Author ORCID Identifier
Doctor of Philosophy
Sarah Kye Price
Sarah Jane Brubaker
Ensuring comprehensive and unbiased contraceptive access are crucial aspects of family planning care that make autonomous reproductive decisions possible. Furthermore, contraceptive access influences contraceptive behavior, and inequities in contraceptive access ultimately lead to health disparities. Contraceptive access is multidimensional and is determined by many barriers and facilitators of care. There is a lack of research regarding the ways that structural and relational factors influence contraceptive access and regarding the multifaceted impact of contraceptive access on family planning outcomes. In this three-paper dissertation, theoretical foundations in reproductive justice and Levesque et al.’s (2013) healthcare access framework guided examinations of the relationships between facilitators of contraceptive access and family planning outcomes.
The first paper involved an analysis of recent policies that influence contraceptive access and a summary of empirical research on the impact of US federal policy on contraceptive access. Papers two and three involved secondary analyses of longitudinal survey data collected across four time points between 2012 and 2014. Participants were US women of reproductive age who were seeking to avoid pregnancy. Path analysis (N = 1,036) was used to investigate pregnancy fatalism, insurance status, provider engagement, family planning Medicaid expansion, and contraceptive knowledge as predictors of contraceptive access and family planning outcomes, and cross-lagged panel analysis (N = 1,247) was used to investigate the cross-lagged relationships between insurance status, contraceptive access, and family planning outcomes.
Paper one findings showed that most identified policy changes were related to the affordability, physical availability, and appropriateness of contraceptive care. Most empirical studies examined the role of the Affordable Care Act and Title X of the Public Health Service Act, showing the benefits of both policies as facilitators of contraceptive access. In paper two, path analysis findings showed that contraceptive knowledge, insurance coverage, and relational provider engagement were significant predictors of optimal contraceptive access. Optimal contraceptive access directly predicted increased contraceptive use and indirectly predicted decreased unintended pregnancy via contraceptive use. In paper three, cross-lagged panel analysis findings provided causal evidence that having health insurance coverage contributes to optimal contraceptive access. Findings also suggested possible causal relationships between contraceptive access and contraceptive use and possible bidirectional relationships between contraceptive use and unintended pregnancy.
Across these three papers, which engaged distinct aspects of review and analysis, this study makes unique contributions to research on contraceptive access, reinforcing the importance of affordability as a domain of healthcare access and supporting the use of Levesque et al.’s (2013) framework to study contraceptive access. Findings indicated that pathways through contraceptive access may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. Continued research regarding barriers and facilitators of contraceptive access is needed to increase reproductive autonomy and meet the family planning needs of patients in the United States.
© Laura E. T. Swan
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VCU University Archives
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VCU Theses and Dissertations
Date of Submission
Available for download on Saturday, April 18, 2026