No Perfect Method: Exploring How Past Contraceptive Methods Influence Current Attitudes Toward Intrauterine Devices

Association of willingness to use hormonal contraception with knowledge: A national survey

OBJECTIVE

To determine if willingness to use and concern with using hormonal contraception (HC) is associated with knowledge about HC.

STUDY DESIGN

We conducted an online cross-sectional survey of self-identified women, US residents 18 and older using Amazon Mechanical Turk and ResearchMatch.org. Primary outcome was HC knowledge level, with participants categorized into binary knowledge level variable based on accuracy of responses to seven statements about HC (e.g. HC causes infertility, HC decreases acne). We assessed participant willingness and concern with using HC, including the primary type of concern with HC (physical, emotional, complications, other). We used bivariate tests and a multivariable logistic regression model to test the association of willingness and concern about HC to knowledge level.

RESULTS

Of 1041 respondents ages 18-81, 18% had no concerns and were willing to use HC, 64% had some concerns but were willing to use HC, and 18% had concerns and were not willing to use HC. Respondents who had concerns but were still willing to use HC were less likely to be concerned about complications than those who were unwilling (31.0% vs. 43.7%; p < 0.001). The median number of correct responses to knowledge statements was three (IQR 2-5) and 94.8% of participants answered at least one statement incorrectly. After controlling for age, current form of contraception, education, rurality, census region, political, and religious beliefs, participants who were willing to use HC without concerns (aOR=4.32; 95% CI: 2.45-7.62) and those who were willing but had concerns (aOR=2.11; 95% CI: 1.35-3.30) was associated with being more knowledgeable as compared to those not willing to use HC (reference).

CONCLUSION

Women willing to use HC are more likely to be more knowledgeable about HC. More than 80% of women report concerns with HC.

IMPLICATIONS

Patients unwilling to use HC are more likely to have knowledge gaps in their understanding of HC side effects and risk of complications. For shared decision-making, providers should specifically address the facts and myths surrounding HC to ensure patients are making informed decisions about their reproductive health.

Integrating Sexual and Reproductive Health Equity Into Public Health Goals and Metrics: Comparative Analysis of Healthy People 2030's Approach and a Person-Centered Approach to Contraceptive Access Using Population-Based Data

BACKGROUND

The Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals' self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access.

OBJECTIVE

We aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users.

METHODS

We used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric.

RESULTS

Comparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers-individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex.

CONCLUSIONS

Our analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale

INTRODUCTION

Concerns about safety and side effects from contraceptives are widespread and related to reluctance to use them. Measuring these concerns is an essential component of understanding contraceptive decision-making and guiding contraceptive and interpregnancy clinical care.

METHODS

We used qualitative research and item response theory to develop and test a psychometric instrument to measure contraceptive concerns and beliefs. We developed 55 candidate scale items and tested them among 572 adolescents and adults across nine California healthcare facilities in 2019-2020. We derived a 6-item scale and assessed differences by age and social determinants of health with multivariable regression.

RESULTS

In qualitative data, participants voiced both concerns and positive beliefs about contraception. Quantitative survey respondents were aged 21 years on average, and 24% were parous. Over half (54%) worried contraception has dangerous side effects, and 39% worried it is unnatural. The mean Contraceptive Concerns score, increasing with higher concerns, was 1.85 (SD: 1.00, range 0-4, α = 0.81). Items fit a partial credit item response model and met prespecified criteria for internal structure validity. Contraceptive use declined with increasing Concerns score (adjusted prevalence ratio [aPR] = 0.81 [0.72-0.92]). Scores were elevated among Black (mean: 2.06; aβ = 0.34 [0.09, 0.59]) and Multiracial or other race (2.11; aβ = 0.34 [0.02, 0.66]) respondents vs. White (1.66), but not Latinx respondents (1.81; aβ = 0.11 [- 0.11, 0.33]). Scores were also elevated among participants with lower maternal education (high school/Associate's 1.89 versus college 1.60; aβ = 0.28 [0.04, 0.53]).

DISCUSSION

The psychometrically robust Concerns instrument can be used in research to measure autonomous contraceptive decision-making and to design person-centered care.

Assessing contraceptive use as a continuum: outcomes of a qualitative assessment of the contraceptive journey

BACKGROUND

Contraceptive use is often a multi-decade experience for people who can become pregnant, yet few studies have assessed how this ongoing process impacts contraceptive decision-making in the context of the reproductive life course.

METHODS

We conducted in-depth interviews assessing the contraceptive journeys of 33 reproductive-aged people who had previously received no-cost contraception through a contraceptive initiative in Utah. We coded these interviews using modified grounded theory.

RESULTS

A person's contraceptive journey occurred in four phases: identification of need, method initiation, method use, and method discontinuation. Within these phases, there were five main areas of decisional influence: physiological factors, values, experiences, circumstances, and relationships. Participant stories demonstrated the ongoing and complex process of navigating contraception across these ever-changing aspects. Individuals stressed the lack of any "right" method of contraception in decision-making and advised healthcare providers to approach contraceptive conversations and provision from positions of method neutrality and whole-person perspectives.

CONCLUSIONS

Contraception is a unique health intervention that requires ongoing decision-making without a particular "right" answer. As such, change over time is normal, more method options are needed, and contraceptive counseling should account for a person's contraceptive journey.

Factors affecting contraceptive choice in women over 40: a qualitative study

OBJECTIVE

To explore the views of women over 40 years in choosing and using contraception, and to inform how contraceptive counselling for this age group could be improved.

