Abstract
Background
The study was conducted to determine whether perceived racial, economic, and gender discrimination has an impact on contraception use and choice of method.
Methods
We analyzed the first 2,500 women, aged 14–45 years enrolled in the Contraceptive CHOICE Project, a prospective cohort study aimed to reduce barriers to long-acting reversible contraception. Items from the “Experiences of Discrimination” (EOD) scale measured experienced race-, gender-, and economic-based discrimination.
Results
Overall, 57% of women reported a history of discrimination. Thirty-three percent reported gender- or race-based discrimination and 24% reported discrimination attributed to socioeconomic status (SES). Prior to study enrollment, women reporting discrimination were more likely to report any contraception use (61% vs. 51%, p<0.001), but were more likely to use less effective methods (e.g., barrier methods, natural family planning or withdrawal; 41% vs. 32%, p<0.001). In adjusted analyses, gender-, race- or SES-based discrimination were associated with increased current use of less effective methods (adjusted risk ratio (aRR) 1.22, CI 1.06–1.41; aRR 1.25, CI 1.08–1.45; aRR 1.23, CI 1.06–1.43, respectively). After enrollment, 67% of women with history of experience of discrimination chose a long-acting reversible contraceptive method (intrauterine device or implantable) and 33% chose a depo-medroxyprogesterone acetate or contraceptive pill, patch or ring.
Conclusions
Discrimination negatively impacts a woman’s use of contraception. However, after financial and structural barriers to contraceptive use were eliminated, women with EOD overwhelmingly selected effective methods of contraception. Future interventions to improve access and utilization of contraception should focus on eliminating barriers and targeting interventions that encompass race-, gender-, and economic-based discrimination.
Keywords: Discrimination, contraception, race, socioeconomic status, gender
1. Introduction
Efforts to identify and overcome disparities in health status for disadvantaged populations continue to be a high priority across all fields of medicine, especially women’s health. Discriminatory practices and policies that compromise women’s well -being or impede their economic and social opportunities need to be addressed. Previously published reports have not only documented that perceived prejudice in health care delivery is significantly higher in women than in men [1], but more specifically, that the majority of African Americans report having at least one experience with discrimination in their lifetime across a variety of domains, including the workplace and medical care [2–3]. Already a foundation exists to further explore the interplay between discrimination and race, socioeconomic status, and gender; however few studies have undertaken this task within the realm of women’s reproductive health.
Despite increasing options for safe, effective family planning, women continue to face a number of obstacles, especially those who are an ethnic minority or from a socially disadvantaged background. Examples of such barriers include lack of insurance coverage, reduced access to medical care, poverty, inadequate resources, mistrust of health care systems, and living in communities with high prevalence of sexually transmitted infections (STIs). In the United States, the rates of chlamydia, gonorrhea, and syphilis infection in African American women are 8, 19 and 7 times higher, respectively, than that among white women [4].
The persistence of racial disparity in women’s health outcomes has stimulated scientific interest in other factors that may account for such disparities. Given the known negative effects of discrimination on mental and physical health [5,6], recent attention has been drawn to better understanding the relationship between perceived discrimination and health care utilization. Findings from a cross-sectional study of 326 African American women showed that 67% reported race-based discrimination when obtaining family planning service, especially those women with stronger Black identity, younger age, and lower income [2]. Other studies have demonstrated an association between perceived discrimination and substituting alternative medicine for conventional care; medical care delays (e.g., obtaining prescriptions, treatments, or tests); and non-adherence to medical advice [7–11].
Despite this growing body of literature, there still remains limited data on women’s present day experiences of discrimination, especially within preventive services and reproductive health care. The objective of our cross- sectional analysis is to examine whether there is a relationship between self-reported discrimination and choice of contraception. Specifically, we hypothesize that prior to study enrollment, use of effective contraceptive methods – that is, intrauterine device, implantable, depo medroxyprogesterone acetate (DMPA), and contraceptive pill, patch and ring - is negatively impacted by perceived racial, economic and gender discrimination. Therefore, by eliminating financial and structural barriers to contraceptive use, we hope to demonstrate a positive effect on women’s decision to choose effective methods of contraception compared to less effective methods (e.g., barrier methods, natural family planning or withdrawal) despite any previous experiences with discrimination.
