In Mexico, getting birth control should be a straightforward process. The reality may be more complicated.
A national family planning program makes birth control available to women over-the-counter, regardless of whether they have health insurance. But while measures like these have reduced the country’s birth rates over the course of several decades, experts say that the picture is more fraught. Stigma, gender relationships, and ethnicity may all play a role in a woman’s experience of receiving birth control.
“It’s viewed badly to use contraception,” explained Mariana Alarcón-Cassius, the Program Director of Reproductive Health at CASA, a center for sexual and reproductive health care in San Miguel de Allende, Mexico. Alarcón-Cassius leads a contraception-access program that makes condoms available for free at commonly frequented businesses, such as convenience stores and barbershops.
For unmarried women, contraception is particularly taboo, Alarcón-Cassius said: “A girl that has sex before marriage is made out to be a bad woman.”
For that reason, many young women experience judgment or resistance when trying to access birth control, particularly methods that aren’t sold over the counter, like the IUD. One 2018 study found that providers may hesitate to provide education or contraception to teenagers and women in their early 20s.
“The role of the provider and how they treat the client has an outsized role on whether that woman is going to be able to access contraception,” said Dr. Jean Marie Place, a professor at Ball State University in Muncie, Indiana, and the study’s lead author.
The study recruited women to act as “simulated clients” at health care facilities in Mexico City. The women were instructed to ask providers about their options for long-term contraceptives — methods that aren’t available over the counter and that usually require insertion by a provider.
“In some cases, providers didn’t want to provide information, but they weren’t direct about saying so,” she said. They would come up with excuses, such as telling the women, who ranged in age from 15-24, they were too young to be using contraception or they needed a parent present. “Many women…said to me, ‘I’ll never go back to that clinic, they were so disrespectful’ or ‘I felt so judged’ or ‘I felt so rushed that I’ll never go back to that clinic,’” said Place.
The source of this stigma – and the degree to which it affects birth control access – is up for debate.
Some experts point to religion. “It’s a heavily religious country with a predominantly Catholic faith, and so the faith may have played into some of those providers’ perspectives of not wanting to provide contraception,” said Place.
Others are skeptical of religion’s role: “I would say quite honestly, that in some ways, contraceptive access and stigma, religious stigma, is stronger [in the United States] than in Mexico,” said Dr. Deborah Billings, a reproductive and sexual health care researcher who has worked and studied extensively in Mexico.
For Billings, the bigger issue is reproductive coercion. While conducting research at a textile factory on the border, Billings found many of the women had partners who didn’t allow them to use birth control, “because, it’s like, ‘You’re mine. You will have my children. I have control over you.’”
Women described having to sneak contraception past their partner. “Trying to negotiate with a partner to say… ‘We can’t have sex right now because I’m going to get pregnant,’ was in most cases not going to fly,” said Billings. Instead, women opted for birth control injections, which last for up to three months and are virtually undetectable.
At CASA, patients have noted similar experiences. “I have seen women choose methods based on the comfort of the partner,” said Laura Herrera, a midwife at the center. “Some men believe that methods such as the IUD will cause sexual intercourse to be uncomfortable, that it will decrease women’s libido.” Others worry it’ll lead to infidelity.
These beliefs are often attributed to a hyper-masculine culture. “En Mexico, la cultura es muy machisma,” said Alarcón -Cassius. For women, this often means less autonomy over their bodies.
“Basically, what the hell are men or anyone doing telling anyone that identifies as a woman what they should do or not do with their body?,” said Nadine Goodman, a sexual and reproductive health activist who has worked in Mexico for decades “Gender inequality” is the main issue, Goodman said.
While intimate relationships can lead to reproductive coercion, health care providers are guilty of it, too, Billings said. While working at a hospital in Mexico, she often saw providers insert IUDs, without a woman’s permission, after giving birth. “There are definitely problems with consent,” she said.
Laura Herrera, the midwife from CASA, has had patients recount this same experience. “The biggest problem is that the changes or implications caused by the use of these contraceptive methods, especially hormonal ones, are not explained to women,” she said. “Women don’t receive adequate counseling.”
For indigenous women, the problems are worse. Providers are more likely to make decisions about their use of birth control post-delivery, according to Billings, who said it was especially common for providers to withhold information about their options or insert IUDs without their consent. “It’s not just a gender thing,” she said. There’s an “ethnicity dimension.”
When it comes to seeking out birth control, indigenous women are also more likely to be dismissed by providers, according to Place: “The providers were a little bit more harsh in rejecting the young women’s requests or in saying things like, ‘You know, you shouldn’t be having sex,’ and being forthright and…not using those nicety excuses.”
Economic status and location – rural patients are less likely to have their choice of birth control, Herrera said – also play a role in the complex question of how a woman will experience reproductive health care.
But these issues are not unique to Mexico. In many countries, women’s access to reproductive health care is complicated by social and economic factors. “I think worldwide it’s just a continuum,” said Goodman.
For Billings, access to contraception isn’t just about location or age. It’s about power. “The less power you have in society overall, the harder it is for you to access contraceptives,” she said.
Over the course of CASA’s eleven-year partnership with Direct Relief, the centers have received numerous shipments of medical aid to support their family planning programs and midwifery clinic, including hormonal birth control, condoms, and supplies to equip midwives for safe labor and delivery. Since July 2020, Direct Relief has provided CASA with more than $84,000 in grant funding to support its initiative to make birth control and sexual health education more readily available in the community.