Journal of Adolescent Health 54 (2014) 704e709
www.jahonline.org Original article
Religious Variations in Perceived Infertility and Inconsistent Contraceptive Use Among Unmarried Young Adults in the United States Amy M. Burdette, Ph.D. a, *, Stacy H. Haynes, Ph.D. b, Terrence D. Hill, Ph.D. c, and John P. Bartkowski, Ph.D. d a
Department of Sociology and Center for Demography & Population Health, Florida State University, Tallahassee, Florida Department of Sociology, Mississippi State University, Starkville, Mississippi c Department of Sociology, University of Utah, Salt Lake City, Utah d Department of Sociology, University of TexaseSan Antonio, San Antonio, Texas b
Article history: Received May 6, 2013; Accepted November 4, 2013 Keywords: Perceived infertility; Contraceptive use; Religion; Sexual health
A B S T R A C T
Purpose: In this paper, we examine associations among personal religiosity, perceived infertility, and inconsistent contraceptive use among unmarried young adults (ages 18e29). Methods: The data for this investigation came from the National Survey of Reproductive and Contraceptive Knowledge (n ¼ 1,695). We used multinomial logistic regression to model perceived infertility, adjusted probabilities to model rationales for perceived infertility, and binary logistic regression to model inconsistent contraceptive use. Results: Evangelical Protestants were more likely than non-affiliates to believe that they were infertile. Among the young women who indicated some likelihood of infertility, evangelical Protestants were also more likely than their other Protestant or noneChristian faith counterparts to believe that they were infertile because they had unprotected sex without becoming pregnant. Although evangelical Protestants were more likely to exhibit inconsistent contraception use than non-affiliates, we were unable to attribute any portion of this difference to infertility perceptions. Conclusions: Whereas most studies of religion and health emphasize the salubrious role of personal religiosity, our results suggest that evangelical Protestants may be especially likely to hold misconceptions about their fertility. Because these misconceptions fail to explain higher rates of inconsistent contraception use among evangelical Protestants, additional research is needed to understand the principles and motives of this unique religious community. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Because roughly half of all pregnancies in the United States (US) are unplanned, unintended pregnancy continues to be of critical importance to public health practitioners and policy makers [1]. Research suggests that most unintended pregnancies are the result of inconsistent use or nonuse of contraceptives, rather than contraceptive failure [2]. Despite decades of * Address correspondence to: Amy M. Burdette, Ph.D., Department of Sociology, Florida State University, 526 Bellamy Building, Tallahassee, FL 32306-2270. E-mail address: [email protected] (A.M. Burdette).
IMPLICATIONS AND CONTRIBUTION
Perceived infertility is associated with higher rates of contraceptive nonuse, contraceptive discontinuation, and sexually transmitted infections among adolescents and young adults. This study is among the first to examine religious variations in perceived infertility among unmarried young adults in the United States.
scholarship, public health practitioners have a limited understanding of the factors that undermine regular contraceptive use, including among young adults. This research gap is problematic because young women between the ages of 18 and 29 years have a higher rate of unintended pregnancy than any other age group [3]. This pattern clearly emphasizes the need for research focused on the sexual and reproductive health of young adults. One reason for inconsistent use or nonuse of contraceptives is that some women believe that they are unlikely or unable to
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conceive [4,5]. These perceptions are important because evidence among young women suggests that young adults may overestimate their actual infertility. For example, infertility estimates for married women in the US suggest that approximately 6% of those between the ages of 15 and 29 years are likely to be infertile [6]. To put this rate into perspective, a recent nationally representative study of unmarried young adults estimates that approximately 19% of unmarried women between the ages of 18 and 29 years believe that they are very likely to be infertile [7]. The significance of the discrepancy between reproductive perception and reproductive reality is compounded by studies showing that perceived infertility is associated with higher rates of contraceptive nonuse, contraceptive discontinuation, and sexually transmitted infections [8e10]. Although previous research has made significant contributions to our understanding of perceived infertility [7e9], scholars have only begun to consider the social patterning of these perceptions. Using data from the National Survey of Reproductive and Contraceptive Knowledge, a nationally representative probability sample of 1,800 unmarried men and women aged 18e29 years in the US (also known as the Fog Zone data set), Polis and Zabin [7] showed that rates of perceived infertility were higher among young adults who were Hispanic or had received public assistance in the past year (women only). Polis and Zabin also found that born-again, fundamentalist, or evangelical young men (not women) were more apt to believe that they were not likely to be infertile (compared with slightly likely) than young men with no religious affiliation. Because Polis and Zabin did not focus on religion, it is important to build on their foundational work. By concentrating on the link between religion and infertility perceptions, we may extend the growing body of literature concerning religion and reproductive health, while also augmenting public health research on the antecedents of perceived infertility. A great deal of research has demonstrated that religion exerts a powerful impact on the social attitudes and behavior of American youth and emerging adults, including their sexual views and practices [11e13]. Research on adolescent sexual behavior consistently shows that highly religious teens (e.g., those with high levels of religious commitment, religious attendance, religious salience, and prayer) initiate sexual activity later [14e16] and report fewer sexual partners [17,18] than do their less religious peers. Religious involvement may delay or reduce sexual activity by promoting sexual morality and embedding individuals within sexually conservative contexts [13], where informal social sanctions are regularly enforced against persons suspected of non-marital sexual activity [19]. Conversely, affiliating with a conservative religious group or movement has been associated with nonuse of contraception among adolescents [14,17,20], although this association is less consistent in the literature [21,22]. In their work on virginity pledging, a movement primarily sponsored by the Southern Baptist Church, Bearman and Brückner [20] explained that pledgers were less likely to be prepared for an experience that they had promised to avoid. The authors argued that being “contraceptively prepared” may actually be psychologically distressing for teens who had publicly vowed to abstain from sexual intercourse until marriage. Far fewer studies focus on the association between religion and sexual health among young adults; however, limited data suggest that indicators of religious involvement (e.g., religious attendance and religious salience) are also associated with delayed sexual activity and fewer partners in this population [23e25].