2. Materials and methods
Data from this study were derived from the first 2,500 women enrolled in the Contraceptive CHOICE Project, a prospective cohort study recruiting 10,000 women in the St. Louis region. Participants in this analysis enrolled between August 2007 and December 2008. Each participant is provided the contraceptive method(s) of her choice at no cost to her for up to three years. Prior to the initiation of the study, all procedures were reviewed and approved by the Washington University in St. Louis School of Medicine Human Research Protection Office. A full description of the methods of this study has been published elsewhere [12]. Screening and enrollment of women for CHOICE began in August 2007 and is currently ongoing. Participants are recruited from university-affiliated clinics and providers, two facilities providing abortion services, and community clinics that provide family planning, obstetric/gynecologic, and/or primary care. Recruitment is also achieved principally through direct patient contact, clinic-based advertising and word of mouth.
Women were eligible to participate if 14–45 years of age, resided in or sought clinical services in designated recruitment sites in the St. Louis region, had been sexually active with a male partner in the past six months or anticipate sexual activity in the next six months, had not had a tubal ligation or hysterectomy, did not desire pregnancy in the next year, and not currently using a contraceptive method or interested in starting a new reversible contraceptive method. Parental consent and minor assent (minor’s written agreement) were obtained for participants under 18 years of age. Emancipated minors were able to complete consent without a parent.
The baseline questionnaire collected comprehensive information on demographic characteristics, past and current reproductive history including contraception use, sexual and reproductive history as well as experiences of discrimination and violence. We analyzed information from the baseline questionnaire to assess whether patients have experienced discrimination because of their 1) race, ethnicity, or color; 2) economic position; or 3) gender. We adapted items from the 9-item “Experiences of Discrimination” (EOD) measure, an instrument tested and shown by Krieger et al. [13]. to be a valid and reliable self-report measure of racial discrimination. It was originally based on a prior instrument used in the Coronary Artery Risk Development in Young Adults (CARDIA) study, and first tested in a population of working class African American and Latino adults [14,15]. Confirmatory factor analysis indicated scale reliability was high, and further testing with structural equation modeling demonstrated the EOD had the highest correlation (r=0.79) with an underlying discrimination factor compared to other self-report discrimination measures [13]. Given our specific objectives and appropriate sample population with regards to race/ethnicity, we adapted items from the EOD instrument to answer our study questions. We asked participants the following questions with respect to each of the 3 categories listed above: “Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations: 1) at work or school; 2) getting medical care; 3) on the street or in public; 4) getting a job; 5) getting a house or apartment; or 6) getting contraception?” Response options were yes or no, with positive responses further assessed using the following scale: once, seldom, occasionally, or often.
Prior to, and after, enrollment into the Contraceptive CHOICE Project, we compared whether EOD was associated with selection of an effective method of contraception (e.g., intrauterine device, implantable, depo-medroxyprogesterone acetate or contraceptive pill, patch, or ring) or less effective method of contraception (barriers, natural family planning, withdrawal, etc.) compared to no contraceptive use. We hypothesized that eliminating structural and financial barriers to contraception would eliminate differences in use of effective contraceptives in women with a history of perceived discrimination. Statistical analyses were performed using SAS Software v. 9.2 (SAS Institute, Cary, NC). Categorical variables were compared using either chi-square or Fisher’s exact tests; while continuous variables were compared using t-tests. Relative risks were estimated using Poisson regression with robust error variance. This method provides an unbiased estimate of relative risk when a binary outcome is common.
