Summary of "Racial and ethnic differences in women's preferences for features of contraceptive methods," Jackson et al., Contraception, November 2015.
"Unintended pregnancy and abortion are concentrated among racial/ethnic minority and [low-income] women in the United States," trends that could be linked to racial and ethnic disparities in contraceptive use, according to Andrea Jackson, of the University of California-San Francisco's Department of Obstetrics, Gynecology and Reproductive Sciences, and colleagues.
The researchers cited several studies on racial and ethnic disparities in contraceptive use, including a 2010 survey by Lessard and colleagues that identified contraceptive features "women consider to be very important -- efficacy, lack of side effects, affordability, ease of use, being woman-controlled -- and [found] that very few available methods of contraception had all the features that women preferred."
The researchers used the Lessard data and "data from women being seen at family planning clinics" to assess whether "contraceptive feature preferences differ by women's race/ethnicity" and whether there are "racial/ethnic differences in the degree to which available contraceptive methods match these preferences." They hypothesized "that women's preferences for specific features of methods vary by race/ethnicity, and that this may explain some of the observed racial and ethnic disparities in contraceptive use."
Methods
The researchers examined data from the Lessard survey, which was distributed to women seeking abortion care at six U.S. clinics between April and September 2010, and a second survey that was distributed to "women with no history of abortion who were seeking health care services in 13 family planning clinics in six states ... between January and May 2011."
For the study, the researchers "assessed contraceptive features relating to five areas": discontinuation of the method; method use; access to the method; concerns about the method's side effects or health complications; and perceptions about method use control; and privacy. According to the researchers, women marked each of the questions in each of the five categories as "extremely," "somewhat" or "not at all" important.
The researchers categorized contraceptive methods by efficacy:
- Highly effective methods included sterilization for men and women, an implant or an intrauterine device (IUD);
- Moderately effective methods included oral contraception, injectables, the patch and the ring; and
- Least effective methods included condoms, diaphragm, emergency contraception, natural family planning, sponge and withdrawal.
According to the researchers, "'No method' was a separate category."
Results
The final sample included 1,263 women from the family planning clinic survey and 520 women from the abortion clinic survey, for a total of 1,783 women. Of the eligible participants, 39 percent were white, 30 percent were black, 24 percent were Latina and 7 percent were Asian Pacific Islander (API).
Important features of contraceptives by race/ethnicity
According to the study, black women reported a mean of 11.7 "extremely important" contraceptive features; Latina women reported a mean of 11.3; API women reported a mean of 10.8 and white women reported a mean of 10.2.
The researchers also found that black women more frequently cited 16 of the 18 contraceptive features as "extremely important" than white women, 14 of which retained significance when considered in a multivariate analysis. The 16 features included "the ability to become pregnant immediately after using the method (57% vs. 36% ...), the method having a health benefit (65% vs. 46% ...) and the woman, and not her partner, being responsible for the contraceptive (76% vs. 53% ...)."
According to the researchers, "there were 14 features that were significantly different between Latinas and Whites, including the ability to become pregnant immediately after discontinuation of method (56% vs. 36% ...) and using the method only with intercourse (40% vs. 19% ...)." Nine of the features retained significance "after controlling for covariates."
The researchers also found "nine features that were different between API and Whites, including protection against sexually transmitted infections [STIs] (63% vs. 50% ...), no interference with menstrual cycles (51% vs. 34% ...) and that no one can tell a woman is using the method (59% vs. 49% ...)." Six of the features retained significance "after controlling for covariates."
The researchers noted that "a smaller percentage of Latina or API wom[e]n indicated that affordability of the method was 'extremely important' compared to Whites (80% vs. 86% ... and 77% vs. 86% ...)." Further, the researchers found that black, Latina and API women were less likely than white women to rate "having a method that does not interfere with their (63% vs. 74% ... 68% vs. 74% ... 64% vs. 74% ... ) or their partner's (60% vs. 74% ... 67% vs. 74% ... 63% vs. 74% ...) sexual enjoyment" as extremely important.
Conversely, the three features that black, Latina and API women were more likely than white women to rate as extremely important were "being able to stop using the method at any time, using a method only with intercourse and having a method that does not change her menstrual periods." According to the researchers, three other factors that black and Latina women were likely to rate as extremely important compared with white women included "protection against [STIs], having control over when and whether to use the method, and being able to become pregnant after stopping use."
Participants' planned contraceptive method and percent match by race/ethnicity
The researchers found that "[p]ills (52%) and condoms (36%) were the most frequently reported planned contraceptive method among all participants."
According to the researchers, "Black women were more likely than Whites to report that they intended to use injectable contraceptives (22% among Blacks compared to 9% among Whites ...) and condoms (48% vs. 39% ...) and less likely to plan to use the pill (42% vs. 64% ...) or withdrawal (4% vs. 8% ...)." When comparing Latina and white women, the researchers found that Latina women were more likely to plan to use an implant (6 percent vs. 2 percent), but less likely to plan to use oral contraception (52 percent vs. 64 percent).
The researchers found that "[t]here was no contraceptive method that matched all of any racial or ethnic groups' desired features," with matches varying between 33 and 66 percent. Overall, "Use of no method of contraception ... had the highest match with preferred features at 66%," the researchers wrote. According to the researchers, when compared with non-Hispanic white women, "Black, Latina and API race/ethnicity were associated with lower match with highly effective methods of contraception (Black: 53% vs. 55% ...; Latina: 53% vs. 55% ...; API: 51% vs. 55% ...) and higher average match with condoms (Black: 42% vs. 35% ...; Latina: 39% vs. 35% ...; API: 41% vs. 35% ...)."
Discussion
"In this study, we found that there was no contraceptive method that completely matched any racial or ethnic group's stated preferences, with women of color having preferences for features that appear to more closely match lower efficacy methods as compared to Whites," the researchers wrote.
The researchers wrote that the findings on the contraceptive features that women of color consider extremely important , such as "their desire for self-control over initiating and discontinuing their chosen method ... [and] preferences regarding return to fertility and freedom from interference with menstrual cycles" are more closely met by lower efficacy methods, which "are associated with features that allow for more patient control and fewer side effects."
The researchers write that the findings suggest that women of color "desire to preserve control over…reproduction," and they noted that while their study did not examine the reasons behind women's preferred features, "these trends may relate to concerns and myths about birth control, stemming from a history of reproductive abuse of racial and ethnic minorities." The researchers noted that the "United States has a history of social and legislative policies aimed at controlling the reproductive health of [low-income] and disenfranchised women," largely affecting Latina and black communities, which "disproportionately live in poverty."
According to the researchers, "A highly effective contraceptive that is exclusively patient-controlled, instead of provider-controlled, could be one solution to this complex problem." They noted that "[i]ncreasing patient control over high efficacy methods may help to increase acceptability and use among women with concerns regarding possible contraceptive coercion," as could "the availability of highly effective methods with improved side effect profiles."
The researchers wrote that "providers should be aware of the possibility of differences in preferences among their patients, and that these differences may arise from the historical and cultural context in which birth control decisions are made." They noted, "Explicitly inquiring about and incorporating these preferences into contraceptive counseling in a patient-centered manner may improve providers' ability to help women of diverse race/ethnicities to select a method that she would want to use consistently."
According to the researchers, the "study suggests that the racial/ethnic differences in contraceptive use by patient race and ethnicity in the United States may have to do with the fact that women of color may have a lower match for current contraceptives available." They conclude, "Patient-centered counseling, combined with attention to the need for contraceptive methods that meet a greater number of women's feature preferences, has the potential to positively impact persistent disparities in unintended pregnancy."
