Knowledge, attitudes, and practices regarding conception and fertility: a population-based survey among reproductive-age United States women Lisbet S. Lundsberg, Ph.D., M.P.H.,a Lubna Pal, M.B.B.S., M.R.C.O.G., M.S.,b Aileen M. Gariepy, M.D., M.P.H.,a Xiao Xu, Ph.D.,a Micheline C. Chu, M.D.,c and Jessica L. Illuzzi, M.D., M.S.a a Section of Clinical and Outcomes Research in Women’s Health, and b Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut; and c Recurrent Pregnancy Loss Program, Hofstra North Shore-LIJ School of Medicine at Hofstra University, Hempstead, New York
Objective: To assess overall knowledge, attitudes, and practices related to conception and fertility among reproductive-age women in the United States. Design: Online survey of a cross-sectional sample of 1,000 women. Setting: United States, March 2013. Patient(s): Women aged 18–40 years. Intervention(s): None. Main Outcome Measure(s): Knowledge, attitudes, and practices regarding selected topics in reproductive health. Result(s): Forty percent of women across all age groups expressed concerns about their ability to conceive. Yet one-third of women were unaware of adverse implications of sexually transmitted infections, obesity, or irregular menses for procreative success, and one-fifth were unaware of the effects of aging. Approximately 40% were unfamiliar with the ovulatory cycle. Overall, younger women (18–24 years) demonstrated less knowledge regarding conception, fertility, and ovulation, whereas older women tended to believe in common myths and misconceptions. Respondents in all age groups identified women’s health care providers (75%) and Web sites (40%) as top sources of reproductive health–related information; however, engagement with providers on specific factors affecting fertility is sparse. Conclusion(s): Knowledge regarding ovulation, fertility, and conception is limited among this sample of reproductive-age US women. Future initiatives should prioritize improved provider Use your smartphone engagement and accurate information dissemination in Web-based venues. (Fertil SterilÒ to scan this QR code 2014;101:767–74. Ó2014 by American Society for Reproductive Medicine.) and connect to the Key Words: Knowledge, fertility, conception, ovulation Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/lundsbergl-knowledge-attitudes-practices-conception-fertility/
Received August 8, 2013; revised November 20, 2013; accepted December 3, 2013; published online January 30, 2014. L.S.L. has nothing to disclose. L.P. has nothing to disclose. A.M.G. has nothing to disclose. X.X. has nothing to disclose. M.C.C. has nothing to disclose. J.L.I. has nothing to disclose. Sampling and data collection for this study were conducted by Edelman-Berland, a market research firm, and funded by Church & Dwight Co. Inc., maker of First Response fertility, ovulation, and pregnancy at-home test kits. Yale University received an unrestricted educational grant for collaboration on this project. The analysis and interpretation of the results was conducted independently by the authors and was not influenced by Church & Dwight Co. Inc. Reprint requests: Lisbet S. Lundsberg, Ph.D., M.P.H., Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 330 Cedar St., FMB 307 P.O. Box 208063, New Haven, Connecticut 06520-8063 (E-mail: [email protected]). Fertility and Sterility® Vol. 101, No. 3, March 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2013.12.006 VOL. 101 NO. 3 / MARCH 2014
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
T
he changing reproductive landscape in the United States is characterized by lower rates of teen pregnancy and increasing numbers of births to older women who may have postponed childbearing owing to pursuit of higher education, career advancement, or financial stability, and later age of marriage or other unions. At the same time, nearly half of the 6.7 million pregnancies in the United States each year are unintended 767
ORIGINAL ARTICLE: ENVIRONMENT AND EPIDEMIOLOGY (1). Comorbidities such as obesity, sexually transmitted infections, endometriosis, and other lifestyle factors may further impact reproduction. To date, studies investigating women’s knowledge of reproductive health, particularly with respect to fertility and conception, are generally limited to international settings (2–8) and often restricted to university students (2–6, 9). Identifying gaps in knowledge, including prevalent misconceptions, attitudes, and practices, across a more diverse sample of American women of reproductive age is important to optimize reproductive and pregnancy outcomes. The American College of Obstetricians and Gynecologists has emphasized the importance of optimizing women’s ‘‘health and knowledge before planning and conceiving a pregnancy’’ as part of preconception care (10). Likewise, understanding how women access information about reproductive health can highlight opportunities for enhanced communication with providers and information dissemination in other venues. The present study sought to examine overall knowledge, attitudes, and practices regarding reproductive health and conception among a sample of 1,000 women aged 18–40 years from across the United States.
