Racial and ethnic disparities in contraceptive method choice in California

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.

"I probably have access, but I can't afford it": expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA

BACKGROUND

Disparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals' lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access-affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South.

METHOD

Between January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access.

RESULTS

Affordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A "poor fit" between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance.

CONCLUSIONS

Affordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Development of a Peer-Based Intervention Educating Teenagers about Long-Acting Reversible Contraception (LARC)

OBJECTIVE

Despite a decrease in teenage pregnancy rates in the U.S. in the past decades, teen pregnancy continues to be a considerable health issue. In this paper, we outline the development of our novel peer-based intervention, appropriately named Get It?, that aims to increase awareness of and self-efficacy to use long-active reversible contraceptives (LARCs) among teenagers.

METHODS

Peer narrative videos were created from audio-recording semi-structured, one-on-one interviews with teenage LARC users. Focus groups of young women 19 years old and younger were conducted to choose the most audience-appropriate videos to be included in the final intervention. Using a thematic content analysis approach, transcripts of the audio-recorded focus groups were reviewed and manually coded.

RESULTS

The final layout of Get It? included 4 videos that were chosen by participants of the focus groups, as well as supplemental activities that included a basic description of the LARC devices, the ability to anonymously post personal stories about LARC that can be shared with others, and the opportunity to email the primary investigator questions about LARC. Thematic analysis of the focus group discussions revealed when it came to narrative videos, participants desired: (1) an authentic narrator, (2) more information on the narrator, (3) narrators displaying ample emotions.

CONCLUSION

Peer narratives play a vital role in influencing a teenager's perspective on their health status, therefore understanding what constitutes reliable narration from an online format was critical in the development of a peer-based electronic intervention that informs teenagers of the most effective contraceptive available to them.

Factors associated with long-acting reversible contraception usage: Results from the National Survey of Family Growth

OBJECTIVE

The authors aimed to identify factors associated with long-acting reversible contraception (LARC) usage.

METHODS

The current cross-sectional study used data from the National Survey of Family Growth from 2011 to 2019. Respondents aged 15 to 44 years were included. Those with previous sterilization, infertility, or pregnant were excluded. The outcome evaluated was use of a LARC.

RESULTS

Of 61 543 814 women, 44 287 911 (72.0%) met inclusion criteria. The rate of LARC use was 13.4%. Factors associated with an increased likelihood of LARC usage were married/living with a partner (adjusted relative risk [aRR], 1.18 [95% CI, 1.02-1.37]), perceived good health (aRR, 1.44 [95% CI, 1.13-1.84]), year of survey 2017 to 2019 (aRR, 1.53, [95% CI, 1.28-1.83]), one or two past pregnancies (aRR, 1.62 [95% CI, 1.24-2.12]) or three or more past pregnancies (aRR, 1.67 [95% CI, 1.22-2.28]), age at first live birth <20 years (aRR, 1.58 [95% CI, 1.20-2.08]) or 20 to 24 years (aRR, 1.45 [95% CI, 1.13-1.87]), age at onset of sexual activity 13-19 years (aRR, 1.50 [95% CI, 1.26-1.78]), and a 0- to 5-month period of nonintercourse in the past year (aRR, 1.63 [95% CI, 1.40-1.90]). Factors associated with decreased LARC usage were age ≥ 35 years (aRR, 0.74 [95% CI, 0.65-0.85]), being non-Hispanic Black (aRR, 0.75 [95% CI, 0.62-0.89]) or non-Hispanic other (aRR, 0.72 [95% CI, 0.59-0.88]), intending to have children (aRR, 0.65 [95% CI, 0.57-0.74]), and never being sexually active (aRR, 0.10 [95% CI, 0.06-0.16]).

CONCLUSIONS

Using a nationally representative sample of women in the United States, the authors identified modifiable factors associated with LARC use. Results may be used to plan interventional trials to increase LARC usage.

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.

Psychological factors that may influence use of long-acting reversible contraceptives (LARC): A qualitative study

Although long-acting reversible contraceptives (LARC) remain the most effective method of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to investigate possible psychological factors that may lead to this low uptake rate by studying the LARC decisionmaking process among teenagers. In-depth, semistructured, open-ended interviews of sexually active teenagers who had LARC devices placed prior to 18 years of age were conducted. Four key themes emerged from the interviews: (a) the influences of peers (friends and family members) on LARC decision-making; (b) the lack of awareness about obtaining LARC devices; (c) the fear of weight gain as a driving force during contraceptive and LARC decision-making; and (d) the disproportional anxiety about pain from LARC insertion. The results suggest that a paradigm shift in contraceptive counseling is necessary in order to tackle these psychological barriers to teenage LARC use.

