A Mixed Methods Study of Contraceptive Effectiveness in a Relationship Context Among Young Adult, Primarily Low-Income African American Women

Desire to Avoid Pregnancy scale: clinical considerations and comparison with other questions about pregnancy preferences

BACKGROUND

Clinicians and women of reproductive age would benefit from a reliable way to identify who is likely to become pregnant in the next year, in order to direct health advice. The 14-item Desire to Avoid Pregnancy (DAP) scale is predictive of pregnancy; this paper compares it with other ways of assessing pregnancy preferences to shortlist options for clinical implementation.

METHODS

A cohort of 994 UK women of reproductive age completed the DAP and other questions about pregnancy preferences, including the Attitude towards Potential Pregnancy Scale (APPS), at baseline and reported on pregnancies quarterly for a year. For each question, DAP item and combinations of DAP items, we examined the predictive ability, sensitivity, specificity, area under the receiver operating curve (AUROC), and positive and negative predictive values.

RESULTS

The AUROCs and predictive ability of the APPS and DAP single items were weaker than the full DAP, though all except one had acceptable AUROCs (>0.7). The most predictive individual DAP item was 'It would be a good thing for me if I became pregnant in the next 3 months', where women who strongly agreed had a 66.7% chance of pregnancy within 12 months and the AUROC was acceptable (0.77).

CONCLUSION

We recommend exploring the acceptability to women and healthcare professionals of asking a single DAP item ('It would be a good thing for me if I became pregnant in the next 3 months'), possibly in combination with additional DAP items. This will help to guide service provision to support reproductive preferences.

Sexual and Reproductive Health and Reproductive Coercion in Women Victim/Survivors Receiving Housing Support

Housing instability and intimate partner violence (IPV) compromise women's sexual and reproductive health (SRH) through reduced contraceptive access and increased risk of unintended pregnancy. This study describes the reproductive health status and needs of IPV survivors receiving housing support and explores factors influencing their experience of reproductive coercion (RC), specifically. Cross-sectional baseline data from a quasi-experimental study of 70 IPV survivors enrolled in housing programs in the Baltimore, MD, metropolitan area from June 2019 through December 2020 were analyzed. Of the 70 women enrolled in the study, 70.3 percent (n = 45) desired to avoid pregnancy, but 57.4 percent were either using no contraceptive method (31.2%) or methods with low effectiveness (26.2%). Approximately, 1 in 6 women (16.4%, n = 11) experienced RC in the past 3 months, which was associated with frequency and severity of IPV (p = 0.001 to 0.005) and PTSD (p = 0.001), as well as not sharing children with the abusive partner (p = 0.002). This study highlights reproductive health risks in an important and under-studied population of women seeking housing due to IPV. Leaving an abusive relationship is a uniquely vulnerable time, and also a time of opportunity, as women are accessing services that can be tailored to their SRH needs. Significant results highlight vulnerability to and consequences of RC in this population. This study has implications for IPV support programs and housing programs that serve women.

Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy Among Latina Women

Reproductive coercion (RC) describes a range of behaviors that restrict reproductive autonomy including pregnancy coercion, birth control sabotage, and controlling the outcome of a pregnancy. RC is associated with pregnancies that are mistimed and unwanted (i.e., unintended). Past research demonstrates that Latina women have higher risk for RC and for unintended pregnancy. This cross-sectional descriptive study with Latina women (n = 482) examined prevalence and risk factors for RC, evaluated the association of RC and unintended pregnancy among women with a past-year pregnancy, and explored use of safety and harm reduction strategies. A tablet survey was administered to women attending a community health center, between the ages of 15 and 45, who self-identified as Latina and who had a dating or sexual partner in the past year. Approximately one in six (16.8%) experienced past-year RC and risk factors included younger age (adjusted odds ratio [AOR] = 0.95, 95% confidence interval [CI] = [0.91, 1.00], p = .038) and concurrent intimate partner violence (IPV; AOR = 4.47, 95% CI = [2.06, 9.70], p < .001). IPV questions were specific to the partner involved with RC behaviors. For the 185 participants who reported a past-year pregnancy, RC was associated with lower pregnancy planning scores (β = -.27, 95% CI = [-0.41, -0.13], p < .001). The combination of experiencing RC and IPV appeared particularly potent in lowering pregnancy planning scores (β = -.15, 95% CI = [-0.29, 0.00], p = .052). Approximately 10.6% of participants engaged in harm reduction strategies, most commonly ending an unhealthy or abusive relationship (6.1%) and using less detectable methods of contraception so that partners would not find out (3.4%). The study articulates the risk of RC and its intersection with IPV and unintended pregnancy for Latina women. Providers working with racially and ethnically marginalized women have an important role in promoting safety and harm reduction strategies that include offering less detectable methods of contraception and support in leaving unhealthy and abusive relationships.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders

OBJECTIVES

Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers.

METHODS

We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health.

RESULTS

Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews.

CONCLUSIONS

Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions

CONTEXT

Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use.

METHODS

We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy.

RESULTS

After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively).

CONCLUSIONS

Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Exploring Reproductive Coercion in Relationship Contexts Among Young Adult, Primarily African American Women at Three Women's Health Clinics

Understanding reproductive coercion experiences in marginalized populations is important to assist in tailoring care and services. Reproductive coercion is consistently associated with intimate partner violence (IPV), engaging in sexual risk-taking, and is more commonly reported among non-White women. We conducted a secondary analysis of data from a mixed methods study to examine reproductive coercion in relationship contexts among a sample (N = 130) of young adult, primarily African American women recruited from three women's health clinics; 12 also participated in an in-depth interview. Thirty-six women (27.7%) reported reproductive coercion in the past year. Past-year reproductive coercion was associated with relationship trust, (t(128) = -3.01, p = .003), and past-year IPV (Fisher's exact test, p = .005). In the best-fit model, odds of past-year reproductive coercion increased by 4% with each one-point increase in relationship trust score (indicating reproductive coercion increased with lower trust; adjusted odds ratio [AOR] = 1.04; 95% confidence interval [CI] = [1.00, 1.08]), and by more than 4 times with past experience of IPV (AOR = 4.74; 95% CI = [1.07, 20.86]). Qualitative analysis revealed women's awareness of reproductive coercion whether or not they personally experienced it. Those who experienced reproductive coercion identified it as a form of abuse and additionally described experiences of pressure to conceive from the partner's family. Our results support routine screening for IPV and reproductive coercion. Furthermore, the intersection of partner reproductive coercion with family pressure related to reproductive decision making should be explored to better inform clinical interventions.

Revisiting the Association between Race, Ethnicity, and Beliefs about Pregnancy

Objective

Black and Latinx individuals are often the focus of health educational efforts to 'correct' perceived flawed beliefs about pregnancy, in order to increase contraceptive use and reduce unintended pregnancies. We sought to revisit the association between race, ethnicity, and beliefs about pregnancy.

Methods

We administered a web-based survey to 2,099 heterosexual men and women aged 21-44 years, using non-probability quota sampling. We analyzed a subset who were not currently pregnant (n=1,884) and conducted chi-square tests to examine the association between race/ethnicity and beliefs about avoiding pregnancy (can be avoided, determined by fate/God, 'just happens,' and is a natural process). We then performed a two-stage multinomial logistic regression, modeling the belief that pregnancy can be avoided. The first model included sociodemographic characteristics and the second model added feelings about pregnancy.

Results

Bivariate analyses revealed that, compared with Whites, those who identified as Black/African American or Latinx were significantly more likely to believe that pregnancy was determined by fate/God (15%,13% vs 9%, respectively) or a natural process (13%,13% vs 9%, respectively) and less likely to report that it can be avoided (57%,56% vs 67%, respectively; P=.001). In the first regression model, these differences persisted. However, in the second model, being Black/African American or Latinx was not significantly associated with beliefs about avoiding pregnancy.

Conclusions

Our findings suggest that once more nuanced beliefs about pregnancy prevention are considered, Black and Latinx individuals do not hold strongly different beliefs than Whites. Efforts that exclusively focus on people of color to change beliefs about pregnancy appear unwarranted.

Examining Women's and Men's Ideal Criteria Before Forming Families

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.