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Prior Family Planning Experiences of Obese Women Seeking Abortion Care
Women's Health Issues 24-1 (2014) e125–e130
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Original article
Prior Family Planning Experiences of Obese Women Seeking Abortion Care Natalie Ingraham, MPH a,*, Sarah CM. Roberts, DrPH b, Tracy A. Weitz, PhD, MPA b a
Department of Social & Behavioral Sciences, University of California, San Francisco, San Francisco, California Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California b
Article history: Received 9 August 2013; Received in revised form 23 October 2013; Accepted 24 October 2013
a b s t r a c t Background: The prevalence of obesity among women of reproductive age calls for research focused on strategies that ensure obese women receive high-quality reproductive health care. This study adds to this literature on service delivery by exploring obese women’s experiences receiving or avoiding family planning care. Methods: We included 651 women seeking abortion care who completed iPad surveys about their previous family planning experiences. Findings: One quarter were classified as obese, with almost 5% morbidly obese. Only 1% of obese women reported avoiding family planning care. More than 12% of morbidly obese women reported not having their family planning needs met (pap smears, sexually transmitted infection testing, or ultrasonography). This is compared with only 2% among overweight and obese women and 0% among normal and underweight women. Almost 10% of obese and morbidly obese women reported that at least one of the previous family planning clinics they had visited was not prepared to provide care for heavier women and around 25% of obese women reported at least one item in the clinic (such as blood pressure cuffs and examination gowns) was not adequate for their size. Results: Contrary to expectations, we did not find that obese women avoided family planning care. However, morbidly obese women reported not having all of their family planning needs met when they attended care. Family planning providers should ensure that their facilities have the capacity to meet the family planning needs of obese women and that they have adequate equipment to care for this population of women. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Most studies of weight and women’s health focus on the negative outcomes associated with obesity (Saguy, 2011). Within reproductive health, attention is usually paid to the relationship between obesity and pregnancy complications (Arendas, Qiu, & Gruslin, 2008; Marshall & Spong, 2012; Yogev & Catalano, 2009) and, conversely, the impact of obesity on impaired fertility (Brewer & Balen, 2010; Sarwer, Allison, Gibbons, Markowitz, & Nelson, 2006). Despite the prevalence of obesity among women of reproductive age and the role that family planning can play in helping women to manage fertility and prevent unintended pregnancies, there has been less focus on strategies that ensure obese women
* Correspondence to: Natalie Ingraham, MPH, Department of Social & Behavioral Sciences, University of California, San Francisco, Laurel Heights, 3333 California Street, L-Hts 455, Box 0612, San Francisco, CA 94118. Phone: (405) 833-3075; fax: 510-986-8960. E-mail address: [email protected] (N. Ingraham).
receive high-quality reproductive health care that meets their family planning needs. Currently, between one half and two thirds of women aged 20 to 39 are classified as overweight or obese (Flegal, 2012) and about one fourth of pregnant women were obese before pregnancy, with prevalence of prepregnancy obesity as high as 33% in some states (Chu, Kim, & Bish, 2008). The limited family planning research about obese women tends to address the role of high body mass index (BMI) on contraceptive failures (Edelman & Kaneshiro, 2013; Lopez et al., 2013; Murthy, 2010; Trussell, Schwarz, & Guthrie, 2009) or variation in contraceptive method use by BMI (Schraudenbach & McFall, 2009; Scott-Ram, Chor, Bhogireddy, Keith, & Patel, 2012; Vahratian, Barber, Lawrence, & Kim, 2009). However, information about barriers to family planning services for obese women, including barriers associated with previous experiences with prior family planning services, is glaringly absent from the literature. Research outside of the reproductive health context suggests that one potential barrier
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to health services for obese individuals is previous negative experiences with health care providers or providers refusing to provide services to women with higher BMIs (Drury & Louis, 2002; Puhl & Heuer, 2009; Teixeira & Budd, 2010). The Rudd Center (2012) at Yale University examined a series of studies and found that weight bias is common in general health care settings. A few studies have found that some providers openly admit to negative attitudes toward obese patients and many express dissatisfaction in caring for obese patients (Hebl & Xu, 2001; Jay et al., 2009; Schwartz, Chambliss, Brownell, Blair, & Billington, 2003). Other research has found that health care providers are among the most common sources of weight bias (Puhl & Brownell, 2006) and that this weight bias can reduce the quality of care received (Teachman & Brownell, 2001). Research also finds that health care facilities may be unprepared to care for larger patients (Ahmed, Lemkau, & Birt, 2002; Bradway, DiResta, Fleshner, & Polomano, 2008; Imperiali, Cirillo, Brunani, Capodaglio, & Capodaglio, 2013; Tizer, 2007). In relation to reproductive health care, the research is more limited. Amy, Aalborg, Lyons, and Keranen (2006) found delays in gynecological cancer screening among White and Black obese women. They found that previous negative provider response, embarrassment at being weighed, unsolicited advice to lose weight from a provider, and concerns about inadequate equipment (e.g. examination tables) were factors in women’s delay. Wee, McCarthy, Davis, and Phillips (2000) found that morbidly obese women (BMI 40 kg/m2) were less likely have gynecological cancer screening than normal weight women. Research has also identified obesity as a factor associated with delay in receiving abortion care (Foster et al., 2008; Lee & Ingham, 2010), in part owing to delay in discovering or testing for pregnancy (Foster et al., 2008). One study found that later presentation for abortion care among obese women may also be owing to clinical policies and practices at some outpatient abortion providers that make it so that they cannot provide abortion care to obese women (Cosby, Weitz, & Foster, 2006). The authors speculated that obese women affected by these facility policies may experience extra time, travel, and expense in locating a provider who will perform their abortion (Cosby et al., 2006). Our study adds to this literature on service delivery by exploring obese women’s experiences receiving or avoiding family planning care. Materials and Methods Population and Study Design Data for analyses presented in this paper were collected as part of a larger study about the experiences of women seeking abortion. Even though this is a study about obese women’s experiences with family planning, we recruited women seeking abortion care rather than family planning care. We recruited in this way because we expected that obese women who both did not want to become pregnant and had avoided family planning care would not be available for recruitment at family planning centers, but might present for abortion care if they became pregnant. Additionally, because we were interested in prior negative experiences with family planning care, we believed that family planning providers that were less prepared to provide high-quality reproductive health care to obese women would agree to serve as sites for recruitment. Finally, because of the limited number of facilities where abortions are performed (Jones, Zolna, Henshaw, & Finer, 2008), women seeking care at
