Race, ethnicity and differences in contraception among low-income women: methods received by Family PACT Clients, California, 2001-2007

Trends in different contraception methods among women attending the Melbourne Sexual Health Centre from 2011 to 2020

OBJECTIVES

The efficacy and availability of contraception have changed in the last several decades; however, unintended pregnancies continue to be an issue in Australia. This study aimed to describe trends in contraception in women attending a sexual health service over 9 years.

STUDY DESIGN

Repeated cross-sectional study.

METHODS

Women aged 16-49 years attending Melbourne Sexual Health Centre between 2011 and 2020 were included. Women were asked what methods of contraception they currently use. Contraception were categorised into long-acting reversible contraception (LARC; e.g. intrauterine devices and implants classified as highly effective), moderately effective contraception (e.g. oral contraception pill), less effective contraception (e.g. condom and withdrawal) and no contraception, as defined by US Centers for Disease Control and Prevention guidelines. Multivariable logistic regression was used to examine the factors associated with the use of moderate-high-efficacy contraception.

RESULTS

A total of 38,288 women were included with a median age of 25 (interquartile range: 22-29). Between 2011 and 2020, there was a decreasing trend in condom (63.3%-56.1%; Ptrend <0.001) and oral contraception (27.2%-20.5%; Ptrend <0.001) use, whilst there was an increasing trend in the use of LARCs: implant (4.6%-6.0%; Ptrend = 0.002) and intrauterine device (2.8%-11.8%; Ptrend <0.001). Increasing age was associated with decreased odds of using moderate-high-efficacy contraception (Ptrend <0.001). Compared with Oceanian-born women, Asian (adjusted odds ratios [aOR] = 0.63, 95% confidence interval [CI]: 0.56-0.72) and Middle Eastern-born women (aOR = 0.60, 95% CI: 0.48-0.74) had lower odds of using moderate-high-efficacy contraception, whilst European (aOR = 1.23, 95% CI:1.07-1.41) and North American-born women (aOR = 1.51, 95% CI: 1.22-1.87) had higher odds of using moderate-high-efficacy contraception.

CONCLUSIONS

Between 2011 and 2020, LARC use has increased, whilst less effective contraceptives, such as condom and oral contraception, have decreased among women at Melbourne Sexual Health Centre. Further research is required to understand age and ethnic disparities in contraception methods for future family planning programmes.

Claims for Contraceptive Services and Chlamydia and Gonorrhea Testing Among Insured Adolescent and Young Adult Females in the United States

Objective: To examine claims for reversible prescription contraceptives and chlamydia and gonorrhea testing among commercially and Medicaid-insured adolescent and young adult (AYA) females in the United States. Methods: Using IBM MarketScan Research Databases, we identified sexually active, nonpregnant AYA (15- to 24-year-old) females enrolled in 2018. We examined claims for reversible prescription contraceptives and chlamydia and gonorrhea testing, using drug names and diagnosis/procedure codes, by age-group in commercially and Medicaid-insured separately and by race/ethnicity in Medicaid-insured. Results: Among 15- to 19-year-old and 20- to 24-year-old females, 67.2% and 67.9% of commercially insured and 57.3% and 54.0% of Medicaid-insured, respectively, had claims for reversible prescription contraceptives in 2018. Across insurance types among both age-groups, the most common claim for contraceptives was prescription for combined oral contraceptives. Among Medicaid-insured 15- to 19-year-olds, claims for contraceptives ranged from 42.6% for Hispanic females to 63.4% for non-Hispanic White females; among Medicaid-insured 20- to 24-year-olds, claims ranged from 50.4% for non-Hispanic Black females to 57.0% for non-Hispanic White females. Approximately half of the commercially and Medicaid-insured females had claims for chlamydia and gonorrhea testing. Non-Hispanic Black females had the highest percentages of claims for chlamydia testing (56.3% among 15- to 19-year-olds and 61.1% among 20- to 24-year-olds) and gonorrhea testing (61.6% among 15- to 19-year-olds and 64.9% among 20- to 24-year-olds). Conclusion: Approximately, two-thirds of commercially insured and more than half of Medicaid-insured, sexually active, nonpregnant AYA females had claims for reversible prescription contraceptives. Race/ethnicity data were available for Medicaid-insured females, and there were differences in claims for contraceptives and chlamydia and gonorrhea testing by race/ethnicity. Half of the AYA females had claims for chlamydia and gonorrhea testing suggesting missed opportunities.

Characteristics Associated With Physician Bias in Contraceptive Recommendations

OBJECTIVE

We aimed to examine associations between obstetrician-gynecologist (OBGYN) contraceptive recommendations and sociodemographic characteristics of patients and recommending physicians.

METHODS

OBGYNs affiliated with residency programs across the United States were recruited via email to participate in an online exploratory survey depicting scenarios of reproductive-age women of differing race and socioeconomic status, all other factors identical, and were asked to provide contraceptive recommendations. The χ2 test, Fisher's exact tests, and logistic regression were used to analyze recommendation differences based on physician and patient characteristics.

RESULTS

Of 172 physician respondents, large proportions self-identified as white (74%) and attending physicians (56%) from the Mid-Atlantic (42%). In multivariate logistic regression, self-administered methods (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-0.8) and condoms (OR, 0.5; 95% CI, 0.3-0.9) were recommended significantly less to Black high SES patients compared with white high SES patients. Non-white physicians recommended tubal ligation (OR, 0.7; 95% confidence interval [CI], 0.5-0.9) significantly less than white physicians, and recommended long-acting reversible contraception (OR, 3.3, CI 2.2-5.2) and condoms (OR, 1.4; 95% CI, 1.1-1.9) significantly more. Trainee physicians recommended self-administered methods (OR, 0.3; 95% CI, 0.2-0.4), condoms (OR, 0.2; 95% CI, 0.2-0.3), and tubal ligation (OR, 0.4; 95% CI, 0.3-0.6) significantly less than attending physicians.

CONCLUSIONS

OBGYN contraceptive recommendations differed based on patients' perceived race and SES. Recommendations also differed based on race, training level, and geographic location of the recommending physician. Results suggest that physician bias contributes to contraceptive recommendations. OBGYNs should receive education about contraceptive coercion and patient-centered decision-making so that they provide high-quality counseling to all patients.

Non-barrier contraceptive use patterns among Latina adolescents attending California reproductive health centers: A longitudinal study

OBJECTIVES

To describe use of non-barrier contraceptives over a 9-month period, consistency in method use, and identify factors associated with method nonuse, switching, and consistency among Latina adolescents attending California sexual and reproductive health (SRH) centers.

STUDY DESIGN

We conducted a cohort study using data self-reported at baseline, and 3- and 9-months post-baseline. The analysis included 1162 sexually active adolescents aged 18 to 19 who self-identified as female and Latina, indicated that they were not currently pregnant or trying to become pregnant, and who attended California SRH centers between June 2016 and June 2020. We used binomial generalized multivariable linear models with a log link to assess the likelihood of nonbarrier method consistency, switching, and non-use.