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In this article, we employ data from a nationally representative probability sample of unmarried US young adults to build on the work of Polis and Zabin [7] in three specific ways. First, to arrive at a better understanding of religious variations in perceived infertility, we focused exclusively on the role of religion and incorporated into our analyses multiple indicators of personal religiosity (i.e., religious affiliation and religious attendance). Second, to grasp more fully the principles and motives of unique religious communities, we explored religious variations in rationales for infertility perceptions. Finally, to elaborate on the association between personal religiosity and inconsistent contraceptive use, we considered the potential mediating influence of infertility perceptions. Methods Data To address these issues, we employed data from the National Survey of Reproductive and Contraceptive Knowledge, which was commissioned by the National Campaign to Prevent Teen and Unplanned Pregnancy and conducted by researchers at the Guttmacher Institute from October 2008 to April 2009. This study was designed to explore understudied factors such as knowledge, attitudes, and beliefs about contraception that influence the ability of young adults to use contraception effectively. A report detailing preliminary findings, as well as a more in-depth description of the study design and methods, was made available in 2010 [26]. The sample was selected so that the weighted results were representative of the US population of unmarried 18- to 29-year-olds. Of the 1,800 total respondents, about 10% were reached through randomdigit dialing of landline phone numbers, 50% through a sample of landline numbers with a high probability of containing unmarried residents in their twenties, and 40% by cell phone. AfricanAmerican and Hispanic young adults were oversampled. The field-tested questionnaire, which was offered in both English and Spanish, was approved by the Guttmacher Institute’s institutional review board [10]. We excluded from all analyses respondents who were currently pregnant or who were sterilized. Our final sample included 1,695 respondents. Measures Perceived infertility was measured via responses to the question, “Some people are unable to become pregnant, even if they want to. How likely do you think it is that you are infertile or will have difficulty getting [a woman] pregnant when you want to?” Responses included “not at all likely,” “slightly likely,” “quite likely,” and “extremely likely.” Following the work of Polis and Zabin [7], we combined the categories of “quite likely” and “extremely likely.” Preliminary analyses showed no religious differences between these two categories. Therefore, in the analyses conducted for this study, we modeled three categories: (1) not at all likely; (2) slightly likely; and (3) quite/extremely likely. Infertility rationales were assessed exclusively among women because men who perceived themselves as infertile did not receive these follow-up questions. Female respondents who perceived some degree of infertility were asked whether they believed they were infertile or might have had trouble getting pregnant because: (1) a doctor told them that they were infertile or might have difficulty getting pregnant; (2) other women in their family were infertile; and/or (3) they had sex without birth control and had never become pregnant. Although most fertility
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problems are not hereditary, some fertility-impairing conditions, such as premature ovarian insufficiency (i.e., the loss of all oocytes before age 40 years), have clear familial links [27]. Because respondents were able to select multiple rationales for perceived infertility, we created separate dummy variables for each fertility rationale (e.g., 1 ¼ unprotected sex; 0 ¼ some other rationale). Given the importance of the unprotected sex rationale, we created an additional dummy variable that isolated women who selected this rationale and no other rationale (¼ 1) versus women who selected any other rationale(s) (¼ 0). Inconsistent contraceptive use was assessed using a series of questions about the use of certain contraceptive methods (e.g., birth control pill, condoms, other hormonal methods). For example, respondents were first asked if they had ever used condoms as a method of birth control. Individuals who indicated they had used condoms were then asked about the consistency of condom use within the past 3 months. Specifically, respondents were asked whether they had used condoms “every time,” “most of the time,” “about half of the time,” “less than half of the time,” or “none of the time” when they had sexual intercourse over the reference period. Respondents using a longacting method (e.g., intrauterine device) or consistently using a short-term method (e.g., birth control pills, condoms) were coded as consistently using contraceptives. Respondents who were unprotected, used a less effective method (e.g., withdrawal), or inconsistently used a short-term method were coded as inconsistently using contraceptives, and therefore were at risk of an unplanned pregnancy (1 ¼ inconsistent contraceptive use). Unfortunately, inconsistent contraceptive use could not be assessed for roughly 18% of the sample because of a limited number of follow-up questions on consistency of contraceptive use for certain contraceptive methods. For example, female respondents who indicated they were using the birth control patch, a vaginal ring, or a diaphragm were not asked questions about consistency of use, even though these are not long-term methods of birth control. These individuals were removed from subsequent analyses. Neither of our focal variables (i.e., religious affiliation and religious attendance) was associated with an inability to categorize a respondent’s protection status. Personal religiosity was indicated by standard measures of religious affiliation and religious attendance. Religious affiliation was assessed by first asking respondents whether they had no religious affiliation or whether they identified as Protestant, Catholic, Jewish, or some other religion. Respondents who indicated that they were Protestant or a member of some other Christian group were asked if they self-identified as fundamentalist or evangelical, or considered themselves a born-again Christian (a common marker of evangelical Protestant identity) [28]. These items were combined, resulting in a series of six dummy variables: no religious affiliation (the reference category), evangelical Protestant (self-identified fundamentalist, evangelical, or born-again), other Protestant (Protestants not identifying as fundamentalist, evangelical, or born-again), Catholic, other Christian (e.g., those identifying as “just Christian”), and “other” religion (e.g., Buddhist, Jewish, Muslim). Religious attendance was assessed with the following question: “About how often do you attend religious services? Would you say once a week or more, one to three times per month, less than once a month, or never?” Coded responses for religious attendance range from 1 ¼ “never” to 4 ¼ “once a week or more.” Based on previous research, our multivariate regression models included controls for an extensive set of background