one abortion facility are likely to come a geographic area served by a large network of family planning providers (Frost & Lindberg, 2013). Thus, sampling women from an abortion facility may give us a broad picture of women from across geographic regions, rather than specific experience within the facilities sampled. Data were collected between May and July 2011 at six abortion care facilities across the United States. Facilities were located in Illinois, Georgia, Arkansas, California, New Jersey, and Texas. Respondents were recruited in facility waiting rooms. They were eligible for inclusion if they were a patient at the facility seeking an abortion or an abortion follow-up appointment, between ages 15 and 60, female, and able to read English or Spanish. Women completed surveys via a self-administered iPadbased questionnaire. A research assistant led women through information about the study and provided a short training on the iPad. Participants gave consent before starting the survey. No identifying information was collected. Participants received $20 to remunerate them for their time. The study protocol was approved by the University of California, San Francisco Committee on Human Research. Study procedures are described in more detail elsewhere (Jones, Upadhyay, & Weitz, 2013). A total of 757 women were eligible and invited to participate in the study and 651 agreed (86%). A subsample of 124 obese women (BMI >30 kg/m2) was asked additional questions about prior experiences with family planning and their experience seeking and receiving abortion care for the current pregnancy. Measures The survey included questions on weight, height, sociodemographic characteristics, contraceptive use, prior experiences with family planning care, and current experiences with abortion care. Analyses for this paper focus on a subset of questions on prior experiences with family planning. Our main independent variable of interest was obesity status. Our main outcome variables of interest were family planning needs being met and facility preparedness indicators. Obesity status Obesity status was calculated using the Centers for Disease Control and Prevention BMI categories (Centers for Disease Control and Prevention, 2011). Women were classified as under/normal weight (BMI of 24.99 kg/m2), overweight (25– 29.99 kg/m2), obese (30–39.99 kg/m2), or morbidly obese (40 kg/m2). Height was recorded as height in feet and height in inches in two separate questions. Only women with complete height and weight data (n ¼ 622) were used for analysis. Women with a BMI over 30 kg/m2 answered additional questions about their family planning experiences. Forty obese women were not correctly identified as obese by the iPad program and thus did not complete the subset of questions designed for obese women. Demographics Race/ethnicity is a categorical variable: Non-Hispanic White, non-Hispanic Black/African-American, Hispanic/Latina, and other (Asian/Pacific Islander/biracial/other). Economic status is a dichotomous variable of below or above 200% of the federal poverty line. Education is a dichotomization of high school/GED or less (yes/no) and having attended any college or more. Insurance is a dichotomous (yes/no) variable of whether the woman reported having insurance for her regular source of medical care (“How do you usually pay for your medical
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care?”); those who reported having any type of insurance coverage for health care, regardless of whether they also reported self-pay, are classified as having insurance. An additional demographic was a dichotomous variable of having a romantic partner (yes/no). Previous family planning experiences Previous family planning visit is a dichotomous variable of ever having had a previous family planning visit. Obese women who had a previous family planning in the last 3 years were asked an additional series of questions about their experiences during the visits including interactions with providers and clinic preparedness. Obese women were also asked if they had ever avoided general health care because of their weight as well as if they had ever avoided family planning care because of their weight. These are dichotomous (yes/no) variables. Reproductive health history Women were asked about number of pregnancies (gravidity), including the pregnancy associated with their current abortion visit. Needs met is a dichotomous (yes/no) variable of women who reported that they were “able to get all the family planning services you needed during [their] visits.” Only women who had previous family planning visits were asked this question. This question also included an open-ended question about which services were not received. Clinic preparedness A subsample of obese women who had had a family planning visit in the last 3 years was asked the question, “At any of your family planning visits in the last 3 years, which items were NOT adequate for your size?” Women checked all that applied from a list of from a list of five items: Gowns too small, inadequate blood pressure cuffs, inadequate examination tables, inadequate weight scale, and inadequate waiting room chairs. These were turned into dichotomous variables for descriptive analysis. Women were also asked, “How prepared was the clinic in providing care for heavier women?” A four-category Likert scale was used to rate facilities, which was recoded as a categorical variable: Prepared (very prepared/prepared), unprepared (neither prepared nor unprepared/underprepared), and “I don’t know.” Three years was selected as the cutoff because, at the time of the survey, it was the outer interval for recommended time between pap smears and, thus, recommended family planning visits (American College of Obstetricians and Gynecologists, 2012). Body size satisfaction All women were asked about their current body size satisfaction levels with the question, “How satisfied are you with your current body weight and body shape?”
Data Analysis Statistical analysis was performed used STATA 12.0 (Stata Corp, College Station, TX). Bivariate mixed effects regression analyses to account for clustering by site were used to describe relationships between obesity status and outcomes by site. Multivariate analysis examining whether women had their family planning needs met also used mixed effects regression, to account for clustering by site.
