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Health Disparities and Bias in Contraception Access and Care

Medically Reviewed by Nivin Todd, MD on June 13, 2022

If you’re sexually active, odds are you’ve come across some form of contraceptive (birth control). That could be a pill, a condom, a patch, or an intrauterine device (IUD). In fact, it’s estimated that 99% of women ages 15-44 who have had sex have used at least one type of birth control. But your race, social and economic factors, and even your ZIP code can play a role in whether you have access to effective and affordable birth control options.

Studies show that more than 19 million women live in “contraceptive deserts” in the U.S. These are places that lack access to a full range of birth control methods. Among those people, about 1.2 million live in counties that don’t have a single health center that has complete birth control services.

What Are the Common Barriers to Birth Control Access?

Access to effective birth control is important in terms of public health, especially since almost 50% of the pregnancies in America are not intended. But access to affordable health care isn’t available everywhere across the U.S. This causes gaps in equal and equitable (fair) ways of getting birth control. And that can affect overall health outcomes for women, especially among people of color and people who live in low-income communities.

If you need birth control and are looking for options, you might face many systemic roadblocks along the way.

Some common barriers include:

Racial and ethnic bias. People of color face several social and structural issues that affect their access to effective birth control. For one, Hispanic and Black women have the highest rates of unintended pregnancy. And statistically, birth control use among Black women ages 15-49 is lower than that of white women.

Many factors play into those statistics, including low income, little or no health insurance, and lack of information about contraception. Lack of trust in doctors due to implicit bias can also play a part.

For example, long-acting reversible contraceptives (LARCs) such as IUDs and hormonal implants have gotten more popular. They’re safe to use among people of all reproductive ages and they’re effective for 3-12 years. Yet, Black and Hispanic women are less likely to use such birth control options. One reason may be because LARC birth control requires a visit to the doctor’s office, where it’s put into the uterus or under your skin. Mistrust can stem from America’s history of forced sterilizations and reproductive injustices against women of color in the early to mid-1900s.

Cost of birth control. To use most birth control options, you first need a prescription from your nurse or doctor.

In 2010, 1 in 4 women in the U.S. went for birth control services at publicly funded family planning health clinics. These clinics use funds from Medicaid or the Title X program to provide free or reduced-fee birth control methods to those who need them. People who are uninsured, women of color, and those from low-income communities benefit the most from such services.

But for most of these people, the overall cost of time and money for birth control will keep them from getting it. Several expenses are related to accessing and using birth control. For one, the upfront cost of birth control options like LARC methods (an IUD or a hormonal implant) is high. It might be out of reach if you don’t have enough health insurance coverage. The total bill for an IUD can be more than $1,000.

High out-of-pocket costs, deductibles, and copays might limit you even if you have private health insurance from your employer. Some newer birth control methods – gels and certain vaginal rings – aren’t covered, or they may have high copays. And some insurance plans also won’t let about 73% of women get more than one month’s supply of birth control at a time. And often they can’t get refills on time. This happens even though studies show that having a year’s supply is more cost-effective and improves your ability to stick with birth control and stop unintended pregnancies.

There are also other costs associated with accessing birth control that can add to barriers, such as:

  • Unpaid time off work to go to the doctor
  • Child care needs
  • Cost of transportation to and from your health provider

Location. Where you live matters, too. Research shows that in 2010, more than half of the 37 million women in the U.S. who needed contraceptive services depended on publicly funded family planning clinics to get their birth control. That’s because either their income was 250% below the federal poverty line or they were younger than 20 years old.

Yet, there’s a growing number of contraceptive deserts in America – geographical areas that lack funding from federal and state programs, like Title X and Medicaid, to run the number of low-cost clinics needed to serve a population. To put it plainly, if you have to drive 30 minutes or longer to get to the nearest birth control clinic, you live in a contraceptive desert. In most cases, state-level politics can influence how funds are given out or used.

One study took a look at the difference in birth control access in North Carolina and Texas. The study found that around 2 million, or 20%, of North Carolinians live in a contraceptive desert. But in Texas – which is 5 times the size of North Carolina and has 3 times the population – around 10 million people, or over 35% of Texans, live in a contraceptive desert. While those who live in North Carolina have better access to birth control, compared to Texas, both states have deserts in rural areas with low-income populations that have a higher need for affordable and effective birth control options.

If you live in a contraceptive desert and don’t have a reliable way to get around – like a car or access to public transportation – it could stack on additional barriers.

