Survey of Women About Their Knowledge, Attitudes, and Practices Regarding Their Reproductive Health
Glamour; Kaiser Family Foundation; Princeton Survey Research Associates
Summary of Major Findings
February 1997
The Kaiser Family Foundation partnered with Glamour magazine on a national survey to find out how
much women know about their reproductive health care needs and whether they are taking important
steps to protect their reproductive health, covering such critical issues as: routine gynecological exams,
contraception, emergency contraception, sexually transmitted disease, HIV/AIDS, the patient-physician
relationship, health insurance coverage, and communication with sexual partners. To explore women's
awareness of these issues and others, Glamour and the Kaiser Family Foundation designed and
Princeton Survey Research Associates conducted a nationally representative telephone survey of 1,001
women in the U.S., ages 18 to 44. The survey was conducted between July 10 and July 28, 1996.
The margin of error for results based on the total sample is plus or minus four percentage points. The
results of the survey are reported in the February 1997 issue of Glamour.
The following is a summary of findings prepared by Molly Parker at the Kaiser Family Foundation and
Diane Colasanto and Susan Kannel at Princeton Survey Research Associates. Topline survey results
are also available free of charge from the Kaiser Family Foundation request line, 1-800-656-4KFF.
Women's Utilization of Reproductive Health Care
Almost all of the women surveyed (97%) report having had a gynecological exam at some point in their
lives. Eighty-five percent have a regular health care provider who they see for gynecological exams and
a majority (69%) have a regular gynecologist or obstetrician-gynecologist as opposed to another type
of health provider for their reproductive care. Three-quarters (75%) report getting a gynecological
exam at least once a year and 87 percent of those who have experienced some kind of reproductive
health problem got medical attention immediately.
- Of the 3 percent of women ages 18-44 who have never had a gynecological exam, most are under the age of 25, and half of them have never had sex.
- Women who have had a reproductive health problem at some point in their lives are more likely than those who have not to get annual exams (81% v. 72%).
What's recommended by the American College of Obstetricians and Gynecologists and the American Academy of Family Physicians:
American College of Obstetricians and Gynecologists (ACOG) and American Academy of Family
Physicians (AAFP) recommend that all women 18 and over and 13-18 year-olds who are or have been
sexually active undergo an annual pap smear and pelvic examination.
1 After a woman has had three or
more consecutive, satisfactory pap smears with normal findings, the pap smear may be performed less
frequently in a low-risk woman at the discretion of her physician.
2 For most women this means once a
year because low risk is defined as a woman who had first intercourse at age 18-20 or older and only
one lifetime partner. But even if a pap smear is not needed, a woman should still have an annual
exam.
3
Women's Satisfaction with Reproductive Health Care
Few women voice complaints about the way their gynecological care provider interacts with them.
Describing their most recent gynecological exam, almost all women say they were treated with respect
(98%), felt comfortable asking a question about anything that was on their mind (95%), spent enough
time with their health care provider (94%), and got all the information they needed at that visit (94%).
- Women who report having had reproductive health problems were somewhat less satisfied with
the care they received as compared to women who were problem-free. Fewer of those with a
current reproductive health problem were satisfied with the information they received on their last
visit (80% v. 96% for those with no current problem), were content with the amount of time they
had with their health care provider (84% v. 95%), and felt comfortable asking questions (87% v.
96%). Still, the large majority of women with a reproductive health problem voiced no complaints
about the care they received at their most recent gynecological visit.
- Women who do not have a regular gynecological health care provider were also slightly less
satisfied with their last visit than those with a regular provider, although the majority were satisfied
with their visit. Among those who don't have a regular provider, 83 percent say they got all the
information they needed on their last visit, 86 percent say they spent enough time with their
provider, and 87 percent felt they could ask any questions they needed to.
Health Insurance Status and Coverage of Reproductive Health Care
Eighty-two percent of women surveyed had health insurance, and 69 percent report they were
covered, at least in part, for routine gynecological care. Women who do not have health insurance
were less likely than insured women to have a regular gynecological care provider (72% v. 88%) and
to get a gynecological examination at least once a year (67% v. 76%).
- Younger women are less likely to have health insurance: only about three-quarters of women ages
18 to 29 who were surveyed (77%) had health insurance as compared to 85 percent of women
age 30 to 39 and 87 percent of women age 40 to 44.