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Results About half of the sample were under or normal weight (48%), followed by overweight (27%), obese (20%), and morbidly obese (5%). The study population was racially and ethnically diverse, with the greatest portion of the sample being Black followed by White, Hispanic/Latina, and other (Table 1). The average age for the overall sample was 25.4 6.33 years. Most women (71%) reported having two or more pregnancies, including the pregnancy at the time of data collection. Most women reported some type of health insurance coverage (75%), including private and public insurance. Information about health insurance coverage to pay for abortion care specifically is described elsewhere (Jones et al., 2013). Overweight, obese, and morbidly obese women were older than normal weight women, reported higher poverty levels and were more likely to be Black. There were significant differences in gravity across BMI, with obese and morbidly obese women reporting significantly higher number of pregnancies compared with under/normal weight women (obese, odds ratio [OR], 2.02; p < .01; morbidly obese, OR, 2.86; p < .05). Among women with a previous family planning visit, obese women (OR, 6.55; 85% CI, 4.96–19.47), morbidly obese women (OR, 3.68; 85% CI, 2.82–30.18), and overweight women (OR, 3.54; 85% CI, 1.55–4.56) were more likely to report body dissatisfaction when compared with normal weight women (p < .001). There were no differences between women across BMI category in terms of health insurance, partner status, or education level. Avoidance of Care Four percent of obese women (n ¼ 5) reported avoiding general health care and 1% (n ¼ 1) reported avoiding family planning care because of their weight. Because this was such a rare outcome, we did not examine factors associated with it. Needs Met There were no differences across BMI category in ever having had a previous family planning visit, with about 55% of women in each BMI category reporting ever having had a family planning visit (Table 1). Of women who ever had a previous family planning visit, a little over 5% reported they were not able to get all of their family planning needs met during their visits. More than 12% of morbidly obese women reported not having their family planning needs met. Among obese and overweight women, this was 2%, and among normal and underweight women, this was 0%. In multivariate analysis, controlling for race, age, and gravidity, the odds of reporting not having family planning needs met was significantly greater among morbidly obese women compared with all other women (p < .01). Needs not met for obese and morbidly obese women during the visits included not getting a desired pap smear (n ¼ 1), not getting tested for sexually transmitted infections (n ¼ 2), or not getting an ultrasound (n ¼ 1), and not getting an abortion (n ¼ 1). There were no differences across BMI category in the number of previous abortion providers called or visited. Facility Preparedness Almost 10% of obese and morbidly obese women reported one of the previous family planning clinics they had visited was not
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Table 1 Sample Description Demographic Characteristic
Total Sample 622 (100%)
BMI (kg/m2) Age, mean (SD) Race (n ¼ 622) White (non-Hispanic) Black/African-American (non-Hispanic) Latina/Hispanic Asian/PI/other (Native American, multi, missing) Income (n ¼ 604) <200% below family planning L 200% below family planning L Education (n ¼ 621) HS or less Any college Partnered (n ¼ 617) Yes No Has health insurance (n ¼ 621) NS Yes No Ever had a previous family planning visit (n ¼ 622) Yes No Gravidity (no. of pregnancies) (n ¼ 614) 1 2 3 4 Current unsatisfied with body shape (n ¼ 339) Yes No Clinic location (n ¼ 622) Texas New Jersey California Illinois Georgia Arkansas *
25.4 (6.33) 151 278 102 91
(24) (45) (16) (15)
Normal/ Underweight 301 (48%)
Overweight 168 (27%)
Obese 125 (20%)
Morbidly Obese 28 (5%)
25 24.2 (.36)
25–29.99 25.5 (.47)y
20–39.99 27.6 (.56)*
40 28 (1.11)*
*
*
y
93 101 50 57
(31) (34) (16) (19)
35 88 28 17
(21) (52) (17) (10)
207 (71) 85 (29)
(17) (54) (16) (13)
2 22 4 0
(7) (79) (14) (0)
y
*
465 (77) 139 (23)
21 67 20 17
134 (84) 26 (16)
101 (82) 23 (18)
23 (82) 5 (18)
z
250 (40) 370 (60)
121 (40) 180 (60)
71 (43) 96 (57)
45 (36) 80 (64)
14 (50) 14 (50)
495 (80) 121 (19)
245 (81) 55 (18)
137 (82) 29 (17)
91 (73) 33 (26)
23 (82) 4 (14)
462 (74) 159 (26)
216 (72) 84 (28)
125 (74) 43 (26)
97 (78) 28 (22)
24 (86) 4 (14)
340 (55) 282 (45)
163 (54) 138 (46)
96 (57) 72 (43)
64 (51) 61 (49)
17 (61) 11 (39)
182 120 107 205
115 59 49 77
*
(30) (20) (17) (33)
(38) (20) (16) (26)
y
*
34 39 38 56
(20) (23) (23) (34)
*
28 18 15 58
(23) (15) (13) (49)
*
5 4 5 14
(18) (14) (18) (50)
*
148 (44) 191 (56)
41 (25) 122 (75)
45 (47) 50 (53)
49 (77) 23 (23)
13 (76) 4 (24)
206 111 90 89 75 51
105 54 41 44 29 28
50 32 27 22 27 10
41 18 22 19 13 12
10 7 0 4 6 1
(33) (18) (15) (14) (12) (8)
(35) (18) (13) (15) (10) (9)
(30) (19) (16) (13) (16) (6)
(33) (14) (18) (15) (10) (10)
(36) (25) (0) (14) (21) (4)
p .01, yp .05, and zp .10 compared with normal/underweight women.
prepared to provide care for heavier women. More (38%) reported they that did not know if the clinic was prepared or not. One fourth of obese women, however, reported at least one item in a family planning clinic they previously attended was inadequate for their size (Table 2). The most common way a clinic was unprepared was having gowns that were too small for the patient.
likely to receive unsolicited advice to lose weight than normal weight women (p < .01). There were no differences between overweight and normal weight women around unsolicited advice to lose weight.
