Center /orMississippi Health Policy AN ANALYSIS OF A SURVEY OF MISSISSIPPI WOMEN "REGARDING CONTRACEPTION July 2019 Table of Contents Methodology and Limitations ..............ccccccccccccccecsecssesesesseceececcesecsecsuscssssesueseeeseuseeeecsesuuensaeaeeeseuseeneessscsssusaseaeeaeeeseseessssassesasaeaeseeeeseesesesesesuecesansaesecsuseeseessasansesaeens 3 Survey Sample Demographics. ...........cccccccccsssscecessecssnseecsseeeseneecssseeesnseessseesescsaesssseeesceaessaneesceeeeessensescasessansescsneessansescsaeeessanseesseessusnaeessneessaasessansesssaaeesseneaseness 4 Framework for Reviewing Survey ReSUIts............ccccccccccecceseeeeeeeeeeee cease eeeeeeeneeeaeesaee es aeesa essa eae eaaeeeeaee geese seas saeeeaeesaeessaessaaeseaaaesaaeeeaeeseeesaeeseesseeseeeseeeeesaeeseaeeeeees 5 Findings Related to Payor ............::s:cccscsecceccceeececssessssesaeeeceeceenecsesuseenauesaesaeeecessesessassseaseseeseesessssasasaaeeaeseeeessesessesassaseesaeeaeeesssuseeeesusssesesaasseeeseuseeesssesesaesssesnsaseneess 6 Findings Related to Provider ..........: ci te iii i nnn nnn nn nn nnn IEEE ELE EEE ILE EEE ELE IEEE ee 12 Findings Related to Race .............cccssssssscceccceecescsseseaesseeeceseeescasesesaesaeeeseeeceseusesssssaasseauseseesessess sass sassaaeaesaesecesseseessssuceaeeaeeeseeesesesessascseensaeeeseuseseeessseseseseeenseeeess 16 ParousS ReSPONCENTS ....0... cc rn nnn I A nn nnn nn HL En nn pn nnn nn En En pn nnn 2 oo nn ee 22 NulliparouS RESPONCEMS ...........cccccccesssseccecsssnseceecsensaesecssenseeeecsensaeseessesaesecanaeeeessenaesecaensaeseecseueeeesecssenseeseceenseasescganseseecsauseseessenseesecssenseseesesenseseessssnsaesesssnes 29 GIOSSALY 0... .ccceessccecssseseceecssnaeeeecssseaeeeecseneeececgaaaeeeeeecgaeeeeeeesseeeeeeesageeeeeeeessgeeeeeeesgeeeeeeesageeaeeeesaseeeeeeeesaseeeeeesaseeeeeeesseeeeeeeesseeeeeeeesaseeaeeeesseeeeeseseseseueeessssseesseesseseeneeess 43 Appendix |. LARCs: Respondent Experience, Knowledge, and Satisfaction .............ccccccccccssssseeccecsssneeseecsenseeeecssenseseecsenseeeseessenseesesssenseeeessenseesessseneseesesssanaess 40 2 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Methodology and Limitations DISTRIBUTION OF PARTICIPATING CHILDCARE CENTERS In 2018, the Center for Mississippi Health Policy contracted with researchers at the Department of Social Work at the University of Southern Mississippi to carry out a survey of women of child-bearing age in Mississippi to better understand ee their knowledge of and behaviors related to contraception as well as any perceived ® barriers to obtaining effective contraception. The research team developed a survey © instrument for women who have given birth and women who have not given birth, as well as a survey design that efficiently identified members of both groups for random selection. @ A random sample of women with children was obtained via a two-stage stratified probability design. Ninety-five licensed childcare facilities were randomly selected e from 1500 licensed childcare centers across the state in the first stage, and two to three classrooms from within the sampled centers were then randomly selected e e @ using equal probability systematic sampling. Women of children in the classrooms were given an opportunity to participate in the survey with incentivization, as well as incentivization to recruit acquaintances who were not mothers. In total, 811 responses from mothers of children in the childcare centers and 850 responses from women who were not mothers were included. O) Data were analyzed for significance at the 95 percent confidence interval and included only survey responses of women of childbearing age (15-44). Survey results are presented for nulliparous (women who have not given birth) and parous (women who have given birth at least once) separately. While survey results O may be presented and discussed concurrently, the two groups were recruited differently and reflect different degrees of representativeness to the broader population. Therefore, the two groups cannot be combined for analysis. © For analysis presented in this chartbook, unless otherwise specified, "all" e represents valid responses to individual questions. Some data columns may not total to 100 percent due to rounding. Source: Kolbo, J.R., Ismail, O., McLeod, S., Bradwell, M., Funchess, T., and Zhang, L. (ote : © Women's Health Care and Contraceptive Practices in Mississippi. Technical Report. © 3 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = uty 2019 Survey Sample Demographics This respondent sample reflects a majority employed and insured women, offering an opportunity to better understand women of all incomes, but predominantly women from low- income, working households most of whom are also covered by health insurance. Unlike previous research* which used Title X program utilization data and was limited to populations relying on publicly funded healthcare services, providers, and payors, this sample offers insight into less obvious barriers that may be endemic to all women no matter their socioeconomic status, but that also limit their access to a full range of contraceptive services. Too few respondents from groups other than non-Hispanic black and non-Hispanic white participated in the survey to allow for separate analysis. Responses from other groups are included in combined presentations of data labeled as "All." Where categories of data equaled less than one percent, those data were omitted from this presentation of the analysis results. Respondents Who Ever Used Contraception PAROUS 94% NULLIPAROUS I 0% 20% 40% 60% 80% 100% Respondents Using Contraception Currently PAROUS 49% NULLIPAROUS ee 0% 20% 40% 60% 80% 100% * Unintended Pregnancy in Mississippi, An Analysis of Unintended Pregnancy in Mississippi. EMPLOYMENT HOUSEHOLD RACE AGE EMPLOYMENT RACE HOUSEHOLD AGE STATUS INCOME INCOME 4 of 46 SURVEY PARTICIPANT DEMOGRAPHICS BY PARITY PAROUS Employed 86% Unemployed Student Other Less than $10,000 10,000-$24,999 25,000-$49,999 $50,000-$74,999 $75,000 or more Don't Know 29.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NULLIPAROUS Employed 70.1% Unemployed Student Other Less than $10,000 10,000-$24,999 25,000-$49,999 $50,000-$74,999 $75,000 or more Don't Know 76.8% 35-39 10.2% 40-44 4.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Framework for Reviewing Survey Results Previous research* in this area among Mississippi women has demonstrated some key points that are useful in reviewing before proceeding to this survey's findings. 1. The type of provider a woman visits for birth control in Mississippi, whether a family practice doctor, nurse practitioner or obstetrician-gynecologist, impacts the array of contraceptive options to which she may have timely access. 2. Women accessing birth control services through publicly funded sites such as Federally Qualified Health Centers and Public Health Department clinics in Mississippi do not use the most effective reversible methods at rates that similar groups in other states do. 3. Women in Mississippi who rely on public insurance such as Medicaid do not use the most effective reversible methods at rates comparable to privately insured women. The following data presentation and discussion are framed by related questions about the influence of provider, setting, and payor on access to contraception (as reported by survey participants) as well as the knowledge and attitudes toward pregnancy and contraception that may also factor into a respondent's choices and behaviors. * Unintended Pregnancy in Mississippi, An Analysis of Unintended Pregnancy in Mississippi, and LARCs: A Survey of Mississippi Healthcare Providers 5 of 46 REPORTED PAYOR, PROVIDER, AND SETTING FOR WOMEN'S HEALTHCARE SERVICES BY PARITY PAROUS RESPONDENTS Clinic/Doctor's Office 86.9% Health Department OB-GYN 83.3% Family Practice Nurse Practitioner Private Insurance Public Insurance Cash/Self-pay 8.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% "Other Payor or | Don't Know = 2.3% NULLIPAROUS RESPONDENTS Clinic/Doctor's Office 75.9% Health Department Family Practice Nurse Practitioner Private Insurance Public Insurance Cash/Self-pay 13.