MCHB/EPI Miami Conference — December 7 - 9, 2005

Unplanned Parenthood: Why I Choose Not to Use — Transcript

SHANNA COX: Ok, good morning, my name is Shanna Cox and today I'll be presenting on Influences of Personal and Partner Attitudes on Contraceptive Decision-Making. I would like to thank my co-author and mentor, Dr. Samuel Posner and also my other co-author, Dr. Haleh Sangi-Haghpeykar.

So as we all know half of all pregnancies are unintended highlighting the need to promote effective contraceptive use to prevent mistimed and unwanted pregnancies. Sexually transmitted diseases remain a major public health challenge in the United States and even though substantial progress has been made in treating and reducing the prevalence of certain STDs, the CDC estimates that 19 million new infections occur each year.

The influences of intrapersonal and interpersonal characteristics influence the use of effective contraceptive methods and a developmental goal of Healthy people 2010 is to increase male involvement in pregnancy prevention and family planning efforts. Therefore, understanding factors that influence contraceptive decision-making is important.

So our analysis question was: Who is responsible for contraceptive decision-making. We looked at demographic and behavior variables as well as reproductive history, personal partner attitudes about condom use for the relative importance in predicting who was responsible for contraceptive decision-making.

We used data from a prospective study of psychosocial predictors of condom use among injectable contraceptive users. All women who visited 10 family planning provider sights in Texas from August 1999 through December 2001 were potential study participants. The normal procedure for obtaining contraceptives in these clinics included counseling and educational sessions at which time each available method and their contraindications were explained. Women who expressed interest in Depo Provera or oral contraceptives for the first time were invited to participate in the study. After consent was given each participant completed a self-administered questionnaire available in both English and Spanish that took approximately 15 minutes to complete.

In total we recruited 600 women, 200 of which expressed interest in oral contraceptives and 400 who expressed interest in Depo Provera. We restricted analysis to non-Hispanic whites, Latinos and African Americans due to small sample sizes of other ethnicities and to women who recently had sex with a main partner, retaining 95 percent of our original sample.

We first conducted a bi-variant analysis exploring demographic and behavior variables using chi-square tests. Variables significantly associated with contraceptive decision-making at a p-alpha level of less than 0.1 were included in multi-variant analyses. We used logistic regression to evaluate personal and partner attitudes independently and then we evaluated personal and partner attitudes simultaneously.

Our outcome of interest was, in general, who was responsible for making sure some form of birth control is used. Women who responded were classified as having sole responsibility for contraceptive decision-making. Although it would have been interesting to have 3 categories, only 8 women reported that it was their partner's responsibility. Therefore, women who responded, "my partner" or "both" were classified as, "he/we are responsible."

The demographic variables that we looked at were age, education, ethnicity, marital status, relationship status and the number of reported pregnancies. We evaluated risk factors of unintended pregnancy and sexually transmitted diseases such as history of abortion, history of STDs, the number of reported sexual partners in the past year and having a high-risk partner. A woman was classified as having a high-risk partner if she reported her partner used injection drugs in the past year, had unprotected sex with others within in the past year or had a sexually transmitted disease within the past year.

Behavioral variables explored included past use of condoms with a main partner and past use of birth control with the main partner. Birth control use with a main partner was classified into 3 methods: ineffective methods of pregnancy prevention, which included withdrawal and rhythm method; effective methods of pregnancy prevention only, which were primarily hormonal forms of contraception; and effective disease and pregnancy prevention, which included barrier methods.

Partner attitudes were evaluated by the question, "How does your main partner feel about using condoms with you?" Responses were: indifferent, positive, negative or I did not use condoms with this partner. Personal attitudes about condom use were explored by asking women if they believe condoms should always be used for vaginal sex, anal sex, even if they know each other very well, or even if they're using another form of birth control. Women were also asked to rank importance of birth control as being effective in preventing HIV or effective in preventing sexually transmitted diseases.

So now I would like to present our results. The average age of our participants was 24. It was a multi-ethnic sample with 42 percent of our respondents reported being of Hispanic ethnicity. The majority of the women were in a monogamous relationship. 34 percent reported at least one abortion, 30 percent were classified as having a high risk-partner, 71 percent reported previous use of birth control, with condoms being the most common form of birth control used with 66 percent of the sample reporting past use of condoms with their main partner.

In our bi-variant analysis, demographic variables associated with sole responsibility of contraceptive decision-making, Hispanic women were more likely than non-Hispanic white women to be solely responsible. There was increased likelihood of sole responsibility with increasing age and reported number of pregnancies. Women who reported being in a non-monogamous relationship were also more likely to be solely responsible for contraceptive use than women in a monogamous relationship.

We also found an increased likelihood of sole responsibility for contraceptive decision-making with women who had a history of abortion and women who were classified as having a high-risk partner. In our behavioral variables, women who did use condoms with their main partner were also more likely to be solely responsible for contraceptive decision-making. And women who used hormonal methods of birth control with their partner were more likely than women who used barrier methods to be solely responsible for contraceptive decision-making.

In our independent models, women who reported that their partners had negative feelings about condom use were more likely to be solely responsible for birth control versus women whose partners had positive feelings, adjusting for factors that we found significant in the bi-variant analysis. Five of the six personal attitudes were not independently associated with who was responsible for birth control. Only women who regarded birth control as being effective in preventing sexually transmitted diseases as being very or somewhat important approached marginal significance as less likely to report sole responsibility for contraceptive decision-making.

In our simultaneous model, women who reported that their partners had negative attitudes remained significantly associated with contraceptive decision-making, whereas personal attitudes did not. Other variables that remained significant in the model were age, ethnicity, having a high-risk partner and marital status.

Some limitations of our study, selection bias may be present if there is a difference between women who agreed to participate and those who did not. We only assess correlates of contraceptive decision-making with a main partner and results may differ regarding secondary partners of non-monogamous women. This is a self-administered questionnaire therefore it is subject to measurement bias. However, during pilot testing most of the constructs did have good internal consistent reliability and retest reliability. And those that did not were modified or omitted from the survey. And as is prevalent in literature on social relationships and health, we attempted to investigate relationship dynamics without didactic data. However, one may argue that is the influence of a woman's perception of how her partner feels that is more important than concordance with how the partner may actually respond.

So in conclusion, we found that sole decision makers were more likely to be of Hispanic ethnicity, have high-risk partners, be in a non-monogamous relationship and not report use of condoms. These are attributes that may put them at risk, higher risk for unintended pregnancy and sexually transmitted diseases. Sole decision-makers were more likely to be users of effective pregnancy prevention only, have partners with negative attitudes about condoms and rank birth control as not important in preventing STDS.

Some public health implications of this study, sole decision-makers may be a useful market to identify women at risk for unintended pregnancy and sexually transmitted diseases. Health providers may target this population to promote the use of contraceptive methods that provide dual protection against unintended pregnancy and sexually transmitted diseases.