imperial County, n.d.). The
population of Imperial County is 81% Hispanic; women constitute 48.8% of the population, of
whom 44% are of reproductive age (13–44 years; U.S. Census Bureau, 2015). Of these women
of reproductive age, 21,000 (25%) are in need of contraceptive services and supplies (defined as
women aged 13–44 who are sexually active and able to become pregnant, but do not wish to
become pregnant; Frost et al., 2013).
The percentage of persons living at or below the poverty level in Imperial County is 23%
(U.S. Census Bureau, 2010). Poverty is a known correlate of women’s inability to plan and space
their children, higher rates of adolescent pregnancy, and inequitable access to health care
(Hasstedt, 2013; Sampson et al., 2009; Sonfield et al., 2013). In Imperial County, 35% of women
of reproductive age are in need of publicly supported contraceptive services and supplies because
of their poverty status (Frost et al., 2013).
Antelope Valley is located in one of the most rural regions of Los Angeles County and
has a population of roughly 500,000 people (U.S. Census Bureau, 2015). This rapidly growing
community is 45% Hispanic with an unintended pregnancy rate of 59% (Los Angeles County
Department of Public Health, 2014).
Binational community. In a binational community, tens of thousands of Mexican and
U.S. residents cross the border at Calexico every day to work, shop, attend school, and visit
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 12
families. Some of the individuals in this community are able to cross back and forth between the
two nations, whereas others are unable to do so because of their legal documentation status.
Services in border-region communities are particularly important because these areas have
higher rates of many infectious diseases (National Rural Health Association, 2010).
Hispanic women and the need for reproductive health services. One goal of this
research is to highlight the reproductive health care needs of Hispanic women. In the United
States, unintended pregnancy remains a problem, especially among adolescents and young
women, racial and ethnic minorities, and women with less education and lower socioeconomic
status (Peipert, Madden, Allsworth, & Secura, 2012). Hispanics account for 1 of every 5 women
in the United States (Gándara, 2015) and are more likely to have low-income status than the
general population (Eichner & Gallagher Robbins, 2015).
Family dynamics and provider acculturation influence Hispanic women’s ability to
access information and services. Women feel stigmatized for not speaking English when seeking
services, even if the provider speaks Spanish (Betancort, Colarossi, & Perez, 2013). Cultural
beliefs and values regarding sex include a high value placed on virginity, a presumption that
unmarried women do not have sex, and a belief that discussing reproductive health leads to
sexual activity (Caal, Guzman, Berger, Ramos, & Golub, 2013).
Immigrant women face numerous obstacles in accessing reproductive health care
services. Lack of access to reproductive services is further compounded by fear of using public
services; this comes from real or perceived conceptions of local law enforcement entities
(National Institute for Reproductive Health, 2009). Policy changes made to federal health care
programs that make it nearly impossible for both documented and undocumented immigrant
women to access programs for the poor further compound the issue. Before 1996, lawfully
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 13
residing immigrants in the United States were eligible for benefit programs comparable to those
available to their citizen counterparts. That changed with welfare reform, which left immigrants
who came to the United States after 1996 ineligible for benefits during the first 5 years of their
lawful status, thus restricting their access to programs such as Medicaid (Hasstedt, 2013).
In California, where no racial or ethnic group constitutes a majority (27% of the
population is foreign born; Johnson, 2014), an extreme disparity in insurance coverage exists for
all immigrants regardless of legal status. Despite the passage and implementation of the
Affordable Care Act (ACA) in 2010 (U.S. Department of Health and Human Services, 2017),
health care coverage has not been extended for undocumented immigrants (Hasstedt, 2013). This
remaining deficit obstructs immigrants’ access to health care, including sexual and reproductive
health services (Hasstedt, 2013). In fact, immigrant women of reproductive age are more likely
to have gone without reproductive health care in the last year (Frost, 2013). Researchers found
that in a sample of Hispanic women who attempted to self-induce abortion, immigration status
and language barriers were the main reasons that they did not attempt to access a clinic-based
abortion procedure (see Lara, Holt, Peña, & Grossman, 2015). The inability to obtain sexual and
reproductive health care puts immigrant women (who are more likely to be young and of low-
income status) at a disproportionately high risk of negative health outcomes including
unintended pregnancy and sexually transmitted infections (Hasstedt, 2013).
California-dwelling Hispanic women have the greatest need for contraceptive services
and supplies (25%; Frost et al., 2013). Because contraceptive cost is an important factor that
interferes with women’s use of contraceptive methods, eliminating cost sharing for all
contraceptive methods could reduce unplanned births among immigrant women (Hasstedt,
2013). By introducing specialized reproductive health services to immigrant women in rural
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 14
areas and increasing access to the full range of contraceptive options, health systems can better
meet the needs of immigrant women.
Discourse often excludes the wider social and economic conditions under which
reproductive rights are defined (Price & Hawkins, 2007). Although undocumented immigrants
are more likely to be of reproductive age and Hispanic origin, limited evidence is available that
is specific to immigrant women and their use of preventive reproductive health services and
contraception (Hasstedt, 2013). To reduce this disparity, qualitative studies are needed that aim
to lend a more nuanced understanding of contraceptive and abortion access among rural women
(especially Spanish speakers) and how these needs can be addressed by their communities
(Foulkes, Donoso, Fredrick, Frost, & Singh, 2005; Sampson et al., 2009).
Stigma. Abortion stigma shames and silences women and plays an integral role in the
social, medical, and legal marginalization of abortion care around the world (IPAS, n.d.).
Women who have abortions challenge social norms of sexuality, which elicits stigmatizing
responses from the community (Hanschmidt, Linde, Hilbert, Riedel-Heller, & Kersting, 2016).
Women who have abortions attempt to reduce the likelihood of stigmatizing interactions by not
talking about their experiences with others (Cockrill & Nack, 2013), thus further reinforcing
stigmatization around abortion. The stigmatization of abortion is only one facet of the women’s
reproductive health stigma. While some research has focused on abortion stigma, stigma around
other reproductive health choices, including contraception, has not been widely investigated.
Cultural and individual values that include religiosity and beliefs about gender roles
determine whether or not virginity is honored or stigmatized (Faulkner, 2003). In communities
where there is a high value placed on virginity and it is presumed that unmarried women are not
sexually active (Caal, et al., 2013), there is the potential to complicate experiences of
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 15
contraceptive stigma. Latina women report that if their friends and family members do not
support the use of contraception, they may choose to refrain from the use of contraceptives in
order to meet normative expectations (Unger, 2000). Stigma hinders young women’s use of
contraception and researchers have identified the need for inquiry that explores stigma beyond
abortion, sexually transmitted disease, and HIV/AIDS (Hall et al., 2017). Expanding research
that focuses on contraceptive stigma, in addition to abortion, is critical to understanding how
individual and family-level characteristics influence stigmatization and the impact of religion
and culture on women’s reproductive health behaviors.
Provision of reproductive health. The provision of reproductive health services is not
sufficient if the social and economic conditions of a community do not allow women to exercise
their reproductive rights (Currie & Wiesenberg, 2003). In rural communities where few facilities
provide reproductive health services or the only facilities in the community restrict the provision
of such services because of religious beliefs (Fogel & Rivera, 2003), the privileging of choice
contributes to the marginalization and oppression of women’s bodies by ignoring issues of
justice. These issues contribute to oppression of women based on race, class, and gender. The
term choice labels women who do not have sufficient resources as individuals who make bad
choices (Roberts, 2015). Further, when women use birth control, they are labeled as promiscuous
in the eyes of family, friends, and potential partners (Caal et al., 2013). These system- and
family-level stressors ignore the structural inequalities that women in rural areas face and
contribute to racial and class bias while perpetuating the stigmatization of women’s choices.
The women most affected by the decisions of policy makers and elected officials often do
not have a strong voice in the community. Policy decisions at organizational, city, county, state,
and federal levels dictate availability of health care services in a community. Heavy-handed
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 16
reproductive health policy has created a uniquely gendered dialogue on health rights. This
dialogue is further influenced by sexist power structures, which facilitate culturally acceptable
control over women’s bodies (Bird, 2016). True reproductive justice is built on a belief that
women have the right to have children and raise them in a safe, healthy, and supportive
environment while also ensuring that women have the right not to have children (Roberts, 2015).
Barriers to reproductive health care for rural women violate their legal right to access safe,
affirming, and open reproductive health care services.
Women living in rural areas experience great need when it comes to accessing
reproductive health services. In these areas where poverty is high and transportation difficult,
women’s ability to access care may be particularly complicated. Hispanic women at the
intersection of poverty, gender inequality, ethnic and racial discrimination, and immigrant status
face economic disparities, language barriers, and policy decisions. These factors intertwine to
create a complicated web of service provision that can leave many women with few options for
reproductive health care services.
Previous Research
The principal investigator (PI) of this study conducted previous research with religious
and community leaders regarding the provision of reproductive health care services in Imperial
County. One of the pervasive themes was the notion that women who seek services in a family-
planning clinic are seen as “dirty,” “one of those girls,” “shameful,” or “slutty” (Bird,
unpublished data). Respondents repeatedly expressed the idea that seeking reproductive health
services automatically places women of any age in a less-than-desired social position. In
interviews, this idea was expressly mirrored by the notion that women should remain virginal
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 17
until marriage, and even then, they should try and live in the image of Mary because that is their
duty as good women.
These findings map directly onto the Madonna–Whore binary made famous by Sigmund
Freud (Tumanov, 2011). The Madonna–Whore binary suggests that to explain a man’s anxiety
regarding a woman’s sexuality, he must cast her into one of two categories: (a) the Madonna,
whom he respects and admires, or (b) the whore, whom he is attached to and therefore does not
respect (Tumanov, 2011). Because this dichotomized thinking was so pervasive in interviews
with community leaders, this theoretical framework guided the interview questions and informed
the data analysis and interpretation.
Theoretical Framework: Madonna–Whore Binary
The Madonna–Whore binary categorizes women in terms of two opposites, typically
characterized as Eve (the whore) and the Virgin Mary (the Madonna; Tumanov, 2011). This
predominant mindset in Judeo–Christian culture places an emphasis on virginity and a
condemnation of female sexuality (Tumanov, 2011). A woman is viewed as “lascivious and
largely unable to control her weakness. … This female force brings Original Sin and sexuality in
equal measure into the world, and it is counterbalanced by Mary who simultaneously stands for
motherhood and purity” (see Tumanov, 2011, p. 512). This contradiction of motherhood and
purity presents a pervasive binary that most women fall victim to in a culture largely influenced
by Christian values. Women are expected to become mothers while at the same time remaining
pure. In communities that are considered religiously conservative, this contradiction places
women, especially Christian women, in a bind that becomes nearly impossible to navigate and
balance. Tumanov (2011) argued that Eve represents female sexuality and female sexual choice,
which is the source of paternal uncertainty and masculine anxiety. This uncertainty cannot be
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 18
eliminated as long as female sexuality exists, causing an obsessive concentration on a single
aspect of femaleness (Tumanov, 2011). From puberty, many U.S. women are placed in a bind
that holds them to the Christian standard of the biblical figure Mary, who remained a virgin