MATERIALS AND METHODS An online survey was conducted by Edelman-Berland, a market research company, from March 4 to March 10, 2013, using existing panels of potential respondents who had previously agreed to receive survey invitations for which they may be eligible. Interested respondents were screened for gender and age eligibility (female, aged 18–40 years) and gave consent via an online privacy statement (11). By utilizing quotas for geographic region and ethnicity, survey administration targeted participation of 1,000 reproductive-age women from various ethnic and racial groups that are representative of the general US population. No personally identifying information was collected. A total of 1,606 individuals were eligible after screening and initiated the online survey. Of those, 73 did not complete the survey because of quota restrictions, 363 surveys were incomplete, 15 surveys did not meet data quality standards, and 155 were randomly removed to meet final quota restrictions for ethnicity and geographic region. The final data set for this analysis included survey information from 1,000 participants. Analysis of this deidentified survey dataset was determined to be exempt from institutional review board review by the Yale University Human Subjects Committee. The survey included collection of demographic variables as well as questions to assess knowledge, attitudes, beliefs, and practices regarding conception, pregnancy, and reproductive health (see study survey in Supplemental Material, available online). Responses to survey questions were analyzed using descriptive statistics. Comparisons among subgroups were performed using c2 and Fisher's exact tests where appropriate. Age was categorized as 18–24 years, 25–29 years, 30–34 years, and 35–40 years according to US Census age categories (12). The mid-categories (25–29 and 30–34 years) were combined, given the similarities within these two age groups with regard to demographic variables, including completion of education, marital 768
status, participation in the workforce, and childbearing. Given the differences in demographic characteristics and outcome variables across the three age groups, age group is presented as the primary variable for stratification describing the sample.
RESULTS Respondent Characteristics Descriptive statistics of the total sample and the sample stratified by age groups are presented in Table 1. Overall, 73% were non-Hispanic white; 8% non-Hispanic black; 4% Asian; and 12.5% Hispanic. Most of the subjects had some college education or college degree (80%), >50% were employed (full-time or part-time), approximately half were married, and 43% reported annual household income over $50,000. In terms of geographic representation, 35% resided in the South, 23.0% and 23.5% were in the West and Midwest, respectively, and 18.5% were in the Northeast region of the United States. Fifty-eight percent of women in the sample acknowledged having children, 7% were pregnant at the time of the survey, and 9% were actively trying to conceive. Forty-six percent acknowledged the possibility of having more children in the future, and 15% of surveyed women reported having no intention of ever having children. Overall, 80% of the sample reported being currently sexually active, and 7% identified their sexual orientation as gay or bisexual. Women in each age category did not differ by education, race/ethnicity, or region. Middle and older reproductive-age women (aged 25–34 and 35–40 years) were more likely to be married, employed full-time, have higher income, and to have children compared with younger women (aged 18–24 years) (P< .01). Younger women were more likely to be students (P< .01).