RESULTS

At baseline, 453 of 1162 (39%) of respondents were using short-acting methods (pill, patch, ring, or injection), 113 of 1162 (9.7%) were using long-acting methods (implants or intrauterine devices [IUDs]), and 596 of 1162 (51.3%) reported using neither short- nor long-acting methods. Over a 9-month period, 22/33 (66.7%) of those using IUDs consistently used the method, which was a statistically greater frequency of consistency than individuals who selected other nonbarrier methods (270/530 [50.9%], aRR: 1.40; 95% CI: 1.11, 1.77). Implant users had rates of method consistency similar to users of other nonbarrier methods (aRR: 1.11; 95% CI: 0.89, 1.38). Factors independently associated with method consistency included being older, having never been pregnant, having greater perceived risk of pregnancy, and greater contraceptive knowledge.

CONCLUSION

Sexually active Latina adolescents attending California SRH centers who were not trying to become pregnant maintained consistent contraceptive use more frequently when using an IUD. Using a patient-centered approach, contraceptive counseling for Latina adolescents can describe the combined efficacy and contraceptive stability offered by IUDs should patients desire it.

IMPLICATIONS

This study addressees gaps in knowledge about U.S. Latina adolescents' contraceptive use patterns. We demonstrate that IUD users, and not implant users, appear more likely to consistently use their method than those using non-LARC methods. Patient-centered contraceptive counseling for Latina adolescents can describe the greater contraceptive stability that IUDs may offer.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients

OBJECTIVES

To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients.

STUDY DESIGN

We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital.

RESULTS

Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%).

CONCLUSIONS

In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care.

IMPLICATIONS

Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Disparities in postpartum contraceptive use among immigrant women with restricted Medicaid benefits

BACKGROUND

The Emergency Medicaid program offers restricted Medicaid benefits for people who meet the same financial eligibility criteria as Traditional Medicaid recipients but do not meet the citizenship requirements for enrollment in Traditional Medicaid. By federal law, Emergency Medicaid covers care for life-threatening emergencies or a hospital admission for childbirth. No prenatal or postpartum care is covered. Most of the women enrolled in Emergency Medicaid are Latina.

OBJECTIVE

We assessed postpartum visits and receipt of postpartum contraception and compared the outcomes for Emergency (restricted benefit) Medicaid recipients with those of Traditional (full-benefit) Medicaid recipients in Oregon and South Carolina, 2 states with similar-sized immigrant populations.

STUDY DESIGN

We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data of live births covered by Medicaid (Traditional and Emergency) between January 1, 2010 and September 30, 2017, in Oregon and South Carolina. Our analysis was at the individual level. Primary outcomes were postpartum visit attendance and receipt of postpartum contraception within 2 months. We examined differences in demographic and delivery characteristics by Medicaid type. If women received postpartum contraception, we compared the timing of receipt (immediate postpartum, ≤1 month, 1–2 months, and 2–6 months after delivery) by the type of Medicaid. Among women using contraception, we described the type of contraceptive received at each time point, stratified by Medicaid type. Associations between Medicaid type (Traditional vs Emergency) and postpartum visit attendance and contraception use were assessed using adjusted absolute predicted probabilities from logistic regression models. We ran models for the entire cohort and conducted a subanalysis restricted to only Latina women.

RESULTS

Our study included 375,544 live births to 288,234 women, with 12.7% of births among Emergency Medicaid recipients. Women enrolled in Emergency Medicaid tended to be older (age >35 years; 18.1% vs 7.2%; P<.001) and were more likely to be multiparous (76.8% vs 60.8%; P<.001) and Latina (80.3% vs 9.5%; P<.001) than their Traditional Medicaid peers. Among women enrolled in Emergency Medicaid, the probability of having a postpartum visit was 6.1% (95% confidence interval, 5.9–6.4) compared with 58.8% (95% confidence interval, 58.6–58.9) for women covered by Traditional Medicaid. After 6 months following delivery, 97.6% of Emergency Medicaid recipients had no evidence of contraceptive use compared with 55.6% of Traditional Medicaid enrollees (P<.001). In our adjusted model, Emergency Medicaid recipients were also significantly less likely to receive postpartum contraception than Traditional Medicaid enrollees (1.9% vs 35.5%; 95% confidence interval, [1.8–2.1] vs [35.4–35.7]). We examined the role that race may play in postpartum contraceptive use by conducting a subanalysis restricted to Latina women only.

Latinas with births covered by Emergency Medicaid had a 1.9% (95% confidence interval, 1.8–2.0) adjusted probability of postpartum contraception use within 2 months compared with 39.8% (95% confidence interval, 38.7–39.9) among Latinas enrolled in Traditional Medicaid.

CONCLUSION

Women enrolled in Emergency Medicaid experience large disparities in postpartum care and contraceptive use. Policies that restrict Medicaid coverage following delivery exacerbate inequities in postpartum care, potentially leading to worse health outcomes for low-income immigrants and their children.

Does cosmopolitan culture weaken ethnic and regional diversity: contraceptive behaviours of women in Istanbul, Turkey

OBJECTIVE

The primary aim of the study was to examine the relationship between self-reported ethnic identity, region of birth and contraceptive use, in Istanbul, Turkey.

METHODS

Cross-sectional data from a random sample of 3038 married women of reproductive age living in two urban districts of Istanbul were used in a series of logistic regression models to assess key relationships.

RESULTS

Kurdish ethnic minority women were less likely than Turkish ethnic majority women to use traditional contraceptive methods over no method (relative risk ratio [RRR] 0.69; 95% confidence interval [CI] 0.50, 0.96). However, there were no significant differences between ethnicities (i.e., Turkish, Kurdish and other) and modern method use. Among Turkish women, those born in regions farther away from the western region were more likely to use traditional methods (RRR_northern 2.06; 95% CI 1.31, 3.22).

CONCLUSION

While Kurdish ethnic minority women were less likely to use traditional methods, compared with Turkish ethnic majority women, the difference might have been due to the length of time living in a neighbourhood. Regional variations in contraceptive use were concentrated only among Turkish ethnic majority women and for traditional methods. Regional norms of traditional method use may be a barrier to modern contraceptive use in Turkey.

The Flint women's study: community perspectives on contraception and family planning, sexuality education and barriers to reproductive health

Teenage pregnancy can have adverse social and health outcomes, and rates are high in Flint, Michigan as compared to the rest of the state and the USA. It is important to understand contributing factors to adolescent pregnancy to be able to better address this issue. This study examined qualitative data from interviews with 100 community members who participated in the Flint Women's Study, a study designed to better understand the hopes, dreams and needs of women in Flint, and their suggestions for how to address identified needs. Using a Community Based Participatory Approach, data were collected and analysed by a team of community members and academic researchers. The paper focuses on the theme of family planning among young women which included attitudes about contraception, sexuality education and bio-medical and structural barriers to accessing reproductive health. Community members emphasised the need for increased access to comprehensive contraception options, improved sexuality education in schools and from health care providers, and ultimately valuing young women.

