https://orcid.org/0000-0002-9888-4304
Figures
Abstract
While many frameworks exist for building person-centered and equitable systems of contraceptive care, evidence indicates that the reality of patients’ experiences of care is often not in alignment with these ideals. Historical and current contexts of racism in the healthcare system contribute to negative perceptions and experiences of care, as well as reduced care-seeking behavior, for those who identify as Black, Indigenous, and people of color (BIPOC). Our objective in this analysis is to examine whether people’s past experiences of contraceptive care are a driver of subsequent barriers to contraceptive access, and whether this relationship differs across racial and ethnic identity. We draw on panel data from five waves of surveys collected between 2018–2023 among patients ages fifteen and older seeking family planning care at sites that receive public funding for these services in Arizona, Iowa, and Wisconsin. Overall and stratified by race/ethnicity, we examine cross-sectional and longitudinal associations between patients’ experiences of high-quality, person-centered contraceptive care and three contraceptive access outcomes: use of preferred contraception, satisfaction with contraceptive method, and experience of no barriers to accessing preferred contraception. We find longitudinal associations between patients experiencing higher-quality, more person-centered contraceptive care and subsequent satisfaction with contraceptive methods. Among non-Hispanic white-identifying patients, we find similar associations between shifting to higher-quality contraceptive care and use of preferred contraception, but we find no statistical relationship between experiencing higher-quality care and subsequent contraceptive outcomes for patients who identify as Black, Indigenous, or Person of Color (BIPOC). Highlighting the dissonance between clinical guidance for quality contraceptive care and patient experiences of care, and especially whether similar experiences across racial and ethnic identity lead to differential outcomes, is a crucial step toward bringing contraceptive care systems into alignment with principles of sexual and reproductive health equity.
Citation: Kavanaugh ML, Haas M, Douglas-Hall A (2024) Differential associations between experiences of contraceptive care and subsequent contraceptive access and preferences among family planning patients by racial and ethnic identity: Evidence from Arizona, Iowa, and Wisconsin. PLoS ONE 19(10): e0312111. https://doi.org/10.1371/journal.pone.0312111
Editor: Doris Verónica Ortega-Altamirano, National Institute of Public Health: Instituto Nacional de Salud Publica, MEXICO
Received: December 15, 2023; Accepted: September 27, 2024; Published: October 11, 2024
Copyright: © 2024 Kavanaugh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because data contain potentially identifying or sensitive patient information. Data will be made available by the Guttmacher Institute to researchers who meet the criteria for access to confidential data (contact via the Research Management Team at rmt@guttmacher.org).
Funding: This study was made possible by a grant to the Guttmacher Institute from an anonymous donor and the William and Flora Hewlett Foundation (MK, Award #2017-6247). The findings and conclusions in this article are those of the authors and do not necessarily reflect the positions and policies of the donor. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Reproductive autonomy, or the ability to be fully empowered in reproductive decisions and to access reproductive health services without interference or coercion, requires access to desired contraceptive care [1, 2]. Contraceptive care should be high quality, equitable, and accessible to all those who need and want it, and it should be built from a framework that considers an individual’s community, family, health systems, and socio-economic contexts [3, 4]. Person-centered care, or care that prioritizes a person’s lived experiences, desires, and reproductive autonomy, is identified as an essential domain of health care quality by the National Academies of Medicine [5]. Healthcare systems realize sexual and reproductive health equity when they are aligned with principles of person-centered care and are built to ensure that all people, regardless of age, race, sex, gender and other intersectional identities, have what they need to achieve their highest level of sexual and reproductive health and well-being [6].
While many frameworks exist for imagining these person-centered and equitable systems of contraceptive care, evidence indicates that the reality of patients’ experiences of care is often not in alignment with these ideals. Historical and current contexts of racism, reproductive coercion, and abuse of individuals who identify as Black, Indigenous, and people of color (BIPOC) within the healthcare system contribute to negative perceptions and experiences of care, as well as reduced care-seeking behavior [2, 7–10]. Evidence indicates that patient characteristics, particularly race and class, are associated with the type and quality of family planning services received; providers disproportionately recommend long-acting reversible contraception to low-income women of color, regardless of their contraceptive preferences [11], and low-income Black and Latina women report higher levels of discrimination within contraceptive counseling discussions than their middle-income, white counterparts [7]. While around 65% of sexually active women aged 18–49 are using contraceptives, only about 40% of them report having received person-centered contraceptive care, and only 30% report having all the information they needed to choose a method [12]. Uninsured women and those identifying as non-Hispanic Black, Spanish-speaking Hispanic, and non-Hispanic other or multiple racial identities report lower levels of person-centered contraceptive care than their insured and non-Hispanic white counterparts, respectively [12, 13].