Experiences during Prior Family Planning Visits
Almost half of women presenting for abortion care were classified as overweight or obese, with almost 5% morbidly obese. Thus, managing undesired fertility is a significant issue for women of higher body weight. This study is among the first to examine how obesity status impacts women’s use of reproductive health care and explore obese women’s experiences with family planning services. Contrary to our expectations, almost all obese and morbidly obese women reported that they were not avoiding either general health care or family planning care. However, morbidly obese women were more likely to report that they did not receive all the services they needed because of their weight. They also reported that some equipment at clinics such as gowns or blood pressure cuffs were not adequate for their size. These findings suggest that although obese women seek family planning care, they are not necessarily receiving all needed care, and are greeted by equipment inadequate for their size. In addition, women with higher BMIs also report significantly more dissatisfaction with body size as well as more prior
According to bivariate logistic regression, overweight (OR, 2.36, p < .05; 85% CI, 1.16–4.88), obese (OR, 3.11, p < .001; 85% CI, 1.57–7.26) and morbidly obese women (OR, 2.33, p < .05; 85% CI, 1.25–13.48) all reported more embarrassment at being weighed at a family planning visit than underweight or normal weight women. Obese (OR, 4.16; 85% CI, 1.50–11.54) and morbidly obese (OR, 9.56; 85% CI, 2.56–35.74) women were more Table 2 Items Reported as “Not Adequate for Your Size” Clinic Items
Women Reporting (%)
Gowns too small Inadequate blood pressure cuffs Inadequate exam tables Inadequate weight scale Inadequate waiting room chairs
10 7 4 2 2
Discussion
N. Ingraham et al. / Women's Health Issues 24-1 (2014) e125–e130
experience with inadequate sized gowns. How women with poor body dissatisfaction experience care when dressed in a gown that is too small or when naked because the gown cannot be used may prove a productive site for further research. Comfort, both physical and psychological, in the clinical encounter has been shown to be important for health care more generally (Doyle, Lennox, & Bell, 2013). Although not the purpose of this analysis, we find low rates of prior family planning care utilization by most women, with almost half of all women presenting for an abortion having never sought family planning services. We found this despite high rates of insurance coverage among women in the sample and the availability of low-cost family planning services in the states where women reside (Jones et al., 2013). Thus, rather than finding that obese women are unique in poor utilization of family planning services, we find substantial need for greater access to family planning care for women of all weights. Obese women, however, may have greater difficulty having their needs met once arriving for family planning care. Overweight and obese women in our study were more likely to have greater overall gravidity, specifically three or more pregnancies. We acknowledge that our study cannot explain whether these higher rates are the result of poorer contraceptive options and use among obese women or whether the obesity is the result of greater weight gain across multiple pregnancies. Literature in the field finds that weight gain during pregnancy is related to long-term maternal overweight and obesity (Gunderson, 2009; Mamun et al., 2010), so it logically follows that multiple pregnancies would increase this risk. Regardless of the causal relationship, women at higher BMI are more likely to experience a greater number of pregnancies. This suggests that the capacity to provide high-quality, nonstigmatizing health care for the range of women’s family planning needs, including abortion. Contrary to expectations, we did not find evidence that obese women had more difficulty finding a provider to perform their abortion. One woman did report that she was not able to obtain a desired abortion owing to her weight. However, because this was only one woman in our sample, no conclusions can be drawn about this issue from this study. Additional research is needed on this topic to understand the extent to which obese women have more difficulty obtaining abortion care. We found that obese women in our sample reported not getting specific family planning needs met, including desired pap smears, getting tested for sexually transmitted infections, or getting an ultrasound related to pregnancy or other gynecological concern. However, our study only provides limited information about what the family planning needs are for obese women in particular. Therefore, there is also a need for additional research with obese women to understand their specific family planning needs; this includes obese women who do not currently receive family planning care or do not seek abortion when faced with an unintended pregnancy. This research could help to better explain what women mean when they say that their family planning needs are not being met. In particular, this research should explore whether women were unable to get specific methods of contraception, such as intrauterine contraception, which may have greater efficacy for women with higher body weight (Lopez et al., 2013). Unmet family planning needs could also result in abortion delay; although our data did not assess delay in abortion care, other studies have shown that obesity is associated with abortion delay (Foster et al., 2008). Additional research is also needed to examine what policies, procedures, and equipment are considered necessary for a family
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planning clinic to be prepared for larger patients and which features improve patient experiences and health outcomes. Limitations of this study included the small sample size of obese and morbidly obese women. Small sample size means low precision of effect estimates and the possibility that we did not detect a small effect. However, we did find significant differences between obesity categories on family planning needs met, suggesting there may be a large effect for morbidly obese women worthy of further investigation. Further, because we sampled women seeking abortion care, our sample may have reported higher rates of previous family planning care receipt than a nonclinical sample of obese and morbidly obese women because these women had subsequently gotten themselves to a clinic. However, the inverse could also be true, that these women actually have lower rates of family planning care and are thus getting an abortion for their current pregnancy. The sampling of women from abortion clinics also excluded women with unintended pregnancies who carried their pregnancies to term and these women may have different family planning needs or patterns of avoiding family planning care. A population-based study might identify more women who report avoiding family planning care. Implications for Policy and/or Practice Family planning providers should undertake and evaluate interventions geared at improving the clinical experience of obese and morbidly obese women. Our study identified several areas where providers could make improvements. Specifically, to make obese women feel more welcome in the family planning care setting, providers should have an adequate supply of larger gowns and larger blood pressure cuffs, as well as purchase higher capacity examination tables and scales. It is worth noting that some of these items are not solely about women’s comfort; for example, having properly fitting blood pressure cuffs is essential to get accurate blood pressure measurements and thus not overdiagnose hypertension (Maxwell, Schroth, Waks, Karam, & Dornfeld, 1982). Currently, there are no family planning program recommendations for caring for women with higher body weights. The federal family planning program, Title X, should identify best practices and disseminate those as part of its overall recommendations for how to provide appropriate family planning care. Acknowledgments This project was funded by the David and Lucile Packard Foundation. The authors would like to thank Sandi Ma, MS for programming the survey for the iPads, Erica Sedlander, MPH for leading the participant recruitment process, Jen Grand and Ushma Upadhyay, PhD, MPH for data analysis consulting and Maya Newman, BA for her assistance with participant recruitment. We would also like to thank Deborah Karasek, MPH and Diana Greene Foster, PhD for her insights on study design. Natalie Ingraham had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. References Ahmed, S. M., Lemkau, J. P., & Birt, S. L. (2002). Toward sensitive treatment of obese patients. Family Practice Management, 9(1), 25–28. American College of Obstetricians and Gynecologists. (2012). Well-woman visit: Committee opinion no. 534. Washington, DC: Author 421–424.
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Author Descriptions Natalie Ingraham, MPH, is a PhD Candidate in Sociology in the Department of Social and Behavioral Sciences at the University of California, San Francisco (UCSF).
Sarah CM. Roberts, DrPH, is a public health social scientist. She studies policy and social determinants of women’s health, with a focus on alcohol and drug use in the context of pregnancy, parenting, and abortion.