characteristics that were at least theoretically associated with religious involvement and perceived infertility [7,10]. These background characteristics included gender, age, race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, Hispanic, other race), education (i.e., less than high school, high school degree, some college, college or higher), region of residence (i.e., South, West, Northeast, Midwest), whether the respondent was currently in school, insurance status (i.e., Medicaid, private insurance, uninsured), whether the respondent ever had sexual intercourse, and whether the respondent had a child. Statistical procedures Our analyses proceeded in four steps. We began with the presentation of descriptive statistics (Table 1). We then modeled perceived infertility as a function of personal religiosity and background variables (Table 2). Because preliminary analyses failed to support the proportional odds assumption, we employed multinomial logistic regression to model perceived infertility in lieu of ordered logistic regression [29]. We
Table 1 Descriptive statistics (n ¼ 1,695) Mean/Proportion Dependent variables Perceived infertility Reason for perceived infertilitya Unprotected sex Medical reason Family reason Inconsistent contraceptive useb Individual-level variables Religious affiliation Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith No religious affiliation Religious attendance Male Age Race/ethnicity African-American Non-Hispanic white Hispanic Other race Level of education Less than high school High school Some college College Currently in school Region of residence South West Northeast Midwest Insurance status Medicaid Private insurance Uninsured Never had sexual intercourse Has children a
1.77
Standard deviation .87
.37 .23 .26 .48
.29 .08 .23 .11 .04 .25 2.48 .51 22.19
1.19 3.34
.19 .51 .22 .08 .13 .28 .43 .16 .48 .33 .24 .15 .26 .20 .57 .23 .18 .18
Among women who perceived some degree of infertility (n ¼ 496). Limited to those who reported being sexually active within the year, were not pregnant or trying to become pregnant, or were not sterilized, and for whom protection status could be categorized (n ¼ 943). b
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Table 2 Odds ratios obtained from multinomial logistic regression analysis of perceived infertility Not likely (n ¼ 784) Quite likelya (n ¼ 266) (Odds ratio [95% (Odds ratio [95% Confidence interval]) Confidence interval]) Male Age African-American Hispanic Other race Less than high school Some college College Currently in school South West Northeast Medicaid Private insurance Never had sexual intercourse Has children Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith Religious attendance Pseudo R2
1.98*** (1.57e2.49) 1.00 (.96e1.04) 1.18 (.86e1.62) 1.36 (.99e1.87) 1.32 (.85e2.05) .95 (.66e1.39) .93 (.69e1.24) .92 (.62e1.35) 1.20 (.93e1.54) 1.09 (.82e1.45) .69* (.51e.95) .76 (.54e1.08) .97 (.67e1.39) 1.01 (.76e1.34) .90 (.67e1.21) 2.79*** (1.96e3.98) 1.02 (.71e1.46) 1.01 (.64e1.58) .84 (.60e1.18) 1.35 (.90e2.02) .55* (.31e.97) 1.10 (.98e1.23)
.95 (.69e1.30) 1.00 (.95e1.06) 1.84** (1.22e2.79) 1.97** (1.30e2.98) 2.20** (1.24e3.89) .70 (.43e1.15) .70 (.48e1.03) .41** (.24e.72) .76 (.53e1.07) 1.47 (.98e2.21) 1.14 (.74e1.77) 1.57 (.98e2.50) 1.26 (.80e1.98) .88 (.60e1.29) .80 (.53e1.21) 1.00 (.62e1.60) 1.71* (1.05e2.77) 1.30 (.67e2.52) 1.46 (.93e2.31) 1.45 (.81e2.58) .62 (.27e1.45) .95 (.81e1.10) .055
n ¼ 1,695. Reference categories for predictors: non-Hispanic white, high school education, no insurance, Midwest, no religious affiliation. a Compared with slightly likely (n ¼ 649). * p < .05. ** p < .01. *** p < .001.
Figure 1. Adjusted probabilities for perceived infertility rationales, by religious affiliation.
individuals were not at risk of an unplanned pregnancy. Unlike our analysis in Table 2, we employed an ordinal specification of perceived infertility in Table 3. Our decision to treat perceived infertility as an ordinal predictor variable was supported by ancillary analyses showing a linear relationship between perceived infertility and protection status. All analyses were conducted using Stata SE (version 12; StataCorp, College Station, TX). Multivariate analyses employed the weight provided to account for complex survey design and to generate population-level estimates. To address the issue of missing data, we used regression-based imputation for all independent variables in our regression models. Results
acknowledge that other studies of perceived infertility stratified their analyses by gender [7] or focused exclusively on women [30]; however, subsequent analyses included women and men to maximize statistical power. Ancillary analyses showed no gender variations in the association between personal religiosity (affiliation and attendance) and perceived infertility. Next, we estimated adjusted probabilities for perceived infertility rationales by religious affiliation (Figure 1). This analysis is limited to women who reported at least some likelihood of infertility. The probabilities and confidence intervals presented in Figure 1 were generated from binary logistic regression models for each infertility rationale. We estimated probabilities for each rationale using binary logistic regression to clearly present the probability of a given classification relative to all other classifications (as opposed to another given classification). In Figure 1, point estimates for each religious group are presented graphically, with vertical lines depicting 95% confidence intervals around each probability estimate. These results provide estimates of the average respondent’s probability of selecting each rationale. Figure 1 does not show religious attendance because ancillary analyses indicated that this factor was not associated with infertility rationales among the women in our sample. Finally, we examined religious affiliation variations in inconsistent contraceptive use and the potential mediating influence of perceived infertility (Table 3). This analysis was limited to respondents who reported being sexually active within the past 12 months, because questions about contraception use were asked only of these individuals. In addition to excluding respondents who were not sexually active, we omitted individuals actively trying to become pregnant, because by definition, those
Table 1 displays descriptive statistics for all variables used in our analyses. Table 2 shows the results of the multinomial logistic regression analysis predicting the odds of being (1) “not likely” infertile and (2) “quite/extremely likely” infertile versus being (3) “slightly likely” infertile. This analysis reveals three important patterns. First, the odds of reporting that one is “quite likely” or “extremely likely” to be infertile were elevated by 71% (OR, 1.71; confidence interval [CI], 1.05e2.77; p < .05) for evangelical Protestants compared with respondents with no religious affiliation. Second, the odds of reporting that one is “not likely” to be infertile were reduced by 44% (OR, .55; CI, .31e.97; p < .05) for Table 3 Odds ratios obtained from binary logistic regression analysis of inconsistent contraceptive use
Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith Perceived Infertility Pseudo R2
Model 1 (Odds ratio [95% Confidence interval])
Model 2 (Odds ratio [95% Confidence interval])
1.51* .75 1.29 1.22 1.03
1.49* .76 1.27 1.23 1.02 1.18*
(1.03e2.20) (.43e1.31) (.87e1.90) (.75e1.98) (.50e2.13) .053
(1.02e2.18) (.43e1.32) (.86e1.88) (.75e1.99) (e.49e2.10) (1.01e1.38) .057
n ¼ 943. Data are limited to those who reported being sexually active within the year, were not pregnant or trying to become pregnant, were not sterile, and for whom protection status could be categorized. Both models include controls for all covariates. * p < .05.