- Six out of ten insured women (62%) -- both those who have already had an unplanned pregnancy
and those who have not -- don't know whether their health insurance policy covers an abortion.
Typical health insurance coverage of reproductive health care:
A gynecological check up: Virtually all health maintenance organizations (HMOs) (99%) routinely
cover an annual gynecological exam, but only 88 percent of point-of-service (POS) networks, 64
percent of preferred provider organizations (PPOs), and 49 percent of indemnity plans do. All HMOs
and virtually all POS networks provide at least some coverage of pap smears and chlamydia cultures,
but not all indemnity plans or PPOs do. And almost all HMOs and POS networks routinely cover
mammograms for women older than 50, while only eight out ten PPOs and indemnity plans do.
4
Birth control: Managed care plans -- HMOs, PPOs, and POS networks -- are much more likely to
cover at least some of the cost of reversible birth control methods than traditional indemnity insurance.
Half (49%) of traditional indemnity plans do not cover any birth control methods, and only 15 percent
cover provider costs for the five most commonly used reversible methods (IUD, diaphragm,
contraceptive implant, injection and birth control pills). In contrast, only 7 percent of HMOs provide no
coverage of birth control methods, and 39 percent routinely cover all five major methods. Coverage of
the various methods varies widely by type of method, from 59 percent for contraceptive implant
insertion to 86 percent for IUD insertion. Among the types of managed care plans, coverage also
varies: PPO coverage is closer to that of indemnity plans than HMOs, and POS networks' coverage
falls between HMO and indemnity plan coverage. All types of plans tend not to offer coverage for
over-the-counter contraceptives, such as condoms or spermicides, although some HMO pharmacies
sell them at a discount to their members. In keeping with health insurance plans' propensity for
covering surgical procedures, surgical sterilization is well covered in all types of health insurance.
Tubal ligation and vasectomy are covered by 85-90 percent of all policies, regardless of type.
5 A
survey of HMOs found that 97 percent of plans covered vasectomy and 98 percent covered tubal
ligation.
6
Abortion: At least two-thirds of typical managed care plans -- 67 percent of PPOs, 83 percent of POS
networks, and 70 percent of HMOs -- along with two-thirds of indemnity plans, routinely cover abortion
performed by dilation and curettage or suction aspiration. An additional 20 percent of HMOs and
PPOs offer coverage in restricted circumstances, such as when there is a medical indication for the
procedure; 5 percent of POS networks and 23 percent of indemnity plans also include these
restrictions.
7 A more recent survey of managed care plans regarding their coverage of reproductive
health services yielded somewhat similar results: 57 percent of HMOs cover abortions and 15 percent
reported that coverage depends on certain circumstances.
8
Comparison of Care Received by Women Who Have a Regular Provider of Gynecological
Care Compared with Women Who Do Not
Women who have a regular gynecologist or other health provider who they routinely see for
reproductive health care are more likely to have annual exams, discuss birth control options, and get
tested for HIV than women who have no one they regularly see for their reproductive care.
- Women who see a gynecologist (85%) and women who use another health professional for their
routine gynecological care (69%) are more likely to get an exam at least once a year than women
who do not have a regular provider for this care (42%).
- Women who see a gynecologist (52%) are more likely to have discussed birth control at their last
gynecological visit than women who use another health professional for their routine gynecological
care (40%) or women who do not have a regular provider for this care (36%).
- Women who see a gynecologist (52%) are more likely to have had an HIV test at some point than
women who use another health professional for their routine gynecological care (42%) or women
who do not have a regular provider for this care (37%).
- Women who see a gynecologist (50%) are more likely to have had an STD test at some point than
either women who use another health professional for their routine gynecological care (32%) or
women who do not have a regular provider for this care (44%).
Care Provided by Female Health Professionals as Compared to Male
About a third (35%) of women of childbearing age who have a regular health care provider for
gynecological care see a female provider and 64 percent see a male provider. Women under 30 are
the most likely to see a female provider for their gynecological care (42%).
- Seven out of ten (72%) women who see a female provider for their gynecological care say gender
was very (48%) or somewhat (24%) important to them in choosing their provider. By contrast,
83 percent of those with a male provider say gender was not too (17%) or not at all (66%)
important in their choice of provider.
