Access to Reproductive Health Services Among People With Disabilities

This cross-sectional study examines the logistical, access, cost, privacy, and interpersonal barriers to reproductive health care in females with varying disabilities and levels of functioning.


Introduction
The Americans with Disability Act (ADA) defines disability as a "physical or mental impairment that substantially limits 1 or more major life activity." 1Levels of difficulty functioning can range in severity and span across multiple domains, each requiring unique accommodations to ensure adequate access and provision of high-quality health care, including sexual and reproductive health (RH) services.][4][5][6][7][8][9][10][11] Although the ADA requires equal access to health care for people with disabilities, inequities persist. 12Understanding the barriers that prevent people with disabilities from accessing RH services is critical to identifying inequities and informing patient-centered approaches to services.
Ableism, the practice of giving privilege to able-bodied people, adversely affects people's access to and experiences with RH services as well as their reproductive well-being. 131][22] Experiences of discrimination, exclusion, and stigma, paired with a health care infrastructure that does not adequately address the needs of people with disabilities, have likely contributed to substantial disparities in RH outcomes.[25][26] Small qualitative studies have described the challenges that people with disabilities experience when trying to access RH services.1][22] However, the extent to which people with disabilities experience insurance, privacy-related, and other barriers is unknown.
Limitations of studies that have examined the barriers experienced by people with disabilities include small sample sizes, no assessment of the barrier types experienced, a focus on a sample of pregnant people rather than preventive RH care, and minimal recent evidence.Given the increase in barriers to RH access since the COVID-19 pandemic, particularly among historically structurally marginalized populations, 27 an examination of the barriers experienced by people with disabilities is warranted.The current study aimed to assess the national prevalence of barriers to RH access experienced by people with disabilities, thereby filling an important research gap.We also examined the same barriers documented among the general public between 2017 and 2022. 27Using these previous data allowed us to compare the prevalence of access barriers among people with disabilities vs the general public.For this study, the 2 primary research questions were (1) what is the prevalence of barriers in trying to access RH services among people with disabilities?and (2) do the barriers vary by disability status and disability type?By surveying people from December 2021 to January 2022 regarding barriers to RH access in the past 3 years, we captured their experiences during the COVID-19 pandemic.We hypothesized that people with disabilities, particularly those with multiple disabilities, experience more barriers to care.

Study Design
This cross-sectional study analyzed results of an online, probability-based national survey, which was designed to assess the prevalence of attempts to self-manage an abortion, attitudes toward selfmanaged abortion, and interest in alternative models of medication abortion provision.The University of California San Francisco Institutional Review Board approved this study.Participants provided electronic informed consent before taking the survey.We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
From December 2021 to January 2022, we fielded a large national survey to English-and Spanish-speaking, reproductive-aged (ages 15-49 years) people assigned female or male at birth; this analysis included only those AFAB.A market research firm administered the survey to their panel members (KnowledgePanel; Ipsos), using probability-based sampling techniques so that panelist recruitment was representative of the noninstitutionalized, English-and Spanish-speaking population living in the US when survey weights were applied. 28Panelists were invited to participate in a survey on their RH experiences and opinions.The survey collected data on barriers to accessing RH services, health care experiences, abortion attitudes, and sociodemographic characteristics.
Automatic reminders were sent to nonresponders 3 and 8 days after the initial survey invitation.
Participants were reimbursed through a points program, whereby they received cash-equivalent checks in amounts reflecting their level of panel participation, which commonly amounted to $4 to $6 per month.

Outcome Variables
The primary outcomes were the number and types of barriers when trying to access RH services in the past 3 years, using previously published items. 27,29Reproductive health services were defined as "a Pap smear, which is a test to check for cervical cancer, or family planning, like birth control methods."Those who had ever tried to access RH services were asked to select the barriers they had experienced in the past 3 years from a predefined list of 10 barriers: finding transportation to an office or clinic, getting time off work or school to go to the appointment, finding childcare so I could go to the office or clinic, finding a place that offers RH services, finding a place where I felt comfortable, finding services with people who speak my language, paying for services, finding a place that accepts my insurance, getting services without telling people you did not want to tell, and going to the clinic because my partner or family member did not want me to go.We created a 4-part categorical variable for the number of barriers experienced (none, 1, 2, and Ն3) and grouped barriers into 5 conceptual themes (logistical, access, cost, privacy, and interpersonal relationship), consistent with a previous study. 27

Independent Variables
We created 8 disability indicators as the primary exposures, using 5 of the 6 Washington Group Short Set (WG-SS) on Functioning items 30  the attention-deficit/hyperactivity disorder measure, and changes to the analytic plan.We changed the analytic plan to focus on WG-SS items, which were based on self-reported activity limitations, instead of including formal mental health diagnoses from a health care practitioner.For each item, the Likert-type answer options included no difficulty, some difficulty, a lot of difficulty, and cannot do at all.Following WG-SS criteria, participants who reported a lot of difficulty or cannot do at all in 1 or more domain were considered to have a disability (overall disability status) or a domain-specific disability (vision, hearing, mobility, ADLs, and communication). 31We also lowered the cutoff to measure some difficulty functioning (defined as some or more difficulty functioning in Ն1 domain) and included a measure of multiple disabilities (defined as a lot or more difficulty functioning in Ն2 domains), following WG-SS criteria.

