Street-level Pastors: How Contraceptive Providers Engage in Benevolent Coercion

In 2012, South Carolina introduced Medicaid guidance to provide immediate postpartum long-acting reversible contraceptives (IPLARCs) to Medicaid patients at no cost to them. This policy quickly spread and now exists in some form in the majority of U.S. states. Reducing short interval pregnancies has been put forth as a key raison d'être for Medicaid-covered IPLARC, and this practice has therefore been endorsed by public health officials and medical practitioners. However, IPLARCs have also been criticized for their coercive potential given the marginalized status of the targeted population and the timing of the procedure (i.e., immediately postpartum). Through a textual ethnography in which I iterate between medical literature and guidance on short interval pregnancies and interviews with health care providers, I explore the consequences of IPLARC policies. Theorizing IPLARCs as a biopolitical tool and health care providers as “street level pastors”— “street level bureaucrats” who employ pastoral power—I analyze providers’ implementation of IPLARC policies and the impact this has on the patients they serve. I find that providers engage in “benevolent coercion,” in which they subtly pressure Medicaid patients to obtain IPLARCs with the framing that they are empowering and promoting health among these patients. Providers weaponize scientific evidence surrounding short interval pregnancies to exert this pressure, leaving patients with few other “responsible” options besides IPLARC. By contrast, IPLARCs are rarely offered to privately insured patients. In fact, these patients are often actively discouraged from obtaining IPLARCs due to risks of expulsion and perforation. Ultimately, this creates bifurcated birthing experiences for marginalized and privileged women. While the latter are afforded the ability to focus on the mental and physical labor of pregnancy and delivering a child, and are encouraged to heal and bond with their baby in the immediate postpartum period, marginalized women are repeatedly pressured to obtain IPLARCs during prenatal appointments as well as during labor and delivery. Despite explicit goals of empowerment and health-promotion, IPLARCs thus become a biopolitical tool that perpetuates a legacy of restricting the reproductive freedom of Black, poor, and other marginalized bodies.