"I'm not going to be a guinea pig:" Medical mistrust as a barrier to male contraception for Black American men in Los Angeles, CA

BACKGROUND

Racial disparities in unintended pregnancy and contraceptive use in the United States are not mediated by access to family planning services alone. Rather, a history of medical mistrust underlies Black Americans' adoption of new medical technologies, inclusive of contraception. Efforts to develop hormonal male contraceptives need to incorporate Black Americans' experiences and perspectives so that new contraceptives enable their reproductive goals and promote gender equity.

STUDY DESIGN

Working with our community-based partner, Healthy African American Families in Los Angeles, California, we conducted six 60-minute focus group discussions with 39 Black men over age 18, in ongoing heterosexual relationships, to explore attitudes towards and willingness to use hormonal male contraceptives.

RESULTS

Just over one-third (35%) of respondents reported willingness to use or rely on hormonal male contraceptives. The majority held negative attitudes about hormonal male contraceptives, citing concerns about side effects and safety. Several respondents expressed mistrust of the medical community and medical research, noting that hormonal male contraceptives could be used against Black communities; several expressed unwillingness to trial hormonal male contraceptives without years of testing. However, all groups described scenarios where they would use them despite stated concerns.

CONCLUSIONS

Black men's hypothetical willingness to use hormonal male contraceptives is limited by medical mistrust, which may be overcome by their concerns about the unreliability of current options or the contraceptive behaviors of female partners. Nevertheless, addressing Black Americans' history of medical mistreatment and exploitation will be essential for hormonal male contraceptives to positively contribute to Black men's reproductive options and agency.

IMPLICATIONS

While the development of reversible, hormonal male contraception intends to fulfill unmet global needs for contraception, the utility of these hormonal male contraceptive methods among Black men living on low incomes in Los Angeles, California cannot be fully realized until developers address and overcome historical and ongoing medical mistrust.

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.

How Religion, Social Class, and Race Intersect in the Shaping of Young Women's Understandings of Sex, Reproduction, and Contraception

Using a complex religion framework, this study examines how and why three dimensions of religiosity-biblical literalism, personal religiosity, and religious service attendance-are related to young women's reproductive and contraceptive knowledge differently by social class and race. We triangulate the analysis of survey data from the Relationship Dynamics and Social Life study (RDSL) and semi-structured interview data from the National Study of Youth and Religion (NSYR) to identify and explain patterns. From the quantitative data, we find that all three dimensions of religiosity link to young women's understandings of sex, reproduction, and contraception in unique ways according to parental education and racial identity. There is a lack of knowledge about female reproductive biology for young women of higher SES with conservative Christian beliefs (regardless of race), but personal religiosity and religious service attendance are related to increased contraceptive knowledge for young black women and decreased knowledge for young white women. From the qualitative data, we find that class and race differences in the meaning of religion and how it informs sexual behavior help explain results from the quantitative data. Our results demonstrate the importance of taking a complex religion approach to studying religion and sex-related outcomes.

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.

Social inequalities in the use of contraceptives in adult women from Southern Brazil

OBJECTIVE:

To describe the contraceptive methods used by adult women and the associated socioeconomic and demographic factors.

METHODS:

Population-based cross-sectional study with 20 to 49-year-old women from São Leopoldo, state of Rio Grande do Sul, in 2015. Three outcomes were considered to analyze the association with demographic and socioeconomic characteristics: use of oral contraceptive pills, tubal ligation and male condom. The crude prevalence ratios, stratified by age, and 95% confidence intervals (95%CI) were obtained using Poisson regression, taking the experimental error into account.

RESULTS:

A total of 736 women, aged from 20 to 49 years old, were evaluated. The prevalence of the use of oral contraceptive pills, tubal ligation and male condom were respectively 31.8% (95%CI 28.4–35.3), 11.1% (95%CI 9.0–13.6) and 10.9% (95%CI 8.7–13.3). In addition, 10.5% (n = 77) of the women reported making combined use of oral contraceptive pills and condom. In the stratified analysis, younger women with lower education level and from lower social classes reported less use of oral contraceptive pills. Tubal ligation was more prevalent among the lower social classes, but only in the age group from 30 to 39 years old. No differences were found in relation to male condom.