In addition to differential experiences of contraceptive care, inequities in access to this care, including realization of contraceptive preferences, persist. Nationally, 23% of contraceptive method users and 39% of people not using a method would prefer to use a different method if cost was not an issue [14]; experiences of person-centered contraceptive counseling reduce the odds of reporting unfulfilled contraceptive preferences [14]. More broadly, 25% of contraceptive method users aren’t using their preferred method; reasons for this vary by ethnicity, income, and age [12]. Misalignment of contraceptive preferences and actual contraceptive use is associated with discontinued method use and pregnancy [15].
Highlighting the dissonance between clinical guidance for quality contraceptive care and patient experiences of care is a crucial step toward bringing contraceptive care systems into alignment with the principles of sexual and reproductive health equity. This is especially the case with regards to these systems valuing and supporting everyone justly and fairly to attain their highest level of sexual and reproductive health [6]. To move in this direction, we need to understand whether people’s past experiences of care are a driver of subsequent barriers to access, and whether this relationship differs across axes of identity. Much of the existing literature examining the interplay between these two research domains—contraceptive care experiences and realization of contraceptive preferences—is comprised of qualitative studies and cross-sectional analyses of survey data [16, 17]. Our analysis draws on a unique panel dataset of family planning patients to examine whether experiences of contraceptive care are associated with subsequent realization of contraceptive preferences and, given broad evidence on poorer experiences of contraceptive care among BIPOC individuals compared to those identifying as white, whether this relationship differs according to racial and ethnic identity. We hypothesized that more positive contraceptive care experiences would lead to fewer barriers to attaining contraceptive care and greater use of preferred contraceptive methods over time and that this pathway would differ according to racial and ethnic identity.
Methods
Data
For this analysis, we drew on longitudinal survey data collected under a larger research initiative called the Reproductive Health Impact Study (RHIS), a multistate, multiyear effort to document the impact of policy changes on the publicly funded family planning health care system and on those who rely on it for care [18]. We drew on panel data from five waves of the RHIS Family Planning Clinic Patient Surveys which, at baseline, are representative of patients ages fifteen and older seeking family planning care at sites that receive public funding for these services in Arizona (AZ), Iowa (IA), and Wisconsin (WI). The nonpartisan and objective research organization NORC at the University of Chicago (formerly called the National Opinion Research Center) managed all electronic data collection for these surveys. More detail on sampling and data collection protocols for these baseline surveys has been published elsewhere [19].
All study participants initially provided verbal consent to receiving information about the study at baseline. For all web-based surveys, the first screen presented prior to entering the electronic survey included a statement of informed consent. In order to officially proceed to initiate the survey, respondents pressed a submit button. This passive consent is the field standard for most web surveys for Federal and Non-Federal patients [20]. Participants of all ages in the study, including minors ages 15–17, followed this process. Federal guidelines allow for minor adolescents who receive family planning services to do so without the consent of a parent; thus, the IRB deemed minors obtaining family planning services in this study as capable of consenting to complete a questionnaire.
Seventy-one percent of the 6,074 respondents who completed the baseline surveys in these three states agreed to be contacted for subsequent, biannual follow-up surveys during the following 24 months. NORC sent a survey link in the mail and/or via email to those who opted to participate in these longitudinal surveys. NORC offered respondents incentives, starting at $15 total at baseline and increasing by $5 with each follow-up survey. Incentives were paid mainly through Amazon gift codes after survey completion, however, NORC sent an initial $5 cash pre-incentive to those invited to participate by mail for each follow-up survey. All survey instruments included questions about contraceptive use and satisfaction, sexual and reproductive health care use and access, and demographic information, among other foci. NORC formatted the follow-up surveys to be accessible online on the secure Voxco platform; respondents took approximately 10–15 minutes to complete.