3. Results
We analyzed the first 2,500 women enrolled in the Contraceptive CHOICE Project. Forty-four percent of the cohort were black and over half of women were considered disadvantaged or low socioeconomic status (SES), that is, had trouble paying for basic living expenses or were receiving government assistance (Table 1). Forty- two percent were uninsured. There was a mean number of lifetime sexual partners of 8.3 and 71% of the sample had at least one pregnancy. Forty -four percent had been diagnosed with a sexually transmitted infection and 55% reported a history of violence. Fifty-seven percent of our study sample reported some experience of discrimination (EOD). Thirty-eight percent reported gender discrimination, 34% reported race-based discrimination and 24% reported discrimination attributed to economic status.
Table 1.
Overview of participant characteristics by experience of discrimination
| All women | Experience of discrimination
|
||||
|---|---|---|---|---|---|
| Any | Gender | Race | SES3 | ||
|
| |||||
| N (row %) | N (row %) | N (row %) | N (row %) | ||
|
| |||||
| All women | N=2500 | 1419 (57) | 956 (38) | 838 (34) | 605 (24) |
|
| |||||
| Demographic characteristics | |||||
|
| |||||
| Age, mean ± SD | 25.0 ± 5.6 | 25.4 ± 5.6 | 25.5 ± 5.6 | 25.6 ± 5.9 | 25.8 ± 5.5 |
|
| |||||
| N (col %)4 | N (row %)5 | N (row %) | N (row %) | N (row %) | |
|
| |||||
| Race | |||||
| White | 1086 (44) | 646 (53) | 496 (41) | 215 (18) | 260 (22) |
| Black | 1209 (49) | 636 (59) | 362 (33) | 517 (48) | 303 (28) |
| Other | 190 (8) | 128 (67) | 90 (48) | 99 (52) | 39 (21) |
|
| |||||
| Ethnicity - Hispanic | 114 (5) | 64 (56) | 46 (40) | 48 (42) | 22 (19) |
|
| |||||
| Trouble paying for basic expenses or government assistance | 1281 (51) | 789 (62) | 486 (38) | 502 (39) | 429 (33) |
|
| |||||
| Education | |||||
| Less than high school | 286 (11) | 126 (44) | 63 (22) | 86 (30) | 48 (17) |
| High school or GED | 564 (23) | 271 (48) | 155 (28) | 176 (31) | 138 (24) |
| Some college/vocational/technical | 1062 (43) | 641 (60) | 421 (40) | 388 (37) | 289 (27) |
| College degree | 587 (24) | 381 (65) | 317 (54) | 188 (32) | 130 (22) |
|
| |||||
| Education level of mother | |||||
| Less than high school | 230 (10) | 127 (55) | 82 (36) | 89 (39) | 56 (24) |
| High school or GED | 809 (34) | 428 (53) | 287 (36) | 251 (31) | 210 (26) |
| Some college/vocational/technical | 630 (26) | 366 (58) | 229 (36) | 222 (35) | 171 (27) |
| College degree | 738 (31) | 463 (63) | 344 (47) | 250 (34) | 153 (22) |
|
| |||||
| Medical insurance | |||||
| None | 1039 (42) | 613 (59) | 375 (36) | 388 (37) | 323 (31) |
| Medicaid/Medicare | 214 (9) | 505 (58) | 375 (43) | 285 (33) | 180 (21) |
| Private | 875 (35) | 112 (52) | 57 (27) | 77 (36) | 54 (25) |
| Other1 | 343 (14) | 171 (51) | 139 (41) | 81 (24) | 43 (13) |
|
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| Sexual and reproductive Health | |||||
|
| |||||
| Sex in the past 30 days | 2008 (82) | 1154 (57) | 781 (39) | 682 (34) | 508 (25) |
|
| |||||
| Lifetime sexual partners, mean ± SD | 8.3 ± 11.4 | 9.4 ± 13.7 | 9.5 ± 13.8 | 9.2 ± 11.5 | 10.1 ± 15.5 |
|
| |||||
| Recent sexual partners, mean ± SD | 0.9 ± 0.6 | 0.9 ± 0.5 | 0.9 ± 0.5 | 0.9 ± 0.5 | 0.9 ± 0.5 |
|
| |||||
| Ever pregnant | 1765 (71) | 980 (56) | 610 (37) | 627 (36) | 460 (26) |
|
| |||||
| Age at first pregnancy, mean ± SD2 | 19.5 ± 4.0 | 19.6 ± 3.9 | 19.9 ± 4.2 | 19.3 ± 3.9 | 19.5 ± 3.6 |
|
| |||||
| Parity, mean ± SD | 0.9 ± 1.2 | 0.9 ± 1.1 | 0.8 ± 1.1 | 1.0 ± 1.2 | 1.1 ± 1.2 |
|
|
|||||
| Number of unintended pregnancies, mean ± SD | 2.3 ± 1.7 | 2.4 ± 1.7 | 2.3 ± 1.5 | 2.4 ± 1.7 | 2.5 ± 1.7 |
|
