Sunday, December 10, 2006

Increasing the Use of Effective Birth Control is Not an Adequate Strategy to Prevent Unwanted Pregnancies among Young Latinas – Nilda L. Moreno

Latinas living in the United States have the highest pregnancy rate when compared to white and black women. According to Finer, this rate about 144 pregnancies per 1,000 women in their reproductive years which is almost double when compared to white women (2006). This translates to that Latinas is the ethnic group who has the highest unintended birth rate. In addition, slightly more than half of the pregnancies among Latinas are unintended and about 43% of this end in an abortion (Finer 2006). Therefore, the increased unintended pregnancy rate and unintended birth rate among Latinas, when compared to other ethnic groups, suggests a health disparity that needs further exploration.

In this paper I would like to criticize that the pregnancy prevention programs that focus only on increasing access to and use of birth control methods, specifically targeting Latinas, is not an adequate approach to decrease the rate of unintended pregnancies among this group. My interest in this topic arisen when I started practicing obstetrics and gynecology here at Boston Medical Center. I specialize in Family Planning and therefore, I take care of women from different ethnic groups who have unintended/unwanted pregnancies and who desire to prevent pregnancies. During the year and a half that I had been taking care of women, I noticed the decision making process related to contraception and abortion is a complex one, particularly for my Latina patients.

In the counseling sessions with Latina women regarding contraceptive plans a variety of concerns arise that are not necessarily related to the method itself, but to their socio-cultural context. Topics like partner (and how both of them have different goals related to family size), family (and how they approve or not certain methods) and friends (and the related word of mouth about what method is better, side effects, etc). In addition, I face the challenge to dispel many misconceptions that are attributed to the use of birth control methods, like infertility and a variety of side effects that are not cited in the medical text books. I also noticed that younger pregnant Latina women didn’t perceive a risk for getting pregnant while sexually active and were not using any contraceptive method. As I started looking into the scientific literature in order to try to find a validation of my observations and try to understand my patients better, I came across some articles that explored the complexities of Latinas when preventing pregnancies. I contrasted these insightful findings to the current approach to Latinas by the family planning clinic and staff at Boston Medical Center, which for the most part don’t incorporate these complexities into the equation when offering contraceptive counseling. This also contrasts with other family planning programs that don’t specifically address the particular needs of different ethnic groups and focus only on increasing access to contraception and promote use.

The fact that one of the most important goals of the Healthy People 2010 (Department of Health and Human Services) is the elimination of health disparities among different segments of the U.S. population makes me think that to eliminate the reproductive health care disparities among Latinas, specially decrease the rate of unintended pregnancies, have to incorporate issues beyond access to and use of contraceptives. I will present three arguments to support my criticism and present an alternative approach to the prevention of unintended pregnancies among Latinas living in the U. S.

Contraceptive Use Among Latinas and Socio-cultural Factors:
Research conducted among Latina women suggests that the use of contraception involves a complex decision making process, which is affected by level of acculturation, socio-cultural norms, and misconceptions regarding contraception. First, we need to look at how contraceptive use correlates with socio-cultural factors and not only access to the methods. A survey conducted by Unger among Latinas, found that 90% of them reported at least one barrier to contraceptive use and the top three reasons were not related to the actual access to the methods but the following: birth control is the woman’s responsibility, the partner doesn’t want them to use it, sex is more romantic when no birth control is used (1998). In addition, other significantly associated variables to perceived barriers to contraceptive use were found to be: cultural attitudes favoring large families, perceptions that contraceptives interfere with sexual pleasure, perceived stigma associated with contraceptive use, embarrassment about negotiating contraceptive use with partners and embarrassment about buying contraceptives.

