This analysis provides valuable information about the provision of contraceptive methods in a system where all methods are available at no charge. Our study population is limited by Family PACT policy to women with an income no higher than 200% of the federal poverty line; however, within this income range, we expand on earlier work by providing information about the association of method choice with race and ethnicity independent of financial access. In addition, our study yields information about the provision of contraceptives during a period in which new methods were introduced.
Our data show that the contraceptive methods women received differed substantially by race and ethnicity. After adjustment for age and parity, white women were more likely than Latina, black or Asian women to receive the pill, ring or IUD, while Latina and black women were more likely than whites to receive the injectable, patch or barrier methods. Although such differences most likely do not entirely explain racial and ethnic disparities in unintended pregnancy rates, our findings suggest that variations in use of highly effective methods may be one factor.
The persistence of racial and ethnic differences in methods received in a program in which all contraceptive methods are covered suggests that socioeconomic status and health care access are not the only factors that contribute to such differences. Patient preferences and knowledge may also play a role. Results of previous studies have suggested that black and Latina patients tend to have misconceptions and fears about hormonal contraceptives.12–14
These concerns may in part be a result of minority women’s having lower levels of knowledge than white women about birth control,15–17
and may be related to and reinforced by information obtained through social networks.12,18–20
In addition, these perceptions may be shaped by knowledge of the history of coercive family planning programs motivated by racist beliefs;21,22
one study found that more than one-third of black women felt that “medical and public health institutions use poor and minority people as guinea pigs to try out new birth control methods,” and 20% believed that “governmental family planning policies are designed to control the number of black people.”23
An additional potential source of racial and ethnic variation in contraceptive use is provider influence. Providers in clinics or communities serving minority women may be more likely than providers caring for white women to recommend or provide certain methods, such as the patch, although this has not been studied. Alternatively, providers may make different recommendations depending on clients’ race and ethnicity. While this possibility has not been well studied in the reproductive health field, race and ethnicity is a factor in recommendations in other areas of clinical medicine24
(the issue has been examined most fully in cardiology25,26
). Moreover, in one study, providers were more likely to recommend the IUD to low-income minority women than to low-income white women.27
Although this finding differs from ours (the odds of receiving an IUD were highest among white Family PACT clients), the study suggests that patient race and ethnicity can influence provider behavior in a reproductive health context.
We found that receipt of hormonal contraceptives increased after the introduction of the patch and the ring; provision of these new methods more than offset a decline in provision of the injectable. Importantly, the increase in provision of hormonal methods, and the corresponding decrease in receipt of barrier methods, was most prominent among black and Latina clients, and was largely attributable to the increasing receipt of the patch. Together, these trends resulted in a narrowing of the gaps between provision of hormonal methods to whites and to black and Latina clients, at least between 2001 and 2005. However, these differences widened slightly after 2005, because of a decline in dispensing of the patch. This change is likely related to the FDA’s 2005 black box warning that use of this method results in higher serum levels of estrogen than does use of the pill, possibly resulting in an increased risk of venous blood clots.28
Nonetheless, our results suggest that minority women’s disinclination to use hormonal contraceptives12–14
may be overcome at least in part by the development of novel modes of drug delivery. This underscores the importance of the development of methods appropriate for women with a range of needs and preferences, and illustrates the potential for new methods to affect disparities in use.
Parity and age were also independently associated with receipt of contraceptive methods. Notably, nulliparous women were more likely than parous women to receive oral contraceptives and the ring, and women 29 or younger were more likely than older women to receive the injectable (trends by age for other methods were less clear). Reasons for these variations are unknown; future research could investigate the extent to which the disparities relate to provider or patient preference. In addition, women 40 or older were more likely than those aged 20–29 to receive barrier methods, but less likely to receive hormonal methods. This is of interest because the contraceptive use of women in their 40s has not been well studied. An analysis of NSFG data found that women in this age-group are more likely than younger women to not use any contraceptive methods.3
While our study is limited by the fact that women who had been sterilized in previous years would not be included in the Family PACT data, our findings are consistent with the NSFG analysis in suggesting that women 40 and older may have an elevated risk for unintended pregnancy because of low use of effective contraceptives.
The proportions of women receiving various contraceptive methods in 2007 are themselves of interest. Only about one-quarter of Family PACT clients who obtained a method received the injectable, ring, patch or IUD, which do not require daily administration and may be easier for women to use effectively than pills (the method received by almost half of clients). Possible reasons for the low rates of use of these methods include women’s lack of familiarity with them and concerns about side effects.29–32
In addition, many providers have misconceptions about the safety of the IUD and therefore inappropriately limit its use.33,34
Interventions designed to improve knowledge and dispel misconceptions about these methods may increase their use and ultimately help reduce the high rate of unintended pregnancy.
Data on the prevalence of IUD use since the 2000 introduction of the levonorgestrel-containing intrauterine system are limited. In our multivariate analyses, we found that in 2007, this method was more commonly provided to white women than to black or Asian women, to women aged 20–29 than to younger or older women, and to parous women than to women with children. While NSFG data regarding IUD use have not been evaluated using multivariate methods, the 2006–2008 NSFG results for age and parity appear to be consistent with our results.2
Our data have some limitations. First, our measure of the primary method women received does not fully capture the complexity of method use within a given year. We categorized women according to the most effective method they received during the year, and did not take into account the variety of methods they may have received or the length of time that they may have used each. Furthermore, because we used claims data related to the provision of the method, our analysis provides limited insight into the use of long-term methods (such as the IUD and sterilization) that do not require one or multiple visits each year. Given that the proportion of women using these methods within the Family PACT program is small, this limitation should not have a marked impact on our findings.
Moreover, our data set included only women who accessed services through Family PACT, and not those who were eligible but did not receive methods through the program. This limitation may be especially relevant to our ability to identify women who used barrier methods or emergency contraceptive pills, as opposed to no method, because women could have bought these methods over the counter without accessing their Family PACT benefits. Some women whom we classified as nonusers, and hence excluded, may in fact have been using barrier methods, while others may have been trying to become pregnant or may not have been sexually active. However, when we included in our analyses women who had not received a method, the findings did not vary.
An additional limitation of our data set is that it does not include claims that were denied and thus never paid, even if the client received the method. Also, any fraudulent or erroneous claims that were not associated with actual provision of a method but were paid would have been included in our data set. Moreover, the data provide direct information about the methods dispensed to Family PACT clients, but not about the methods used by these clients. However, we have no reason to believe that actual use differed by method, except for the injectable, the IUD and tubal sterilization, which are provided in the health care setting.
These limitations are generally inherent to the use of claims data. As we would not expect these data quality issues to be differentially associated with use of particular methods, with specific patient demographic characteristics or with specific calendar years, they are unlikely to have altered our findings. Further, our results regarding oral contraceptives and condoms are similar to those found in a study using self-reported data.6
While the limitations of self-reported data, such as recall bias,35
differ from those of claims data, the concordance of these findings supports the validity of our results.
A final limitation to consider is the potential for residual confounding. Most notably, although the incomes of Family PACT clients do not exceed 200% of the federal poverty level, variations in socioeconomic status may exist among these individuals. We did not have access to information on other client characteristics, such as education and wealth, to control for variations in socioeconomic status within the Family PACT population.36
Therefore, some of the racial and ethnic differences we identified could be due to differences related to socioeconomic status.