Women With Intellectual and Developmental Disabilities Less Likely to Receive Effective Contraceptives

By Will Boggs MD and Marilynn Larkin

August 17, 2018

NEW YORK (Reuters Health) - Women with intellectual and developmental disabilities (IDD) are less likely to receive effective reversible contraception, a large study shows.

A separate study found that women with IDD had close to double the rate of repeat pregnancy within a year compared to women without these disabilities.

Dr. Justine Wu from University of Michigan, Ann Arbor, a coauthor of one of the studies, said pervasive stereotypes about women with disabilities negatively affect the way health care providers counsel women about their reproductive and contraceptive options and how women perceive their own sexual and reproductive agency. These stereotypes, she wrote by email, include the notions that women with IDD "are neither interested in - nor able to have - mutually consensual sex and romantic relationships and are also unsuitable to be parents."

Dr. Wu and colleagues used data from the 2012 Massachusetts All-Payer Claims database to study fertile women with (n=13,059) and without (n=902,502) IDD. Overall, 4.1% of women were provided long-acting reversible contraception (LARC), 29.8% were prescribed moderately effective methods, and 66.1% received neither, they reported August 6th online in Obstetrics and Gynecology.

Women with IDD were provided moderately effective methods less often than their peers without IDD (21.1% vs 29.9%). This difference was far greater for LARC (2.1% versus 4.2%, respectively).

After adjusting for demographic variables, women with IDD had 57% lower odds of receiving LARC and 32% lower odds of receiving moderately effective methods, compared with women without IDD.

A second study published online August 13 in CMAJ found that Canadian women with IDD had close to double the rate of repeat pregnancy within a year than women without these disabilities.

"Healthcare providers should keep in mind that a single week-6 postpartum visit, when contraception counseling is usually provided to women, may be inadequate for this population," coauthor Dr. Hilary K. Brown of the University of Toronto told Reuters Health by email.

"Longer and more frequent visits with accessible take-home materials may be necessary to ensure that they are equipped to make informed decisions about contraception and childbearing," she said.

Dr. Brown's study involved 2,855 women with IDD and 923,367 without IDD who had a live birth between 2002 and 2013. After controlling for demographic factors, the rate of rapid repeat pregnancy was 7.6% in women with IDD vs. 3.9% in women without IDD (adjusted relative risk, 1.34). The risk was attenuated upon further adjustment for social, health and healthcare disparities (adjusted RR, 1.00).

Interactions between disability status and neighborhood income (p=0.01) and receipt of social assistance (p=0.004) were statistically significant, Brown's team notes.

Further analyses suggested that the impact of disability status was weakest for women living in lower-income neighborhoods and those receiving social assistance. All other interactions were nonsignificant.

"Our research showed that issues like poverty also partly explained high rates of rapid repeat pregnancy in (these) women," Dr. Brown pointed out. "Therefore, efforts should also focus on addressing vulnerabilities which may act as barriers to accessing high-quality reproductive health care."

"The need for continuity and comprehensiveness of care suggests a role for primary care in addressing these issues," she added.

Dr. Melanie P. Ornstein from Michael Garron Hospital and the University of Toronto, who studies gynecologic and reproductive care for women with developmental disabilities, noted that barriers to care include "physical accessibility, time for visits with adequate compensation for providers, involving women with disabilities in their health care decisions where possible, health care providers' lack of knowledge and experience, (and) societal biases."

"All women have a basic right to receive equitable healthcare irrespective of race, ethnicity, socioeconomic status, medical insurance coverage, and the presence of a physical and or cognitive impairment," she said by email.

Dr. Wu said she would like to see two wide-scale interventions: "fully accessible health facilities, which includes not just physical accommodations (for example, adjustable exam tables and staff trained in safe transfers of women from wheelchair to table), but also aids and services to promote effective health communication; and . . . systematic and mandatory training of health care providers in disability health, including gynecologic and family planning services (how to perform a pelvic exam and inserting IUDs for women with disabilities in a manner that minimizes pain and anxiety)."

Dr. Paula J. Adams Hillard from Stanford University Medical Center in California, who wrote an editorial related to the Wu team's report, said by email that doctors caring for patients with intellectual disabilities must "be sure that the criteria of truly informed consent are met, and that all options are offered and considered. Providing gynecologic care for these individuals often requires more time than caring for the average patient."

"Physicians need to listen to patients and to their family members or caretakers to attend to their concerns, informing them as well about medical management options," she said. Issues of importance to girls and women with IDD, she noted, include "sexuality, risks of sexual abuse, menstrual hygiene, medical comorbidities that may have a menstrual exacerbation (seizures, etc.), and behavioral issues with a menstrual relationship."

Dr. Hillard recommends resources provided by the American College of Obstetricians and Gynecologists at http://bit.ly/2B87vAY.

Dr. Carol Hogue, professor of child and maternal health at Emory University's Rollins School of Public Health in Atlanta, noted by email that in the Canadian study, "among women on social assistance, intellectually challenged women were somewhat less likely to have a rapid repeat pregnancy than non-challenged women (the reverse being observed among women not receiving social assistance)."

"Since social assistance per se was the strongest associated factor for rapid repeat pregnancy, the social safety net in Canada should be examined for ways to improve adequate knowledge and accessibility of effective contraception . . . for all women receiving social assistance," she said.

"Healthcare providers for intellectually vulnerable women not receiving social assistance may need to be retrained to recognize instances in which their patients are sexually active and at risk of unintended pregnancy, as well as how to offer contraceptive education and methods to their patients," Dr. Hogue concluded. SOURCES: http://bit.ly/2BaKP2Q and http://bit.ly/2BbHK2F Obstet Gynecol 2018. http://bit.ly/2BbgSjd CMAJ 2018.