More recent findings reported by Romo suggest that acculturation may play a positive effect in consistent contraceptive use among Latinas (2004). Interestingly, religiosity and years of education were not associated with contraceptive use but it was with family size. Also, women who had planned the most recent pregnancy and those who had fewer children used contraception in a more consistent way. In addition, women who lived longer in the U.S. reported more consistent patterns of contraceptive use.These two investigations suggest that when designing a family planning program, issues beyond the actual access to the methods need to be included into the equation. These should include (but by no means limited to): incorporating the partner in the decision making, values/goals clarification (to put in perspective family size, resources), sexuality in the context of use of contraception and planning pregnancies (in the context of values and goals). Acculturation was defined by Sabogal and Perez as a process of change in beliefs, attitudes and values that occurs when two cultural groups interact over a period of time (1995). I think acculturation plays an important role in contraceptive use; which may be related to changing economic goals, assimilation of different values, the incorporation of the women to the work force and the desire to attain higher levels of education, as described by Jimenez (2002).

Contraceptive use among Latinas is affected by the significance of pregnancy
When we look at the numeric description of the high overall pregnancy and unintended pregnancy rates among Latinas when compared to other ethnic groups, we need to contextualize these numbers in terms of what a pregnancy means for Latinas. For many Latinas, particularly those with low levels of acculturation, pregnancy and motherhood (even if occurs in young women) are consistent with the perceived traditional cultural norms (Unger 2000). In addition, this researcher found that among un-acculturated Latina women perceive pregnancy as a positive thing regardless if it happens in young women. Russell reported similar findings (1993). Her study found that low levels of acculturation were associated with positive attitudes about pregnancy and childbearing, need for information about birth control methods and the perception that birth control methods are ‘bad’ and ‘don’t work well’.

The significance of a pregnancy may or may not vary with acculturation levels, like discussed in the previous argument. It can be related to personal goals, family values and role models. These factors can work independent to acculturation. Therefore, understanding the significance of a pregnancy and how that varies among Latina women in relation to their values and goals is crucial when designing effective pregnancy prevention programs for Latinas. This also, allows the individualization of counseling to meet each woman’s contraceptive needs.

Patterns of Contraceptive and Unwanted Pregnancies and Abortions
About half of Latina women obtaining abortions in 2001 were not using any birth control method and they were twice as likely to report inconsistent use when compared to white women (Jones 2002, b). Only a small proportion was using the most effective birth control methods and also a small proportion reported barriers related to access. In my opinion, what this illustrates is that a high proportion of the women who had an abortion (because they had an unintended pregnancy) were not perceiving (nor doing anything about) the risk of getting pregnancy or were not using the contraception consistently. In addition, Latina women reported in higher proportion that ambivalence and concerns toward use of birth control methods were factors that precluded them to use contraception, when compared to other ethnic group (including White). Finally, a very interesting finding was that Latinas reported in higher proportion that their parents’ opinion and partner preference prevented them to use contraception.

These facts complement the previous arguments and suggest that we need to give one step backwards and ask why so few Latinas are using contraception and why those who are using contraception, are not using it consistently. As suggested previously in this paper and supported by Jones’ findings, the decision to use contraception among Latinas involves a complex interaction of factors that involve personal concerns, partner’s preference and family’s opinion (2002, b).

The concerns that arise form these patterns of contraceptive use are the occurrence of unwanted pregnancies and abortion. This observation is supported by a published analysis, also by Jones, in which Latinas are reported to have the highest pregnancy rate when compared to other ethnic groups as well as a higher than average abortion rate (2002, a). In addition, the analysis reports that for women younger than 20 years of age, Latinas have the highest abortion rate. However, as a national trend, abortion and pregnancy rates are declining among teenagers, but this decline is less for Latina adolescents. While this last finding is encouraging, it supports the revision and improvement of current strategies.