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| History of STI | 1081 (44) | 648 (60) | 403 (37) | 462 (43) | 315 (29) |
|
| |||||
| History of abortion, mean (±SD) | 0.7 ± 1.1 | 0.8 ± 1.1 | 0.7 ± 1.0 | 0.9 ± 1.1 | 0.8 ± 1.1 |
|
| |||||
| Baseline STD testing (any STD) | 125 (7) | 74 (59) | 43 (34) | 53 (42) | 33 (26) |
|
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| History of violence | 1359 (55) | 933 (69) | 637 (47) | 569 (42) | 439 (32) |
|
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| Smoking | 1267 (51) | 745 (55) | 517 (36) | 386 (37) | 341 (21) |
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| Drug use | 487 (20) | 320 (66) | 209 (43) | 179 (37) | 147 (30) |
|
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| Alcohol use | 1792 (72) | 1063 (59) | 747 (42) | 598 (33) | 445 (25) |
Bold = p<0.05.
Other=parents, military or student insurance.
N=1765.
Column %: % amongst all women.
Row %: % amongst subgroups by row.
SES – socioeconomic status
Col – column percent, percent among the entire sample
Row – row percent, percent among a subgroup (in that row)
Women who reported a history of EOD were more likely compared with women without a history of EOD to be older (mean age 25.4 vs. 24.4 years), have a high school education or higher, and have a mother who obtained a high school education or higher. History of discrimination was also associated with medical insurance status (none or Medicaid/Medicare vs. private/other), number of lifetime sexual partners (9.4 vs. 7.0) and a history of STI. However, women reporting discrimination did not have higher STI rates at enrollment compared to women reporting no discrimination Further, women with a history of discrimination had higher rates of prior interpersonal violence, smoking, drug and alcohol use compared to women without a history of EOD. There was no difference between the number of unintended pregnancies, history of abortion, or age at first pregnancy in women reporting EOD at enrollment compared to women who did not. These patterns were similar by type of discrimination experienced (gender-, race-, SES-based), with a few exceptions. The most common setting of reported discrimination was at work/school (38%) followed by on the street/in public (36%), while receiving medical care (13%), and obtaining contraception (3%) (data not shown). Black women reported higher rates of race- and economic-based discrimination and lower rates of gender-based discrimination. Specifically, Black women reported higher rates of EOD at work/school, on the street/in public, and while seeking a job or housing compared to their white counterparts. Women of disadvantaged SES reported higher rates of discrimination overall compared to women without disadvantaged SES. The setting in which these experiences occurred were the following: at work/school (41%), while seeking a job (19%) or housing (18%) and obtaining medical care (19%) or contraception (4%).
3.1. Contraceptive choice prior to enrollment
Table 2 presents the contraceptive method chosen as part of the study and the current contraceptive method used prior to enrollment by EOD. Women who reported any EOD were significantly more likely to use a contraceptive method prior to study enrollment (61% vs. 51%, p<0.001); but they were more likely to report use of less effective methods (e.g., barrier methods, natural family planning or withdrawal) compared to women with no history of discrimination (41% vs. 32%, p<0.001). This finding held true for gender- or race-based discrimination, but not SES-based discrimination. Less effective methods of contraception were more prevalent among white women reporting gender-based discrimination and black women reporting race-based discrimination.