"Far More than Just a Prescription": Focus Groups With U.S. Family Planning Providers and Staff About Integrating PrEP for HIV Prevention Into Their Work

BACKGROUND

Cisgender women in the United States use pre-exposure prophylaxis (PrEP) for HIV prevention at lower rates relative to other groups. Advocacy groups and patients identify family planning clinics as the preferred sites to lead PrEP implementation for women in the United States. However, limited qualitative exploration exists of U.S. family planning practitioners' attitudes toward integrating PrEP into their work.

METHODS

We conducted qualitative focus groups with a convenience sample of family planning clinicians, counselors, and clinic managers to explore barriers and facilitators to PrEP provision in U.S. family planning clinics.

RESULTS

We conducted six focus groups (total participants = 37) with respondents who worked in family planning clinics in San Francisco, California; Kansas City, Missouri; and Philadelphia, Pennsylvania. Key themes emerged highlighting how PrEP at times runs contrary to other family planning agendas, including efficient clinic visits, condom promotion, and long-acting reversible contraception counseling. Throughout these discussions, participants expressed discomfort with HIV vulnerabilities rooted in social and structural determinants of health.

CONCLUSIONS

Findings suggest that those seeking to implement PrEP for U.S. cisgender women may benefit from exploring 1) how to integrate patient/provider conversations about the structural determinants of health and their relationship to HIV and other sexual and reproductive health outcomes and 2) how to foster person-centered prevention conversations in the context of busy family planning visits.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.

Association of race and ethnicity with postpartum contraceptive method choice, receipt, and subsequent pregnancy

BACKGROUND

We sought to assess racial/ethnic differences in choice of postpartum contraceptive method after accounting for clinical and demographic correlates of contraceptive use.

METHODS

This is a secondary analysis of a single-center retrospective cohort study examining postpartum women from 2012 to 2014. We determined the association between self-identified race/ethnicity and desired postpartum contraception, receipt, time to receipt, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 8649 deliveries in this study, 46% were by Black women, 36% White women, 12% Hispanic, and 6% by women of other races. Compared with White women, Black and Hispanic women were more likely to have a postpartum contraception plan for all methods. After multivariable analysis, Hispanic women (relative to White women) were less likely to receive their chosen method (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.64-0.87). Women of races other than Black or Hispanic were less likely to experience a delay in receipt of their desired highly-effective method compared to White women (hazard ratio [HR] = 0.70, 95% CI 0.52-0.94). There were no differences between racial/ethnic groups in terms of postpartum visit adherence. Black women were more likely to be diagnosed with a subsequent pregnancy compared to White women (OR 1.17, 95% CI 1.04-1.32).

CONCLUSION

Racial/ethnic variation in postpartum contraceptive outcomes persists after accounting for clinical and demographic differences. While intrinsic patient-level differences in contraceptive preferences should be better understood and respected, clinicians should take steps to ensure that the observed differences in postpartum contraceptive plan methods between racial/ethnic groups are not due to biased counseling.

Contraceptive selection and practice: Associations with self-identified race and socioeconomic disadvantage

Many researchers and policymakers have linked contraceptive programs to improvements in women's and children's socioeconomic outcomes. However, these studies have overlooked how socioeconomic status may be an initial driver of contraceptive choice and behavior. Here, I examine the relationship between a comprehensive measure of socioeconomic disadvantage, self-identified race, and contraceptive method selection at enrollment in a unique longitudinal study of contraceptive clients who received a new type of method at no cost. I then examine whether socioeconomic disadvantage has an association with contraceptive switching or discontinuation. I demonstrate that socioeconomic disadvantage decreases the chance of selecting any IUD, while Black racial membership increases the chance of selecting the 3-month injectable and Multiracial membership increases the chance of selecting the Vaginal Ring. I then demonstrate that socioeconomic disadvantage and self-identified race have intersectional and variable associations with switching, and, to a lesser extent, discontinuing methods. These findings offer an important insight for implementation in contraceptive programs: eliminating financial barriers to access contraceptive services does not eliminate the socioeconomic contexts that influence method selection and use that occur as part of everyday lived experiences. Taken cumulatively, these results suggest that contraceptive services should be offered to women in ways that ensure access to reproductive justice without obscuring the need for social changes in the institutions that create disadvantage and shape contraceptive use itself.

Meeting Women's Requests for Intrauterine Device and Contraceptive Implant Discontinuation: An Exploratory Survey of Physicians

Long acting reversible contraceptives (LARC), including intrauterine devices (IUDs) and contraceptive implants, can support an individual in meeting their reproductive goals by allowing them to prevent pregnancy effectively. These devices can also limit an individual's control over reproduction because they generally require an in-person visit to a health care provider for removal. Returning for another visit may be logistically challenging for many individuals who may need to arrange for transportation, childcare, or take time off from work. Effectively negotiating with a provider to request removal may be additionally challenging for medically underserved and disenfranchised people who may not feel empowered to do so. The objective of this study was to assess providers' willingness to honor patients' requests for IUD and contraceptive implant removal on the day of the request. A survey was conducted in which clinicians were presented with scenarios of women requesting IUD or implant removal. Clinicians were asked what they were most likely to do. A total of 105 clinicians were surveyed. The responses of 60 clinicians who inserted IUDs and 57 who provided the contraceptive implant were included in the analysis. When asked about same-day removal of an IUD or implant from a dissatisfied patient who requested removal, 40% stated they would remove the implant, and 57% stated they would remove the IUD on the day of the request. Findings from this study suggest many clinicians would be unwilling or unable to accommodate a patient's request for device removal at the time of their visit. This delay or refusal represents a significant barrier for patients and has implications for reproductive autonomy that should be further explored.

Racial Differences in the Biochemical Effects of Stress in Pregnancy

Prenatal stress has been linked to preterm birth via inflammatory dysregulation. We conducted a cross-sectional study on female participants who delivered live, singleton infants at University of Pittsburgh Medical Center Magee Women’s Hospital. Participants (n = 200) were stratified by cumulative risk scores using a combination of individual factors (maternal education, diabetes, hypertension, smoking, relationship status, obesity, depression) and neighborhood deprivation scores. We hypothesized that inflammatory cytokines levels differ by risk group and race. Multiplex analyses of IL-6, IL-8, IL-10, IL-13 and TNF-alpha were run. We found that Black birthing people had more risk factors for chronic stress and had lower levels of IL-6 compared to White birthing people. When stratified by risk group and race, low-risk Black birthing people had lower levels of IL-6 compared to low-risk White birthing people, and high-risk Black birthing people had lower levels of IL-8 compared to high-risk White birthing people. Higher area deprivation scores were associated with lower IL-6 levels. Our results suggest that the relationship between chronic stress and inflammatory cytokines is modified by race. We theorize that Black birthing people encounter repetitive stress due to racism and social disadvantage which may result in stress pathway desensitization and a blunted cytokine response to future stressors.

