Social Context Brief: Disparities in Unplanned Pregnancy and Contraception Use in Racial Minority Populations

Unplanned pregnancies are a significant issue in the US as there are 3 million annually, comprising 49% of all pregnancies, which is highest in any developed nation (Dehlendorf et al. 2011). They lead to a variety of short and long term consequences for mother, child, and society. Women may be forced to compromise education or employment opportunities and drastically alter their life path (Haider et al. 2013). Unplanned pregnancies are associated with more relationship conflict, higher depression and anxiety, less financial stability, and children with an increased likelihood of developmental delays (Haider et al. 2013). Additionally, 64% of unintended births are publically funded, costing upwards of $11.1 billion (Haider et al. 2013). Contraception is often used to avoid unintended pregnancy, but not all methods are equivalent in effectiveness. In fact, 54% of unintendedly pregnant women state that they were using some form of contraception before becoming pregnant (Haider et al. 2013). These issues are of particular interest in minority populations because racial minority women have higher incidence rates of unintended pregnancy and lower uses of contraceptives. Unplanned pregnancies often compound the issues that disadvantaged minority women already face. This problem is a multicultural issue and involves several overarching multicultural processes including culture and health, worldviews, racism, and institutions.

The disparities in unintended pregnancy involve the process of the influence of culture on health. This is supported by the fact that first, there are significant differences in the incidence of unplanned pregnancy between minority and white women. 42% of all pregnancies are unintended for white women, but 54% and 69% are unplanned for Latinas and black women respectively (Dehlendorf et al. 2011). Minority adolescents have rates of unintended pregnancy that are up to three times those of adolescent whites (Haider et al. 2013). Clearly, these stark disparities show that being of a minority race is correlated with much higher risk of unintended pregnancy. Additionally, there are racial disparities in the use of contraceptives. Differences in the incidence of unintended pregnancy are certainly influenced by the fact that a higher percentage of minority women do not use contraceptives. Of women not desiring pregnancy, 9% of whites do not use birth control, compared to 12% and 16% of Latina and blacks respectively (Dehlendorf et al. 2011). This is evidence that culture has a significant impact on health choices. Finally, the impact of culture and health processes on unplanned pregnancy and contraception use also involves minority women having greater mistrust in their physicians and healthcare system when compared to white women. Mistrust in the medical field is a significant issue because trusting a physician and the system are essential to good health practices. One third of racial minority individuals believe that they are used as “guinea pigs” to try out new medicines and 20% of the black women believe that doctors use birth control to control the number of black people who are reproducing (Dehlendorf et al. 2011). These findings can be attributed to the perception of racism in the medical field which leads to mistrust, ultimately contributing to the disparities in the use of contraceptive methods and unplanned pregnancy among racial groups. It is clear that culture’s intersection with health plays a role in the mistrust of health providers and disparities in both unplanned pregnancy rates and contraception use.

Differences in worldviews are also an important process to consider because are several aspects of the worldview of minority women that differ from white women with regards to pregnancy and contraception. These differences contribute in turn to the stark disparities in family planning outcomes. First, attitudes towards unplanned pregnancy differ by race. For example, both black and Latina women of all ages have more positive attitudes towards pregnancy and early motherhood than their white counterparts and these attitudes are positively correlated with higher rates of unplanned pregnancy (Rocca et al. 2012). Additionally, a greater percentage of Latina and black women express ambivalence or fatalistic attitudes about pregnancy which are associated with decreased and inconsistent use of contraceptives and the increased likelihood of unplanned pregnancy (Callegari et al. 2017). Another aspect of minority women’s worldview that differs from the worldview of white women with regards to family planning involves preferences for different types of birth control. It has been found that minority women prioritize the attributes of less effective and more inconsistent methods such as barrier methods over more effective ones (Haider et al. 2013). This may be explained by the fact that black and Hispanic women express greater concern about the safety of hormonal methods and their associated side effects (Dehlendorf et al. 2018). This difference in view contributes to the fact that minority women are less likely to use hormonal methods and more likely to use less effective barrier methods compared to white individuals which can explain the differential incidence in unintended pregnancies (Dehlendorf et al. 2018). The final aspect of minority women’s worldview that contributes to family planning disparities is the fact that minority women tend to rely more on family and peers for advice than their healthcare providers (Haider et al. 2013). One study found that groups of minority women trust information and recommendations from their peers more than those from their doctor and another found that black women tend to prefer birth control approaches recommended by their friends opposed to those prescribed by a doctor (Haider et al. 2013; Dehlendorf et al. 2018) This may stem from a greater independence on the family and peers in minority cultures which are more collectivistic in their worldviews. Again this contributes to the differences in the type of birth control used as minority women tend to opt for methods that are recommended by peers which may be less effective.