Knowledge Figure 1 illustrates knowledge of common factors that may be associated with a woman’s ability to conceive. More than twothirds of all participants were unaware that painful menses (e.g., through conditions such as endometriosis) may correlate with a women’s ability to conceive; almost one-third were unaware that a history of sexually transmitted infections may adversely affect fertility, and approximately one-quarter were not aware of implications of obesity or menstrual irregularity for fertility. In general, knowledge gaps were more evident in the younger age group (aged 18–24 years) compared with older women (aged 25–34 and 35–40 years), especially with regard to the impact of obesity (P< .01) and irregular menses (P< .01) (Supplemental Table 1). Knowledge about the impact of maternal age on time to conception and early pregnancy was further explored (Fig. 1). Women aged 25–34 years were significantly more likely to be aware of adverse implications of advancing age on the length of time to get pregnant (P< .05) and the chance for miscarriage compared with other age groups (P< .05). Younger women (aged 18–24 years) were less likely to know (70%) that aging increases the chances of having a child with a genetic abnormality compared with women older than 24 years (approximately 80%) (P< .05). VOL. 101 NO. 3 / MARCH 2014
Fertility and Sterility®
TABLE 1 Demographic characteristics of the study population. Age (y) Characteristic Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Asian Other Education High school or less Some college or more Region of the country Northeast Midwest South West Dwelling Urban Suburban Rural Employment Employed full-time Employed part-time Unemployed Homemaker Student Retired or not answered Household income $50,000 Relationship status Single and not dating Single and dating In a relationship, not cohabitating Not married, cohabitating Married Pregnancy history Have no children And do not intend to have children But may want to have children And currently pregnant And trying to conceive Have children And completed having children But may want more children And currently pregnant And trying to conceive Sexual orientation Heterosexual Bisexual Gay or lesbian Other or prefer not to answer Smoking status Never smoked Past smoker Occasional Current smoker Alcohol use No Yes
Total sample
18–24 (n [ 163)
25–34 (n [ 592)
35–40 (n [ 245)
731 (73.1) 78 (7.8) 125 (12.5) 44 (4.4) 22 (2.2)
108 (66.3) 18 (11.0) 23 (14.1) 9 (5.5) 5 (3.1)
444 (75.0) 42 (7.1) 72 (12.2) 23 (3.9) 11 (1.9)
179 (73.1) 18 (7.3) 30 (12.2) 12 (4.9) 6 (2.4)
201 (20.1) 795 (79.4)
37 (22.7) 125 (76.7)
119 (20.1) 471 (79.5)
45 (18.4) 198 (80.9)
185 (18.5) 230 (23.0) 350 (35.0) 235 (23.5)
34 (20.9) 33 (20.3) 61 (37.4) 35 (21.3)
113 (19.1) 125 (21.1) 213 (36.0) 141 (23.8)
38 (15.5) 72 (29.4) 76 (31.0) 59 (24.1)
269 (26.9) 462 (46.2) 251 (25.1)
56 (34.4) 61 (37.4) 40 (24.5)
147 (24.8) 290 (49.0) 147 (24.8)
66 (26.9) 111 (45.3) 64 (26.1)
366 (36.6) 160 (16.0) 115 (11.5) 266 (26.6) 81 (8.1) 12 (1.2)
31 (19.0) 26 (16.0) 27 (16.6) 23 (14.1) 56 (34.4) 0
235 (39.7) 96 (16.2) 67 (11.3) 169 (28.5) 22 (3.7) 3 (0.5)
100 (40.8) 38 (15.5) 21 (8.6) 74 (30.2) 3 (1.2) 9 (3.6)
517 (51.7) 431 (43.1)
105 (64.4) 46 (28.2)
305 (51.5) 255 (43.1)
107 (43.7) 130 (53.1)
150 (15.0) 63 (6.3) 100 (10.0) 170 (17.0) 514 (51.4)
38 (23.3) 15 (9.2) 36 (22.1) 42 (25.8) 32 (19.6)
93 (15.7) 39 (6.6) 49 (8.3) 97 (16.4) 312 (52.7)
19 (7.8) 9 (3.7) 15 (6.1) 31 (12.7) 170 (69.3)
145 (14.5) 217 (21.7) 22 (2.2) 38 (3.8)
22 (13.5) 74 (45.4) 8 (4.9) 8 (4.9)
92 (15.5) 127 (21.5) 10 (1.7) 20 (3.4)
31 (12.7) 16 (6.5) 4 (1.6) 10 (4.1)
249 (24.9) 237 (23.7) 44 (4.4) 48 (4.8)
6 (3.7) 27 (16.6) 10 (6.1) 8 (4.9)
116 (19.6) 166 (28.0) 29 (4.9) 32 (5.4)
127 (51.8) 44 (18.0) 5 (2.0) 8 (3.3)
907 (90.7) 60 (6.0) 13 (1.3) 20 (2.0)
134 (82.2) 21 (12.9) 1 (0.6) 7 (4.3)
543 (91.7) 32 (5.4) 9 (1.5) 8 (1.4)
230 (93.9) 7 (2.9) 3 (1.2) 5 (2.0)
621 (62.1) 170 (17.0) 50 (5.0) 159 (15.9)