Statistical Analysis
For all analyses, we used sampling weights to produce estimates that were representative of the noninstitutionalized US population AFAB, based on US Census data.Design weights accounted for any differential nonresponse.We estimated weighted proportions and conducted χ 2 analyses by overall disability status and participant characteristics (Table 1), by attempts to access RH services and domain-specific disability (Table 2), and by number (Figure ) and types of barriers when trying to access RH services and disability indicators (Table 3).We conducted unadjusted and adjusted log-binomial regression analyses to assess associations between disability indicators and types of barriers experienced when trying to access RH services (Table 4).Covariates were selected a priori.
We adjusted for age group (15-17, 18  of each type of barrier in trying to access RH services in the past 3 years compared with their counterparts (Table 3).In adjusted and unadjusted regression analyses, participants with overall disability status (eg, logistical barriers: risk ratio [RR], 1.32; 95% CI, 1.14-1.52)and those with multiple disabilities (eg, logistical barriers: RR, 1.61; 95% CI, 1.33-1.93)were significantly more likely to have experienced all types of barriers in trying to access RH services (Table 4).Participants with some difficulty functioning (eg, logistical barriers: RR, 1.19; 95% CI, 1.07-1.32)were significantly more likely to experience each barrier, except for access barriers, which were not statistically significant in adjusted analyses.

Discussion
In this large national representative survey conducted around the time of the COVID-19 pandemic, 8.5% of participants AFAB of reproductive age met the disability status threshold, of whom over two-thirds experienced barriers to RH access in the past 3 years. 30While attempts to access RH services were largely similar by disability status, people with disabilities, particularly those with multiple disabilities, experienced more barriers in trying to access care.Participants with ADL or communication disabilities experienced the greatest number of barriers, with as many as threequarters experiencing 3 or more barriers in the past 3 years, suggesting that these groups may require the most support.3][34] Thus, disparities in gynecological cancer screenings and contraceptive use may be due to structural barriers to care.Future research needs to examine access to other RH services, such as screening for sexually transmitted infections (STIs) and abortion care, which were not examined in this study, although we did find that people with disabilities are more likely to consider SMA than people without disabilities.
Previous work found that these same barriers to RH access increased from before (2017) to during the COVID-19 pandemic, particularly among people living in poverty and with less formal education. 27Thus, the structural barriers to RH care observed in this study may have been compounded during the pandemic, disproportionately affecting people with disabilities.Many factors may explain the barriers experienced during this time, including health risks from COVID-19, lost wages, in-person care restrictions, reduced number of Title X family planning clinics, and other RH-related policy changes. 35By assessing the attempts to access RH care, we captured the experiences of people who needed but may have been unable to receive care.
Similar to other work, 36,37 we found variation in demographic characteristics by disability status.
Participants with disabilities were significantly more likely to be Black or Latinx individuals, live below the federal poverty level, and identify as LGBTQAI, and they were much more likely to report experiencing medical mistreatment (eg, being ridiculed, humiliated, or ignored by health care practitioners), receiving fair or poor-quality medical care from their regular physician, and to consider self-managed abortion.These participants may be further marginalized due to ableism, discrimination, limited resources, and intersectional racism and homophobia and thus may  We used multiple categorizations of disability to examine variability in the magnitude and types of barriers experienced by people with a range of disability statuses.We found significant inequities among participants across disability indicators, including those above and below the disability threshold, and all of these participants experienced more of any barrier to RH care compared with those without disabilities.This finding is especially important, as people with some difficulty functioning are often not categorized as having a disability in RH studies. 38Efforts to increase the accessibility of RH care must move beyond complying with the ADA standards toward accommodating varying experiences of people with different conditions and levels of functioning.
Participants with disabilities most commonly experienced logistical (ie, finding transportation, getting time off work or school, and finding childcare) and access barriers (eg, finding a place that offers RH services; finding a place where I felt comfortable).A transportation infrastructure that does not meet the needs of people with disabilities likely contributes to inequitable access to care. 39lehealth models of care may help to streamline access and better serve the needs of some people. 40,41The high proportion of people who reported difficulty finding a place where they felt comfortable may be associated with previous medical mistreatment and poor-quality health care, and may explain the higher proportion of people with disabilities vs those without disabilities who considered self-managed abortion.Additionally, participants with disabilities also reported difficulty with going to the clinic because their partner or family member did not want them to go.This finding may be explained in part by the greater interdependence between people with disabilities and others for transportation and support with accessing care as well as by the likelihood of people with disabilities to experience intimate partner violence, reproductive coercion, and abuse. 20,26,42,43ecial attention is needed to address privacy concerns and to identify potential coercion and abuse that might prevent people with disabilities from accessing care.

Limitations
Findings should be interpreted according to study limitations.First, the measures of access and barriers to care were not comprehensive of all RH services, such as STI screening and abortion care, and did not include all access-related or disability-specific barriers.For example, we did not include barriers related to accessible equipment (eg, adjustable beds), methods of providing information (eg, compatibility of written materials with screen readers), or availability of sign language interpreters.
Future research should examine these disability-specific barriers and the implications of abortion

Figure .
Figure.Number of Barriers to Reproductive Health Services in Past 3 Years by Disability Indicators Among Survey Participants Assigned Female at Birth (n = 6027) 100

Table 3 .
Barriers to Reproductive Health (RH) Services in the Past 3 Years by Disability Indicators Among Survey Participants Assigned Female at Birth Who Ever Tried to Access RH (N = 6027) a Types of barriers to RH services Disability indicator, weighted proportion (95% CI) Had difficulty in past 3 y Logistical encounter additional barriers to care and may experience poor quality and potentially discriminatory health care.

Table 2 .
Association Between Domain-Specific Disability Level and Attempt to Access Reproductive Health (RH) Services in Past 3 Years Among Survey Participants Assigned Female at Birth

Table 4 .
Associations Between Disability Indicators and Types of Barriers to Reproductive Health (RH) Services in the Past 3 Years Among Survey Participants Who Ever Tried to Access RH (N = 6027)