This analysis includes data from the baseline through 24-month follow-up surveys. Iowa data cover the period of May 2018 through February 2021, Arizona data cover the period of May 2019 through January 2022, and Wisconsin data cover the period from June 2020 to August 2023. Data are weighted to reflect the universe of patients served at publicly funded family planning centers in 2018 (Iowa and Arizona) or in 2020 (Wisconsin) [21].
Our and our data management partner’s Institutional Review Boards (DHHS identifier IRB00002197) approved all study protocols for the Family Planning Clinic Patient Surveys.
Measures
Our analytic sample comprises pooled data from respondents across the three states. Given our overall research question to understand the sequential relationship between contraceptive care experiences and subsequent contraceptive access and preferences, we limit eligibility for our analysis to baseline survey respondents who received contraceptive services at least once in the year prior to baseline survey completion. We conduct analyses with both this full baseline sample and with a longitudinal sample that further limits eligibility to respondents who completed at least one follow-up survey. The longitudinal sample represents an unbalanced panel, with 53% completing all five rounds of data collection and the rest participating in two to four rounds.
We considered contraceptive care experiences as our key independent variable. To reflect quality of contraceptive care experiences, we used the Person-Centered Contraceptive Counseling (PCCC) metric, a validated 4-item measure in which respondents rate the healthcare provider they saw most recently for birth control-related services with regards to four key aspects of care [22]. These include: “Respecting me as a person,” “Letting me say what mattered to me about my birth control method,” “Taking my preferences about my birth control seriously,” and “Giving me enough information to make the best decision about my birth control method.” Each of the items is rated on a 5-point likert scale from “Poor” to “Excellent”, and the final PCCC score is calculated as the percentage of respondents who gave a top score (“Excellent”) on all four items. We operationalized the final measure in this way to align with published guidance on using it for analytic purposes and to account for the skewedness toward positive scores found in many patient satisfaction and experience measures [23, 24].
We examined three key outcomes representing access to contraception in this analysis, including use of preferred contraception, satisfaction with contraceptive methods used, and experience of no barriers to realizing contraceptive preferences. We determined use of a preferred method among all respondents—both contraceptive users and nonusers—at all survey timepoints (except for IA baseline) by responses to the question “If you could use any birth control method you wanted, what method(s) would you use?,” with options including “I’m using the method that I want to use” followed by a list of contraceptive methods and an open-ended option. We consider both users and nonusers who indicated "I am using the method that I want to use" to be using their preferred contraception, including not using a method if that is the stated preference. To assess satisfaction with current method(s), respondents who reported current contraceptive method use in the three months prior to each of the survey time points rated how satisfied they were with their current birth control method on a 5-point likert scale from 1 (Very satisfied) to 5 (Very unsatisfied). We recoded responses into a binary variable, grouping very and somewhat satisfied into the satisfied category and the remaining three categories into not satisfied. To assess experiences of no barriers to realizing contraceptive preferences, all respondents indicated if they had “delayed or had trouble getting the birth control method [they] wanted for any reason” in the last 12 months in the baseline survey. This question was asked only of contraceptive users in the AZ and WI 6-month follow-up and in all other subsequent follow-up surveys across states at 12, 18, and 24 months. We considered responses of “no” to represent experiencing no barriers to preferred contraception.
We included several variables describing the study population at baseline including age, household income as a percentage of the federal poverty level, ethnicity, race, sexual and gender minority status, educational attainment, employment level, relationship status, nativity to the U.S., and health insurance coverage. Respondents reported their ethnicity as identifying as either “Hispanic, Latina or Latinx” or “none of these,” with "Hispanic" primarily being associated with having a Spanish-speaking origin, whereas "Latino" and "Latinx" being associated with broader categories encompassing people of Latin American descent, and "Latinx" being a gender-neutral option. We determined racial identity of respondents based on responses to the baseline survey question “which one or more of the following best describes your race?” with options to choose one or more of the following: Black or African American, white, Asian or Asian American, Native American, Alaska Native, or American Indian, Native Hawaiian or Pacific Islander, and an open-ended box for respondents to write-in other racial identities. During analysis we created an additional “multiracial” category to capture all respondents who reported more than one racial identity. For analytic purposes, due to smaller percentages of some racial identities in the sample, we also created two additional variables that condensed racial identity into either four categories (Black/African American; white; Asian or Asian American or Pacific Islander (AAPI), Native, or Other; and Multiracial) or two categories (BIPOC vs. Non-Hispanic white). We determined this latter categorization of the binary BIPOC variable based on responses to both the ethnicity and racial identity questions.