118 (72.4) 17 (10.4) 11 (6.7) 17 (10.4)
354 (59.8) 100 (16.9) 30 (5.1) 108 (18.2)
149 (60.8) 53 (21.6) 9 (3.7) 34 (13.9)
524 (52.4) 476 (47.6)
93 (57.1) 70 (42.9)
301 (50.8) 291 (49.2)
130 (53.1) 115 (46.9)
P value .616
.568 .149
.083
< .001
< .001 < .001
< .001
.0003
.006
.362
Note: Numbers may not add to n ¼ 1,000 because of missing values. Values are number (percentage). Lundsberg. Knowledge of fertility among US women. Fertil Steril 2014.
Gaps in knowledge about the ovulatory cycle and conception were also identified. Although 95% of surveyed women correctly defined ovulation as ‘‘an egg being released from the ovary,’’ one-quarter of the sample were unaware that VOL. 101 NO. 3 / MARCH 2014
normal menstrual cycles can vary between 25 and 35 days, and 40% did not know that ovulation usually occurs 14 days before menses or that clear mucous vaginal discharge is a sign of impending ovulation (Fig. 1). Close to 60% 769
ORIGINAL ARTICLE: ENVIRONMENT AND EPIDEMIOLOGY
FIGURE 1
Women’s knowledge (percentage answering ‘‘true’’). *P
Objective: To assess overall knowledge, attitudes, and practices related to conception and fertility among reproductive-age women in the United States. Design: Online survey of a cross-sectional sample of 1,000 women. Setting: United States, March 2013. Patient(s): Women aged 18–40 years. Intervention(s): None. Main Outcome Measure(s): Knowledge, attitudes, and practices regarding selected topics in reproductive health. Result(s): Forty percent of women across all age groups expressed concerns about their ability to conceive. Yet one-third of women were unaware of adverse implications of sexually transmitted infections, obesity, or irregular menses for procreative success, and one-fifth were unaware of the effects of aging. Approximately 40% were unfamiliar with the ovulatory cycle. Overall, younger women (18–24 years) demonstrated less knowledge regarding conception, fertility, and ovulation, whereas older women tended to believe in common myths and misconceptions. Respondents in all age groups identified women’s health care providers (75%) and Web sites (40%) as top sources of reproductive health–related information; however, engagement with providers on specific factors affecting fertility is sparse. Conclusion(s): Knowledge regarding ovulation, fertility, and conception is limited among this sample of reproductive-age US women. Future initiatives should prioritize improved provider Use your smartphone engagement and accurate information dissemination in Web-based venues. (Fertil SterilÒ to scan this QR code 2014;101:767–74. Ó2014 by American Society for Reproductive Medicine.) and connect to the Key Words: Knowledge, fertility, conception, ovulation Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/lundsbergl-knowledge-attitudes-practices-conception-fertility/
Received August 8, 2013; revised November 20, 2013; accepted December 3, 2013; published online January 30, 2014. L.S.L. has nothing to disclose. L.P. has nothing to disclose. A.M.G. has nothing to disclose. X.X. has nothing to disclose. M.C.C. has nothing to disclose. J.L.I. has nothing to disclose. Sampling and data collection for this study were conducted by Edelman-Berland, a market research firm, and funded by Church & Dwight Co. Inc., maker of First Response fertility, ovulation, and pregnancy at-home test kits. Yale University received an unrestricted educational grant for collaboration on this project. The analysis and interpretation of the results was conducted independently by the authors and was not influenced by Church & Dwight Co. Inc. Reprint requests: Lisbet S. Lundsberg, Ph.D., M.P.H., Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 330 Cedar St., FMB 307 P.O. Box 208063, New Haven, Connecticut 06520-8063 (E-mail: [email protected]). Fertility and Sterility® Vol. 101, No. 3, March 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2013.12.006 VOL. 101 NO. 3 / MARCH 2014
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