while conceiving her son. This biblical narrative creates a foundation for the cultural expectation
that women can remain virginal while still reproducing. The counterexample to this cultural
morass is the biblical figure Eve, whose wrongdoing results in a sentence of painful childbirth
(Tumanov, 2011). Communities that are steeped in Judeo–Christian cultural traditions impress
upon women the complete social acceptance of virginity and the virgin birth narrative. However,
as noted by Tumanov (2011), this discourse is problematic in that “the Madonna represents an
extreme form of sexual behavior—an impossible point of reference with immense ideological
weight” (p. 517). Women experience the ideological weight of this binary; many will go to great
lengths to hide their use of reproductive health services from parents, partners, or both (Caal et
al., 2013) and will try to hide unplanned pregnancies due to shame or lack of someone to tell
(Betancourt et al., 2013).
Judeo–Christian ideology takes the evils of sexuality further by focusing on women and
their sexuality as a source of danger (Barrett & Harper, 2000). During the Victorian era, women
were divided into the good and the sexual (Tavris & Offir, 1977). Prudery was exemplified by a
denial of female sexuality (Barrett & Harper, 2000). Good character and spiritual purity were
directly related to a lack of sexual pleasure, especially among women (Tavris & Offir, 1977). In
this view, women are only considered pure if their sexuality is absent or passive (Barrett &
Harper, 2000). Our nation’s long history of connecting perceptions of a respectable society to
anxiety regarding contraception and sexual promiscuity (Barrett & Harper, 2000) has led to the
policing of women’s bodies through legislation.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 19
There is also an assumption that sex does not happen if contraception is not available or
being used. The high value placed on virginity, combined with a parental view that young
women who seek out reproductive services are dirty or shameful, contributes to the false notion
that discussing sexual and reproductive health services encourages sexual activity (Caal et al.,
2013). A sexual double standard represents women through stark dichotomies that leave them
admired or admonished, revered or reviled, good or sexual, virgin or whore, cherished or
loathed, sacred or profane (Begun & Walls, 2015; Bordini & Sperb, 2013; Tavris & Wade,
1984). This double standard is exacerbated when it comes to premarital sexual intercourse,
which is often labeled as wrong for women but allowed for men (Bordini & Sperb, 2013;
Quelopana & Alcalde, 2014). The false narrative that improved access to reproductive health
services would affect sexual behavior and lead to an increase in sex among women places an
undue burden on women who fall victim to ongoing attacks, leading to the erosion of health care
access (Fried, 2013). Some health professionals falsely believe that restrictions on the
availability of contraception act as a control on sexual behavior and that removing this control
would lead to promiscuity, particularly among young people (Barrett & Harper, 2000).
The expression of the Madonna–Whore binary is pervasive. Society continues to see
young women as illegitimate family planners (Hawkes, 1996) who should maintain their virginal
status. The binary implies that women’s sexuality has an ominous dark side whereby women are
irresponsible and scheming by nature, thus setting up conflicts between health professionals and
women (Barrett & Harper, 2000). Findings from previous work demonstrate how this binary
comes to fruition in policy decisions and service provision at the community and systems levels
(Bird, unpublished data). In the current study, this framework informed the interview protocol
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 20
and was used to explore women’s perceptions and internalized standpoints of this binary in the
context of reproductive health care.
Limited access to basic health care has created insurmountable barriers for reproductive
health care decisions among women in the United States (Nash & Gold, 2016). Recent efforts by
policy makers to eliminate federal funding that provides women in rural areas with low-cost
reproductive health services (Nash & Gold, 2016) present a unique opportunity to explore
cultural preconceptions regarding women’s sexuality and fertility. This research sought to make
sense of the complexities of women as gendered subjects and how they navigate these dialectic
perceptions of their gender identity in their pursuit of reproductive health. The findings can be
used to develop social policies that are informed by rural women and that affect rural women.
Definition of Terms
Because of the specific language tied to U.S. reproductive health care policy, the
definitions of contraception and contraceptive access, as used in this work, are described here.
Contraception. For the purposes of this research, contraception is defined as birth
control that interferes with the normal process of ovulation, fertilization, and implantation.
Contraceptive methods include hormonal methods (hormones to prevent ovulation), barrier
methods (prevention of the sperm meeting and fertilizing the egg), spermicides (medications that
kill sperm on contact), intrauterine devices (prevents egg from implanting in the uterus), tubal
ligation (permanent medical procedure for women), and vasectomy (permanent medical
procedure for men).
Contraceptive access. Defining contraceptive access is important because it explicates
how access to contraception has changed after the passage of the ACA of 2010. Since this bill
passed, access to contraception for low-income women in California has reduced from 18 to 3
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 21
months of contraceptive coverage (C. Huerta, personal communication, 2015). This change in
access, however, has not been well communicated to the targeted population. Many women do
not know that there is no longer a copay for contraception and many questions remain about
whether all methods of contraception are covered by the ACA (C. Huerta, personal
communication, 2015). Reimbursement rates are also changing for providers and it remains
unclear how this will directly affect contraceptive access in California.
Abortion. Contentious and contrasting beliefs about abortion and contraception in the
United States reflect different worldviews and value systems (Luker, 1984). The values
represented by those fighting against abortion and contraception are reflective of a form of
patriarchal misogyny that sustains religious and philosophical myths about female sexuality and
fertility through policy development and implementation. Symbolic predispositions to political
ideology, morality, and religiosity influence abortion attitudes and policy preferences (Sahar &
Karasawa, 2005). For example, individuals who are more politically conservative and religious
are less likely to approve of abortion (Luker, 1984; Sahar & Karasawa, 2005). These
predispositions have sustained the reproductive choice movement for years, effectively
supporting the work of White middle-class women and creating a system wherein the real-world
needs of poor women and women of color are ignored by reproductive rights advocates and
government leaders.
The right to privacy as defined by the reproductive rights movement assumes access to
resources and a livelihood that is rich in autonomy (Luna & Luker, 2013). Many U.S. women do
not have access to such reproductive privileges because they rely on government support for
education, family formation, or employment (Luna & Luker, 2013). This ideology is further
exacerbated by the fact that the legal and medical communities assume that private physicians
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 22
will make abortion and contraception available to all women, thus further reinforcing that access
determines who obtains reproductive health care (Luna & Luker, 2013). Causes for unintended
pregnancy and abortion, such as not using birth control, are perceived to be the woman’s
responsibility (Sahar & Karasawa, 2005). As noted by Sahar and Karasawa (2005), if a woman
fails to live up to her responsibility, her choice to have an abortion receives less sympathy, more
anger, and lower approval than a scenario in which she is not responsible, such as rape or
malfunction of birth control. Women are held responsible for their unintended pregnancies when
people are more traditionally conservative about their beliefs regarding family and sexuality
(Zucker, 1999). The mainstream reproductive rights movement has reinforced this conservative
view by insisting on focusing on privacy and autonomy as the foundation to a woman’s right to
control her own fertility. This framework is an inadequate answer to issues of sexuality and
fertility and denies the social responsibility of communities to improve the conditions of all
women regardless of background (Luna & Luker, 2013).
In 2017, legislation was introduced in Congress to repeal and replace the ACA. As a
result, the state of California will have to reassess how women are insured, thus creating an
additional cloud of uncertainty as to how such policy changes will directly affect women in rural
parts of the state. Additionally, current policy restrictions exacerbate existing barriers to
coverage for immigrant women (Center for Reproductive Rights, 2014). Immigrants are more
likely to work in low-wage jobs that lack employer-based insurance coverage (Center for
Reproductive Rights, 2014). Combined with policy barriers to public and private insurance, this
means immigrant women are often unable to access the reproductive health care they need
(Center for Reproductive Rights, 2014). Immigrant women of reproductive age are 70% more
likely than their U.S.-born peers to lack health insurance (Center for Reproductive Rights, 2014).
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 23
In rural California communities in which many young women are raised by conservative
immigrant parents, it is critical to address how issues of virginity, promiscuity, and policy
implementation interact to create a system of health care provision. In addition, this research
explored how needed resources, accessibility of services, and issues of justice are experienced by
women in the community.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 24
Chapter 3: Research Methods
This study sought to explore the experiences of women in rural California seeking access
to reproductive health care services, including contraception and abortion. This section describes
the research design, data collection, and data analysis methods.
Study Purpose
The purpose of this research was to describe women’s experiences accessing
contraception or abortion services in rural California. Through exploration of women’s lived
experiences, this research explored women’s health care access experiences, stigma associated
with contraception and abortion, and how women navigate the health care system in rural
California. The following research questions guided the work.
1. How do women residing in rural settings describe accessing reproductive health care
services?
2. How do women understand other’s perceptions of their receipt of reproductive health care
services?
3. How do women describe their personal experiences of stigma related to reproductive health
services, specifically those generated by racial, gender, religious, political, and cultural
identities?
4. How is women’s engagement with reproductive health care providers influenced by their
perceptions of religious and political leaders and their perceived community norms?
5. What recommendations do rural women offer regarding reducing barriers and increasing
facilitators to reproductive health services?
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 25
Research Design
For this work, semi structured narrative interviews were undertaken with the goal of
producing a contextual understanding of women’s experiences while exploring the complexity of
women’s reproductive lives. Qualitative research seeks to understand human behavior, allows
the researcher to pursue a topic with great sensitivity and emotional depth, and allows for a
greater understanding of the reasons people engage in certain behaviors (Padgett, 2008).
Creswell and Plano Clark (2011) stated that qualitative research may be best when “the
researcher aims to explore a problem, honor the voices of participants, map the complexity of the
situation, and convey multiple perspectives of participants” (p. 7). The use of semi-structured
interviews allows for a conversational two-way discussion and provides a flexible structure that
allows the interviewer to seek greater detail when necessary (Cohen & Crabtree, 2006).
The interview script (Appendix A) was framed by the specific research questions of the
study and results of previous research performed with stakeholders in the community. The
interviews were open ended to enable participants to discuss issues they consider to be relevant
to the topics of barriers and facilitators to reproductive health services, stigma affecting
reproductive health services, and unmet needs of the community. This helped to elicit a broader
range of experiences and perspectives and allowed for an opportunity to humanize a subject
often minimized as merely politics. Approval was obtained from the University of Southern
California Institutional Review Board and the internal research review boards of the involved
reproductive health clinics.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 26
Participant Recruitment and Screening
A convenience sample of 68 adult women (aged 18–44 years) was recruited from waiting
rooms in three health care clinics in Southern California between November 2016 and January
2017.
Initial contact was made with the clinical director of a community health center in
Imperial County, the director of research at a reproductive health clinic in Imperial County, and