Analytic strategy
We first conducted descriptive analyses of our sample. We then examined cross-sectional associations between our key independent variable and each of our three outcome variables via logistic regression, adjusting for respondent characteristics, all drawing on baseline data from across the three states. We then examined changes in our key variables over time, including chi-square tests to determine whether each of these changed significantly over the full study period. We conceptualized changes in the variables as being “consistently yes” (respondents who indicated experiencing the outcome at every time point for which we had data, e.g., respondents who reported experiencing high quality contraceptive care at every time point), “consistently no” (respondents who indicated not experiencing the outcome at every time point for which we had data, e.g., respondents who did not use their preferred method at any time point), “any change from yes to no” (respondents who indicated “yes” on an outcome in an earlier survey and “no” to the same outcome in any later survey for which we had data, e.g., respondents who were satisfied with their method at baseline, but were dissatisfied with their method at any subsequent time point) and “any change from no to maintenance of yes” (respondents who indicated “no” on an outcome in an earlier survey and “yes” to the same outcome in every subsequent survey for which we had data, e.g., respondents who had delays/trouble getting preferred method at baseline, but no delays/trouble at any subsequent time point).
Finally, we estimated conditional logistic regression models that controlled for observed (measured within datasets) and unobserved (not measured) non-changing characteristics within individuals to examine fixed effects of the experience of contraceptive care (measured by the PCCC) on the three outcomes (use of preferred contraceptive method, satisfaction with contraceptive method used, and no barriers to accessing preferred contraception). In each model, we adjusted for key time-varying sociodemographic variables that have been linked to contraceptive access in other research: sexual and gender minority status, employment, relationship status, and health insurance coverage. We ran each of the three models overall and, given baseline cross-sectional differences in two of the outcomes by racial/ethnic identity (use of preferred method and satisfaction with method used), we also ran each model stratified by the binary race/ethnicity identity variable. We use the binary version of the race/ethnicity identity variable in all multivariable models given small numbers of respondents identifying as a race/ethnic group besides non-Hispanic white. We lagged the PCCC measure in our final model examining the relationship between the receipt of quality contraceptive care and no barriers to accessing preferred contraception to ensure that the timeframe covered by this key independent variable preceded that of the outcome. For all models, we present adjusted odds ratios, 95% confidence intervals, and p values; we highlight findings in which associations between predictors and outcomes are significant at the p<0.05 level. We based all analyses on weighted data and we used the svy command in Stata 18.0 to account for the complex sampling designs.
Findings
We present characteristics of the analytic sample of family planning patients in Arizona, Iowa, and Wisconsin who reported receiving recent contraceptive care during baseline surveys, as well as characteristics of the narrower sample who also completed at least one follow-up survey, in Table 1. For both these samples, the majority of these patients were ages 20–29, had incomes at 200% or more of the federal poverty level, had at least some college or associate degree, were employed for wages, and had some form of health insurance. A majority also identified as non-Hispanic, white, having been born in the U.S., as straight, and cisgender, while about half reported not living with a romantic partner nor being married. The majority of the sample indicated using some form of contraception (90%, unweighted N = 2797). At baseline, 66% (unweighted N = 2046) indicated that their recent contraceptive care had been person-centered. When examining racial differences in experiences of quality care, patients identifying as white reported higher baseline levels on each of the four domains of the PCCC (between 3–7 percentage points) than those identifying as BIPOC (not shown).
We present cross-sectional associations between the key independent variables of contraceptive care experiences, racial identity (four category variable), ethnicity, and three outcomes representing contraceptive access in Table 2. Adjusting for respondent demographics, at baseline those who reported receiving recent person-centered contraceptive care had higher adjusted odds of using a preferred method of contraception (aOR = 1.9, CI = 1.3–2.6), satisfaction with their method (aOR = 1.7, CI = 1.2–2.4), and experiencing no delays or trouble in realizing their contraceptive preferences (aOR = 2.0, CI = 1.5–2.7).