T
he changing reproductive landscape in the United States is characterized by lower rates of teen pregnancy and increasing numbers of births to older women who may have postponed childbearing owing to pursuit of higher education, career advancement, or financial stability, and later age of marriage or other unions. At the same time, nearly half of the 6.7 million pregnancies in the United States each year are unintended 767
ORIGINAL ARTICLE: ENVIRONMENT AND EPIDEMIOLOGY (1). Comorbidities such as obesity, sexually transmitted infections, endometriosis, and other lifestyle factors may further impact reproduction. To date, studies investigating women’s knowledge of reproductive health, particularly with respect to fertility and conception, are generally limited to international settings (2–8) and often restricted to university students (2–6, 9). Identifying gaps in knowledge, including prevalent misconceptions, attitudes, and practices, across a more diverse sample of American women of reproductive age is important to optimize reproductive and pregnancy outcomes. The American College of Obstetricians and Gynecologists has emphasized the importance of optimizing women’s ‘‘health and knowledge before planning and conceiving a pregnancy’’ as part of preconception care (10). Likewise, understanding how women access information about reproductive health can highlight opportunities for enhanced communication with providers and information dissemination in other venues. The present study sought to examine overall knowledge, attitudes, and practices regarding reproductive health and conception among a sample of 1,000 women aged 18–40 years from across the United States.
MATERIALS AND METHODS An online survey was conducted by Edelman-Berland, a market research company, from March 4 to March 10, 2013, using existing panels of potential respondents who had previously agreed to receive survey invitations for which they may be eligible. Interested respondents were screened for gender and age eligibility (female, aged 18–40 years) and gave consent via an online privacy statement (11). By utilizing quotas for geographic region and ethnicity, survey administration targeted participation of 1,000 reproductive-age women from various ethnic and racial groups that are representative of the general US population. No personally identifying information was collected. A total of 1,606 individuals were eligible after screening and initiated the online survey. Of those, 73 did not complete the survey because of quota restrictions, 363 surveys were incomplete, 15 surveys did not meet data quality standards, and 155 were randomly removed to meet final quota restrictions for ethnicity and geographic region. The final data set for this analysis included survey information from 1,000 participants. Analysis of this deidentified survey dataset was determined to be exempt from institutional review board review by the Yale University Human Subjects Committee. The survey included collection of demographic variables as well as questions to assess knowledge, attitudes, beliefs, and practices regarding conception, pregnancy, and reproductive health (see study survey in Supplemental Material, available online). Responses to survey questions were analyzed using descriptive statistics. Comparisons among subgroups were performed using c2 and Fisher's exact tests where appropriate. Age was categorized as 18–24 years, 25–29 years, 30–34 years, and 35–40 years according to US Census age categories (12). The mid-categories (25–29 and 30–34 years) were combined, given the similarities within these two age groups with regard to demographic variables, including completion of education, marital 768
status, participation in the workforce, and childbearing. Given the differences in demographic characteristics and outcome variables across the three age groups, age group is presented as the primary variable for stratification describing the sample.
