Provider Advice to Women May Vary by Women’s Social Class and Ethnicity
Low-income black and Latina women surveyed in the Los Angeles area were more likely than middle-class whites to say that during a current or recent pregnancy, a health care professional had advised them to limit their childbearing.1 In a multivariate analysis of the survey results, ethnicity and social class were the only characteristics associated with the odds that women had received this kind of advice. Low-income Latinas (along with women who had large families and unmarried women) also had elevated odds of saying that their doctor or someone else had discouraged them from having children.
The survey sample consisted of 193 low-income and 146 middle-class women who were pregnant or had given birth in the previous five years. Women were considered low-income if they were on welfare, had health coverage through Medi-Cal (California’s Medicaid program) or were uninsured; low-income participants were recruited at offices of the Special Supplementary Food Program for Women, Infants and Children. Women were classified as middle-class if they had a college or graduate degree and had health insurance other than Medi-Cal; these women were recruited at a variety of locations in middle-class neighborhoods and through electronic mailing lists.
Survey questions covered women’s demographic characteristics, their sources of reproductive health care and the topics they discussed with reproductive health care providers. Women’s reproductive health care experiences during pregnancy were measured through two scales: a three-item scale assessing restrictive recommendations regarding childbearing; and a four-item scale assessing discouragement of motherhood. Scores above the median on the first were taken to mean that women felt that their doctor or another medical professional had advised them to limit their childbearing, and scores above the median on the second were interpreted as an indication that women felt that their doctor or someone else had discouraged them from having children. Researchers used logistic regression to identify characteristics associated with these outcomes.
The low-income participants were 26 years old, on average; 33% were Latina, 26% were black, 26% were white and the rest reported a variety of other racial and ethnic backgrounds. Most were unmarried (68%), had a high school education or less (58%), and had an annual household income of less than $20,000 (73%). By contrast, the middle-class respondents were, on average, 35 years of age; 50% of these women were white, 16% Latina, 12% black and the remainder of other racial or ethnic backgrounds. The great majority were married (86%) and reported an annual household income of more than $40,000 (95%); this group was about evenly divided between women who had only a college degree and those who had a higher degree. Most women in both social class groups had one or two children; low-income women were more likely than middle-class respondents to have three or more.
Individual experiences that made up the restrictive recommendations scale were not widely reported: Thirteen percent of women said that while they were pregnant, a doctor or other health care provider had often or very often discussed with them the importance of limiting family size; 7–8% reported that a provider had often or very often talked with them about their undergoing sterilization or their partner’s having a vasectomy. Reports of experiences pointing to discouragement also were not common. Only 3% of participants said that they had often or very often felt that their doctor did not want them to have a child or that their doctor had tried to persuade them not to do so; 74% had generally considered their doctor supportive of their decision to have a baby, and 78% said that others were supportive of the pregnancy. The possible range of scores for each scale was 1–5, and the median score on each was 1.3, indicating relatively little experience with restrictive recommendations and discouragement.
The likelihood that a woman reported having received advice to limit her childbearing was significantly higher among low-income blacks and low-income Latinas than among middle-class whites (odds ratios from multivariate analysis, 3.2 and 3.4); no other characteristics included in the analysis (age, parity and marital status) were associated with having received such advice. Low-income Latinas also were more likely than middle-class whites to say they had been discouraged from having children (2.6). Parity and being unmarried were positively associated with women’s odds of having felt discouraged by their doctors’ and others’ support during their pregnancy (1.3 and 2.4, respectively).
While acknowledging the shortcomings of the sample and other methodological limitations, the researchers conclude that their study “provides insight into how low-income women and women of color perceive the care they receive and the role of health care providers in unequal treatment in reproductive health care.” They recommend several avenues for further study, including direct investigation of providers’ attitudes toward low-income patients and “how negative health care experiences affect women’s trust in the health care system and their providers, and how such issues affect willingness to seek care.”
1. Downing RA, LaVeist TA and Bullock HE, Intersections of ethnicity and social class in provider advice regarding reproductive health, American Journal of Public Health, 2007, 97(10):1803–1807.