Highly-Effective Contraception Use More Likely Among Native Hawaiian Women than Non-Native Hawaiian Women at Title X Clinics in Hawai'i

Differences in contraceptive method use have been noted among women of different races, but studies describing contraceptive method use among Native Hawaiian women have not been published. To examine method choice in this group, the authors conducted a database review of the Hawai'i State Department of Health Title X program. Reviewed were client visit records (CVRs) that health care providers completed for women who were ages 15-44 years, avoiding pregnancy, not currently pregnant, and using a contraceptive method (N=54 513). Because a patient could have had several visits during the study period, the contraceptive method chosen at the last visit was selected for analysis. Statistical analyses included descriptive statistics, bivariate analyses, and logistic regression. The proportion of Native Hawaiian women who selected a highly-effective method of contraception (HEC), defined as an intrauterine device, implant, or permanent contraception, was higher than the proportion of non-Native Hawaiian women who selected an HEC. Overall, 15.4% of Native Hawaiian women during the study period chose HEC, compared to 8.8% of non-Native Hawaiian women. In a logistic regression analysis, Native Hawaiian women ages 15-29 were 1.46 times more likely to use HEC (95% CI: 1.35-1.58) than non-Native Hawaiian women ages 15-29, and Native Hawaiian women ages 30-44 were 1.69 times more likely to use HEC (95% CI: 1.53-1.87) than non-Native Hawaiian women in the same age group. Because Native Hawaiian women are reported to have higher rates of unintended pregnancy in the state compared to other racial groups, additional research exploring contraceptive non-use and pregnancy intention are needed.

The Association of Public Insurance with Postpartum Contraception Preference and Provision

BACKGROUND

Prior studies have noted that public insurance status is associated with increased uptake of postpartum contraception whereas others have pointed to public insurance as a barrier to accessing highly effective forms of contraception.

OBJECTIVE

To assess differences in planned method and provision of postpartum contraception according to insurance type.

STUDY DESIGN

This is a secondary analysis of a retrospective cohort study examining postpartum women delivered at a single hospital in Cleveland, Ohio from 2012-2014. Contraceptive methods were analyzed according to Tier-based effectiveness as defined by the Centers for Disease Control and Prevention. The primary outcome was postpartum contraception method preference. Additional outcomes included method provision, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 8281 patients in the study cohort, 1372 (16.6%) were privately and 6990 (83.4%) were publicly insured. After adjusting for the potentially confounding clinical and demographic factors through propensity score analysis, public insurance was not associated with preference for a Tier 1 versus Tier 2 postpartum contraceptive method (matched adjusted odds ratio [maOR] 0.89, 95% CI 0.69-1.15), but was associated with a preference for Tier 1/2 vs Tier 3/None (maOR 1.41, 95% CI 1.17-1.69). There was no difference between women with private or public insurance in terms of method provision by 90 days after delivery (maOR 0.94, 95% CI 0.75-1.17). Public insurance status was also associated with decreased postpartum visit attendance (maOR 0.54, 95% CI 0.43-0.68) and increased rates of subsequent pregnancy within 365 days of delivery (maOR 1.29, 95% CI 1.05-1.59).

CONCLUSION

Public insurance status does not serve as a barrier to either the preference or provision of effective postpartum contraception. Women desiring highly- or moderately effective methods of contraception should have these methods provided prior to hospital discharge to minimize barriers to method provision.

Household income and contraceptive methods among female youth: a cross-sectional study using the Canadian Community Health Survey (2009-2010 and 2013-2014)

BACKGROUND

Low socioeconomic status is one of many barriers that may limit access to family planning services. We aimed to examine the relation between household income and contraceptive methods among female youth in Canada.

METHODS

Our study population included sexually active females aged 15-24 who were trying to avoid pregnancy. We used cross-sectional data from the 2009-2010 and 2013-2014 cycles of the Canadian Community Health Survey to compare household income and other sociodemographic covariates for those using oral contraceptives, injectable contraceptives, condoms or a dual method (condoms plus oral or injectable contraceptives).

RESULTS

Of female youth at risk for unintended pregnancy, 59.2% reported using oral contraceptives, 29.0% used dual methods, 16.8% used condoms only, 2.5% used injectable contraceptives and 13.6% did not use contraception. In multiple regression models, lower annual household income (< $80 000) was associated with decreased use of oral contraceptives (relative risk [RR] 0.85, 95% confidence interval [CI] 0.80-0.91) and dual methods (RR 0.81, 95% CI 0.71-0.91), increased use of condoms (RR 1.36, 95% CI 1.11-1.67) and injectable contraceptives (RR 1.69, 95% CI 0.98-2.92), and a greater risk of contraceptive nonuse (RR 1.19, 95% CI 0.94-1.50).

INTERPRETATION

We found that lower household income was associated with decreased use of oral contraceptives and increased reliance on injectable contraceptives and condoms only. Young, low-income females may face barriers to accessing the full range of contraceptive methods available in Canada. Easier access to affordable contraception may decrease the number of female youth at risk for unintended pregnancy due to financial barriers.

Contraceptive Desert? Black-White Differences in Characteristics of Nearby Pharmacies

OBJECTIVES

Race differences in contraceptive use and in geographic access to pharmacies are well established. We explore race differences in characteristics of nearby pharmacies that are likely to facilitate (or not) contraceptive purchase.

STUDY DESIGN

We conducted analyses with two geocode-linked datasets: (1) the Relationship Dynamics and Social Life (RDSL) project, a study of a random sample of 1003 women ages 18-19 living in a county in Michigan in 2008-09; and (2) the Community Pharmacy Survey, which collected data on 82 pharmacies in the county in which the RDSL study was conducted.

RESULTS

Although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance.

CONCLUSIONS

Relative to white women, African-American women may face a "contraception desert," wherein they live nearer to pharmacies, but those pharmacies have characteristics that may impede the purchase of contraception.

Predictors of contraceptive switching and discontinuation within the first 6 months of use among Highly Effective Reversible Contraceptive Initiative Salt Lake study participants

BACKGROUND

Nearly half of women will switch or discontinue using their selected contraceptive method in the first year. Research on early switching or discontinuation provides important clinical and public health insights, although few studies have assessed associated factors, particularly among longitudinal cohorts.

OBJECTIVE

The current study explores attributes associated with early contraceptive method switching or discontinuation (<6 months of initiation) among participants enrolled in the intervention cohorts of the Highly Effective Reversible Contraceptive Initiative Salt Lake Contraceptive Initiative (Utah, United States).

