The European Journal of Contraception and Reproductive Health Care, 2013; 18: 468–479
Contraceptive use and method among immigrant women in France: Relationship with socioeconomic status Lorraine Catherine Poncet∗, Nicole Huang∗,†, Wenmay Rei†, Yun-Chen Lin† & Chuan-Yu Chen†,‡ ∗International Health Programme, Institute of Public Health, National Yang-Ming University, Taiwan, †Institute of Public Health, School of Medicine, National Yang Ming University, Taiwan, and ‡Centre of Neuropsychiatric Research, National Health Research Institutes, Taiwan
ABSTRACT
Objectives We investigated the relationship between socioeconomic status and the use and method of contraception among immigrant, second-generation immigrant, and nonimmigrant women in France. Methods We analysed data from the 2008–2009 survey ‘Trajectories and origins: Survey on the diversity of populations in France’. A total of 7070 women aged 18 to 45 years were identified, and information concerning contraceptive use and choice was obtained by selfreport. Polytomous logistic regression models were used to assess association estimates. Results Recent contraceptive use among immigrant and second-generation immigrant women was significantly lower than that of non-immigrant women. Lower educational attainment and unemployment were associated with an estimated 31∼59% reduction in odds of contraceptive use for immigrant and second-generation immigrant women; however, this was not the case for non-immigrant women. Among the latter, lower educational attainment appeared to be associated with increased use of oral contraceptives. Conclusions Our findings suggest the need to advance our understanding of potential barriers to contraceptives created by socioeconomic forces across different societal/cultural contexts.
K E Y WO R D S
Contraceptives; Immigration; Survey; Socioeconomic status
I N T RO D U C T I O N
Contraception, in addition to preventing conception, also promotes psychosexual well-being1,2. Around the world there is a wide range of individual- and community-level determinants for contraceptive use. Women are more likely to use contraception when
their spouses/partners agree with the decision and when members of their community approve of family planning (FP)3. Other than demographic and cultural backgrounds (e.g., marital status and religious affiliation), socioeconomic status is the factor most
Correspondence: Chuan-Yu Chen, PhD, Associate Professor, Institute of Public Health, National Yang-Ming University, 155, Sec. 2, Linong Street, Taipei city 112, Taiwan. E-mail: [email protected]
© 2013 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2013.835394
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commonly documented in relation to the use of contraception4–7. Contraceptive methods differ not only in their mechanisms, side effects and efficacy, but also in their symbolic meaning and acceptance by individual cultures and societies8,9. Women’s choice of contraceptive methods is affected by demographics, cultural norms, level of commitment to avoiding pregnancy, socioeconomic status and perceived access to healthcare10–14. For example, in France a tacit norm exists for ‘adequate’ contraceptives based on women’s reproductive status: when the woman is at the beginning of a new sexual relationship, in an unstable relationship or having sex with multiple partners, condoms are often expected to be used. When the relationship with the sexual partner stabilises, women are often directed towards ‘the pill’ (oral contraceptives [OCs]). After women have reached the desired family size, intrauterine devices (IUDs) are the typical birth control method recommended15. Until now, the connection between socioeconomic status indicators and contraceptive method was somehow mixed10–12. In the United States, women who are poor or have lower educational attainment tend to use condoms12. In France, using IUDs was found to be associated with women of higher socioeconomic status7. The differences may be partly explained by healthcare insurance policies, availability of certain contraceptive methods and healthcare providers’ preferences in each country11. In France, some OCs, implants, IUDs and diaphragms are reimbursed up to 65% of their cost by the standard national health insurance (NHI) plans and by the Universal Medical Coverage, which is available to those not eligible for the standard insurance. Other methods are not covered by NHI plans but they can be reimbursed by private complementary insurance plans. A number of studies have proposed that focusing on at-risk populations with regard to contraception may be inappropriate since vulnerability may be attached to situations rather than individuals or groups14–19. Nevertheless, some disadvantaged or disempowered groups, such as women with immigrant or minority backgrounds, are likely to be vulnerable because of a possible lack of knowledge, access and resources when it comes to certain forms of contraception. Several explanations, including socioeconomic inequality and restricted access to material resources, have been put forward to account for observed immigration-related vulnerability20,21; meanwhile, the
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integration policy of host countries affects the outcome of immigrant healthcare, as do stigmatisation and structural barriers directed at immigrants22–24. Population-based evidence shows that immigrant women use contraceptives less often; however, little attention has been given to whether potential effects of socioeconomic status on contraceptive use/methods operate homogenously across subgroups defined by immigration background24–26. To fill these gaps, we turned to the Trajectory and Origins survey which investigated national and immigration origin-related inequalities in France. The goal of the present study was to investigate the extent to which educational attainment, type of occupation and household income are related to the use of contraception and choice of contraceptive method. We also explored whether the observed connection with these three socioeconomic indicators was homogeneous across women with different immigration backgrounds.
M AT E R I A L S A N D M E T H O D S
Study population In 2008, 5.3 million immigrants were living in France. The poverty rate was estimated to be 36% among immigrants, compared to 13.5% among non-immigrants in 200727,28. The immigrant population in France is a mixture of immigrants and descendants of immigrants, also known as ‘second-generation immigrants’. In the present study, immigrants were defined as individuals living in France who were born outside France, who were not French at birth, and who experienced migration either as children or as adults. They may or may not have acquired the French nationality. Second-generation immigrants were defined as those born in France, who were French at birth, and who had at least one immigrant parent. We used the data from the Trajectory and Origins survey (Trajectoires et Origines [TeO])29. The TeO survey was conducted in continental France by the National Institute of Demographic Studies (INED) and the National Institute of Statistics and Economic Studies (INSEE), from September 2008 to February 2009. Its purpose was to measure the impact of origins on living conditions and social trajectories. On the basis of the 2007 census, the target population consisted of men and women aged 18 to 60 years living in ordinary households in metropolitan France. An
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official authorisation was awarded by the CNIL (‘Commission nationale de l’informatique et des libertés’, the independent French administrative authority whose mission is to ensure that the data privacy law is applied to the collection, storage, and use of personal data) to INSEE and INED for the survey with regard to ethical considerations and the confidentiality of the respondents. Data related to immigration status were obtained from registrations at the INSEE and city councils, with special permission granted by the National Commission for Computers and Freedom (CNIL) to access names in order to identify and locate potential respondents. Translators were used for respondents with little or no knowledge of French. A total of 21,761 respondents were interviewed face-to-face by trained interviewers using standardised questionnaires. These interviews covered five sub-groups: immigrants (n 8456), second-generation immigrants (n 8110), overseas citizens (n 712), descendants of overseas citizens (n 702), and nonimmigrants (n 3781).The overall response rate to the survey was 61%, with a slightly higher rate for nonimmigrants (66%); the corresponding rates for immigrants and second-generation immigrants were 62% and 60%, respectively. Students, unemployed people and unskilled salaried workers had reduced response rates. Our request to use the data for the present analyses was reviewed and ethically approved by the Maurice Halbwachs Centre. For the purpose of this research, we limited the sample to adult female respondents who (i) were of reproductive age at the time of the survey (i.e., 18 to 45 years of age); (ii) responded to the questions concerning contraceptive use; (iii) were at risk of pregnancy at the time of the survey (women who were currently pregnant or reported menopause or sterility were excluded); and (iv) were not planning to become pregnant (women reporting no contraceptive use due to planning a pregnancy were excluded) (n 7070).
method of contraception recently used (e.g., OCs, condoms and IUDs, among others). Several important variables were obtained from standardised questionnaires, including socioeconomic status indicators (educational attainment, employment status and total household income), demographic variables (e.g., age, marital status, relationship/cohabitation status, number of children and immigration background), national health insurance (NHI) plan enrolment, complementary insurance enrolment and the number of medical visits during the 12 months prior to the survey. In the case of first-generation immigrants, the number of years since their immigration to France was also retrieved. Statistical analysis The Chi-squared test was initially used to examine potential subgroup-associated heterogeneity by immigration background. Considering potential heterogeneity in demographic composition and cultural attitudes toward birth control, we decided to carry out the analyses with stratification by immigration background. First we evaluated the association estimates linking the three previously mentioned socioeconomic status indicators with contraceptive use by multivariate logistic regression analyses, with adjustments for age, relationship status, number of children, insurance enrolment status and number of medical visits (N 7070). Then, to investigate whether socioeconomic status may have a relationship with contraceptive methods and probe possible immigration background-related variation, we conducted a series of polytomous logistic regression analyses on those women who reported recently using ‘condoms,’ ‘OCs’ or ‘IUDs’ (n 4919). All tests were two-sided, with an alpha value of 0.05 (∗), 0.01(∗∗) and 0.001(∗∗∗) to indicate the probability of Type I errors. Data were processed and analysed using the statistical software SPSS, version 17.
