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Reproductive Health of Urban American Indian and Alaska Native Women: Examining Unintended Pregnancy, Contraception, Sexual History and Behavior, and Non-Voluntary Sexual Intercourse A Division of the Seattle Indian Health Board February 2010 The mission of the Urban Indian Health Institute is to support the health and well- being of Urban Indian communities through information, scientific inquiry and technology. Recommended Citation: Urban Indian Health Institute, Seattle Indian Health Board. Reproductive Health of Urban American Indian and Alaska Native Women: Examining Unintended Pregnancy, Contraception, Sexual History and Behavior, and Non-Voluntary Sexual Intercourse. Seattle: Urban Indian Health Institute, 2010. 2 R e p r o d u c t i v e H e a l t h o f A l a s k a N a t i v e W o m e n U r b a n A m e r i c a n I n d i a n a n d Please contact the Urban Indian Health Institute with your comments: info@uihi.org or 206-812-3030. You can also fill out the form on page 45 with comments or questions. 4 L E T T E R from Sarah Deer, contributing author to Amnesty International’s 2007 Report: Maze of Injustice 5 EXECUTIVE SUMMARY 9 S E C T I O N I : Background 11 S E C T I O N I I : Methods 14 S E C T I O N I I I : Results 30 S E C T I O N I V : Discussion 37 S E C T I O N V : Limitations 38 S E C T I O N V I : Recommendations 40 S E C T I O N V I I : References 45 FEEDBACK FORM 47 A P P E N D I X A : Brief Outline of the NSFG Cycle 6 Survey Topics 48 A P P E N D I X B : Region of Residence 48 A P P E N D I X C : Contraceptive Methods 49 A P P E N D I X D : List of Tables TABLE OF CONTENTS TA B L E O F CO N T E N T S ACKNOWLEDGEMENTS The UIHI would like to gratefully acknowledge: • A Division of the Seattle Indian Health Board This project was funded by Health Services Research Administration, Maternal and Child Health Bureau [Grant #R40MC08954]. This project was also funded in part by the Indian Health Service Division of Epidemiology and Disease Prevention. R e p r o d u c t i v e • • • The Public Health – Seattle & King County for their assistance in making this report possible. We would like to send a special thank you to Mike Smyser, MPH, from the Epidemiology, Planning, and Evaluation Unit for his critical skills, attention to detail, and thoughtful input. The UIHI’s Maternal and Child Health Advisory Council members who were critical in the development of the project and in providing support and guidance throughout. The staff of the National Survey of Family Growth, especially Drs. Abma and Jones for their support of this project. The staff of the NCHS Research Data Center, especially Karen E. Davis, MA. H e a l t h o f U r b a n A m e r i c a n I n d i a n a n d A l a s k a N a t i v e W o m e n 3 LETTER FROM SARAH DEER FROM SARAH DEER, CONTRIBUTING AUTHOR TO AMNEST Y INTERNATIONAL’S 2007 REPORT: MAZE OF INJUSTICE February 2010 To Interested Parties: As a lawyer and activist, I am always grateful for the work that social scientists do to help us understand the complexities of our world. The work to end violence against Native women requires monumental collaboration and partnerships between and among a variety of disciplines and grassroots activists. As one of many collaborators on Amnesty International’s 2007 report entitled Maze of Injustice: The Failure to Protect Indigenous Women from Sexual Violence in the USA, I have seen first‐hand the impact that statistics can have on policy makers and direct service providers. Advocates for Native women may not be surprised by many of these findings, but this report confirms what many have been saying for years: Native women continue to be socially, economically, and physically marginalized by a society that doesn’t prioritize and sometimes doesn’t even acknowledge the realities of their lives. This report also makes crucial connections between violence and health. Violence against Native women is a public health crisis, and the urban experience has not received the same degree of attention as that on reservations and rural tribal communities. This report will not only improve lives but save lives. Health practitioners need to understand trends to better identify and respond to individual health needs. Activists and politicians need data in order to develop better policies and garner resources to address these concerns. Behind each set of numbers are faces and voices of exceptional Native women. These numbers tell stories that we need to honor. The trends identified in this report are alarming, but I am hopeful that increased attention to the marginalization of Native women will generate important discussion and dialogue. As you read this report, I urge you to consider the unique needs of Native women residing in urban areas and the critical need to develop interventions and programs that are tailored and customized to individual experiences. Sincerely, Sarah Deer (Muscogee Creek) Assistant Professor 4 R e p r o d u c t i v e H e a l t h o f A l a s k a N a t i v e W o m e n U r b a n A m e r i c a n I n d i a n a n d INTRODUCTION This report presents information on pregnancies, births, sexual history and behavior, contraceptive use, non-voluntary sex, and unintended pregnancy among urban American Indian/Alaska Native (AI/AN) women nationwide. We examined national data which has never been examined for AI/AN, in order to help fill a need for baseline information and to better understand previously identified disparities in health status and risk behaviors in this population. METHODS We analyzed data on American Indian and Alaska Native female respondents in Cycle 6 (2002) of the National Survey of Family Growth (NSFG), which represents the U.S. household population age 15-44 years. Non-Hispanic whites (NH-whites) were used as the comparison group. “Urban” was defined as living within a metropolitan statistical area. Percent estimates, 95% confidence intervals (CI’s) and p-values were calculated. Differences in rates between or within groups were deemed statistically significant by non-overlapping CI’s or a significance level of p ≤ 0.05. Linear and logistic regression analyses were used to further examine the relationship between race and unintended pregnancy, and select sexual history and behavior factors. EXECUTIVE SUMMARY EXECUTIVE SUMMARY RESULTS A total of 7,643 females completed Cycle 6 of the NSFG in 2002. Three hundred and fifty-seven (5%) AI/AN and 4,039 (53%) NH-whites were included in the sample. Of these, 299 AI/AN and 3,173 NH-whites were defined as urban. Results are presented for urban AI/AN and urban NH-whites. Demographics • Urban AI/AN women were younger with a mean age of 28 years compared to 31 years for NH-whites. • A high proportion of urban AI/AN were from the Western region of the US (57%). • Urban AI/AN were more likely to report fair or poor health status than NH-whites (14% vs. 5%). We examined national data which has never been examined for AI/AN. Socio-economic factors • Urban AI/AN were more likely to be poor, have lower levels of education and lack health insurance than NH-whites. • Socio-economic disparities among urban AI/AN were associated with high fertility rates, unintended pregnancy, and use of specific contraceptive methods, such as Depo-Provera and female sterilization. • Urban AI/AN were more likely than NH-whites to be cohabitating (15% vs. 8%) and less likely to be married (37% vs. 51%). R e p r o d u c t i v e H e a l t h o f U r b a n A m e r i c a n I n d i a n a n d A l a s k a N a t i v e W o m e n 5 EXECUTIVE SUMMARY EXECUTIVE SUMMARY Pregnancies, births & birth outcomes • Urban AI/AN were more likely to have had three or more pregnancies and births than NH-whites. High fertility rates were also seen among young urban AI/AN women age 15-24 years. • Urban AI/AN reports of 2 or more abortions was twice that of NH-whites (10% vs. 5%). Sexual history & behavior • A higher percentage of young urban AI/AN women had their period at age 11 years or younger compared to NH-whites. • Young urban AI/AN women are having more unprotected first sex and first sex with older partners compared to NH-whites. Contraception use • A lower proportion of urban AI/AN teens are using contraception overall compared to NH-white teens and fewer urban AI/AN who have sex at a young age are using condoms. • Rates of current Depo-Provera use among urban AI/AN women age 15-24 years were more than three times that of NH-white women. • Rates of female sterilization were significantly higher among urban AI/AN compared to NH-whites, especially among women age 3544 years. Non-voluntary sexual intercourse • Urban AI/AN women experienced non-voluntary first sexual intercourse at a rate more than twice that of NH-whites (17% vs. 8%). • Urban AI/AN women who had ever been forced to have sexual intercourse were more likely than NH-whites to have initiated sex at a young age. Unintended pregnancies • Urban AI/AN had higher rates of unintended pregnancies and higher rates of mistimed pregnancies than NH-whites. • In adjusted analyses, urban AI/AN who had unprotected sex in the past year, had sex before age 15 and who had more than two sex partners in the past three months, are 77% more likely to have had an unintended pregnancy than NH-whites with the same sexual risk status. DISCUSSION This is the first study to provide information on the reproductive health of urban AI/AN women age 15-44 years nationally. The findings provide critical baseline data for future surveillance and in-depth analyses, and offer guidance for programming priorities. 