CONCLUSIONS:

The results indicated that differences persist in relation to contraception, which can be associated with both the difficulties of access to these inputs and the frailty of actions in reproductive health to achieve the needs and preferences of women who are more socially vulnerable.

Pharmacists expand access to reproductive heaLthcare: PEARL study protocol

BACKGROUND

In 2016, Oregon became the first of eight states to allow pharmacists to directly prescribe hormonal contraception (HC), including the pill, patch, or ring, without a clinic visit. In the two years following this policy change, the majority of ZIP codes across the state of Oregon had a pharmacist certified to prescribe HC.

METHODS

We will utilize complementary methodologies to evaluate the effect of this policy change on convenient access to contraception (cost, supply dispensed), safety, contraceptive continuation and unintended pregnancy rates. We will conduct a prospective clinical cohort study to directly measure the impact of provider type on contraceptive continuation and to understand who is accessing hormonal contraception directly from pharmacists. We will concurrently conduct a retrospective analysis using medical claims data to evaluate the state-level effect of the policy. We will examine contraceptive continuation rates, incident pregnancy, and safety measures. The combination of these methodologies allows us to examine key woman-level factors, such as pregnancy intention and usual place of care, while also estimating the impact of the pharmacist prescription policy at the state level.

DISCUSSION

Pharmacist prescription of HC is emerging nationally as a strategy to reduce unintended pregnancy. This study will provide data on the effect of this practice on convenient access to care, contraceptive safety and continuation rates.

Contraceptive Care in the Veterans Health Administration

In recent years, the number of women Veterans obtaining care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. Women Veterans are a diverse group of women with complex sociodemographic and medical backgrounds, and meeting their needs presents a unique challenge for VA. Efforts including the establishment of comprehensive women's health clinics and training practitioners in women's health have greatly improved healthcare services for women Veterans over the last few decades. Recent data from a large cross-sectional survey study suggest that contraceptive use in VA is similar to the general population and that rates of unintended pregnancy, while still significant, are not higher than that in the general population. Subgroup analyses of this survey data, however, suggest that ongoing efforts are needed to improve outcomes in vulnerable subpopulations of women Veterans, particularly ethnic/racial minorities and Veterans with complex medical backgrounds. Policy changes such as the elimination of copayments for contraceptive prescriptions and the dispensing of more months of contraceptive supply are evidence-based starting points for improvements, in addition to leveraging VA's integrated system and research infrastructure to improve patient-centered counseling and contraceptive access.

Contraceptive Method Choice Among Young Adults: Influence of Individual and Relationship Factors

Because decisions related to contraceptive behavior are often made by young adults in the context of specific relationships, the relational context likely influences use of contraceptives. Data presented here are from in-person structured interviews with 536 Black, Hispanic, and White young adults from East Los Angeles, California. We collected partner-specific relational and contraceptive data on all sexual partnerships for each individual, on four occasions, over one year. Using three-level multinomial logistic regression models, we examined individual and relationship factors predictive of contraceptive use. Results indicated that both individual and relationship factors predicted contraceptive use, but factors varied by method. Participants reporting greater perceived partner exclusivity and relationship commitment were more likely to use hormonal/long-acting methods only or a less effective method/no method versus condoms only. Those with greater participation in sexual decision making were more likely to use any method over a less effective method/no method and were more likely to use condoms only or dual methods versus a hormonal/long-acting method only. In addition, for women only, those who reported greater relationship commitment were more likely to use hormonal/long-acting methods or a less effective method/no method versus a dual method. In summary, interactive relationship qualities and dynamics (commitment and sexual decision making) significantly predicted contraceptive use.

The sexual and reproductive health of foreign-born women in the United States

Objective

To explore the sexual and reproductive health (SRH) behaviors, health insurance coverage and use of SRH services of women in the United States (U.S.) by nativity, disaggregated by race and ethnicity.

Study design

We analyzed publicly available and restricted data from the National Survey of Family Growth to assess differences and similarities between foreign-born and U.S.-born women, both overall and within Hispanic, non-Hispanic (NH) white, NH black and NH Asian groups.

Results

A larger proportion of foreign-born women than U.S.-born women lacked health insurance coverage. Foreign-born women utilized SRH services at lower rates than U.S.-born women; this effect diminished at the multivariate level, although race and ethnicity differences remained. Overall, foreign-born women were less likely to pay for SRH services with private insurance than U.S.-born women. Foreign-born women were less likely to use the most effective contraceptive methods than U.S.-born women, with some variation across race and ethnicity: NH white and NH black foreign-born women were less likely to use highly effective contraceptive methods than their U.S.-born counterparts, but among Hispanic women, the reverse was true.

Conclusion

Our findings demonstrate that the SRH behaviors, needs and outcomes of foreign-born women differ from those of U.S-born women within the same race/ethnic group.

Implications

This paper contributes to the emergent literature on immigrants in the U.S. by laying the foundation for further research on the SRH of the foreign-born population in the country, which is critical for developing public health policies and programs to understand better and serve this growing and diverse population.

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.

Racial/Ethnic Differences in Women's Experiences of Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy

OBJECTIVE

To explore racial/ethnic differences in reproductive coercion (RC), intimate partner violence (IPV), and unintended pregnancy (UIP).

MATERIALS AND METHODS

We analyzed cross-sectional, baseline data from an intervention that was conducted between August 2008 and March 2009 in five family planning clinics in the San Francisco, California area, to examine the association of race/ethnicity with RC, IPV, and UIP among female patients aged 16-29 (n = 1234).

RESULTS

RC was significantly associated with race/ethnicity, p < 0.001, [prevalence estimates: Black (37.1%), multiracial (29.2%), White (18.0%), Hispanic/Latina (24.0%), and Asian/Pacific Islander/other (API/other) (18.4%)]. Race/ethnicity was not associated with IPV. UIP was more prevalent among Black (50.3%) and multiracial (47.2%) women, with an overall range of 37.1%-50.3% among all racial/ethnic groups (p < 0.001). In adjusted analyses, factors associated with UIP were RC [adjusted odds ratio (AOR) = 1.59, 95% confidence interval (95% CI) = 1.26-2.01] and Black (AOR = 1.63, 95% CI = 1.02-2.60) and API/other (AOR = 1.41, 95% CI = 1.15-1.73) race/ethnicity, which remained significant in the presence of RC. Race-stratified models revealed that RC increased odds of UIP for White (AOR = 2.06, 95% CI = 1.45-2.93) and Black women (AOR = 1.72, 95% CI = 1.14-2.60).

CONCLUSIONS

Black and multiracial women seeking care in family planning clinics have a disproportionately high prevalence of RC and UIP. RC may partially explain differences in UIP prevalence, with the effect of race/ethnicity slightly attenuated in RC-adjusted models. However, the impact of RC on risk for UIP was similar for White and Black women. Findings from this study support the need to understand and prevent RC, particularly among women of color. Results are foundational in understanding disparities in RC and UIP that may have implications for refinement of clinical care.

Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study

OBJECTIVE

To assess whether racial/ethnic disparities in contraceptive knowledge observed in the general US population are also seen among women Veterans served by the Veterans Affairs (VA) healthcare system.

STUDY DESIGN

We analyzed data from a national telephone survey of 2302 women Veterans aged 18-44 who had received care within VA in the prior 12 months. Twenty survey items assessed women's knowledge about various contraceptive methods. Multivariable logistic regression was used to examine racial/ethnic variation in contraceptive knowledge items, adjusting for age, marital status, education, income, parity, and branch of military service.

RESULTS

Contraceptive knowledge was low among all participants, but black and Hispanic women had lower knowledge scores than whites in almost all knowledge domains. Compared to white women, black women were significantly less likely to answer correctly 15 of the 20 knowledge items, with the greatest adjusted difference observed in the item assessing knowledge about the reversibility of tubal sterilization (adjusted percentage point difference (PPD): -23.0; 95% CI: -27.8, -18.3). Compared to white women, Hispanic women were significantly less likely to answer correctly 11 of the 20 knowledge items, with the greatest adjusted difference also in the item assessing tubal sterilization reversibility (PPD: -13.1; 95% CI: -19.5, -6.6).

CONCLUSION

Contraceptive knowledge among women Veterans served by VA is suboptimal, especially among racial/ethnic minority women. Improving women's knowledge about important aspects of available contraceptive methods may help women better select and effectively use contraception.

IMPLICATIONS

Providers in the VA healthcare system should assess and address contraceptive knowledge gaps as part of high-quality, patient-centered reproductive health care.

Black-White Differences in Sex and Contraceptive Use Among Young Women

This study examines black-white and other sociodemographic differences in young women's sexual and contraceptive behaviors, using new longitudinal data from a weekly journal-based study of 1,003 18- to 19-year-old women spanning 2.5 years. We investigate hypotheses about dynamic processes in these behaviors during early adulthood in order to shed light on persisting racial differences in rates of unintended pregnancies in the United States. We find that net of other sociodemographic characteristics and adolescent experiences with sex and pregnancy, black women spent less time in relationships and had sex less frequently in their relationships than white women, but did not differ in the number of relationships they formed or in their frequency or consistency of contraceptive use within relationships. Black women were more likely to use less effective methods for pregnancy prevention (e.g., condoms) than white women, who tended to use more effective methods (e.g., oral contraceptives). And although the most effective method for pregnancy prevention-long-acting reversible contraception (LARC)-was used more often by black women than white women, LARC use was low in both groups. In addition, black women did not differ from white women in their number of discontinuations or different methods used and had fewer contraceptive method switches. Further, we find that net of race and adolescent experiences with sex and pregnancy, women from more-disadvantaged backgrounds had fewer and longer (and thus potentially more serious) relationships, used contraception less frequently (but not less consistently), and used less effective methods (condoms) than women from more-advantaged backgrounds.

Attitudes about partner communication regarding contraceptive use among hispanic male college students

OBJECTIVE

The purpose of this exploratory study was to examine cultural factors that influence Hispanic male college students' intention to communicate with partners about contraception use.

PARTICIPANTS

A sample of 239 self-identified Hispanic participants enrolled in at least 1 college course participated in this study in the spring 2014 semester.

METHODS

Students completed a 47-item paper survey. Data were analyzed with multiple regression and descriptive methods.

RESULTS

Participants with more siblings were more likely to intend to communicate with partners about contraception use than those with fewer siblings. Participants who received contraceptive information exclusively from fathers exhibited a more favorable attitude toward partner communication. Mother's education level was positively correlated with participants' contraceptive knowledge.

CONCLUSIONS

These results emphasize the importance of support from family members to this sample's intentions to communicate with partners about contraceptive use. Parental involvement and male responsibility, in regards to contraceptive use, should be integrated into Hispanic-focused sexual health improvement efforts.

Changes in the Use of Contraception at First Intercourse: A Comparison of the National Survey of Family Growth 1995 and 2006-2010 Databases

STUDY OBJECTIVE

To determine trends in characteristics associated with contraceptive use at coitarche from 1995 to 2006-2010.

METHODS

The National Survey of Family Growth (NSFG) 1995 and 2006-2010 databases were used to abstract variables of interest. Generalized linear models (GLM) were applied to examine the association between the use of contraceptive methods at coitarche and variables abstracted for each database.

RESULTS

Of the 9599 women from the 1995 database included in this study, 3885 (40%) used contraception at coitarche in comparison to 4860 (82%) out of 5931 women assessed in 2006-2010. For both time periods, Hispanic women were significantly less likely to use contraception at coitarche when compared to White women. In the 1995 database, only women from families with incomes >$50,000 were more likely to use contraception at coitarche, while women from families with income > $20,000 were more likely to use contraception at coitarche in 2006-2010. There were some differences noted in the association between age at coitarche and contraception use at coitarche, but in general, women who had a higher age at coitarche were more likely to use contraception. For both time periods, women were more likely to use contraception at coitarche if they used barrier methods as their first form of contraception or if they obtained their first contraceptive method from a spouse, partner, or friend.

CONCLUSIONS

Our results suggest that access to contraception may be associated with use of a contraceptive method at coitarche. Innovative measures need to be investigated so that this young population has increased access to more reliable methods before their first sexual experience.

Psychometric Properties of a Measure Assessing Attitudes and Norms as Determinants of Intention to Use Oral Contraceptives

PURPOSE

Asian immigrant and Asian American women are less likely to use oral contraceptives (OCs) and tend to rely on low-efficacy methods of contraception. This contraceptive pattern remains poorly understood, in part, because no theory-driven measurement exists to assess psychosocial determinants essential in explaining behaviors related to OC use in this population. The current study aimed to evaluate the psychometric properties of a measure of attitudes and subjective norms toward OC use among Korean American women as a first step to determine whether the measure can be used in this population and, potentially, in other Asian ethnic groups.