RESULTS Respondent Characteristics Descriptive statistics of the total sample and the sample stratified by age groups are presented in Table 1. Overall, 73% were non-Hispanic white; 8% non-Hispanic black; 4% Asian; and 12.5% Hispanic. Most of the subjects had some college education or college degree (80%), >50% were employed (full-time or part-time), approximately half were married, and 43% reported annual household income over $50,000. In terms of geographic representation, 35% resided in the South, 23.0% and 23.5% were in the West and Midwest, respectively, and 18.5% were in the Northeast region of the United States. Fifty-eight percent of women in the sample acknowledged having children, 7% were pregnant at the time of the survey, and 9% were actively trying to conceive. Forty-six percent acknowledged the possibility of having more children in the future, and 15% of surveyed women reported having no intention of ever having children. Overall, 80% of the sample reported being currently sexually active, and 7% identified their sexual orientation as gay or bisexual. Women in each age category did not differ by education, race/ethnicity, or region. Middle and older reproductive-age women (aged 25–34 and 35–40 years) were more likely to be married, employed full-time, have higher income, and to have children compared with younger women (aged 18–24 years) (P< .01). Younger women were more likely to be students (P< .01).
Knowledge Figure 1 illustrates knowledge of common factors that may be associated with a woman’s ability to conceive. More than twothirds of all participants were unaware that painful menses (e.g., through conditions such as endometriosis) may correlate with a women’s ability to conceive; almost one-third were unaware that a history of sexually transmitted infections may adversely affect fertility, and approximately one-quarter were not aware of implications of obesity or menstrual irregularity for fertility. In general, knowledge gaps were more evident in the younger age group (aged 18–24 years) compared with older women (aged 25–34 and 35–40 years), especially with regard to the impact of obesity (P< .01) and irregular menses (P< .01) (Supplemental Table 1). Knowledge about the impact of maternal age on time to conception and early pregnancy was further explored (Fig. 1). Women aged 25–34 years were significantly more likely to be aware of adverse implications of advancing age on the length of time to get pregnant (P< .05) and the chance for miscarriage compared with other age groups (P< .05). Younger women (aged 18–24 years) were less likely to know (70%) that aging increases the chances of having a child with a genetic abnormality compared with women older than 24 years (approximately 80%) (P< .05). VOL. 101 NO. 3 / MARCH 2014
Fertility and Sterility®