Lack of awareness. A large number of young people in the U.S. hear the message of “abstinence only” in sex education. This can create the wrong idea about how effective contraceptives are. Or it could lead to worries about safety and side effects of birth control. Many people even incorrectly believe that birth control is the same as abortion. It’s not. FDA-approved birth control options prevent you from getting pregnant in the first place. If you are already pregnant, you should not use an IUD.

By comparison, fully detailed sex education is designed to help you make an informed decision about birth control and find a method that helps you avoid unintended pregnancy.

Other barriers to birth control. In some cases, religious beliefs or moral attitudes can keep you from getting birth control or family planning that works for you. For example, many large health systems in the country are funded by religious organizations. The core beliefs of such organizations could mean roadblocks or legal hurdles when you need your health provider to write your contraceptive prescription. And six states – including Arizona, Arkansas, and Georgia – allow pharmacists to legally refuse to fill your birth control prescription or give you emergency contraceptives. Alternative options may not always be available.

What’s Being Done to Improve Access to Birth Control?

The American College of Obstetricians and Gynecologists urges doctors and health care professionals to use their platform and knowledge to speak out for their patients whenever possible. To bridge the unequal access to birth control and reduce the overall number of unintended pregnancies, they suggest:

Improve public funds. Medicaid eligibility and Title X Family Planning Program expansion in all states can drastically improve access to millions of people who rely on free or reduced-fee services to get birth control.

Get rid of unnecessary medical practices. Doctors and other health care providers can remove some medical procedures, such as pelvic or cervical exams before clearing you for birth control pills. Some people, especially teenagers, may wait to get birth control if they’re worried about these clinical visits. This might push them to rely on less effective over-the-counter birth control, like condoms.

Reduce multiple medical appointments for birth control. It’s common for doctors to ask you to come into their office twice when you want birth control: first to discuss options like an IUD or hormonal implant, and the second to insert it. Depending on your insurance coverage, that may be required. But cutting it down to a single visit can improve access for many, especially if you’re short on time or have other obligations.

Remove insurance coverage rules for birth control. To qualify for long-acting birth control methods that are highly effective but cost more money – like IUDs and implants – some health insurance companies require you to “fail” other, cheaper birth control options before doctors can recommend one for you. Cutting out such unnecessary barriers can improve your access to the birth control that works best for you. The Affordable Care Act and many states have requirements that would make exceptions for contraceptives that usually aren’t covered (like some newer methods, or brand names instead of generics). But many people don’t know about the exceptions policies.

Check for unspoken bias. The American College of Obstetricians and Gynecologists urges doctors and other health providers to take a hard look at and understand any racial or ethnic biases or prejudices that can affect patient care. This would help improve relationships between you and your providers and reduce the odds of racially motivated unequal health care. If you’re uncomfortable with a provider, get a second opinion.

If you’re planning to start birth control, speak with your doctor about it. They can help sort out any confusion or worries and recommend a method that works best with your sexual needs or family planning goals. Ask about all of the available options and find one that suits your needs best.

If you live in a contraceptive desert, check to see whether you can try telehealth or get birth control delivery to your door. If you’re not sure about costs or whether your insurance covers them, call your company and ask. You can also call your local health department to see if you qualify for free or reduced-fee birth control services.

Show Sources

SOURCES:

The American College of Obstetricians and Gynecologists: “Access to contraception.”

Guttmacher Institute: “Refusing to Provide Health Services,” “Contraceptive Use in the United States.”

University of Minnesota: “Variation in Title X Leads to Contraception Deserts.”

Contraception and Reproductive Medicine: “Are higher unintended pregnancy rates among minorities a result of disparate access to contraception?”

Bedsider Provider: “Access to birth control is about more than where you live.”

Powertodecide.org: “Birth Control Access.”

Obstetrics and Gynecology: “Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020.”

Women’s Health Issues: “Access to Removal of Long-acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care.”

Journal of Adolescent Health: “Cost as a Barrier to Long-Acting Reversible Contraceptive (LARC) Use in Adolescents.”

University of Michigan Institute for Healthcare Policy & Innovation: “Forced sterilization policies in the US targeted minorities and those with disabilities – and lasted into the 21st century.”

National Women’s Law Center: “Exception Policies: Advocating for No-Cost Coverage of Noncovered Contraceptives.”

Kaiser Family Foundation: “Contraception Is Free to Women, Except When It’s Not.”

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