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *Other Provider = 6.3%; Other Payor or | Don't Know = 8% Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juy 2019 Findings Related to Payors The following pages explore the role that payor type may play in contraceptive utilization among survey respondents. Responses reflect payor type used for birth control as well as women's health services, as not all respondents reported currently using birth control. Private insurance is used to describe directly purchased and employer- sponsored plans. Public insurance includes publicly funded health coverage available through TRI-Care, Medicaid, Medicare, Children's Health Insurance iS 7) Program, and Indian Health Services. Ln, Y Self-pay reflects payment not made through an insurance plan and is often referred to as "out of pocket" or "cash." 6 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 How Birth Control Is Paid for by Age and Parity PAROUS 100% ' es iter ees 80% 60% eA orem WA a RIL 40% | ble iehobre 20% LON '0 VAY iRyar cha 0% 15-19 20-24 25-29 30-34 35-39 40-44 All Mi Pubic WE Private Self-Pay Analysis of payor type by age revealed no significant differences among women who have children. However, younger respondents reported higher rates of public insurance. Eighty percent of women 15-19 and nearly 60 percent of women 20-24 rely on public insurance for birth control. While all pregnant women with household incomes under 194 percent of the Federal Poverty Level are eligible for Medicaid coverage while pregnant, the women 18 and under would likely be eligible for Medicaid and CHIP up to age 19. The number of parous women 15-19 in this sample (9) is low; interpret findings with caution. NULLIPAROUS 1. 3.5% ~| ey a m7 ry Mer el ee - avn 80% 0, 60% aera ay oe Reh poles 73.5% RIL 40% ORE 20% EY 8.3% 19.6% | eee f (v) 0% 15-19 20-24 25-29 30-34 35-39 40-44 All © Pubic 8 Private Self-Pay Note: Statistically significant difference (p=0.038). Payor type and age are significantly associated for nulliparous women. Private insurance is the primary payment source used to cover birth control for all age groups of nulliparous women except for those ages 15-19, who rely heavily on public insurance, highlighting the importance of CHIP and Medicaid for teen pregnancy prevention. Women 20-24 and women 40-44 report the highest rates of paying out of pocket for birth control. It is worth noting that the women 20-24 are allowed to access coverage until age 26 through a parent's private insurance plan per the Affordable Care Act. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Payor for Birth Control and Impact of Insurance and Expenses on Birth Control by Parity PAROUS 2.3% Hl Private Insurance H Self-Pay HB Public insurance = HN | don't know/Other NULLIPAROUS i) | Private Insurance [i Self-Pay WS Public insurance | don't know/Other My insurance does not matter 56.4% If | did not have insurance | would not be able to use birth control My insurance covers some birth control but nat the type | would like to use If | had insurance | would use a different type of birth control 0% 20% 40% 60% 80% 100% PERCENT OF RESPONDENTS The majority of both parous and nulliparous respondents were insured, predominantly through private coverage. It is notable that so many nulliparous respondents reported not knowing the payor for their birth control. More than a quarter of parous (28%) and nearly as many nulliparous (23%) women reported that they would not be able to use birth control without insurance to pay for it. Nearly 20 percent of nulliparous respondents reported not using their preferred method because their insurance did not cover it, and 13 percent would use a different type of birth control if they had insurance. More than half of nulliparous and parous women reported that their insurance did not matter to their current birth control use. My insurance does not matter 44.7% If | did not have insurance | would not be able to use birth control My insurance covers some birth control but not the type | would like to use If | had insurance | would use a different type of birth control 0% 20% 40% 60% 80% 100% PERCENT OF RESPONDENTS Source: Women's Health Care and Contraceptive Practices in Mississippi. 8 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 How Birth Control Is Paid for by Method and Parity PAROUS 100% ; 93.4% 80% ! ! ! 66.5% 63.3% Not a single parous woman paying out of pocket (self-pay) for son : 58.9% ! birth control reported choosing the most effective methods. Both privately and publicly insured women reported opting for the most ! effective methods at higher rates than the least effective methods, 40% ! 32.8% | 98294 with nearly one-third of privately insured women and one-quarter 24.4% | of publicly insured women opting for the most effective methods. 20% The relationship between payor type and birth control method 9% | 83% ; 6.6% we | 85% effectiveness for parous women was not statistically significant. 0% PUBLIC PRIVATE SELF-PAY ALL INSURANCE INSURANCE Nulliparous women paying out of pocket for birth control reported using the most effective methods less than any insured group and reported using the least effective methods (condoms, withdrawal) at twice the rate of any insured group. Privately insured women reported the highest rate of accessing the most effective methods. 100% ; These findings were not statistically significant. 85.4% WE LeastEfectve Hi Moderately Effective BB Most Effective NULLIPAROUS 81.6% 81.2% Moderately effective methods, such as birth control pills or Depo- Provera injections, require at least annual provider visits for administration of the method or a prescription. Least effective methods like condoms and natural family planning are inexpensive I 78.8% | I I I I and do not require medical guidance but providers do counsel I I I I I I I I I I I 80% 60% and educate patients about them. The most effective (reversible and permanent) methods include intra-uterine devices, implants, 18.6% or surgical sterilization. These can have higher upfront costs, but i 12.6% 509 greater effectiveness and longer effectiveness periods. 40% 20% "| 10.4% 10.8% 17.6% i. ie PUBLIC PRIVATE SELF-PAY ALL INSURANCE INSURANCE 0% WS Least Effective Moderately Effective BS Most Effective Source: Women's Health Care and Contraceptive Practices in Mississippi. 9 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Most Recent Provider Visit by Payor and Parity PAROUS WOMEN PUBLIC INSURANCE Ab VERY PRIVATE INSURANCE 1isKoy/ 21.4% SELF-PAY 66.5% 33.5% 0% 20% 40% 60% 80% 100% Within the Last Year HI One or More Years NULLIPAROUS WOMEN PUBLIC INSURANCE rib 21.9% PRIVATE INSURANCE 86.1% AAS) SELF-PAY AR 26.9% 0% 20% 40% 60% 80% 100% ) Within the Last Year 0) One or More Years Note: Statistically significant difference (p=0.003). 10 of 46 The majority of parous women of all coverage groups reported seeing a provider within the last year (i.e. preventive screenings, birth control counseling, etc) for women's health care services. Slightly more women without insurance reported going one or more years since their last visit to a provider. This difference was not found to be statistically significant. Nulliparous women who pay out of pocket for healthcare services were significantly more likely to report one or more years since their most recent women's health visit. Most high quality birth control that is not considered long-acting requires at least annual visits to renew prescriptions. Privately insured nulliparous women were most likely to report having had a visit within the last year at 86 percent compared with only 79 percent of privately insured parous respondents. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Summary of Key Findings Related to Payors Results of this survey indicate that for this sample insurance is not associated with any discouragement from a particular method during a provider visit, suggesting that payor policies are not influencing practice-level decisions (data not presented in this chartbook). However, respondents do report that insurance coverage matters in deciding to use birth control as well as the type of birth control to use. Both parous and nulliparous respondents who were not covered by public or private health insurance were more likely to report not having seen a healthcare provider in the past year. They were also less likely to report using the most effective reversible methods of birth control (which typically have higher upfront costs). Women under 20 in this sample are more likely to report relying on Medicaid for contraception. Payor type or coverage may be a key factor in understanding contraceptive access in Mississippi. In general, the more effective a method of contraception is, the more is required financially and clinically to obtain the method. Least effective methods are either free or cheaply available and do not require a clinician's involvement. Moderately effective methods require at least annual, if not quarterly, visits to a provider and have higher costs to obtain in addition to office visit fees. The most effective methods require a clinical procedure and can cost in the hundreds to more than a thousand dollars. These methods are the most expensive, but due to long-lasting effectiveness are the most cost effective. For many women a most effective method may be out of reach without from insurance coverage. See the Glossary (pg. 45) for types of birth control for each of these method effectiveness groups. 