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Title: How Living in a Disadvantaged Neighborhood is Associated with Abortion Access and Contraceptive Behavior
Citation Type: Dissertation/Thesis
Publication Year: 2023
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Abstract: Background: Contraception and abortion access are essential to reproductive justice and women’s equality. These services are critical for women to achieve their reproductive goals. Extensive studies have measured the association between individual-level characteristics with abortion access and contraceptive behavior, especially with different types of contraceptive methods. Limited studies were completed to investigate how living in a disadvantaged neighborhood can impact contraceptive behavior and abortion access. These limited studies mostly used income/poverty to measure neighborhood socioeconomic and structural conditions, which are single-level measurements and do not capture resources and opportunities available in each neighborhood. In addition, studies that measure contraceptive behavior often use type of contraceptive methods as the outcome; no study has been completed to investigate how living in a disadvantaged neighborhood is associated with whether women report using their preferred contraceptive method. Limited studies have been completed to investigate how the COVID-19 pandemic affected the change of contraceptive behavior. Thus, the goal of my dissertation is to fill the aforementioned gaps. Methods: To measure how living in a disadvantaged neighborhood affects abortion access and contraceptive behavior, this dissertation used two data sources. The first data source used to measure abortion access was collected by the Ohio Policy Evaluation Network (OPEN), where a 20% sample of 2014 to 2018 abortion records was drawn from three abortion facilities in the State of Ohio. The second data source used to measure contraceptive behavior was the Ohio Survey of Women, an Ohio population-representative survey collected by the National Opinion Research Center (NORC). To measure neighborhood socioeconomic and structural conditions, we used the Ohio Opportunity Index (OOI), which includes seven domain scores (transportation, education, employment, housing, health, environment, and crime) and a composite of all seven domain scores that captures that neighborhood’s opportunity and resources. In Aim 1, I used Generalized Estimating Equation (GEE) models to measure the association between neighborhood effects using the OOI and access to abortion. I assessed four outcomes: 1) whether the individual received an abortion after visiting an abortion facility, 2) the type of abortion method patients chose, 3) the number of days between the first abortion appointment visit to the surgical abortion, and 4) the gestational stage at the surgical abortion. In Aim 2, I used the weighted GEE to measure the association between neighborhood effects using the OOI and contraceptive behavior. I assessed four outcomes: 1) choosing female sterilization or long-acting reversible contraception (LARC) over other highly effective methods (e.g., injection, oral contraception, patch, and ring), 2) choosing highly effective methods (≤10% failure rate) over not highly effective methods (e.g., cervical cap, diaphragm, sponge, male condom, female condom, spermicides, and fertility awareness-based methods), 3) using any contraceptive method compare to not using any, and 4) using their preferred method compared to a non-preferred method. In Aim 3, I used a Sankey diagram to show how the non-response (loss to follow-up) and type of contraceptive method change over time. I performed descriptive analyses to explore individual and neighborhood characteristics in relation to non-response and contraceptive method change over time, and how COVID related to these changes. Results: Of the neighborhood-level characteristics examined, all variables except health resources were significantly associated with whether a patient received a surgical abortion at a later gestational stage (>64 days). Living in a neighborhood with more resources and opportunities (transportation, education, employment, and housing), as well as lower crime, lowers the odds of getting a surgical abortion at a later gestational stage; whereas, living in a neighborhood with more environmental resources increases the odds of getting a surgical abortion at a later gestational stage. In this study, neighborhoods’ environmental resources were highly correlated to rural/urban characteristics of the neighborhood, where rural areas have less pollution and more green space. Although most neighborhood-level characteristics were not significantly associated with contraceptive behavior, a consistent pattern was observed when modeling type of contraceptive method as the outcome. After controlling individual-level characteristics, women who lived in a disadvantaged neighborhood had increased odds of using contraception (compared to not using), increased odds of choosing LARC and female sterilization over other highly effective methods, and increased odds of choosing highly effective methods over not highly effective methods, compared to those who living in a neighborhood with more resources and opportunities. However, opposite relationships were observed when using the preferred contraception method as the outcome. When investigating the distribution of methods across different neighborhoods, among participants who reported using their preferred method, women who reported using LARC and living in neighborhoods with the lowest resources and opportunities were significantly more likely to report using their preferred method. However, they were less likely to report other non-LARC methods as their preferred method compared to women living in a neighborhood with more resources and opportunities. During the early and mid-pandemic phases (2019-2021), there was an increase in changes to less effective contraceptive methods compared to the late pandemic (2021-2022). Black women, women with less than high school degree, and women living in neighborhoods with less resources and opportunities were more likely to report changing to less effective methods, and more likely to be lost to follow-up. Discussion: This study shows that living in disadvantaged neighborhoods is associated with getting an abortion at a later gestational stage. Compared to neighborhoods with more resources, women who live in disadvantaged neighborhoods are more likely to report using highly effective contraception, especially LARC and female sterilization. However, they are more likely to report they are not using their preferred contraception, because dissatisfaction with their less effective and non-LARC contraceptive methods. The result indicates that neighborhood interventions can help women access abortion services in time, and more studies are needed to investigate why women living in disadvantaged neighborhoods are dissatisfied with non-LARC methods. Interventions that target women who use non-LARC methods in disadvantaged neighborhoods can improve access to their preferred methods. Disparities in access to contraception during the pandemic suggest that interventions should be tailored to specific subgroups, such as Black women, women with low education levels, and women living in disadvantaged neighborhoods.
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Authors: Lang, Kaiting
Institution: The Ohio State University
Department: Public Health
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Pages: 1-157
Data Collections: IPUMS USA
Topics: Fertility and Mortality, Gender, Health, Population Mobility and Spatial Demography, Race and Ethnicity, Reproductive and Sexual Health
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