Alternative Approach
In February 2004, the Latino Issues Forum (LIF) and the Allan Guttmacher Institute (AGI) organized a meeting to begin a discussion on improving policymaking, research and resources for Latina sexual health and reproductive health nationwide (Foulkes 2005). In that meeting, health care professionals, advocates and researchers were present. The action plan that resulted from that meeting focused on the following 5 areas: 1) Improving access to information and services; 2) Adolescents and young women; 3) Abortion: Attitudes and Experiences; 4) Advocacy and communication and 5) Research approaches. What makes this plan a comprehensive one, is that each of this 5 areas specifically approaches the reproductive and sexual health of Latinas in the context of the complex family dynamics, socio-cultural influences (including acculturation) and the communities in which the women live. This plan is an example of the application of social and behavioral sciences to eliminate health disparities among Latinas, like the Department of Health and Human Services and its plan “Healthy People 2010” proposes to achieve. This is so because this plan recognizes that overcoming access barriers is not enough. The plan emphasizes on the importance of exploring the attitudes and experiences related to reproductive health among Latinas in order to design cost-effective strategies increase use/access to reproductive health services and to decrease unintended pregnancies. For example, the lack of linguistically and culturally competent services compromises the quality of information that is delivered. In contrast, incorporating peer education (Promotoras de Salud) had proven to be an effective strategy among Latinas. Therefore, an important next step of this plan is related to research strategies to understand the meaning of pregnancy among young Latinas in the context of family relations and personal goals.

In my opinion, a second important step is the use of peer education to deliver a prevention message that is culturally and linguistically sensitive, like suggested above. To make this prevention message more effective, planning future pregnancies (another way to say unwanted pregnancy prevention) should be addressed in the context of exercising autonomy, control of the body (and fertility) and freedom. By delivering the message based on these 3 core values, the young Latinas could be engaged to prevent unwanted pregnancies.

Discussion and Conclusion
As discussed above, increase use of contraception among Latinas to prevent unwanted pregnancies, as a single strategy, is unlikely to be effective. The arguments discussed in this paper support this. As discussed earlier, there is good evidence to support a comprehensive approach to pregnancy prevention among Latinas. In addition to access to information and to the methods, an effective prevention strategy should integrate a discussion of how the women’s personal goals, acculturation level and the significance of pregnancy affect the decision making process when deciding to prevent or delay having children. In order to incorporate these topics and design effective interventions, research, with a social and behavioral science perspective, is needed to design effective intervention programs, like suggested by the Latino Issues Forum. I would add that pregnancy prevention messages directed toward young Latinas should incorporate core values like autonomy, control of the body and freedom to make it more effective and engaging.

Finer LB, Henshaw SB. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health 2006;38(2):90-96.

Foulkes R, Donoso R, Fredrick B, Frost JJ, Singh S. Opportunities for Action: Addressing Latina sexual and reproductive health. Perspectives on Sexual and Reproductive Health 2005;37(1):39-44.

Jimenez J, Potts MK, Jimenez DR. Reproductive attitudes and behavior among Latina adolescents. Journal of Ethics and Cultural Diversity in Social Work 2002;11(3-4):221-249.

(a) Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000-2001. Perspectives on Sexual and Reproductive Heath 2002;34(5):226-235.

(b) Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000-2001. Perspectives on Sexual and Reproductive Health 2002;34(6):294-303.

Noone J. Cultural perspectives on contraception: A literature review. Clinical Excellence for Nurse Practitioners 2000;4(6):336-340.

Romo LF, Berenson AB, Segars A. Sociocultural and religious influences on the normative contraceptive practices of Latino women in the United States. Contraception 2004;69:219-225.

Russell AY, Williams MS, Farr PA, Schwab AJ, Plattsmier S. Patterns of contraceptive use and pregnancy among young Hispanic women on the Texas-Mexico border. Journal of Adolescent Health 1993;14:373-379.

The Allan Guttmacher Institute, “Get in the know about pregnancy, contraception and abortion”

Sabogal F, Perez-Stable E, Eliseo J. Gender, ethnic and acculturation differences among Hispanic and non-Hispanic white adults. Hispanic Journal of Behavioral Sciences 1995; 17:139-159

Unger JB, Molina GB. Acculturation and attitudes about contraceptive use among Latina women. Health Care for Women International 2000;21:235-249.

Unger JB, Molina GB. Contraceptive use among Latina women: social, cultural and demographic correlates. Women’s Health Issues 1998;8(6):359-369


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