Associations between unfulfilled contraceptive preferences due to cost and low-income patients' access to and experiences of contraceptive care in the United States, 2015-2019

Where do female contraceptive users get their methods, and does this differ by insurance coverage? A state-level examination

OBJECTIVE

Describe where female contraceptive users obtained their method, by insurance and state.

STUDY DESIGN

Using 2022 Behavioral Risk Factor Surveillance System data from female contraceptive users in 26 states, we describe source of contraception by state and type of insurance coverage.

RESULTS

Most female contraceptive users utilized private providers, but those with public or no insurance often used community health centers and family planning clinics, which commonly receive public funding.

CONCLUSION

People who are publicly insured or uninsured often rely on publicly supported providers.

IMPLICATIONS

Supporting a variety of providers may facilitate people accessing care, regardless of income.

Disparities in Highly Effective Contraceptive Use Among U.S. Active Duty Service Women, Fiscal Years 2020-2023

Background: Despite universal coverage of all highly effective contraceptive (HEC) methods in the Military Health System (MHS), active duty service women (ADSW) have higher rates of unintended pregnancy and lower rates of HEC use than the general U.S. population. Between 2016 and 2019, racial minority and lower socioeconomic status (SES) ADSW demonstrated lower odds of HEC use. This study further investigated factors associated with HEC use among ADSW to assess their reproductive health needs. Methods: We conducted a cross-sectional study using fiscal year 2020-2023 data from the MHS Data Repository for all ADSW aged 18-45 years. Statistical analyses included descriptive statistics and logistic regression models, adjusted and unadjusted, determining the odds of HEC use overall, by method, and by social characteristics, including race and military rank as a proxy for SES. Results: Of the 339,011 ADSW identified, 164,756 (48.6%) used at least one HEC method during the study period. Black (odds ratio [OR] = 0.89; 95% confidence interval [CI] = 0.88-0.91) and Asian/Pacific Islander (OR = 0.88; 95% CI = 0.78-0.82) ADSW demonstrated lower odds of overall HEC use than White ADSW. Junior Enlisted ADSW demonstrated lower odds of overall HEC use than nearly all other ranks. Conclusions: The proportion of ADSW using HEC methods has decreased since 2019, while HEC use in the general population has increased. Racial and socioeconomic disparities remain, highlighting the need for future research to investigate reasons for these disparities in order to design effective mitigation strategies to ensure access to contraceptive care for all ADSW.

Relationship between experiencing a challenge or delay accessing contraception and contraceptive self-efficacy: Data from a 2022 nationally representative online survey

BACKGROUND

Previous research has found self-efficacy is associated with reproductive health behaviors and outcomes. However, few studies have quantitatively examined the relationship between barriers accessing contraception and self-efficacy. In addition, existing population-level metrics of contraceptive access tend to focus on method availability, uptake, and use, rather than people's self-defined needs and preferences. This study uses person-centered metrics to assess the relationship between experiencing a recent challenge or delay obtaining desired contraception and two measures of contraceptive self-efficacy.

METHODS

In 2022, we fielded a nationally representative survey in English and Spanish using NORC's AmeriSpeak panel, surveying non-sterile 15- to 44-year-olds assigned female sex at birth in the U.S. We describe common challenges and delays obtaining contraception and present the distribution of experiencing a challenge or delay obtaining contraception by key sociodemographic and reproductive health characteristics. We also conduct logistic regression analyses to investigate associations between experiencing a challenge/delay and two measures of contraceptive self-efficacy: confidence in obtaining a desired method when wanted and perceived ease of switching methods when wanted.

RESULTS

Among the analytic sample of respondents who had ever used or tried to obtain a contraceptive product, device, or procedure (unweighted n = 2,771), about 14% experienced a challenge/delay obtaining desired contraception in the past year. The most common reasons for challenges or delays were related to logistics (transportation, childcare, scheduling; 38.2%) and cost/insurance coverage (35.8%). Among those who experienced a challenge/delay obtaining desired contraception (unweighted n = 301), higher proportions were younger, identified as non-heterosexual, had lower educational attainment, and could afford smaller emergency expenses compared to the subgroup that did not experience a challenge/delay. Experiencing a challenge/delay was associated with decreased odds of feeling very or somewhat confident in obtaining a desired method (aOR 0.14; 95% CI 0.07, 0.25) and decreased odds of feeling it would be very or somewhat easy to switch contraceptive methods (aOR 0.48; 95% CI 0.33, 0.71).

