Roma health mediators are part of a government funded, community-led health intervention. One of the programme’s central aims is to improve access to reproductive care for Roma women, often said to be one of the most disadvantaged population groups in Europe. This paper is a critical analysis of mediation in Romania, focusing on how social determinants shape access to family planning and how mediators are employed to address inequalities. It is based on ethnographic observations of mediators at work, as well as in-depth interviews with community members, health professionals, and mediators. Health professionals tended to see Roma families as wanting and having an unreasonably large number of children and tried to curtail this through the promotion of contraception. This contrasted with the perspective of community members, who appeared not to choose having many children but who instead struggled to access contraception for financial reasons. Roma health mediators generally seemed aware of multiple and intersecting pressures that women were facing, but ultimately tended to frame family planning as a matter of choice, culture, and knowledge. I set these perspectives against the background of anti-Roma racism and eugenic sentiments, reflected in popular discourses about Roma reproduction. I explore how an intervention that nominally aims to promote the emancipation of Roma communities, in fact entrenches some of the racially fused assumptions that are connected to inequalities of access to reproductive health care in the first place. The discussion has implications for Roma reproductive health interventions across Europe, and for participatory interventions more globally.