MATERIALS AND METHODS

Highly Effective Reversible Contraceptive Initiative Salt Lake participants have access to no-cost contraception for 3 years. This includes both the initial selection and the ability to switch or to discontinue methods without cost. Methods available included the following: nonhormonal behavioral methods (male/female condoms, withdrawal, diaphragms, cervical caps, and fertility awareness); short-acting methods (pill, patch, ring, and injectable); and long-acting methods (intrauterine devices and contraceptive implants). Participants completed surveys at baseline and at 1, 3, and 6 months. We collected data on participant demographics, contraceptive continuation, switching, and discontinuation, as well as factors associated with these changes, including established measures of pregnancy intention and ambivalence and reasons for switching or discontinuing. We conducted descriptive statistics, univariable, and multivariable Poisson regression analyses to assess predictors of both discontinuation and switching. We also conducted χ2 analyses to compare reported reasons for stopping between switchers and discontinuers.

RESULTS

At 6 months, 2,583 women (70.0%) reported continuation of their baseline method, 367 (10%) reported at least 1 period of discontinuation, 459 (12.4%) reported switching to a different method, and 279 (7.6%) did not provide 6-month follow-up. Factors associated with discontinuation included selection of a short-acting method (incidence rate ratio [IRR], 2.49; 95% confidence interval [CI], 1.97, 3.12), report of Hispanic ethnicity (IRR, 1.45; 95% CI, 1.12, 1.89) and nonwhite race (IRR, 1.48; 95% CI, 1.08, 2.02), and having any future pregnancy plans, even years out. Participants with some college education were less likely to report discontinuation (IRR, 0.73; 95% CI, 0.57, 0.94). Selecting a short-acting method at baseline was also associated with increased likelihood of method switching (IRR, 2.29, 95% CI, 1.87, 2.80), as was having 2 or more children (IRR, 1.37; 95% CI, 1.08, 1.74). Women were less likely to switch if they were on their parents' insurance (IRR, 0.74; 95% CI, 0.56, 0.99). Among participants who switched methods, 36.9% switched to a long-acting reversible method, 31.7% switched to a short-acting hormonal method, and 31.1% switched to a nonhormonal behavioral method, such as condom use. Of participants providing a reason for stopping, 454 women (73.2%) reported side effects as 1 reason for switching or discontinuing their initial method.

CONCLUSION

Early contraceptive method switching and discontinuation are frequent outcomes of contraceptive use. These changes are common even with removal of contraceptive access barriers.

A review of the effects of healthcare disparities on the experience and survival of ovarian cancer patients of different racial and ethnic backgrounds

Ovarian cancer (OC) is a serious condition that often presents at advanced stages and has high mortality rates, with the current mode of early-stage screening lacking sensitivity and specificity. OC often presents asymptomatically, which renders early diagnosis difficult. Furthermore, many patients lack significant risk factors or family history of the disease. Five-year survival rates differ between patients with OC among racial, ethnic, and social groups as a result of different social barriers. This review article aims to present the currently existing data regarding health care disparities among OC patients of different ethnic, demographic, and socioeconomic backgrounds, and what next steps should be taken to better understand and eventually eliminate these potentially devastating health care disparities. Increasing data support the notion that a combination of genomic, socioeconomic status, social factors, and cultural differences lead to differential treatments and therefore health care disparities. While genomic and biological factors are important, language barriers, geographic and travel barriers, differences in comorbidity likelihood between populations, and different treatment plans seem to have a greater impact on 5-year survival rates of patients from diverse backgrounds. Language barriers limit a shared-decision model of care. Transportation limitations and geographic differences can lead to limited follow-up and insufficient care in resource and equipment restrictive settings. Patients with these barriers also tend to have a higher incidence of comorbidities that raise the mortality rate of OC. Further research needs to explore effective solutions to bridge health care disparities and understand why they occur.

Availability of long-acting reversible contraceptives in Los Angeles County clinics through a Medicaid state plan amendment program

OBJECTIVE

To assess the availability of long acting reversible contraceptive (LARC) methods in Los Angeles County through providers participating in a California State Medicaid State Plan Amendment Program called Family Planning, Access, Care and Treatment (Family PACT).

STUDY DESIGN

This was a cross-sectional telephone survey utilizing "secret shopper" methodology. From 855 Family PACT providers in Los Angeles County in 2015, a representative sample of 400 providers was selected for study. Young female researchers posing as potential patients called each sampled clinic to ask a scripted series of questions about LARC availability for Family PACT patients in that practice.

RESULTS

All but one eligible practice (99.7%) responded to our questions. Among the 336 responding practices, 284 said they accepted Family PACT. Of those accepting Family PACT, staff answering the telephone call at 61% said they did not provide any LARC method onsite, 2% provided all currently available LARC methods, and 6% provided same-day placement of any LARC.

CONCLUSION

The majority of Family PACT practices surveyed said that they did not provide any LARC onsite, and very few provided same-day LARC placement despite easy patient enrollment procedures, relatively reasonable reimbursement and concerted efforts to increase LARC use. Substantial barriers to greater uptake may rest at the provider level with either actual unavailability of LARC or staff perception of unavailability.

IMPLICATIONS

Only a minority of Family PACT practices said that LARC methods were available onsite, which imposes substantial restriction to access for women who are entitled to have access without cost. Other states developing programs should be aware of this challenge.

Trends in long-acting reversible contraceptive (LARC) use, LARC use predictors, and dual-method use among a national sample of college women

OBJECTIVE

Assess long-acting reversible contraceptive (LARC) and other contraceptive use trends, identify LARC use predictors, and examine dual method use.

PARTICIPANTS

Women in the American College Health Association-National College Health Assessment (ACHA-NCHA) II, aged 18-24 years, who reported having vaginal sex (N = 37,899).

METHODS

Secondary analyses of Fall 2011-2014 ACHA-NCHA II data.

RESULTS

Statistically significant increases in LARC usage and, specifically, implant usage, were found. Characteristics associated with LARC use included age, race/ethnicity, relationship status, and school type. Students reporting LARC use had lower odds of condom usage compared with non-LARC hormonal method users.

CONCLUSION

This analysis of LARC predictors and dual LARC/condom use has implications for research and health promotion efforts. Findings suggest that college health services are well positioned to meet the sexual and reproductive health needs of diverse populations of students. College health professionals should elicit students' individual and/or relationship priorities to tailor messaging/services offered for pregnancy/STI prevention.

Contraceptive Method Use and Chlamydia Positivity Among California Family Planning Clients: The Case for New Multipurpose Prevention Technologies

BACKGROUND

Adolescent girls and young women experience high rates of sexually transmitted infection (STI) with currently available contraceptive methods, yet few studies examine the burden of chlamydial infection by contraceptive method used.

