Women's race and class impact contraception recommendations, UCSF study shows

A woman’s race/ethnicity and socioeconomic status impact whether health care providers recommend one of the most highly effective forms of contraception, a UCSF study confirms. The results also indicate that the interaction of both factors plays a role in clinicians’ decisions. 

Recommendations by health care providers previously have been found to vary by patients’ race and socioeconomic status, contributing to health disparities, according to the researchers. The team investigated the effect of these factors on recommendations for contraception.

Study results appear in the October print edition of the American Journal of Obstetrics and Gynecology and are available online at http://www.ajog.org/article/S0002-9378(10)00578-8/fulltext. An editorial commenting on the study also is included in the Journal.

In the study, clinicians’ recommendations for intrauterine devices (IUDs), considered among the most effective forms of contraception, were affected by both the patient’s class and her race/ethnicity.

• Clinicians were less likely to recommend IUDs to white women of low socioeconomic status than to white women of high socioeconomic status.
• Socioeconomic status had no significant effect on recommendations for IUDs for Latinas and black women.
• But when the researchers evaluated the groups by race/ethnicity, clinicians were more likely to recommend IUDs to Latinas and black women of low socioeconomic status than to white women of low socioeconomic status.

“Understandably, people want simple answers but the complexity of the results is not surprising. We live in a complex world where race and class are intertwined, ” said Christine Dehlendorf, MD, MAS, assistant professor in the UCSF Department of Family and Community Medicine and the UCSF Department of Obstetrics, Gynecology & Reproductive Sciences. “Clinicians need to be cognizant of how their patients’ characteristics may influence the care they provide.”

In the study, one of 18 videos depicting patients with varying socioeconomic and racial characteristics was shown to 524 healthcare providers, who then were asked whether they would recommend an IUD to the patient. The study group was drawn from medical physicians, osteopathic physicians, nurse practitioners and physician assistants who attended meetings of professional societies of family medicine and gynecology.

Previous research on the effect of patient race/ethnicity and class on clinicians’ behaviors has focused on patient-provider interactions involving medical decisions about diseases, such as coronary artery disease, for which there is general consensus about appropriate treatments. Decisions about family planning, in contrast, involve multiple clinically appropriate options. The most effective choice may depend on a patient’s personal preference, the team states.

“Providing contraceptive services is a particularly sensitive area of health care, both because of the intimate nature of the discussion of sexual behavior and because of the historical relationship of efforts to promote contraception with attempts to limit the fertility of minority and poor women in the United States,” Dehlendorf said. “Family planning providers should work to ensure that they provide quality, patient-centered care to all women.”

The inconsistency in health care provider recommendations for such an effective contraception method suggests a need for further research into the influence of clinicians’ recommendations on family planning and ways to prevent the differences in care, she said.

The IUD, a small, plastic device that is inserted and left inside the uterus to prevent pregnancy, is more effective than most other forms of birth control, according to the American Congress of Obstetricians and Gynecologists.

“This is an especially important area of research given the high rate of unintended pregnancy in the US. It is critical that we provide comprehensive contraceptive counseling and equitable access to highly effective long-acting reversible contraceptives such as the IUD to all women,” said Jody Steinauer, MD, MAS, senior study author and associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

Co-authors are Rachel Ruskin, MD, of the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences; Kevin Grumbach, MD, of the UCSF Department of Family and Community Medicine; Eric Vittinghoff, PhD, of the UCSF Department of Epidemiology and Biostatistics; Kirsten Bibbins-Domingo, MD, PhD, of the UCSF Department of Epidemiology and Biostatistics and UCSF Department of Medicine; and Dean Schillinger, MD, of the UCSF Department of Medicine.

The study was funded by the Fellowship in Family Planning and by the National Institutes of Health. 

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