The Conception of Coverage

Contraceptive options for women often vary based on their socioeconomic status. Some of this variance can be explained by the unwillingness of some providers to prescribe intrauterine contraception to low SES women.

are well documented.  The role of provider bias in perpetuating disparities is an area of ongoing research.  Contrary to other areas of medicine, contraceptive management involves not only consideration of clinically appropriate options but also patients’ personal preferences.

This study sought to determine if race, ethnicity, or socioeconomic status (SES) affect provider recommendations for intrauterine contraception (IUC; commonly the intrauterine device, IUD).  Using standardized patients, three women portrayed patients that varied by race and ethnicity (White, Black, or Latina), SES (low or upper-middle class), and gynecological history (one with no perceived risk factors and two with perceived risk factors – (1) never pregnant and (2) history of pelvic inflammatory disease). Both the high SES and low SES patients were portrayed by the same actress within each racial/ethnic category.

Videos of the standardized patients were shown to healthcare providers recruited from professional society meetings of family medicine and obstetrics and gynecology.  Each provider was told that the patient was 27-years-old, had normal blood pressure, had a recent negative test for sexually transmitted illnesses (STIs) and a normal Pap smear, was in a monogamous relationship, did not want to become pregnant for several years, and had insurance coverage for all contraceptive methods. Each of the 524 providers was randomly assigned to one situation and then completed a survey which included ranking their recommendations for several methods of contraception.

In considering the patients with no perceived risks, providers were less likely to recommend IUC to low SES women than to high SES women (57 percent versus 75 percent, p=0.01).  Black women were significantly more likely to have IUC recommended compared to white women (75 percent versus 57 percent, p=0.04). Recommendations between Latina and White women showed no difference.   Amongst White women, providers were less likely to recommend IUC to low SES women than to high SES women (p=0.01). The same trend was found amongst Black women (p=0.04).

Amongst low SES women, providers were more likely to recommend IUC to Black and Latina patients than to White women (p=0.4 and p=0.3, respectively), although there were no significant difference amongst high SES women.

The authors concluded that race, ethnicity, and SES did play a role in IUC recommendations. They also suggested that epidemiological evidence or clinical experience might result in “statistical discrimination” whereby the appropriate individualization of care is hindered.  They considered as a limitation that providers would be less likely to recommend IUC to low SES women because of concern about insurance, though they considered this unlikely.

Commentary

Nearly half of all pregnancies in the United States are unintended, with a higher percentage amongst low SES women than high SES women.  Unintended pregnancies often precede abortion. A previous study showed increases in contraceptive use, particularly IUCs, when insurance companies covered contraception under state mandate.  Can equitable contraceptive coverage decrease disparities in unintended pregnancies?

Proponents of contraception coverage are advocating its placement on the list of required preventive services under healthcare reform law.  The Health Resources and Services Administration has been directed to draft a guideline addressing family planning which would be included in the Women’s Health Amendment.  Without insurance, a woman’s contraceptive decision is highly based on affordability rather than pregnancy prevention effectiveness.  IUC, which approaches 100% effectiveness, ranges in price from $150 – $500.  While equitable coverage would likely not eradicate provider bias, it would offer currently unaffordable, highly effective options for groups at risk for unintended pregnancy.  Increasing these options will prove both financially and socially beneficial.

Unfortunately, this study demonstrates that bias goes well beyond equitable insurance coverage. Including contraception coverage in the Women’s Health Amendment would put low SES women one step closer to receiving the care they deserve.  In the coming months, regulators will decide if all women, regardless of SES, deserve the same opportunities for effective family planning.  Amongst other things, this will provide great insight to the nation’s commitment to its goals of reducing unintended pregnancies and abortion.

Dehlendorf C, Ruskin R, Grumbach K, et al. Recommendations for Intrauterine Contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status. Am J Obstet Gynecol. 2010. 203 (4): 319.e1-8.

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Renée Volny, DO, MBA