MATERIALS AND METHODS

In this cross-sectional analysis, we linked July 2012-June 2013 claims from a publicly-funded family planning program in California to chlamydia laboratory test results. Female clients were classified by the most effective contraceptive method reported by providers during the year: tier 1 (high-efficacy permanent or long-acting reversible methods), tier 2 (shorter-acting hormonal methods), or tier 3 (barrier methods, emergency contraception, or natural family planning). In addition, we identified clients who received condoms from providers. We used log-binomial models to estimate adjusted prevalence ratios comparing chlamydia positivity by contraceptive method(s).

RESULTS

Of 74,636 female clients of ages 15-29 years with chlamydia test results, 5.1% had at least one positive test during the year. Chlamydia positivity was highest among tier 2 users (5.3%) compared with 4.5% and 4.9% among tiers 1 and 3 users, respectively (p < 0.001). Positivity was higher among clients who received condoms from providers than those who did not (6.3% vs. 4.3%, p < 0.001). In adjusted analyses, there were no significant differences in positivity by contraceptive tier. However, clients who received condoms had 1.32 (95% confidence interval: 1.24-1.40) times the positivity of those who did not.

CONCLUSIONS

We found high chlamydia positivity among young female family planning clients regardless of contraceptive method. The development and provision of additional Multipurpose Prevention Technologies that confer protection against both pregnancy and STIs may help to address unmet need for STI prevention.

Muslim Women's use of contraception in the United States

Background

American Muslim women are an understudied population; thus, significant knowledge gaps exist related to their most basic health behaviors and indicators. Considering this, we examined American Muslim women’s contraception utilization patterns.

Methods

Self-reported data collected in late 2015 were analyzed. Women who identified as Muslim, were at least 18 years old, sexually active, and current residents of the United States (n = 224) met the inclusion criteria. Convenience sampling was employed. Multivariate logistic regression models estimated associations between demographics, marital status, ethnicity, nativity, health insurance, religious practice, and contraception use.

Results

Identifying as Muslim, in general, was significantly associated with greater odds of using contraception in general and condoms compared to American Muslim women who identify as Sunni. Identifying as Shia was associated with greater odds of using oral contraceptive pills relative to Sunni respondents. South Asian ethnicity was associated with higher odds of using oral contraceptive pills compared to those of Middle Eastern or North African ethnicity.

Conclusions

Findings suggest American Muslim women’s contraception utilization patterns share certain similarities with both American women in general and disadvantaged racial and ethnic minority groups in the United States, implying that factors that influence American Muslim women’s use of contraceptives are possibly countervailing and likely multifaceted. More research is needed to accurately identify associates of contraceptive use in this population. This work serves as a starting point for researchers and practitioners seeking to better understand reproductive health decision in this understudied population.

Recommendations for Contraception: Examining the Role of Patients' Age and Race

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai'i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient's name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ² tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient's race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities.

Associations Between Sex Education and Contraceptive Use Among Heterosexually Active, Adolescent Males in the United States

PURPOSE

This study examined associations between reports of receiving education on topics commonly included in sex education (e.g., abstinence only, comprehensive) prior to age 18 years and contraceptive use at the last sex among heterosexually active, 15- to 20-year-old males in the United States.

METHODS

Cross-sectional data from 539 males participating in the 2011-2013 National Survey of Family Growth were analyzed. Bivariate and multinomial logistic regression analyses adjusting for confounding estimated associations between receipt of seven sex education topics (e.g., information on HIV/AIDS, how to say no to sex) and contraceptive use at the last sex (i.e., dual barrier and female-controlled effective methods, female-controlled effective method only, barrier method only, and no method).

RESULTS

Nearly, all participants (99%) reported receiving sex education on at least one topic. Education on sexually transmitted diseases (94.7%) and HIV/AIDS (92.0%) were the most commonly reported topics received; education on where to get birth control was the least common (41.6%). Instruction about birth control methods (adjusted odds ratio [AOR] = 3.01; 95% confidence interval [CI] = 1.32-6.87) and how to say no to sex (AOR = 3.39; CI = 1.33-8.64) were positively associated with dual contraception compared to no use. For each additional sex education topic respondents were exposed to, their odds of using dual methods compared to no method was 47% greater (AOR = 1.47; CI = 1.16-1.86).

CONCLUSIONS

Exposure to a larger number of sex education topics is associated with young men's report of dual contraception use at the last sex. Comprehensive sex education, focusing on a range of topics, may be most effective at promoting safer sex among adolescent males.

Types of oral contraceptives and breast cancer survival among women enrolled in Medicaid: A competing-risk model

INTRODUCTION

Oral contraceptive pills have been implicated in the pathophysiology of breast cancer. Although many studies have examined the relationship between combined oral contraceptives (COCs) and breast cancer, there is a paucity of literature that discusses progestin-only oral contraceptives (POCs) and breast cancer. The purpose of this investigation is to examine potential associations between different types of oral contraceptives and breast cancer mortality in the South Carolina Medicaid population among different racial/ethnic groups.

METHODS

Subjects included 4816 women diagnosed with breast cancer between 2000 and 2013. Kaplan-Meier curves were calculated to determine time-to-mortality rates among users of oral contraceptives. Competing-risks models and Cox multivariate survival models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer and other-cause mortality, as well as all-cause mortality.

RESULTS

POCs were associated with a significantly decreased risk of breast cancer mortality (HR: 0.07; 95% CI: 0.01, 0.52) and a non-significant increased risk of all-cause mortality (HR: 1.04; 95% CI: 0.52, 2.07). COCs increased the risk of breast cancer mortality (HR: 1.61; 95% CI: 1.14, 2.28) and all-cause mortality (HR: 1.83; 95% CI: 1.30, 2.57).

CONCLUSION

Use of POCs may be associated with a decreased risk of breast cancer mortality. Due to the small sample size of POC users in the current study, additional research is needed to confirm these findings.

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services

BACKGROUND

Although the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods.

METHODS

Using data from 771 nonpregnant, non-pregnancy-seeking women receiving gynecological services in the Cincinnati-Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed.

FINDINGS

RLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison.

CONCLUSIONS

In this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.

Exploring the relationship between socioeconomic factors, method of contraception and unintended pregnancy

BACKGROUND

It is estimated that approximately one-third of pregnancies in Canada are unintended, meaning they were either mistimed (the woman wanted to be pregnant at a different point in time) or undesired (the woman did not want to be pregnant). This study aimed to assess the impact of socioeconomic variables and method of contraception on the decision to either terminate or continue and unintended pregnancy.

METHODS

Data were obtained from two contemporaneous studies in Calgary Canada--a cross-sectional study involving women seeking abortion services (n = 577) and a longitudinal cohort study involving women with continuing pregnancies (n = 3552) between 2008 and 2012. Chi square tests and logistic regression were used to examine the association between socioeconomic variables, use of contraception and pregnancy intention.