the CEO of a reproductive health clinic in Antelope Valley. The purposes of the research project
were explained and the representatives received a recruitment flyer and the study’s institutional
review board approval letter. Once accessing women through the clinics was authorized, flyers
were left in the waiting rooms of each clinic. In some cases, clinic staff members helped recruit
participants; in other cases, the PI or research assistant approached clients in the waiting room
and recruited them directly. All potential participants were screened to ensure they met eligibility
criteria, which included: (a) being a woman aged 18–44 years; (b) participating in a reproductive
health visit (e.g., routine gynecological exam, family planning, sexually transmitted infection or
pregnancy testing, emergency contraception, or abortion); and (c) English or Spanish speaking.
Clinic sites in support of the research and approved by the institutional review board were
Planned Parenthood of the Pacific Southwest, Clinicas de Salud del Pueblo, and Planned
Parenthood Los Angeles County. These three research sites were chosen because they are the
only clinics in the target rural areas that provide reproductive health care services to all women
regardless of need.
Data Collection
Once eligibility was established, the PI or research assistant met immediately with each
participant in a private room at the clinic site. Each participant received an information sheet in
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 27
his or her preferred language explaining the purpose of the study, its voluntary nature, and the
benefits and risks. Consent was obtained verbally and standards of anonymity and confidentiality
were explained to the participant. Once consent was obtained, participants completed a brief
survey (Appendix B) that collected demographic data on including age (continuous), race and
ethnicity (nominal), marital status (nominal), children (continuous from 0), level of education
(nominal), and income (nominal).
Particular attention was paid to the participants by ensuring that the surveys and
subsequent interviews took place in their preferred language. Semi structured interviews lasted
between 30 minutes and 1 hour and explored women’s feelings about contraception and abortion
and their views of religious and cultural stigma in their communities. Questions included: Do
you use contraception? Who do you talk to about contraception? Have you ever had a medical
abortion? Do you think that there is stigma around contraception in your community? Do you
think religion and culture affect stigma around abortion in your community? For the full
interview guide, see Appendix A.
Twenty interviews were conducted by a trained research assistant from the local
community at a community health clinic in Imperial County. Six of those interviews were
conducted in Spanish; the remaining 14 were conducted in English. Twenty-three interviews
were conducted by the PI at a reproductive health care clinic in Imperial County. Twenty-five
interviews were conducted by the PI at a reproductive health care clinic in Antelope Valley.
Interviews were audio recorded and maintained in a password-protected computer. Each
participant received a $25 gift card as compensation for the interview.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 28
Ethical Considerations
The researchers worked systematically to ensure that high ethical standards were
maintained in the collection and maintenance of data. Participation in the research was voluntary
and all participants had the opportunity to provide verbal consent and opt out of the study for any
reason at any time. Each interview was assigned a numerical code that correlated with the
demographic information provided by the participant. Confidentiality was maintained according
to the standards set forth by the University of Southern California’s Institutional Review Board
and the Planned Parenthood of America’s Institutional Review Board, both of which provided
approval for the research.
Data Coding and Analysis
Interviews were transcribed verbatim by a professional transcriptionist and subsequently
reviewed and corrected by the PI. Thematic analysis was employed to analyze data at the latent
level to identify underlying ideas, assumptions, and conceptualizations (Braun & Clarke, 2006).
The PI immersed herself in the data by reading and rereading transcripts and developed an initial
codebook based on the questions in the semi structured interview and the information contained
in the transcripts. Simultaneously, a co-coder also immersed herself in the data by randomly
selecting 34 transcripts. Analysis began by reducing the data through a process of selecting,
simplifying, and transforming the data (Miles & Huberman, 1994). The PI and co-coder
independently established a taxonomy of main themes and subthemes (Braun & Clarke, 2006).
The PI and co-coder met and refined and clarified each code by adding, eliminating, and
collapsing codes. The PI and co-coder agreed on a final code list containing 27 primary codes
(Appendix C). This coding process established intercoder reliability and reduced bias in the
findings (Hruschka et al., 2004). The researchers then applied the final codebook to all
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 29
transcripts separately and reviewed the codes for consistency and validity in relation to the
dataset (Braun & Clarke, 2006). This process is detailed in Appendix D.
Finally, the PI employed an audit trail to explain why decisions were made. Memos that
noted key decisions made during the data collection, coding, and analyses were used to
document each step of the research study (Padgett, 2012). Memos also disclosed the role of the
PI, including its impact on the interpretations made in the research study.
Summary
This chapter provided an overview of the methodology employed in the collection of
data, including research design, participant recruitment and screening, data collection, data
coding and analysis, and ethical considerations. Subsequent chapters report the findings of the
study, conclusions, and discussion of policy implications, study limitations, and suggestions for
future research.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 30
Chapter 4: Results
Sample Description
Sixty-eight women participated in semi-structured interviews. The age range of
participants was 18–44 years; 90% self-identified as Hispanic. A majority of women reported
that they were married or in a serious relationship (58%); 45.6% had never had a child. Sample
demographics are presented in Table 1.
Table 1
Participant Demographics (N = 68)
n (%)
Race and ethnicity
Hispanic or Latino 61 (89.7)
Black 3 (4.4)
White 2 (2.9)
Asian 1 (1.5)
Multiracial or other 1 (1.5)
Age
18–25 years 41 (60.3)
26–34 years 21 (30.9)
35–44 years 6 (8.8)
Relationship status
Single or never married 23 (33.8)
In a relationship, not married 21 (30.9)
Married 19 (27.9)
Separated 3 (4.4)
Divorced 2 (2.9)
Highest level of education
None 6 (8.8)
High school or GED 27 (39.7)
Vocational or trade school 20 (29.4)
Associate’s degree 10 (14.7)
Bachelor’s degree 3 (4.4)
Postgraduate degree 2 (2.9)
Enrolled in school
Yes 25 (36.8)
No 43 (63.2)
Number of children
None 31 (45.6)
1 child 15 (22.1)
2 children 14 (20.1)
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 31
3 or more children 8 (11.8)
Income
$0–$10,000 26 (38.2)
$10,000–$20,000 21 (30.9)
$20,000–$30,000 14 (20.6)
More than $30,000 7 (10.3)
Findings
Women’s responses to questions about their reproductive health were classified into four
distinct themes. Themes articulate the ecological nature of these women’s experiences,
highlighting experiences at the individual, family, community, and policy levels. Results are
presented using this framework to illustrate how each stratum (theme) contributes to
reproductive health care choices. To preserve the anonymity of the participants, each respondent
was given a code (including a letter and numbers) that coincides with the research site where the
interview took place (CP = Clinicas, PP = Imperial County, and AV = Antelope Valley). Direct
quotes are provided to illuminate findings about women’s experiences of contraception and
abortion stigma, contraception, and abortion, thus providing the reader with a deeper
understanding about how women experience reproductive health access in rural California.
Theme I: Experiences of Individual and Family-Level Stigma
Participant responses indicated that women had experienced individual and family-level
stigma related to sexual activity and the use of contraception. The condemnation in these
communities of engaging in premarital sexual activity greatly affected a woman’s ability to
freely access critical reproductive health care services. Stigma played out in a variety of ways,
including not having access to care, not talking about contraception, violating the cultural norm
of not having sex before marriage, and fear of someone finding out that they are engaging in
sexual activity. Some described this stigma as gender inequality and a glorification of sex for
men coupled with judgment and stigmatization against women.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 32
The assumed connection between contraception and sex was further described as a
phenomenon that gave implicit permission for sexual activity, especially among younger people,
because it was not a behavior condoned by adults in the community. Women reported that the
lack of familial openness about contraception contributes to teen pregnancy. Some participants
talked about wanting to be prepared to prevent pregnancy but noted how that preparation was
seen as leading to increased sexual activity or multiple partners among women. One woman
highlighted this when she was talking about condoms: “It’s just that they don’t want us to get
condoms because we’re going to have sex more; we’re going to have more sex” (PP6).
Women described a nuanced decision-making process that they or their friends
experienced when deciding to use contraception or have an abortion if they experienced an
unintended pregnancy. This process was complicated by several factors including the inability to
discuss contraception or abortion freely with those in their social support networks. Some
participants discussed contraception decision making as a way to avoid having to make the
decision to have an abortion. This is illustrated by one respondent (AV5) who said she tells her
friends that if they cannot afford to have a child, they should use contraceptives, which are “free
if you qualify” and a way to prevent unintended pregnancy. One woman shared: “We talk about
abortion, but that’s the reason I want to take those contraceptive steps, to avoid being in that
issue” (AV20). Individual experiences of stigma have an impact on women’s contraceptive and
abortion behaviors and how they discuss personal experiences with others. Relationships with
friends and women’s ability to talk to family members governed how they navigated individual
stigma experiences.
Family-level stigma. Women expressed how fear of judgment by family members led
them to undertake great efforts to hide their accessing reproductive health care services and use
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 33
of contraception. This fear of surveillance and judgment by family created an isolating effect,
leaving women feeling unsupported. One woman specifically articulated the direct judgment of
family members as a reason that she has difficulty seeking reproductive health care services.
I can be honest, I don’t feel comfortable. I don’t feel like I can tell my mom or my sister
because I’m just going to be judged because I was with that person. Not because of
anything else, because I was with that person, I’m just judged already. (CP20)
This was echoed by others who said their family members believed that the use of
contraceptives meant that women were engaging in sexual activity. Women described personal
attacks as presenting significant challenges to their accessing contraception. Women reported
being told things like, “don’t be like her” or “because you’re on birth control you’re going to be
out there having sex.” One woman (PP13) said that when someone in her family found out she
was using contraception, their response was, “So you’re sleeping around or something?”
Participants talked about hiding or not using any contraception because they were afraid
of their parent or parents finding out (this was the case even though they were adult women).
Hiding birth control was seen as a necessary behavior if a woman was having difficulty
following the prescribed conventions of her family by having sex before marriage. “So, that’s
probably hard to follow that rule … and then hiding the birth control because you’re having
intercourse, but you’re not supposed to” (AV10).
Some women openly admitted how critical they felt it was to keep a “tight lid on it”
(meaning their use of contraception) because if someone in the community found out that they
were seeking contraception, then it is likely their family and relatives would “find out.” This
discovery was devastating to many women, creating internalized shame that led to reproductive
health care access barriers. For some women, the fear of familial stigma lent to more extreme
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 34
choices like crossing the border into Mexico to avoid having their parents find out that they are
using contraception. As one participant reported:
I’d rather pay this $10 that equals 100 pesos to get birth control than to come here to a
family doctor and have them tell. I feel that’s the fear, too. Like I’m going to go to my
family doctor and they’re going to tell my parents. (PP19)
Participant descriptions of familial stigma illuminate the internalized struggle of
balancing the desire for and pleasure of sexual activity with feelings of shame related to such
behaviors. This shame influences how women make reasoned decisions about contraception in
an effort to avoid feelings of stigma related to reproductive health care choice. The process of