According to the women interviewed, male and female health care providers provide similar care --
they are equally attentive to their patients, equally likely to have patients who routinely have an annual
exam and who seek immediate medical care when they feel they have a reproductive health problem,
and equally likely to have patients who feel comfortable asking questions during their gynecological
exam.
What percentage of obstetrician-gynecologists are female?
Women accounted for 26 percent of all obstetrician-gynecologists (ob-gyns) in 1993.
9 However, the
proportion of ob-gyns who are women is increasing with time: in 1994, 59 percent of all first-year ob-
gyn residents were women.
10
Discussions with Health Care Providers about Birth Control
Three out of ten women who are at risk for an unplanned pregnancy -- defined as currently sexually
active, able to conceive, and not pregnant or trying to be -- had not talked with their health care
provider about birth control at their most recent visit.
- Only about half -- 51 percent -- of women who don't use birth control every time they have
intercourse talked about birth control with their health care provider at their last gynecological visit.
- Eighteen percent of women who have been surgically sterilized or are infertile report never having
had a conversation about birth control with a health care provider.
- Only about half (48%) of women over age 17 who are virgins have at some point talked with a
health professional about birth control; 41 percent discussed birth control at their last visit.
Discussions with Sexual Partners about STDs, Including HIV/AIDS
Fewer than half of the sexually-active women surveyed (44%) had ever had a conversation with their
current partner about the risk of infecting each other with HIV, and only about a quarter talked with
their partner about their risk of infecting each other with a sexually transmitted disease other than HIV
(27%).
- Almost all the women who have never talked with their partner about STDs (95%) say their partner has never had an STD, yet how could they know? Fourteen percent of women who havehad a conversation with their partner say their partner has been infected with an STD and close to half (46%) of women who have had an STD say they have not discussed STDs with their current or most recent partner.
- One of the groups of women considered most at risk for STDs, unmarried women who have had
7 or more sexual partners, is more likely to have talked with their current sexual partner about the
transmission of sexually transmitted diseases, including HIV. However, only 68% have talked
about HIV and 52% have talked about STDs other than HIV with their partner.
Getting Tested for HIV and Other STDs
Many women may be mistaken in thinking they are being screened for HIV infection or STDs when
they go for a routine gynecological exam. Five percent think HIV screening is automatically included in
their exam without having to request it (another 12 percent don't know whether this is automatic or not)
and 42 percent think screening for STDs is a routine part of an annual check-up (19 percent more
aren't sure).
Fewer than half of the women surveyed report having ever been tested for HIV (47%) or for other
sexually transmitted diseases (45%).
The most common reason women give for not being tested for HIV is that they don't think they're at
risk, with two-thirds (67%) of those who haven't been tested giving this reason. The next most
common reason, given by 19 percent of untested women, is that they just haven't gotten around to it
yet. Relatively few women who have been tested say the reason was because they thought they have
been exposed to a disease or virus (about 10 percent of women who are tested for HIV and 30
percent of women tested for an STD). Most often women say they just thought it was a good idea to
get tested for HIV.
- Women who have had an STD have been tested more often than other women for HIV (65% v.
45%). Still, a third (34%) of women who have had an STD have never had an HIV test.
Are all STDs automatically tested for in an annual exam?
STD and HIV tests are not automatically included in a woman's routine gynecological exam. ACOG
recommends doing tests for STDs on patients who have a history of multiple sex partners or a sex
partner with multiple contacts, sex contacts with people proven to have STDs, people with a history of
repeated episodes of STDs, and people who attend clinics for STDs. STDs are particularly prevalent
among young women, so routine annual testing for all women 25 years old and younger is often
recommended.
HIV tests cannot be run by a clinician without the patient's prior consent, unless the patient is unable to
consent and there is a need to know if the patient is HIV positive.
11 In addition, for reasons of
confidentiality, HIV tests are often not provided as part of a routine gynecological exam. Patients at
high risk for HIV, and for whom testing is recommended, are people seeking treatment for STDs,
people with past or present drug use by injection, people with a history of prostitution, women whose
past or present partners are HIV positive or bisexual or injection drug users, people with long-term
residence or birth in an area with a high prevalence of HIV infection, and people with a history of
transfusion between 1978 and 1985.