Measurements In the present study, the primary outcome variables, current contraceptive use and method, were assessed by a series of standardised questions, beginning with the following question: ‘Currently, do you or your partner, if you have one, use any methods to avoid having a child?’ A positive response was followed by a single-choice question with a list of methods to inquire about the 470
R E S U LT S
Selected socio-demographic, insurance and medical characteristics of the sample are summarised in Table 1. Non-immigrants had a higher level of education; 49% had a baccalaureate degree or above. The unemployment rates among immigrants and second-generation
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Table 1 Distribution of selected socio-demographic, insurance, and medical characteristics, by immigration background in France (N 7070). Variablesa n Age, yrs∗∗∗ 18–30 31–40 41–45 Educational attainment∗∗∗ No formal education Primary/junior high Professional/high school Baccalaureate/above Occupational status/type∗∗∗ Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/technicians Total household income, Euros∗∗∗ 1300 or less 1301–2000 2001–3000 3000 or more Missing Marital status∗∗∗ Married Unmarried Relationship/cohabitation status∗∗∗ No relationship In a relationship, living together In a relationship, not living together Number of children∗∗∗
Immigrants
Second-generation immigrants
Non-immigrants
2387
3453
1230
701 (29.6) 1086 (45.5) 594 (24.9)
2029 (58.7) 1089 (31.5) 335 ( 9.7)
482 (39.2) 464 (37.7) 284 (23.1)
521 372 470 945
(21.8) (15.6) (19.7) (39.6)
341 320 1194 1594
(9.9) (9.3) (34.6) (46.2)
84 85 456 602
(6.8) (6.9) (37.1) (48.9)
379 669 423 503 410
(15.9) (28.0) (17.7) (21.1) (17.2)
598 733 277 1025 817
(17.3) (21.2) (8.0) (29.7) (23.7)
107 223 129 375 385
(8.7) (18.1) (10.5) (30.5) (31.3)
385 459 546 396 601
(16.1) (19.2) (22.9) (16.6) (25.2)
489 539 725 604 1096
(14.2) (15.6) (21.0) (17.5) (31.7)
166 153 302 268 341
(13.5) (12.4) (24.6) (21.8) (27.7)
1730 (72.5) 657 (27.5)
1638 (47.4) 1815 (52.6)
796 (64.7) 434 (35.3)
504 (21.1) 1691 (70.8) 192 (8.0)
1281 (37.1) 1550 (44.9) 622 (18.0)
286 (23.3) 769 (62.5) 175 (14.2)
0 1 2–3 3 or more Religion∗∗∗
517 402 1147 321
(21.7) (16.8) (48.1) (13.4)
1831 525 1001 96
(53.0) (15.2) (29.0) (2.8)
453 207 527 43
(36.8) (16.8) (42.8) (3.5)
Do not have a religion Have a religion Refuse to say Do not know Enrolment of NHI plan∗∗∗
406 (17.0) 1963 (82.2) 13 (0.5) 5 (0.2)
1017 2410 15 11
(29.5) (69.8) (0.4) (0.3)
576 647 3 4
(46.8) (52.6) (0.2) (0.3)
2047 (85.8) 275 (11.5) 27 (1.1) 33 (1.4) 5 (0.2)
3151 267 5 23 7
(91.3) (7.7) (0.1) (0.7) (0.2)
1162 57 4 7 0
(94.5) (4.6) (0.3) (0.6) (0.0)
Standard CMU AME None Don’t know
(Continued)
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Table I. (Continued)
Variablesa Complementary insurance∗∗∗ Have Do not have Do not know Medical visit in last 12 months∗∗∗ No visit One visit Two or more visits Contraception use∗∗∗ Yes No Years of immigration 0–5 6–10 11–20 21 or more
Immigrants
Second-generation immigrants
Non-immigrants
1869 (78.3) 510 (21.4) 8 (0.3)
2925 (84.7) 515 (14.9) 13 (0.4)
1155 (93.9) 74 (6.0) 1 (0.1)
195 (8.2) 634 (26.6) 1556 (65.3)
223 (6.5) 767 (22.2) 2463 (71.3)
43 (3.5) 227 (18.5) 960 (78.0)
1661 (69.6) 726 (30.4)
2267 (65.7) 1186 (34.3)
991 (80.6) 239 (19.4)
415 533 654 784
(17.4) (22.3) (27.4) (32.9)
NA
NA
Chi-Square test: *p 0.05, **p 0.01, ***p 0.00; NHI, National Health Insurance; CMU, Universal Medical Coverage; AME, State Medical Help; NA, not applicable. aColumns may not add up to 100% due to missing values (less than 3%).
immigrants were higher than that of non-immigrants (28% and 21% vs. 18%). Immigrant women were more likely to have unskilled occupations, whereas secondgeneration immigrants and non-immigrants tended to hold positions as clerks/skilled workers or professionals/technicians. Non-immigrants had higher household incomes, with 46% earning more than 2000 Euros per month, compared to 40% for immigrants and 39% for second-generation immigrants. More immigrant women were married (73%) and had a religion (82%) than their second-generation immigrant and non-immigrant counterparts. We first focused our analyses on the variable concerning immigration background. With non-immigrants as a reference group, we found that women in the two immigrant groups were less likely to use contraception (Odds Ratio [OR]: 0.55, 95% confidence interval [CI]: 0.46–0.65 for immigrants; OR: 0.46, 95% CI: 0.39–0.54 for the second generation immigrants) (data not shown here). We found that lower educational attainment, having never worked and lower household income were associated with reduced use of contraceptives in the three groups of women (Table 2). When age, relationship status, number of children, NHI enrolment status, and 472
number of medical visits were taken into account by statistical adjustment (Model 1), part of the association linked to these three socioeconomic status indicators remained for immigrants and second-generation immigrants and disappeared for non-immigrants. Immigrant women who never worked were just under half as likely to use contraceptives when compared with non immigrants in a professional job (adjusted Odds Ratio [aOR]: 0.45, 95% CI: 0.29–0.68, p 0.001), and the corresponding estimate in the second-generation immigrants was 0.48 (95% CI: 0.34–0.67, p 0.001).Taking ‘years since immigration’ into account for immigrants (Model 2), immigrant women who had never worked had 59% reduced odds of using contraception (95% CI: 0.27–0.61, p 0.01). None of the three socioeconomic status indicators (i.e., educational attainment, occupational status/type and total household income) were found to correlate with contraceptive use among non-immigrants. Figure 1 shows the distribution of contraceptive methods used by women who reported using contraception at the time of the survey (n 4919). Women of all groups relied mainly on OCs, followed by IUDs and male condoms. Over 60% of second-generation immigrants used the pill as the only contraceptive.
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1.00
0.79 (0.63–0.99)∗
0.80 (0.57–1.13)
0.70 (0.55–0.90)∗∗ 0.87 (0.75–1.03)
0.69 (0.49–0.98)∗
Model 1a aOR (95%CI)
0.78 (0.61–1.00)
Crude OR (95%CI)
1.00
0.98 (0.71–1.34)
0.71 (0.41–1.22)
0.46 (0.27–0.76)∗∗
Crude OR (95%CI)
1.00
1.15 (0.76–1.76)
1.04 (0.52–2.10)
0.89 (0.43–1.81)
Model 1a aOR (95%CI)
Non-immigrants
0.23 (0.16–0.31)∗∗∗ 0.34 (0.23–0.50)∗∗∗ 0.85 (0.61–1.18) 1.00 0.69 (0.49–0.97)∗
1.00
0.94 (0.70–1.27)
0.78 (0.51–1.21) 1.02 (0.63–1.66) 1.10 (0.75–1.60) 1.00 0.80 (0.56–1.15)
1.00
0.83 (0.57–1.21)
0.65 (0.43–0.98)∗ 0.83 (0.52–1.32) 0.99 (0.69–1.43) 1.00 0.71 (0.50–1.01)
1.00
0.89 (0.62–1.26)
0.27 (0.21–0.36)∗∗∗ 0.31 (0.22–0.44)∗∗∗ 0.88 (0.67–1.16) 1.00 0.56 (0.41–0.75)∗∗∗
1.00
0.71 (0.57–0.88)∗∗
1.18 (0.82–1.70) 0.97 (0.63–1.50) 1.08 (0.76–1.52) 1.00 0.63 (0.46–0.85)∗∗
1.00
0.80 (0.60–1.06)
0.34 (0.20–0.56)∗∗∗ 0.53 (0.27–1.04) 0.73 (0.45–1.19) 1.00 0.79 (0.47–1.33)
1.00
0.96 (0.66–1.41)
1.53 (0.78–3.00) 1.54 (0.66–3.57) 0.92 (0.53–1.59) 1.00 0.85 (0.50–1.45)
1.00
0.84 (0.51–1.37)
0.54 (0.40–0.73)∗∗∗ 0.45 (0.29–0.68)∗∗∗ 0.41 (0.27–0.61)∗∗∗ 0.21 (0.16–0.26)∗∗∗ 0.48 (0.34–0.67)∗∗∗ 0.42 (0.26–0.69)∗∗∗ 0.70 (0.33–1.48) 0.94 (0.71–1.25) 0.82 (0.56–1.18) 0.79 (0.56–1.11) 0.57 (0.46–0.72)∗∗∗ 0.71 (0.52–0.97)∗ 0.70 (0.46–1.07) 0.66 (0.37–1.16) 0.73 (0.54–0.98)∗ 0.68 (0.46–1.01) 0.68 (0.48–0.98)∗ 0.61 (0.45–0.82)∗∗∗ 0.65 (0.44–0.97)∗ 0.75 (0.45–1.24) 0.65 (0.34–1.23)
1.00
1.50 (1.09–2.07)∗
1.19 (0.93–1.53) 1.00
1.28 (0.94–1.75)
1.11 (0.79–1.55)
1.14 (0.87–1.49)
1.00
0.97 (0.70–1.34)
0.77 (0.57–1.05)
0.63 (0.47–0.83)∗∗
Model 2b aOR (95%CI)
0.83 (0.66–1.05)
Model 1a aOR (95%CI)
Second-generation immigrants
OR, odds ratio; aOR, adjusted odds ratio; CI, confidence interval; ∗p 0.05; ∗∗p 0.01; ∗∗∗p 0.001. aModel 1: The OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits, and three socioeconomic indicators simultaneously. bModel 2: The OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits, three socioeconomic indicators, and years since immigration simultaneously.