It is also important to consider the disparities in unplanned pregnancy in the context of racism. Provider factors play an important role in patient care and many studies have explored how patients are treated differently in the health system based on race (Dehlendorf et al. 2018). Minority women may experience differential treatment from their providers which can come in the form of overt, intentional racism or covert, unintentional racism. This is illustrated by the fact that 67% of racial minority women identify with having experienced race-related discrimination is using family planning services and minority women rate their family planning visits less positively than their white counterparts (Dehlendorf et al. 2018). This evidence shows that racism is definitely experienced by minority women when they use family planning services and leads to dissatisfaction with their care. This can certainly affect both their contraceptive use and unplanned pregnancy outcomes as women who are satisfied with their relationships with their providers are more likely to use their birth control prescriptions consistently and effectively (Dehlendorf et al. 2018). Additionally, discrimination from providers may come in the form of what type of birth control is prescribed. Providers who serve minority women may be more likely to recommend or provide certain methods or may make their recommendations based on race. In fact, 28% of black women agree that they had been encouraged to use one form of birth control when the preferred another (Dehlendorf et al. 2011). It is possible that provider recommendations influenced by racism are a cause of the discrepancies in contraception use among minority women. Finally, historical issues of racism are also still relevant in minority women’s relationship with their contraception provider. Mistrust of doctors is heavily influenced by racist practices in the past that involved promoting contraception and attempting to limit the fertility of minority populations in addition to current experiences with racism. Just a few of these historical examples of racism include practicing gynecological surgical techniques on slaves, the use of government-funded clinics to attempt to lower the birthrate of blacks, and forced sterilizations as part of the eugenics movement (Dehlendorf et al. 2018). These past events are still relevant and can certainly affect a woman’s relationship with her healthcare provider. Mistrust due to historical instances of racism in the medical field is known to cause perceptions of lower quality care and this may deter minority women from going to their providers in the first place, which, in turn, contributes to the disparities in unintended pregnancy.

The final process involved in the issue of unplanned pregnancy disparities is the role of institutions. First, there are structural barriers in access to contraceptives and family planning providers at the institutional level. A visit with an appropriate provider and prescription contraceptives are quite expensive and not covered by some insurances. Although legislation, including expansions to Medicaid and Title X, have improved access, family planning services are still limited in certain populations (Dehlendorf et al. 2018). Half of reproductive-aged women are in need of publicly funded services and only half of them actually receive them (Dehlendorf et al. 2018). Greater percentages of minority women are uninsured and underinsured compared to whites and women with no insurance coverage are 30% less likely to use prescription contraception (Dehlendorf et al. 2018). Thus, cost and lack of coverage are significant structural barriers that prevent minority women from accessing birth control, contributing to their higher incidences of unintended pregnancy. Another institutional issue is differential access to abortion. Access is affected by the fact that minority women may not be able to afford the cost of the procedure when it not covered by insurance. One institutional barrier is the Hyde amendment, which prohibits federal Medicaid funds from paying for abortion (Dehlendorf et al. 2018). This disproportionally affects racial minority groups and may contribute to more unintended pregnancies resulting in births. Minority populations may also come across a barrier in finding a location to perform the procedure as 87% of US counties do not have an abortion provider and it may be harder for minority women of lower SES status to travel (Dehlendorf et al. 2018). These barriers help account for the greater portion of births from unexpected pregnancies in minority populations.