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adherents of “other religious faiths” or non-Christian religious faiths compared with non-affiliates. Finally, we observed that infertility perceptions did not vary according to level of religious attendance. Figure 1 presents adjusted probabilities for infertility rationales, by religious affiliation. The key result of this analysis suggested that the infertility concerns of evangelical Protestant women were disproportionately linked to having had unprotected sex without becoming pregnant. In fact, the probability of attributing one’s perceived infertility to this particular rationale is notably higher for evangelical Protestant women (predicted probability [PP], .37; CI .27e.47) than for their other Protestant (PP, .13; CI, .04e.23) counterparts. Although few religious variations emerged with regard to medical reasons for perceived infertility, the probability of linking one’s infertility to having been told by a doctor were considerably higher for women of other religions or non-Christian religious faiths (PP, .50; CI, .28e.72) than for evangelical Protestant women (PP, .18; CI, .12e.25). The probabilities associated with linking one’s perceived infertility to the rationale of family background were comparable across religious groups. Finally, we examined the probability of attributing perceived infertility exclusively to having had unprotected sex without becoming pregnant. Similar to the results above, the probability of attributing one’s perceived infertility to unprotected sex (only) was higher for evangelical Protestant women (PP, .22; CI, .13e.30) than for their other Protestant (PP, .04; CI, .00e.09) or non-Christian faith (PP, .04; CI, .00e.11) counterparts. Table 3 displays the results of the logistic regression analysis predicting the odds of inconsistent contraceptive use. Because findings in Table 2 indicated that religious attendance was unrelated to infertility perceptions, we limited our analysis in Table 3 to religious affiliation. Model 1 indicates that the odds of inconsistent contraceptive use were elevated by 51% (OR, 1.51; CI, 1.03e2.20; p < .05) for evangelical Protestants compared with non-affiliates. No other affiliation differences in consistency of contraceptive use were statistically significant at conventional levels. Model 2 suggests that each unit increase in perceived infertility was associated with an 18% (OR, 1.18; CI, 1.01e1.38; p < .05) increase in the odds of inconsistent contraceptive use. However, the addition of perceived infertility in Model 2 only slightly reduced the coefficient for evangelical Protestant affiliation. Indeed, in the final model, the difference in the odds of inconsistent contraceptive use for evangelical Protestants compared with non-affiliates remained statistically significant (OR, 1.49; CI, 1.02e2.18; p < .05). Discussion Despite recent research linking perceived infertility with inconsistent contraceptive behavior and sexually transmitted infections [6,8e10], few studies have examined the social patterning of infertility perceptions. This research gap is important because understanding patterns of perceived infertility may aid public health officials in addressing the sexual health of atrisk groups. Toward this end, we used data from a nationally representative sample of unmarried young adults to explore associations among personal religiosity, perceived infertility, and inconsistent contraceptive use. Our results suggest that evangelical Protestants are more likely to perceive that they are infertile than their nonreligious counterparts. We also found that evangelical Protestant women
who perceived some degree of infertility were also more likely than their other Protestant or non-Christian faith counterparts to attribute their condition to having had unprotected sex without becoming pregnant. Finally, we observed that evangelical Protestants were more likely to exhibit inconsistent contraceptive use than non-affiliates, even after adjusting for infertility perceptions. Significant differences in infertility perceptions, infertility rationales, and inconsistent contraceptive use according to religious affiliation suggest the cultural importance of religious doctrines. Whereas all major religious traditions place some restrictions on physical or sexual relations, religious denominations vary in their emphasis on sexual purity and adherence to religious proscriptions. Evangelical Protestant leadership tends to stress a traditional view of dating, sexuality, and marriage, while emphasizing scriptural passages that valorize nuclear family arrangements [31,32]. Theoretically, unmarried young adults who adhere to principles such as these may have limited access to accurate information concerning sexual health [33]. Conservative religious communities also tend to transmit messages supporting abstinence, noting that pregnancy can result from a single act of intercourse. Scholars have argued that oversimplified messages such as these may inadvertently lead some individuals to assume that they are infertile if pregnancy does not occur after one or more acts of unprotected intercourse [7,8]. Our results are generally consistent with these ideas. Although several studies have examined the association between religious affiliation and inconsistent contraceptive use among adolescents [14,22], our study is among the few to examine religious variations in inconsistent contraceptive use among young adults. Evangelical Protestants are more likely to believe that they are infertile, and they are more likely to attribute their perceived infertility to having had unprotected sex without pregnancy; but greater infertility perceptions do not explain why evangelical Protestants are less likely to use contraceptives consistently. Taken together, these results raise yet another important question: Why are evangelical Protestants less likely to consistently use contraceptives? We are confident that the answer to this question lies in the precise measurement of specific evangelical Protestant beliefs concerning sexuality, fertility, and contraceptive use. In the process of addressing these issues, it is important for future research to confront the limitations of the current study. First and foremost, the cross-sectional nature of the data makes it impossible to establish any causal priorities. Our study has merely identified statistically significant associations among personal religiosity, perceived infertility, and inconsistent contraceptive use. Second, the data for this investigation were restricted to perceptions of infertility. Direct measures of biological infertility would clearly improve upon previous work. Finally, our measure of inconsistent contraceptive use (and associated unplanned pregnancy risk) was also limited because we were unable to categorize roughly 18% of the sample, owing to the inconsistent follow-up protocol for specific contraceptive methods. Although ancillary analyses showed no religious differences in the categorization of protection status, this limitation remains a major drawback of the current study. Despite these limitations, our study uniquely contributes to previous research by examining the link between personal religiosity and perceived infertility among young adults, a group that is characterized by especially high rates of unintended pregnancy. Whereas most studies of religion and health emphasize
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the salubrious role of personal religiosity, our results suggest that evangelical Protestants may be especially likely to hold misconceptions about their fertility. Because these misconceptions fail to explain higher rates of inconsistent contraception use among evangelical Protestants, additional research is needed to understand the principles and motives of this unique religious community. Funding Sources There were no sources of funding, either direct or indirect, for this study. References [1] Finer LB, Kost K. Unintended pregnancy rates at the state level. Perspect Sex Reprod Health 2011;43:78e87. [2] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38: 90e6. [3] Boonstra HD. The challenge in helping young adults better manage their reproductive lives. Guttmacher Pol Rev 2009;12:13e8. [4] Raine T, Minnis AM, Padian NS. Determinants of contraceptive method among young women at risk for unintended pregnancy and sexually transmitted infections. Contraception 2003;68:19e25. [5] Miller WB. Why some women fail to use their contraceptive method: A psychological investigation. Fam Plann Perspect 1986;18:27e32. [6] Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;25:1e160. [7] Polis CB, Zabin LS. Missed conceptions or misconceptions: Perceived infertility among unmarried young adults in the United States. Perspect Sex Reprod Health 2012;44:30. [8] Downs JS, Bruine de Bruin W, Murray PJ, Fischhoff B. When “it only takes once” fails: Perceived infertility predicts condom use and STI acquisition. J Pediatric Adolesc Gynecol 2004;17:224. [9] Kinsella EO, Crane LA, Ogden LG, Stevens-Simon C. Characteristics of adolescent women who stop using contraception after use at first sexual intercourse. J Pediatric Adolesc Gynecol 2007;20:73e81. [10] Higgins JA, Popkin RA, Santelli JS. Pregnancy ambivalence and contraceptive use among young adults in the United States. Perspect Sex Reprod Health 2012;44:236e43. [11] Smith C, Snell P. Souls in transition: the religious and spiritual lives of emerging adults. New York: Oxford Univ Press; 2009. [12] Regnerus MD. Forbidden fruit: sex and religion in the lives of American teenagers. New York: Oxford Univ Press; 2007.