6 R e p r o d u c t i v e H e a l t h o f A l a s k a N a t i v e W o m e n U r b a n A m e r i c a n I n d i a n a n d Socioeconomic disparities among urban AI/AN seen in other data sources were also seen in this study. There is a clear need to address the upstream causes underlying many factors which are associated with poor health outcomes for AI/AN. Surveillance of the topic areas addressed in this study, such as fertility, family planning, contraceptive use, and sexual violence, should continue and could be improved upon for urban AI/AN. Specifically, the high rates of Depo-Provera use and the associated increased risk for overweight AI/AN, as well as female sterilization in relation to the documented history of abuse with this method by government agencies, should be studied further. Also, the high rates of abortion seen among urban AI/ AN should be further examined to confirm the current findings and to understand the unique context for urban AI/AN women given IHS funding restrictions and other factors. EXECUTIVE SUMMARY EXECUTIVE SUMMARY The high rates of sexual violence experienced by urban AI/AN women is intolerable. The context in which sexual violence occurs for urban AI/AN communities must be examined closely to learn how to promote justice and address the underlying issues. The development of resources which address the specific healthcare needs of urban AI/AN women could significantly improve health outcomes for this population. In order to provide culturally appropriate reproductive health services to urban AI/AN, recognition, examination and education about the history and impact of reproductive rights abuses should be pursued. Risk factors associated with contraceptive use and sexual behaviors are seen especially among young urban AI/AN women. Youth should be a focus for programming to address risk for unintended pregnancy and poor birth outcomes as well as STIs. Successful programs must be tailored to the unique culture and needs of urban AI/AN communities and evaluated for their effectiveness on this basis. The development of resources which address the specific healthcare needs of urban AI/AN women could significantly improve health RECOMMENDATIONS Improved access to data on urban AI/AN • Adequate sampling is essential to allow for more in-depth analysis of urban AI/AN and subgroups. • Data must be collected and reported for all Office of Management and Budget racial categories. • Sampling of AI/AN males in the NSFG should be increased to allow for analysis of this subgroup. outcomes for this population. R e p r o d u c t i v e H e a l t h o f U r b a n A m e r i c a n I n d i a n a n d A l a s k a N a t i v e W o m e n 7 EXECUTIVE SUMMARY EXECUTIVE SUMMARY Further investigation and continued surveillance of reproductive health topics for AI/AN • Continued and expanded surveillance is essential on topic areas where greater clarification is needed on the current findings, such as early menarche, abortion, Depo-Provera and female sterilization use, and high fertility rates. • Additional questions should be added on contextual factors in national surveys such as the NSFG. • Qualitative studies must be conducted to verify survey data and provide information that cannot be gathered from national survey methods. • Future studies must be conducted with the involvement of AI/AN at all levels of project development. Increased funding for urban AI/AN research and programming • There must be an increase in the allocation of funds for programming and research which is inclusive of urban AI/AN. • Funds must be made available to community based organizations, Urban Indian health organizations, Tribal Governments, Urban, Tribal and Native Epidemiology Centers, and Tribal Colleges and Universities to collect data and to assure the proper distribution and utilization of findings. • Resources must be identified and set aside for programs to work with urban AI/AN youth and those affected by sexual violence. There is a need for improved access to data on urban American Indians and Alaska Natives. 8 R e p r o d u c t i v e H e a l t h o f A l a s k a N a t i v e W o m e n U r b a n A m e r i c a n I n d i a n a n d URBAN AMERICAN INDIANS AND ALASKA NATIVES American Indians and Alaska Natives (AI/AN) living in urban areas are a diverse and growing population. Over the past three decades, AI/AN have increasingly relocated from rural communities and reservations into urban centers. Often overlooked as a result of lack of understanding or inclusion, this “invisible” population now makes up more than half of all American Indians and Alaska Natives living in the United States. Urban AI/AN are a very diverse group, and include members, or descendents of members, of many different tribes. Represented tribes may or may not be federally recognized, and individuals may or may not have historical, cultural, or religious ties to their tribal communities. Individuals may travel back and forth between their tribal communities or reservations on a regular basis, and the population as a whole is quite mobile (Lobo, 2003). Urban AI/AN are also generally spread out within the urban center instead of localized within one or two neighborhoods, and thus are often not seen or