Educational attainment No formal education Primary/junior high Professional/ high school Baccalaureate/ above Occupational status/type Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/ technicians Total household income (Euros) 1300 or less 1301–2000 2001–3000 3001 or more Missing
Variables
Crude OR (95%CI)
Immigrants
Table 2 Socioeconomic status indicators in relation to contraceptive use, stratified by immigration status (N 7070).
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Figure 1 Distribution of contraceptive methods among women using contraception (n 4919). OC, oral contraceptive; IUD, intrauterine device. Chi-square test: p 0.0001.
Approximately 23% of non-immigrants reported the use of IUDs, more frequently than did immigrants and second-generation immigrants. Immigrant women use more ‘other methods’, including non-medical methods (withdrawal and fertility awareness methods). The pattern of contraceptives differs significantly across the three groups of women (chi-squared test, p 0.001; data not shown here). For the women who reported recent use of contraceptives (n 4919), Table 3 presents the association estimates derived from the polytomous logistic regression, with stratification by immigration background. In terms of outcome variable, both OC (first column) and IUD (second column) were compared against male condom (reference group). With adjustment for age, relationship status, number of children, NHI enrolment status, number of medical visits, educational attainment, occupational status and household income, we found that socioeconomic status-related risk 474
estimates appeared to be significant in only two groups, namely, second-generation immigrants and non-immigrants.Among the second-generation immigrants, we found that women who never worked were 66% less likely to use an IUD than male condoms, compared to women with professional occupational status (95% CI: 0.13–0.90, p 0.01). Non-immigrants with professional/high school degree were 2.5 times more likely to use an OC, compared to their peers with a baccalaureate or higher degree. DISCUSSION
Based on our nationally representative sample, the results show that the use of contraception was not homogeneously distributed among women with different immigration backgrounds in France. Three indicators of socioeconomic status appear to affect contraceptive use differently across the three groups of
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0.96 (0.41–2.24) 0.87 (0.44–1.75) 0.74 (0.40–1.36) 1.00 0.95 (0.51–1.75)
(0.47–2.39) (0.79–2.87) (0.72–3.20) (0.47–1.65) 1.00
1.06 1.50 1.52 0.88
1.14 1.20 1.45 0.94
(0.59–2.21) (0.69–2.09) (0.70–2.76) (0.55–1.59) 1.00
1.39 (0.74–2.61) 0.90 (0.48–1.68) 1.36 (0.77–2.39) 1.00
IUD aOR (95%CI)
1.51 (0.86–2.65) 1.18 (0.69–2.00) 1.05 (0.64–1.71) 1.00
OC aOR (95%CI)
(0.33–0.94)∗ (0.34–0.91)∗ (0.47–1.90) (0.61–1.47) 1.00
1.71 (0.96–3.07) 1.88 (1.06–3.35)∗ 1.11 (0.69–1.79) 1.00 1.08 (0.68–1.70)
0.56 0.56 0.95 0.95
0.99 (0.56–1.77) 0.93 (0.53–1.62) 1.31 (0.90–1.91) 1.00
OC aOR (95%CI)
(0.13–0.90)∗ (0.33–1.08) (0.40–1.95) (0.54–1.51) 1.00
0.53 (0.21–1.30) 1.35 (0.67–2.70) 0.95 (0.55–1.64) 1.00 0.92 (0.53–1.57)
0.34 0.60 0.89 0.90
0.82 (0.41–1.64) 0.74 (0.38–1.47) 1.18 (0.74–1.86) 1.00
IUD aOR (95%CI)
Second-generation immigrantsa,c
(0.27–1.83) (0.26–1.09) (0.25–1.55) (0.77–3.18) 1.00 1.28 (0.48–3.42) 1.12 (0.47–2.67) 0.90 (0.44–1.82) 1.00 0.93 (0.47–1.82)
0.71 0.53 0.63 1.57
4.34 (1.17–16.10)∗ 1.10 (0.43–2.76) 2.46 (1.32–4.57)∗∗ 1.00
OC aOR (95%CI)
1.08 (0.28–4.07) 0.60 (0.20–1.73) 1.39 (0.66–2.93) 1.00 1.06 (0.51–2.19)
– 0.54 (0.24–1.22) 0.73 (0.27–1.98) 1.61 (0.75–3.45) 1.00
1.26 (0.27–5.69) 0.84 (0.29–2.38) 1.76 (0.88–3.50) 1.00
IUD aOR (95%CI)
Non-immigrantsa,c
aOR,adjusted odds ratio, CI, confidence interval; ∗p 0.05; ∗∗p 0.01; ∗∗∗p 0.001. aReference group: male condoms; bThe OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, years since immigration, number of medical visits in the past 12 months and three socioeconomic indicators simultaneously; cThe OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits in the past 12 months and three socioeconomic indicators simultaneously.
Educational attainment No formal education Primary/junior high Professional/high school Baccalaureate/above Occupational status/type Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/technicians Total household income, Euros 1300 or less 1301–2000 2001–3000 3001 or more Missing
Variables
Immigrantsa,b
Table 3 Socioeconomic indicators in relation to contraceptive choice among women currently using contraception, oral contraceptive (OC) and intrauterine device (IUD) use as compared to male condom use (N 4919).
