A Survey of Mississippi Women
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Mississippi women have historically reported high rates of unintended pregnancy. The Affordable Care Act and state-level health policies have broadened access to reproductive health services and contraception in recent years benefitting Mississippians of all incomes. Access to contraception including the most effective reversible forms of birth control is wider than ever. However, despite improved access, evidence suggests that utilization of the most effective methods of birth control is low. To understand how Mississippians access birth control generally, the Center for Mississippi Health Policy commissioned a survey of Mississippi women of reproductive age to understand what factors influence women’s choice of birth control methods and what barriers, if any, limit them in obtaining the method of their choice.
Survey respondents were recruited from a geographically diverse sampling that included women who had enrolled children in licensed daycare facilities across the state. These mothers also recruited women who had not given birth to a child (nulliparous). The final sample included parous (women who have given birth) and nulliparous respondents of reproductive age (15-44).
Women who have given birth to at least one child are described as parous, while women who have not given birth are described as nulliparous.
Providers and Coverage Are Key to Contraceptive Access
Both groups of women surveyed reported largely similar experiences of reproductive healthcare. Obstetricians and gynecologists (OB-GYNs) were most often reported as the provider type last seen for birth control, but parous respondents were much more likely to see an OB-GYN. Over one-third of nulliparous women relied on a family practice physician or nurse practitioner for birth control. Parous women report far higher rates of use of the most effective methods (Figure 1) and are less likely to be uninsured. Both nulliparous and parous women in this study reported high rates of insurance coverage. Approximately one-quarter of respondents reported that if they did not have insurance they would not be able to access birth control.
Birth Control Method Effectiveness
Effectiveness of preventing pregnancy varies across birth control methods. The most effective permanent methods are male and female sterilization, while the most effective reversible methods are Intrauterine Devices (IUDs) and hormonal implants often referred to as long-acting reversible contraceptives (LARCs).
Many types of birth control are available without having to access the healthcare system; these types of birth control are generally the least effective methods that have significantly higher rates of failure (i.e. unintended pregnancy). Moderately effective methods and the most effective methods (both permanent and reversible) are provider-dependent, meaning users must access the healthcare system to obtain them.
Decision-Making About Birth Control
Women’s Perceptions, Beliefs, and Knowledge
The vast majority of respondents report a belief in personal responsibility to prevent unintended pregnancy, as well as a sense of being in control of their reproductive health. However, factors outside a woman’s immediate sphere of control, including a lack of information about all methods, may impact her ability to access the best means for her to prevent pregnancy.
Responses indicate many women have common perceptions that may influence their choice or even whether they seek information from their provider:
| Statement | % Agree with Statement Parous | % Agree with Statement Nulliparous |
|---|---|---|
| If an IUD or implant was right for me my healthcare provider would have recommended it to me. | 70% | 57% |
| IUDs and implants are too expensive. | 22% | 33% |
| IUDs and implants cause medical problems like pelvic inflammatory disease, etc. | 45% | 47% |
Responses indicate gaps in knowledge about the most effective methods of contraception.
| Statement | % Don’t Know / Incorrect Answer Parous | % Don’t Know / Incorrect Answer Nulliparous |
|---|---|---|
| Women of all ages can use an IUD. | 69% | 63% |
| You must have a child to use an IUD. | 43% | 80% |
| IUDs and implants are a type of birth control that can be reversed at any time. | 29% | 42% |
As seen in the charts below, respondents are more likely to use methods they feel they know enough about to make a choice.
Provider Clinical Guidance
Providers play a critical role beyond just facilitating access to birth control; they may often be the primary factor influencing a woman’s choice of methods. Survey respondents overwhelmingly indicated reliance on providers as a key source for decision-making, for help in choosing a method, and for medically appropriate guidance. A 2018 survey of Mississippi providers documented significant differences in education by provider type; fewer than half of family practice doctors and nurse practitioners reported formal training in Long-Acting Reversible Contraceptives (LARC) counseling compared to 86 percent of OB-GYNs.
Comprehensive counseling has been linked to higher utilization of LARC methods, as shown by the Missouri CHOICE Project which saw 72 percent of participants choose a LARC method after counseling on the effectiveness, risks, benefits, and common side effects of all non-permanent options for birth control.
Additional Barriers to Obtaining Birth Control
Low-income women
Engaging with the health system is necessary for women who want highly effective birth control, and for most women in Mississippi, health insurance coverage is a crucial first step. Previous research has shown that publicly insured women in the state are less likely than privately insured women to use the most effective methods.
Approximately one quarter of respondents reported that if they did not have insurance they would not be able to use birth control.