In adjusted models assessing the cross-sectional relationships between experiences of care and the outcomes of preferred contraceptive use and satisfaction with contraception, we found associations between respondents’ racial and ethnic identity and both of these outcomes. Specifically, when comparing to patients identifying as white, those identifying as AAPI, Native, or other race reported higher levels of preferred contraceptive use (aOR = 2.7, CI = 1–7.2) and those identifying as multiracial reported marginally higher levels of satisfaction with their current methods (aOR = 1.7, CI = 0.9–3). Compared to patients identifying as non-Hispanic, those identifying as Hispanic reported lower levels of preferred contraceptive use (aOR = 0.6, CI = 0.3–0.9) as well as lower levels of satisfaction with their current methods (aOR = 0.5, CI = 0.4–0.8).
Given the cross-sectional associations found between patients’ experiences of contraceptive care and the key outcomes, we present changes in these experiences and outcomes over time, overall and by racial and ethnic identity, in Table 3. Most patients reported receiving consistent person-centered contraceptive care (53%, unweighted N = 914), being consistently satisfied with their contraceptive method (65%, unweighted N = 1102), and consistently experiencing no delays or barriers to their preferred contraception (62%, unweighted N = 1131) across timepoints, with non-Hispanic white-identifying respondents having slightly higher levels of consistent use of preferred methods and satisfaction with methods than BIPOC respondents and BIPOC respondents having consistently higher levels of receiving high-quality care than non-Hispanic white respondents. Almost one-fifth of respondents (19%, unweighted N = 349) reported receiving consistently lower-quality, or non-person-centered care, and non-Hispanic white respondents reported slightly lower levels of this consistent lower quality care than BIPOC respondents (17%, unweighted N = 159; and 20%, unweighted N = 187, respectively). A smaller percentage of respondents indicated experiencing shifts towards more negative experiences and outcomes over time, with 17% (unweighted N = 327) indicating that they experienced a shift from high-quality to lower-quality care at any time over the study period, 42% (unweighted N = 694) indicating that they shifted from using to not using their preferred contraception, 18% (unweighted N = 333) indicating that they shifted from being satisfied to not being satisfied with their contraceptive method, and 28% (unweighted N = 476) indicating that they shifted from not experiencing barriers to their preferred contraception to experiencing these barriers over time. We observe that BIPOC respondents more commonly reported these negative shifts over time in use of preferred contraception and satisfaction with method use and less commonly reported shifts towards less high-quality care than did non-Hispanic white respondents. Less than 15% of respondents (unweighted N <229) indicated a positive shift from “no” to staying at “yes” on these experiences and outcomes over the study period. Slightly higher levels of BIPOC patients indicated this shift towards more positive outcomes of preferred use and satisfaction with methods than non-Hispanic white-identifying patients over time.
We present associations between changes in experiences of person-centered contraceptive counseling and subsequent changes in realization of contraceptive preferences, satisfaction with contraception, and no barriers to realizing contraceptive preferences as adjusted odds ratios in Table 4. After adjusting for all time-invariant sociodemographic characteristics as well as the time-varying variables of sexual and gender minority status, employment, relationship status, and insurance coverage status, those who changed from receiving less to more person-centered care had marginally increased adjusted odds of being satisfied with their contraceptive method (aOR = 1.9, CI = 1–3.7). Among the full study population, we detected no significant association between changes in experiences of contraceptive care and subsequent reports of realization of preferred method use or no delays or trouble realizing contraceptive preferences.
When stratifying the sample by race/ethnicity, among respondents who identify as non-Hispanic white, compared to those who did not experience a change in the quality of contraceptive care received over time, we find those who reported experiencing higher-quality contraceptive care over time had higher odds of subsequently using their preferred contraceptive method (aOR = 2.4, CI = 1.2–4.9) and marginally higher odds of being satisfied with their contraceptive method (aOR = 2.1, CI = 0.9–5.1). On the other hand, among respondents who identified as BIPOC, we find no statistically significant associations between changes in care experiences and these outcomes, although the pattern is in the same direction as with those who identify as non-Hispanic white.
