Uncharted Terrains: New Directions in Border Research Methodology, Ethics, and Practice

Chapter Thirteen. Lessons for Border Research: The Border Contraceptive Access Study

249 chapter thirteen Lessons for Border Research The Border Contraceptive Access Study Jon Amastae, Michele Shedlin, Kari White, Kristine Hopkins, Daniel A. Grossman, and Joseph E. Potter Introduction The U.S.–Mexico border has become increasingly a focus of and site for research. Interdependent economies, cultures, and natural environments on which a political border is overlaid contain both challenges and stimuli for inhabitants and investigators alike. Many of the topics and methods of our investigations require special sensitivity to the conduct of any project, including ethical and political issues. This paper describes some of these in a large study of access to and use of hormonal contraceptives among mostly Mexican-origin women in the border city of El Paso.1 Since their introduction nearly 50 years ago, oral contraceptive pills (OCs) have become one of the most effective and widely used family planning methods worldwide. New, lower-dose formulations also make OCs one of the safest options (Chaktoura et al. 2009; Khader et al. 2003; Vandebroucke et al. 2001; Farley and Collins 1999; Schwingl et al. 1999). The circumstances under which OCs are sold to women, however, vary considerably across countries. One of the main differences is whether a doctor’s prescription is required before a woman can purchase OCs. In the United States, hormonal contraceptives require at least a health care provider’s prescription if not a physical examination, which some public health experts consider unjustified (Stewart et al. 2001). In neighboring Mexico, while current law requires prescriptions for most medicines, in practice OCs have typically been readily available from pharmacies 250 • A Fence on Its Side Is a Bridge without a prescription. Policy debate about relaxing the U.S. prescription requirement for OCs has focused on whether over-the-counter (OTC) access is safe and how it might influence use (Trussell et al. 1993; Grossman 2008; Jarvis 2008). The Border Contraceptive Access Study (BCAS) was designed to address a number of questions, previously unresolved empirically. Specifically , the primary aims of the study were: 1) to determine what motivates women to obtain OCs directly from a pharmacy in Mexico, as opposed to from a U.S. family planning clinic; 2) to measure and compare knowledge about OC use between Mexican pharmacy users and U.S. family planning clinic users; 3) to examine the effect of supplying women with a written informational leaflet on women’s knowledge about OCs; 4) to assess whether women who obtain OCs over the counter from a Mexican pharmacy have poorer contraceptive satisfaction, compliance , continuation, and unintended pregnancy over the course of nine months; and 5) to assess the role of other factors that may lead to poor compliance, early discontinuation, or unintended pregnancy among OC users. To assess these aims, we carried out a prospective survey of oral contraceptive users in El Paso, Texas—a unique setting along the U.S.–Mexico border where U.S. residents have the option of obtaining OCs at pharmacies in Ciudad Juárez, Chihuahua, Mexico, without a prescription at a cost of approximately US$5.00 per cycle. Previous studies have established that women in El Paso do indeed cross the border to Mexico to obtain hormonal contraception such as oral contraceptive pills and injectables (Potter et al. 2003; Grossman et al. 2008). In the sections that follow, we describe some of the methodological issues we faced while implementing this prospective study, and their importance in conducting research in communities such as this one. The combination of a personally and culturally sensitive topic; wide variation in several demographic characteristics of the sample; crossborder interaction, which fell by chance at a difficult time for the border region; changes in state funding for reproductive health services; and the organizational challenges of a large project required an agile and adaptive response on the part of the research team. Lessons for Border Research • 251 El Paso Context The combined population of El Paso and Ciudad Juárez is approximately 2.4 million; the population of the El Paso metropolitan area is approximately 800,000 and is roughly 80 percent Hispanic, mostly of Mexican background. El Paso is among the poorest communities in the United States. According to the 2004 American Community Survey (Fronczek 2010), El Paso’s median household income of $31,764 ranked 61 among the 70 cities with populations greater than 250,000. The border is quite porous; four bridges link the two cities, and thousands cross frequently...