Nulliparous women who paid for birth control out of pocket or by public insurance were more likely to report that their most recent visit to a provider was longer than a year ago. This can be a consequential length of time for users of moderately effective and most effective reversible birth control as these methods are provider-dependent and require a renewed prescription, administration of a drug, or a physical check annually to continue use. None of the parous women who paid for their birth control out of pocket reported currently using a LARC method, which has high upfront costs ($300-$1000) but is also the most cost-effective method due to the long life of the device (up to 12 years depending on the exact method).
Women under 25
Young women in Mississippi are at a disadvantage due to socioeconomic realities that are associated with age, such as lack of employer-based insurance or financial means of paying for health services. Women under 20 in this sample were much more likely to rely on public insurance for birth control, and women under 25 had relatively high rates of paying out of pocket (21 percent). Most women 15-19 with and without children are publicly insured (82 percent and 68 percent, respectively). Nulliparous women 15-19 reported the highest rates of seeing family practice doctors for birth control (27 percent), and the 2018 survey of Mississippi providers indicated 70 percent of family practice physician respondents would not recommend LARC for someone in this age group.
Black women
Access to birth control services is significantly different for both parous and nulliparous black women compared to white women. Black women are significantly more likely to report the following:
- relying on publicly funded clinics;
- relying on public insurance for birth control;
- seeing a family practice physician for birth control; and
- using a least effective method of birth control.
Nulliparous women
Nulliparous women are more likely to see family practice physicians or nurse practitioners for birth control and are less likely to use the most effective birth control methods. The fact that fewer nulliparous women than parous women see an OB-GYN is consistent with their pregnancy and childbirth status; however, it may reveal an additional barrier to receiving the most effective birth control methods prior to a first pregnancy.
84 and 65 percent of parous and nulliparous respondents, respectively, reported that their OB-GYN was their 3rd source for information about birth control.
Discussion
While efforts to improve contraceptive access for Mississippi women should not focus solely on increasing utilization of specific methods, efforts should be made to ensure that women have been informed of all of their options when choosing their best option. New insights gained from this survey highlight the critical role of providers in decision-making about birth control, as well as misperceptions and a lack of information about LARCs and other methods among respondents.
Demonstrated gaps in knowledge and differences in utilization of the most effective methods point to hurdles for Mississippi women beyond initial access barriers. A prior review of unintended pregnancy and a subsequent survey of Mississippi healthcare providers revealed several potential barriers to contraceptive access:
- Mississippi has very low usage rates for the most effective reversible methods;
- Many women seek care from providers who have not been trained to provide all methods of birth control; and
- Some providers hold beliefs and attitudes about the appropriateness of LARCs for certain patients that are inconsistent with national guidelines.
This survey provides additional insight on how women make decisions about birth control:
- Women use methods they feel they know enough about to make a decision;
- They rely heavily on their providers for information and guidance about birth control; and
- Few women indicate a comprehensive knowledge of birth control methods.
These findings corroborate the experience of other states: efforts to improve access to the most effective contraceptive methods must include both clinician training and patient education. Because many women in Mississippi use primary care clinicians for reproductive health and access to birth control, these providers should be trained in counseling women on all methods of contraception.
More information about this sample’s responses to questions of satisfaction, personal beliefs and attitudes, as well as an exploration by race and parity can be found in a complementary chartbook An Analysis of a Contraceptive Survey of Women in Mississippi. See also Preventing Unintended Pregnancy in Mississippi and Long-Acting Reversible Contraceptives: A Survey of Mississippi Healthcare Providers.
Sources
- Center for Mississippi Health Policy. (2018). Preventing Unintended Pregnancy in Mississippi. https://mshealthpolicy.com/preventing-unintended-pregnancies/
- Center for Mississippi Health Policy. (2018). Long-Acting Reversible Contraceptives: A Survey of Mississippi Healthcare Providers. https://mshealthpolicy.com/larc-provider-survey/
- Kolbo, J., Ismail, O., Mcleod, S., and Zhang, L. (2018). Women’s Health Care and Contraceptive Practices Survey.
- Pellegrine, I. & Southward, L. (2018). Long-Acting Reversible Contraceptives: Survey Results from Mississippi Health Care Providers. Social Science Research Center. Mississippi State University. Prepared for the Center for Mississippi Health Policy.
- Birgisson, N.E., Zhao, Q., Secura, G.M., Madden, T., and Peipert, J. (2015). Preventing unintended pregnancy: The contraceptive CHOICE project in review. Journal of Women’s Health, 24(5), 349–353. http://doi.org/10.1089/jwh.2015.519