personal empowerment gives women the opportunity to control their own fertility while
maintaining personal autonomy.
Women’s navigation of individual and family-level stigma creates an opportunity for
women to explore their own internalized beliefs about reproductive choice while reconciling
interpersonal conflicts that may arise as a result of stigmatization.
Theme II: Abortion Stigma
Access to abortion allows a woman to shape her reproductive life by allowing her to
decide freely if, when, and how to have children. Participants were asked about abortion stigma
and how it relates to access to services in the community. These questions elicited many
responses about personal experiences with abortion and condemnation of abortion in certain
circumstances. The findings highlight how nuanced abortion services can be in a rural
community and the complexities surrounding women’s decisions about abortion care.
Some women expressed that their process regarding abortion services was easier than
they imagined, even though they were still torn about their decision to have the abortion
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 35
procedure itself. Women reflected a wide range of feelings about their abortion experiences,
including being nervous and scared, feelings of regret, acknowledgment that they never thought
they would choose abortion, and a strong sense of empowerment that this was the best decision
for them. Some women felt that they didn’t want to raise a family. One woman had this to say
about her abortion experience,
It’s not that I couldn’t do it, that I couldn’t raise a family, it’s I didn’t want to. I didn’t
want my child to grow up the way I grew up. I didn’t want to take a chance of not being
able to provide and give everything to someone else. I didn’t want to take that experience
away from myself either, for it to be a good experience of being a mom and going
through pregnancy. So my partner and I decided that that’s the best thing. We didn’t
really tell anyone. I told maybe like two people. It was something I regretted for a little
while and it was something that it took a long time for me to get over, but I did. (CP13)
Participants also shared their experiences of being called murderers after they had
pursued an abortion. As one woman (AV21) stated, “This person had an abortion. She’s a child
killer. And it’s really sad because it could be the best decision for that person, but people view it
as bad and they’ll be judged upon it.” Other women reflected how they perceived abortion was a
misunderstood phenomenon that should not be judged by others. For example, one woman talked
about abortions for the “right reasons” and community judgment around those decisions,
I mean the only thing you really heard about abortion is that you shouldn’t be doing it;
abortion shouldn’t be allowed. It’s terrible. That’s all you really hear about it, but you
don’t really have people talking about them getting abortions for the right reasons, or for
their own reasons. (AV4)
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 36
Many participants expressed intense feelings about women who did not “take care of
themselves” and then chose to have an abortion. Women identified the difference between
themselves and women who choose not to “take care of themselves.” These women were
stigmatized by the respondents for choosing to have an abortion instead of keeping the baby and
taking “responsibility” for their actions. “If you were irresponsible and you just didn’t take care
of yourself and you came out pregnant and then you just want to end it, that makes me feel mad”
(CP8). Their expression of free agency in this manner created judgment toward women who do
not engage in these same behaviors. This passionate opposition illustrates the complexity of this
issue and why some people oppose abortion in certain circumstances.
Many women in this study reflected that if they were not taking care of themselves
through the use of contraception, they would live with their pregnancy rather than obtaining an
abortion. These women felt that having a child, even from an unplanned pregnancy, would be
“their responsibility”; because they wanted to be sexually active, they believed they should “own
up” to the result. As one woman explained, “If I was pregnant because I wasn’t taking care of
myself, I’d have to just suck it up and say, this is your mistake, you have to live with it” (CP16).
These participants’ articulation reflects a deep and nuanced conceptualization of abortion choice
that describes the use of contraception not as an option, but as an imperative to engage
responsibly in sexual activity. Women who were perceived as “preferring to get pregnant” so
they can have an abortion were harshly judged by other women and described as irresponsible
and selfish.
Many women in this study articulated rape as a primary exception in which abortion
should not only be considered but also encouraged. Participants indicated that women have “the
right” to abortion if they become pregnant from a rape. One respondent expressed that although
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 37
she is opposed to abortion, she would understand why a woman would get one in the instance of
sexual assault. “If someone gets like raped, I would understand why she did it because maybe
seeing the baby’s face and he looks like the raper, it would be like something hard for the
person” (PP23). Another participant (AV4) listed “valid” reasons for abortion that included
“sexual abuse” and “if you just can’t handle it.”
The topic of abortion is convoluted by the complexities of the choice to have the
procedure. For women in this study, this complexity is presented as an idea that they can be pro-
choice for other people but antiabortion for themselves. One woman talked about the
acceptability of her sister having an abortion even though she herself was personally opposed to
abortion. “Because she already had three other kids, this would have been her fourth one. And
it’s not for me, but if someone like my sister who already has three kids and is barely hanging on
there, I think it’s OK” (CP5). In some cases, participant statements reflected the idea that
abortion is acceptable to prevent the suffering of a fetus that has some sort of anomaly. In this
case, abortion is seen as an act of mercy, “because I don’t think you should bring someone into
the world knowing that they’re going to suffer” (CP3).
Theme III: Religious Stigma
The theme of religious stigma represents a framework for how women experience the
condemnation of reproductive choice in their communities. In these heavily Latino communities,
religion has shaped the way the culture has developed. Religious stigma encompasses cultural,
social and religious norms about sexuality, contraception and abortion. Many women talked
about the role religion plays in creating stigma throughout the community. One woman described
religion as a barrier to seeking services, “since religion says you should be married before being
sexually active, it stops you from looking for help” (PP5). Several participants reflected that
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 38
religiosity was directly responsible for stigmatizing sexual activity before marriage, thus
reinforcing the belief that women did not need contraception because women shouldn’t be
having sex before marriage.
Religion was described as the dominant reason that women did not talk about
contraception. In one instance, a woman was worried that someone would stop her from going to
her appointment. She said, “I didn’t want to go through that talk, to go through the hassle. I
didn’t want to go through them trying to come to the appointment, pulling me out. So I just did
it” (CP17). Another woman talked about how religion made having sex or an abortion shameful,
yet “once people get pregnant, it’s kind of like overlooked” (CP13). She continued to describe
how in a community where babies are considered a “blessing sent by God,” using contraception
is unacceptable: “My grandma is from Mexico and she grew up really poor. It didn’t matter if
she was poor or not, had a baby or not. All of my family, it’s just babies are a blessing no matter
what” (CP13).
For some women, religion felt like something that got in the way of health care decision-
making. To counterbalance this, women shared how they created intimate relationships with
friends to normalize their experiences and discuss reproductive health free of judgment from
family members.
There’s three of us now that are on some sort of birth control. I’m on the pill, another
friend’s on the pill, and another friend had an IUD [intrauterine device]. I didn’t know
she had an IUD till she brought up that she had one. And I was like, OK. But most of us,
I think they use condoms. So I think now, because I said I was on it, they’re like maybe I
should take care of myself, too. (CP20)
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 39
Openness with friends and the internalized notion that women were making decisions that
were best for their bodies allowed women to pursue contraceptive services, despite the stigma
related to violating cultural and religious norms. Many women described how religious stigma
created shame among those who engage in reproductive health care choices, even when those
choices represent what is best for themselves and their families.
Participants described how candidness with their mothers contributed to the use of
contraceptive methods. “I’m very open with my mother about contraception. At a very young
age, she was always like make sure you’re being responsible and being safe, practice safe sex”
(AV5). However, several women described a willingness to “take care of themselves” despite
their mother’s religious objection, which presented an area of conflict for women. Despite this
judgment, women used contraceptives if they felt it was the best choice given their engagement
in sexual activity.
Women identified several stigmatizing events surrounding their sexuality and the use of
reproductive health care services driven by religious stigma. These experiences ranged from not
knowing what was happening to their body when they reached puberty to experiencing overt
sexism because it was taboo for girls to be sexually active. Participants discussed how they were
told, “You just aren’t supposed to do that.” For example, one respondent said, “In the Hispanic
culture, they criticize you more when you have sex as a teenager or as a woman” (PP18). One
woman related her experiences of stigma as an explicit ban on any sexual activity by her parents:
“They never talked to me about it. If they would have mentioned it, they were so like, ‘Oh no,
you’re just not going to have sex and that’s it’ type of thing” (AV9). Religious stigma is
intertwined with the stigma of promiscuity and sexualized behavior. This left women with the
belief that there is no other option than to have a baby if they have sex and get pregnant.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 40
Several of the participants in this study described the stigma imposed on women who
engage in sexual activity; these women were seen as “less than desirable.” Many women talked
about how their norms expected them to remain virgins until they were married and that many
people in the community describe women who seek reproductive health care as “sluts” or
“promiscuous.” Some women had difficulty using the derogatory words that women were often
called; a few were embarrassed to be discussing the issue because they were not “those girls.” “I
don’t know how to say that in a nice way. I’ve heard people call them a lot of terrible things,
saying that they’re easier because they’re this and that” (AV4). This stigma did not keep women
from seeking reproductive health care services but it did prevent them from feeling like they
could freely discuss their reproductive health care choices with people they would otherwise rely
on for support.
Being “one of those girls” was described by many women as a barrier to achieving
autonomy in reproductive health care choices. Being put in the “category of slut” was a cultural
experience that a majority of women were actively trying to avoid. As one woman said, “You’re
looked down upon. You’re bad names or a bad person” (PP7). Another described sexually
promiscuous girls as “acting like guys” (PP23). Another respondent said that people in the
community talk about other girls that they believe have had sex and say unkind things. “I feel
like they think that girls that have abortions are like whores or whatever and because they have
sex with everybody, they go and get pregnant and just have an abortion” (CP7). Yet another
participant (AV4) reflected on judgment against women in the community by saying that young
men receive positive reinforcement for being sexually promiscuous. “Most of the time when you
hear about young couples having sex, you hear them talking about the girl. It’s like she’s easy
and she’s just giving it up … but when it comes to the guy, no one ever really says anything. …
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 41
They’re giving him props for it.” These descriptions are reflective of the communities’
expectations of appropriate gender roles in relation to expectations for the way women and men
should behave.
Religious stigma about reproductive health choice was exacerbated by one of the most
visible barriers to women obtaining reproductive health care services, the presence of protesters
outside clinics. Protesters did not just create physical barriers to accessing reproductive health
care, they also created a fear of judgment for participants. Further, this judgment would come
from people they knew; this left them vulnerable to their choices being “found out” by family
members or friends. For one woman who was seeking abortion services, her fear of protesters
was enhanced because one of the protestors was her mother. This woman described
transportation issues, which initially delayed her seeking a first trimester abortion. In addition,
