Shortcomings and disparities in contraception counseling and use by hypertensive individuals at risk for unintended pregnancy: a comparative analysis of the National Survey of Family Growth

Abstract

BackgroundHypertension is a leading cause of adverse pregnancy outcomes. These outcomes disproportionately affect Black individuals. Reproductive life planning that includes patient-centered contraception counseling could mitigate the impact of unintended pregnancy. ObjectiveThe primary objective of the study is to compare contraception counseling and use among hypertensive and non-hypertensive individuals at risk for unintended pregnancy. Our secondary objectives are 1) to evaluate the effect of race on the probability of counseling and the use of contraception and 2) to evaluate the methods used by individuals with hypertension. MethodsData from the 2015-2017 and 2017-2019 National Survey of Family Growth Female Respondent Files were used to analyze whether individuals who reported being informed of having high blood pressure within the prior 12 months received counseling about contraception or received a contraceptive method. Covariates considered in the analysis included age, race, parity, educational attainment, body mass index, smoking, diabetes, and experience with social determinants of health (SDH). The SDH covariate was based on reported experiences within five SDH domains: food security, housing stability, financial security, transportation access, and childcare needs. Linear probability models were employed to estimate the adjusted probability of receiving counseling and the use of a contraceptive. Using difference in difference analyses, we compared the change in counseling and use between hypertensive and non-hypertensive respondents by race, relative to White respondents. ResultsOf the 8,625 subjects analyzed, 771 (9%) were hypertensive. Contraception counseling was received by 26.2% (95%CI 20.4-31.9) of hypertensive individuals and 20.7% (95%CI 19.3-22.2) of non-hypertensive individuals. Contraception use was reported by 39.8% (95% CI 33.2-46.5) of hypertensive and 35.3% (95%CI 33.3-37.2) of non-hypertensive individuals. The linear probability model adjusting for age, parity, education attainment, body mass index, smoking, diabetes and SDH indicated that hypertensive individuals were 8 percentage points (95%CI 3, 18 percentage points). more likely to receive counseling and 9 percentage points (95%CI 3, 16 percentage points) more likely to receive contraception. Hypertensive Black individuals did not receive more counseling or use more contraceptives compared to non-hypertensive Black women. The lack of difference in counseling when hypertension is present is 13 percent less than the change we observed for White respondents when hypertension was present (p=0.01). The most frequently used contraceptive method among hypertensive individuals was combined oral contraceptive pills (COCs) [54.0% (95%CI 44.3-63.5%)]. ConclusionsDespite a higher likelihood of receiving contraception counseling and using contraception among hypertensive individuals at risk for unintended pregnancy, two-thirds of this population did not receive contraception counseling, and less than 40% used any contraceptive method. Furthermore, unlike for White individuals, Black individuals with hypertension did not receive more contraception care than non-hypertensive Black individuals. Of all those who used contraception, half relied on a method classified as Center for Disease Control Medical Eligibility Criteria Category 3. These findings highlight a substantial unmet need for safe and accessible contraception options for hypertensive individuals at risk for unintended pregnancy, emphasizing the importance of targeted interventions to improve contraceptive care and counseling in this population.