Cultural and historical context

Although the epidemiology of family planning disparities is similar to disparities in other areas of health, with poor and minority women experiencing worse outcomes, the unique historical and cultural context of family planning provides added complexity. Specifically, consideration of disparities in unintended pregnancy and adolescent pregnancy requires consideration of a broad range of social and cultural issues, ranging from sexuality to attitudes toward pregnancy to sex relations to beliefs about contraception and abortion. In addition, although disparities in undesired fertility are the focus of this review, it is essential to acknowledge that disparities in access to desired fertility have and continue to play an important role in the issue of family planning disparities. The historical relationship between discriminatory beliefs toward poor and minority populations and some family planning programs and policies, including the nonconsensual sterilization of mentally ill, poor, minority, and immigrant women and coercive family planning programs, affects the relationship between these communities and family planning providers. In fact, coercion around family planning has never receded completely to the background, as evidenced by controversy over recent programs in which specific populations were paid to use highly effective contraceptive methods. Furthermore, decisions about childbearing in the United States occur in a social and economic context in which vast differences in resources to devote to child rearing exist. The family planning experiences of disadvantaged women are inevitably affected by these inequities. Attention to the unique personal, historical, economic and cultural context in which family planning decisions and outcomes occur is an indispensable consideration in promoting reproductive health for all women.

Disparities in family planning outcomes

All adverse family planning outcomes–unintended pregnancy, unintended births, abortions, and teen pregnancies–occur more commonly among minority and low socioeconomic status (SES) women. Although how best to measure unintended pregnancy is debated in the literature, with concern that standard survey questions used may not adequately assess intention, and with some evidence that this construct may have variable meanings across cultural and socioeconomic groups, the National Survey of Family Growth provides the most commonly used data on this subject. The most recent of these surveys found that approximately 69% of pregnancies among black women and 54% among Hispanics were unintended, compared with 40% among white women. Having low income and lower levels of education (the most commonly used measures of SES) were also associated with increased risk for unintended pregnancies, with 62% of pregnancies being unintended among those earning <100% of the Federal Poverty Level (FPL), compared to 38% of pregnancies in those earning >200% of the FPL. As race/ethnicity and SES are often correlated in the United States, whether these demographic factors are independently related to unintended pregnancies has also been investigated. Race/ethnicity was found to be a predictor of unintended pregnancies even within each income group, and having a lower income was found to be a predictor of unintended pregnancies within each racial/ethnic group.

This higher rate of unintended pregnancies among minority and lower income women results in higher rates of both unintended births and abortions. Births to both Hispanic and black women as well as to women with lower levels of education are more likely to be reported as unintended, and these differences have increased over time. Abortion rates are also strikingly different across racial/ethnic and SES categories; in 2000 black women had a rate of 49 per 1000, Hispanic women 33 per 1000 women of reproductive age, and women with an income of <100% of the FPL 44 per 1000. In contrast, the rate for both white women and women earning >200% of the FPL was only 13 per 1000. Between 1994-2000, the proportion of women having abortions who were low SES or minority women increased markedly.

Although rates of adolescent childbirth have been decreasing in the United States over the past few decades, significant disparities by both race/ethnicity and SES persist. In 2005, the birth rate in women between the ages of 15-19 years was 26 per 1000 among whites, whereas the equivalent rates among blacks and Hispanics were 61 per 1000 and 82 per 1000. Adolescent childbirth has been an issue for Hispanics in particular, as this group has both the highest overall rate and the smallest decrease over the past 15 years. Lower SES has also been shown to be associated with earlier initiation of sexual intercourse and with adolescent pregnancy and childbirth.

Disparities in family planning outcomes are related to disparities in patterns of contraceptive use

Given the consistent finding that race/ethnicity and SES factors are associated with higher levels of unwanted fertility, it is not surprising to find that studies have found strong relationships between these demographic factors and less effective use of contraception. There is evidence that minority and low SES women are less likely to use contraception overall, use different contraceptive methods, and have higher rates of contraceptive failure than white and higher SES women.

The 2002 National Survey of Family Growth found that, of women at risk for unintended pregnancy, 9% of whites, 12% of Hispanics, and 15% of blacks did not use contraception. With respect to income, 12% of women earning <150% of the FPL were not using contraception, compared to 9% of those earning >300% of the FPL. Between 1995-2002 (the last data available), the gaps in contraceptive use between poor and nonpoor women and minority and white women increased.

Studies have also found that different demographic groups choose to use different methods of contraception. Although approximately equal percentages in each racial/ethnic group rely on sterilization, the distribution between male and female sterilization is quite different. Black and Hispanic women are more likely to use female sterilization, with 22% and 20% of sexually active women in these racial/ethnic groups using this method. In contrast, only 16% of white women depend on female sterilization. This pattern is reversed for male sterilization, with 8% of white women relying on male sterilization for birth control, compared to 1% and 3% of black and Hispanic women. Other differences in method choice include that black and Hispanic women are more likely to use the contraceptive injection and condoms, and white women are more likely to use oral contraceptives. With increasing levels of education, women are also more likely to use oral contraceptives, and less likely to rely on female sterilization. Although the overall effect of these differences in contraceptive methods on the risk of unintended pregnancies by race/ethnicity and SES is difficult to determine, the higher rate of use of lower effectiveness barrier methods by black and Hispanic women may shift the overall effect of method choice to increased risk among minority women, whereas the effect by SES is less clear.

Additional studies have identified that even when using the same method of contraception, minority and poor women experience higher rates of method failure and discontinuation. For example, analyses of the National Survey of Family Growth have found that 14% of those earning <100% of the FPL experience a pregnancy in the first year of oral contraceptive use, compared to 5% of those earning >250% of the FPL. Similar findings were noted by race/ethnicity and across different contraceptive methods.

In summary, minority and low SES women are at increased risk of experiencing unintended pregnancies, and its consequences of unplanned birth and abortion, as well as teen pregnancy. Differences in contraception choices and use of contraception likely explain some of these differences in undesired fertility.