Tracy A. Weitz, PhD, MPA, is an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, and the Director of Advancing New Standards in Reproductive Health (ANSIRH), both at the University of California, San Francisco (UCSF).
www.whijournal.com
Original article
Prior Family Planning Experiences of Obese Women Seeking Abortion Care Natalie Ingraham, MPH a,*, Sarah CM. Roberts, DrPH b, Tracy A. Weitz, PhD, MPA b a
Department of Social & Behavioral Sciences, University of California, San Francisco, San Francisco, California Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California b
Article history: Received 9 August 2013; Received in revised form 23 October 2013; Accepted 24 October 2013
a b s t r a c t Background: The prevalence of obesity among women of reproductive age calls for research focused on strategies that ensure obese women receive high-quality reproductive health care. This study adds to this literature on service delivery by exploring obese women’s experiences receiving or avoiding family planning care. Methods: We included 651 women seeking abortion care who completed iPad surveys about their previous family planning experiences. Findings: One quarter were classified as obese, with almost 5% morbidly obese. Only 1% of obese women reported avoiding family planning care. More than 12% of morbidly obese women reported not having their family planning needs met (pap smears, sexually transmitted infection testing, or ultrasonography). This is compared with only 2% among overweight and obese women and 0% among normal and underweight women. Almost 10% of obese and morbidly obese women reported that at least one of the previous family planning clinics they had visited was not prepared to provide care for heavier women and around 25% of obese women reported at least one item in the clinic (such as blood pressure cuffs and examination gowns) was not adequate for their size. Results: Contrary to expectations, we did not find that obese women avoided family planning care. However, morbidly obese women reported not having all of their family planning needs met when they attended care. Family planning providers should ensure that their facilities have the capacity to meet the family planning needs of obese women and that they have adequate equipment to care for this population of women. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Most studies of weight and women’s health focus on the negative outcomes associated with obesity (Saguy, 2011). Within reproductive health, attention is usually paid to the relationship between obesity and pregnancy complications (Arendas, Qiu, & Gruslin, 2008; Marshall & Spong, 2012; Yogev & Catalano, 2009) and, conversely, the impact of obesity on impaired fertility (Brewer & Balen, 2010; Sarwer, Allison, Gibbons, Markowitz, & Nelson, 2006). Despite the prevalence of obesity among women of reproductive age and the role that family planning can play in helping women to manage fertility and prevent unintended pregnancies, there has been less focus on strategies that ensure obese women
* Correspondence to: Natalie Ingraham, MPH, Department of Social & Behavioral Sciences, University of California, San Francisco, Laurel Heights, 3333 California Street, L-Hts 455, Box 0612, San Francisco, CA 94118. Phone: (405) 833-3075; fax: 510-986-8960. E-mail address: [email protected] (N. Ingraham).
receive high-quality reproductive health care that meets their family planning needs. Currently, between one half and two thirds of women aged 20 to 39 are classified as overweight or obese (Flegal, 2012) and about one fourth of pregnant women were obese before pregnancy, with prevalence of prepregnancy obesity as high as 33% in some states (Chu, Kim, & Bish, 2008). The limited family planning research about obese women tends to address the role of high body mass index (BMI) on contraceptive failures (Edelman & Kaneshiro, 2013; Lopez et al., 2013; Murthy, 2010; Trussell, Schwarz, & Guthrie, 2009) or variation in contraceptive method use by BMI (Schraudenbach & McFall, 2009; Scott-Ram, Chor, Bhogireddy, Keith, & Patel, 2012; Vahratian, Barber, Lawrence, & Kim, 2009). However, information about barriers to family planning services for obese women, including barriers associated with previous experiences with prior family planning services, is glaringly absent from the literature. Research outside of the reproductive health context suggests that one potential barrier
1049-3867/$ - see front matter Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.10.008
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to health services for obese individuals is previous negative experiences with health care providers or providers refusing to provide services to women with higher BMIs (Drury & Louis, 2002; Puhl & Heuer, 2009; Teixeira & Budd, 2010). The Rudd Center (2012) at Yale University examined a series of studies and found that weight bias is common in general health care settings. A few studies have found that some providers openly admit to negative attitudes toward obese patients and many express dissatisfaction in caring for obese patients (Hebl & Xu, 2001; Jay et al., 2009; Schwartz, Chambliss, Brownell, Blair, & Billington, 2003). Other research has found that health care providers are among the most common sources of weight bias (Puhl & Brownell, 2006) and that this weight bias can reduce the quality of care received (Teachman & Brownell, 2001). Research also finds that health care facilities may be unprepared to care for larger patients (Ahmed, Lemkau, & Birt, 2002; Bradway, DiResta, Fleshner, & Polomano, 2008; Imperiali, Cirillo, Brunani, Capodaglio, & Capodaglio, 2013; Tizer, 2007). In relation to reproductive health care, the research is more limited. Amy, Aalborg, Lyons, and Keranen (2006) found delays in gynecological cancer screening among White and Black obese women. They found that previous negative provider response, embarrassment at being weighed, unsolicited advice to lose weight from a provider, and concerns about inadequate equipment (e.g. examination tables) were factors in women’s delay. Wee, McCarthy, Davis, and Phillips (2000) found that morbidly obese women (BMI 40 kg/m2) were less likely have gynecological cancer screening than normal weight women. Research has also identified obesity as a factor associated with delay in receiving abortion care (Foster et al., 2008; Lee & Ingham, 2010), in part owing to delay in discovering or testing for pregnancy (Foster et al., 2008). One study found that later presentation for abortion care among obese women may also be owing to clinical policies and practices at some outpatient abortion providers that make it so that they cannot provide abortion care to obese women (Cosby, Weitz, & Foster, 2006). The authors speculated that obese women affected by these facility policies may experience extra time, travel, and expense in locating a provider who will perform their abortion (Cosby et al., 2006). Our study adds to this literature on service delivery by exploring obese women’s experiences receiving or avoiding family planning care. Materials and Methods Population and Study Design Data for analyses presented in this paper were collected as part of a larger study about the experiences of women seeking abortion. Even though this is a study about obese women’s experiences with family planning, we recruited women seeking abortion care rather than family planning care. We recruited in this way because we expected that obese women who both did not want to become pregnant and had avoided family planning care would not be available for recruitment at family planning centers, but might present for abortion care if they became pregnant. Additionally, because we were interested in prior negative experiences with family planning care, we believed that family planning providers that were less prepared to provide high-quality reproductive health care to obese women would agree to serve as sites for recruitment. Finally, because of the limited number of facilities where abortions are performed (Jones, Zolna, Henshaw, & Finer, 2008), women seeking care at