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www.jahonline.org Original article
Religious Variations in Perceived Infertility and Inconsistent Contraceptive Use Among Unmarried Young Adults in the United States Amy M. Burdette, Ph.D. a, *, Stacy H. Haynes, Ph.D. b, Terrence D. Hill, Ph.D. c, and John P. Bartkowski, Ph.D. d a
Department of Sociology and Center for Demography & Population Health, Florida State University, Tallahassee, Florida Department of Sociology, Mississippi State University, Starkville, Mississippi c Department of Sociology, University of Utah, Salt Lake City, Utah d Department of Sociology, University of TexaseSan Antonio, San Antonio, Texas b
Article history: Received May 6, 2013; Accepted November 4, 2013 Keywords: Perceived infertility; Contraceptive use; Religion; Sexual health
A B S T R A C T
Purpose: In this paper, we examine associations among personal religiosity, perceived infertility, and inconsistent contraceptive use among unmarried young adults (ages 18e29). Methods: The data for this investigation came from the National Survey of Reproductive and Contraceptive Knowledge (n ¼ 1,695). We used multinomial logistic regression to model perceived infertility, adjusted probabilities to model rationales for perceived infertility, and binary logistic regression to model inconsistent contraceptive use. Results: Evangelical Protestants were more likely than non-affiliates to believe that they were infertile. Among the young women who indicated some likelihood of infertility, evangelical Protestants were also more likely than their other Protestant or noneChristian faith counterparts to believe that they were infertile because they had unprotected sex without becoming pregnant. Although evangelical Protestants were more likely to exhibit inconsistent contraception use than non-affiliates, we were unable to attribute any portion of this difference to infertility perceptions. Conclusions: Whereas most studies of religion and health emphasize the salubrious role of personal religiosity, our results suggest that evangelical Protestants may be especially likely to hold misconceptions about their fertility. Because these misconceptions fail to explain higher rates of inconsistent contraception use among evangelical Protestants, additional research is needed to understand the principles and motives of this unique religious community. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Because roughly half of all pregnancies in the United States (US) are unplanned, unintended pregnancy continues to be of critical importance to public health practitioners and policy makers [1]. Research suggests that most unintended pregnancies are the result of inconsistent use or nonuse of contraceptives, rather than contraceptive failure [2]. Despite decades of * Address correspondence to: Amy M. Burdette, Ph.D., Department of Sociology, Florida State University, 526 Bellamy Building, Tallahassee, FL 32306-2270. E-mail address: [email protected] (A.M. Burdette).
IMPLICATIONS AND CONTRIBUTION
Perceived infertility is associated with higher rates of contraceptive nonuse, contraceptive discontinuation, and sexually transmitted infections among adolescents and young adults. This study is among the first to examine religious variations in perceived infertility among unmarried young adults in the United States.
scholarship, public health practitioners have a limited understanding of the factors that undermine regular contraceptive use, including among young adults. This research gap is problematic because young women between the ages of 18 and 29 years have a higher rate of unintended pregnancy than any other age group [3]. This pattern clearly emphasizes the need for research focused on the sexual and reproductive health of young adults. One reason for inconsistent use or nonuse of contraceptives is that some women believe that they are unlikely or unable to
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conceive [4,5]. These perceptions are important because evidence among young women suggests that young adults may overestimate their actual infertility. For example, infertility estimates for married women in the US suggest that approximately 6% of those between the ages of 15 and 29 years are likely to be infertile [6]. To put this rate into perspective, a recent nationally representative study of unmarried young adults estimates that approximately 19% of unmarried women between the ages of 18 and 29 years believe that they are very likely to be infertile [7]. The significance of the discrepancy between reproductive perception and reproductive reality is compounded by studies showing that perceived infertility is associated with higher rates of contraceptive nonuse, contraceptive discontinuation, and sexually transmitted infections [8e10]. Although previous research has made significant contributions to our understanding of perceived infertility [7e9], scholars have only begun to consider the social patterning of these perceptions. Using data from the National Survey of Reproductive and Contraceptive Knowledge, a nationally representative probability sample of 1,800 unmarried men and women aged 18e29 years in the US (also known as the Fog Zone data set), Polis and Zabin [7] showed that rates of perceived infertility were higher among young adults who were Hispanic or had received public assistance in the past year (women only). Polis and Zabin also found that born-again, fundamentalist, or evangelical young men (not women) were more apt to believe that they were not likely to be infertile (compared with slightly likely) than young men with no religious affiliation. Because Polis and Zabin did not focus on religion, it is important to build on their foundational work. By concentrating on the link between religion and infertility perceptions, we may extend the growing body of literature concerning religion and reproductive health, while also augmenting public health research on the antecedents of perceived infertility. A great deal of research has demonstrated that religion exerts a powerful impact on the social attitudes and behavior of American youth and emerging adults, including their sexual views and practices [11e13]. Research on adolescent sexual behavior consistently shows that highly religious teens (e.g., those with high levels of religious commitment, religious attendance, religious salience, and prayer) initiate sexual activity later [14e16] and report fewer sexual partners [17,18] than do their less religious peers. Religious involvement may delay or reduce sexual activity by promoting sexual morality and embedding individuals within sexually conservative contexts [13], where informal social sanctions are regularly enforced against persons suspected of non-marital sexual activity [19]. Conversely, affiliating with a conservative religious group or movement has been associated with nonuse of contraception among adolescents [14,17,20], although this association is less consistent in the literature [21,22]. In their work on virginity pledging, a movement primarily sponsored by the Southern Baptist Church, Bearman and Brückner [20] explained that pledgers were less likely to be prepared for an experience that they had promised to avoid. The authors argued that being “contraceptively prepared” may actually be psychologically distressing for teens who had publicly vowed to abstain from sexual intercourse until marriage. Far fewer studies focus on the association between religion and sexual health among young adults; however, limited data suggest that indicators of religious involvement (e.g., religious attendance and religious salience) are also associated with delayed sexual activity and fewer partners in this population [23e25].