Table 2.
Contraceptive method use and choice by experience of discrimination
| All women | EOD | Gender EOD | Race EOD | SES EOD | |||||
|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | Yes | No | ||
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| Among all women | |||||||||
|
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| Contraceptive choice 1 | |||||||||
|
| |||||||||
| LARC | 1677(67.1) | 936(66.0) | 741(68.6) | 621(65.0) | 1052(68.4) | 538(64.2) | 1139(68.5) | 411(67.9) | 1266(66.8) |
| DMPA, pill, patch, ring | 820(32.8) | 482(34.9) | 338(31.3) | 334(34.9) | 485(31.5) | 299(35.7) | 521(31.4) | 194(32.1) | 626(33.0) |
| Other | 3(0.1) | 1(0.1) | 2(0.1) | 1(0.1) | 2(0.1) | 1(0.1) | 2(0.1) | 0 (0.0) | 3(0.2) |
|
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| Contraceptive method prior to enrollment 2 | |||||||||
|
| |||||||||
| Nothing | 1074(43.0) | 551(38.8) | 523(48.4) | 362(37.9) | 710(46.1) | 331(39.5) | 743(44.7) | 242(40.0) | 832(43.9) |
| LARC | 10 (0.4) | 3(0.2) | 7(0.7) | 0 (0.0) | 9(0.6) | 3(0.4) | 7(0.4) | 2(0.3) | 8(0.4) |
| DMPA, pill, patch, ring | 621(24.8) | 364(25.7) | 257(23.8) | 259(27.1) | 360(23.4) | 200(23.9) | 421(25.3) | 136(22.5) | 485(25.6) |
| Other | 926(37.0) | 577(40.7) | 349(32.3) | 392(41.0) | 533(34.6) | 343(40.9) | 583(35.1) | 249(41.2) | 677(35.7) |
|
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| Among white women | |||||||||
|
| |||||||||
| All white women | EOD | Gender EOD | Race EOD | SES EOD | |||||
| Yes | No | Yes | No | Yes | No | Yes | No | ||
|
| |||||||||
| Contraceptive choice 1 | |||||||||
|
| |||||||||
| LARC | 820 (68) | 433 (67) | 387 (69) | 326 (66) | 493 (69) | 138 (64) | 682 (69) | 184 (71) | 636 (67) |
| DMPA, pill, patch, ring | 386 (32) | 212 (33) | 174 (31) | 169 (34) | 216 (30) | 76 (35) | 310 (31) | 76 (29) | 310 (33) |
| Other | 3 (0.3) | 1 (1) | 2 (1) | 1 (1) | 2 (1) | 1 (1) | 2 (1) | 0 (0) | 3 (1) |
|
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| Contraceptive method prior to enrollment 2 | |||||||||
|
| |||||||||
| Nothing | 463 (38) | 228 (35) | 235 (42) | 166 (33) | 297 (42) | 71 (33) | 392 (39) | 96 (37) | 367 (39) |
| LARC | 5 (0.4) | 1 (0.2) | 4 (0.7) | 0 (0) | 5 (0.7) | 1 (0.5) | 4 (0.4) | 1 (0.4) | 4 (0.4) |
| DMPA, pill, patch, ring | 363 (30) | 201 (31) | 162 (29) | 162 (33) | 199 (28) | 64 (30) | 299 (30) | 72 (28) | 291 (31) |
| Other | 453 (37) | 259 (40) | 194 (34) | 206 (42) | 246 (35) | 92 (43) | 361 (36) | 103 (40) | 350 (37) |
|
| |||||||||
| Among black women | |||||||||
|
| |||||||||
| All black women | EOD | Gender EOD | Race EOD | SES EOD | |||||
| Yes | No | Yes | No | Yes | No | Yes | No | ||
|
| |||||||||
| Contraceptive choice 1 | |||||||||