RESULTS

96.5% of women seeking an abortion and 19.6% of women with ongoing pregnancies reported having an unintended pregnancy. Women with unintended pregnancies were significantly younger (p < 0.001), less educated (p < 0.001), had a lower household income (p < 0.001), were less likely to be in a stable relationship (p < 0.001), and less likely to speak English in the home (p < 0.002). 20.2% reported not using any form of birth control despite their desire to not get pregnant. Among women with unintended pregnancies, the only significant demographic predictor of not using any form of contraception was low educational attainment (OR = 1.7, 95% CI: 1.2-2.4).

CONCLUSIONS

Low educational attainment was associated with not using any form of contraception among women with unintended pregnancies. However, as unintended pregnancy occurs across all socio-demographic groups, care providers are encouraged to have an open discussion regarding fertility goals and contraception with all patients and refer them to appropriate resource materials.

Women's experiences after Planned Parenthood's exclusion from a family planning program in Texas

OBJECTIVE

We assessed the impact on depot medroxyprogesterone continuation when a large care provider was banned from a state-funded family planning program.

STUDY DESIGN

We used three methods to assess the effect of the ban: (a) In a records review, we compared how many state program participants returned to two Planned Parenthood affiliates for a scheduled dose of depot medroxyprogesterone acetate (DMPA) immediately after the ban; (b) We conducted phone interviews with 224 former Planned Parenthood patients about DMPA use and access to contraception immediately after the ban; (c) We compared current contraceptive method of our interviewees to that of comparable DMPA users in the National Survey of Family Growth 2006-2010 (NSFG).

RESULTS

(a) Fewer program clients returned for DMPA at a large urban Planned Parenthood, compared to a remotely located affiliate (14.4%, vs. 64.8%), reflecting different levels of access to alternative providers in the two cities. (b) Among program participants who went elsewhere for the injection, only 56.8% obtained it at no cost and on time. More than one in five women missed a dose because of barriers, most commonly due to difficulty finding a provider. (c) Compared to NSFG participants, our interviewees used less effective methods of contraception, even more than a year after the ban went into effect.

CONCLUSIONS

Injectable contraception use was disrupted during the rollout of the state-funded family planning program. Women living in a remote area of Texas encountered more barriers.

IMPLICATIONS

Requiring low-income family planning patients to switch healthcare providers has adverse consequences.

The impact of postpartum contraception on reducing preterm birth: findings from California

OBJECTIVE

Family planning is recommended as a strategy to prevent adverse birth outcomes. The potential contribution of postpartum contraceptive coverage to reducing rates of preterm birth is unknown. In this study, we examine the impact of contraceptive coverage and use within 18 months of a birth on preventing preterm birth in a Californian cohort.

STUDY DESIGN

We identified records for second or higher-order births among women from California's 2011 Birth Statistical Master File and their prior births from earlier Birth Statistical Master Files. To identify women who received contraceptive services from publicly funded programs, we applied a probabilistic linking methodology to match birth files with enrollment records for women with Medi-Cal or Family Planning, Access, Care, and Treatment Program (PACT) claims. The length of contraceptive coverage was determined through applying an algorithm based on the specified method and the quantity dispensed. Preterm birth was defined as a birth occurring <37 weeks' gestation, and calculated from the medical record. We further examined differences in preterm birth using subcategories defined by the World Health Organization: extremely preterm (<28 weeks); very preterm (28 to <32 weeks); and moderate to late preterm (32 to <37 weeks). We built a multivariable regression model to examine the effect of contraceptive coverage on the odds of a preterm birth and control for key covariates.

RESULTS

The cohort consisted of 111,948 women who were seen at least once by a Medi-Cal or Family PACT provider within 18 months of delivery. Of the cohort, 9.75% had a preterm birth. Contraceptive coverage was found to be protective against preterm birth. For every month of contraceptive coverage, odds of a preterm birth <37 weeks decrease by 1.1% (odds ratio, 0.989; 95% confidence interval, 0.986-0.993).

CONCLUSION

Improving postpartum contraceptive use has the potential to reduce preterm births.

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012

OBJECTIVE

To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15-44 years using contraception between 2008-2010 and 2011-2013 with specific attention to associations between race, income, and age and their LARC use.

METHODS

We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15-44 years, consisting of 6,428 females in 2008-2010 and 5,601 females in 2011-2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview.

RESULTS

The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1-11.1%), those with fewer than two sexual partners in the previous year (9.2-12.4%), and those who were nulliparous (2.1-5.9%) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women.

CONCLUSION

During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users.

LEVEL OF EVIDENCE

III.

Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

OBJECTIVE

Women who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.

STUDY DESIGN

Women presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.

RESULTS

A total of 260 women, aged 18-45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.

CONCLUSION

A variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.

IMPLICATIONS

In contraceptive counseling, after screening for IPV, assessing patient's stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient's choice of method.

Risk factors for endometrial cancer in black and white women: a pooled analysis from the Epidemiology of Endometrial Cancer Consortium (E2C2)

PURPOSE

Endometrial cancer (EC) is the most common gynecologic cancer in the USA. Over the last decade, the incidence rate has been increasing, with a larger increase among blacks. The aim of this study was to compare risk factors for EC in black and white women.

METHODS

Data from seven cohort and four case-control studies were pooled. Unconditional logistic regression was used to estimate adjusted odds ratios (OR) and 95 % confidence intervals for each risk factor in blacks and whites separately.

RESULTS

Data were pooled for 2,011 black women (516 cases and 1,495 controls) and 19,297 white women (5,693 cases and 13,604 controls). BMI ≥ 30 was associated with an approximate threefold increase in risk of EC in both black and white women (ORblack 2.93, 95 % CI 2.11, 4.07 and ORwhite 2.99, 95 % CI 2.74, 3.26). Diabetes was associated with a 30-40 % increase in risk among both groups. Increasing parity was associated with decreasing risk of EC in blacks and whites (p value = 0.02 and <0.001, respectively). Current and former smoking was associated with decreased risk of EC among all women. Both black and white women who used oral contraceptives for 10 +years were also at reduced risk of EC (OR 0.49, 95 % CI 0.27, 0.88 and OR 0.69, 95 % CI 0.58, 0.83, respectively). Previous history of hypertension was not associated with EC risk in either group.

CONCLUSIONS

The major known risk factors for EC exert similar effects on black and white women. Differences in the incidence rates between the two populations may be due to differences in the prevalence of risk factors.

Bringing patients' social context into the examination room: an investigation of the discussion of social influence during contraceptive counseling

BACKGROUND

Although social networks are an increasingly recognized influence on contraceptive use, little is known about if and how social influences are discussed during women's contraceptive counseling visits.

METHODS

We performed a mixed-methods analysis of audio recordings of contraceptive counseling visits. We examined predictors of discussion of social influence arising in a contraceptive counseling visit and analyzed the content and process of social influence discussions.

RESULTS

Social influences were mentioned in 42% of the 342 visits included in the sample, with these discussions most commonly initiated by patients. Younger patients were more likely to have social influence mentioned than older patients. The content of social influence focused on side effects and adverse events, with the sources of influence being predominantly patients' friends and the media, with little input from partners. Providers were more likely to engage around the content of the social influence than the social influence itself.

