Unsatisfied contraceptive preferences due to cost among women in the United States.

OBJECTIVES: To examine prevalence and characteristics associated with cost barriers to preferred contraceptive use. STUDY
DESIGN: Among a nationally representative sample of women at risk of unplanned pregnancy in 2015-2017, we used Poisson regression to assess characteristics associated preferring a(nother) method in the absence of cost.
RESULTS: Overall, 22% preferred to use a(nother) method. Women using less-effective methods, who were Black or Hispanic, ages 15-24 and had low incomes, were more likely to report cost barriers.
CONCLUSIONS: Using a preferred method is an indicator of access to care and reproductive autonomy. These results provide a benchmark to track the impact of policy changes.

Introduction

Throughout the history of fertility surveys in the United States and other countries, the questionnaire design has, with rare exceptions, implicitly assumed that people are using the contraceptive method that they want to use by assessing contraceptive use but not contraceptive preferences [1,2]. The 2015–2017 round of the National Survey of Family Growth (NSFG) broke with this tradition and asked: “If you did not have to worry about cost and could use any type of contraceptive method available, would you want to use a [different] method?” Identifying discrepancies between current and preferred use is important, as access to one's preferred method of contraception is an indicator of reproductive autonomy [3]. Through a similar survey question, we found that preferences for highly effective contraception were often unsatisfied among postpartum women in Texas [4,5]. This new question in the NSFG allows us to explore unsatisfied preferences due to cost at the national level.

Affordable access to contraception in the United States has improved in recent years as a result of the Affordable Care Act (ACA) contraceptive coverage mandate and publicly funded family planning programs [6]. The reduction of cost barriers has facilitated access to more effective methods, which may be preferable but otherwise not affordable [[4], [5], [6]]. Despite efforts to facilitate affordability, cost may remain a barrier for some because they are enrolled in insurance plans that have not complied with the contraceptive coverage mandate [6], reside in states that do not operate a Medicaid family planning program or have not expanded Medicaid [7], or have limited access to other programs that provide affordable contraception.

However, continued progress on removing cost barriers is far from assured. Recently, a 2019 rule change to the Title X family planning program restricting referrals for abortion has led more than one in five providers in this nationwide network to withdraw from the program [8]. Moreover, while insurance coverage under the ACA peaked in 2016 [9], current proposals that expand employers' religious exemptions to the contraceptive coverage mandate would increase out-of-pockets costs if they withstand legal challenges [10].

In this analysis, we used the new NSFG question to assess the extent to which cost served as a barrier to using one's preferred method of contraception at the height of insurance coverage under the ACA and prior to the Title X rule change. We also examined characteristics associated with reporting a cost barrier to using a preferred method.

Materials and methods

We used data from the 2015–2017 NSFG, a nationally representative survey of the noninstitutionalized population ages 15–49. Our analysis focused on female respondents ages 15–44 who had heterosexual intercourse within the last 3 months and were not pregnant or trying to become pregnant at the time of the interview (i.e., at risk of unplanned pregnancy; n = 2864). We excluded respondents who were sterile for noncontraceptive reasons (n = 71), those who were ≤ 2 months postpartum (n = 24) and those with missing responses on the dependent variable (n = 25), resulting in an analytic sample of 2744 women.

The primary outcome was an unsatisfied contraceptive preference due to cost, measured by women's response to the question regarding cost serving as a barrier to using a(nother) method. We examined the distribution of unsatisfied preferences by current contraceptive method and respondent characteristics that have been associated with barriers to affordable care: race/ethnicity, age, household income as percent of the federal poverty level and insurance coverage [9,11]. We estimated unadjusted and adjusted prevalence ratios using Poisson regression with robust standard errors using Stata 16.0, accounting for survey design and sampling weights in all analyses.

Results

Overall, 22% of women at risk of an unplanned pregnancy reported that they would want to use a different contraceptive method if cost were not an issue (Table 1). Roughly one third of women using condoms/withdrawal and no method of contraception would prefer to use another method. Black and Hispanic women and those of other races/ethnicities had a higher prevalence of unsatisfied preferences compared with white women. Reports of cost barriers to a preferred method declined with increasing age and income. One in three uninsured and one in four publicly insured women would prefer another method compared to one in five women with private insurance.