|
| |||||||||
| LARC | 734 (68) | 418 (66) | 316 (70) | 233 (64) | 499 (69) | 335 (65) | 399 (70) | 196 (65) | 538 (69) |
| DMPA, pill, patch, ring | 352 (32) | 218 (34) | 134 (30) | 129 (36) | 223 (31) | 182 (35) | 170 (30) | 107 (35) | 245 (31) |
| Other | -- | -- | -- | -- | -- | -- | -- | -- | -- |
|
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| Contraceptive method prior to enrollment 2 | |||||||||
|
| |||||||||
| Nothing | 515 (47) | 265 (42) | 250 (56) | 156 (43) | 358 (50) | 213 (41) | 302 (53) | 128 (42) | 387 (49) |
| LARC | 5 (1) | 2 (0.3) | 3 (0.7) | 0 (0) | 4 (0.6) | 2 (0.4) | 3 (0.5) | 1 (0.3) | 4 (0.5) |
| DMPA, pill, patch, ring | 203 (19) | 123 (19) | 80 (18) | 69 (19) | 134 (19) | 107 (21) | 96 (17) | 52 (17) | 151 (19) |
| Other | 410 (38) | 273 (43) | 137 (30) | 154 (43) | 256 (35) | 219 (42) | 191 (34) | 131 (43) | 279 (36) |
Bold = p<0.05.
Bold & Shade = p<0.01.
P value compares LARC to DMPA, pill, patch, ring only.
Contraceptive groups are all Yes/No with only Yes results reported. P-values compare contraceptive group Yes/No to EOD Yes/No.
Finally, using multinomial regression, we examined whether EOD was associated with type of method used prior to enrollment (more effective and less effective vs. non-contraceptors) (Table 3). We found that women who reported any EOD and gender-, race- and SES-based discrimination were significantly more likely to report using a less effective method compared to women who did not report discrimination. When stratified by race, these associations were observed only among black women. Prior experience of discrimination when obtaining medical care or contraception was not associated with type of method used in adjusted models for either white or black women.
Table 3.
Crude and adjusted relative risks for effective methods and less effective methods at time of enrollment compared to non-contraceptors
| All | White only | Black only | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| RR (95% CI) | aRR (95% CI)1 | RR (95% CI) | aRR (95% CI)2 | RR (95% CI) | aRR (95% CI)2 | |
|
| ||||||
| Any EOD | ||||||
| Effective | 1.19 (1.05–1.35) | 1.20 (0.99–1.44) | 1.13 (0.97–1.32) | 1.20 (0.91–1.59) | 1.29 (1.02–1.63) | 1.12 (0.86–1.45) |
| Less effective | 1.32 (1.18–1.48) | 1.30 (1.12–1.51) | 1.19 (1.02–1.39) | 1.12 (0.89–1.41) | 1.51 (1.27–1.80) | 1.44 (1.17–1.77) |
|
| ||||||
| Gender | ||||||
| Effective | 1.22 (1.08–1.38) | 1.02 (0.84–1.23) | 1.21 (1.04–1.41) | 1.06 (0.80–1.41) | 1.10 (0.87–1.40) | 0.97 (0.74–1.28) |
| Less effective | 1.22 (1.10–1.36) | 1.22 (1.06–1.41) | 1.21 (1.05–1.41) | 1.17 (0.93–1.46) | 1.21 (1.03–1.42) | 1.23 (1.01–1.49) |
|
| ||||||
| Race | ||||||
