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Institut National d′Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit – UR14, 9 cours des Humanités, Aubervilliers, FranceUniversité Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
Institut National d′Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit – UR14, 9 cours des Humanités, Aubervilliers, FranceUniversité Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
Major socioeconomic differences in contraceptive use are observed in high-income countries. Cost is often cited as a main factor to explain these differences but other barriers may also exist. Our aim was to compare prescribed contraceptive use among low-income and non-low-income women in a national context of full health insurance coverage.
Study design
In the French national health insurance database, we selected all women (14.8 million) aged 15–49 years living in France in 2019. We compared the prevalence of use of each prescribed contraceptive between low-income and non-low-income women: oral contraceptives, copper intrauterine devices (IUDs), the levonorgestrel intrauterine system (LNG-IUS), and implants.
Results
In the study population, 11% had a low income. Fewer low-income women used prescribed contraceptives than non-low-income women (36% vs. 46%, p < 0.001). When using a contraceptive, low-income women used a different method: at 20–24 years old, they used less oral contraceptives (60% vs. 77%, p < 0.001) and more implants (22% vs. 9%, p < 0.001), while at 40–44 years, they used less levonorgestrel intrauterine systems (18% vs. 30%, p < 0.001).
Conclusions
Even in a national context of free access to medical care for low-income women, they use less and different prescribed contraceptives than non-low-income women. These results could reflect barriers other than financial cost to the use of prescribed contraceptives by low-income women.
Implications
Financial barriers need to be removed in order to increase contraceptive use. However, this may not be sufficient and further research should explore barriers that low-income women may encounter in accessing and choosing their contraception.
To promote their sexual and reproductive health and rights, women need full access to contraception and choice of contraceptive method. Contraception is one of the most important tools to decide freely the number, spacing, and timing of children, considered as a basic human right since the 1994 Conference on Population in Cairo, Egypt [
United Nations Population Fund, editor. Programme of action: adopted at the International Conference on Population and Development, Cairo, 5–13 September 1994. United Nations Population Fund. New York: 2004.
], substantial differences in contraception use have been shown in countries such as the United States, Australia, the United Kingdom, and Spain, with lower use among low-socioeconomic-level women [
], and differences may exist even in the context of free access. France offers the opportunity to explore this issue with a nationally based public health policy allowing low-income women free access to prescribers and to prescribed contraception.
The aim of this study was to estimate the use of prescribed contraception among low-income women in a national context of full health insurance coverage and to compare it with use in the non-low-income population.
2. Materials and methods
2.1 Data sources
The French health insurance database includes 98% of the resident population. These data have been presented in detail elsewhere [
Value of a national administrative database to guide public decisions: from the système national d′information interrégimes de l′Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.
]. They provide information on all healthcare reimbursements as well as some information on the patient: age, sex, place of residence, and registration with French-specific healthcare insurance for low-income people. This specific healthcare insurance is granted to persons below the poverty line, that is, with an income less than 50% of median income [
Consommations de soins des bénéficiaires de la couverture maladie universelle complémentaire (CMUC) ou de l′aide pour une complémentaire santé (ACS) en 2012.
]. Access to these data is regulated and our institutional data protection officer approved this research under the reference 2019-DPD-0013.
2.2 Study population
We selected all women (n = 14,785,929) aged 15–49 years living in France (after exclusion of French overseas territories) in 2019. This study population included 1640,457 low-income women (i.e., covered by the French-specific healthcare insurance for low-income people) and 13,145,472 non-low-income women (i.e., not covered by the specific healthcare insurance).
2.3 Outcome
Prescribed contraception included oral contraceptives (first- and second-generation combined oral contraceptive pills and progesterone-only pills), copper intrauterine devices (copper IUD), the levonorgestrel intrauterine system (LNG-IUS), and implants (progestogen-only implants). To consider the population that used contraceptives on October 31, 2019, we selected all women whose last prescribed contraceptive purchased had a recommended duration of use still ongoing at that date.
2.4 Statistical analysis
The prevalence of prescribed contraception use in the population was estimated for all prescribed contraceptives and by type of contraceptive (oral contraceptive, copper IUD, LNG-IUS, and implant). Prevalences of low-income and non-low-income women were compared with a χ2 test using a 0.05 level of significance. We carried out analyses using SAS version 9.4 (SAS Institute, Cary, NC).
3. Results
In our study population, 11% were low-income women. Thirty-six percent of low-income women used a prescribed contraceptive versus 46% of non-low-income women (p < 0.001). Use of prescribed contraception varied by age: in both groups, contraception was the lowest in the youngest and oldest age groups and highest in women aged 30–39 years (Fig. 1).
Fig. 1Prescribed contraceptive use among low-income (n = 1,640,457) and non-low-income women (n = 13,145,472) in France, 2019.
Among women using a prescribed contraceptive (n = 6,588,703), the type of prescribed contraceptive used differed greatly over the reproductive period (Table 1). Among both low-income and non-low-income women, implants were mostly used by those aged 20–24 years (22% and 9%, respectively), whereas the LNG-IUS was mostly used by those aged 40–45 years (18% and 30%, respectively). Differences between low-income and non-low-income women are given in greater detail in Fig. 2. For example, the difference in implant use in the 15–19 years age group was 13% (i.e., this was the difference between use by low-income women, which was 19%, and use by non-low-income women, which was 6%). Substantial differences between the two groups were observed among women aged under 30 years for implants (more used by low-income than non-low-income women with a difference of 11–13%) and for oral contraception (less used by low-income women with a difference of −12% to −17%). Differences were also observed among women aged 40 and over for the LNG-IUS (less used by low-income women with a difference of −12% to −17%).
