Disparities in Contraceptive Care

As providers who work in Harlem, caring for many women of reproductive age, we have been troubled by the difficulties we see in our patients’ efforts to succeed in using contraception. This brought us to think about Sankofa—the West African (Akan) symbol representing the importance of examining the lessons of our past in order to reach the full potential of our future. To eliminate health disparities in reproductive health, we must work to understand their history. In this article, we aim to investigate the social, economic, and cultural influences that affect reproductive health, and our role as providers in helping patients overcome barriers.

The cases described below provide a glimpse into two patients’ lives and the varying influences on their contraception choices.

Case #1

Ms. B.G. is a 43-year old African American woman with hypertension who came into our community health center with misgivings about her current contraceptive method. She had recently been switched from combined oral contraceptive pills to progestin-only pills because of her blood pressure. She was frustrated with the side effect of irregular uterine bleeding. The spotting bothered her and negatively affected her sex life, but she and her partner did not want to risk a late-life pregnancy. In her 20s, after the birth of her three children, she had repeatedly sought a tubal ligation as she had borne all of the children she wanted in life. Her request was denied because she was “too young.” In our discussion, Ms. B.G. refused to even talk about an intrauterine device (IUD), as she was against anything that would need to be inserted into her “female parts.” She and her partner had discussed a vasectomy, but he had not agreed to this. Her best friend had recently gotten the subdermal implant, Nexplanon, so she asked me [VW] for more information about it.

Case #2

Ms. L.S. is a 19-year-old college student in Manhattan. I [GB] met her during a group contraception visit at her school. She is a second-generation Puerto Rican American and is the first person in her family to go to college. She wants to be a lawyer. She told me that she recently started having sex with her boyfriend of three years and has never been on birth control. She comes from a big family and never wants children. She requests birth control that will not affect her periods because her mother monitors her pads at home. She heard “the IUD hurts and can rupture your uterus.” Her aunt told her that the implant in your arm is a bad idea because she had trouble getting hers removed in the past. The pastor in her church says that emergency contraception is like having an abortion. She felt very bad about having sex before marriage and definitely did not want to get pregnant.

Figure 1.

Influences on contraception decision-making.

Reproductive Health Disparities—The Facts

The Guttmatcher Institute reports wide differences in the rates of unintended pregnancy, abortion, and unplanned births based on the race and ethnicity of U.S. women of reproductive age (see Figure 1).¹

Specifically, contraception care statistics demonstrate:

• 83% of Black women at risk of unintended pregnancy (i.e., having sex with men when not purposely trying to conceive) currently use a contraceptive method, in comparison to 91% of their Hispanic and White peers and 90% of Asian women.²

• 92% percent of women at risk of unintended pregnancy with incomes of 300% or more of the federal poverty level are currently using contraceptives, compared with 89% among those living at 0–149% of the poverty line.²

• Female sterilization is most common among Blacks and Hispanics, women living below 150% of the federal poverty level, women with less than a college education, and women that are publicly insured or are uninsured.²

• Vasectomy prevalence Is highest among White men (9.1%) and lower among Blacks (2.4%), Hispanics (2.1%), and men reporting themselves as belonging to another race/ethnicity...