Thursday, September 18, 2014

Family Walking in the WoodsEarlier this month, we attended the 2014 National Reproductive Health Conference as part of Altarum’s work with the Family Planning National Training Centers.  The conference focused on a host of important issues related to family planning and reproductive health.

We found one session, in particular, highly compelling given our work and interest in addressing health disparities. Dr. Sonya Borrero with the Center for Health Equity Research and Promotion (CHERP) offered an overview of disparities in family planning with a specific emphasis on contraception counseling.  Contraception counseling helps women and men plan the number and spacing of their children and prevent unintended pregnancies.The ability to plan if and when to have children is important both to the health and social functioning of women, as well as the economic well-being of society on the whole.

Unintended pregnancies have profound consequences for women, their children, and society. Women with unintended or mistimed pregnancies are more likely to receive inadequate or delayed prenatal care, have higher rates of depression and intimate partner violence, and more likely to give birth to low birth weight babies.[1]  The children born from these pregnancies are more likely to experience developmental delays and are less likely to be breastfed.[2]

From a societal and economic standpoint, unintended pregnancies have been associated with lower educational attainment and less financial stability for women. In 2008, two-thirds (65%) of the 1.7 million births resulting from unintended pregnancies were paid for by public insurance programs, primarily Medicaid. In comparison, 36% of births resulting from intended pregnancies were publicly funded. [3]

Stark disparities in unintended pregnancy and contraception use exist in the United States. In 2008, black women had the highest unintended pregnancy rate of any racial or ethnic group. In fact, it was more than double that of white women (38 versus 92 per 1,000). Borrero also noted that when compared to whites, African-American women are less likely to use contraception, more likely to use less effective methods, and more likely to have inconsistent or incorrect use of any particular method.  But, more interestingly than just the “numbers,” she went on to discuss contributing factors from the perspective of the patient, the provider and the system.  Where system level challenges such as access and cost contribute to many disparities, in this case, she found that women who rely on publicly funded clinics (like Title X Family Planning Clinics)  may receive more comprehensive services and are offered more contraceptive options than those relying on private doctors.  She also found that cost is not a reason commonly cited by women for not using contraception.

Instead, Dr. Borrero discussed an array of patient and provider-level factors that can only be understood by looking at this issue from a cultural and historical perspective. For example, black and Hispanic women are more likely to report contraceptive safety concerns as a reason for non- use. Safety concerns and mistrust of the medical establishment are often well founded based on the very real history of the use of contraception and sterilization to control the fertility of women of color. Specific examples include the nonconsensual sterilization of poor women and women of color in the 1960s-70s and, more recently, legislative proposals in the 1990s to make receipt of welfare benefits contingent upon Norplant use (an old contraceptive implant, no longer available in the U.S.).  One study found that 34% of African Americans believed that whites want to keep the number of black people down and 37% believed that medical/public institutions use poor and minority people as guinea pigs to try new birth control methods.[4]

WhiIe understanding the individual drivers of contraception use is critical, it is also important to look at the skills, attitude, and potential bias (conscious or subconscious) of providers. In 2002, the IOM published Unequal Treatment:  Confronting Racial and Ethnic Disparities in Health Care, which stated: “research suggests that healthcare providers’ diagnostic and treatment decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity and that these differences may contribute to disparities in health outcomes.” Multiple studies have shown that some providers treat patients of color differently.  For example, low-income women of color are more likely to report being advised to limit their childbearing than middle-class white women and a survey of family planning clients found blacks were more likely than whites to report having been pressured by a clinician to use contraception.  [5]

It’s clear that the nexus of system, provider, and patient-level factors are integral to consider when developing solutions to the widespread problem of unintended pregnancies.  But Dr. Borrero honed in on two key factors that are vital to our success in doing so:  1) What we say and do matters (as clinicians, providers, researchers, and human beings) and 2) we must examine our own complicity in perpetuating this disparity. Health care providers have to work extra hard to provide quality, patient-centered care while maintaining a sensitivity to the historical, cultural and racial context in the lives of their patients. More specifically, providers cannot make assumptions about their clients based on their race/ethnicity (or sex, income or age, for that matter) but, instead, need to ask questions, listen carefully, and then provide individual, client-centered care.

And all of us must understand our own biases and stereotypes as a key step in preventing unintended pregnancies and health disparities in general.  To achieve health equity, we must examine our own complicity and remember that what we say and what we do can have a vast impact on the individuals and communities we serve.


[1] Gipson, J. D., Koenig, M. A. and Hindin, M. J. (2008), The Effects of Unintended Pregnancy on Infant, Child, and Parental Health: A Review of the Literature. Studies in Family Planning, 39: 18–38. doi: 10.1111/j.1728-4465.2008.00148.

[2] Haider, S. MD, MPH; Stoffel C.; RN, MPH; Donenberg G. PhD;  Geller S., PhD, (2013) Reproductive Health Disparities: A Focus on Family Planning and Prevention Among Minority Women and Adolescents. Global Adv Health Med. 94-99.

[3] Sonfield A. and Kost K. (2013)  Public Costs from Unintended Pregnancies and the Role of Public Insurance Programs in Paying for Pregnancy and Infant Care: Estimates for 2008, New York: Guttmacher Institute <>.

[4] Thorburn S. and Bogart L. (2005) Conspiracy Beliefs About Birth Control: Barriers to Pregnancy Prevention Among African Americans Reproductive Age. Health Educ Behav 2005 32: 474

[5] Dehlendorf C., MD MAS, Rodriguez M., MD, Levy K. , BA, Borrero S., MD MS, Steinauer J, MD MAS, (2010) Disparities in Family Planning.Am J Obstet Gynecol. 202(3): 214–220.  

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