12
Close to half (45%) of the women surveyed said they would be "very likely" to use a new home HIV
test if they thought there was a chance they had been infected with the HIV virus. Over a third (35%)
say they would be not too likely or not likely at all to use this new test. Women who have never been
tested for HIV are no more likely to want to use the home test than those who already have been
tested.
- The main reason women give for not being likely to use a home HIV test is that they prefer to see
a physician about HIV testing (53%). In addition, over a quarter (28%) of those who feel they're
not likely to use a home test say they would be worried about its accuracy.
New HIV home tests introduced:
Two HIV antibody home tests have been approved by the Food and Drug Administration (FDA). On
May 14, 1996, the FDA approved the first HIV test system to include an over-the-counter home-use
specimen collection kit. The test, called Confide, is manufactured and distributed by Direct Access
Diagnostics (DAD), a subsidiary of Johnson & Johnson, and is available nationwide in local pharmacies
or by calling 1-800-THE-TEST.
13
With Confide, the user mails a laboratory a blood sample from a finger prick. A week later, the user
can obtain their test results by telephone. Confide is thought to be extremely accurate -- only one
person in 1,000 is expected to test falsely positive and no one is expected to test falsely negative. Over
the phone post-test counseling is included in the cost of Confide.
14
On June 6, 1996, the FDA approved the OraSure oral HIV antibody home testing kit, produced by
Epitome Inc. OraSure is an oral HIV test that allows testing for HIV without blood or needles. The
user places a specially treated pad between their cheek and gum for 2 minutes, and then mails the pad
in a preservative vial to the laboratory for analysis. Results are available within 3 days. In clinical
trials, OraSure accurately indicated a person's HIV status in 99.97 percent of 3,570 people. OraSure
costs about the same as a blood test for HIV. It will be marketed by SmithKline Beecham Consumer
Healthcare. The test is currently available only through certain physicians.
15
On August 6, 1996, the FDA approved Sentinel, a test which detects antibodies to HIV present in
simple plastic-cup specimens of urine. The FDA approved the test as a supplemental diagnostic test
because it is not meant to substitute for the standard blood test to screen donors at blood banks. The
test can only be used by doctors in public health clinics, hospitals and private practices. It cannot be
used in homes or workplaces and it is against the law to test someone for HIV without their consent.
Unplanned Pregnancy
Unplanned pregnancies are common among American women from all walks of life:
- Forty-two percent of sexually active women age 18 to 44 report having had an unplanned
pregnancy. Another 23 percent of women have taken a pregnancy test at some point in their lives
but never experienced an unplanned pregnancy, indicating that they also suspected they were
unintentionally pregnant one or more times.
Yet, many American women are not aware that unplanned pregnancies are as widespread as they are.
- Fifty-six percent think an average woman is more likely to get a sexually transmitted disease than
to have an unplanned pregnancy, compared to only 31 percent who think it's more likely she'll
have an unplanned pregnancy (and 13 percent who don't know).
- Most women (65%) know that unplanned pregnancies are more common than fertility problems,
although about a third (35%) mistakenly think the opposite is true or say they don't know which is
more common.
How prevalent are unplanned pregnancies? How prevalent are STDs?
According to the Alan Guttmacher Institute, 46 percent of all U.S. women aged 15-44 have ever
experienced an unplanned pregnancy that ended in birth or abortion.
16 In contrast, about one in four -
- and possibly up to one in two -- Americans will contract an STD in their lifetime.
17 Since women
account for about half of all sexually transmitted infections every year,
18 between 25-50 percent of all
women will experience an STD in their lifetime.
Birth Control Use
Seventy-three percent of women surveyed who are at risk for an unplanned pregnancy say they use
birth control every time they have sexual intercourse (13% use it sometimes, and 12% never use birth
control).
- Just over half (54%) of at-risk women age 40-44 say they use birth control all of the time
(compared with 79% of women age 18-29 and 73% of women in their 30s).
- The 42 percent of women in the survey who said they had experienced an unplanned pregnancy
were no more likely than the others to use birth control every time they have sex: only 70 percent
of these women say they use birth control all of the time.