11 of 46 INSURANCE COVERAGE BY PARITY PAROUS 2.3% Hl Private Insurance = M self-Pay HB Public insurance ~=--s H | don't know/Other NULLIPAROUS Sh) I) Private Insurance [i Self-Pay QS Public insurance [| don't know/Other Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Findings Related to Providers The following pages explore the role of healthcare providers in contraceptive utilization among survey respondents. Several physician types and non-physician practitioners treat women for reproductive health concerns and family planning matters. However, Mississippi's workforce providing these services is predominantly comprised of three clinician types (as verified by insurance claims). Previous research into provider training and attitudes about contraception in Mississippi presents data for these clinician types and is complementary to the research presented here.* Obstetrician-gynecologists (ob-gyn) treat women's reproductive health concerns including during pregnancy and have the broadest formal training on contraception. Family Practice Physicians are trained to treat the broadest patient population and provide women's health services and family planning, but many refer patients to other providers for some contraceptive services. Nurse Practitioners are advanced practice nurses also trained to treat a broad patient population. They may provide some reproductive healthcare and family planning, but many refer patients to other providers for some contraceptive services. Most nurse practitioners in Mississippi are certified in family practice. * Center for Mississippi Health Policy. (2018). Long https://mshealthpolicy.com/larc-provider-survey/ 12 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Birth Control Method Effectiveness by Provider and Parity PAROUS 100% 80% 72.8% 60% 40% 20% 0% OB-GYN FAMILY NURSE ALL PRACTICE PRACTITIONER HE Least Effective i Moderately Effective BB Most Effective Note: Statistically significant difference (p=0.004). Women with children using any provider type were more likely to report using moderately effective methods than other effectiveness types (64.2%). However, more than a quarter reported use of the most effective methods of birth control (28%). Parous women relying on ob-gyn's report using the most effective methods of birth control at rates twice those of women seeing family practice physicians and more than three times as frequently as women seeing nurse practitioners. They were also much less likely to use the least effective methods. Reported use of the least effective methods for patients of family practice doctors was four times higher than for patients of ob-gyn's. Provider type and birth control method were found to be significantly associated. NULLIPAROUS 100% 80% 83.9% 83.1% 82.5% 79.5% 60% 40% 20% 0 O% OB-GYN FAMILY NURSE ALL PRACTICE PRACTITIONER WS Least Effective Moderately Effective BB Most Effective Note: Statistically significant difference (p=0.009). The majority of nulliparous women who visited any provider of women's healthcare services were likely to report using moderately effective methods of birth control. They were also more likely to report using less effective methods than to report using the most effective methods, except for those who see nurse practitioners for care. Women who rely on family practice physicians reported using the least effective methods at higher rates (17.9%) than women seeing ob-gyn's and nurse practitioners. Those women were more likely to report higher rates of use of the most effective methods, 7 percent and 9.9 percent, respectively, compared to only 2.9 percent of patients of family practice physicians. Provider type and birth control method were found to be significantly associated. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Birth Control Method Effectiveness Type by Provider Setting and Parity PAROUS WOMEN HEALTH 9 9 5 5 The majority of parous women report using private clinics for CLINIC Sy birth control and reproductive care (87%). However, 10 percent of ao eee eee ee ee eee eee parous respondents go to public health department clinics, and , " they were more likely to report using the least effective methods of birth control and less likely to use the most effective methods Tn than respondents who received their contraception from private ALL an clinics. Provider setting and birth control method were found to be significantly associated. 0% 20% 40% 60% 80% 100% OTHER I Least Effective Hl Moderately Effective HB Most Effective Note: Statistically significant difference (p=0.036). NULLIPAROUS WOMEN HEALTH 9 ATH co cunic (ERER Nulliparous respondents using any healthcare setting : : overwhelmingly report relying on moderately effective methods, like Fe birth control pills. However, those women who received their birth control from public health department clinics were more likely to use the least effective methods and the most effective methods than OE respondents who received their contraception from clinics. Provider ITM 12.6% Ph setting and birth control method were found to be significantly associated. OTHER 0% 20% 40% 60% 80% 100% 1) Least Effective I) Moderately Effective Most Effective Note: Statistically significant difference (p=0.017). 14 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Summary of Key Findings Related to Providers The majority of women, parous or nulliparous, visiting any provider type and in any healthcare setting reported relying on moderately effective methods of birth control. Most women reported seeking care at private clinics or doctors' offices with slightly more nulliparous women relying on public clinics. Similarly, most respondents report seeing ob-gyn's for reproductive care and family planning, with considerably more nulliparous women seeing other provider types. Women who go to publicly funded clinics reported higher usage of the least effective methods, especially women who have not yet had a child (nulliparous). Parous women who visit ob-gyn's for birth control reported far greater use of the most effective methods and less use of the least effective methods than parous women who visit other provider types. A Survey of Mississippi Healthcare Providers A previous survey of Mississippi providers demonstrated wide variability in birth control services available to patients across provider types.* Specifically, it was shown that obstetrician-gynecologists (ob-gyn's) were significantly more likely to be trained in provision of long-acting reversible contraceptives (LARC) than family practice physicians and nurse practitioners. Ob-gyn's reported significantly higher rates of LARC insertions as well as greater likelihood of practicing in settings that support efficient and timely provision of LARCs. Family practice doctors and nurse practitioners reported lower rates of LARC provision, but high rates of referral to other providers for patients who wanted a LARC method. Variability in training by provider type, as well as approaches to LARC and amenability of settings have implications for the overall utilization of LARC, the most effective reversible means of birth control available. *Center for Mississippi Health Policy. (2018). Long-Acting Reversible Co Providers. https://mshealthpolicy.com/larc-provider-survey/ 15 of 46 DRIVE-TIME TO VISIT AN OB-GYN IN MISSISSIPPI @ 15 minutes @ 30 minutes © 60 minutes or more ESTIMATED TIME WOMEN IN THIS AREA MUST DRIVE TO ACCESS SERVICES FROM AN OB-GYN Source: American College of Obstetricians & Gynecologists. (2014) Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Findings Related to Race While women of many racial and ethnic backgrounds participated in this survey, too few responses from some groups were received to report representative findings. People who identify as non-Hispanic black or African American make up 37.8 percent of the state population, but black women experience disproportionate rates of pre-term birth (16.0 per 1,000 births v. 11.3 per 1,000 births for white women) and maternal mortality (51.9 per 100,000 deaths v. 18.9 per 100,000 deaths for white women) than other racial groups in the state. Unintended pregnancy, which black women in Mississippi are more likely than white women to report (72% v. 46% of women recently giving birth), is a risk factor for these negative health outcomes. Examining access to birth control for different racial groups in Mississippi is essential for addressing health inequities in the state. Too few respondents from groups other than non-Hispanic black and non-Hispanic white participated in the survey to allow for separate analysis. Responses from other groups are included in combined presentations of data labeled as "All." Where categories of data equaled less than one percent, those data were omitted from this presentation of analysis results. Sources: American Community Survey. United States Census Bureau. (2018). PRAMS. CDC. (2009-2011). Maternal Mortality Report. Mississippi State Department of Health 2013-2016. (2019). Infant Mortality Report. Mississippi State Department of Health. (2018 16 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Type of Provider Used for Birth Control by Race and Parity PAROUS WOMEN NURSE PRACTITIONER OB-GYN 40% 92.3% | 100% 20% 10.6% 4.5% 77.3% 80% 0% Black White ! ALL 60% 40% 20% | 0 Black White 0% t FAMILY PRACTICE 40% I 1 20%! 