CONCLUSIONS

Eliminating barriers to contraceptive care is crucial to achieving person-centered access. Our research suggests that experiencing a challenge/delay has implications not only for recent contraceptive access but also influences self-efficacy, potentially inhibiting future ability to obtain and use desired contraception.

Etonogestrel Subdermal Implant in Adolescents: Everything We Should Know to Conduct Proper Counseling, a Narrative Review

Background/Objectives: Comprehensive sexual education and access to contraceptives play a vital role in alleviating the economic, health, and social challenges associated with unplanned pregnancies in adolescents. According to the World Health Organization (WHO), adolescence refers to the transitional stage from childhood to adulthood, encompassing individuals aged 10 to 19. This period is critical for reproductive decision making, making it essential to closely observe patterns of sexual activity and contraceptive use among young people. Despite advancements, many adolescents still encounter significant barriers to accessing and effectively utilizing contraceptive methods. Methods: A bibliographic search was performed across three major biomedical databases: PubMed, Embase, and CINAHL. The research question was developed utilizing the PIO (Population, Intervention, Outcome) framework to guide the investigation. Results: Long-acting reversible contraceptives (LARCs), including the etonogestrel (ENG) implant, have been recognized for their ability to significantly reduce maternal and neonatal mortality and morbidity as well as decrease the incidence of unsafe abortions. Conclusions: Access to adequate counseling and effective contraceptive services can profoundly impact young people's lives, preventing unplanned pregnancies and promoting optimal sexual and reproductive health.

Patient Preferences or Provider Pressure? The Relationship Between Coercive Contraceptive Care and Preferred Contraceptive Use

Background/Objectives: Coercion in contraceptive care occurs when healthcare providers unduly influence patients to use or not use birth control. Contraceptive coercion is antithetical to quality patient-centered care. However, it is unclear how experiencing contraceptive coercion relates to patients' lives and contraceptive outcomes. In this study, we examined associations between contraceptive coercion and a patient-centered outcome: preferred contraceptive use. Methods: In 2023, we used the Prolific panel to recruit reproductive-aged people in the USA who were assigned female at birth. Our analytic sample included surveyed participants who had ever talked to a healthcare provider about contraception (N = 1197). We conducted chi-square and regression analyses to investigate associations between contraceptive coercion and preferred contraceptive use. We added context by mapping the current and preferred contraceptive method(s) for participants who experienced coercion and were not using their preferred method(s). Results: After adjusting for potential confounders, participants who reported downward coercion (pressure to not use birth control) at their last contraceptive counseling were less likely to be using their preferred contraceptive method(s). The odds of using preferred contraception did not differ significantly based on whether participants experienced upward contraceptive coercion (pressure to use birth control). Patterns in unmet contraceptive preference for patients experiencing coercion include use of the pill when it is not the desired method and unmet desire for permanent contraception. Conclusions: In this study, patients who perceived pressure from a provider to not use birth control were less likely to be using their preferred contraceptive method(s). Promoting reproductive autonomy requires comprehensive, patient-centered, and unbiased contraceptive care.

Exploring adolescent-facing US clinicians' perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study

BACKGROUND

Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

METHODS

We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.

RESULTS

We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using "ask then explain" or "explain then ask" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.

CONCLUSION

Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.

