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

Unplanned Parenthood: Why I Choose Not to Use — Transcript

JENNIFER BREWER: Good morning. The title of my presentation is: Understanding Why Women Do Not Use Contraception, Even Though They Do Not Desire Pregnancy. And this presentation comes out of a larger study designed to broaden our understanding of the problem of unintended pregnancy among U. S. women by exploring women's reasons for not using contraception and thus having unprotected intercourse, from the point of view of the user. And in an effort to inform the design of more effective interventions in the U. S. to lower rates of unintended pregnancy. And just a little bit of background quickly. You've heard some of this.

Unintended pregnancies account for approximately half of all pregnancies in the United States and many of those leading to live births and those leading to live births are associated with less favorable health and socioeconomic outcomes for mom and baby and the obvious link between unintended pregnancy and abortion rates that you heard. Ninety percent of unintended pregnancies do occur among adult women because pregnancy is more common among adult women than in adolescents and this is why our study focuses on adult women of reproductive age.

Many of these women were not using any method of contraception at the time they conceived and thus raising the question why do so many women have unprotected intercourse, not use effective methods of contraception for the purposes of pregnancy prevention despite the seemingly negative impacts. A paradoxical question for many health practitioners and providers. And just taking a look at the existing studies quickly.

There are studies in the literature that focus on predictors and demographic and environmental risk factors and their link to unintended pregnancy. You also find studies on single method clinical efficacy trials looking at the acceptability and women's reasons for discontinuation from which women and the user's reasons for not using further or for discontinuing a method can be extrapolated. And while those types of studies do a lot and have done a lot and continue to do so, to increase our understanding of a complex problem of unintended pregnancy in the United States, we argue that more studies are needed on women's reasons from the point of view of the user and thus allowing us to look at the reasons for non-use through the lens of the women's perception and in the context of her personal narrative of what's going on in her world, including her perceived options and perceptions of her relationships.

And this was a qualitative and descriptive study. Our methods included 4 focus groups and it's a small sample of 32 women. Women were recruited through mass mailings to low income urban areas in Michigan that had high rates of abortion. To participate women needed to be on Medicaid or have a child receiving Medicaid. All of the women were fertile, currently had had a male sexual partner in the last year, not consistent contraceptive users or non-users at all.

The focus groups were taped and transcripts produced word-for-word. Thematic analysis of the transcripts were done using the qualitative program in Vivo. And some of the thematic categories were determined or we had an idea of them prior to the thematic analysis based on the review of the literature, but multiple meetings for consensus were conducted and the categories modified and subcategories developed as needed. And these are the 4 main categories that came out of our analysis, that we grouped women's reasons for non-use in and this is important to note that women, even though there were 32 women and they had close to 200 reasons for non-use. So there was no loss for words why they chose not to use contraception.

The reasons fell into these categories largely: method related reasons, user related, partner/relationship related, and cost/access related. And I just want to note that most women's reasons seemingly, their ultimate decision or practice to not use, as you would imagine, came from reasons and the complex relationship of reasons in multiple categories. Method related in relation to their partner, their perception of their partner support or their own attitudes toward contraception or pregnancy.

And to give some examples of the different reasons in the categories, method related reasons largely included experiences with or fear of side effects and this was a major method-related reason and actually a dominant theme in all of the focus groups and I'll give you a little bit more on that later given it's seemingly significant to the women's decision. Other method-related reasons included concerns about the effectiveness of the method, including things like, "I know plenty of people that have gotten pregnant on the pill, it's easy to get pregnant on the pill, it's not a hundred percent anyway. "Physical inconvenience, the reasons largely coded into this category, included things like, in relation to the pill, you have to take it every day, I don't want to insert anything into my vagina. But I would say the larger category of things, the things most coded into physical inconvenience were in relationship to condom use, "have to interrupt the encounter to use," "it slips off," those kinds of things.

And I just wanted to note here that interestingly we did find a large number of the female participants had an equal amount of displeasure or seemed to of using condoms or lack of motivation to use condoms as their male partner, given that they were discussed as reducing the pleasure of the sexual encounter.