CONCLUSION

The frequency with which social influence was mentioned in these visits supports the importance of women's social context on their contraceptive decision making. However, the fact that patients initiated the discussion in the majority of cases suggests that providers may not recognize the relevance of these influences or may not be comfortable engaging with them. Increasing providers' ability to elicit and engage patients about their social context with regard to contraception could enhance providers' ability to understand women's contraceptive preferences and provide appropriate counseling to address their specific concerns or questions.

Race, Ethnicity, and the Changing Context of Childbearing in the United States

In what ways do childbearing patterns in the contemporary United States vary for white, black, and Hispanic women? Why do these differences exist? Although completed family size is currently similar for white and black women, and only modestly larger for Hispanic women, we highlight persistent differences across groups with respect to the timing of childbearing, the relationship context of childbearing, and the extent to which births are intended. We next evaluate key explanations for these differences. Guided by a "proximate determinants" approach, we focus here on patterns of sexual activity, contraceptive use, and post-conception outcomes such as abortion and changes in mothers' relationship status. We find contraceptive use to be a particularly important contributor to racial and ethnic differences in childbearing, yet reasons for varying use of contraception itself remain insufficiently understood. We end by reflecting on promising directions for further research.

Race, Ethnicity, and the Changing Context of Childbearing in the United States

In what ways do childbearing patterns in the contemporary United States vary for white, black, and Hispanic women? Why do these differences exist? Although completed family size is currently similar for white and black women, and only modestly larger for Hispanic women, we highlight persistent differences across groups with respect to the timing of childbearing, the relationship context of childbearing, and the extent to which births are intended. We next evaluate key explanations for these differences. Guided by a "proximate determinants" approach, we focus here on patterns of sexual activity, contraceptive use, and post-conception outcomes such as abortion and changes in mothers' relationship status. We find contraceptive use to be a particularly important contributor to racial and ethnic differences in childbearing, yet reasons for varying use of contraception itself remain insufficiently understood. We end by reflecting on promising directions for further research.

Racial/ethnic disparities in contraceptive use: variation by age and women's reproductive experiences

OBJECTIVE

Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a woman's life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by women's age, parity, and history of unintended pregnancy.

STUDY DESIGN

We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy.

RESULTS

Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by women's age, with younger women having more prominent disparities.

CONCLUSION

Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.

Pull and pray or extra protection? Contraceptive strategies involving withdrawal among US adult women

OBJECTIVE

Research assessing contraceptive use often focuses on the most effective method used and suggests that very few women rely on withdrawal. We adopted a new measurement strategy in an attempt to measure contraceptive practices and withdrawal in particular.

STUDY DESIGN

We collected data from a national sample of 4634 US women aged 18-39; the survey was administered online in November and December 2012. We obtained information about recent use of hormonal methods and coital methods using two separate items, and we placed withdrawal first on the list of coital methods. The analysis examines several measures of withdrawal use in the last 30 days: most effective method used, any use, use with other methods and withdrawal "method mix."

RESULTS

Among women at risk of unintended pregnancy, 13% reported that withdrawal was the most effective method used in the last 30 days, but 33% had used withdrawal at least once. Most women who used withdrawal had also used a hormonal or long-acting method (13% of the sample) or condoms (11%) in the last 30 days, and a minority reported using only withdrawal (12%). Younger women, women in dating relationships and women strongly motivated to avoid pregnancy had some of the highest levels of "dual" use of withdrawal with condoms or highly effective methods.

CONCLUSION

Many women and couples in our sample used withdrawal in combination, or rotation, with condoms and highly effective methods. Findings suggest that some people who use withdrawal may be more versus less vigilant about pregnancy prevention.

IMPLICATIONS

Health care providers who discuss contraception should include withdrawal in these conversations. A substantial minority of individuals has used it recently, and many appear to be using it as a backup or secondary method. If dual use were more widespread, it could help reduce the incidence of unintended pregnancy.

Exploring young adults' contraceptive knowledge and attitudes: disparities by race/ethnicity and age

BACKGROUND

Half of pregnancies in the United States are unintended, with the highest proportions occurring among Blacks, Hispanics, and teenagers. Understanding differences in knowledge and attitudes about contraception by race/ethnicity and age can improve efforts to reduce disparities in unintended pregnancy.

METHODS

This analysis used data from the 897 female respondents in National Survey of Reproductive and Contraceptive Knowledge, a survey exploring young adults' knowledge and attitudes about contraception and pregnancy. Bivariate and multivariate logistic regression analyses were used to assess racial/ethnic and age group differences in knowledge and attitudes about contraceptives.

FINDINGS

Hispanics and teenagers (aged 18-19) had lower awareness of available contraceptive methods, and lower knowledge about individual methods compared with White women and young adults (age 20-29). For example, Hispanics (74%) and teenagers (77%) were less likely to have heard of the intrauterine device (IUD) than were White women (90%) and young adults (90%), and were less likely to know that a woman experiencing side effects could switch brands of oral contraceptive pills (72% of Hispanics vs. 86% of White women; 76% of teenagers vs. 90% of young adults). Hispanics born outside the United States had lower knowledge about contraceptives than U.S.-born Hispanics. For example, foreign-born Hispanics were less likely than U.S.-born Hispanics to have heard of the IUD (59% vs. 82%) or the vaginal ring (55% vs. 95%).

CONCLUSIONS

Lower contraceptive knowledge among teenagers and Hispanics, particularly immigrants, suggests the importance of disseminating family planning information to these women as one means to address disparities in unintended pregnancy.

Limited socioeconomic opportunities and Latina teen childbearing: a qualitative study of family and structural factors affecting future expectations

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

Racial and ethnic differences in men's knowledge and attitudes about contraception

BACKGROUND

Little is known about racial/ethnic differences in men's contraceptive knowledge and attitudes.

STUDY DESIGN

We used multivariable logistic regression to examine racial/ethnic differences in contraceptive knowledge and attitudes among 903 men aged 18-29 in the 2009 National Survey of Reproductive and Contraceptive Knowledge.

RESULTS

Black and Hispanic men were less likely than Whites to have heard of most contraceptive methods, including female and male sterilization, and also had lower knowledge about hormonal and long-acting reversible methods. They were less likely to know that pills are ineffective when 2-3 pills are missed [Blacks: adjusted odds ratio (aOR)=0.42; Hispanics: aOR=0.53] and that fertility was not delayed after stopping the pill (Blacks: aOR=0.52; Hispanics: aOR=0.27). Hispanics were less likely to know that nulliparous women can use the intrauterine device (aOR=0.47). Condom knowledge was similar by race/ethnicity, but Blacks were less likely to view condoms as a hassle than Whites (aOR=0.46).

CONCLUSIONS

Efforts to educate men, especially men of color, about contraceptive methods are needed.