one abortion facility are likely to come a geographic area served by a large network of family planning providers (Frost & Lindberg, 2013). Thus, sampling women from an abortion facility may give us a broad picture of women from across geographic regions, rather than specific experience within the facilities sampled. Data were collected between May and July 2011 at six abortion care facilities across the United States. Facilities were located in Illinois, Georgia, Arkansas, California, New Jersey, and Texas. Respondents were recruited in facility waiting rooms. They were eligible for inclusion if they were a patient at the facility seeking an abortion or an abortion follow-up appointment, between ages 15 and 60, female, and able to read English or Spanish. Women completed surveys via a self-administered iPadbased questionnaire. A research assistant led women through information about the study and provided a short training on the iPad. Participants gave consent before starting the survey. No identifying information was collected. Participants received $20 to remunerate them for their time. The study protocol was approved by the University of California, San Francisco Committee on Human Research. Study procedures are described in more detail elsewhere (Jones, Upadhyay, & Weitz, 2013). A total of 757 women were eligible and invited to participate in the study and 651 agreed (86%). A subsample of 124 obese women (BMI >30 kg/m2) was asked additional questions about prior experiences with family planning and their experience seeking and receiving abortion care for the current pregnancy. Measures The survey included questions on weight, height, sociodemographic characteristics, contraceptive use, prior experiences with family planning care, and current experiences with abortion care. Analyses for this paper focus on a subset of questions on prior experiences with family planning. Our main independent variable of interest was obesity status. Our main outcome variables of interest were family planning needs being met and facility preparedness indicators. Obesity status Obesity status was calculated using the Centers for Disease Control and Prevention BMI categories (Centers for Disease Control and Prevention, 2011). Women were classified as under/normal weight (BMI of 24.99 kg/m2), overweight (25– 29.99 kg/m2), obese (30–39.99 kg/m2), or morbidly obese (40 kg/m2). Height was recorded as height in feet and height in inches in two separate questions. Only women with complete height and weight data (n ¼ 622) were used for analysis. Women with a BMI over 30 kg/m2 answered additional questions about their family planning experiences. Forty obese women were not correctly identified as obese by the iPad program and thus did not complete the subset of questions designed for obese women. Demographics Race/ethnicity is a categorical variable: Non-Hispanic White, non-Hispanic Black/African-American, Hispanic/Latina, and other (Asian/Pacific Islander/biracial/other). Economic status is a dichotomous variable of below or above 200% of the federal poverty line. Education is a dichotomization of high school/GED or less (yes/no) and having attended any college or more. Insurance is a dichotomous (yes/no) variable of whether the woman reported having insurance for her regular source of medical care (“How do you usually pay for your medical
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care?”); those who reported having any type of insurance coverage for health care, regardless of whether they also reported self-pay, are classified as having insurance. An additional demographic was a dichotomous variable of having a romantic partner (yes/no). Previous family planning experiences Previous family planning visit is a dichotomous variable of ever having had a previous family planning visit. Obese women who had a previous family planning in the last 3 years were asked an additional series of questions about their experiences during the visits including interactions with providers and clinic preparedness. Obese women were also asked if they had ever avoided general health care because of their weight as well as if they had ever avoided family planning care because of their weight. These are dichotomous (yes/no) variables. Reproductive health history Women were asked about number of pregnancies (gravidity), including the pregnancy associated with their current abortion visit. Needs met is a dichotomous (yes/no) variable of women who reported that they were “able to get all the family planning services you needed during [their] visits.” Only women who had previous family planning visits were asked this question. This question also included an open-ended question about which services were not received. Clinic preparedness A subsample of obese women who had had a family planning visit in the last 3 years was asked the question, “At any of your family planning visits in the last 3 years, which items were NOT adequate for your size?” Women checked all that applied from a list of from a list of five items: Gowns too small, inadequate blood pressure cuffs, inadequate examination tables, inadequate weight scale, and inadequate waiting room chairs. These were turned into dichotomous variables for descriptive analysis. Women were also asked, “How prepared was the clinic in providing care for heavier women?” A four-category Likert scale was used to rate facilities, which was recoded as a categorical variable: Prepared (very prepared/prepared), unprepared (neither prepared nor unprepared/underprepared), and “I don’t know.” Three years was selected as the cutoff because, at the time of the survey, it was the outer interval for recommended time between pap smears and, thus, recommended family planning visits (American College of Obstetricians and Gynecologists, 2012). Body size satisfaction All women were asked about their current body size satisfaction levels with the question, “How satisfied are you with your current body weight and body shape?”
Data Analysis Statistical analysis was performed used STATA 12.0 (Stata Corp, College Station, TX). Bivariate mixed effects regression analyses to account for clustering by site were used to describe relationships between obesity status and outcomes by site. Multivariate analysis examining whether women had their family planning needs met also used mixed effects regression, to account for clustering by site.