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women. Immigrant and second-generation immigrant women who had a lower level of educational attainment or who had never worked were less likely to use contraception (their odds of contraceptives use was reduced by 31∼59%), whereas no significant odds associated with socioeconomic status existed for nonimmigrants. In terms of contraceptive methods, the analyses indicate that socioeconomic status is a salient factor among second-generation immigrants and nonimmigrants. Non-immigrants with no formal education were nearly four times more likely to use an OC, compared to their peers with baccalaureate degrees; second-generation immigrants who never worked were only a third (0.34) as likely to use IUDs, compared to their professional counterparts. Several limitations of this study are worth noting. First, our analyses indicated that the item-specific response rate (concerning contraceptive use) for immigrants and second-generation immigrants was 95% and 96%, respectively, as opposed to 98% for non-immigrants. The generalisability to those who did not respond to questions concerning contraceptives or those who refused to participate in the Trajectory and Origins survey may be limited. Comparative analyses suggested that women with no responses to the contraceptive questions were often those who were childless, had higher educational attainment, had never worked and had missing values for household income. Therefore, when we restricted our analytic sample to women who provided answers concerning contraception use, the association estimates for the three socioeconomic indicators may possibly be vulnerable to bias. Be that as it may, perhaps the major drawback of the survey is that it assessed only the respondents’ relationship status, excluding questions about their sexual activity. In the cases where women reported no use of contraceptives, we were unable to identify whether this status was a result of choice or the existence of obstacles to contraceptive use. Finally, because contraceptive use and methods were assessed based on recent experience, we were unable to determine the effects of socioeconomic status on women’s access to and/or choice of contraceptives as an evolving process or from a life course perspective. Notwithstanding these limitations, this study has several strengths. First, the data were collected from community-dwelling women with national representativeness. The large sample size generally allowed for reliable comparisons 476
with adjustments for other confounding factors, although limitations may still exist in some subgroup analyses (e.g., non-immigrant women who never worked). Second, unlike many previous studies that focused only on the immigrant population, this study includes women of three differing immigration backgrounds and provides an opportunity to examine and compare potential immigration-related variations in socioeconomic influences. Consistent with prior studies conducted in other parts of the world (e.g., the United States and Yugoslavia)17–19, our analyses indicated that women with an immigration or minority background generally had a lower rate of contraceptive use than nonimmigrant women. Some ethnic minority women (i.e., Hispanic or African-Americans) used contraceptives less often than non-Hispanic and white women in the United States (69.9% and 70.3% vs. 75.8%)13. Only 63.5% of immigrant women of Mexican origin living in the United States used contraceptives, which is significantly less than women of Mexican origin born in the United States (67.9%).5 The lower utilisation rate of contraceptives may partially be a result of complex micro- and macro-social processes associated with an immigration background, such as awareness or knowledge of reproductive health; socio-cultural beliefs; values and norms toward contraceptive practices; the freedom to make safe reproductive choices and barriers encountered in accessing sexual or reproductive healthcare services29–32. Our results indicate that the relationship between the three socioeconomic status indicators and contraceptive use is not uniform across different immigration backgrounds; in particular, none of the three socioeconomic indicators serve as significant predictors for contraceptive use for non-immigrants. The observed nonexistence of socioeconomic status-differentials among non-immigrant women may be partly contributed to by a wider coverage of several contraceptive methods under a national insurance plan, a greater knowledge about contraceptive services and the existence of norms regarding contraceptives in this study population32. For immigrant and second-generation immigrant women in France, contraceptive use was strongly associated with socioeconomic status. Although the association pattern was similar to that of women with Hispanic origins in the United States14,31, one
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noteworthy point should be made in regard to the differential process of higher educational attainment. To elaborate, most immigrant women in our sample had either completed higher education or had no formal education, suggesting the existence of two separate immigration flows. First-generation immigrant women who reached higher education before immigration into France might have more autonomy or freedom to control their lives, be more aware of birth control or might wish smaller, higher livingquality families, as compared with their peers without formal education. As to second-generation immigrants, because structural barriers often hinder them from obtaining higher education, those who do obtain degrees may possess special characteristics, such as a drive for academic and social success, adherence to parental expectations and trust in the institutional path for reaching social success21. These same characteristics may also be motivating factors in the question of contraceptives; that is to say, a higher drive to obtain educational success may be accompanied by a greater capacity to plan the future and thus the right time to have children32. Finally, with educational level and household income statistically adjusted, we found that the employment category of ‘never worked’ remained significantly associated with a lower likelihood of contraceptives use among the first- and secondgeneration immigrant women. Considering that second-generation immigrant women often encountered more barriers to obtain employment and reach high occupational positions than non-immigrants and, furthermore, that a double discrimination may exist for immigrant women based on ethnic and cultural grounds33,34, women who achieved high occupational status might be part of a select group. The resources that members of this group possess might contribute to a higher rate of contraceptive use. In contrast, the lifetime non-participation in the labour force may have restricted immigrant women’s access to social networks and interaction with outside communities and insurance programmes, thereby reducing their access to information and healthcare, where contraceptive services are concerned35. Similar processes may underlie the reason for reduced contraceptive use among those who had lower occupational status or those who did not respond to the question regarding household income in the questionnaire.
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As for the choice of contraceptive method, we found that socioeconomic status was an explanatory factor only for second-generation immigrants and non-immigrants. Among second-generation immigrants, the gradient in the association estimates linking occupational status/type with IUD use can partially explain the variation in long-term birth control plans for working women. Compared to previous research suggesting that disadvantaged socioeconomic backgrounds were associated with the increased likelihood of condom use in the United States12, our study shows that for non-immigrants, a lower level of educational attainment was significantly associated with using oral contraceptives (relative to condoms). This observed difference in association patterns can be explained, to some extent, by differences in healthcare policy and insurance coverage between the two countries. To illustrate, before the Patient Protection and Affordable Care Act of 2012 was implemented, contraceptive coverage largely depended on individual insurance plans in the United States36. Some plans did not cover contraceptive drugs and devices. In addition, 16.5% of the population was uninsured in 200937,38. For women without insurance or contraceptive coverage, male condoms are likely to be the cheapest and most accessible method of contraception. In contrast, as most contraceptive methods are covered by the National Health Insurance in France, male condoms are not cheaper than reimbursed oral contraceptives. It is therefore possible that socioeconomic influences operate differently in relation to contraceptive options in these two contexts39. Our findings demonstrate that there is much to investigate in the socioeconomic status-related barriers to contraception use. This evidence should provide policymakers with concrete indications for improving contraceptive care among immigrant groups. For example, contraceptive packages offering prevention and free contraception consultations, developed in some areas for youth and young adults, can be implemented for women with immigrant backgrounds40. This can involve a diffusion of contraceptive information and prevention strategies through channels other than schools, thereby reaching a higher percentage of segregated and marginalised groups and reducing disadvantaged socioeconomic effects that limit women’s voluntary use of contraception.
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CONCLUSION
AC K N OW L E D G E M E N T S
Women with an immigrant background were less likely to use contraception and socioeconomic status affects access to contraception among immigrant groups. For second-generation immigrants and non-immigrants, socioeconomic status may have an impact on the choice of contraceptive method. Such information is needed, not only to understand the way that disadvantaged social and economic status may negatively impact on reproductive health and sexual wellbeing among women, but also to act in a relevant manner to alleviate immigration-related vulnerability in contraceptive care.
The authors would like to thank the Maurice Halbwachs Centre for granting us permission to use their data for this study.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. Dr Chen was supported by a grant from the Ministry of Education of Taiwan ROC, Aim for the Top University Plan.
REFERENCES
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11. Perez G, Villegas R, Ruiz-Munoz D, Rodriquez-Sanz M. Determinants of oral contraception use in a southern European setting. Eur J Contracept Reprod Health Care 2010;15:48–53. 12. Oddens B, Lehert P. Determinants of contraceptive use among women of reproductive age in Great Britain and Germany I: Demographic factors. J Biosoc Sci 1997;29: 415–35. 13. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health 2008;40:94–104. 14. Bogue D. Contraception, attitude-practice, and fertility differentials among US Hispanics, African-American and white women. J Popul Res 2010;27:275–92. 15. Bajos N, Ferrand M, Hassoun D. Au risque de l’échec: la contraception au quotidien. In Bajos N, Ferrand M, and Equipe Gine, eds. De la contraception à l’avortement Sociologie des grossesses non prévues. Paris: Editions Inserm 2002:33–78. 16. Moreau C, Bouyer J, Gilbert F, et al. Social, demographic and situational characteristics associated with inconsistent use of oral contraceptives: Evidence from France. Perspect Sex Reprod Health 2006;38:190–6. 17. Kossler K, Kuroki LM, Allsworth JE, et al. Perceived racial, socioeconomic and gender discrimination and its impact on contraceptive choice. Contraception 2011;84:273–9. 18. Newell A, Sullivan A, Halai R, Boaq F. Sexually transmitted diseases, cervical cytology and contraception in immigrants and refugees from the former Yugoslavia. Venereology 1998;11:25–7. 19. United Nations Population Fund. State of world population 2006. New York, NY: UNFPA 2006. Accessed 12 August 2013 from: http://www.unfpa.org/swp/2006/ pdf/en_sowp06.pdf
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20. Mora L. Las fronteras de la vulnerabilidad: Genero, migracion y derechos reproductivos. Paper presented at the Hemispheric Conference on International Migration: Human Rights and Trafficking in Persons in the Americas 2002. 21. Borrell C, Muntaner C, Sola J, et al. Immigration and self-reported health status by social class and gender:The importance of material deprivation, work organisation and household labour. J Epidemiol Community Health 2008;62:e7. 22. Szreter S, Woolcock M. Health by association? Social capital, social theory, and the political economy of public health. Int J Epidemiol 2004;33: 650–67. 23. Bollini P, Pampallona S, Wanner P, Kupelnick B. Pregnancy outcome of migrant women and integration policy: A systematic review of the international literature. Soc Sci Med 2009;68:452–61. 24. Larchanche S. Intangible obstacles: Health implications of stigmatization, structural violence, and fear among undocumented immigrants in France. Soc Sci Med 2012;74:858–63. 25. Turki R, Ferrand M, Bajos N. Femmes migrantes ou issues de l’immigration maghrébine: un rapport spécifique à la contraception? In Bajos N, Ferrand M, and Equipe Gine, eds. De la contraception à l’avortement – Sociologie des grossesses non prévues. Paris: Editions Inserm 2002:303–36. 26. Sexualité, fécondité, maternité chez les jeunes filles de parents maghrébins immigrés. Migrations Santé workshop record, 8–9 December 1989. Migrations Santé 1990;64/65:15–6. 27. INSEE (National Institute of Statistics and Economic Studies). Niveau de vie et pauvreté des immigrés en 2007. Paris: National Institute of Statistics and Economic Studies 2007. 28. INSEE (National Institute of Statistics and Economic Studies). Les revenus et le patrimoine des ménages. Paris: National Institute of Statistics and Economic Studies 2010.