she was forced to wait because she had to go to the clinic on a day when her mother was not
protesting. This meant that she was now in her second trimester and therefore had to find
transportation to a larger city to pursue her abortion.
My mom is very Catholic. She’s actually one of those ladies that would be out there
protesting. They’re a literal barrier to get through and they make you feel guilty about it.
She’s had a sign and the sign would be right there in front of the door and I would see it
sometimes. Once I got into that situation myself where I had to make that choice, it’s
really not that big of a deal like they make it seem. I don’t know what kind of life I would
be giving this child because I’m not financially stable. And it takes more than love to
raise a child right. So they do put a barrier. (PP4)
Participants talked about how several of the protestors had a religious affiliation and that
they used religion to judge women seeking contraceptive services. Women who were trying to
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 42
“protect themselves” against pregnancy felt ridiculed by protestors who assumed that all women
who were obtaining services from the clinic were there for an abortion. This offended several
respondents because they considered themselves to be against abortion. One woman described
this difficulty:
Just to come here, it is very hard, or to support someone, but you have no control. Then,
there’s people outside making it even harder, judging you. It’s just we don’t know what
people are going through. You don’t know the situation or the trauma or anything that’s
going on really. (PP14)
Being in a rural community makes it difficult for women to freely receive reproductive
health services. Women described religious stigma as putting additional pressure on them
because people are judging their behavior, regardless of the choices they make.
Theme IV: Information About Reproductive Health
Women communicated with different types of people in their networks to make choices
about reproductive health care services and use of contraception. The people whom women
trusted with their questions were typically family members. However, in some instances, women
did not feel that they could talk with anyone in their families (because of the religious beliefs
noted in Theme III), and therefore relied on information from friends or the Internet to gather
information.
Several women specifically articulated how their experiences talking with family
members about reproductive health care choices led them to feeling empowered about their
health care decisions. Some women were able to seek advice from their mothers about
contraception and several received messages about the importance of “protecting themselves” if
they are going to have sex. “My mom … it was good. She just told me that I should take care of
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 43
myself when I start having sex, that I should protect myself” (PP18). If women were not
comfortable going to their mothers, they discussed seeking guidance from sisters or aunts. This
was especially true when those persons worked in the medical field and were perceived as able to
provide accurate information about contraception. “Oh, my sister, she’s an RN [registered nurse]
so she tells me the good and the bad” (CP5). Another participant said, “My aunt, she’s a
gynecologist in San Jose, and I recently asked her. I asked her about I think it’s called the IUD”
(CP20). Because of their conservative backgrounds, some participants did not have any family
members to talk to, so they described their experiences relying on themselves, the Internet, or
doctors for information. One woman spoke about her experience and stated:
Actually, Internet a lot now. I mean coming from a Hispanic background, it’s really hard
for you to try to go to your parents about, ‘Hey, I’m looking—trying to get this.’ I think
you get the turn away, like, ‘No,’ you know. You get the information quicker, and it’s
mostly reliable sometimes if you go to the perfect page. (AV21)
Participants also received information from friends who had experience using varied
types of contraception or family members who were married and assumed to have experience
with contraception because of their marital status, “My sister in law, I trust her because she
knows more because she’s married. So she has more experience than I do” (PP6). Women chose
whom they communicated with about contraception and abortion based on whom they felt could
be trusted to give them nonjudgmental information and keep their confidence. Ultimately, talking
openly about contraception was described as an open secret in the community.
People know that some people do it, but you don’t really want to talk about it. I mean I
don’t really blame them because then that kind of opens a lot of it to judgment. It’s like
we know it’s done, but nobody’s going to really talk about it. (PP3)
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 44
For some women, this was a way to avoid judgment by community members; for others, it
protected them from their parents’ finding out they were using contraception.
Several women, either because of personal or professional experience, became sources of
information among their family members and friends. Some women talked about how and why
they gave information about contraception to their peers. One woman said because Mexican men
do not like to wear condoms, she talks to her friends about taking their own contraceptive
measures. She stated, “I know they don’t want any more future kids. I tell them to make sure
they’re on some type of birth control if the guy doesn’t want to use condoms” (PP12).
Some women described their responsibilities as older family members to discuss
contraception with younger siblings, nieces, and nephews. One woman identified herself as a
source of information because her sister did not discuss the topic of reproductive health with her
children. She said, “[I talk] with nieces because my sisters won’t have the conversation with their
kids because they’re very Hispanic. We’re not supposed to talk about that type of thing. So I will
bring it up with my niece, like it’s time to start birth control” (AV1). One participant (PP17)
shared how she told her nieces that they “need to have a life before you start a life.” Women
became sources of information for a variety of reasons, including playing a matriarchal role in
the family, having a professional background in the health care industry, or having experience as
a trusted friend. Women who became sources of information helped other women make
informed decisions about what is right for their body, which they saw as critical to control of
reproductive health.
Participant descriptions of how women decided what contraceptives to use varied based
on what they believed was best for them personally. Several women described fears about using
contraception. These fears are often unfounded and without medical merit, and they also tend to
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 45
feed into the stigmatization of reproductive health care. For example, participants described
weight gain as their primary concern about taking contraception. One woman said, “Oh, the
shot…but it makes you fat, you know don’t get Depo because it makes you fat. So, I never got
accurate information from other people.” (PP3)
Even when women knew it about myths regarding contraceptives, they still refused to use
certain forms of contraception. As one women said, “The shot, even though it’s a myth, I’m
scared to gain weight on it. I’m short and stumpy as it is. So, I don’t want to gain weight on it”
(AV8). Still others discussed their fears of contraception causing cancer and permanent infertility
and described contraception as dangerous and not good for the body. “Because I think that it is
dangerous because we don’t know what happens after that … maybe like cancer or something
like that … just that it can cause another illness” (PP15). How women receive information about
contraception was as varied as their contraceptive choices. Whom women choose to receive
information from was wide ranging depending on their personal experiences of stigma.
Provider stigma. The women in this study identified widespread stigmatization by
doctors as an issue, especially when it came to discussing abortion or choosing to use
contraception to “take care of themselves” before marriage. This created internal conflicts that
left participants feeling judged for their personal decisions. In one instance, a participant who
volunteered at a women’s clinic and had an unexpected pregnancy was surprised to find out that
her doctor would no longer provide her health care services if she terminated her pregnancy.
I found out I was pregnant and the doctor that I went to, she made a comment, “You’re
keeping your baby, right?” I was shocked. I said, “Well, yeah. That’s not really any of
your business” and she’s like, “Because I’m against abortion.” I said, “But you work in a
women’s clinic. You can’t have a judgment on that.” She’s like, “Well, it’s my personal
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 46
belief. If you’re not going to keep it, then I can’t be your doctor.” I don’t know if she told
me because I knew her; how many people has she told that to? (PP17)
Women shared experiences of overhearing doctors and nurses judging their decision to
use contraception, whereas others described experiences with doctors who told them they were
too young to be using contraception. One woman said that the doctor told her that she would
have to go through testing to make sure she would be safe using contraception because of her
age. “I’ve been to one doctor who wanted to pretty much do this whole testing on me before I
could do it because he said I was too young” (AV4). Women in this study had to navigate
judgment by providers who they had been taught they could trust. Many women described how
conservative medical providers deliberately misled women into believing false narratives about
their reproductive health choices, thus perpetuating their own misperceptions regarding
contraception.
Like you would ask questions and they’d be like, “So, what are you going to want?” It’s
just like, “Oh, I have questions. Is my period going to be regular?” And she’d be like,
“Oh, birth control is the same. It’s all the same. It’s up to you. Either you gain weight,
you lose weight.” That was like their answer for everything. (PP16)
These narratives are reflected in the stories of women who tried to go to their regular
doctors and were told they could not get the contraceptive method they wanted for different
reasons. Women described being told by their doctor that they were too young for sex and
therefore they would not be provided with any contraceptive options. Participant accounts of this
judgment paint a picture of particularly dehumanizing experiences. For example, one woman
talked about going to a local community clinic:
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 47
I tried to go to the clinic and as soon as I went in and I gave them my birth date and they
asked me if I was married and I said no, the nurses immediately gave me this face, like
they were just in shock, like it was something completely new to them or something.
When I went to try to talk to a doctor about it, the first thing he asked was, well, why was
I having unprotected sex so young? And I had to defend myself by telling him I wasn’t. I
was using protection. (AV4)
Some women said their regular doctors simplified birth control side effects or were not
willing to discuss actual side effects of the birth control pills women were choosing. “Well, they
don’t talk so much about the side effects. Like my past doctor, she told me, ‘Oh, you’re going to
get hungry. Eat an apple and drink water.’ It’s not that easy” (PP19).
Several women experienced unwillingness on the part of obstetricians to provide them
with postpartum contraception, even when women were directly asking for it because they
wanted to prevent future pregnancies. One woman described what it is like trying to receive
contraception postpartum:
I ask them when you go to your OB doctor [obstetrician], they give them the option of
like, “Oh, do you want to have any more children?” Here a lot, the answer I get is that
they don’t let them. They’re like, “Oh, no, you can’t get that yet.” And they don’t even
offer birth control. They’re like, “OK, we’ll see you next month” and don’t offer any kind
of method … like they won’t provide that service, even though they do provide it there,
but they won’t do it. And again, I would believe that because there are conservative
doctors out here, and I say that because of personal experience. (AV8)
Another participant talked about wanting to use the birth control pill but her regular
doctor told her that pills would cause her and her husband problems and they should just use
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 48
condoms, even though they are less effective than the birth control pill at preventing an
unintended pregnancy. “We use it because the doctor told us to. Since we got married and started
having intercourse, we didn’t want to get pregnant right away. He told us it was easier to use
condoms, not pills” (CP18). Many women said they wished that their provider would have given
them accurate information so that they would not feel stigmatized or judged for taking care of
themselves. Misinformation about contraception can lead to difficulty making informed
decisions about women’s health.
Summary
Overall, women’s experiences of reproductive health were described as a conflict
between familial and community-based stigma and the need for personal autonomy and free
agency over health care choices. Several factors contributed to judgment about contraceptive and
abortion services. For women to overcome these obstacles, they had to resolve their inner
conflict about their choice to engage in sexual activity on their own terms. These results
