3/12/2016 Disclosures Addressing Disparities in We have no disclosures relevant to this talk Abortion & Contraception Acknowledgements Karen R Meckstroth, MD, MPH Clinical Professor, Obstetrics, Gynecology & R.S. to Andrea Jackson, MD Director, UCSF Women’s Options Center and & Christine Dehlendorf, MD, MAS Beth Harleman, MD for their research and slides Professor of Medicine and Obstetrics, Gynecology and R. S. Disparities for Women Objectives Less social and economic power At the end of this talk, you will be able to: � Lower income for similar work � Shoulder higher burden of unpaid and hidden work � � Help poor women navigate care for undesired Receive less preventative care for CVD pregnancies � Higher rates of depression � Higher risk of being uninsured � � Choose safe methods of contraception in women with medical illness Since women’s care often split (reproductive and � primary), higher risk of inadequate care. � Utilize a shared decision-making model for contraceptive counseling 1
3/12/2016 Case � Young woman, post-partum � My desire: to give her “highly effective” contraception Why I’m motivated… Unintended Pregnancy with Blacks & Hispanics have high Patch-Pill-Ring vs. LARC rates of unintended pregnancy Finer, LB. AJPH 2014 2
3/12/2016 Abortion rates mirror unintended pregnancy rates for ethnicity & SES Poor women are overrepresented Abortion stigma among abortion patients Women who have “A negative attribute abortions are often ascribed to women regarded as: who seek to terminate • Selfish • Promiscuous a pregnancy that • Irresponsible ‘marks’ them as • Heartless inferior to ideals of • Abnormal womanhood” 83% of abortions occur in women Women hide abortion < 300% of FPL Jones RK, et al, Characteristics of U.S. Abortion Patients, Guttmacher, 2014 Kumar et al 2009; Norris et al. 2011 3
3/12/2016 Dramatic increase in U.S. Restrictive abortion laws abortion restrictions disproportionately affect poor women � Travel, childcare, time off work � Poor girls more likely to live with one or neither parent � Public facilities affected by restrictive laws � Religious facilities often in poor communities � Default enrollment Legal status does not predict Restrictive U.S. abortion laws incidence worldwide # states � Physician-only 38 Rates per 1000 women aged 15-44 � Hospital-only after certain gestation 19 Western Europe � Facilities restrictions (TRAP laws) 26 Southern Africa North America � Funding restrictions 32 Eastern Asia Unsafe � No private insurance coverage 11 Central America Abortion Southeast Asia Eastern Africa � Parental involvement 38 Safe Abortion � Waiting periods (24-72 hrs) 28 Developed regions � State-mandated counseling of false info 17 Developing regions � Ultrasound viewing or listen to heart 21 World 0 10 20 30 40 Guttmacher Feb 2016 WHO 2014 & Lancet 2012 4
3/12/2016 The Hyde Amendment Effects of funding restrictions � Bans federal funding of abortion Evidence supports: � Only 17 states use state funds to pay for � Decreased rate of abortions abortions for women with Medicaid � Delay in access to abortion � Fewer abortion providers � Higher costs to gov’t social programs Studies suggest: � Rates of illegal abortions � Abortion complication rates � Pregnancy complications (PTD, low BWt) � Child abuse rates � Suicide rates Henshaw et al. Restrictions on Medicaid Funding for Abortions: Guttmacher Jun 2009 Reasons for delay in Medi-Cal (mis)information 2 nd -trimester patients Didn ’ t suspect pregnancy Calls to 30 county social services in CA: 34%* In denial about being pregnant 21%* � <21yo woman wants Medi-Cal for pregnancy Difficulty in getting to our clinic 63%* � 17% not in service or unanswered Initially referred to other clinic(s) 47%* � Frequent incorrect info: Difficulty figuring out where to go 20%* Difficulty with Medi-Cal, money, insurance 20%* � 53%: Must bring ID and citizenship docs Emotional factors 51% � 23%: Parents have to be involved Unsure of decision 30%* � 17% mentioned Minor Consent for Sensitive Afraid 35% Services Unsupportive partner 19% *statistically significant vs. early abortion patients, p<0.05 Access/WHRC Mar 2009 Drey E et al, Ob Gyn, 2006 5
3/12/2016 Case � Young woman, post-partum � My desire: to give her “highly effective” 21 contraception counties in CA 45 � Her concern: counties autonomy in NY “ Are health care providers using U.S. black population? ” Contraception for abortion to curb the growth of the Underserved Women Mar 13, 2010 Patient Patient factors factors Barriers to Barriers to contraceptive contraceptive success success System System Provider Provider factors factors factors factors Safe prescribing for women with medical illness � Shared decision-making � 6
3/12/2016 PCP ’ s underestimate risk of Low income women and women of color unintended pregnancy have higher illness burden � Underestimate risks: Higher rates of chronic diseases: � prevalence of unintended pregnancy by 23% � HTN � risk of pregnancy with no contraception by 35% � DM � 85% underestimate failure rate of OCP ’ s � Underestimate failure rates: � Obesity Many chronic diseases: � 62% for condoms � Worsen in pregnancy � 16% for injectables � Have potentially teratogenic effects � Treated using potentially teratogenic meds Parisi Contraception 2012 Contraception in women CDC MEC for CV disease � Don ’ t forget! with medical illness Prog DMP Cu- LNG- CHC Implant A IUD IUS � Weigh risk of pregnancy against risk of method Multiple risk factors of 3/4 3 � Use a resource: 2 1 2 CAD � http://www.cdc.gov/reproductivehealth/Uni BP systolic >160 or 4 3 ntendedPregnancy/USMEC.htm 2 1 2 diastolic >100 � Search for “ CDC MEC ” � Rates methods for medical conditions 4 3 Vascular disease 2 1 2 1=no restriction; 4=unacceptable risk 4 History of DVT/PE 2 2 1 2 4 2 2 2 Current DVT/PE 2 � Available as an App Major surgery- 4 prolonged 2 2 1 2 immobilization 7
3/12/2016 Why do underserved women have Blacks and Latinas disproportionately higher rates of unintended use lower efficacy methods pregnancy? P <0.001 Jones, Natl Health Stat CDC 2012 Jones, Natl Health Statistics CDC 2014 Reproductive abuse in the US Reproductive abuse in the US � American Eugenics movement, 1907-1960 • 2006-2010, � >100,000 sterilized California prisons � >30 states • 150 female inmates � California 60,000 � Norplant, 1990s � Government aid � Target racial/ethnic minorities 8
3/12/2016 Women of color have concern about Women of color have concern about contraceptive methods reproductive harm Cross-sectional telephone national survey of Black � � Focus groups of black participants 1 Americans, reproductive age 1 � Changes in menstrual cycle is evidence of � “Poor and minority women are sometimes forced to be sterilized…” reproductive harm � “Medical and public health institutions use poor and minority people as guinea pigs…” � Majority of long-acting reversible contraception has this side-effect Survey black parishioners, 35 churches in � Louisiana 2 � Believe family planning programs are a form of genocide 1. Thorburn Bird, Jnl of Hlth Statistics 2003, 2. Parsons, Simmons 1999 Clark, Contraception 2006 Contraceptive features preferred by Are women of color counseled patient race/ethnicity differently? 1700 women, 13 clinics, nation-wide � � More dissatisfied with their family planning Black, Latina, White, Asian Pacific Islander � provider, many report racial discrimination Surveyed during family planning encounter � � More likely to report being pressured to: Examples: Stopping use of the method (return to fertility)* � Use birth control � Ease of use � � Limit their family size Getting the method (cost, clinic visit) � Side effects or health concerns � Efficacy � Control and privacy* � Forrest, Fam Plan Perspect 1999, Thorburn Womens Health 2005 Jackson, AV unpublished data 9
3/12/2016 Why are women of color Are women of color counseled counseled differently? differently? � Statistical discrimination Providers more likely to: � Use of group averages � agree to sterilize minority and poor women � Stereotyping � Fixed and oversimplified image or idea � recommend the IUD to women of color and � Not necessarily negative poor women � How we organize our complex world � History of racism makes racial and ethnic stereotyping impossible to avoid Harrison Obsetrics and Gyn 1988, Dehlendorf AJOG 2010 Implicit bias can contribute to Implicit bias in family planning family planning disparities Differential pressure to control fertility can: � Young woman, post-partum Increase mistrust between Increase mistrust between � My desire to give patient & provider patient & provider her “highly effective” resistance from patient resistance from patient contraception � Her concern: greater tendency to greater tendency to autonomy discontinue methods discontinue methods � Did I not trust her? health disparities health disparities 10
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