Table 1Types of prescribed contraceptives used by low-income and non-low-income women in France, 2019.
Fig. 2Difference in use of prescribed contraceptives between low-income women (n = 593,942) and non-low-income women (n = 5,994,761) in France, 2019. All bars with a value less than 0 indicate that low-income women used that method less than non-low-income women. Conversely, where the value is greater than 0, low-income women use the method designated by the bar more than non-low-income women. Notes: (a) For example, the first blue bar on the left of the figure showing 13% implant use in the 15–19 years age group corresponds to the difference in the prevalence of implant use in this age group between low-income (19%) and non-low-income (6%) women. (b) LNG-IUS = levonorgestrel intrauterine system. (c) Copper IUD = copper intrauterine device.
Even in a national context where low-income women have free access to medical care, they used less prescribed contraception than non-low-income women over the reproductive period. When they did use prescribed contraception, low-income women used different types of contraceptives: younger women used less oral contraceptives and more implants, whereas older women used the LNG-IUS less.
Our results are in line with a US study showing that use of contraception only slightly increased when implementing a program (Medicaid) with free access to contraceptives for low-income women [
]. Despite free access to contraception, lower use of contraception was also observed among women living in socioeconomically disadvantaged areas in the United Kingdom [
] but in these works, copper IUDs, the LNG-IUS, and implants were grouped together as long-acting reversible contraceptives (LARC). As our results showed very different tendencies between these three contraceptives, the relevance of LARC as a category should be questioned.
Differences observed in contraception use among low-income women in a national context of full health insurance coverage may reflect differences in women’s choices. Indeed, French low-income women more often use contraceptive methods that do not require prescriptions, such as withdrawal, barrier methods, or natural family planning [
]. This may reflect women’s preferences for non prescribed contraceptives and greater ambivalence toward unintended pregnancies among low-income women [
However, these differences may also reflect inequities in access to contraception even after eradication of financial barriers. Based on the literature, several mechanisms could be considered as possible mediators of unequal access to contraception.
First, low-income women may use prescribed contraceptives less because they face difficulties of access to prescribers of contraception, for example, to obtain an appointment with a contraceptive provider, to access a specialist such as a gynecologist, or to go through the administrative process to obtain and maintain their specific health insurance [
]. Faced with these difficulties, low-income women may withdraw from contraceptive care or tend to consult a general practitioner. When contraception is prescribed by a general practitioner, women may face a restricted contraceptive choice as general practitioners are less inclined than gynecologists to insert an IUD that requires a gynecological examination [
Trends and determinants of use of long-acting reversible contraception use among young women in France: results from three national surveys conducted between 2000 and 2010.
]. This would lead to less use of prescribed contraceptives by low-income women, as observed in this study. Moreover, low-income women are usually targeted in public health programs on contraception because they have more unintended pregnancies and (repeated) abortion than other women [
]. For this reason, with these women, medical professionals may tend to encourage the use of more effective contraceptives such as the implant rather than the pill [
Value of a national administrative database to guide public decisions: from the système national d′information interrégimes de l′Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.
]. However, the women with the very lowest incomes may not request the specific health coverage and thus not be considered here. These women without insurance are known to use less contraceptives [
] and if they were considered, the differences between the two groups would probably have been greater. Another limitation of the health insurance database is the absence of data on non-reimbursed prescribed contraceptives (3rd- and 4th-generation pills, patch, and contraceptive ring), but low-income women probably do not make much use of these methods because of the financial barriers. If these contraceptives were included in the analysis, the differences between the two groups would probably increase further. Last, our data relate to purchases in pharmacies, and it is possible that some contraceptives were bought but not used by women.
To conclude, the lower use of contraceptives and the differences in contraceptive use in low-income women may be an indicator of non financial barriers in access to contraception, and these should be investigated. In order to ensure that all women may decide freely the number, spacing, and timing of their children, it is very important to understand the barriers to use and choice of contraceptives.
Data Availability
To request access to the French health insurance database, please contact the Health Data Hub (website: https://www.health-data-hub.fr/).
Acknowledgments
We thank Jérôme Brocca (Agence Régionale de Santé Centre, France) and Pierre-Louis Bithorel (Ined, France) for their assistance in managing data from the complex French health insurance databases. We thank Nina Crowte for professional assistance in language editing.
References
United Nations Population Fund, editor. Programme of action: adopted at the International Conference on Population and Development, Cairo, 5–13 September 1994. United Nations Population Fund. New York: 2004.
Value of a national administrative database to guide public decisions: from the système national d′information interrégimes de l′Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France.
Consommations de soins des bénéficiaires de la couverture maladie universelle complémentaire (CMUC) ou de l′aide pour une complémentaire santé (ACS) en 2012.
Trends and determinants of use of long-acting reversible contraception use among young women in France: results from three national surveys conducted between 2000 and 2010.
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