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29. Beauchemin C, Hamelle C, Simon P. Trajectories and origins – Survey on population diversity in France, initial findings. Paris: INED-INSEE 2010. 30. Bongaarts J, Bruce J. The causes of unmet need for contraception and the social content of services. Stud Fam Plann 1995;26:57–75. 31. Gonzalez EU, Sable MR, Campbell JD, Dannerbeck A. The influence of patriarchal behavior on birth control access and use among recent Hispanic immigrants. J Immigr Minor Health 2010;12:551–8. 32. Robey B, Ross J, Bhushan I. Meeting unmet need: New strategies. Popul Rep J 1996;43:1–35. 33. Meurs P, Pailhe A. Position sur le marché du travail des descendants directs d’immigrés en France: les femmes doublement désavantagées? Econ Stat 2010;431-432:129–51. 34. Llacer A, Amo JD, Garcia-Fulgueiras A, et al. Discrimination and mental health in Ecuadorian immigrants in Spain. J Epidemiol Community Health 2009;63:766–72. 35. Malmusi D, Borrell C, Benach J. Migration-related health inequalities: Showing the complex interactions between gender, social class and place of origin. Soc Sci Med 2010;71:1610–9. 36. Adler NE, Newman K. Socioeconomic disparities in health: Pathways and policies. Health Aff (Millwood) 2002;21:60–76. 37. Guttmacher Institute. State policies in brief: Insurance coverage of contraceptives. New York, NY: Guttmacher Institute 2012. 38. DeNavas-Walt C, Bernadette DP, Jessica CS, US Census Bureau. Income, poverty and health insurance coverage in the United States: 2009. Washington, DC: US Census Bureau 2010. 39. Layte R, McGee H, Rundle K, Leigh C. Does ambivalence about becoming pregnant explain social class differentials in use of contraception? Eur J Public Health 2007;17:477–82. 40. Viswanathan K, Hansen PM, Rahman MH, et al. Can community health workers increase coverage of reproductive health services? J Epidemiol Community Health 2012;66:894–900.
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Contraceptive use and method among immigrant women in France: Relationship with socioeconomic status Lorraine Catherine Poncet∗, Nicole Huang∗,†, Wenmay Rei†, Yun-Chen Lin† & Chuan-Yu Chen†,‡ ∗International Health Programme, Institute of Public Health, National Yang-Ming University, Taiwan, †Institute of Public Health, School of Medicine, National Yang Ming University, Taiwan, and ‡Centre of Neuropsychiatric Research, National Health Research Institutes, Taiwan
ABSTRACT
Objectives We investigated the relationship between socioeconomic status and the use and method of contraception among immigrant, second-generation immigrant, and nonimmigrant women in France. Methods We analysed data from the 2008–2009 survey ‘Trajectories and origins: Survey on the diversity of populations in France’. A total of 7070 women aged 18 to 45 years were identified, and information concerning contraceptive use and choice was obtained by selfreport. Polytomous logistic regression models were used to assess association estimates. Results Recent contraceptive use among immigrant and second-generation immigrant women was significantly lower than that of non-immigrant women. Lower educational attainment and unemployment were associated with an estimated 31∼59% reduction in odds of contraceptive use for immigrant and second-generation immigrant women; however, this was not the case for non-immigrant women. Among the latter, lower educational attainment appeared to be associated with increased use of oral contraceptives. Conclusions Our findings suggest the need to advance our understanding of potential barriers to contraceptives created by socioeconomic forces across different societal/cultural contexts.
K E Y WO R D S
Contraceptives; Immigration; Survey; Socioeconomic status
I N T RO D U C T I O N
Contraception, in addition to preventing conception, also promotes psychosexual well-being1,2. Around the world there is a wide range of individual- and community-level determinants for contraceptive use. Women are more likely to use contraception when
their spouses/partners agree with the decision and when members of their community approve of family planning (FP)3. Other than demographic and cultural backgrounds (e.g., marital status and religious affiliation), socioeconomic status is the factor most
Correspondence: Chuan-Yu Chen, PhD, Associate Professor, Institute of Public Health, National Yang-Ming University, 155, Sec. 2, Linong Street, Taipei city 112, Taiwan. E-mail: [email protected]
© 2013 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2013.835394
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commonly documented in relation to the use of contraception4–7. Contraceptive methods differ not only in their mechanisms, side effects and efficacy, but also in their symbolic meaning and acceptance by individual cultures and societies8,9. Women’s choice of contraceptive methods is affected by demographics, cultural norms, level of commitment to avoiding pregnancy, socioeconomic status and perceived access to healthcare10–14. For example, in France a tacit norm exists for ‘adequate’ contraceptives based on women’s reproductive status: when the woman is at the beginning of a new sexual relationship, in an unstable relationship or having sex with multiple partners, condoms are often expected to be used. When the relationship with the sexual partner stabilises, women are often directed towards ‘the pill’ (oral contraceptives [OCs]). After women have reached the desired family size, intrauterine devices (IUDs) are the typical birth control method recommended15. Until now, the connection between socioeconomic status indicators and contraceptive method was somehow mixed10–12. In the United States, women who are poor or have lower educational attainment tend to use condoms12. In France, using IUDs was found to be associated with women of higher socioeconomic status7. The differences may be partly explained by healthcare insurance policies, availability of certain contraceptive methods and healthcare providers’ preferences in each country11. In France, some OCs, implants, IUDs and diaphragms are reimbursed up to 65% of their cost by the standard national health insurance (NHI) plans and by the Universal Medical Coverage, which is available to those not eligible for the standard insurance. Other methods are not covered by NHI plans but they can be reimbursed by private complementary insurance plans. A number of studies have proposed that focusing on at-risk populations with regard to contraception may be inappropriate since vulnerability may be attached to situations rather than individuals or groups14–19. Nevertheless, some disadvantaged or disempowered groups, such as women with immigrant or minority backgrounds, are likely to be vulnerable because of a possible lack of knowledge, access and resources when it comes to certain forms of contraception. Several explanations, including socioeconomic inequality and restricted access to material resources, have been put forward to account for observed immigration-related vulnerability20,21; meanwhile, the
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integration policy of host countries affects the outcome of immigrant healthcare, as do stigmatisation and structural barriers directed at immigrants22–24. Population-based evidence shows that immigrant women use contraceptives less often; however, little attention has been given to whether potential effects of socioeconomic status on contraceptive use/methods operate homogenously across subgroups defined by immigration background24–26. To fill these gaps, we turned to the Trajectory and Origins survey which investigated national and immigration origin-related inequalities in France. The goal of the present study was to investigate the extent to which educational attainment, type of occupation and household income are related to the use of contraception and choice of contraceptive method. We also explored whether the observed connection with these three socioeconomic indicators was homogeneous across women with different immigration backgrounds.
M AT E R I A L S A N D M E T H O D S
Study population In 2008, 5.3 million immigrants were living in France. The poverty rate was estimated to be 36% among immigrants, compared to 13.5% among non-immigrants in 200727,28. The immigrant population in France is a mixture of immigrants and descendants of immigrants, also known as ‘second-generation immigrants’. In the present study, immigrants were defined as individuals living in France who were born outside France, who were not French at birth, and who experienced migration either as children or as adults. They may or may not have acquired the French nationality. Second-generation immigrants were defined as those born in France, who were French at birth, and who had at least one immigrant parent. We used the data from the Trajectory and Origins survey (Trajectoires et Origines [TeO])29. The TeO survey was conducted in continental France by the National Institute of Demographic Studies (INED) and the National Institute of Statistics and Economic Studies (INSEE), from September 2008 to February 2009. Its purpose was to measure the impact of origins on living conditions and social trajectories. On the basis of the 2007 census, the target population consisted of men and women aged 18 to 60 years living in ordinary households in metropolitan France. An
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official authorisation was awarded by the CNIL (‘Commission nationale de l’informatique et des libertés’, the independent French administrative authority whose mission is to ensure that the data privacy law is applied to the collection, storage, and use of personal data) to INSEE and INED for the survey with regard to ethical considerations and the confidentiality of the respondents. Data related to immigration status were obtained from registrations at the INSEE and city councils, with special permission granted by the National Commission for Computers and Freedom (CNIL) to access names in order to identify and locate potential respondents. Translators were used for respondents with little or no knowledge of French. A total of 21,761 respondents were interviewed face-to-face by trained interviewers using standardised questionnaires. These interviews covered five sub-groups: immigrants (n 8456), second-generation immigrants (n 8110), overseas citizens (n 712), descendants of overseas citizens (n 702), and nonimmigrants (n 3781).The overall response rate to the survey was 61%, with a slightly higher rate for nonimmigrants (66%); the corresponding rates for immigrants and second-generation immigrants were 62% and 60%, respectively. Students, unemployed people and unskilled salaried workers had reduced response rates. Our request to use the data for the present analyses was reviewed and ethically approved by the Maurice Halbwachs Centre. For the purpose of this research, we limited the sample to adult female respondents who (i) were of reproductive age at the time of the survey (i.e., 18 to 45 years of age); (ii) responded to the questions concerning contraceptive use; (iii) were at risk of pregnancy at the time of the survey (women who were currently pregnant or reported menopause or sterility were excluded); and (iv) were not planning to become pregnant (women reporting no contraceptive use due to planning a pregnancy were excluded) (n 7070).