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In this article, we employ data from a nationally representative probability sample of unmarried US young adults to build on the work of Polis and Zabin [7] in three specific ways. First, to arrive at a better understanding of religious variations in perceived infertility, we focused exclusively on the role of religion and incorporated into our analyses multiple indicators of personal religiosity (i.e., religious affiliation and religious attendance). Second, to grasp more fully the principles and motives of unique religious communities, we explored religious variations in rationales for infertility perceptions. Finally, to elaborate on the association between personal religiosity and inconsistent contraceptive use, we considered the potential mediating influence of infertility perceptions. Methods Data To address these issues, we employed data from the National Survey of Reproductive and Contraceptive Knowledge, which was commissioned by the National Campaign to Prevent Teen and Unplanned Pregnancy and conducted by researchers at the Guttmacher Institute from October 2008 to April 2009. This study was designed to explore understudied factors such as knowledge, attitudes, and beliefs about contraception that influence the ability of young adults to use contraception effectively. A report detailing preliminary findings, as well as a more in-depth description of the study design and methods, was made available in 2010 [26]. The sample was selected so that the weighted results were representative of the US population of unmarried 18- to 29-year-olds. Of the 1,800 total respondents, about 10% were reached through randomdigit dialing of landline phone numbers, 50% through a sample of landline numbers with a high probability of containing unmarried residents in their twenties, and 40% by cell phone. AfricanAmerican and Hispanic young adults were oversampled. The field-tested questionnaire, which was offered in both English and Spanish, was approved by the Guttmacher Institute’s institutional review board [10]. We excluded from all analyses respondents who were currently pregnant or who were sterilized. Our final sample included 1,695 respondents. Measures Perceived infertility was measured via responses to the question, “Some people are unable to become pregnant, even if they want to. How likely do you think it is that you are infertile or will have difficulty getting [a woman] pregnant when you want to?” Responses included “not at all likely,” “slightly likely,” “quite likely,” and “extremely likely.” Following the work of Polis and Zabin [7], we combined the categories of “quite likely” and “extremely likely.” Preliminary analyses showed no religious differences between these two categories. Therefore, in the analyses conducted for this study, we modeled three categories: (1) not at all likely; (2) slightly likely; and (3) quite/extremely likely. Infertility rationales were assessed exclusively among women because men who perceived themselves as infertile did not receive these follow-up questions. Female respondents who perceived some degree of infertility were asked whether they believed they were infertile or might have had trouble getting pregnant because: (1) a doctor told them that they were infertile or might have difficulty getting pregnant; (2) other women in their family were infertile; and/or (3) they had sex without birth control and had never become pregnant. Although most fertility
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problems are not hereditary, some fertility-impairing conditions, such as premature ovarian insufficiency (i.e., the loss of all oocytes before age 40 years), have clear familial links [27]. Because respondents were able to select multiple rationales for perceived infertility, we created separate dummy variables for each fertility rationale (e.g., 1 ¼ unprotected sex; 0 ¼ some other rationale). Given the importance of the unprotected sex rationale, we created an additional dummy variable that isolated women who selected this rationale and no other rationale (¼ 1) versus women who selected any other rationale(s) (¼ 0). Inconsistent contraceptive use was assessed using a series of questions about the use of certain contraceptive methods (e.g., birth control pill, condoms, other hormonal methods). For example, respondents were first asked if they had ever used condoms as a method of birth control. Individuals who indicated they had used condoms were then asked about the consistency of condom use within the past 3 months. Specifically, respondents were asked whether they had used condoms “every time,” “most of the time,” “about half of the time,” “less than half of the time,” or “none of the time” when they had sexual intercourse over the reference period. Respondents using a longacting method (e.g., intrauterine device) or consistently using a short-term method (e.g., birth control pills, condoms) were coded as consistently using contraceptives. Respondents who were unprotected, used a less effective method (e.g., withdrawal), or inconsistently used a short-term method were coded as inconsistently using contraceptives, and therefore were at risk of an unplanned pregnancy (1 ¼ inconsistent contraceptive use). Unfortunately, inconsistent contraceptive use could not be assessed for roughly 18% of the sample because of a limited number of follow-up questions on consistency of contraceptive use for certain contraceptive methods. For example, female respondents who indicated they were using the birth control patch, a vaginal ring, or a diaphragm were not asked questions about consistency of use, even though these are not long-term methods of birth control. These individuals were removed from subsequent analyses. Neither of our focal variables (i.e., religious affiliation and religious attendance) was associated with an inability to categorize a respondent’s protection status. Personal religiosity was indicated by standard measures of religious affiliation and religious attendance. Religious affiliation was assessed by first asking respondents whether they had no religious affiliation or whether they identified as Protestant, Catholic, Jewish, or some other religion. Respondents who indicated that they were Protestant or a member of some other Christian group were asked if they self-identified as fundamentalist or evangelical, or considered themselves a born-again Christian (a common marker of evangelical Protestant identity) [28]. These items were combined, resulting in a series of six dummy variables: no religious affiliation (the reference category), evangelical Protestant (self-identified fundamentalist, evangelical, or born-again), other Protestant (Protestants not identifying as fundamentalist, evangelical, or born-again), Catholic, other Christian (e.g., those identifying as “just Christian”), and “other” religion (e.g., Buddhist, Jewish, Muslim). Religious attendance was assessed with the following question: “About how often do you attend religious services? Would you say once a week or more, one to three times per month, less than once a month, or never?” Coded responses for religious attendance range from 1 ¼ “never” to 4 ¼ “once a week or more.” Based on previous research, our multivariate regression models included controls for an extensive set of background
