Christine Dehlendorf

Disparities in family planning

Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider 3 factors that contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider-related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility.

Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems

Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient’s preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems.

Women's preferences for contraceptive counseling and decision making

BACKGROUND Little is known about what women value in their interactions with family planning providers and in decision making about contraception. STUDY DESIGN We conducted semistructured interviews with 42 black, white and Latina patients. Transcripts were coded using modified grounded theory. RESULTS While women wanted control over the ultimate selection of a method, most also wanted their provider to participate in the decision-making process in a way that emphasized the womens values and preferences. Women desired an intimate, friend-like relationship with their providers and also wanted to receive comprehensive information about options, particularly about side effects. More black and Spanish-speaking Latinas, as compared to whites and English-speaking Latinas, felt that providers should only share their opinion if it is elicited by a patient or if they make their rationale clear to the patient. CONCLUSION While, in the absence of medical contraindications, decision making about contraception has often been conceptualized as a womans autonomous decision, our data indicate that providers of contraceptive counseling can participate in the decision-making process within limits. Differences in preferences seen by race/ethnicity illustrate one example of the importance of individualizing counseling to match womens preferences.

Recommendations for Intrauterine Contraception: A Randomized Trial of the Effects of Patients’ Race/Ethnicity and Socioeconomic Status

OBJECTIVE Recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to health disparities. This study investigated the effect of these factors on recommendations for contraception. STUDY DESIGN One of 18 videos depicting patients of varying sociodemographic characteristics was shown to each of 524 health care providers. Providers indicated whether they would recommend levonorgestrel intrauterine contraception to the patient shown in the video. RESULTS Low socioeconomic status whites were less likely to have intrauterine contraception recommended than high socioeconomic status whites (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.06-0.69); whereas, socioeconomic status had no significant effect among Latinas and blacks. By race/ethnicity, low socioeconomic status Latinas and blacks were more likely to have intrauterine contraception recommended than low socioeconomic status whites (OR, 3.4; and 95% CI, 1.1-10.2 and OR, 3.1; 95% CI, 1.0-9.6, respectively), with no effect of race/ethnicity for high socioeconomic status patients. CONCLUSION Providers may have biases about intrauterine contraception or make assumptions about its use based on patient race/ethnicity and socioeconomic status.

Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use.

Improving the quality of contraceptive counseling is one strategy to prevent unintended pregnancy. We identify aspects of relational and task-oriented communication in family planning care that can assist providers in meeting their patients’ needs. Approaches to optimizing women’s experiences of contraceptive counseling include working to develop a close, trusting relationship with patients and using a shared decision-making approach that focuses on eliciting and responding to patient preferences. Providing counseling about side effects and using strategies to promote contraceptive continuation and adherence can also help optimize women’s use of contraception.

Racial/ethnic disparities in contraceptive use: Variation by age and women's reproductive experiences

OBJECTIVE Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a womans life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by womens age, parity, and history of unintended pregnancy. STUDY DESIGN We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy. RESULTS Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by womens age, with younger women having more prominent disparities. CONCLUSION Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.

Preferences for Decision-Making About Contraception and General Health Care Among Reproductive Age Women at an Abortion Clinic

OBJECTIVE Studies suggest that not all patients desire shared decision making, and little is known about decision making around contraception. This study compared decision-making preferences for contraception to preferences for general health among reproductive-aged women. METHODS 257 women receiving abortion care in an urban hospital completed a survey which included questions adapted from the Problem-Solving Decision-Making Scale about their preferences for medical decision making. RESULTS Women were significantly more likely to desire autonomous decision making about contraception than about their general health care (50% vs. 19%, p<.001). No patient characteristics were associated with contraceptive decision-making preferences. Women with Medicaid insurance were more likely to desire autonomous decision making about contraception than about general health care (51% vs. 17%, p<.001). CONCLUSION Women desire more autonomy in their contraceptive decisions than in their decisions about general health care. PRACTICE IMPLICATIONS Health care providers should be attentive to the existence of variation in preferences in decision making across health domains. Contraceptive providers should proactively assess decisional preferences to ensure the most appropriate counseling is provided to each individual.

Race, Ethnicity and Differences in Contraception Among Low-Income Women: Methods Received By Family PACT Clients, California, 2001–2007

CONTEXT The extent to which racial and ethnic differences in method choice are associated with financial barriers is unclear. Understanding these associations may provide insight into how to address racial and ethnic disparities in unintended pregnancy. METHODS Claims data from the California Family PACT program, which provides free family planning services to low-income residents, were used to determine the proportions of women receiving each type of contraceptive method in 2001-2007. Bivariate and multivariate analyses were performed to identify associations between womens race and ethnicity and the primary contraceptive method they received in 2007. RESULTS Compared with white women, blacks and Latinas were less likely to receive oral contraceptives (odds ratios, 0.4 and 0.6, respectively) and the contraceptive ring (0.7 and 0.5), and more likely to receive the injectable (1.6 and 1.4) and the patch (1.6 and 2.3). Black women were less likely than whites to receive the IUD (0.5), but more likely to receive barrier methods and emergency contraceptive pills (2.6); associations were similar, though weaker, for Latinas. Racial and ethnic disparities in receipt of effective methods declined between 2001 and 2005, largely because receipt of the patch (which was introduced in 2002) was higher among minority than white women. CONCLUSION Although Family PACT eliminates financial barriers to method choice, the methods women received differed substantially by race and ethnicity in this low-income population. The reduction in racial and ethnic disparities following introduction of the patch suggests that methods with novel characteristics may increase acceptability of contraceptives among minority women.

A Qualitative Analysis of Approaches To Contraceptive Counseling

CONTEXT Underuse and inconsistent use of contraceptives contribute to the continued high rate of unintended pregnancy in the United States. High-quality interaction between patient and provider about contraception is associated with improved contraceptive use, yet little is known about how providers support patients in the decision-making process. METHODS A random sample of 50 family planning visits by patients in the San Francisco Bay Area was selected from a larger sample of 342 audio-recorded visits to six clinics between 2009 and 2012. In qualitative analysis guided by grounded theory techniques, transcripts were assessed to determine counseling approaches and patterns in the use of these approaches. RESULTS Providers employed three counseling approaches: foreclosed (in 48% of visits), characterized by discussion of few contraceptive methods and method selection by the patient with no involvement from the provider; informed choice (30%), characterized by detailed description of multiple methods, but little or no interaction between the patient and the provider; and shared decision making (22%), characterized by the providers interactive and responsive participation with the patient in method selection. Use of these approaches varied by patients age: Women 25 or younger experienced the foreclosed approach more often than older women, and patients older than 35 were far more likely than their younger counterparts to experience the shared decision-making approach. CONCLUSIONS Most visits did not include interactive engagement between the patient and the provider. Contraceptive counseling interventions should encourage providers to responsively engage with patients of all ages to better meet their contraceptive needs.

Disparities in Abortion Rates: A Public Health Approach

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities. As efforts to restrict abortion will have no effect on these underlying factors, and instead will only result in more women experiencing later abortions or having an unintended childbirth, they are likely to result in worsening health disparities. We provide a review of the causes of abortion disparities and argue for a multifaceted public health approach to address them.