| Effective | 1.04 (0.91–1.19) | 1.18 (0.97–1.44) | 1.10 (0.90–1.33) | 1.21 (0.87–1.68) | 1.37 (1.09–1.72) | 1.17 (0.91–1.51) |
| Less effective | 1.20 (1.08–1.34) | 1.25 (1.08–1.45) | 1.22 (1.02–1.45) | 1.26 (0.98–1.60) | 1.34 (1.14–1.57) | 1.23 (1.02–1.49) |
|
| ||||||
| SES | ||||||
| Effective | 0.98 (0.84–1.13) | 1.13 (0.92–1.39) | 0.97 (0.80–1.18) | 1.25 (0.91–1.70) | 1.02 (0.79–1.33) | 0.98 (0.72–1.33) |
| Less effective | 1.19 (1.06–1.33) | 1.23 (1.06–1.43) | 1.11 (0.93–1.32) | 1.11 (0.86–1.43) | 1.27 (1.08–1.49) | 1.32 (1.08–1.60) |
|
| ||||||
| Work/school | ||||||
| Effective | 1.12 (0.99–1.27) | 1.15 (0.95–1.38) | 1.12 (0.96–1.31) | 1.25 (0.95–1.65) | 1.17 (0.93–1.48) | 1.02 (0.78–1.33) |
| Less effective | 1.32 (1.19–1.46) | 1.35 (1.17–1.55) | 1.31 (1.13–1.51) | 1.34 (1.07–1.67) | 1.37 (1.18–1.60) | 1.32 (1.09–1.59) |
|
| ||||||
| Medical care | ||||||
| Effective | 0.87 (0.71–1.07) | 1.08 (0.83–1.39) | 0.88 (0.68–1.14) | 1.25 (0.88–1.77) | 0.91 (0.64–1.29) | 0.91 (0.60–1.37) |
| Less effective | 1.00 (0.86–1.17) | 1.04 (0.86–1.27) | 1.02 (0.82–1.26) | 1.03 (0.76–1.40) | 1.02 (0.81–1.27) | 1.08 (0.83–1.40) |
|
| ||||||
| Street/public setting | ||||||
| Effective | 1.23 (1.09–1.40) | 1.13 (0.93–1.36) | 1.14 (0.97–1.33) | 0.93 (0.68–1.28) | 1.42 (1.13–1.79) | 1.27 (0.98–1.65) |
| Less effective | 1.25 (1.13–1.39) | 1.27 (1.10–1.47) | 1.10 (0.94–1.29) | 0.99 (0.78–1.27) | 1.44 (1.24–1.69) | 1.49 (1.23–1.80) |
|
| ||||||
| Getting job | ||||||
| Effective | 0.80 (0.65–0.98) | 0.85 (0.65–1.12) | 0.66 (0.45–0.95) | 0.66 (0.36–1.21) | 1.10 (0.84–1.46) | 0.95 (0.69–1.31) |
| Less effective | 1.10 (0.96–1.26) | 1.13 (0.95–1.35) | 0.94 (0.73–1.23) | 1.00 (0.70–1.42) | 1.23 (1.03–1.46) | 1.23 (0.99–1.52) |
|
| ||||||
| House/apartment | ||||||
| Effective | 1.03 (0.85–1.25) | 1.38 (1.09–1.74) | 0.93 (0.70–1.24) | 1.38 (0.95–2.01) | 1.38 (1.04–1.82) | 1.51 (1.12–2.04) |
| Less effective | 1.21 (1.05–1.39) | 1.36 (1.15–1.61) | 1.14 (0.91–1.43) | 1.23 (0.90–1.67) | 1.33 (1.10–1.59) | 1.50 (1.22–1.85) |
|
| ||||||
| Contraception | ||||||
| Effective | 0.80 (0.49–1.32) | 0.90 (0.49–1.67) | 0.75 (0.36–1.54) | 1.33 (0.63–2.81) | 1.04 (0.53–2.06) | 0.71 (0.26–1.99) |
| Less effective | 1.25 (0.97–1.61) | 1.07 (0.73–1.58) | 1.22 (0.83–1.80) | 1.20 (0.64–2.26) | 1.22 (0.83–1.78) | 1.04 (0.62–1.73) |
Effective = intrauterine device, implantable, DMPA, contraceptive pill, patch or ring.
Less effective = barrier method, natural family planning, withdrawal, etc.
Reference category = non-contraceptors.
Age (continuous), race, trouble paying for basics, number of unintended pregnancies (continuous).
Age (continuous), trouble paying for basics, number of unintended pregnancies (continuous).