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Results About half of the sample were under or normal weight (48%), followed by overweight (27%), obese (20%), and morbidly obese (5%). The study population was racially and ethnically diverse, with the greatest portion of the sample being Black followed by White, Hispanic/Latina, and other (Table 1). The average age for the overall sample was 25.4 6.33 years. Most women (71%) reported having two or more pregnancies, including the pregnancy at the time of data collection. Most women reported some type of health insurance coverage (75%), including private and public insurance. Information about health insurance coverage to pay for abortion care specifically is described elsewhere (Jones et al., 2013). Overweight, obese, and morbidly obese women were older than normal weight women, reported higher poverty levels and were more likely to be Black. There were significant differences in gravity across BMI, with obese and morbidly obese women reporting significantly higher number of pregnancies compared with under/normal weight women (obese, odds ratio [OR], 2.02; p < .01; morbidly obese, OR, 2.86; p < .05). Among women with a previous family planning visit, obese women (OR, 6.55; 85% CI, 4.96–19.47), morbidly obese women (OR, 3.68; 85% CI, 2.82–30.18), and overweight women (OR, 3.54; 85% CI, 1.55–4.56) were more likely to report body dissatisfaction when compared with normal weight women (p < .001). There were no differences between women across BMI category in terms of health insurance, partner status, or education level. Avoidance of Care Four percent of obese women (n ¼ 5) reported avoiding general health care and 1% (n ¼ 1) reported avoiding family planning care because of their weight. Because this was such a rare outcome, we did not examine factors associated with it. Needs Met There were no differences across BMI category in ever having had a previous family planning visit, with about 55% of women in each BMI category reporting ever having had a family planning visit (Table 1). Of women who ever had a previous family planning visit, a little over 5% reported they were not able to get all of their family planning needs met during their visits. More than 12% of morbidly obese women reported not having their family planning needs met. Among obese and overweight women, this was 2%, and among normal and underweight women, this was 0%. In multivariate analysis, controlling for race, age, and gravidity, the odds of reporting not having family planning needs met was significantly greater among morbidly obese women compared with all other women (p < .01). Needs not met for obese and morbidly obese women during the visits included not getting a desired pap smear (n ¼ 1), not getting tested for sexually transmitted infections (n ¼ 2), or not getting an ultrasound (n ¼ 1), and not getting an abortion (n ¼ 1). There were no differences across BMI category in the number of previous abortion providers called or visited. Facility Preparedness Almost 10% of obese and morbidly obese women reported one of the previous family planning clinics they had visited was not
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Table 1 Sample Description Demographic Characteristic
Total Sample 622 (100%)
BMI (kg/m2) Age, mean (SD) Race (n ¼ 622) White (non-Hispanic) Black/African-American (non-Hispanic) Latina/Hispanic Asian/PI/other (Native American, multi, missing) Income (n ¼ 604) <200% below family planning L 200% below family planning L Education (n ¼ 621) HS or less Any college Partnered (n ¼ 617) Yes No Has health insurance (n ¼ 621) NS Yes No Ever had a previous family planning visit (n ¼ 622) Yes No Gravidity (no. of pregnancies) (n ¼ 614) 1 2 3 4 Current unsatisfied with body shape (n ¼ 339) Yes No Clinic location (n ¼ 622) Texas New Jersey California Illinois Georgia Arkansas *
25.4 (6.33) 151 278 102 91
(24) (45) (16) (15)
Normal/ Underweight 301 (48%)
Overweight 168 (27%)
Obese 125 (20%)
Morbidly Obese 28 (5%)
25 24.2 (.36)
25–29.99 25.5 (.47)y
20–39.99 27.6 (.56)*
40 28 (1.11)*
*
*
y
93 101 50 57
(31) (34) (16) (19)
35 88 28 17
(21) (52) (17) (10)
207 (71) 85 (29)
(17) (54) (16) (13)
2 22 4 0
(7) (79) (14) (0)
y
*
465 (77) 139 (23)
21 67 20 17
134 (84) 26 (16)
101 (82) 23 (18)
23 (82) 5 (18)
z
250 (40) 370 (60)
121 (40) 180 (60)
71 (43) 96 (57)
45 (36) 80 (64)
14 (50) 14 (50)
495 (80) 121 (19)
245 (81) 55 (18)
137 (82) 29 (17)
91 (73) 33 (26)
23 (82) 4 (14)
462 (74) 159 (26)
216 (72) 84 (28)
125 (74) 43 (26)
97 (78) 28 (22)
24 (86) 4 (14)
340 (55) 282 (45)
163 (54) 138 (46)
96 (57) 72 (43)
64 (51) 61 (49)
17 (61) 11 (39)
182 120 107 205
115 59 49 77
*
(30) (20) (17) (33)
(38) (20) (16) (26)
y
*
34 39 38 56
(20) (23) (23) (34)
*
28 18 15 58
(23) (15) (13) (49)
*
5 4 5 14
(18) (14) (18) (50)
*
148 (44) 191 (56)
41 (25) 122 (75)
45 (47) 50 (53)
49 (77) 23 (23)
13 (76) 4 (24)
206 111 90 89 75 51
105 54 41 44 29 28
50 32 27 22 27 10
41 18 22 19 13 12
10 7 0 4 6 1
(33) (18) (15) (14) (12) (8)
(35) (18) (13) (15) (10) (9)
(30) (19) (16) (13) (16) (6)
(33) (14) (18) (15) (10) (10)
(36) (25) (0) (14) (21) (4)
p .01, yp .05, and zp .10 compared with normal/underweight women.
prepared to provide care for heavier women. More (38%) reported they that did not know if the clinic was prepared or not. One fourth of obese women, however, reported at least one item in a family planning clinic they previously attended was inadequate for their size (Table 2). The most common way a clinic was unprepared was having gowns that were too small for the patient.
likely to receive unsolicited advice to lose weight than normal weight women (p < .01). There were no differences between overweight and normal weight women around unsolicited advice to lose weight.
