The medical literature has documented racial and ethnic disparities in access to healthcare, as well the quality of that care for more than a decade. In 2003, the Institute of Medicine determined “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 unfortunately demonstrated that African-American and Latina women from low socioeconomic backgrounds have been strongly encouraged to limit their family sizes and have been pressured to start contraception or proceed with tubal sterilization [12, 13].
Historically, the United States has had a shameful history regarding forced sterilizations and reproductive injustices which may lead minority women to be distrustful of contraception [14, 15]. There are also racial differences in contraceptive preferences. Because it is important to many African American women to avoid the use of hormones, they may be less likely to choose highly effective contraception such as implants, injectable contraception or levonorgestrel containing intrauterine devices (IUDs) . Outside of preferences guided by historical weight, there are also distinctive barriers to reproductive access.
This idea of disparity in contraceptive access is echoed in the discordance between desired fertility and chosen method of contraception. A study of 110 (48 African-Americans, 43 Hispanics, 19 Caucasians) low-income women who lived in an underserved area found that 40% of women who did not desire pregnancy had unprotected intercourse within the last 12 months . Similarly, a study examining contraception trends found that 16% of African-American women who were at risk of unintended pregnancy were not using contraception compared to about 9% of Hispanic, white and Asian women .
Attitudes and norms regarding contraception in minority groups are often different than those of Caucasian women. Frequently, when African-American and Latina women choose contraception, they choose less effective contraception options (i.e. condoms) compared to white women [12,13,14]. Interestingly, data from the contraceptive CHOICE project revealed that prior to enrollment in the study, African-American women who have had a history of discrimination were more likely to choose less efficacious contraceptive measures (specifically barrier methods, natural family planning and withdrawal) but after enrollment, 67% of these women elected to use long-acting reversible contraception (LARC) . The script that was used in the CHOICE study provided important information about the effectiveness of various contraceptive methods, and patients were free to choose whatever method they desired. Patient education played a pivotal role in the success of the CHOICE project, but it is imperative that other contraceptive programs provide education and not coercion.
High unintended pregnancy rates, particularly among low-income women and women of color, have persisted despite the expanded options for highly efficacious contraceptives. LARC, which includes IUDs and subdermal contraceptive implants, are cost-effective and highly efficacious, with an annual failure rate of 0.05% (implants) and 0.2–0.8% (IUDs) . Despite the efficacy of these methods, they are often associated with up-front out-of-pocket costs which may be prohibitive to poorer women [10, 17]. When women were given multiple options for contraception, and cost was not a consideration, 67% elected to use long-acting reversible contraceptive (LARC) . In comparison, non-LARC contraceptive options were 20 times more likely to have an unintended pregnancy, demonstrating how much effective contraception is of paramount importance for preventing unintended pregnancy .
Any efforts to decrease unintended pregnancy will need to include elimination of barriers such as a lack of insurance, inadequate coverage that requires large out of pocket expenses, or extremely high premiums. One potential strategy is to educate third party payers about the cost savings associated with widely available contraception. One study estimated that the direct medical cost of unintended pregnancy in the United States was more than $4.6 billion annually . Women ages 18–24 have the highest risk of unintended pregnancy. Using cost models, one review found that if 10% of women ages 20–29 who used oral contraception changed to LARC, the total costs associated with unintended pregnancy would decrease by $288 million per year . Third party payers should consider access to contraception as effective preventive health care that will decrease medical costs.
Although decisions regarding contraception are often left up to the female partner, the role of the male partner must be examined as part of the strategy to decrease unintended pregnancy. Utilizing data from the 2006–2010 National Survey of Family Growth, one study attempted to better understand knowledge of contraception among young men . Researchers found that although 96.6% of men reported formal sex education, Black men were less likely to receive contraceptive education . Another study examining contraceptive knowledge found that men were more likely to “display serious gaps in objective knowledge about the major contraceptive options” . Despite men often being left out of conversations involving contraception, counseling that reflects a couple’s culture and values may help increase compliance especially amongst minority groups .
Age plays a significant role in the likelihood of having an unintended pregnancy. Young women who become sexually active at an early age are particularly at risk for an unplanned conception. Data from Demographic and Health Surveys revealed that a significant proportion of adolescents in 16 countries reported sexual activity. In 9 of these 16 countries, approximately 40% of women reported sexual activity before age 18 while men engaging in intercourse before age 18 ranged from 25 to 75% . There is a clear need for access to contraception among adolescents in many of these countries. However, adolescents in low and middle-income countries face additional barriers regarding contraception. These include poor understanding of how to use various methods correctly and law or policies preventing young unmarried women from accessing contraception . The following recommendations are potential solutions to the disparities of contraception access facing minority population.