Pathways to Reproductive Autonomy: Using Path Analysis to Predict Family Planning Outcomes

Background and Purpose: Reproductive autonomy requires access to safe and effective contraception that matches individuals’ contraceptive needs and preferences. Although research has explored predictors of contraceptive adherence, contraceptive effectiveness, and unintended pregnancy, there is a lack of research regarding the factors associated with individuals’ ability to access their preferred contraceptive method(s). Studies examining the complex relationships between contraceptive access and family planning outcomes are also lacking. Therefore, the purpose of this study was to investigate pathways from indicators of contraceptive access to preferred contraceptive use and other family planning outcomes.

Methods: We conducted a secondary analysis of survey data collected by the Guttmacher Institute across four time points between November 2012 and June 2014. The current study used data from US women of reproductive age who were seeking to avoid pregnancy (N = 1,036; M_age = 27.91, SD = 5.39; 6.9% Black, 13.6% Hispanic, 70.2% white, 9.4% other race/ethnicity). Grounded in Levesque et al.’s (2013) healthcare access framework, we conducted mediational path analysis in Mplus 8.0 using the robust weighted least squares (WLSMV) estimator to investigate pathways from indicators of contraceptive access (pregnancy fatalism, insurance status, provider engagement, state family planning Medicaid expansion, and contraceptive knowledge) to preferred contraceptive use and other family planning outcomes (effectiveness of contraceptive method used and unintended pregnancy).

Results: Slightly over half of participants reported being able to access their preferred contraceptive method (52%, n = 539), whereas 48% (n = 497) reported being unable to access their preferred method. The hypothesized model provided good fit to the data (χ² = 8.049, df = 9, p = 0.5292, comparative fit index [CFI] = 1.00, Tucker-Lewis index [TLI] = 1.00, root mean square error of approximation [RMSEA] < 0.000 [90% CI: 0.000, 0.032], weighted root mean square residual [WRMR] = 0.381). Results indicated that contraceptive knowledge (β = 0.116, p = 0.004), insurance coverage (β = 0.423, p < 0.001), and provider engagement (β = 0.265, p = 0.011) were significant predictors of ability to access preferred contraceptive method(s). The ability to access the preferred contraceptive method(s) directly predicted use of more effective contraceptive methods (β = 0.260, p < 0.001) and indirectly predicted decreased likelihood of experiencing unintended pregnancy via contraceptive use (β = -0.014, 95% confidence interval: -0.041, -0.005).

Conclusions and Implications: This study corroborates theoretical frameworks that suggest that contraceptive approachability, affordability, and appropriateness are critical aspects of contraceptive access. Study findings identified pathways from these indicators to family planning outcomes, highlighting contraceptive knowledge, insurance status, and provider engagement as important predictors of the ability to access preferred contraceptive method(s), use of more effective contraceptive methods, and unintended pregnancy. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients’ needs and priorities.

References: Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International journal for equity in health, 12(1), 1-9.