elucidate the complexity of women’s lived experiences with their most private and personal
health care decisions.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 49
Chapter 5: Discussion
This study explored the sexual and reproductive decisions and experiences of women in
rural California. Several themes emerged from qualitative analysis of interview data. Although
some of these themes arose directly from the semi-structured interview questions (deductively),
others emerged inductively. The interviews highlighted how stigma affects reproductive health
care access. This was particularly visible in the efforts of women to “take care of themselves”
through contraception use (in a conscious effort to prevent abortion). Participants described how
they navigate stigma and judgment in their communities and identified their strategies for
accessing reproductive health care despite this stigmatization. Recent shifts in attitudes toward
contraception have led to unprecedented ideological opposition in the politics of abortion and
contraception (Aiken & Scott, 2016). This work extended knowledge of women’s experiences in
rural California and generated innovative findings regarding contraceptive use and abortion
stigma.
This research highlighted the deep complexity of women’s reproductive lives and
experiences. More specifically, these interviews revealed the deep internal conflicts that women
experience as a result of their decisions to engage in sexual activity and use reproductive health
care services. Participants described how they navigated contraceptive and abortion stigma in
their communities and identified strategies they used for accessing reproductive health care
despite the judgment of family and community members. Women at once experienced and
propagated the very perspective contributing to their internal struggles. In one manifestation of
these struggles, participants learned how to reconcile their enjoyment of sexual activity and
subsequent use of contraception with an internalized sense that these acts were promiscuous.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 50
Women addressed these internalized pressures by “taking care of themselves” despite familial
and cultural regard for babies as blessings.
Individual and Family-Level Stigma
In the early 1960s, Erving Goffman described stigma as an attribute that discredits
individuals in its transformation of an individual from whole to damaged (Goffman, 1963). This
construct has been conceptualized in the abortion literature as particularly relevant due to the
stigmatizing responses toward women who challenge social norms of sexuality and motherhood
by pursuing abortion procedures (Cockrill, Upadhyay, Turan, & Greene Foster, 2013; Cowan,
2017; Ellison, 2003; Hanschmidt, Linde, Hilbert, Riedel-Heller, & Kersting, 2016; Harris, 2012).
Participants described experiences of stigma as subtle instances that take place in their everyday
lives. Religion and culture in their communities were two distinctly separate constructs, each one
directly related to women’s experiences of stigma.
Research on abortion and concealment has shown an association among secrecy, thought
suppression, intrusive thoughts, and psychological distress among women who have had
abortions (Major & Gramzow, 1999). Women in this study had a difficult time describing their
intimate experiences. These findings reveal that women used processes of concealment and
secrecy in all aspects of their reproductive lives, not just in instances of abortion. Several of the
women reported that they had never discussed their reproductive experiences with anyone. For
some women, they had kept their contraceptive use a secret for fear of stigma from family or
friends. Further, for some study participants, fear of stigma was so significant that they had never
before the interview told anyone they had used abortion services. The stigma related to
reproductive health care is silencing for many women in rural communities. Existing literature
that focused on women’s experiences in rural communities described stigma in countries outside
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 51
of the United States (Ganatra & Hirve, 2002; Haws et al., 2010; Levandowski et al., 2012;
Shellenberg et al., 2011; Sorhaindo et al., 2014; Varkey, Balakrishna, Prasad, Abraham, &
Joseph, 2000). Findings in the current study indicate that future research should explore
stigmatization of women in rural communities in the United States.
Previous research suggested that stigma about abortion can prevent women from seeking
or receiving social support (Norris et al., 2011). Women in this study shared that the opportunity
to tell their stories was empowering and that the interview itself changed how they thought about
their reproductive health experiences. Some women reported that they had previously felt
burdened by their reproductive health secrets. They shared gratitude for the opportunity to
discuss the intimate details of their lived experiences with the interviewers. These findings
highlight the power of storytelling (Hemmings, 2011), especially as an intervention to reduce
internal conflict and shame about reproductive health choices among women experiencing shame
and stigma.
Participants in the study did not directly refer to any particular religious or community
leaders in their descriptions of barriers to accessing reproductive health care. Instead, women
talked about their family’s religious beliefs (with a particular focus on their mother’s religiosity)
and how this directly affected their ability to discuss sex or contraception, knowledge of
contraceptive methods and devices, and willingness to defy their mother’s wishes about
remaining abstinent until marriage. Although some researchers have found that parents’ cultural
beliefs play a significant role in reproductive health-seeking behaviors (Caal et al., 2013), this
research expanded that work by exploring the relationship between religious stigma and those
behaviors. Although mothers played a meaningful role in participants’ decision making about
reproductive health care use, many respondents indicated that they sought advice and validation
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 52
from sisters or aunts whom they knew would support their decision to “take care of themselves,”
particularly when their mothers would not. Women who felt deep shame related to contraception
or abortion stigma reported feelings of deep isolation and noted that they would seek information
directly from the Internet or health care providers rather than family members or close friends.
These findings are partially supported by existing literature citing a fear of judgment (a
manifestation of abortion stigma) as one of the main reasons that people do not share their
abortion experiences with loved ones (Nixon et al., 2017). This finding additionally suggests that
the fear of judgment in rural communities also extends to the use of contraception. This should
be explored further in future research.
Contraception and Abortion Barriers
The issue of abortion was deeply nuanced for women in rural communities. When asked
about abortion stigma, many participants shared they “take care of themselves” by successfully
implementing the use of contraception, preventing their need for abortion services. This idea of
“taking care of their bodies and their health” was central to women’s contraception beliefs, even
in circumstances wherein conservative religious or cultural values often took precedence over
health care decisions. Even though the use of contraception did not align with women’s religious
beliefs, in this context, contraception was seen as a core value to many participants, especially as
it related to the prevention of abortion. Respondents’ less stigmatized view toward contraceptive
use appeared to facilitate judgment against women who “fail to take care of themselves” and
subsequently choose abortion for unintended pregnancies. One reason for this might be their
counterintuitive relationship with contraception. Participants found a way to value contraception
despite their religious and cultural beliefs with regard to abortion. This internal conflict was
externalized in their judgment of women who choose abortion rather than contraception use.
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 53
Participants indicated that their successful circumnavigation of cultural and religious
barriers to contraception meant an acceptable path to abortion prevention existed. This sensibility
was translated as a perception that women who ultimately choose abortion are simply
“irresponsible.” This type of judgment is reflective of the internalization of stigmatization by
women in communities in which secrecy allows them to retain their status as a “whole,
untainted, or unmarked person” (Harris, 2012, p. 1472), thus differentiating themselves from
“those girls.” This mode of thinking underlies the social norms of marianismo, a term used to
describe the idealized belief that Latina women are virtuous and spiritually superior to men
(Castillo, Perez, Castillo, & Ghosheh, 2010), which is intertwined with familismo, which places
importance on family and adherence with traditional gender roles within the family (Flores,
Eyre, Millstein, 1998). In these communities, violation of these cultural ideals results in their
being stigmatized for simply having sex or wanting to take care of themselves. Thus, these
norms end up being a root cause of stigmatization for seeking reproductive health care services.
Women in these communities described themselves as “pro-life” in almost every
circumstance, with the exceptions of rape or failed contraception (i.e., if a woman was “taking
care of herself” and her contraception fails in some way). Choosing abortion in these instances
reflected that all other avenues of choice had been exhausted. In fact, although women may
identify themselves as opposed to abortion, the stigma of abortion is frequently reduced if a
woman has endured a sexual assault (Cook & Dickens, 2014). However, this must be
contextualized by the reality that in cultures wherein young women are valued for their virginity,
the stigmatization of rape can be more destructive for a family than the stigmatization of abortion
(Cook & Dickens, 2014). This contributes to women’s bifurcated view of abortion. Alas, this
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 54
notion of choice has vast ramifications for the reproductive rights movement, which rarely raises
the specter of limited and circumstantial reproductive freedom (Chrisler, 2014).
This research highlights how women in rural communities experience stigma and
judgment around abortion. Many of the participants described stigmatization and the act of
discrediting women’s abortion experiences. Some women identified stigma about their own
experiences and others described the relationship between contraception and abortion prevention.
These findings point to the use of contraception as a protective measure to prevent against
abortion, which presents an opportunity to explore further the internalized struggle of reconciling
sexual activity with contraceptive and abortion stigma.
Religious Stigma
Literature on reproductive health care has focused on the role of media in perpetuating
abortion stigma (Kumar, Hessini, & Mitchell, 2009). The construction of abortion stigma is a
particularly social phenomenon ascribed to women who pursue abortion services; these
depictions regard women as inferior to ideals of womanhood (Kumar et al., 2009). Engaging in
behaviors that “terminate a life” is a challenge to the moral order (Kumar et al., 2009), which
gives rise to stigma in rural communities wherein deep cultural norms are predominantly
influenced by conservative religious beliefs. The continuation of the myth that heterosexual
women are responsible for their reproductive outcomes is the cornerstone of patriarchy. The
findings in this study suggest that a pervasive notion persists that women’s promiscuity is a
foundational narrative for women’s lives. This creates a duality for women who see
contraception as an empowering form of protection from unintended pregnancy and abortion.
The stigmatization of women’s fertility is responsible for the current wave of anti-woman
reproductive health care policy (Aiken & Scott, 2016), which has conscripted the Madonna–
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 55
Whore binary into policy making in a way that had previously never occurred in modern
America. This overt attack positions women as the Madonna by supporting the notion that
womanhood is synonymous with motherhood (Bird, 2016). Forcing a woman to remain pregnant
to keep her position in society “clear” strips her of her bodily autonomy, effectively shackling
her decision-making abilities and leaving her helpless against the machinations of governing
bodies (Bird, 2016). Women in this study identified a pervasive stigma in their communities that
shamed and silenced women who choose abortion services. Researchers, policy makers, health
care providers, and those who advocate for reproductive justice should consider these findings
when evaluating outcomes for women in rural parts of the country, paying particular attention to
the shame and guilt created by stigma in rural communities.
Information about Reproductive Health
Interviews with women highlighted how stigma affected reproductive health care access.
Participants shared information about choice in contraception, how they choose their provider,
and provider stigma associated with sexual activity outside of marriage. Some women described
“taking care of themselves” in the context of buying condoms or getting contraception in the
local drug store. In this context, women took pride in maintaining control over their reproductive
lives. In some instances, these public displays of sexuality resulted in women’s embarrassment
or shaming town gossip.
Postpartum contraception allows women to extend pregnancy intervals and reduces
unintended pregnancy (Committee on Obstetric Practice, 2016). Many women in this study