49.0% Ml oB-GYN 3.2% | WB Family Practice 9, - Black White BB Nurse Practitioner Note: Overall statistically significant difference by race (p=0.002). Unsurprisingly, the overall reliance on ob-gyn's for birth control services is high among women who have given birth to a child. Marked and statistically significant differences in the reported use of specific healthcare providers for birth control can be seen between black and white respondents. Black women reported receiving birth control services from family practice doctors and nurse practitioners at greater than triple and double the rates (respectively) than white women reported using these provider types. White women overwhelmingly reported relying on ob-gyn's (92.3%). NULLIPAROUS WOMEN NURSE PRACTITIONER OB-GYN 40% 100% 20%| 14.4% 84.3% 6.4% 80% 0% m.... Black White ALL 51.7% 60% I 40% 20% 0, ; Black White O% i t FAMILY PRACTICE 40%! 33.9% 20% M@ op-cyn ! 9.3% ! M8 Family Practice 9 --_ % Black White 1 Nurse Practitioner Note: Overall statistically significant difference by race (p=0.000). Differences observed between white and black parous women using ob-gyn's are also apparent for nulliparous women with statistical significance. More than three times as many black women reported relying on family practice doctors for birth control services than white women, and more than twice as many black women than white women reported seeing nurse practitioners for birth control. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Healthcare Setting Where Birth Control Is Received by Race and Parity PAROUS WOMEN BLACK OR AFRICAN AMERICAN WHITE ALL 0% 20% 40% 60% 80% 100% {8 Clinic or doctor's office J Health Department § Urgent Care Center or a Walk-In Clinic Note: Statistically significant difference (p=0.000). Columns may not total to 100% due to rounding. NULLIPAROUS WOMEN BLACK OR 5.2% AFRICAN way a AMERICAN BO 3.5% 28% WHITE a 4.7% ALL TAs a 0% 20% 40% 60% 80% 100% {§) Clinic or doctor's office {) Health Department 8) Urgent Care Center or a Walk-In Clinic Note: Statistically significant difference (p=0.000). Columns may not fotal to 100% due to rounding. 18 of 46 Parous respondents overwhelmingly reported relying on private physicians offices or clinics as site of service for birth control. A statistically significant difference was observed between black and white women by site of service. More black women reported relying on public health departments than white women. Like parous respondents, a full two-thirds of nulliparous women reported getting birth control in a clinic setting. However, black women reported using public health department clinics for birth control services nearly seven times the rate of white women, a statistically significant difference. This difference is noteworthy as public health departments in Mississippi are currently less likely to offer the full range of contraceptive services, including the most effective reversible methods, or to have clinicians regularly available who are trained in providing the most effective methods. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 How Birth Control Is Paid for by Race and Parity PAROUS WOMEN NULLIPAROUS WOMEN 100% : : 100% 90% 90% 80% 80% 78.3% 70% 70% 60% 60% 50% 50% ix 40% TAY TY 40% 30% 30% 20% 20% 10% j 10% ti 0 Ne Ee 1.3% ° BLACK WHITE ALL ° BLACK WHITE ALL MM Pubic WE Private I SelfPay MM Pubic [Private MM Self Pay Note: Statistically significant difference (p=0.000). Note: Statistically significant difference (p=0.000). Payment for birth control differed significantly by race among Over 80 percent of nulliparous respondents reported using parous women. Roughly four times as many black women with insurance for birth control, and nearly 60 percent reported private children reported relying on public insurance for birth control than coverage from employers or directly purchased. Black women were white women with children. twice as likely as white women to report using public insurance to cover the cost of birth control. The percentages of women reportedly paying out of pocket were roughly equivalent across black and white groups. This difference in payor type by race among nulliparous women was statistically significant. Source: Women's Health Care and Contraceptive Practices in Mississippi. 19 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Primary Birth Control Effectiveness Type by Race and Parity PAROUS WOMEN 100% 80% 1% 60% 40% 20% BLACK WHITE ALL HB Least Effective ii Moderately Effective BB Most Effective Note: Statistically significant difference (p=0.005). Among women who have had children and who currently use birth control, fewer than 10 percent reported using the least effective methods. Among black and white women, the majority reported using moderately effective methods. For all groups, reported use of the most effective methods was high relative to nulliparous women; however, white parous women reported using the most effective methods twice as often as black parous women. This difference in method effectiveness by racial groups was statistically significant. NULLIPAROUS WOMEN 100% 82.7% 81.3% 81.2% 80% 60% 40% 20% 9, 0% BLACK WHITE ALL W Least Effective Moderately Effective BB Most Effective Note: Statistically significant difference (p=0.000). A majority of nulliparous women, white and black, reported currently using a method of birth control that is moderately effective, such as hormonal injections, birth control pills, or the hormonal patch. White respondents were nearly three times as likely as black respondents to report using the most effective methods of contraception. Black women were more than twice as likely to report relying on the least effective methods. This observed difference was found to be statistically significant. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Summary of Key Findings Related to Race Fewer black women than white women reported using ob-gyn's for reproductive health care and birth control. This difference is important as ob-gyn's are more likely than family practice physicians and nurse practitioners (providers black women more frequently report seeing) to be trained to provide all methods of birth control including the most effective reversible forms. The differences were reported by both parous and nulliparous women, but a starker disparity is evident among the nulliparous group. More black parous women reported relying on public insurance to cover birth control than white women. This difference was observed for both parous and nulliparous groups, but most obvious for women who have given birth. Mississippi has wide racial health inequities that extend to reproductive health and family planning. Most alarming are the rates at which black women experience negative maternal and infant health outcomes (e.g. pre-term birth, maternal mortality). Effective contraception and family planning can be key to improving health outcomes for pregnant women and their children by helping to extend intervals between pregnancies. Previous research has indicated differences in contraceptive use among black and white women in publicly funded clinics*. The survey data presented here indicated these differences may exist across settings and payor type for both racial groups. * Unintended Pregnancy in Mississippi, An Analysis of Unintended Pregnancy in Mississippi, 21 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Parous Respondents Parous women, generally, are more likely to engage with the health system due to their prior pregnancies. Pre and post natal visits provide ample opportunity for counseling by a provider best trained to provide all methods of birth control. In this sample, they were also more likely to report relying on an ob-gyn for reproductive health services and birth control. 22 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Reason to Use Birth Control, Parous Women TOP 3 REASONS REPORTED FOR USING BIRTH CONTROL (CHECK ALL} Avoid Pregnancy Reduction of Negative Symptoms Recommended by Health Care Provider 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PERCENT OF RESPONDENTS METHOD EFFECTIVENESS OF PRIMARY METHOD OF BIRTH CONTROL, PAROUS WOMEN I Least Effective Methods HB Moderately Effective Methods I Most Effective Methods Just 49 percent of parous respondents reported using birth control currently. Of those, 83.7 percent selected pregnancy avoidance as a reason that they do so. One-fifth reported relying on birth control to reduce negative symptoms of their menstrual cycle and another 18 percent reported using birth control at the recommendation of a healthcare provider. The clear intent to avoid pregnancy may be echoed in the choice of birth control that parous women report making. Over a quarter of parous women reported using the most effective methods of birth control with fewer than 10 percent relying on methods that are the least effective at preventing pregnancy. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Decision Making and Knowledge of Birth Control Methods, Parous Women REPORTED TOP 3 FACTORS INVOLVED IN YOUR DECISION TO USE OR NOT USE BIRTH CONTROL How easy it is to use 36.6% Side effects or health complications 35.7% Helping reduce problems | have had with my cycle 32.5% My ability to become pregnant later 29.4% How long it works 27.2% How likely | will get pregnant using it 26.9% My healthcare provider's recommendation 24.6% Cost or what my insurance will/will not cover 16.8% How much responsibility/time it requires from me 16.1% The hormones it has in it 16% How easy it is to get 14.3% How it may affect me having sex 8.5% What my partner thinks about it 8.2% Religious and/or moral beliefs |) 3.8% 0% 20% 40% 60% 80% 100% PERCENT OF RESPONDENTS REPORTED TOP 3 SOURCES USED FOR DECISION MAKING ABOUT BIRTH CONTROL Gynecologist or OB-GYN Friends or peers 84.3% My mother/a mother figure in my life Other healthcare provider Online sources Other relatives Printed sources Social media 8.4% Teacher(s) or counselor(s) 74% Spiritual leader(s) } 3.5% Other news sources |] 2.8% 0% 20% 40% 60% 80% 100% PERCENT OF RESPONDENTS 24 of 46 Survey participants were asked to select the top 3 factors involved in their decisions to use or not use birth control, as well as the top 3 sources of information used for making decisions about birth control. Perhaps surprisingly, the effectiveness or how likely a woman is to get pregnant using a birth control method was only the sixth most frequently selected factor for using a method. Ease of use and side effects were the most frequently selected factors in deciding to use a method. The majority of parous respondents reported relying on a healthcare provider as a top source of information used in deciding about a birth control method (84.3% reported ob-gyn and 37.9% reported other healthcare provider). Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = wuLy 2019 Experience and Knowledge of Birth Control Methods, Parous Women CURRENT BIRTH CONTROL METHODS BY THE TYPES OF BIRTH CONTROL WOMEN KNOW ENOUGH ABOUT TO MAKE A CHOICE Birth Control Pills Male Condoms Withdrawal Shois/Injections Emergency Contraception Not Having Sex at Certain Times Contraceptive Ring Female Condoms Contraceptive Patch Hormonal IUD Contraceptive Implant Foam, Jelly, Film, or Cream Copper IUD Diaphragm, Cervical Cap, or Sponge 0% 20% 40% 60% 80% |_| Type of Birth Control Women Know Enough About to Make a Choice I Birth Control Ever Used Note: Statistically significant relationship (p=0.000). Source: Women's Health Care and Contraceptive Practices in Mississippi. Parous women more often reported knowing enough about moderately effective methods (e.g. pills, hormonal injection, contraceptive ring) and least effective methods (e.g. withdrawal, condoms, natural family planning) to make a decision about using those methods than knowing enough about the most effective permanent and reversible methods (e.g. sterilization, |UDs, and implants). A statistically significant association was found between the types of birth control parous women reported knowing enough about to make a choice and the types of birth control they had ever used. A reasonable implication of this association is that women using birth control will use only methods they feel they know enough about, which further suggests that a lack of knowledge about methods may be limiting women's full range of contraceptive choices. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Current Method of Birth Control and Satisfaction by Method, Parous Women PRIMARY BIRTH CONTROL METHOD, PAROUS WOMEN BIRTH CONTROL PILLS 44.3% lUD Sixty-three percent of women with children reported using a SHOTS/INJECTIONS moderately effective method of birth control as their primary method with birth control pills being the most reported method (44.3%). PATCH OR RING Nearly one-third of respondents reported relying on the most IMPLANT effective methods (reversible and permanent). CONDOMS (MALE & FEMALE) STERILIZATION (MALE & FEMALE) 0% 10% 20% 30% 40% 50% PERCENT OF RESPONDENTS Note: Withdrawal, Emergency Contraception, and Other Method accounted for less than 1% of responses. SATISFACTION BY METHOD EFFECTIVENESS, PAROUS WOMEN 100% fe 80% 60% 1% One hundred percent of users of the most effective methods reported being very satisfied with their method. Women who reported using moderately effective methods report high levels of satisfaction with minimal reports of dissatisfaction. Users of the least effective methods also reported relatively high levels of satisfaction but also 1% (% 2% the highest levels of ambivalence and dissatisfaction. 40% 40% 24% 25% 20% 9% 5% 5% 0% 5% 5% 39 0% 3% omen 0% VERY SOMEWHAT NEITHER SOMEWHAT VERY SATISFIED SATISFIED DISSATISFIED DISSATISFIED I Least Effective Jj Moderately Effective Jj Most Effective [ij All Source: Women's Health Care and Contraceptive Practices in Mississippi. 26 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Sense of Control by Method Effectiveness, Parous Women RESPONSES TO "I AM IN CONTROL OF MY REPRODUCTIVE HEALTH" BY BIRTH CONTROL EFFECTIVENESS 100% : : : : I I I I I I I I I I I I ye] RMA 1.5 32.4% ' ' ' 80% I I I I I I I I I I I I ' ' ; Among parous respondents, a woman's sense of control over her 60% ' ' ' reproductive health tracked very closely to method effectiveness, ° ' ' ' where users of the most effective methods reported the greatest we levels of control and users of the least effective methods reported the lowest levels of control. For all method effectiveness groups, so ( ge Lt the majority of respondents (over 80%) reported a sense of control Bes) . . . . 1 1 ° le over their reproductive health. No significant relationship was found I I I I . 1 1 1 between method effectiveness and sense of control for parous I I I I women. 20% I I I I I I I I I I I I I I I I I 1 1 I WWAsy: 0% 1 I I 0% I '0 Strongly Agree Neutral Disagree Strongly Agree Disagree ff Least Effective [Jj Moderately Effective [Jj Most Effective Note: Columns may not total to 100% due to rounding. Source: Women's Health Care and Contraceptive Practices in Mississippi. 27 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Reported Discouragement from a Specific Birth Control Method by Provider, Parous Women EVER DISCOURAGED FROMA TYPE OF BIRTH CONTROL BY APROVIDER, PAROUS WOMEN Just 18 percent of women with children reported ever being discouraged by a healthcare provider from using a particular birth control method. For those who reported discouragement from a particular method, those methods were most frequently identified as moderately effective methods, followed by the most effective methods and finally the least effective methods. HE No Hi Yes No association was found between reported discouragement and payor, suggesting that insurance type (public or private or none) is not a barrier for women in this sample if they want a particular type TYPE OF BIRTH CONTROL DISCOURAGED BY of birth control. HEALTHCARE PROVIDER, PAROUS WOMEN (N=135) NUMBER OF 9, WOMEN 62.8% 23.3% 0% 20% 40% 60% 80% 100% [lj Least Effective [Jj Moderately Effective [jj Most Effective Note: Columns may not total to 100% due to rounding. Source: Women's Health Care and Contraceptive Practices in Mississippi. 28 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = vuty 2019 Attitudes About Reproductive Health By Race, Parous Women ATTITUDES ABOUT REPRODUCTIVE HEALTH BY RACE, PAROUS RESPONDENTS Overall parous respondents reported high levels of perceived | am in control of my reproductive health. control over their reproductive health, as well as acknowledging BLACK rr responsibility for finding out how to avoid pregnancy if they desired to. They expressed high levels of disagreement with statements WHITE 85.8% of apathy and fatalism about becoming pregnant and lower levels 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% of deference to healthcare providers' expertise about pregnancy If | want to avoid getting pregnant or having a baby, it is my responsibility to find out how to do that. avoidance. BLACK Parous women of both racial groups responded similarly to attitude WHITE statements. However, a statistically significant difference between groups was found in agreement with the statement that "No matter 0% 10% 20% 50% 10% 50% 0% 0% 80% 0% 100% what | do, I'm likely to get pregnant" with 16 percent of black women If it is meant to be, there is little | can do to stop myself from becoming pregnant. reporting agreement compared to fewer than eight percent of white BLACK aR RG 51.6% women. WHITE an arr ATTITUDES ABOUT REPRODUCTIVE HEALTH, ALL PAROUS RESPONDENTS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% | |am in control of my reproductive health *NomatterwhatIdo,mlikelytogetpregnant. ££ +=&§ = = ea Tes a If want to avoid getting pregnant...itis my responsibility = 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ifit is meant to be, there is little | can do to stop myself from becoming pregnant. ony ath cars rosin ike dts nd rare) can ev shoul do nd doo geting regan m7 Only health care professionals (like doctors and nurses) can tell me what | should do and not do to avoid getting pregnant. 