Determining the Impact of the Reversal of Roe v. Wade on Birth Control and Infertility Trends Using Google Trends

Introduction Overturning Roe v. Wade left many concerned about birth control options and future fertility. This study aims to report Google (Google, Inc., Mountain View, CA) search trends regarding birth control and infertility options before and after the Dobb v. Jackson decision. Methods Google Trends (Google, Inc., Mountain View, CA) data were analyzed between January 2020 and August 2022. The relative search volume (RSV), a measure of proportional search volume, was obtained for terms related to birth control and infertility treatments. Abortion laws and median household income were compared to search term popularity. Linear regression and t-test analysis were performed. Results Interest in surgical birth control increased most in June 2022 compared to June 2021, with vasectomy interest increasing by 142% and tubal ligation by 98%. Surrounding the Roe v. Wade announcement, increases were seen in searches for vasectomy (90%), vasectomy reversal (142%), oral contraceptive pill (56%), plan B (36%), and in vitro fertilization (29%) (P < 0.05). Lower median household income was associated with increased interest in "vasectomy," "tubal ligation," and "plan B," while higher median household income was associated with increased interest in "in vitro fertilization" (P < 0.05). Seven of the top 10 states with the highest interest in surgical birth control had laws banning abortion at any gestational age. Conclusions Changes in access to abortion have led to increased online interest in birth control and fertility treatment options. Surgical birth control searches were highest in states with stricter abortion laws, warranting investigation into access to reversible contraception, while the rise in fertility searches brought to light concerns regarding future laws impacting fertility care.

Differential associations between experiences of contraceptive care and subsequent contraceptive access and preferences among family planning patients by racial and ethnic identity: Evidence from Arizona, Iowa, and Wisconsin

While many frameworks exist for building person-centered and equitable systems of contraceptive care, evidence indicates that the reality of patients' experiences of care is often not in alignment with these ideals. Historical and current contexts of racism in the healthcare system contribute to negative perceptions and experiences of care, as well as reduced care-seeking behavior, for those who identify as Black, Indigenous, and people of color (BIPOC). Our objective in this analysis is to examine whether people's past experiences of contraceptive care are a driver of subsequent barriers to contraceptive access, and whether this relationship differs across racial and ethnic identity. We draw on panel data from five waves of surveys collected between 2018-2023 among patients ages fifteen and older seeking family planning care at sites that receive public funding for these services in Arizona, Iowa, and Wisconsin. Overall and stratified by race/ethnicity, we examine cross-sectional and longitudinal associations between patients' experiences of high-quality, person-centered contraceptive care and three contraceptive access outcomes: use of preferred contraception, satisfaction with contraceptive method, and experience of no barriers to accessing preferred contraception. We find longitudinal associations between patients experiencing higher-quality, more person-centered contraceptive care and subsequent satisfaction with contraceptive methods. Among non-Hispanic white-identifying patients, we find similar associations between shifting to higher-quality contraceptive care and use of preferred contraception, but we find no statistical relationship between experiencing higher-quality care and subsequent contraceptive outcomes for patients who identify as Black, Indigenous, or Person of Color (BIPOC). Highlighting the dissonance between clinical guidance for quality contraceptive care and patient experiences of care, and especially whether similar experiences across racial and ethnic identity lead to differential outcomes, is a crucial step toward bringing contraceptive care systems into alignment with principles of sexual and reproductive health equity.

Use of Preferred Source of Contraception Among Users of the Pill, Patch, and Ring in the US

Importance

Individuals who use contraceptive pills, patches, and rings must frequently interact with the health care system for continued and consistent use. As options for obtaining these methods expand, better understanding contraceptive users' preferences for source of contraception can help facilitate access.

Objective

To describe use of preferred source of contraception and to understand associations between prior reproductive health care experiences and preference for traditional in-person sources vs alternative sources.

Design, Setting, and Participants

This was a cross-sectional nationally representative survey study fielded in the US in 2022 through NORC's population-based AmeriSpeak panel. Eligible panelists were assigned female sex at birth, aged 15 to 44 years, not infecund, and not personally using permanent contraception. Of the screened panelists, 3150 were eligible; 3059 completed the survey (97%). The analysis sample included 595 individuals who currently used a pill, patch, or ring contraceptive. Data were analyzed from January 25, 2023, to August 15, 2024.