The final issue at the institutional level that contributes to the disparities involves the education of women in reproductive knowledge. Studies have found that across all racial groups, women have low levels of understanding of all pregnancy prevention methods, especially hormonal contraceptives which they underestimate in effectiveness and overestimate their side effects (Anachebe et al. 2003). More specifically, black and Hispanic women had consistently lower contraception knowledge scores across all domains and greatly overestimated the effectiveness of the least effective birth control methods (Dehlendorf et al. 2018; Anachebe et al. 2003). This suggests that there is not only a flaw in the education and healthcare systems when it comes educating women on their reproductive health, but it disproportionately affects minority racial groups. Minority women also have more incorrect fears about side effects of hormonal birth control which increases apprehension and deters them from using highly effective methods (Haider et al. 2013). It is important to note that correct knowledge is associated with more effective use of contraception methods and therefore lack of knowledge about contraception in minority populations likely contributes to the higher rate of unintended pregnancy (Anachebe et al. 2003).

The issue of higher rates of unintended pregnancy in minority populations is multifaceted as there are many causes involving multiple processes that contribute to the disparities. While this is problematic in and of itself, it also means that there are many avenues that can be pursued to mediate this problem. One thing that could be accomplished first would be providing universal coverage for contraceptive methods will decrease unintended pregnancies for all women, especially those like many minority groups who do not currently have access. Efforts should be made to increase the access of the most effective contraceptives, such as hormonal methods, over ones that are more difficult to use effectively. Additionally, information about contraception should be provided in creative and accessible ways, keeping in mind the differences in worldviews and communication styles of cultural groups. There is failure in both the educational and healthcare institutions because they are inadequately informing women about hormonal contraception. Patient information about contraception is often at the reading level of high school or above in English, which means that many minorities, particularly those for whom English is their second language, may not be able to understand the information (Dehlendorf et al. 2018). In addition to increasing access and bettering education, there are ways that this problem can be amended by individual healthcare providers. Providers can also play a large role in amending the disparities. We should train our health care professionals to be multiculturally competent so that they can provide the best patient-centered care for all of their culturally diverse patients so that all women can have equal care and opportunity.

References

Anachebe, N. F., & Sutton, M. Y. (2003). Racial disparities in reproductive health outcomes. American Journal of Obstetrics and Gynecology, 188(4). doi:10.1067/mob.2003.245

Callegari, L. S., Zhao, X., Schwarz, E. B., Rosenfeld, E., Mor, M. K., & Borrero, S. (2017). Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans. American Journal of Obstetrics and Gynecology, 216(5). doi:10.1016/j.ajog.2016.12.178

Dehlendorf, C., Foster, D. G., Bocanegra, H. T., Brindis, C., Bradsberry, M., & Darney, P. (2011). Race, Ethnicity and Differences in Contraception Among Low-Income Women: Methods Received By Family PACT Clients, California, 2001-2007. Perspectives on Sexual and Reproductive Health, 43(3), 181-187. doi:10.1363/4318111

Dehlendorf, C., Henderson, J. T., Vittinghoff, E., Steinauer, J., & Hessler, D. (2018). Development of a patient-reported measure of the interpersonal quality of family planning care. Contraception, 97(1), 34-40. doi:10.1016/j.contraception.2017.09.005

Haider, S., Stoffel, C., Donenberg, G., & Geller, S. (2013). Reproductive Health Disparities: A Focus on Family Planning and Prevention among Minority Women and Adolescents. Global Advances in Health and Medicine, 2(5), 94-99. doi:10.7453/gahmj.2013.056

Rocca, C. H., & Harper, C. C. (2012). Do Racial and Ethnic Differences in Contraceptive Attitudes and Knowledge Explain Disparities In Method Use? Perspectives on Sexual and Reproductive Health, 44(3), 150-158. doi:10.1363/4415012