Discussion
Individuals’ experiences of contraceptive care influence how, and whether, they are able to access their preferred contraception and, thus, realize this key aspect of reproductive autonomy. This study confirms that publicly supported family planning patients in Arizona, Iowa, and Wisconsin demonstrate similar cross-sectional relationships between contraceptive care experiences and access to contraception to what has been identified for broader and other populations in the literature. Our findings also highlight that experiencing higher-quality contraceptive care actually leads to subsequent greater satisfaction with one’s contraceptive method [14, 25]. We simultaneously find that the relationship between one’s experience of care and their subsequent contraceptive access outcomes differs based on their racial and ethnic identities. Specifically, those identifying as non-Hispanic white realize the benefit of person-centered contraceptive care on their preferred contraceptive use and satisfaction while their BIPOC-identifying peers do not.
Cross-sectional associations between patients’ experiences of contraceptive care, on one hand, and their ability to realize their contraceptive preferences with no barriers to access, on the other, are important findings that highlight the interconnectedness between these person-centered metrics. Our study, which shows a clear through line from the patient-provider encounter to patients’ subsequent reproductive autonomy, underscores the important role that health care providers play in their patients’ trajectory from care to subsequent contraceptive access. We show that positive experiences of contraceptive counseling yield person-centered positive outcomes, but potentially only for some patients. For patients identifying as BIPOC in our study, receiving high-quality contraceptive care did not necessarily lead to the same, strong association with positive outcomes that we could detect for their non-Hispanic white peers. This may indicate that there may be something different about the translation of person-centered contraceptive counseling into the realization of contraceptive preferences according to racial and ethnic identity.
At the national level, Black women report lower person-centered contraceptive counseling ratings on the specific item within the PCCC of their providers respecting them as a person compared to white women [26]. This variation of experiences in different aspects of the counseling interaction by racial identity, which respondents in our analysis mirrored, may help to explain some of the findings in our study. A wealth of literature documents that provider biases rooted in interpersonal racism, especially with regards to differential assumptions about motivations for contraceptive use or “best” methods to recommend based on (perceptions of) patients’ racial identities, can hamper individuals’ access to their preferred contraception, impeding their ability to realize full reproductive autonomy [10, 27]. Perceptions of mistrust of the broader contraceptive health care system, levels of which are higher among BIPOC individuals due, in part, to historical and ongoing experiences of discrimination and coercion within the U.S. medical system [28], are also linked to lower levels of contraceptive use [29] and preferences for less contact with a healthcare provider to access contraception [1]. To address these differential interpersonal experiences that patients in our study and others experience in the contraceptive encounter, greater emphasis on shared decision-making models that emphasize patients’ preferences and address historical inequities and medical racism is critical [30, 31]. For Black patients, especially, training all providers to address implicit bias and ensuring availability of providers of color to have more concordance between patient and provider backgrounds are two avenues for increasing positive experiences in the healthcare system [32, 33].
Beyond the clinical encounter between patients and providers, systems must be intentionally built and sustained to ensure that all people have what they need to achieve their highest level of sexual and reproductive well-being. These systems- and structural-level shifts are necessary to achieve sexual and reproductive health equity. Our study highlights that the publicly funded family planning care delivery systems in these three states may be falling short of SRHE goals when considering the role that contraceptive care delivery plays in helping people to realize their contraceptive preferences. This may especially be the case with regards to differences across patients’ racial and ethnic identities. U.S. federally supported family planning care via Title X, a federal grant program that provides dedicated funds for the delivery of sexual and reproductive healthcare and prioritizes coverage of care for patients based on their income and age, must follow established federal guidelines for delivering high-quality, equitable, and accessible care [34, 35]. Disruptions over the past several years due to changing regulations for the Title X program during the Trump administration and the COVID-19 pandemic have impeded progress in this area [36–38]. Fluctuating funding levels for the Title X system during this time period have not met the actual level of demand for restoring and building this system to fully realize its objectives [38]. Working to ensure that future funding levels for this program increase to reflect the breadth of patient and provider needs across the system, as well as ensuring that Title X regulations and the underlying statute promote comprehensive, medically sound and patient-centered care are not subject to fluctuating political support are key policy steps towards SRHE. The 2023 Black Reproductive Justice Policy Agenda, developed and endorsed by over 30 reproductive justice organizations, provides a comprehensive roadmap for embedding contraceptive equity within the larger ecosystem of reproductive justice [39]. Policy recommendations in the Agenda highlight the importance of intersectional systems- and structural-level solutions to combat both access barriers and the historical coercion of women of color within the contraceptive healthcare system, all of which are necessary strategies to move towards environments where trust between providers and their patients can be built.