Main Outcomes and Measures

Primary outcomes were use of any preferred source and use of most preferred source when most recently obtaining contraception. Sources included in-person care, telehealth, pharmacist-prescribed, online service, and over the counter. A binary variable captured whether respondents most preferred traditional, in-person contraceptive care vs an alternative approach. Prior reproductive health care experiences included missing a pill, patch, or ring because they couldn't obtain it on-time and receipt of person-centered contraceptive counseling at most recent contraceptive visit. Sociodemographic characteristics and responses are presented as unweighted numbers with weighted prevalences.

Results

In this study, 581 of 595 unweighted respondents (weighted prevalence, 95.9%) of the analytic sample identified as female, 256 unweighted respondents (weighted prevalence, 64.4%) were ages 15 to 29 years, and 448 unweighted respondents (weighted prevalence, 73.8%) had most recently obtained their contraception in-person. Only 197 unweighted respondents (weighted prevalence, 35.6%) selected in-person care as their most preferred source. Additionally, 296 unweighted respondents (weighted prevalence, 49.7%) had most recently obtained their method through any preferred source, and 227 unweighted respondents (weighted prevalence, 39.8%) had obtained it through their most preferred source. In adjusted regression analyses, respondents who previously reported being unable to get their method on time (adjusted odds ratio [aOR], 2.57; 95% CI, 1.36-4.87) had higher odds of preferring an alternative source vs traditional in-person care. Those who recently received person-centered contraceptive counseling (aOR, 0.59; 95% CI, 0.35-0.98) had lower odds of preferring an alternative source.

Conclusions and Relevance

In this national study of individuals who used the pill, patch, and ring, most preferred alternative sources to obtain their contraception, and only half had most recently used a preferred source. These findings suggest that expansion of alternative contraceptive sources can better meet the needs of contraceptive users and support reproductive autonomy.

Exploring primary care physician biases in adolescent contraceptive counseling

OBJECTIVE(S)

While previous literature has shown clinician bias in adult contraceptive counseling, less is known on the biases clinicians may exhibit when counseling adolescents about contraception. Our study aimed to describe long-acting reversible contraception (LARC) counseling and prescribing practices of adolescent-serving clinicians.

STUDY DESIGN

This study used a cross-sectional discrete choice experiment mixed methods design. We sent a survey containing vignettes and items pertaining to demographics and beliefs to a convenience sample of adolescent-serving clinicians across the United States.

RESULTS

Of 296 clinicians, 80% were in pediatrics, and had geographic, practice setting, gender, and racial diversity. Most clinicians reported being up-to-date with current literature regarding contraception. Sixty-eight percent of respondent's practices administer contraceptive injections, but only 17% place intrauterine devices (IUDs). Of those who do insert IUDs, nearly half inserted five or fewer within the last year. Patients' younger age and Hispanic ethnicity were associated with lower odds, and history of pregnancy was associated with higher odds, of clinicians' recommending LARC. Across all vignettes, the top five reasons clinicians chose their first-choice method for the patient were adherence or compliance, efficacy, side effects, patient age, and reversibility.

CONCLUSION(S)

Clinicians often recommend contraceptives based on adherence, efficacy, and age, and we found younger age, minoritized race or ethnicity, and history of pregnancy were all associated with LARC recommendations, indicating potential biases against teen parents and assumptions about adolescents' priorities. This may impede the provision of patient-centered contraceptive counseling for adolescents, and highlights the need for improved education and practice changes post-Dobbs.

IMPLICATIONS

We found that clinicians demonstrated several biases in how they provide contraceptive recommendations to adolescent patients. These biases were often associated with their personal beliefs and experiences. Our findings can guide the development of future interventions aimed at improving adolescent reproductive health counseling and care delivery in primary care settings.

Integrating Sexual and Reproductive Health Equity Into Public Health Goals and Metrics: Comparative Analysis of Healthy People 2030's Approach and a Person-Centered Approach to Contraceptive Access Using Population-Based Data

BACKGROUND

The Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals' self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access.

OBJECTIVE

We aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users.

METHODS

We used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric.

RESULTS

Comparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers-individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex.

CONCLUSIONS

Our analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

Changes in contraceptive method mix following the Colorado Family Planning Initiative

OBJECTIVES

To describe the changes in contraceptive method use and mix among Colorado Title X clients following the 2009 Colorado Family Planning Initiative (CFPI), which allowed Colorado Title X providers to offer all contraceptive methods without medically unnecessary barriers.

STUDY DESIGN

Using data on all visits to Colorado Title X clinics between 2007 and 2016 for women aged 10-49 years, we described trends in contraceptive method use by age group and race/ethnicity prior to and following the implementation of CFPI.

RESULTS

The implementation of CFPI saw an abrupt increase in Title X visits. Visits subsequently declined steeply for non-Hispanic White clients while visits by Hispanic clients remained at elevated levels. During CFPI, the use of long-acting reversible contraceptives increased while the use of oral contraceptive pills decreased. Nonetheless, oral contraceptive pills remained the most common method used by Title X clients throughout the study period. Changes in the method mix varied by age and race/ethnicity. Method switching was relatively uncommon among established Title X clinic users.

CONCLUSIONS

CFPI, which removed financial barriers to the most expensive methods, was associated with increases in the use of long-acting reversible contraceptives and changes in method mix that varied by age group and race/ethnicity.

IMPLICATIONS

CFPI removed barriers to previously inaccessible methods that contributed to changes in the method mix at Title X clinics. That these changes were not uniform across ages and race/ethnicities emphasize that subgroup variation in family planning policy impact stems from heterogeneity in barriers to care and method-specific unmet demand.

Unfulfilled and method-specific contraceptive preferences among reproductive-aged contraceptive users in Arizona, Iowa, New Jersey, and Wisconsin

OBJECTIVE

To identify characteristics associated with unfulfilled contraceptive preferences, document reasons for these unfulfilled preferences, and examine how these unfulfilled preferences vary across specific method users.

DATA SOURCES AND STUDY SETTING

We draw on secondary baseline data from 4660 reproductive-aged contraceptive users in the Arizona, Iowa, New Jersey, and Wisconsin Surveys of Women (SoWs), state-representative surveys fielded between October 2018 and August 2020 across the four states.

STUDY DESIGN

This is an observational cross-sectional study, which examined associations between individuals' reproductive health-related experiences and contraceptive preferences, adjusting for sociodemographic characteristics. Our primary outcome of interest is having an unfulfilled contraceptive preference, and a key independent variable is experience of high-quality contraceptive care. We also examine specific contraceptive method preferences according to current method used, as well as reasons for not using a preferred method.

DATA COLLECTION/EXTRACTION METHODS

Survey respondents who indicated use of any contraceptive method within the last 3 months prior to the survey were eligible for inclusion in this analysis.

PRINCIPAL FINDINGS

Overall, 23% reported preferring to use a method other than their current method, ranging from 17% in Iowa to 26% in New Jersey. Young age (18-24), using methods not requiring provider involvement, and not receiving quality contraceptive care were key attributes associated with unfulfilled contraceptive preferences. Those using emergency contraception and fertility awareness-based methods had some of the highest levels of unfulfilled contraceptive preferences, while pills, condoms, partner vasectomy, and IUDs were identified as the most preferred methods. Reasons for not using preferred contraceptive methods fell largely into one of two buckets: system-level or interpersonal/individual reasons.

CONCLUSIONS

Our findings highlight that avenues for decreasing the gap between contraceptive methods used and those preferred to be used may lie with healthcare providers and funding streams that support the delivery of contraceptive care.

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

BACKGROUND

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling.

METHODS

This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index.

RESULTS

Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester.

CONCLUSIONS

Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Use of preferred contraceptive method among young adults in Texas and California: A comparison by state and insurance coverage

BACKGROUND

Young people's ability to use their preferred contraceptive method is an indicator of reproductive autonomy and healthcare access. State policies can hinder or facilitate access to a preferred contraceptive method.

OBJECTIVE

This study compared use of preferred contraceptive method in Texas and California, states with contrasting health policy contexts that impact health insurance coverage and access to subsidized family planning services.

METHODS

We used baseline survey data from an ongoing cluster randomized controlled trial of sexually active students, assigned female at birth, ages 18-25, at 29 community colleges in Texas and California (N = 1,974). We described contraceptive preferences and use, as well as reasons for nonuse of a preferred method. We conducted multivariable-adjusted mixed-effects logistic regression analyses for clustered data, and then calculated the predicted probability of using a preferred contraceptive method in Texas and California by insurance status.

RESULTS

More Texas participants were uninsured than Californians (30% vs. 8%, p<0.001). Thirty-six percent of Texas participants were using their preferred contraceptive method compared to 51% of Californians. After multivariable adjustments, Texas participants had lower odds of using their preferred method (adjusted odds ratio = 0.62, 95% confidence interval = 0.48-0.81) compared to those in California. Texas participants in all insurance categories had a lower predicted probability of preferred method use compared to California participants. In Texas, we found a 12.1 percentage-point difference in the predicted probability of preferred method use between the uninsured (27.5%) and insured (39.6%) (p<0.001). Texans reported financial barriers to using their preferred method more often than Californians (36.7% vs. 19.2%, p<0.001) as did the uninsured compared to the insured (50.9% vs. 18.7%, p<0.001).

CONCLUSION

These findings present new evidence that state of residence plays an important role in young people's ability to realize their contraceptive preference. Young people in Texas, with lower insurance coverage and more limited access to safety net programs for contraceptive care than in California, have lower use of preferred contraception. It has become urgent in states with abortion bans to support young people's access to their preferred methods.

Intersectionality in Alzheimer's Disease: The Role of Female Sex and Black American Race in the Development and Prevalence of Alzheimer's Disease

It is well known that vascular factors and specific social determinants of health contribute to dementia risk and that the prevalence of these risk factors differs according to race and sex. In this review, we discuss the intersection of sex and race, particularly female sex and Black American race. Women, particularly Black women, have been underrepresented in Alzheimer's disease clinical trials and research. However, in recent years, the number of women participating in clinical research has steadily increased. A greater prevalence of vascular risk factors such as hypertension and type 2 diabetes, coupled with unique social and environmental pressures, puts Black American women particularly at risk for the development of Alzheimer's disease and related dementias. Female sex hormones and the use of hormonal birth control may offer some protective benefits, but results are mixed, and studies do not consistently report the demographics of their samples. We argue that as a research community, greater efforts should be made to not only recruit this vulnerable population, but also report the demographic makeup of samples in research to better target those at greatest risk for the disease.

Where Do Reproductive-Aged Women Want to Get Contraception?

Background: People's preferences regarding how they want to obtain contraception should be considered when building and refining high-quality contraceptive care programs, especially in light of recent shifts to incorporate more telehealth options into contraceptive care due to the coronavirus disease 2019 (COVID-19) pandemic. Methods: Our study is a cross-sectional analysis of population-representative surveys conducted between November 2019 and August 2020 among women aged 18-44 years in Arizona (N = 885), New Jersey (N = 952), and Wisconsin (N = 967). We use multivariable logistic regression to identify characteristics associated with each of five contraception source preference groups (in-person via health care provider, offsite with a provider via telemedicine, offsite without a provider via telehealth, at a pharmacy, or via innovative strategies), and we examine associations between contraceptive care experiences and perceptions and each preference group. Results: Across states, most respondents (73%) expressed preferences for obtaining contraception via more than one source. One quarter indicated a narrow preference for obtaining contraception in-person from a provider, 19% expressed interest in doing so offsite with a provider via telemedicine, 64% for doing so offsite without a provider via telehealth, 71% reported interest in pharmacy-based contraception, and 25% indicated interest in getting contraception through innovative strategies. Those who had experienced nonperson-centered contraceptive counseling reported higher levels of interest in telehealth and innovative sources, and those who expressed mistrust in the contraceptive care system had higher levels of preferring to obtain contraception offsite, via telemedicine, telehealth, and other innovative avenues. Conclusions: Policies that ensure access to a diversity of contraceptive sources, which acknowledge and address people's past experiences of contraceptive care, have the greatest likelihood of closing the gap between people's contraceptive access preferences and realities.

Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.