May 29, 2015 —Summary of "A Population-Based Study of U.S. Women's Preferred Versus Usual Sources of Reproductive Health Care," Hall et al., American Journal of Obstetrics and Gynecology, April 29, 2015.
"The role of specialized women's health providers, including obstetrician/gynecologists (ob/gyns), in providing comprehensive preventive services has become increasingly unclear," partly because of recent "guidelines that significantly reduce the frequency of cervical cancer screening episodes and that recommend against routine pelvic examinations for asymptomatic women -- services historically delivered by women's health specialists," Kelli Stidham Hall, a research investigator at the University of Michigan's Institute for Social Research, and colleagues wrote.
They noted that these recommendations could "have implications for delivery of other reproductive health services, including family planning." According to the authors, roughly "35%-45% of women use multiple providers for their health care needs -- most often a women's health specialist for reproductive health care and a generalist for other health issues." The authors wrote that this "mixture of health care sources women use may reflect their perceived and/or actual need for and access to specific types of services, as well as their preferences for sources of care."
They noted that "preferences for source of care ... defined here as where women would most like to get their care should they not face any barriers to access or utilization, have not been well characterized but are important for efforts to define the role of women's health specialists in current health systems." To better understand these preferences, the authors "describe[ed] and compar[ed] associations between preferred and usual sources of reproductive health care among a population-based cohort of U.S. women."
For the study, the authors used data from a 2013 Internet survey of 1,078 U.S. women ages 18 to 55 called the Women's Health Care Experiences and Preferences Study. According to the authors, the survey consisted of "29 items to measure women's experiences with and preferences for a variety of types of health care and sources of care, especially for reproductive health." The survey compiled information on participants' "sociodemographic characteristics, reproductive and health histories, mental health and social wellbeing, relationship characteristics, health and health service behavioral intentions, and reproductive health care and policy knowledge and attitudes."
The authors included responses from 984 women in the final sample. Participating women had received health care services within the past five years "and responded to all women's health services use and sources of care items." For the analysis, the authors "focus[ed] on reproductive health services, including Pap smear/pelvic exam, contraception, and [sexually transmitted infection] services," as well as certain "demographic, social, and reproductive history factors."
Reproductive Health Services Usage
Among the 984 women included in the analytic sample, 50% said they sought reproductive health services "more than annually," 35% said they sought such services "annually" and 15% said they sought such services "every two to five years." According to the analysis, "[n]early all women (81%) reported at least one reproductive health visit, including service utilization for Pap/pelvic exam (77%), contraception (33%), and STI (8%) care."
The researchers found that a "majority of women used women's health specialists for all types of reproductive health services (Pap/pelvic 68%, contraception 74%, and STI 75%), while use rates of primary care (range 21-29%) and other sources (range 3-5%) were lower." The study also found variances among the demographic "[c]haracteristics associated with usual sources of care." For example, the researchers found that "poor, unmarried, unemployed, and rural-residing women had lower proportions of using women's health specialists and higher proportions of using primary care/other sources, compared to their counterparts."
Reproductive Health Care Preferences
Meanwhile, the researchers found that "[w]omen's health specialists were the most preferred source of care for Pap/pelvic exam (68%), contraception (49%), and STI (35%) services, while 19-26% preferred primary care providers" and "a significant proportion of women reported that they would not seek care for contraception (28%) and STI (42%) services."
According to the analysis, women's preferred care sources were associated with "[n]early all ... sociodemographic and reproductive characteristics." For example, the researchers found that "generally, proportions who preferred women's health specialists were higher among women who were of younger age groups (<45 years), college educated, White race/ethnicity, higher income level (>75k), privately insured, and had [ever] used ... provider dispensed/hormonal contraception, compared to their counterparts." Meanwhile, women ages 35 to 55, those who were married, and those who did not have provider/hormonal contraceptive use histories were more likely to say they would not seek care for contraceptives or STIs.
Agreement and Associations Between Care Source Preferences and Usual Sources of Care
The analysis found that "women's health specialists as the preferred source of reproductive health care was the strongest predictor of utilization of women's health specialists for Pap/pelvic ... and contraceptive services." Meanwhile, the analysis found that sociodemographic characteristics also contributed to women's use of such specialists, such as insurance status and religious affiliation, among other factors.
According to the authors, most women "who had and would use reproductive health services" had "high levels of agreement between their usual versus preferred sources of care." They found that agreement was highest for Pap/pelvic exams (85%) and contraception (86%). Meanwhile disagreement between preference and use "was 15% for contraception, 17% for Pap/pelvic exam, and 22% for STI services, with the most common trend in disagreement being higher proportions preferring but not using women's health specialists, across all three types of care."
Specifically for Pap/pelvic exams, disagreement between preferences and use "were higher among unemployed, uninsured, and lower income (<$25K) women than compared to socioeconomically advantaged women." Meanwhile, for STI services, "women of 'other' race/ethnicity, religious affiliation, and frequent religious service attendance had greater disagreement than their counterparts."
The authors note that while there were some variances in women's preferences for and use of women's health specialists, "the overwhelming majority of women preferred women's health specialists, including ob/gyns and family planning clinics, for their Pap/pelvic, contraception and STI services." In addition, most respondents "experienced high levels of agreement between their preferred and usual sources of care."
According to the authors, women's preferences for reproductive health services "may reflect their desires for, as well as their perceived access to, the specific types of services, settings, and providers they believe will best meet their health needs." However, they noted that the study did not assess women's reasons for care source preference or use and urged further "research ... to understand how women's perceptions of the role of women's health specialists, generalists, and other sources of care may inform patient-centered models of reproductive health care."
The authors added that "[a]n important minority of women ... reported preferring and using primary care sources for their Pap/pelvic exam, contraception, and STI services," particularly "older, less educated, non-White, lower income, unemployed, and uninsured women." According to the authors, the finding could be indicative "that women's preferences for care are shaped by past experience with and access (or lack thereof) to specific types of providers."
Meanwhile, the study also found that "younger, poor, uninsured, and minority women experienced higher rates of discordance between their actual and preferred sources of reproductive health care (up to 21%)," representing "the same groups of women [who] disproportionately experience adverse reproductive health outcomes, including high rates of unintended pregnancy and STIs." According to the authors, the findings could give insight into "whether and why women's health care goals may (or may not) be achieved and help explain the negative, disparate trends in reproductive health service utilization and outcomes among U.S. women."
In addition to providing insight into the role of women's health specialists in providing care, the study's findings also have "implications for integrated models of women's health care," such as primary care providers who offer reproductive health care and women's health specialists who offer primary care services. The authors noted that "[w]omen's ability to receive all of their needed and desired health services from a single provider is unlikely in current ... health systems," but "care coordination models ... that strengthen communication and collaboration between women's health specialists and other providers and link women's preferred sources of care with resources to address all of their health issues are warranted." The authors urged further research to pinpoint "the best strategies and settings to provide accessible, patient-centered, quality women's health care in the" U.S.