Importantly, evidence indicates that people who are not linked to the health care system are likely those who experience the greatest barriers to accessing that care; our study is solely focused on those who already received contraceptive care and thus is likely not capturing those with the greatest access barriers. We hypothesize that this narrowing of the study population is a contributing factor to not identifying overall longitudinal associations with all of our access outcomes, as it is likely individuals who experience the greatest barriers to accessing care, who never make it to the family planning center, who realize the most significant consequences for subsequent contraceptive access over time. Given our focus on racial and ethnic identity in this analysis, and the large body of evidence regarding structural barriers to accessing healthcare among individuals identifying as BIPOC, focusing our stratified analyses only among those who had received recent contraceptive care likely underrepresents differences in contraceptive access across racial and ethnic identities. Future research should examine relationships between contraceptive experiences beyond the clinical context and subsequent contraceptive access outcomes to better capture perspectives of people not already linked to the contraceptive healthcare system.
While a key strength of our study is that we rely on panel data from a large sample of family planning patients, our study still has some important limitations. Key metrics of interest in our study do not change dramatically over the study period, likely because of the narrower focus on individuals who have already been linked into the healthcare system. Therefore, our ability to detect strong associations between how changes in our independent variables lead to changes in our dependent variables over time is limited. We did not explicitly power the broader RHIS clinic patient survey to examine differences in contraceptive access outcomes by race/ethnicity, so our findings stratified by racial and ethnic identity are likely a conservative representation of differentials in outcomes across these axes of identity. In addition, due to our collapsing of multiple racial and ethnic identities into one BIPOC category because of data limitations, we are unable to tease out how the findings documented in these analyses might differ across races and ethnicities. We would expect there to be differences given clear evidence that racism and coercion within the healthcare setting is differentially experienced by and perpetuated on people of color of different races [7, 8, 10, 40]. More research designed specifically to detect differences in these experiences by disaggregated racial identity is warranted.
Given evidence of substandard contraceptive care experiences and lower levels of access to care for other marginalized identities, such as queer, trans/nonbinary, and differently abled people [41, 42], there may be differentials in pathways from care to access along other intersecting axes of identities that this study was not equipped to pick up. Future research should examine how perceptions of trust and experiences of care track against each other over time, with attention to specific aspects of contact with the contraceptive healthcare system that serve as either bridges or barriers to ongoing high-quality care. Finally, two key events of relevance occurred during the study period and at differential timepoints during the fielding of surveys in each state—the 2019 Title X Final Rule and the COVID-19 global pandemic, each of which has been shown to have impacted both the delivery of family planning care as well as whether people were able to access contraception and related care during this time period. Teasing out the role of state context, and the unique or differential role that these specific events may have had on our study outcomes by state, is beyond the scope of this study.
Findings from these analyses can contribute to improved understanding of how to design equitable and person-centered systems for SRH care delivery. By highlighting the interconnectedness between patient experiences, preferences, and their subsequent access to SRH care, our findings highlight that inequities in care experiences lead to ongoing inequities in care access. Without high-quality contraceptive care, individuals are less able to realize their contraceptive preferences and overcome barriers to realizing these preferences. Addressing these inequities requires a focus on supporting providers to confront their own biases towards patients as well as building systems with a foundation of SRHE.
Acknowledgments
We thank Joerg Dreweke, Amy Friedrich-Karnik, Jennifer Frost, and Emma Stoskopf-Ehrlich of the Guttmacher Institute and Sheila Desai, Jamie Hart, and Lisa Stern from CECA for their review and feedback on this manuscript; several colleagues from NORC at the University of Chicago for electronic survey design support and programming; Rubina Hussain, Ellie Leong, Tamrin Lever, Mia Zolna, of the Guttmacher Institute, as well as Florby Dorme, Sean Finn, Christina Geddes, Anqa Khan, Lorraine Kwok, Ashley Little, Katrina MacFarlane, Rachel Murro, Zoe Pleasure and Emma Pliskin, formerly of the Guttmacher Institute, for research assistance. Finally, we extend our gratitude to the site administrators at our pretest and participating healthcare sites, as well as their patients, all of whom made this study possible.
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