Table 1

Sample characteristics, percentage reporting preference for another method in the absence of cost by characteristics, and prevalence ratios assessing association between characteristics and preference for another method in the absence of cost, 2015–2017 NSFG

	Descriptive statistics (n = 2744)		Prevalence ratios
	Sample characteristics, %a	Prefer another method in the absence of cost, %b	Unadjusted	(95% CI)	Adjusted	(95% CI)
All	100	22	–	–	–	–
Current contraceptive method
Pill/patch/ring	20	16	1 (ref)	–	1 (ref)	–
Female sterilization	18	19	1.15	(0.74–1.79)	1.12	(0.71–1.76)
Male sterilization	7	16	0.95	(0.55–1.65)	1.20	(0.66–2.15)
Implant	4	18	1.12	(0.70–1.78)	0.84	(0.52–1.36)
IUD	13	10	0.62	(0.36–1.09)	0.64	(0.37–1.10)
Injectable	2	21	1.29	(0.82–2.02)	1.11	(0.71–1.72)
Condom/withdrawal	25	30	1.86	(1.35–2.56)	1.75	(1.30–2.36)
None	12	36	2.19	(1.61–2.98)	1.94	(1.48–2.56)
Race/ethnicity
White, non-Hispanic	60	17	1 (ref)	–	1 (ref)	–
Black, non-Hispanic	13	28	1.64	(1.19–2.25)	1.35	(1.01–1.81)
Hispanic	21	29	1.73	(1.31–2.30)	1.48	(1.13–1.94)
Other, non-Hispanic	6	31	1.84	(1.16–2.93)	1.63	(1.00–2.65)
Age
15–24	24	29	1 (ref)	–	1 (ref)	–
25–34	40	22	0.76	(0.61–0.94)	0.87	(0.71–1.06)
35–44	37	18	0.62	(0.49–0.78)	0.75	(0.59–0.95)
Household income (as % of federal poverty level)
< 100%	21	29	1.77	(1.34–2.34)	1.45	(1.15–1.83)
100%–199%	23	24	1.47	(1.04–2.06)	1.22	(0.89–1.66)
200%–299%	16	24	1.45	(1.05–2.01)	1.35	(0.99–1.83)
≥ 300%	40	16	1 (ref)	–	1 (ref)	–
Insurance coverage
Privately insured	64	19	1 (ref)	–	1 (ref)	–
Publicly insured	22	24	1.29	(0.98–1.71)	1.02	(0.77–1.36)
Uninsured	14	33	1.77	(1.34–2.35)	1.29	(0.96–1.75)

Values are from Poisson regression and are weighted to account for the NSFG survey design. Adjusted results include all variables in a single model. CI, confidence interval.

Column percentages.

Row percentages.

After multivariable adjustment, associations between unsatisfied contraceptive preferences due to cost and current contraceptive use, race/ethnicity, age and income remained significant.

Discussion

In this analysis, we found that more than one in five women at risk of an unplanned pregnancy in the United States would want to use a different method of contraception if they did not have to worry about cost. In a 2004 study that used a similar question to assess cost barriers, 31% of women would switch methods if cost were not an issue [2]. This decrease in prevalence is consistent with previously reported reductions in out-of-pocket costs following the ACA contraceptive mandate [6].

Those using condoms, withdrawal or no method were more likely to report cost barriers, which may reflect the relative affordability of these methods and their availability without a prescription. The higher prevalence of cost barriers among low-income women may be related to challenges reaching a Title X or Medicaid provider, or living in a state that did not expand Medicaid or does not operate a family planning waiver program [7,9]. Women of color may face obstacles accessing affordable contraception, and this may be especially true for recent and undocumented immigrants due to limited insurance coverage options. Finally, the higher prevalence of cost barriers for younger women underscores the importance of maintaining coverage protections under the ACA and access to Title X clinics for this group.

Unfortunately, the NSFG did not assess which method women would prefer to use, although research from Texas suggests many may prefer more effective methods [4,5]. We recommend that future surveys implement questions to detect both the presence of unsatisfied contraceptive preferences as well as the specific method the respondent would prefer to use. Given that affordability is but one potential barrier to preferred method use, future questionnaires should ask respondents about cost as well as other possible barriers such as getting transportation to a clinic or locating a provider that offers their preferred method.

As substantial changes are being considered and applied to federal laws and programs, monitoring whether people are able to afford their preferred method is an indicator of access to and quality of reproductive healthcare, as well as the state of reproductive autonomy [3]. These results are a benchmark for tracking the impact of policy changes as well as monitoring disparities in affordability across subgroups.

Declaration of competing interest

The authors declare no conflicts of interest.