recognized by the wider population. SECTION I: BACKGROUND SECTION I: BACKGROUND PREVIOUS STUDIES ON REPRODUCTIVE HEALTH AMONG URBAN AI/AN Current literature on reproductive health among AI/AN is lacking and for urban AI/AN, it is even more limited. Most previous studies focused on reproductive health topics among AI/AN included select geographic and reservation populations and many are dated. While these studies most certainly provided important information, it is clear that updated and comprehensive data is needed. Unintended pregnancy has been examined in the general population, yet little is known about unintended pregnancy among urban AI/ AN (Mosher, 1996; Chandra, 2005). The National Survey of Family Growth (NSFG) documents contraceptive trends for whites, blacks and Hispanics, however, factors associated with variations in contraceptive use and risk for unintended pregnancy in the AI/AN population have not been published. Although comprehensive national data is not available, rates of unintended pregnancy among AI/AN women, as reported by some individual counties and states, are higher than for other races (OK PRAMS, 2006;WA Dept. of Health, 2006; NC DHHS, 2005; SeattleKing County, WA Dept. of Public Health, 1999; Warren, 1990). These gaps illustrate the need to establish a baseline for rates of unintended pregnancy and related factors among urban AI/AN women nationwide. Current literature on reproductive health among AI/AN is lacking and for urban AI/AN it is even more limited. Current data is also limited on the topic of contraceptive use among AI/AN and even fewer studies exist on contraceptive use as related to unintended pregnancy (Espey, 2000 and 2003;Williams, 1994). In a study on attitudes toward pregnancy and contraception use among European American (EA), Mexican American (MA) and American Indian (AI) clients in drug recovery programs, AI were similar to EA in reported use of contraception, but were least likely of the race groups to indicate R e p r o d u c t i v e H e a l t h o f U r b a n A m e r i c a n I n d i a n a n d A l a s k a N a t i v e W o m e n 9 SECTION I: BACKGROUND SECTION I: BACKGROUND that abortion is a reasonable alternative for an unwanted pregnancy (Gutierres, 2003). Authors note the importance of considering the potential for a cultural value of large families among AI when providing information on birth control and abortion, as is cited in previous studies among specific Tribes. A recent international study reported that overall women’s adjusted odds of having had an unintended pregnancy were significantly elevated if they had been physically or sexually abused (Odds ratio 1.4) (Pallitto, 2004). In a study of ethnic differences in the impact of sexual abuse on teen pregnancy rates, racial minority teens, including AI, were more likely than whites to have a teenage pregnancy and to have been coerced into having sex, rather than raped, prior to teenage pregnancy (Kenney, 1997). The National Violence Against Women Survey findings show the highest rates of violence occur among AI/AN women; 34.1% of AI/AN women reported rape in their lifetime (U.S. Department of Justice, 1998). In a study of urban AI/AN in New York, 48% reported having been raped (Evans-Campbell, 2006). Previous studies, such as these, highlight the need to examine sexual violence in nationwide urban AI/AN. Results from a previous UIHI examination of Youth Risk Behavior Survey data (Rutman, 2008) showed urban AI/AN youth were significantly more likely than urban white youth to engage in risky sexual behaviors and have had experiences of sexual violence. A higher percent of AI/AN had ever had sexual intercourse compared to white youth and prevalence estimates were also higher among AI/AN compared to white youth for: multiple sex partners and recent sexual intercourse with at least one partner. Reports of early sexual initiation (before age 13), having been pregnant or making someone pregnant were nearly three-fold higher among AI/AN compared to white youth. AI/AN were also more likely to have experienced sexual violence than white youth. Reports of being physically forced to have unwanted sexual intercourse were more than two-fold higher among AI/AN compared to white youth. Additionally, AI/AN were less likely than white youth to have ever been taught about HIV/AIDS in school. The disturbing inequality seen between these populations calls for further investigations in these areas among urban AI/AN women. Previous studies highlight the need to examine sexual We examined national data on sexual history and behavior, contraceptive use, non-voluntary sexual intercourse, and unintended pregnancies among urban AI/AN in order to help fill a need for baseline information and to better understand previously identified disparities. violence in nationwide urban AI/AN. 10 R e p r o d u c t i v e H e a l t h o f A l a s k a N a t i v e W o m e n U r b a n A m e r i c a n I n d i a n a n d