method of contraception recently used (e.g., OCs, condoms and IUDs, among others). Several important variables were obtained from standardised questionnaires, including socioeconomic status indicators (educational attainment, employment status and total household income), demographic variables (e.g., age, marital status, relationship/cohabitation status, number of children and immigration background), national health insurance (NHI) plan enrolment, complementary insurance enrolment and the number of medical visits during the 12 months prior to the survey. In the case of first-generation immigrants, the number of years since their immigration to France was also retrieved. Statistical analysis The Chi-squared test was initially used to examine potential subgroup-associated heterogeneity by immigration background. Considering potential heterogeneity in demographic composition and cultural attitudes toward birth control, we decided to carry out the analyses with stratification by immigration background. First we evaluated the association estimates linking the three previously mentioned socioeconomic status indicators with contraceptive use by multivariate logistic regression analyses, with adjustments for age, relationship status, number of children, insurance enrolment status and number of medical visits (N 7070). Then, to investigate whether socioeconomic status may have a relationship with contraceptive methods and probe possible immigration background-related variation, we conducted a series of polytomous logistic regression analyses on those women who reported recently using ‘condoms,’ ‘OCs’ or ‘IUDs’ (n 4919). All tests were two-sided, with an alpha value of 0.05 (∗), 0.01(∗∗) and 0.001(∗∗∗) to indicate the probability of Type I errors. Data were processed and analysed using the statistical software SPSS, version 17.
Measurements In the present study, the primary outcome variables, current contraceptive use and method, were assessed by a series of standardised questions, beginning with the following question: ‘Currently, do you or your partner, if you have one, use any methods to avoid having a child?’ A positive response was followed by a single-choice question with a list of methods to inquire about the 470
R E S U LT S
Selected socio-demographic, insurance and medical characteristics of the sample are summarised in Table 1. Non-immigrants had a higher level of education; 49% had a baccalaureate degree or above. The unemployment rates among immigrants and second-generation
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Table 1 Distribution of selected socio-demographic, insurance, and medical characteristics, by immigration background in France (N 7070). Variablesa n Age, yrs∗∗∗ 18–30 31–40 41–45 Educational attainment∗∗∗ No formal education Primary/junior high Professional/high school Baccalaureate/above Occupational status/type∗∗∗ Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/technicians Total household income, Euros∗∗∗ 1300 or less 1301–2000 2001–3000 3000 or more Missing Marital status∗∗∗ Married Unmarried Relationship/cohabitation status∗∗∗ No relationship In a relationship, living together In a relationship, not living together Number of children∗∗∗
Immigrants
Second-generation immigrants
Non-immigrants
2387
3453
1230
701 (29.6) 1086 (45.5) 594 (24.9)
2029 (58.7) 1089 (31.5) 335 ( 9.7)
482 (39.2) 464 (37.7) 284 (23.1)
521 372 470 945
(21.8) (15.6) (19.7) (39.6)
341 320 1194 1594
(9.9) (9.3) (34.6) (46.2)
84 85 456 602
(6.8) (6.9) (37.1) (48.9)
379 669 423 503 410
(15.9) (28.0) (17.7) (21.1) (17.2)
598 733 277 1025 817
(17.3) (21.2) (8.0) (29.7) (23.7)
107 223 129 375 385
(8.7) (18.1) (10.5) (30.5) (31.3)
385 459 546 396 601
(16.1) (19.2) (22.9) (16.6) (25.2)
489 539 725 604 1096
(14.2) (15.6) (21.0) (17.5) (31.7)
166 153 302 268 341
(13.5) (12.4) (24.6) (21.8) (27.7)
1730 (72.5) 657 (27.5)
1638 (47.4) 1815 (52.6)
796 (64.7) 434 (35.3)
504 (21.1) 1691 (70.8) 192 (8.0)
1281 (37.1) 1550 (44.9) 622 (18.0)
286 (23.3) 769 (62.5) 175 (14.2)
0 1 2–3 3 or more Religion∗∗∗
517 402 1147 321
(21.7) (16.8) (48.1) (13.4)
1831 525 1001 96
(53.0) (15.2) (29.0) (2.8)
453 207 527 43
(36.8) (16.8) (42.8) (3.5)
Do not have a religion Have a religion Refuse to say Do not know Enrolment of NHI plan∗∗∗
406 (17.0) 1963 (82.2) 13 (0.5) 5 (0.2)
1017 2410 15 11
(29.5) (69.8) (0.4) (0.3)
576 647 3 4
(46.8) (52.6) (0.2) (0.3)
2047 (85.8) 275 (11.5) 27 (1.1) 33 (1.4) 5 (0.2)
3151 267 5 23 7
(91.3) (7.7) (0.1) (0.7) (0.2)
1162 57 4 7 0
(94.5) (4.6) (0.3) (0.6) (0.0)
Standard CMU AME None Don’t know
(Continued)
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Table I. (Continued)
Variablesa Complementary insurance∗∗∗ Have Do not have Do not know Medical visit in last 12 months∗∗∗ No visit One visit Two or more visits Contraception use∗∗∗ Yes No Years of immigration 0–5 6–10 11–20 21 or more
Immigrants
Second-generation immigrants
Non-immigrants
1869 (78.3) 510 (21.4) 8 (0.3)
2925 (84.7) 515 (14.9) 13 (0.4)
1155 (93.9) 74 (6.0) 1 (0.1)
195 (8.2) 634 (26.6) 1556 (65.3)
223 (6.5) 767 (22.2) 2463 (71.3)
43 (3.5) 227 (18.5) 960 (78.0)
1661 (69.6) 726 (30.4)
2267 (65.7) 1186 (34.3)
991 (80.6) 239 (19.4)
415 533 654 784
(17.4) (22.3) (27.4) (32.9)
NA
NA
Chi-Square test: *p 0.05, **p 0.01, ***p 0.00; NHI, National Health Insurance; CMU, Universal Medical Coverage; AME, State Medical Help; NA, not applicable. aColumns may not add up to 100% due to missing values (less than 3%).
immigrants were higher than that of non-immigrants (28% and 21% vs. 18%). Immigrant women were more likely to have unskilled occupations, whereas secondgeneration immigrants and non-immigrants tended to hold positions as clerks/skilled workers or professionals/technicians. Non-immigrants had higher household incomes, with 46% earning more than 2000 Euros per month, compared to 40% for immigrants and 39% for second-generation immigrants. More immigrant women were married (73%) and had a religion (82%) than their second-generation immigrant and non-immigrant counterparts. We first focused our analyses on the variable concerning immigration background. With non-immigrants as a reference group, we found that women in the two immigrant groups were less likely to use contraception (Odds Ratio [OR]: 0.55, 95% confidence interval [CI]: 0.46–0.65 for immigrants; OR: 0.46, 95% CI: 0.39–0.54 for the second generation immigrants) (data not shown here). We found that lower educational attainment, having never worked and lower household income were associated with reduced use of contraceptives in the three groups of women (Table 2). When age, relationship status, number of children, NHI enrolment status, and 472
number of medical visits were taken into account by statistical adjustment (Model 1), part of the association linked to these three socioeconomic status indicators remained for immigrants and second-generation immigrants and disappeared for non-immigrants. Immigrant women who never worked were just under half as likely to use contraceptives when compared with non immigrants in a professional job (adjusted Odds Ratio [aOR]: 0.45, 95% CI: 0.29–0.68, p 0.001), and the corresponding estimate in the second-generation immigrants was 0.48 (95% CI: 0.34–0.67, p 0.001).Taking ‘years since immigration’ into account for immigrants (Model 2), immigrant women who had never worked had 59% reduced odds of using contraception (95% CI: 0.27–0.61, p 0.01). None of the three socioeconomic status indicators (i.e., educational attainment, occupational status/type and total household income) were found to correlate with contraceptive use among non-immigrants. Figure 1 shows the distribution of contraceptive methods used by women who reported using contraception at the time of the survey (n 4919). Women of all groups relied mainly on OCs, followed by IUDs and male condoms. Over 60% of second-generation immigrants used the pill as the only contraceptive.
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1.00
0.79 (0.63–0.99)∗
0.80 (0.57–1.13)
0.70 (0.55–0.90)∗∗ 0.87 (0.75–1.03)
0.69 (0.49–0.98)∗
Model 1a aOR (95%CI)
0.78 (0.61–1.00)
Crude OR (95%CI)
1.00
0.98 (0.71–1.34)
0.71 (0.41–1.22)
0.46 (0.27–0.76)∗∗
Crude OR (95%CI)
1.00
1.15 (0.76–1.76)
1.04 (0.52–2.10)
0.89 (0.43–1.81)
Model 1a aOR (95%CI)
Non-immigrants
0.23 (0.16–0.31)∗∗∗ 0.34 (0.23–0.50)∗∗∗ 0.85 (0.61–1.18) 1.00 0.69 (0.49–0.97)∗
1.00
0.94 (0.70–1.27)
0.78 (0.51–1.21) 1.02 (0.63–1.66) 1.10 (0.75–1.60) 1.00 0.80 (0.56–1.15)
1.00
0.83 (0.57–1.21)
0.65 (0.43–0.98)∗ 0.83 (0.52–1.32) 0.99 (0.69–1.43) 1.00 0.71 (0.50–1.01)
1.00
0.89 (0.62–1.26)
0.27 (0.21–0.36)∗∗∗ 0.31 (0.22–0.44)∗∗∗ 0.88 (0.67–1.16) 1.00 0.56 (0.41–0.75)∗∗∗
1.00
0.71 (0.57–0.88)∗∗
1.18 (0.82–1.70) 0.97 (0.63–1.50) 1.08 (0.76–1.52) 1.00 0.63 (0.46–0.85)∗∗
1.00
0.80 (0.60–1.06)
0.34 (0.20–0.56)∗∗∗ 0.53 (0.27–1.04) 0.73 (0.45–1.19) 1.00 0.79 (0.47–1.33)
1.00
0.96 (0.66–1.41)
1.53 (0.78–3.00) 1.54 (0.66–3.57) 0.92 (0.53–1.59) 1.00 0.85 (0.50–1.45)
1.00
0.84 (0.51–1.37)
0.54 (0.40–0.73)∗∗∗ 0.45 (0.29–0.68)∗∗∗ 0.41 (0.27–0.61)∗∗∗ 0.21 (0.16–0.26)∗∗∗ 0.48 (0.34–0.67)∗∗∗ 0.42 (0.26–0.69)∗∗∗ 0.70 (0.33–1.48) 0.94 (0.71–1.25) 0.82 (0.56–1.18) 0.79 (0.56–1.11) 0.57 (0.46–0.72)∗∗∗ 0.71 (0.52–0.97)∗ 0.70 (0.46–1.07) 0.66 (0.37–1.16) 0.73 (0.54–0.98)∗ 0.68 (0.46–1.01) 0.68 (0.48–0.98)∗ 0.61 (0.45–0.82)∗∗∗ 0.65 (0.44–0.97)∗ 0.75 (0.45–1.24) 0.65 (0.34–1.23)
1.00
1.50 (1.09–2.07)∗
1.19 (0.93–1.53) 1.00
1.28 (0.94–1.75)
1.11 (0.79–1.55)
1.14 (0.87–1.49)
1.00
0.97 (0.70–1.34)
0.77 (0.57–1.05)
0.63 (0.47–0.83)∗∗
Model 2b aOR (95%CI)
0.83 (0.66–1.05)
Model 1a aOR (95%CI)
Second-generation immigrants
OR, odds ratio; aOR, adjusted odds ratio; CI, confidence interval; ∗p 0.05; ∗∗p 0.01; ∗∗∗p 0.001. aModel 1: The OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits, and three socioeconomic indicators simultaneously. bModel 2: The OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits, three socioeconomic indicators, and years since immigration simultaneously.
Educational attainment No formal education Primary/junior high Professional/ high school Baccalaureate/ above Occupational status/type Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/ technicians Total household income (Euros) 1300 or less 1301–2000 2001–3000 3001 or more Missing
Variables
Crude OR (95%CI)
Immigrants
Table 2 Socioeconomic status indicators in relation to contraceptive use, stratified by immigration status (N 7070).
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Figure 1 Distribution of contraceptive methods among women using contraception (n 4919). OC, oral contraceptive; IUD, intrauterine device. Chi-square test: p 0.0001.
Approximately 23% of non-immigrants reported the use of IUDs, more frequently than did immigrants and second-generation immigrants. Immigrant women use more ‘other methods’, including non-medical methods (withdrawal and fertility awareness methods). The pattern of contraceptives differs significantly across the three groups of women (chi-squared test, p 0.001; data not shown here). For the women who reported recent use of contraceptives (n 4919), Table 3 presents the association estimates derived from the polytomous logistic regression, with stratification by immigration background. In terms of outcome variable, both OC (first column) and IUD (second column) were compared against male condom (reference group). With adjustment for age, relationship status, number of children, NHI enrolment status, number of medical visits, educational attainment, occupational status and household income, we found that socioeconomic status-related risk 474
estimates appeared to be significant in only two groups, namely, second-generation immigrants and non-immigrants.Among the second-generation immigrants, we found that women who never worked were 66% less likely to use an IUD than male condoms, compared to women with professional occupational status (95% CI: 0.13–0.90, p 0.01). Non-immigrants with professional/high school degree were 2.5 times more likely to use an OC, compared to their peers with a baccalaureate or higher degree. DISCUSSION
Based on our nationally representative sample, the results show that the use of contraception was not homogeneously distributed among women with different immigration backgrounds in France. Three indicators of socioeconomic status appear to affect contraceptive use differently across the three groups of
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The European Journal of Contraception and Reproductive Health Care 0.92 (0.46–1.83) 0.88 (0.48–1.60) 0.77 (0.45–1.33) 1.00 0.77 (0.45–1.33)
0.96 (0.41–2.24) 0.87 (0.44–1.75) 0.74 (0.40–1.36) 1.00 0.95 (0.51–1.75)
(0.47–2.39) (0.79–2.87) (0.72–3.20) (0.47–1.65) 1.00
1.06 1.50 1.52 0.88
1.14 1.20 1.45 0.94
(0.59–2.21) (0.69–2.09) (0.70–2.76) (0.55–1.59) 1.00
1.39 (0.74–2.61) 0.90 (0.48–1.68) 1.36 (0.77–2.39) 1.00
IUD aOR (95%CI)
1.51 (0.86–2.65) 1.18 (0.69–2.00) 1.05 (0.64–1.71) 1.00
OC aOR (95%CI)
(0.33–0.94)∗ (0.34–0.91)∗ (0.47–1.90) (0.61–1.47) 1.00
1.71 (0.96–3.07) 1.88 (1.06–3.35)∗ 1.11 (0.69–1.79) 1.00 1.08 (0.68–1.70)
0.56 0.56 0.95 0.95
0.99 (0.56–1.77) 0.93 (0.53–1.62) 1.31 (0.90–1.91) 1.00
OC aOR (95%CI)
(0.13–0.90)∗ (0.33–1.08) (0.40–1.95) (0.54–1.51) 1.00
0.53 (0.21–1.30) 1.35 (0.67–2.70) 0.95 (0.55–1.64) 1.00 0.92 (0.53–1.57)
0.34 0.60 0.89 0.90
0.82 (0.41–1.64) 0.74 (0.38–1.47) 1.18 (0.74–1.86) 1.00
IUD aOR (95%CI)
Second-generation immigrantsa,c
(0.27–1.83) (0.26–1.09) (0.25–1.55) (0.77–3.18) 1.00 1.28 (0.48–3.42) 1.12 (0.47–2.67) 0.90 (0.44–1.82) 1.00 0.93 (0.47–1.82)
0.71 0.53 0.63 1.57
4.34 (1.17–16.10)∗ 1.10 (0.43–2.76) 2.46 (1.32–4.57)∗∗ 1.00
OC aOR (95%CI)
1.08 (0.28–4.07) 0.60 (0.20–1.73) 1.39 (0.66–2.93) 1.00 1.06 (0.51–2.19)
– 0.54 (0.24–1.22) 0.73 (0.27–1.98) 1.61 (0.75–3.45) 1.00
1.26 (0.27–5.69) 0.84 (0.29–2.38) 1.76 (0.88–3.50) 1.00
IUD aOR (95%CI)
Non-immigrantsa,c
aOR,adjusted odds ratio, CI, confidence interval; ∗p 0.05; ∗∗p 0.01; ∗∗∗p 0.001. aReference group: male condoms; bThe OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, years since immigration, number of medical visits in the past 12 months and three socioeconomic indicators simultaneously; cThe OR estimates were obtained with simultaneous adjustment for age, relationship status, number of children, insurance enrolment status, number of medical visits in the past 12 months and three socioeconomic indicators simultaneously.
Educational attainment No formal education Primary/junior high Professional/high school Baccalaureate/above Occupational status/type Never worked Unemployed Unskilled workers Clerks/skilled workers Professionals/technicians Total household income, Euros 1300 or less 1301–2000 2001–3000 3001 or more Missing
Variables
Immigrantsa,b
Table 3 Socioeconomic indicators in relation to contraceptive choice among women currently using contraception, oral contraceptive (OC) and intrauterine device (IUD) use as compared to male condom use (N 4919).
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Contraceptive use among immigrant women in France
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women. Immigrant and second-generation immigrant women who had a lower level of educational attainment or who had never worked were less likely to use contraception (their odds of contraceptives use was reduced by 31∼59%), whereas no significant odds associated with socioeconomic status existed for nonimmigrants. In terms of contraceptive methods, the analyses indicate that socioeconomic status is a salient factor among second-generation immigrants and nonimmigrants. Non-immigrants with no formal education were nearly four times more likely to use an OC, compared to their peers with baccalaureate degrees; second-generation immigrants who never worked were only a third (0.34) as likely to use IUDs, compared to their professional counterparts. Several limitations of this study are worth noting. First, our analyses indicated that the item-specific response rate (concerning contraceptive use) for immigrants and second-generation immigrants was 95% and 96%, respectively, as opposed to 98% for non-immigrants. The generalisability to those who did not respond to questions concerning contraceptives or those who refused to participate in the Trajectory and Origins survey may be limited. Comparative analyses suggested that women with no responses to the contraceptive questions were often those who were childless, had higher educational attainment, had never worked and had missing values for household income. Therefore, when we restricted our analytic sample to women who provided answers concerning contraception use, the association estimates for the three socioeconomic indicators may possibly be vulnerable to bias. Be that as it may, perhaps the major drawback of the survey is that it assessed only the respondents’ relationship status, excluding questions about their sexual activity. In the cases where women reported no use of contraceptives, we were unable to identify whether this status was a result of choice or the existence of obstacles to contraceptive use. Finally, because contraceptive use and methods were assessed based on recent experience, we were unable to determine the effects of socioeconomic status on women’s access to and/or choice of contraceptives as an evolving process or from a life course perspective. Notwithstanding these limitations, this study has several strengths. First, the data were collected from community-dwelling women with national representativeness. The large sample size generally allowed for reliable comparisons 476
with adjustments for other confounding factors, although limitations may still exist in some subgroup analyses (e.g., non-immigrant women who never worked). Second, unlike many previous studies that focused only on the immigrant population, this study includes women of three differing immigration backgrounds and provides an opportunity to examine and compare potential immigration-related variations in socioeconomic influences. Consistent with prior studies conducted in other parts of the world (e.g., the United States and Yugoslavia)17–19, our analyses indicated that women with an immigration or minority background generally had a lower rate of contraceptive use than nonimmigrant women. Some ethnic minority women (i.e., Hispanic or African-Americans) used contraceptives less often than non-Hispanic and white women in the United States (69.9% and 70.3% vs. 75.8%)13. Only 63.5% of immigrant women of Mexican origin living in the United States used contraceptives, which is significantly less than women of Mexican origin born in the United States (67.9%).5 The lower utilisation rate of contraceptives may partially be a result of complex micro- and macro-social processes associated with an immigration background, such as awareness or knowledge of reproductive health; socio-cultural beliefs; values and norms toward contraceptive practices; the freedom to make safe reproductive choices and barriers encountered in accessing sexual or reproductive healthcare services29–32. Our results indicate that the relationship between the three socioeconomic status indicators and contraceptive use is not uniform across different immigration backgrounds; in particular, none of the three socioeconomic indicators serve as significant predictors for contraceptive use for non-immigrants. The observed nonexistence of socioeconomic status-differentials among non-immigrant women may be partly contributed to by a wider coverage of several contraceptive methods under a national insurance plan, a greater knowledge about contraceptive services and the existence of norms regarding contraceptives in this study population32. For immigrant and second-generation immigrant women in France, contraceptive use was strongly associated with socioeconomic status. Although the association pattern was similar to that of women with Hispanic origins in the United States14,31, one
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noteworthy point should be made in regard to the differential process of higher educational attainment. To elaborate, most immigrant women in our sample had either completed higher education or had no formal education, suggesting the existence of two separate immigration flows. First-generation immigrant women who reached higher education before immigration into France might have more autonomy or freedom to control their lives, be more aware of birth control or might wish smaller, higher livingquality families, as compared with their peers without formal education. As to second-generation immigrants, because structural barriers often hinder them from obtaining higher education, those who do obtain degrees may possess special characteristics, such as a drive for academic and social success, adherence to parental expectations and trust in the institutional path for reaching social success21. These same characteristics may also be motivating factors in the question of contraceptives; that is to say, a higher drive to obtain educational success may be accompanied by a greater capacity to plan the future and thus the right time to have children32. Finally, with educational level and household income statistically adjusted, we found that the employment category of ‘never worked’ remained significantly associated with a lower likelihood of contraceptives use among the first- and secondgeneration immigrant women. Considering that second-generation immigrant women often encountered more barriers to obtain employment and reach high occupational positions than non-immigrants and, furthermore, that a double discrimination may exist for immigrant women based on ethnic and cultural grounds33,34, women who achieved high occupational status might be part of a select group. The resources that members of this group possess might contribute to a higher rate of contraceptive use. In contrast, the lifetime non-participation in the labour force may have restricted immigrant women’s access to social networks and interaction with outside communities and insurance programmes, thereby reducing their access to information and healthcare, where contraceptive services are concerned35. Similar processes may underlie the reason for reduced contraceptive use among those who had lower occupational status or those who did not respond to the question regarding household income in the questionnaire.
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As for the choice of contraceptive method, we found that socioeconomic status was an explanatory factor only for second-generation immigrants and non-immigrants. Among second-generation immigrants, the gradient in the association estimates linking occupational status/type with IUD use can partially explain the variation in long-term birth control plans for working women. Compared to previous research suggesting that disadvantaged socioeconomic backgrounds were associated with the increased likelihood of condom use in the United States12, our study shows that for non-immigrants, a lower level of educational attainment was significantly associated with using oral contraceptives (relative to condoms). This observed difference in association patterns can be explained, to some extent, by differences in healthcare policy and insurance coverage between the two countries. To illustrate, before the Patient Protection and Affordable Care Act of 2012 was implemented, contraceptive coverage largely depended on individual insurance plans in the United States36. Some plans did not cover contraceptive drugs and devices. In addition, 16.5% of the population was uninsured in 200937,38. For women without insurance or contraceptive coverage, male condoms are likely to be the cheapest and most accessible method of contraception. In contrast, as most contraceptive methods are covered by the National Health Insurance in France, male condoms are not cheaper than reimbursed oral contraceptives. It is therefore possible that socioeconomic influences operate differently in relation to contraceptive options in these two contexts39. Our findings demonstrate that there is much to investigate in the socioeconomic status-related barriers to contraception use. This evidence should provide policymakers with concrete indications for improving contraceptive care among immigrant groups. For example, contraceptive packages offering prevention and free contraception consultations, developed in some areas for youth and young adults, can be implemented for women with immigrant backgrounds40. This can involve a diffusion of contraceptive information and prevention strategies through channels other than schools, thereby reaching a higher percentage of segregated and marginalised groups and reducing disadvantaged socioeconomic effects that limit women’s voluntary use of contraception.
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CONCLUSION
AC K N OW L E D G E M E N T S
Women with an immigrant background were less likely to use contraception and socioeconomic status affects access to contraception among immigrant groups. For second-generation immigrants and non-immigrants, socioeconomic status may have an impact on the choice of contraceptive method. Such information is needed, not only to understand the way that disadvantaged social and economic status may negatively impact on reproductive health and sexual wellbeing among women, but also to act in a relevant manner to alleviate immigration-related vulnerability in contraceptive care.
The authors would like to thank the Maurice Halbwachs Centre for granting us permission to use their data for this study.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. Dr Chen was supported by a grant from the Ministry of Education of Taiwan ROC, Aim for the Top University Plan.
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