reported that area doctors who provide obstetric care did not provide women with postpartum
contraception; in some instances, providers refused to do so (Akers, Gold, Borrero, Santucci, &
Schwarz, 2010; Card, 2007; Collins, 2006; Madden, Allsworth, Hladky, Secura, & Peipert,
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 56
2010). Several women who had given birth reported that they were not provided with postpartum
contraception in their doctor’s offices and that their providers shamed them for requesting it.
This shaming creates an immediate and long-term barrier for women who may feel intimidated
or ashamed to discuss contraceptive options in the future. Future research should explore the
schema and reasoning of how providers make decisions about postpartum contraception and
patient counseling. Better understanding these perspectives is important because they run counter
to best practice guidelines of the American College of Gynecology that state: “Women should be
counseled about all forms of postpartum contraception in a context that allows informed decision
making” (Committee on Obstetric Practice, 2016, p. 422). Despite a prevalent desire to receive
long-acting reversible contraception, providers similarly refused on the basis of their personal
objections to contraception or because they did not carry it on-site. There is scant literature about
the lack of these devices in medical offices. Further research that focuses on primary care
providers would help uncover barriers to counseling women about the advantages and risks of
these devices as recommended by the American College of Obstetricians and Gynecologists
(Committee on Obstetric Practice, 2016).
Participants drew connections between the need to take care of themselves and the
unwillingness or inability of some health care providers to meet their reproductive health care
needs. Women in this study spoke of a preference for less-judgmental health care providers who
could offer all contraception options; they stated that this was the only way they could make
informed decisions about their reproductive health care. Policies that restrict access to women’s
reproductive health care have resulted in two outcomes related to these women’s experience.
First, these policies have created restrictions in how physicians are able to practice reproductive
health medicine (Eisenberg & Leslie, 2016). Second, the policies have facilitated the ire of health
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 57
care practitioners who object to participation in contraception and abortion practice, resulting in
the passage of “conscience to object” polices (Brown, Hasselbacher, & Chor, 2016; Faúndes &
Miranda, 2017). These policies have created an ethical dysmorphia among physicians, which
was described by women in the current study as demeaning and demoralizing. The current study
validates the assumption of patients that providers are ethically mandated to ensure that women
can receive access to services they request (Brown et al., 2016). Reports of the use of
stigmatizing language toward women reveal an apparent fissure in the provision of medical
services, allowing health care providers to openly judge women for their reproductive health care
decisions.
Women’s responses to questions in this study indicate that they had little to no accurate
information about the side effects associated with the use of different forms of contraception.
Many participants said they believe that birth control leaves women infertile, makes women fat,
or can cause serious bodily harm if used for too many years (Gilliam, Warden, Goldstein, &
Tapia, 2004; Russo, Miller, & Gold, 2013; Sangi-Haghpeykar, Ali, Posner, & Poindexter, 2006).
Future research should address this lack of understanding among women and evaluate the long-
term impact of inaccurate information on generations of women, especially when the information
prevents women from using contraception that might best fit their needs.
A few respondents discussed how they or women they knew would regularly crossed the
border to Mexico to access contraception for various reasons, including ease of service, no need
for a prescription, and cost savings. Current media attention has focused on the potential
economic impacts of increased border security along the U.S.–Mexico border (Brooker, 2017; de
la Calle, 2017; Woody, 2017). Given the current policy shift toward increased surveillance along
the border, future research should also pay special attention to women who seek health care
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 58
across the border to understand the role of border crossing in a woman’s ability to access
contraception.
Recommendations for Policy
Policy decisions do not explicitly affect individual experiences until an individual has
taken personal action to access reproductive health services. The women in this study described
their access to reproductive health in the context of overcoming taboos and stigma, which are
exacerbated by policy decisions that directly affect their health care experiences. In these rural
areas, reproductive health care access and choice of provider are directly linked to domestic
health care policy. Given these findings, advocacy is needed for policies that are less restrictive
and adhere more to the human rights and needs of women. During the first months of the 2017
Congressional session, multiple policy measures were set in motion that directly affect the
provision of reproductive health care in the United States and globally. The House of
Representatives voted to make the Hyde Amendment permanent law when they passed H.R. 7,
the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act, sponsored
by Rep. Christopher Smith. If passed, this law would disproportionately affect poor women and
women of color who are enrolled in Medicaid, making it illegal to use public funds to cover
abortion services (Donovan, 2017). Further, the global gag rule was reinstated by executive
order, which directly affects international family planning programs (Starrs, 2017). Rep. Steve
King introduced H.R. 490, the Heartbeat Protection Act of 2017, which bans abortion beginning
at 6 weeks. This legislation represents the most restrictive abortion ban that has ever been
introduced in Congress (Grimaldi, 2017). Rep. Paul Ryan vowed to defund Planned Parenthood
despite the fact that “research shows that Planned Parenthood health centers are better able to
deliver high-quality, timely contraceptive care to more women than other types of publicly
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 59
funded family planning providers” (Hasstedt, 2017, p. 1). The American Health Care Act
prevents Planned Parenthood from using federal funds to provide reproductive health care
services. In its report, the Congressional Budget Office (CBO) states, “The people most likely to
experience reduced access to care would probably reside in areas without other health care
clinics or medical practitioners who serve low-income populations” (CBO, 2017). Further, the
CBO readily admits that unintended pregnancies funded my Medicaid will increase by “several
thousand” due to the defunding of Planned Parenthood (2017). According to the Guttmacher
Institute (2013), nearly one-third of women who need Medicaid covered contraceptives live in a
county where Planned Parenthood is the primary safety-net health provider. In addition, more
than half of Planned Parenthood’s health centers are in rural and underserved communities
reaching over two times as many contraceptive patients as other community health centers
(Guttmacher, 2013). Over half a million Latinos make up nearly one quarter of Planned
Parenthood’s patients as in rural areas, providers who accept Medicaid for ob-gyn care are in
short supply (Planned Parenthood, n.d.). This policy shift directly impacts women in these
communities by eliminating choice in service provider, blocking access to all forms of
contraception, and preventing access to abortion services. The elimination of Medicaid funding
for Planned Parenthood will create a rise in unintended pregnancies, sexually transmitted
diseases, and HIV while simultaneously decreasing vital screening services for breast and
cervical cancers among poor women living in rural communities (Guttmacher, 2013, Planned
Parenthood, n.d.).
The 2016 election has left the conservative movement even more empowered and
emboldened to “govern” women and their human right to safe, affordable health care that works
for their lives. The fear of women using their sexuality to seize political, social, and emotional
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 60
power has led to a hostility that reduces women to sexual objects who cannot be trusted (Begun
& Walls, 2014). Oversimplifying the reproductive health care debate into a conflict between the
rights the government and the right of a woman to control her body ignores the philosophical
underpinnings of the Madonna-Whore binary. Further, this justification allows legislators and
governing bodies to continue the perpetuation of the myth that some women deserve hostile
treatment while others should be treated with benevolence thus confining women to their defined
gender roles.
Given findings in this study, cutting Title X family planning funding would be
detrimental to women living in rural areas, even the state of California, where women have
access to one of the best publicly funded family planning programs in the country (Medi-Cal
FPACT). California must maintain Medi-Cal funding at 2016 levels to ensure that poor women
are able to access publicly funded family planning programs and services, especially in rural
areas. These findings show that women have difficulty accessing contraceptive services, even
when they want the services, because they are unsure where to receive services, they cannot
afford it, and they must overcome onerous stigma associated with living in conservative, rural
areas. Given the federal–state divide in California specifically, local policy makers are in a
unique position to develop measures to support family planning funding without assistance from
the federal government. More specifically, local policy should be more strongly oriented to the
needs of women in rural regions where reproductive health care is lacking.
Findings from this research suggest a need to ensure access to safe and legal abortion
locally and nationally. Even though California is widely regarded as stalwart progressive state,
this study found that women have difficulty accessing abortion for two reasons: they unaware of
its local availability or they are unable to access a noninvasive medical abortion in the first
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 61
trimester because of cost or transportation issues. Women also navigate burdensome stigma that
paralyzes their ability to seek services. Given the current political climate and the number of
restrictions that will directly affect women’s health care, protecting reproductive health care
must take priority over expansion of services.
Study Limitations
Although this work contributes to our understanding of reproductive health care access
for rural women, the findings should be taken with caution, given the study’s limitations. First,
although qualitative data provides rich data that deepens understanding of social problems, the
experiences shared are unique. Therefore, findings can help by highlighting barriers to
reproductive health care in these two communities, but cannot be assumed to represent
experiences in other rural communities. Future studies should examine the shared and unique
experiences of other communities as compared to those in this work. Second, the recruitment
strategy yielded a sample composed of women seeking services in a health care setting and
disproportionately of Hispanic origin. The sample also represents a geographic slice of
California, given its rural focus. The perspectives of women in the sample may consequently be
different than those who are not seeking reproductive health care services in a community clinic.
Additionally, because the women in this study were already seeking some sort of medical service
from their local community clinics and were mostly from border communities, their experiences
might be different than other rural women.
However, this study was successful in recruiting women who had diverse experiences
with abortion and contraceptive services. Many women had overcome great personal stigma to
be able to make their health care decisions freely, and some women relayed stories about their
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 62
reproductive lives that they had never before shared. The diversity in these women’s experiences
indicates a broad range of perspectives, which are reflected in the study findings.
Conclusion
Access to reproductive health services can be severely restricted based on geographical
location. The freedom to make reproductive health choices and access reproductive health
services faces mounting opposition in the United States (Sonfield, 2017). Women in rural areas
have particularly unique experiences related to accessing contraception and abortion services,
especially where providers are scarce and stigma is high. This research shows that the
politicization of abortion has in some ways misdirected the dialogue on women’s health, leaving
women misinformed and with limited resources as they make reproductive health-related
decisions. Given the current political and social climate in the United States, it is critical that we
clearly understand the reproductive health care needs, facilitators, and barriers among women in
rural areas. Learning about reproductive health care experiences directly from women allows
researchers, practitioners, advocates, and policy makers to overcome stigmatization and facilitate
systemic changes to benefit women who require these services.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 63
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Appendix A: Qualitative Survey Instrument