The most common reason women who don't use birth control all the time say they don't is that they
wouldn't mind it if they got pregnant (39%). Other common reasons include: some birth control
methods have unpleasant side effects (28%); the woman relies on having sex only during the "safe time"
of the month (26%); birth control ruins the spontaneity of sex (25%) or interrupts the "moment" (23%).
Nineteen percent of women who don't always use contraception did not give a reason.
Just over half (57%) of at-risk women use condoms and half (50%) use birth control pills. Both
condoms and birth control pills are methods more likely to be used by women under 30 than over 30.
- Never-married women are almost twice as likely as married women to use condoms (79% v.
44%). However, single women who have been married before, i.e., those who are widowed,
divorced, or separated, use condoms much less frequently (56%) than never-married women.
How often do women using birth control experience unplanned pregnancies?
47 percent of all unplanned pregnancies occur among women who report using a reversible method of
birth control.
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Awareness of Emergency Contraception
Relatively few women know that emergency contraceptive pills (ECPs, also sometimes called "morning
after" pills) are available to prevent pregnancy after intercourse has occurred. Only 37 percent of
women of childbearing age say they know a woman can do something to prevent a pregnancy after
having had unprotected sex. When prompted by the interviewer, 66 percent say they have heard of
"morning after" pills. But, just 27 percent of these women say "morning after" pills are available now in
the United States.
1 The large majority of those who know these pills are already available (85%) also
know that a prescription is required for their use. Only 1 percent of all women of childbearing age say
they have ever used "morning after" pills.
What are emergency contraceptive pills?
Emergency contraceptive pills (ECPs), or birth control pills taken postcoitally, reduce the risk of
pregnancy by 75 percent if taken within 72 hours of unprotected intercourse. The six brands of birth
control pills which can be used as ECPs are Ovral, Nordette, Lo/Ovral, and Triphasil, all made by
Wyeth, and Levlen and Tri-Levlen, made by Berlex Laboratories. A toll-free hotline (1-800-584-9911)
sponsored by the Reproductive Health Technologies Project and Bridging the Gap Communications
provides women with information about emergency contraceptives and offers a list of health care
providers who prescribe them.
20
Concerns about Confidentiality of Medical Information
There are steps women can take to protect the confidentiality of their medical information, if they do not
want it made available to their employer, family or insurance company. However, most women may
think their information is completely confidential though it may not be: 81 percent of women believe
information about their gynecological concerns or problems would never be available to their employer,
their insurance company, or family members.
Can information about gynecological concerns or problems be made available to women's
employers, insurance companies, or families?
Yes, but it depends on the plan type and the specific plan within that type. An employer, spouse or
parent may have access to some information pertaining to the enrollee or a dependent of their plan.
Because of doctor-patient confidentiality, the information a patient gives a health provider and the
results of tests are confidential in most cases.
Employers: A small percentage of plans (4% of HMOs, 5% of POS networks, and 6% of indemnity
plans and PPOs) notify employers of the names of individuals who have received specific medical
services (these data reflect the insurers' practices, not those of the employers).
21
Family members: Seventy-one percent of HMOs keep patients' medical information confidential from
family members by offering to mail the bill or summary statement directly to the dependent of the
primary enrollee, rather than to the primary enrollee. However, the dependent -- a spouse or child of
at least 18 years of age -- must specify that they want their confidentiality protected. In the remaining
one-third of HMOs, the primary enrollee is likely to be notified, either in a bill or a summary statement
sent by the HMO, of the medical care his/her family members received. In contrast to HMOs, only 10
percent of POS networks and 12 percent of PPOs offer dependents confidentiality by sending the
explanation of benefits form and the reimbursement amount directly to the dependent, rather than to the
primary enrollee. The remainder of POS networks and PPOs -- the large majority -- require that the
form be sent to the primary enrollee. Similarly, only 12 percent of traditional indemnity plans offer
confidentiality to dependents by allowing them to sign the claim form and receive the explanation of
benefits directly.
22
Insurance companies: Your insurance company may or may not have access to the results of your
tests, but generally does not have access to the information written in your medical chart. A medical
record release -- which would provide medical record copies -- is almost always included as part of a
new application for insurance. Once an application includes this information, it may be "posted" in the
central data base.
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