And this is just a quite abbreviated list of the side effects that women mentioned. We had a very long list of side effects discussed in the focus groups and this was a dominant theme like I said in all the groups and as you can see from the list women were quite informed on the side effects associated with hormonal methods. However, recognizably some of them not very common, such as death, but weight gain and excessive bleeding were definitely the dominant side effects discussed; "I have either experienced" or fear of as a deterrent to use. And some side effects mentioned as a recognizable room for education that have not been attributed to the use of hormonals including causes sterility or carry over obesity, such as after they've discontinued the method. Like "once you've ever used a hormonal method and you've gained weight from it you can't ever lose that weight, like it messes with your metabolism forever. "

Some of the user related reasons, the reasons largely coded into this category we called lack of thought or preparation and these included things like don't want to think about the use of contraception or the risk of pregnancy during an encounter. Too much of a hassle to keep using, such as don't want to prepare, don't want to continue to prepare or take a method. And taking or using contraception puts a damper on the sexual encounter.

Women's attitudes toward pregnancy seem to make up a large group of reasons that were deterrent to use, including pregnancy would not be that bad and just as a note unintended pregnancy doesn't mean unwanted necessarily and many women didn't seem to think that a pregnancy would be that bad either in relationship to their partner or they could handle a pregnancy.

Some women prefer to rely on less alternative methods and this included the calendar-method or the rhythm method although this seemed to be a small portion of our participants. Reliance on, relying on an alternative method was largely in reference to the use of withdrawal and abortion was also mentioned but not a seemingly popular choice, at least vocally during the focus groups among the participants.

Several women had a perceived low-risk of getting pregnant to such as last time it was a long time before I got pregnant, I'm older my fertility, I'm less fertile or have been told by a doctor of physician that they either have no chance of having a baby or a low risk of having a baby.

Pre-existing conditions limiting choice of method, in this category we included not only things like diabetes, but age and smoking as a pre-existing condition, like I mentioned women thinking they were less fertile because of their age or women who smoke so they really felt they had no alternative, especially women who were older and smoked in the focus group, we know that increases the risk of taking hormonal methods. So they really felt they had few options but withdraw.

And shy and embarrassed to acquire contraception actually made up quite a small category among our women and was usually in reference when discussed in the focus group to when they were younger or less experienced.

Partner/relationship reasons focused on partners dislike of using condoms as well as a presumed negative impact on the relationship if they used hormonal methods to prevent a pregnancy or requested that their partner used a condom.

And our focus groups kind of echoed some of the research that suggests condom use is maybe more so equated with the use of disease prevention rather than pregnancy prevention. And this kind of comes out in this reason equated with promiscuity and fidelity. And women saying, "I don't need to use a condom I'm with a safe partner, he's my main partner. "Partner does not women to use also referred here to some partners did not want women to take Depo because she would gain weight or risk her personal health given the other side effects associated with hormonal methods.

And just an example where, as part of the, some of the interactions among the reasons, and this seemed to be a story heard in more than one focus group, if a woman was in a main relationship or in a relationship for some time and she wanted to stop using condoms which women in part seem to be quite motivated to do as well as their partner and they started taking a hormonal method, had a problem with the method, or dislike the method, it seemed to be quite difficult to reintroduce condoms into that relationship. And a lot of those women kind of expressed the feeling that they really, by default their choice was to rely on withdrawal.

And cost/access reasons included too expensive, lack of insurance coverage for either a method or their desired method. Some of the women preferred a little bit less common methods such as the Nuvo Ring or something that some insurance policies don't cover. Access problems also included a displeasure with the services provided, largely in reference to side effects were not adequately discussed, I did not feel that my personal concerns about the risk of side effects were taken seriously by my provider. And some issues with confidentiality. And this is kind of a small category for us. There were not a lot of sub-categories. Cost/access wasn't highly discussed in our focus groups and that's not to say that they weren't as equal a deterrent and strong influence for some of these women, but they did not take on a big part of the focus group discussions.

And just some of the limitations, this was a qualitative study so we were really unable to measure the frequency and relative influence of each reason for the individual women. There were some likely reasons not mentioned by our participants such as rape, violence and forced sex, possibly given the group dynamics of the focus group and no one mentioned it in any group so it never became a thread of any of the conversations. Religious objections to the use of contraception was also, appears in the literature as a reason, but was not mentioned by any of our participants. And lastly we can't generalize these reasons to women of other socioeconomic groups or married women or maybe more educated women.

And in conclusion, women definitely seem to have multiple reasons for non-use that were varying and overlapping and interacted in complex ways within the categories and shifted in relationship to their partner or a changing dynamic of their relationship. And thus we argue multi-level intervention approaches are needed that focus not only on the women's attitudes or access, but the interaction of the partner and the service delivery issues.

And more studies on women's personal reasons, we feel, would help make these design, intervention approaches more effective by including the dynamics of women's decision making process through their perceived practices, reasons for non-use and options.

Okay. And that's it. Thank you.