Beyond choice: social realities shaping pregnancy decisions and family planning agency among Black women in the south.

Introduction: While data on the factors associated with the sexual and reproductive health of Black women is growing, few studies have applied a reproductive justice framework to their analyses, and few have assessed the role social realities play on reproductive decision-making. Methods: We analyzed data collected from a community-based participatory study, conducted between May 2019 and January 2020. The parent study aimed to get an understanding of the reproductive health experiences and concerns of Black women living in two southern states, Georgia and North Carolina. For this paper, we used a thematic analysis to identify themes from codes within the categories: healthcare utilization, pregnancy, and family life. We applied a reproductive justice framework lens to assess pregnancy intentions, pregnancy decision-making, and family planning agency across the full spectrum of family planning. Results: In total, six focus group discussions, with 8-10 participants each, and 25 in-depth interviews were completed. Participants ranged in age, economic, and educational background. We found that social and cultural factors played an important role in pregnancy intentions and decision-making. Community and social norms worked to diminish positive feelings around Black pregnancy and non-childbearing, leading some to feel stigmatized and avoid pregnancy. Factors within the legal, economic, and health systems impacted family planning agency-limiting the ability to access desired family planning services such as abortion and infertility treatments. Participants offered strategies they believed could help counter the impact of these factors. Discussion: Our findings highlight that Black women's pregnancy intentions, pregnancy decision-making, and family planning agency are influenced by their social realities.