Access to Reproductive Health Care in Rural California: A Qualitative Study of Women’s
Perspectives

I. Questions regarding personal use of contraception

1. Do you or someone you are close to use contraception (birth control)?

a. If YES ask:

i. What forms of contraception have you or do you use?
ii. Is there a particular health care provider you get your contraception from?
1. If so, who is it?
iii. Why did you choose that provider?
iv. Who do you rely on to get information about contraception? (ex. Friends, family)
v. Do you talk to your friends about contraception?
vi. Do you talk to your family about contraception?
vii. What are the main issues or challenges you face in getting contraception?
viii. Do you feel like religion affects you getting contraception in your community?

b. If NO ask:

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 76
i. Why not?
ii. Do you use natural family planning methods?
1. If so, what forms do you use?

II. Questions regarding personal experiences with abortion

i. Have you or someone you are close to ever had a medical abortion?

a. If YES ask:

i. Who do you rely on to get information about abortion? (ex. Friends, family)
ii. Do you talk to your friends about abortion?
iii. Do you talk to your family about abortion?
iv. How do you feel about getting an abortion in your community?
v. What are the main issues or challenges you face in getting an abortion?

III. Questions regarding women’s access to reproductive health care in general in the community

1. In general, do you think women in this community access to the reproductive health care
services they need? Why or why not?

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 77
2. Have you or someone you know ever had problems accessing reproductive health care in
your community? If so, could you describe what happened?

3. Do you feel like there is a stigma associated with using contraception in your community?
a. Do you feel like religion and culture influence this stigma? Why or why not?

4. Do you think that stigma prevents women from using contraception?
a. Do you feel like religion and culture influence this stigma? Why or why not?

5. Do you feel like there is stigma associated with abortion in your community?
a. Do you feel like religion and culture influence this stigma? Why or why not?

6. Do you think that stigma prevents women from obtaining abortion services if they want
them?
a. Do you feel like religion and culture influence this stigma? Why or why not?

7. Do you believe that this community’s religious leaders create barriers to women’s
reproductive health care needs? Could you explain that a little further?

8. What do you think could make getting reproductive health care services more acceptable in
your community?

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 78
Appendix B: Demographic Survey Instrument

Access to Reproductive Health Care in Rural California: A Qualitative Study of Women’s
Perspectives

1. What is your date of birth?
_______________

2. Are you Hispanic or Latino?
Yes _____
No _____

3. What would you say is your main racial group?
White (European American or “Anglo”) _____
Black or African American _____
Native American or Alaskan Native _____
Asian _____
Native Hawaiian or other Pacific Islander _____
Multiracial or mixed race (specify): _______________
Some other race (specify): _______________

4. What is your current marital status?
Married _____
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 79
In a serious romantic relationship (not married or in registered domestic partnership) _____
Widowed _____
Divorced _____
Separated _____
Never married _____

5. Do you have any children?
If yes, how many? _____
No _____

6. What is the highest grade of education you have completed and received credit for?
No formal education _____
High school diploma or GED _____
Vocational, business, or trade school _____
Associate’s degree _____
Bachelor’s degree _____
Postgraduate education _____

7. Are you currently enrolled in school or a vocational training program?
Yes _____
No _____

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 80
8. What was your total income last year? (Please consider money from all sources including
any jobs, tips, welfare or general relief, other government help, or any activities either legal or
under the table)
$0–$10,000 _____
$10,000–$20,000 _____
$20,000–$30,000 _____
$40,000–$50,000 _____
$50,000–$60,000 _____
$60,000 or more _____

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 81
Appendix C: Code List
Contraception Code List
Code Planned
Parenthood Los
Angeles County
Clinicas de
Salud del
Pueblo
Planned
Parenthood of the
Pacific Southwest
Total
n n n n
How choose provider 24 19 20 63
Where information comes from 21 15 19 55
FPACT/Medicaid 2 12 5 19
Who communicate with and how 22 15 20 57
Decision making process 25 18 20 63
Challenges 23 18 19 60
Stigma about contraceptive
choice
5 2 4 11
Religion 13 11 11 35
Culture 9 5 7 21

Abortion Code List
Code Planned
Parenthood Los
Angeles County
Clinicas de
Salud del
Pueblo
Planned
Parenthood of the
Pacific Southwest
Total
How choose provider 1 2 6 9
Where information comes from 10 11 8 29
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 82
Who communicate with and how 15 7 12 34
Decision making process 11 3 7 21
Challenges 11 8 9 28
Stigma about abortion 20 16 10 46
Religion 12 9 7 28
Culture 8 9 5 22

Challenges Code List
CODE NAME Planned
Parenthood Los
Angeles County
Clinicas de
Salud del
Pueblo
Planned
Parenthood of the
Pacific Southwest
Total
n n n n
Stigma around sex 14 11 15 40
Stigma around provider 9 0 7 16
Provider judgment 7 3 2 12
Overcoming internal judgment 5 5 6 16
Misperceptions about clinics 3 5 8 16
Religious stigma 19 16 19 54
Cultural stigma 17 12 12 41
Madonna or whore 7 10 9 16

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 83
Appendix D: Chart of Analytic Process
Analytic Activity Purpose Analytic Focus Result
Initial reading of
transcribed interviews
(PI)
Allowed
understanding of the
participants
experiences as a
whole
Intrainterview Able to gain a sense of
which questions were most
relevant to participants
Immersion into data
(PI)
In-depth reading of all
transcripts; creation
of initial code list
Intrainterview Creation of an initial code
list, using data to elicit ideas
and creating appropriate
codes to note quotes; initial
code list was 30 codes
Immersion into data
(Co-coder)
In-depth reading of 34
randomly selected
transcripts; creation
of initial code list
Intrainterview Creation of an initial code
list, using data to elicit ideas
and creating appropriate
codes to note quotes; initial
code list was 28 codes
Review and revision
of initial code lists (PI
and Co-coder)
Compare initial code
lists; refine and
clarify each code,
adding, eliminating,
and collapsing codes
when relevant
Intrainterview Creation of a single code list
containing 27 primary
codes; two codes were
eliminated because they did
not have great relevance to
study purpose and aims; two
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 84
codes were collapsed into
other code categories
because noted definitions
were not distinct from
stronger code categories;
one code was added because
it emerged as a distinct
construct; some codes were
devised by the PI and some
by the co-coder that were
similar but with different
names, thus the name of the
code was resolved via
discussion
Applied new code list
to all transcripts (PI
and Co-coder)
Used established code
lists for data analysis
Intrainterview No new codes were derived
from the data, highlighting
data saturation; noted
emerging themes from the
data; calculated the number
of times each code was
used; specific data
fragments were tagged as
quotes of interest
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 85
Systematically sorted
codes into categories
(PI)
To link codes with
themes, using quotes
Intrainterview Supported themes by linking
quotes to concepts
Note. PI, principal investigator.

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 86
Appendix E: Process Memos

1/29/2017 – Meeting between PI and co-coder
“Talking openly” was a code; however, we decided that it is part of “visibility” in
recommendations section
“Taking care of myself” was identified as a code that was collapsed into another code category
“Sources for information was renamed “where information comes from”
“Personal self-judgment” was renamed “overcoming internal judgment”
“Reasoned decisions” was renamed “decision-making process”

2/5/2017 – Meeting between PI and co-coder
“Madonna or whore” was added as a code
“Religious stigma” remains separate code even though it is related to “Madonna or whore”
because it emerged as its own code
“Engagement with provider” in both contraception and abortion section is subsumed under
“stigma around provider”

REPRODUCTIVE LIFE IN RURAL CALIFORNIA 87
Appendix F: Final Codebook
Contraception
• How choose provider – Process by which women decide to go to a certain clinic or certain
doctor for contraception
• Where information comes from – Whom women obtain initial information about
contraception from (e.g., friends, family, Internet)
• Medicaid or green card (FPACT) – How women in poverty or without insurance obtain
contraception
• Who communicate with and how – How women describe getting or giving information
about contraception and the extent to which those conversations are open and honest
• Decision-making process – How women describe the process they go through to choose
contraception that personally works for them
• Challenges – How women describe obstacles to accessing and using contraception
• Stigma about contraceptive choice – How women experience stigma about using
contraception
• Religion – Women’s description of how religion affects their beliefs about and choice to use
contraception
• Culture – Women’s description of how culture affects their beliefs about and choice to use
contraception

Abortion
• How choose provider – Process by which women decide to a certain clinic or a certain
doctor to obtain an abortion
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 88
• Where information comes from – Whom women obtain initial information from about
abortion (e.g., friends, family, Internet)
• Who communicate with and how – How women describe who they talk to about abortion
(theirs or someone else’s) and the extent to which those conversations are open and honest
• Decision-making process – How women describe their decision to have an abortion
• Challenges – How women describe obstacles to receiving abortion services
• Stigma about abortion choice – How women experience stigma about abortion
• Religion – Women’s description of how religion affects their beliefs about and choice to
have an abortion
• Culture – Women’s description of how culture affects their beliefs about and choice to have
an abortion

Predominant Challenges
• Stigma around sex – How women describe judgment around sex, especially around the use
of contraception
• Stigma around provider – How women describe clinic protestors and other obstacles to
being fully informed about contraceptive choices
• Overcoming internal judgment – How women describe making the choice to use
contraception or get an abortion despite holding religious or cultural beliefs that are against it
• Misperceptions about clinics – How women describe people’s assumptions about the health
care services provided by clinics
• Religious stigma – How women describe predominant religious stigma around reproductive
health as a whole
REPRODUCTIVE LIFE IN RURAL CALIFORNIA 89
• Cultural stigma – How women describe predominant cultural stigma around reproductive
health as a whole
• Madonna or whore – How women describe stigma about women who are using or
perceived to be using contraception

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Asset Metadata

Creator Bird, Melissa (author)

Core Title Women’s stories of reproductive life in rural California: a qualitative study

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/17/2017

Defense Date 03/13/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Abortion,contraception,health care policy,OAI-PMH Harvest,reproductive health,reproductive justice,women's health

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Cederbaum, Julie (committee chair), Baezconde-Garbanati, Lourdes (committee member), Rohrbach, Luanne (committee member), Wenzel, Suzanne (committee member)

Creator Email birdm@usc.edu,melissabird1001@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-354637

Unique identifier UC11255886

Identifier etd-BirdMeliss-5187.pdf (filename),usctheses-c40-354637 (legacy record id)

Legacy Identifier etd-BirdMeliss-5187.pdf

Dmrecord 354637

Document Type Dissertation

Rights Bird, Melissa

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA