In this sample of 4639 sexually active women aged 18–44, we found no racial/ethnic differences in the overall use of family planning services. However, there were differences in the types of services women received. Specifically, Hispanic women were more likely to receive counseling about tubal sterilization, and both Hispanic and black women were more likely than white women to report receipt of counseling for a birth control method in general.
Our results are somewhat reassuring in that they suggest that Hispanic, white, and black women have equal access to family planning services. This could be related to Title X programs and Medicaid expansions implemented to improve access to family planning services for socioeconomically disadvantaged women.22,23
On the other hand, whereas approximately 74% of women had Pap smears, only about 52% received family planning services. Although it is promising that such a large percentage received Pap smears, the annual incidence of cervical intraepithelial neoplasia (CIN) or cancer is <1% in the United States,24
whereas the rate of unintended pregnancy is over 5-fold that, at 5%.16
Moreover, of the women in our sample who had a Pap smear, 45% reported that their physician did not speak to them about birth control. This estimate exposes a tremendous missed opportunity to discuss family planning while women are receiving other reproductive health services. Until we improve provision of contraceptive services, unplanned pregnancy, which accounts for nearly 50% of all pregnancies in the United States,16
will continue to be a major problem.
In a previous analysis using the NSFG database, we found that black women undergo tubal sterilization significantly more often than white women even after adjusting for socioeconomic characteristics.18
Hispanic women also showed higher rates of tubal sterilization, but this trend did not reach statistical significance.18
In this analysis, we were able to examine if minority women more often received sterilization counseling by a healthcare provider. Altough our findings did indicate an ethnic difference in the rate of sterilization counseling, this difference does not necessarily translate into higher rates of sterilization; that is, Hispanic women report getting counseled about sterilization more often but do not actually get sterilized significantly more often than white women.18
Conversely, black women report similar rates of sterilization counseling as white women but do get sterilized significantly more often.18
This could indicate that the decision to undergo tubal sterilization is driven more by patient preference or by system-level factors than by whether or not the healthcare provider provides counseling. One must be cautious in drawing this conclusion, however, because we could only assess frequency of provider counseling not content or quality of the information provided. That is, although black and white women receive sterilization counseling with equal frequency, healthcare providers may simply be providing information to white women but making specific recommendations for sterilization to black women.
In addition to Hispanic women reporting a higher incidence of receiving sterilization counseling, both black and Hispanic women received counseling about birth control more often than did white women. The fact that minority women did not actually obtain more birth control or prescriptions for birth control, however, suggests that the increased frequency of contraceptive counseling reported by minority women was likely not patient initiated. The merits of more reproductive counseling for minority women, therefore, need further understanding. Given the history of efforts to control the fertility of poor and minority women in this country,25–28
more counseling may not necessarily mean better care. This difference might reflect provider bias, a factor that has been implicated by the Institute of Medicine to have a role in racial and ethnic disparities in healthcare.1
The American College of Obstetricians and Gynecologists (ACOG) also recognizes the pervasive role that bias can play in contraceptive counseling and cautions healthcare providers about making recommendations or giving advice regarding contraception that goes beyond health-related issues because it might be difficult to address nonmedical issues (e.g., socioeconomic concerns) without bias.29
In practice, however, parity and socioeconomic concerns often do factor into patient-provider communication about contraception and family planning. For this reason, we adjusted for these factors when examining for racial/ethnic differences in receiving birth control counseling and found that racial/ethnic differences in receipt of sterilization and birth control counseling persisted.
A recent study by Thorburn and Bogart30
examined the frequency of perceived race-based discrimination experienced by black women when obtaining family planning services. Of the 326 women surveyed, 67% reported race-based discrimination, and 52% reported experiences that reflect stereotypes of black women (e.g., provider made assumptions about parity and welfare status). Furthermore, these patients' experiences with discrimination were unrelated to most of the sociodemographic factors examined, including education, employment, parity, and sexual activity, suggesting that patients' race/ethnicity overrides other patient-level factors. The authors comment that this is not surprising, as people are more likely to apply stereotypes unconsciously and automatically and less likely to pay attention to individualizing information, especially under conditions of busyness and time pressure that healthcare providers face.30
Some important limitations must be considered in interpreting our results. First, not all the women included in the sample may have been in need of family planning services. We would argue that all women of reproductive age are at risk for unintended pregnancy and, therefore, in need of family planning services unless she or her partner has been surgically sterilized, she is heterosexually abstinent, or she is actively seeking to get pregnant. Although we excluded women who had been sterilized, who had not had heterosexual intercourse within the past 12 months, and who were trying to get pregnant, we did not exclude women who reported current use of other forms of highly effective contraception. However, in the total NSFG sample,
<5% of women (337 women) reported that their current primary method of contraception was male sterilization, and only about 1.5% of women (119 women) were using either an implant or intrauterine device. A second limitation is that women's reports of having received specific services might not be accurate, especially with regard to more subjective experiences, such as receiving counseling. For example, more women reported that they had had a Pap smear than reported having a pelvic examination, which is impossible. Lastly, we did not adjust for type of setting in which women received the family planning service. It is possible that some women seek care in settings that provide high-quality, comprehensive contraceptive services, and, thus, observed differences in contraceptive counseling may reflect differences in the sources of care.
In summary, in this nationally representative sample of women of reproductive age, we report significant racial/ethnic differences in the receipt of birth control and sterilization counseling by a healthcare provider. However, there were no significant differences in use of family planning services by race or ethnicity. Future studies are needed to examine the quality and content of contraceptive counseling received by minority compared with nonminority women.