Experiences during Prior Family Planning Visits
Almost half of women presenting for abortion care were classified as overweight or obese, with almost 5% morbidly obese. Thus, managing undesired fertility is a significant issue for women of higher body weight. This study is among the first to examine how obesity status impacts women’s use of reproductive health care and explore obese women’s experiences with family planning services. Contrary to our expectations, almost all obese and morbidly obese women reported that they were not avoiding either general health care or family planning care. However, morbidly obese women were more likely to report that they did not receive all the services they needed because of their weight. They also reported that some equipment at clinics such as gowns or blood pressure cuffs were not adequate for their size. These findings suggest that although obese women seek family planning care, they are not necessarily receiving all needed care, and are greeted by equipment inadequate for their size. In addition, women with higher BMIs also report significantly more dissatisfaction with body size as well as more prior
According to bivariate logistic regression, overweight (OR, 2.36, p < .05; 85% CI, 1.16–4.88), obese (OR, 3.11, p < .001; 85% CI, 1.57–7.26) and morbidly obese women (OR, 2.33, p < .05; 85% CI, 1.25–13.48) all reported more embarrassment at being weighed at a family planning visit than underweight or normal weight women. Obese (OR, 4.16; 85% CI, 1.50–11.54) and morbidly obese (OR, 9.56; 85% CI, 2.56–35.74) women were more Table 2 Items Reported as “Not Adequate for Your Size” Clinic Items
Women Reporting (%)
Gowns too small Inadequate blood pressure cuffs Inadequate exam tables Inadequate weight scale Inadequate waiting room chairs
10 7 4 2 2
Discussion
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experience with inadequate sized gowns. How women with poor body dissatisfaction experience care when dressed in a gown that is too small or when naked because the gown cannot be used may prove a productive site for further research. Comfort, both physical and psychological, in the clinical encounter has been shown to be important for health care more generally (Doyle, Lennox, & Bell, 2013). Although not the purpose of this analysis, we find low rates of prior family planning care utilization by most women, with almost half of all women presenting for an abortion having never sought family planning services. We found this despite high rates of insurance coverage among women in the sample and the availability of low-cost family planning services in the states where women reside (Jones et al., 2013). Thus, rather than finding that obese women are unique in poor utilization of family planning services, we find substantial need for greater access to family planning care for women of all weights. Obese women, however, may have greater difficulty having their needs met once arriving for family planning care. Overweight and obese women in our study were more likely to have greater overall gravidity, specifically three or more pregnancies. We acknowledge that our study cannot explain whether these higher rates are the result of poorer contraceptive options and use among obese women or whether the obesity is the result of greater weight gain across multiple pregnancies. Literature in the field finds that weight gain during pregnancy is related to long-term maternal overweight and obesity (Gunderson, 2009; Mamun et al., 2010), so it logically follows that multiple pregnancies would increase this risk. Regardless of the causal relationship, women at higher BMI are more likely to experience a greater number of pregnancies. This suggests that the capacity to provide high-quality, nonstigmatizing health care for the range of women’s family planning needs, including abortion. Contrary to expectations, we did not find evidence that obese women had more difficulty finding a provider to perform their abortion. One woman did report that she was not able to obtain a desired abortion owing to her weight. However, because this was only one woman in our sample, no conclusions can be drawn about this issue from this study. Additional research is needed on this topic to understand the extent to which obese women have more difficulty obtaining abortion care. We found that obese women in our sample reported not getting specific family planning needs met, including desired pap smears, getting tested for sexually transmitted infections, or getting an ultrasound related to pregnancy or other gynecological concern. However, our study only provides limited information about what the family planning needs are for obese women in particular. Therefore, there is also a need for additional research with obese women to understand their specific family planning needs; this includes obese women who do not currently receive family planning care or do not seek abortion when faced with an unintended pregnancy. This research could help to better explain what women mean when they say that their family planning needs are not being met. In particular, this research should explore whether women were unable to get specific methods of contraception, such as intrauterine contraception, which may have greater efficacy for women with higher body weight (Lopez et al., 2013). Unmet family planning needs could also result in abortion delay; although our data did not assess delay in abortion care, other studies have shown that obesity is associated with abortion delay (Foster et al., 2008). Additional research is also needed to examine what policies, procedures, and equipment are considered necessary for a family
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planning clinic to be prepared for larger patients and which features improve patient experiences and health outcomes. Limitations of this study included the small sample size of obese and morbidly obese women. Small sample size means low precision of effect estimates and the possibility that we did not detect a small effect. However, we did find significant differences between obesity categories on family planning needs met, suggesting there may be a large effect for morbidly obese women worthy of further investigation. Further, because we sampled women seeking abortion care, our sample may have reported higher rates of previous family planning care receipt than a nonclinical sample of obese and morbidly obese women because these women had subsequently gotten themselves to a clinic. However, the inverse could also be true, that these women actually have lower rates of family planning care and are thus getting an abortion for their current pregnancy. The sampling of women from abortion clinics also excluded women with unintended pregnancies who carried their pregnancies to term and these women may have different family planning needs or patterns of avoiding family planning care. A population-based study might identify more women who report avoiding family planning care. Implications for Policy and/or Practice Family planning providers should undertake and evaluate interventions geared at improving the clinical experience of obese and morbidly obese women. Our study identified several areas where providers could make improvements. Specifically, to make obese women feel more welcome in the family planning care setting, providers should have an adequate supply of larger gowns and larger blood pressure cuffs, as well as purchase higher capacity examination tables and scales. It is worth noting that some of these items are not solely about women’s comfort; for example, having properly fitting blood pressure cuffs is essential to get accurate blood pressure measurements and thus not overdiagnose hypertension (Maxwell, Schroth, Waks, Karam, & Dornfeld, 1982). Currently, there are no family planning program recommendations for caring for women with higher body weights. The federal family planning program, Title X, should identify best practices and disseminate those as part of its overall recommendations for how to provide appropriate family planning care. Acknowledgments This project was funded by the David and Lucile Packard Foundation. The authors would like to thank Sandi Ma, MS for programming the survey for the iPads, Erica Sedlander, MPH for leading the participant recruitment process, Jen Grand and Ushma Upadhyay, PhD, MPH for data analysis consulting and Maya Newman, BA for her assistance with participant recruitment. We would also like to thank Deborah Karasek, MPH and Diana Greene Foster, PhD for her insights on study design. Natalie Ingraham had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. References Ahmed, S. M., Lemkau, J. P., & Birt, S. L. (2002). Toward sensitive treatment of obese patients. Family Practice Management, 9(1), 25–28. American College of Obstetricians and Gynecologists. (2012). Well-woman visit: Committee opinion no. 534. Washington, DC: Author 421–424.
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Author Descriptions Natalie Ingraham, MPH, is a PhD Candidate in Sociology in the Department of Social and Behavioral Sciences at the University of California, San Francisco (UCSF).
Sarah CM. Roberts, DrPH, is a public health social scientist. She studies policy and social determinants of women’s health, with a focus on alcohol and drug use in the context of pregnancy, parenting, and abortion.
Tracy A. Weitz, PhD, MPA, is an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, and the Director of Advancing New Standards in Reproductive Health (ANSIRH), both at the University of California, San Francisco (UCSF).