DESIGN, SETTING AND PARTICIPANTS

Fourteen women aged 40-52 years were recruited through social media platforms to take part in online, semistructured, in-depth interviews. Transcripts were analysed using a qualitative thematic approach.

RESULTS

(1) Participants were anxious about unplanned pregnancy, and still highly motivated to avoid this. (2) Changes of contraceptive method over the lifecourse were occasionally precipitated by emergent health conditions, but healthcare providers often recommended a change in method on the basis of age alone. (3) Participants were experiencing perimenopausal symptoms but were largely unaware of how hormonal contraception could be used to treat these symptoms. (4) Prior negative experiences with contraceptive methods, coercive experiences with healthcare providers, and traumatic life events all contributed to a narrowing of contraceptive preference in later life.

CONCLUSION

Women over 40 years may be highly motivated to avoid pregnancy. This age group may have complex contraceptive histories with emerging perimenopausal symptoms. Women over 40 years may have accumulated adverse experiences which impact their contraceptive choices. These factors need to be explored by clinicians, to facilitate shared decision-making.

"I talked to a couple of friends that had it": Informal feminized health networks and contraceptive method choices

Scholars recognize that social networks can influence a number of health behaviors, including women's contraceptive method choices. However, the gendered dynamics underlying the process of using non-medical information sources to make decisions about contraception has received less attention. Using 30 semi-structured interviews with women enrolled in a contraceptive initiative in the western United States, we explore how women use gendered understandings of medicine and feminized social networks to make decisions about contraceptives. Frequently categorizing their experiences in medical settings as unsatisfactory, women often turn to social support networks of other women-what we call "informal feminized health networks"-to gather information about the effects of contraceptives on women's bodies and to make decisions about which contraceptives are best. While informal feminized health networks are useful, women utilize them in light of unsatisfactory experiences in clinical settings. Working to uproot the paternalistic legacy of institutionalized medicine and improving provider-patient communication will enhance contraceptive access and help women reach their reproductive goals.

Structural Inequity and Pregnancy Desires in Emerging Adulthood

Public health discourses often claim that delaying pregnancy is associated with social and economic benefits. Yet research suggests that, for young people, structural inequity is most influential in future outcomes, regardless of childbearing. We conducted in-depth interviews with 50 young women (ages 18-24) and their male partners (n = 100) and investigated the influence of structural inequity on pregnancy desires and plans. Three themes emerged, stratified by social advantage. In the "Things Will Be Different Later" theme, socially advantaged participants envisioned that their future lives would surely be different due to achievement of educational, professional, and economic goals; thus, their pregnancy plans aligned with their desires, often reflected in use of highly effective contraception. In the "I Don't Have Everything I Need" theme, participants expressed delaying desired pregnancies (primarily through condom use) until they could contend with structural barriers. Their pregnancy plans, shifted by way of structural inequity, were not aligned with their desires. Under the "I'll Never Have Everything I Need" theme, socially disadvantaged participants expressed significant doubt about ever realizing ideal circumstances for pregnancy preparedness; as pregnancy prevention was not salient, these participants used condoms or no contraception. This analysis indicates that structural inequities constrain reproductive self-determination in emerging adulthood, creating a chasm between desired and actual childbearing that was reflected in contraceptive decision-making. Public health narratives emphasizing the importance of pregnancy prevention for socially disadvantaged groups without addressing the manifestation of structural inequity in their lives perpetuate reproductive oppression vis-à-vis emphasis on contraceptive use to ensure future economic success.

Reasons for rejecting hormonal contraception in Western countries: A systematic review

Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading "hormonophobia", i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

"When Is Health Care Actually Going to Be Care?" The Lived Experience of Family Planning Care Among Young Black Women

While family planning care (FPC) visits may serve as opportunities to address gaps in knowledge and access to limited resources, young Black women may also face structural barriers (i.e., racism, discrimination, bias) to engaging in care due to the intersections of racial identity, age, and socioeconomic status. Findings from interviews with 22 Black women, ages 18 to 29 years, about the lived experience of FPC highlighted dynamic patient-provider encounters. Women's narratives uncovered the following essences: silence around sex impedes engagement in care, patient-provider racial concordance as protection from harm, providers as a source of discouragement and misinformation, frustration as a normative experience, decision making excludes discussion and deliberation, medical mistrust is pervasive and a part of Black consciousness, and meaningful and empathic patient-provider encounters are elusive. Health systems should prioritize developing and enhancing young Black women's relationship with FPC providers to help mitigate persistent inequities that perpetuate disadvantage among this population.

"Since I'm a little bit more mature": contraception and the arc of time for women in midlife

Background

Contraceptive methods have rapidly evolved over the past several decades, but little research has explored how women interact with contraception over time. Exploring contraceptive beliefs, perceptions, and attitudes of women in midlife can reveal much about how lived experience affects contraceptive decisions and reproductive health choices.

Methods

Individual, semi-structured interviews were conducted with 20 women between the ages of 40 and 55 who had not reached menopause and did not have a permanent method of sterilization. Data were coded using qualitative descriptive methods.

Results

Three major themes were identified: 1) journey toward empowerment; 2) finding the right fit: evolution over time; and 3) anticipating a transition. Past experiences with or fear of side effects and hormones were common reasons to change or avoid certain contraceptive methods. Most participants were happy with their contraceptive method; however, those who were unhappy were more likely to vocalize fatigue at continuing to need contraception as menopause approached.

Conclusion

Approaching contraceptive counseling from a place that considers the journey with contraception over a reproductive life span will help identify how beliefs, perceptions, and attitudes of women affect their contraceptive practices and choices.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.