METHODS

The sample consisted of 329 Korean immigrant women living in New York City. The theory of reasoned action guided the development of the measure assessing attitudes and norms. Psychometric evaluation included item analysis, internal consistency estimates of reliability, and construct validity (i.e., factorial, discriminant, and predictive).

RESULTS

All item-total correlations were above the recommendation of .30. The Cronbach's alpha for the attitudes and subjective norms measure was .88 and .86, respectively. Exploratory factor analyses revealed four interpretable factors, and confirmatory factor analyses confirmed that the factor structures derived from the exploratory factor analyses fit the data well. Discriminant and predictive validity of the measure were also established.

CONCLUSIONS

The study provides support for the validity and reliability of the measure and its use for determining the degree to which Korean immigrant women intend to use OCs.

Black-White Differences in Attitudes Related to Pregnancy Among Young Women

In this article, we use newly available data from the Relationship Dynamics and Social Life (RDSL) study to compare a wide range of attitudes related to pregnancy for 961 black and white young women. We also investigate the extent to which race differences are mediated by, or net of, family background, childhood socioeconomic status (SES), adolescent experiences related to pregnancy, and current SES. Compared with white women, black women generally have less positive attitudes toward young nonmarital sex, contraception, and childbearing, and have less desire for sex in the upcoming year. This is largely because black women are more religious than white women and partly because they are more socioeconomically disadvantaged in young adulthood. However, in spite of these less positive attitudes, black women are more likely to expect sex without contraception in the next year and to expect more positive consequences if they were to become pregnant, relative to white women. This is largely because, relative to white women, black women had higher rates of sex without contraception in adolescence and partly because they are more likely to have grown up with a single parent. It is unclear whether attitudes toward contraception and pregnancy preceded or are a consequence of adolescent sex without contraception. Some race differences remain unexplained; net of all potential mediators in our models, black women have less desire for sex in the upcoming year, but they are less willing to refuse to have sex with a partner if they think it would make him angry and they expect more positive personal consequences of a pregnancy, relative to white women. In spite of these differences, black women's desires to achieve and to prevent pregnancy are very similar to white women's desires.

Intimate partner violence and postpartum contraceptive use: the role of race/ethnicity and prenatal birth control counseling

OBJECTIVES

Intimate partner violence (IPV) is a major problem that could affect reproductive decision making. The aim of this study is to examine the association between IPV and contraceptive use and assess whether the association varies by receipt of prenatal birth control counseling and race/ethnicity.

STUDY DESIGN

This study analyzed the 2004-2008 national Pregnancy Risk Assessment Monitoring System (PRAMS) that included 193,310 women with live births in the United States. IPV was determined by questions that asked about physical abuse by a current or former partner in the 12 months before or during pregnancy. The outcome was postpartum contraceptive use (yes vs. no). Multiple logistic regression analyses were conducted to assess the influence of experiencing IPV at different periods (preconception IPV, prenatal IPV, both preconception and prenatal IPV, preconception and/or prenatal IPV). Data were stratified to assess differential effects by race/ethnicity and receipt of birth control counseling.

RESULTS

Approximately 6.2% of women reported IPV, and 15.5% reported no postpartum contraceptive use. Regardless of the timing of abuse, IPV-exposed women were significantly less likely to report contraceptive use after delivery. This was particularly true for Hispanic women who reported no prenatal birth control counseling and women of all other racial/ethnic groups who received prenatal birth control counseling.

CONCLUSIONS

IPV victimization adversely affects the use of contraceptive methods following delivery in women with live births. Birth control counseling by health providers may mitigate these effects; however, the quality of counseling needs further investigation. Better integration of violence prevention services and family planning programs is greatly needed.

IMPLICATIONS

Consistent with national recommendations by the U.S. Preventive Service Task Force, clinicians and public health workers are strongly encouraged to screen for IPV. Health providers should educate women on effective contraceptive options and discuss long-acting reversible contraceptives that are not partner dependent within the context of abusive relationships.

Race-Ethnic Differences in the Non-marital Fertility Rates in 2006-2010

Research in the 1980s pointed to the lower marriage rates of blacks as an important factor contributing to race differences in non-marital fertility. Our analyses update and extend this prior work to investigate whether cohabitation has become an important contributor to this variation. We use data from the 2006-2010 National Survey of Family Growth (NSFG) and to identify the relative contribution of population composition (i.e. percent sexually active single and percent cohabiting) versus rates (pregnancy rates, post-conception marriage rates) to race-ethnic variation in non-marital fertility rates (N=7,428). We find that the pregnancy rate among single (not cohabiting) women is the biggest contributor to race-ethnic variation in the non-marital fertility rate and that contraceptive use patterns among racial minorities explains the majority of the race-ethnic differences in pregnancy rates.

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 and ethnic differences in U.S. women's choice of reversible contraceptives, 1995-2010

CONTEXT

In the United States, unintended pregnancies disproportionately affect minority populations. Persistent disparities in contraceptive use between black and Hispanic women and white women have been identified, but it is unclear whether racial and ethnic differences in use of the most effective methods have changed.

METHODS

Data on 4,727 women from the 1995 National Survey of Family Growth and 5,775 women from the 2006-2010 cycle were used to examine the association between race and ethnicity and women's choice of reversible contraceptives according to level of method effectiveness. Stepwise multinomial logistic regressions were used to identify changes in this association between cycles. Analyses controlled for demographic, socioeconomic, family, religious, behavioral and geographic characteristics.

RESULTS

The proportion of women using the most effective reversible contraceptive methods increased from 46% in 1995 to 53% in 2006-2010. In 1995, black and Hispanic women's use of the most effective reversible contraceptives did not differ from that of white women. By 2006-2010, however, black women were substantially less likely than white women to use highly effective reversible contraceptive methods rather than no method (relative risk ratio, 0.6). An analysis that combined the two data sets and included a term for the interaction between survey year and race and ethnicity found that relative to white women, black women were less likely in 2006-2010 than in 1995 to use more effective methods rather than no method (0.6).

CONCLUSIONS

Further research is needed to identify factors that may be causing racial and ethnic disparities in contraceptive decisions to widen.

Variations in unmet need for contraception in Zambia: does ethnicity play a role?

Ethnicity has been found to be a significant indicator of social position, and many studies have also established that ethnicity is a significant determinant of contraceptive use. This study aims to examine whether ethnicity is an important predictor of unmet need for contraception. Analysis was based on data for 4343 ever-married women drawn from the 2007 Zambia Demographic and Health Survey. Descriptive analysis indicates that in all ethnic groups except the Barotse and Tonga, women aged 15-49 years were married at an average age below 18. The highest mean number of children among the ethnic groups was 6.7, among the Bemba; the lowest was 5.9, among the Barotse. The highest proportion of women with an unmet need for contraception resided in the Eastern region. Multivariate logistic analyses reveal that children ever-born and region of residence were the most important predictors of unmet need for spacing, whereas for unmet need for limiting predictors were age at first marriage and partner's desire for children. Moreover, unmet need for spacing and limiting among women with secondary or higher education was significantly lower (47% and 50%, respectively) compared with those with no education. Ethnicity was not a significant predictor of unmet need for contraception. The findings stress the need for programmes aimed at enhancing the socioeconomic status of women.

Immediate post-abortion insertion of intrauterine contraceptives (IUC) in a diverse urban population

Ethnic minority women have a higher incidence of unintended pregnancy and abortion than Caucasian women, with significant individual and social implications. Post-abortion intrauterine contraceptive (IUC) use may reduce future unintended pregnancy. This was a retrospective review of 265 women undergoing abortion at a Los Angeles County Reproductive Options Clinic. Demographic factors, reproductive history, and post-abortion contraceptive choice were evaluated and analyzed. The population was predominantly Latina (73%) and single, with a mean age of 27. Immediate post-abortion IUC insertion was chosen by 48% overall and more frequently by Latinas (55%) than by African Americans (33%) or Asians (43%) (p = 0.02). IUC use increased with age, undesired future fertility, increasing gravidity, and history of previous abortion in univariate analysis. In multivariate analysis, IUC use increased with Latina ethnicity and increasing gravidity. In a clinic serving low-income urban women in Los Angeles, post-abortal IUC uptake is highest among Latinas and those with prior pregnancies. Future research should examine reasons for and barriers to IUC uptake in diverse communities and methods to improve post-abortion IUC uptake to prevent subsequent unintended pregnancies.