3.2. Contraceptive choice once enrolled
When examining contraceptive choice after enrolling in the study, we found that women overwhelmingly selected a long-acting reversible contraceptive (LARC) method (67%; Table 3). The only difference relating to discrimination history is that women reporting race-based discrimination were slightly less likely to choose a LARC method compared to women who did not report race-based discrimination (64% vs. 69%, p=0.03). When stratified by race, we found no difference in chosen method by EOD among white or black women.
4. Discussion
Women who reported EOD had higher rates of any contraceptive use, but were more likely to be using less effective methods of contraception (e.g., barrier methods, natural family planning or withdrawal) than women with no history of discrimination. However, upon enrolling in the Contraceptive CHOICE Project, a study that seeks to remove financial and structural barriers to contraception and provides a brief education on all methods, women with a history of discrimination overwhelmingly selected LARC methods (intrauterine device and implantable), the most effective methods of contraception.
In our study, 57% of women reported experiencing discrimination in the past. Multiple studies have estimated the prevalence of perceived racial discrimination. Mustillo et al. [16] in 2004 found in four metropolitan areas in the U.S. that 41% of black women experienced racial discrimination in the past compared to 5% of white women. However, African Americans reported much lower rates of discrimination in the health care setting. Borrell et al. [17] in 2006, found that 73% of African American women had experienced discrimination, however only 15% experienced discrimination in a health care setting. Women were much more likely to report discrimination in other areas of their life, for example over 42 % of African American women experienced discrimination when getting a job, and 58% experienced discrimination on the street or a public setting. Furthermore, Casagrande et al. [7] in 2007 found that 7% of men and women reported an EOD in the health care setting, and rates did not differ between African Americans and whites.
In 2001, Bird and Bogart [18] conducted a small, cross-sectional telephone survey to explore the relationship of birth control conspiracy beliefs and perceived discrimination to contraceptive attitudes and behavior among a sample of African Americans aged 18 to 45 years. They found that perceived discrimination is associated with more negative attitudes toward contraception, especially pills, and that the majority of African American women report discrimination when obtaining family planning services. A telephone survey of 500 African American women conducted by Thorburn and Bogart [2] showed nearly 30% of respondents reported that, based on their race, a provider encouraged them to use one method of contraception when they preferred another. With the exception of these two studies, we found no other published studies that have examined the relationship between perceived discrimination and choice of contraception when obtaining family planning services. These high reported rates of discrimination when obtaining contraceptives services are in contrast with our findings; where only 3% of African American women and 2% of White women reported discrimination in this setting. This difference could be a consequence of the different demographics between the study sites.
To our knowledge, the Contraceptive CHOICE Project is the first prospective, longitudinal study that examines women’s history of discrimination and selection of contraceptive method. Our study has a number of strengths that include a large sample size, diverse cohort, and assessment of evidence of discrimination using the EOD instrument. Limitations to the study include non-randomization and potential selection bias. Women were recruited for the study through direct contact, advertisement through clinics, and word of mouth. Perhaps the women who sought enrollment into the Contraceptive CHOICE Project had different perceived experiences of discrimination or differed in their contraceptive history and choices compared to the general population. That is, women who have experienced discrimination may be less trusting of university-based researchers and are less likely to participate in a clinical research project.
Contraceptive decision-making involves many factors; prior experience(s) of discrimination may be one of them. An editorial published in Contraception [19] and supported by the Association of Reproductive Health Professionals board of directors and staff entitled, “Ten priorities for women’s health” highlights key public health policies, research and clinical practices needed to improve women’s health and well- being. One stated priority is a call to better understand the underlying issues that affect access and utilization of contraception that remain unanswered. Our findings shed light on the role that perceived discrimination may play in contraceptive method selection and use. Providers should educate their patients about all contraceptive options and minimize personal biases against a patient’s race, gender, and other sociodemographic characteristics.
Acknowledgments
This research was supported in part by a Midcareer Investigator Award in Women’s Health Research (K24 HD01298), by a Clinical and Translational Science Award (UL1RR024992), and by Grant Number KL2RR024994 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.
Footnotes
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