characteristics that were at least theoretically associated with religious involvement and perceived infertility [7,10]. These background characteristics included gender, age, race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, Hispanic, other race), education (i.e., less than high school, high school degree, some college, college or higher), region of residence (i.e., South, West, Northeast, Midwest), whether the respondent was currently in school, insurance status (i.e., Medicaid, private insurance, uninsured), whether the respondent ever had sexual intercourse, and whether the respondent had a child. Statistical procedures Our analyses proceeded in four steps. We began with the presentation of descriptive statistics (Table 1). We then modeled perceived infertility as a function of personal religiosity and background variables (Table 2). Because preliminary analyses failed to support the proportional odds assumption, we employed multinomial logistic regression to model perceived infertility in lieu of ordered logistic regression [29]. We
Table 1 Descriptive statistics (n ¼ 1,695) Mean/Proportion Dependent variables Perceived infertility Reason for perceived infertilitya Unprotected sex Medical reason Family reason Inconsistent contraceptive useb Individual-level variables Religious affiliation Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith No religious affiliation Religious attendance Male Age Race/ethnicity African-American Non-Hispanic white Hispanic Other race Level of education Less than high school High school Some college College Currently in school Region of residence South West Northeast Midwest Insurance status Medicaid Private insurance Uninsured Never had sexual intercourse Has children a
1.77
Standard deviation .87
.37 .23 .26 .48
.29 .08 .23 .11 .04 .25 2.48 .51 22.19
1.19 3.34
.19 .51 .22 .08 .13 .28 .43 .16 .48 .33 .24 .15 .26 .20 .57 .23 .18 .18
Among women who perceived some degree of infertility (n ¼ 496). Limited to those who reported being sexually active within the year, were not pregnant or trying to become pregnant, or were not sterilized, and for whom protection status could be categorized (n ¼ 943). b
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Table 2 Odds ratios obtained from multinomial logistic regression analysis of perceived infertility Not likely (n ¼ 784) Quite likelya (n ¼ 266) (Odds ratio [95% (Odds ratio [95% Confidence interval]) Confidence interval]) Male Age African-American Hispanic Other race Less than high school Some college College Currently in school South West Northeast Medicaid Private insurance Never had sexual intercourse Has children Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith Religious attendance Pseudo R2
1.98*** (1.57e2.49) 1.00 (.96e1.04) 1.18 (.86e1.62) 1.36 (.99e1.87) 1.32 (.85e2.05) .95 (.66e1.39) .93 (.69e1.24) .92 (.62e1.35) 1.20 (.93e1.54) 1.09 (.82e1.45) .69* (.51e.95) .76 (.54e1.08) .97 (.67e1.39) 1.01 (.76e1.34) .90 (.67e1.21) 2.79*** (1.96e3.98) 1.02 (.71e1.46) 1.01 (.64e1.58) .84 (.60e1.18) 1.35 (.90e2.02) .55* (.31e.97) 1.10 (.98e1.23)
.95 (.69e1.30) 1.00 (.95e1.06) 1.84** (1.22e2.79) 1.97** (1.30e2.98) 2.20** (1.24e3.89) .70 (.43e1.15) .70 (.48e1.03) .41** (.24e.72) .76 (.53e1.07) 1.47 (.98e2.21) 1.14 (.74e1.77) 1.57 (.98e2.50) 1.26 (.80e1.98) .88 (.60e1.29) .80 (.53e1.21) 1.00 (.62e1.60) 1.71* (1.05e2.77) 1.30 (.67e2.52) 1.46 (.93e2.31) 1.45 (.81e2.58) .62 (.27e1.45) .95 (.81e1.10) .055
n ¼ 1,695. Reference categories for predictors: non-Hispanic white, high school education, no insurance, Midwest, no religious affiliation. a Compared with slightly likely (n ¼ 649). * p < .05. ** p < .01. *** p < .001.
Figure 1. Adjusted probabilities for perceived infertility rationales, by religious affiliation.
individuals were not at risk of an unplanned pregnancy. Unlike our analysis in Table 2, we employed an ordinal specification of perceived infertility in Table 3. Our decision to treat perceived infertility as an ordinal predictor variable was supported by ancillary analyses showing a linear relationship between perceived infertility and protection status. All analyses were conducted using Stata SE (version 12; StataCorp, College Station, TX). Multivariate analyses employed the weight provided to account for complex survey design and to generate population-level estimates. To address the issue of missing data, we used regression-based imputation for all independent variables in our regression models. Results
acknowledge that other studies of perceived infertility stratified their analyses by gender [7] or focused exclusively on women [30]; however, subsequent analyses included women and men to maximize statistical power. Ancillary analyses showed no gender variations in the association between personal religiosity (affiliation and attendance) and perceived infertility. Next, we estimated adjusted probabilities for perceived infertility rationales by religious affiliation (Figure 1). This analysis is limited to women who reported at least some likelihood of infertility. The probabilities and confidence intervals presented in Figure 1 were generated from binary logistic regression models for each infertility rationale. We estimated probabilities for each rationale using binary logistic regression to clearly present the probability of a given classification relative to all other classifications (as opposed to another given classification). In Figure 1, point estimates for each religious group are presented graphically, with vertical lines depicting 95% confidence intervals around each probability estimate. These results provide estimates of the average respondent’s probability of selecting each rationale. Figure 1 does not show religious attendance because ancillary analyses indicated that this factor was not associated with infertility rationales among the women in our sample. Finally, we examined religious affiliation variations in inconsistent contraceptive use and the potential mediating influence of perceived infertility (Table 3). This analysis was limited to respondents who reported being sexually active within the past 12 months, because questions about contraception use were asked only of these individuals. In addition to excluding respondents who were not sexually active, we omitted individuals actively trying to become pregnant, because by definition, those
Table 1 displays descriptive statistics for all variables used in our analyses. Table 2 shows the results of the multinomial logistic regression analysis predicting the odds of being (1) “not likely” infertile and (2) “quite/extremely likely” infertile versus being (3) “slightly likely” infertile. This analysis reveals three important patterns. First, the odds of reporting that one is “quite likely” or “extremely likely” to be infertile were elevated by 71% (OR, 1.71; confidence interval [CI], 1.05e2.77; p < .05) for evangelical Protestants compared with respondents with no religious affiliation. Second, the odds of reporting that one is “not likely” to be infertile were reduced by 44% (OR, .55; CI, .31e.97; p < .05) for Table 3 Odds ratios obtained from binary logistic regression analysis of inconsistent contraceptive use
Evangelical Protestant Other Protestant Catholic Other Christian Other religious faith Perceived Infertility Pseudo R2
Model 1 (Odds ratio [95% Confidence interval])
Model 2 (Odds ratio [95% Confidence interval])
1.51* .75 1.29 1.22 1.03
1.49* .76 1.27 1.23 1.02 1.18*
(1.03e2.20) (.43e1.31) (.87e1.90) (.75e1.98) (.50e2.13) .053
(1.02e2.18) (.43e1.32) (.86e1.88) (.75e1.99) (e.49e2.10) (1.01e1.38) .057
n ¼ 943. Data are limited to those who reported being sexually active within the year, were not pregnant or trying to become pregnant, were not sterile, and for whom protection status could be categorized. Both models include controls for all covariates. * p < .05.
