Race, ethnicity and differences in contraception among low-income women: methods received by Family PACT Clients, California, 2001-2007.

Unintended pregnancy is a significant health problem in the United States, where more than three million such pregnancies occur each year.1 The burden of unintended pregnancy falls disproportionately on ethnic minority women—69% of pregnancies among blacks and 54% of those among Latinas are unintended, compared with 42% of those among white women.1 These disparities contribute to substantial differentials in abortion rates—49 abortions per 1,000 black women of reproductive age and 30 abortions per 1,000 Latina women of reproductive age, compared with 13 per 1,000 among whites.1 In addition, low-income women have higher rates of unintended pregnancy and abortion than do women with higher incomes; the largest differences are between women with incomes below 200% of the federal poverty level and those with incomes above this threshold.1 Disparities in unintended pregnancy and abortion rates are driven in part by differences in contraceptive use. Many women at risk for unintended pregnancy do not use a contraceptive method, and the proportion varies by race and ethnicity. The 2006–2008 National Survey of Family Growth (NSFG) found that among women who were sexually active and did not desire pregnancy, 9% of whites, 16% of blacks and 9% of Latinas were not using contraceptives.2 Disparities in use between blacks and whites at risk for unintended pregnancy persist in analyses that control for socioeconomic factors.3,4 Because contraceptive methods vary in their effectiveness, and because half of unintended pregnancies occur among women who are using contraceptives,1 differences by race and ethnicity in method choice may have an effect on racial and ethnic disparities in unintended pregnancy rates. Black and Latina women are more likely than whites to use the injectable and condoms, while whites are more likely than Blacks or Latinas to use oral contraceptives.2,5,6 In addition, Latinas are more likely than either white or black women to use an IUD.2 A few studies have investigated the relationship between contraceptive use and race and ethnicity while controlling for socioeconomic status. In one such study, black women were more likely than white women to have undergone tubal sterilization.7 In another, which controlled for education, income and insurance coverage, black women were less likely than whites to be using oral contraceptives, and more likely than whites to be using condoms and long-acting methods (the patch, ring, injectable, implant and IUD).6 In addition, U.S.-born Hispanics were more likely than white women to be using condoms, while foreign-born Hispanics were more likely than whites to be using long-acting methods. These findings indicate that racial and ethnic differences in use of oral contraceptives and condoms are not entirely due to socioeconomic factors, although conclusions cannot be drawn about the use of other individual methods. In 1997, recognizing that financial access may influence contraceptive use, California implemented the Family PACT (Planning, Access, Care and Treatment) program, which provides free, family planning and reproductive health services to residents with incomes up to 200% of the federal poverty level who have no other source of family planning services. Program benefits include access to all contraceptive methods that have been approved by the Food and Drug Administration (FDA), as well as to screening and treatment for STDs. Family PACT serves more than 1.5 million clients per year, including approximately two-thirds of all women in California who are eligible for services, and reaches a diverse range of economically marginalized populations with poor access to health care services.8 A higher proportion of eligible Latinas (76%) than of whites (53%), Asians (49%) and blacks (43%) participate in the program.9 In 2007, Family PACT services prevented an estimated 296,200 unintended pregnancies in California.10 The availability of the program’s claims data offers a unique opportunity for researchers to analyze contraceptive method provision by clients’ race and ethnicity in a setting where women have access, without financial barriers, to all FDA-approved methods. These data have several valuable features. Because California is the most populous state and is racially and ethnically diverse,11 analyses of its population have relevance for the nation as a whole. In addition, because Family PACT covers only low-income women, the program’s data provide information about women with the greatest need for subsidized contraceptive services. Finally, claims data provide a different perspective on contraceptive provision than self-reported data, which have been the basis for most studies on the distribution of contraceptive methods. In this article, we present characteristics of women receiving contraceptive methods in the Family PACT program in 2007 and review trends in the dispensing of contraceptives between 2001 and 2007. Examining this time period is particularly important given the arrival in 2002 of two new FDA-approved contraceptive methods: the ring and the patch. To date, information about the adoption of these methods has been limited. We will explore how contraceptive method distribution changed when these methods were introduced, as well as investigate trends by race and ethnicity in the receipt of these and other methods.