18.1% RA No matter what | do, I'm likely to get pregnant. 12.0% | 11.2% Rs BLACK WHITE | ech BLACK WHITE 20.6% 51.0% Only health care professionals (like doctors and nurses) can tell me what I should 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% do and not do to avoid getting pregnant. The best way to care for my reproductive health is to visit or talk to my healthcare provider regularly. Roby 19.8% CTA BLACK The best way to care for my reproductive health is to visit or talk to my healthcare provider regularly. I O% = 10% = 20% = 30% = 40% = 50% = 60% = 70% = 80% =- 0% = 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% fl Agree & Strongly Agree [J Neutral {MJ Disagree & Strongly Disagree [ Agree & Strongly Agree (Neutral §§) Disagree & Strongly Disagree WHITE Note: * Indicates statements that were found to have a statistically significant difference by race (p=0.004). Source: Women's Health Care and Contraceptive Practices in Mississippl 29 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Nulliparous Respondents Like parous women in this sample, nulliparous respondents reported relying predominantly on ob-gyn's for birth control and reproductive health services. However, they also reported using family practice physicians and nurse practitioners at higher rates than parous women. 30 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Reason to Use Birth Control, Nulliparous Women RESPONSES Reduction of negative symptoms Avoid Pregnancy associated with menstruation It was recommended to me by a healthcare provider 0% 20% 40% 60% 80% PERCENT OF RESPONDENTS NULLIPAROUS WOMEN, METHOD EFFECTIVENESS OF PRIMARY BIRTH CONTROL I Least Effective Methods HN) Moderately Effective Methods [I Most Effective Methods Among nulliparous respondents, pregnancy avoidance was selected by two-thirds of women as the reason they use birth control. Thirty- three percent reported relying on birth control to reduce negative symptoms of their menstrual cycle and another 28 percent reported using birth control at the recommendation of a healthcare provider. Effectiveness at preventing pregnancy is the primary characteristic used to judge quality of a method. In fact, effectiveness is described as the likelinood that a method will fail given typical use in a year. Fewer than 13 percent of nulliparous respondents reported using the most effective methods. Just over six percent of nulliparous respondents reported using the least effective methods. The great majority of reported relying on moderately effective methods like birth control pills or injections. Moderately effective methods require varying levels of effort on the part of the woman as well as engagement with a clinical provider to maintain consistent effectiveness. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Decision Making and Knowledge of Birth Control Methods, Nulliparous Women REPORTED TOP 3 FACTORS INVOLVED IN YOUR DECISION TO USE OR NOT USE BIRTH CONTROL My health care provider's recommendation 32% Helping reduce problems | have had with my cycle 31.9% How easy it is to use 31.8% Side effects or health complications 29.7% My ability to become pregnant at a later time How long it works How easy it is to get How likely | will get pregnant using it The hormones it has in it How much responsibility/time it requires from me Cost or what my insurance will/will not cover What my partner thinks about it How it may affect me having sex Religious and/or moral beliefs 6.6% Other} | 2.4% 0% 5% 10% 15% 20% 25% 30% 35% PERCENT OF RESPONDENTS *Note: Percentages may not total to 100% due to rounding. For nulliparous respondents, a healthcare provider's recommendation of a specific method was the most frequently reported personal top 3 factor involved in choice for birth control. Method effectiveness or "how likely | will get pregnant using it" was the eighth most frequently reported factor in choice for birth control. Thirty-six percent of respondents indicated a healthcare provider as a top 3 source of information used in deciding about birth control. A gynecologist or ob-gyn was the most frequently selected source of information (22%). A mother figure and a peer or friend were also frequently reported as a Top 3 source of information. Nulliparous REPORTED TOP 3 SOURCES USED FOR DECISION MAKING ABOUT BIRTH CONTROL women reported relying on other people as sources of information over personal reading, research or exposure through broadcast Gynecologist or OB-GYN . 9 media. My mother/a mother figure in my life Friends or peers Other healthcare provider (doctor, nurse...) Other relatives Online sources (Google, Wikipedia, etc.) Printed sources (books, magazines...) Teacher(s) or counselor{s) Social media Spiritual leader(s)| 4.9% Other news sources (TV, podcasts, radio...)|7) 4.8% Other| 0.7% 0% 20% 40% 60% 80% 100% PERCENT OF RESPONDENTS Source: Women's Health Care and Contraceptive Practices in Mississippi. 65.5% 32 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Experience and Knowledge of Birth Control Methods, Nulliparous Women TYPES OF BIRTH CONTROL NULLIPAROUS WOMEN KNOW ENOUGH ABOUT TO MAKE A CHOICE Birth Control Pills Male Condoms Withdrawal Shots/Injections Emergency Contraception Not Having Sex at Certain Times Contraceptive Ring Female Condoms Contraceptive Patch Hormonal IUD Contraceptive Implant Foam, Jelly, Film, or Cream Copper IUD Diaphragm, Cervical Cap, or Sponge 0% 20% 40% 60% 80% a Type of Birth Control Women Know Enough About to Make a Choice WS Birth Control Ever Used Note: Statistically significant relationship (p=0.000). Like parous respondents, nulliparous women more often reported knowing enough about moderately effective methods (pills, hormonal injection, contraceptive ring) and least effective methods (withdrawal, condoms, natural family planning) to make a decision about using those methods than about the most effective permanent and reversible methods (sterilization, intrauterine devices (IUD), and implants). A statistically significant association was found between the types of birth control parous women reported knowing enough about to make a choice and the types of birth control they had ever used. A reasonable implication of this association is that women using birth control will use only methods they feel they know enough about, which further suggests that a lack of knowledge about methods may be limiting women's full range of contraceptive choices. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Current Method of Birth Control and Satisfaction by Method, Nulliparous Women PRIMARY BIRTH CONTROL USED BY METHOD EFFECTIVENESS, NULLIPAROUS BIRTH CONTROL PILLS 58.3% SHOTS/INJECTIONS CONDOMS (MALE & FEMALE) PATCH OR RING EMERGENCY CONTRACEPTION IUD WITHDRAWAL IMPLANT 0% 10% 20% 30% 40% 50% 60% . . Over 80 percent of nulliparous women reported using a moderately PERCENT OF RESPONDENTS . - effective method as their primary form of birth control, the greatest Diaphragrn ootvioal xp. ce sponge (Fancapy Panetta cre number of whom use birth control pills, a method that requires daily effort and, typically, monthly prescription refills. SATISFACTION BY METHOD EFFECTIVENESS, NULLIPAROUS Satisfaction with a method was highest among women who use 100% ; ; the most effective methods with no degree of ambivalence or dissatisfaction reported. Women who reported using moderately effective methods and least effective methods also reported high levels of satisfaction and minimal ambivalence. 80% 18% wos 76% 80% 61% 60% 40% 19% 20% 0; 23% | 20% 20% 14% 3% 2% gy, 3% 0% 0% 0% :9% | 0% 0% 0% 4% VERY SOMEWHAT NEITHER SOMEWHAT VERY SATISFIED SATISFIED DISSATISFIED DISSATISFIED 0% {) Least Effective {§§) Moderately Effective [J Most Effective [ij All Note: Statistically significant difference (p=0.00). Source: Women's Health Care and Contraceptive Practices in Mississippi. 