TABLE 1 Demographic characteristics of the study population. Age (y) Characteristic Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Asian Other Education High school or less Some college or more Region of the country Northeast Midwest South West Dwelling Urban Suburban Rural Employment Employed full-time Employed part-time Unemployed Homemaker Student Retired or not answered Household income $50,000 Relationship status Single and not dating Single and dating In a relationship, not cohabitating Not married, cohabitating Married Pregnancy history Have no children And do not intend to have children But may want to have children And currently pregnant And trying to conceive Have children And completed having children But may want more children And currently pregnant And trying to conceive Sexual orientation Heterosexual Bisexual Gay or lesbian Other or prefer not to answer Smoking status Never smoked Past smoker Occasional Current smoker Alcohol use No Yes
Total sample
18–24 (n [ 163)
25–34 (n [ 592)
35–40 (n [ 245)
731 (73.1) 78 (7.8) 125 (12.5) 44 (4.4) 22 (2.2)
108 (66.3) 18 (11.0) 23 (14.1) 9 (5.5) 5 (3.1)
444 (75.0) 42 (7.1) 72 (12.2) 23 (3.9) 11 (1.9)
179 (73.1) 18 (7.3) 30 (12.2) 12 (4.9) 6 (2.4)
201 (20.1) 795 (79.4)
37 (22.7) 125 (76.7)
119 (20.1) 471 (79.5)
45 (18.4) 198 (80.9)
185 (18.5) 230 (23.0) 350 (35.0) 235 (23.5)
34 (20.9) 33 (20.3) 61 (37.4) 35 (21.3)
113 (19.1) 125 (21.1) 213 (36.0) 141 (23.8)
38 (15.5) 72 (29.4) 76 (31.0) 59 (24.1)
269 (26.9) 462 (46.2) 251 (25.1)
56 (34.4) 61 (37.4) 40 (24.5)
147 (24.8) 290 (49.0) 147 (24.8)
66 (26.9) 111 (45.3) 64 (26.1)
366 (36.6) 160 (16.0) 115 (11.5) 266 (26.6) 81 (8.1) 12 (1.2)
31 (19.0) 26 (16.0) 27 (16.6) 23 (14.1) 56 (34.4) 0
235 (39.7) 96 (16.2) 67 (11.3) 169 (28.5) 22 (3.7) 3 (0.5)
100 (40.8) 38 (15.5) 21 (8.6) 74 (30.2) 3 (1.2) 9 (3.6)
517 (51.7) 431 (43.1)
105 (64.4) 46 (28.2)
305 (51.5) 255 (43.1)
107 (43.7) 130 (53.1)
150 (15.0) 63 (6.3) 100 (10.0) 170 (17.0) 514 (51.4)
38 (23.3) 15 (9.2) 36 (22.1) 42 (25.8) 32 (19.6)
93 (15.7) 39 (6.6) 49 (8.3) 97 (16.4) 312 (52.7)
19 (7.8) 9 (3.7) 15 (6.1) 31 (12.7) 170 (69.3)
145 (14.5) 217 (21.7) 22 (2.2) 38 (3.8)
22 (13.5) 74 (45.4) 8 (4.9) 8 (4.9)
92 (15.5) 127 (21.5) 10 (1.7) 20 (3.4)
31 (12.7) 16 (6.5) 4 (1.6) 10 (4.1)
249 (24.9) 237 (23.7) 44 (4.4) 48 (4.8)
6 (3.7) 27 (16.6) 10 (6.1) 8 (4.9)
116 (19.6) 166 (28.0) 29 (4.9) 32 (5.4)
127 (51.8) 44 (18.0) 5 (2.0) 8 (3.3)
907 (90.7) 60 (6.0) 13 (1.3) 20 (2.0)
134 (82.2) 21 (12.9) 1 (0.6) 7 (4.3)
543 (91.7) 32 (5.4) 9 (1.5) 8 (1.4)
230 (93.9) 7 (2.9) 3 (1.2) 5 (2.0)
621 (62.1) 170 (17.0) 50 (5.0) 159 (15.9)
118 (72.4) 17 (10.4) 11 (6.7) 17 (10.4)
354 (59.8) 100 (16.9) 30 (5.1) 108 (18.2)
149 (60.8) 53 (21.6) 9 (3.7) 34 (13.9)
524 (52.4) 476 (47.6)
93 (57.1) 70 (42.9)
301 (50.8) 291 (49.2)
130 (53.1) 115 (46.9)
P value .616
.568 .149
.083
< .001
< .001 < .001
< .001
.0003
.006
.362
Note: Numbers may not add to n ¼ 1,000 because of missing values. Values are number (percentage). Lundsberg. Knowledge of fertility among US women. Fertil Steril 2014.
Gaps in knowledge about the ovulatory cycle and conception were also identified. Although 95% of surveyed women correctly defined ovulation as ‘‘an egg being released from the ovary,’’ one-quarter of the sample were unaware that VOL. 101 NO. 3 / MARCH 2014
normal menstrual cycles can vary between 25 and 35 days, and 40% did not know that ovulation usually occurs 14 days before menses or that clear mucous vaginal discharge is a sign of impending ovulation (Fig. 1). Close to 60% 769
ORIGINAL ARTICLE: ENVIRONMENT AND EPIDEMIOLOGY
FIGURE 1
Women’s knowledge (percentage answering ‘‘true’’). *P