34 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Sense of Control by Method, Nulliparous Women RESPONSES TO "I AM IN CONTROL OF MY REPRODUCTIVE HEALTH" BY BIRTH CONTROL EFFECTIVENESS 100% : : : | au I I I I I I I I I I I I 80% ; ; ' ' . _ i i i For all method effectiveness groups, the majority of respondents agreed that they felt a sense of control over their reproductive health. A statistically significant association was found between the 60% / ae, method effectiveness and sense of control. Nulliparous women with I I °) I I . ! sei the least sense of control (and also the greatest ambivalence) were ae! 74.1% respondents who reported using the least effective methods of birth control. These methods tend to be single use methods requiring the 40% greatest consistency. I I I I I I I I I I I I I I I I I I I I 20% 1 l l l I I I I | ee ss | ee | (eee tS BoW Ay I I I I I I I I 0% " ° ° ° Strongly Agree Neutral Disagree Strongly Agree Disagree { Least Effective [| Moderately Effective {§§j Most Effective Note: Statistically significant difference (p=0.024). Source: Women's Health Care and Contraceptive Practices in Mississippi. 35 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Reported Discouragement from a Specific Birth Control Method by Provider, Nulliparous Women EVER DISCOURAGED FROM A TYPE OF BIRTH CONTROL BY APROVIDER, NULLIPAROUS WOMEN 85.9% WW No Yes TYPE OF BIRTH CONTROL DISCOURAGED BY HEALTHCARE PROVIDER, NULLIPAROUS WOMEN (N=118) NUMBER OF WOMEN | We 57.6% PAW 0% 20% 40% 60% 80% 100% 1 Least Effective {J Moderately Effective {J Most Effective Fewer than 15 percent of nulliparous women reported ever being discouraged by a healthcare provider from using a particular birth control method. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Attitudes About Reproductive Health by Race, Nulliparous Women ATTITUDES ABOUT REPRODUCTIVE HEALTH BY RACE, NULLIPAROUS RESPONDENTS Most nulliparous respondents reported feeling that they are in control of their reproductive health and that it is their responsibility to take measures to avoid pregnancy if they want to. | am in control of my reproductive health. BLACK WHITE Close to half disagreed with statements that reflect an inability 0% 0% 0% xm oe om sm om" 0m xm 100% to avoid pregnancy. Black and white respondents were much -- 2-28 EE EEE SE EEE aligned in these views until the role of the healthcare provider was *If | want to avoid getting pregnant or having a baby, it is my responsibility to find out how to do that. raised. Twice as many black women (60%) as white women (31%) BLACK agreed that only healthcare providers can tell them how to avoid pregnancy. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The majority of both groups agreed that the best way to care for If it is meant to be, there is little | can do to stop myself from becoming pregnant. their reproductive health is through regular visits to a healthcare = a, provider. ATTITUDES ABOUT REPRODUCTIVE HEALTH, ALL NULLIPAROUS RESPONDENTS WHITE 17.5% nS | am in control of my reproductive health 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% a ern ee *No matter what | do, I'm likely to get pregnant. - 12.7% Ry If | want to avoid getting pregnant...it is my responsibility HbR y7 1s 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% oo naan BST fo BSS oS Pon Bonen Po 32.8% ran YT *Only health care professionals (like doctors and nurses) can tell me what | should do and not do to avoid getting pregnant. WHITE BLACK BLACK WHITE No matter what | do, I'm likely to get pregnant. 15.3% PZB PX WaL 13.2% 63.5% BLACK WHITE VAAL CUA} -- - = ----------------------------- Only health care professionals (like doctors and nurses) can tell me what | should 0% 10% 20% 30% 40% 80% 60% 70% 80% 90% 100% do and not do to avoid getting pregnant. *The best way to care for my reproductive health is to visit or talk to my healthcare provider regularly. es BLACK 10.0% | 10.8% The best way to care for my reproductive health is to visit or talk to my healthcare - provider regularly, ws nom A 1 OI 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (0) Agree & Strongly Agree {J Neutral [§§ Disagree & Strongly Disagree (0) Agree & StronglyAgree Neutral § §§ Disagree & Strongly Disagree Note: * Indicates statements that were found to have a statistically significant difference by race (p=<0.05). Source: Women's Health Care and Contraceptive Practices in Mississippi. 37 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 LARC Appendix 38 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Knowledge and Beliefs about LARC by Race, Parous Women LARC KNOWLEDGE BY RACE 'In Mississippi the Medicaid Family Planning Waiver Program covers the cost of IUDs and implants. sit 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BLACK WHITE *IUDs and implants are a type of birth control that can be reversed at any time. Zr 1% 0% 10% 20% 30% 40% 50% 60% 10% 80% 90% 100% BLACK WHITE *IUDs and implants are too expensive. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 32.7% 29.0% 23.1% OORSh 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% i Agree J Don'tKnow [ij Disagree BLACK WHITE Note: *Indicates a statistically significant difference by race (p=<0.05). 39 of 46 A majority of women from both racial groups agreed with the statement that "If an IUD or implant was right for my health my healthcare provider would have recommended it to me." Statistically significant differences in knowledge and beliefs about long-acting reversible contraception (LARC) were found between racial groups among parous women. Black women were less likely than white women to agree that IUDs and implants (LARC methods) could be reversed at any time, and many also reported not knowing. Conversely, they were more likely to agree that IUDs were too expensive and that surgery was required to have one. These perceptions may lead women to believe that these methods are not appropriate for them. For some questions, half or more of respondents for both racial groups answered "Don't know' which is notable, as participants indicated elsewhere in the survey that they use those methods that they know enough about to make a decision. Additional questions about LARC were asked with no significant difference between groups found. The questions were: = |UDs and implants are some of the most effective types of birth control = |UDs and implants cause medical problems like pelvic inflammatory disease, etc. = Women who are under 18 need a parent's consent to have and IUD or implant put in. = Women of all ages can use IUDs. = [fan IUD or implant was right for me, my healthcare provider would have recommended it to me. = You must have a child to use an IUD. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Knowledge and Beliefs about LARC by Race, Nulliparous Women LARC KNOWLEDGE BY RACE "IUDs and implants are a type of birth control that can be reversed at any time. 35.0% rae Pen 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *IUDs and implants are too expensive. BLACK WHITE BLACK SloKOY/ 43.8% 20.2% WHITE Vail brah RNA 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *You must have a child to use an IUD. BLACK 38.0% 39.9% WHITE | ayA7: 33.5% 59.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% "If an IUD or implant was right for my health my healthcare provider would have recommended it to me. BLACK Brn 33.2% rn WHITE Baar ye 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% "Women have to have surgery to have an IUD. BLACK 33.2% ClO) 26.8% WHITE PAN A SN OR 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% "Women of all ages can use IUDs. BLACK Cay 38.6% 19.9% WHITE Za 47.9% 27.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Agree [) Don'tKnow {i Disagree Note: "Indicates a statistically significant difference by race (p=<0.05), 40 of 46 Statistically significant differences in knowledge and beliefs about long-acting reversible contraception (LARC) were found between racial groups among nulliparous women. Black women were less likely than white women to agree that IUDs and implants (LARC methods) can be reversed at any time. They were more likely to agree that IUDs are too expensive and that surgery is required to have one inserted. White women were more likely to disagree that women of all ages can use an |UD. These perceptions may lead women to believe that these methods are not appropriate for them. Like parous respondents, almost half or more of nulliparous respondents for both racial groups answered "Don't know" for some questions, which is notable, as participants indicated elsewhere in the survey that they use those methods that they know enough about to make a decision. A majority of women from both racial groups agreed with the statement that "If an IUD or implant was right for my health my healthcare provider would have recommended it to me." Additional questions about LARC were asked with no significant difference between groups found. The questions were: = |UDs and implants are some of the most effective types of birth control = IUDs and implants cause medical problems like pelvic inflammatory disease, etc. =» Women who are under 18 need a parent's consent to have an IUD or implant put in = In Mississippi, the Medicaid Family Planning Waiver Program covers the cost of |UDs and Implants. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Experience Accessing LARC by Provider Type, Parous Women PROVIDER WHO INSERTED IUD PAROUS N=122 OB-GYN 89% (109 out of 122 women) FAMILY PRACTICE 2% PHYSICIAN (3 out of 122 women) NURSE PRACTITIONER 7% (9 out of 122 women) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PROVIDER WHO INSERTED IMPLANT PAROUS N=71 OB-GYN 83% (59 out of 71 women) FAMILY PRACTICE 6% PHYSICIAN (4 out of 71 women) NURSE PRACTITIONER 1% (5 out of 71 women) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 41 of 46 LARC methods (i.e. |UDs and implants) are provider-dependent methods, meaning a trained clinician is required to insert or remove them. Ob-gyn's are the clinician type most likely to be trained to insert these methods, although other clinicians can be trained to do so. Among parous women in this sample, the majority reported that an ob-gyn inserted their |UD (89%) or implant (83%). Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = vuty 2019 Experience Accessing LARC by Timing, Parous Women WHEN PROVIDER INSERTED IUD WHETHER LARC WAS INSERTED AS SOON AS DESIRED PAROUS N=108 PAROUS N=157 AGREE/ 7 100% STRONGLY AGREE 8% (137 out of 157 women) 80% I I Pee ee ee nn en enn rrr ner I I I 61% ; ; ; NEUTRAL | 3% 60% I I I (5 out of 157 women) I I eee ee ee ee eee ee ee ee eee ee ee ee ee ee eee I I I 10% ! oe ! ! DISAGREE/ 10% STRONGLY DISAGREE I I I 20% (20 out of 157 women) I I I ; ! 3% ! 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ata scheduled appointment Ata visit soon after m woe . . . 0 PPO ee bith wath. In the emergency room The same day The timing of an appointment for insertion or removal of a LARC after talking to my child's birth with my as an emergency | requested it naan ae _ healthcare provider first healthcare provider contraception method often depends on clinician availability (not all clinics are (66 out of 108 women) (37 outof 108 women) (3 outof 108 women) (2 out of 108 women) staffed by clinicians trained to provide a LARC during all service hours) and inventory of LARC devices which, due to high upfront costs, many clinics order only after a confirmed appointment for a WHEN PROVIDER INSERTED IMPLANT specific patient. LARC insertions on the same day that a woman PAROUS NE7' first requests a device are not the norm, and often, women are +004 required to have at least two appointments for counseling, insertion, ° and follow-up. | | | | | | 80% ; ; Some insurance providers reimburse providers for immediate postpartum LARC insertions and insertions within six weeks of 60% delivery. 46% : : : 40% 319% The majority of parous women in this sample using |UDs and implants (87%) reported receiving their LARC as soon as | | 0, | . . . 20% ! ! 18% ! they wanted it. Most of those insertions occurred at a second a 4% appointment. Implants were slightly more likely to be inserted the 0% ~ _ same day service as requested. Ata scheduled appointment Ata visit soon after my In the emergency room The same day after talking to my child's birth with my as an emergency | requested it healthcare provider first healthcare provider contraception (33 out of 71 women) (22 out of 71 women) (13 out of 71 women) (3 out of 71 women) Source: Women's Health Care and Contraceptive Practices in Mississippi. 42 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = JuLy 2019 Experience Accessing LARC by Provider Type, Nulliparous Women PROVIDER WHO INSERTED IUD NULLIPAROUS N=43 OB-GYN 10% (30 out of 43 women) FAMILY PRACTICE 16% PHYSICIAN (7 out of 43 women) NURSE PRACTITIONER (4 out of 43 women) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The majority of nulliparous respondents, like their parous counterparts, were more likely to report that an ob-gyn inserted their IUD or implant, although a higher percentage reported receiving the service from a Family Practice Physician or Nurse PROVIDER WHO INSERTED IMPLANT Practitioner (14% for nulliparous v. 6% for parous; 14% for NULLIPAROUS N=36 nulliparous v. 7% for parous, respectively). OB-GYN 61% (22 out of 36 women) FAMILY PRACTICE 14% PHYSICIAN (5 out of 36 women) NURSE PRACTITIONER 14% (5 out of 36 women) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: Women's Health Care and Contraceptive Practices in Mississippi. 43 of 46 Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Experience Accessing LARC by Timing, Nulliparous Women WHEN PROVIDER INSERTED IUD NULLIPAROUS N=43 100% 79% 80% ! ! ! ! ! ! 60% ! ! ! ! ! ! 1 1 1 40% 1 1 1 1 1 1 20% 1 14% 1 0 1 1 | | 9, 1 1 eee L Ata scheduled appointment = Atavvisitsoon aftermy --_[n the emergency room The same day after talking to my child's birth with my as an emergency | requested it healthcare provider first healthcare provider contraception (34 out of 43 women) (2 out of 43 women) (1 out of 43 women) (6 out of 43 women) WHEN PROVIDER INSERTED IMPLANT NULLIPAROUS N=36 100% 80% 18% I I 60% ; I I I I 40% ! ! 0, 20% ee I I 3 0% Atascheduled appointment Ata visit soon after my The same day | after talking to my child's birth with my requested it healthcare provider first healthcare provider (28 out of 36 women) (1 out of 36 women) (7 out of 36 women) WHETHER LARC WAS INSERTED AS SOON AS DESIRED NULLIPAROUS N=58 AGREE/ 0; STRONGLY AGREE ach (25 out of 58 women) NEUTRAL 28% (16 out of 58 women} DISAGREE/ 0, STRONGLY DISAGREE 92% (30 out of 58 women) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Although nulliparous women reported higher percentages of same- day IUD and implant insertions than parous women, a much higher percentage of nulliparous women reported that they did not receive their LARC as soon as they wanted it (62% v. 10%). Most of those insertions of both device types occurred at a second appointment. Implants were more likely to be inserted the same day as requested than IUDs. Source: Women's Health Care and Contraceptive Practices in Mississippi. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = Juty 2019 Glossary Family Planning Services-Clinical or nonclinical services provided to women and men who want to avoid unintended pregnancies or achieve intended pregnancies, including lab tests, education, counseling, prescription, and device placement. Method Effectiveness is based on the risk of unintentional pregnancy within the first year of typical use of each method. Most Effective Permanent- Less than 1 pregnancy per 100 women in a year. Male Vasectomy (0.15%) Female Sterilization (0.5%) Most Effective Reversible (_ARCs)-Less than 1 pregnancy per 100 women in a year. Hormonal Implant (0.05% Intrauterine Device (IUD) (0.2-0.8%) Moderately Effective- 6-12 pregnancies per 100 women in a year. Hormonal Injections (Depo Provera) (6%) Oral Contraceptive Pill (9%) Patch (9%) Diaphragm (12%) Less Effective-18 or more pregnancies per 100 women in a year. Male Condoms (18%) Female Condoms (21%) Withdrawal (22%) Sponge (12-24%) Fertility Awareness Method (FAM) (24%) Spermicide (28%) Long-acting reversible contraceptives (_ARCs)- Birth control methods that last 1-12 years and are reversible, including hormonal implants (Norplant, Nexplanon) and IUDs (Mirena, Skyla, Paragard, Liletta). IUDs are inserted in the uterus while implants are inserted into the upper arm. Medicaid Family Planning Waiver- A waiver of typical Medicaid eligibility criteria that enables uninsured men and women of reproductive age to receive reproductive health services including family planning services, preventive screening, and treatment for reproductive illnesses free of cost. Family Planning Waiver- A program of the Division of Medicaid that is 90% federally funded to offer reproductive and sexual health services to men and women who qualify based on income. Obstetrician-Gynecologist (ob-gyn)- A medical doctor with specialized training to provide reproductive healthcare services to women including care in all stages of pregnancy. Family Practice Physician- A medical doctor trained to provide primary care for all genders and ages including women's reproductive care, though often not to the full extent that ob-gyn's are. Nurse Practitioner- An advanced practice nurse trained to provide primary care including reproductive healthcare services to women within a limited scope. Center for Mississippi Health Policy = Chart Book: An Analysis of a Survey of Mississippi Women Regarding Contraception = wuty 2019 AN ANALYSIS OF A CONTRACEPTIVE SURVEY OF WOMEN IN MISSISSIPPI July 2019 Center forMississippi Health Policy Plaza Building, Suite 700 120 N. Congress Street Jackson, MS 39201 Phone 601.709.2133 Fax 601.709.2134 @mshealthpolicy www.mshealthpolicy.com