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adherents of “other religious faiths” or non-Christian religious faiths compared with non-affiliates. Finally, we observed that infertility perceptions did not vary according to level of religious attendance. Figure 1 presents adjusted probabilities for infertility rationales, by religious affiliation. The key result of this analysis suggested that the infertility concerns of evangelical Protestant women were disproportionately linked to having had unprotected sex without becoming pregnant. In fact, the probability of attributing one’s perceived infertility to this particular rationale is notably higher for evangelical Protestant women (predicted probability [PP], .37; CI .27e.47) than for their other Protestant (PP, .13; CI, .04e.23) counterparts. Although few religious variations emerged with regard to medical reasons for perceived infertility, the probability of linking one’s infertility to having been told by a doctor were considerably higher for women of other religions or non-Christian religious faiths (PP, .50; CI, .28e.72) than for evangelical Protestant women (PP, .18; CI, .12e.25). The probabilities associated with linking one’s perceived infertility to the rationale of family background were comparable across religious groups. Finally, we examined the probability of attributing perceived infertility exclusively to having had unprotected sex without becoming pregnant. Similar to the results above, the probability of attributing one’s perceived infertility to unprotected sex (only) was higher for evangelical Protestant women (PP, .22; CI, .13e.30) than for their other Protestant (PP, .04; CI, .00e.09) or non-Christian faith (PP, .04; CI, .00e.11) counterparts. Table 3 displays the results of the logistic regression analysis predicting the odds of inconsistent contraceptive use. Because findings in Table 2 indicated that religious attendance was unrelated to infertility perceptions, we limited our analysis in Table 3 to religious affiliation. Model 1 indicates that the odds of inconsistent contraceptive use were elevated by 51% (OR, 1.51; CI, 1.03e2.20; p < .05) for evangelical Protestants compared with non-affiliates. No other affiliation differences in consistency of contraceptive use were statistically significant at conventional levels. Model 2 suggests that each unit increase in perceived infertility was associated with an 18% (OR, 1.18; CI, 1.01e1.38; p < .05) increase in the odds of inconsistent contraceptive use. However, the addition of perceived infertility in Model 2 only slightly reduced the coefficient for evangelical Protestant affiliation. Indeed, in the final model, the difference in the odds of inconsistent contraceptive use for evangelical Protestants compared with non-affiliates remained statistically significant (OR, 1.49; CI, 1.02e2.18; p < .05). Discussion Despite recent research linking perceived infertility with inconsistent contraceptive behavior and sexually transmitted infections [6,8e10], few studies have examined the social patterning of infertility perceptions. This research gap is important because understanding patterns of perceived infertility may aid public health officials in addressing the sexual health of atrisk groups. Toward this end, we used data from a nationally representative sample of unmarried young adults to explore associations among personal religiosity, perceived infertility, and inconsistent contraceptive use. Our results suggest that evangelical Protestants are more likely to perceive that they are infertile than their nonreligious counterparts. We also found that evangelical Protestant women
who perceived some degree of infertility were also more likely than their other Protestant or non-Christian faith counterparts to attribute their condition to having had unprotected sex without becoming pregnant. Finally, we observed that evangelical Protestants were more likely to exhibit inconsistent contraceptive use than non-affiliates, even after adjusting for infertility perceptions. Significant differences in infertility perceptions, infertility rationales, and inconsistent contraceptive use according to religious affiliation suggest the cultural importance of religious doctrines. Whereas all major religious traditions place some restrictions on physical or sexual relations, religious denominations vary in their emphasis on sexual purity and adherence to religious proscriptions. Evangelical Protestant leadership tends to stress a traditional view of dating, sexuality, and marriage, while emphasizing scriptural passages that valorize nuclear family arrangements [31,32]. Theoretically, unmarried young adults who adhere to principles such as these may have limited access to accurate information concerning sexual health [33]. Conservative religious communities also tend to transmit messages supporting abstinence, noting that pregnancy can result from a single act of intercourse. Scholars have argued that oversimplified messages such as these may inadvertently lead some individuals to assume that they are infertile if pregnancy does not occur after one or more acts of unprotected intercourse [7,8]. Our results are generally consistent with these ideas. Although several studies have examined the association between religious affiliation and inconsistent contraceptive use among adolescents [14,22], our study is among the few to examine religious variations in inconsistent contraceptive use among young adults. Evangelical Protestants are more likely to believe that they are infertile, and they are more likely to attribute their perceived infertility to having had unprotected sex without pregnancy; but greater infertility perceptions do not explain why evangelical Protestants are less likely to use contraceptives consistently. Taken together, these results raise yet another important question: Why are evangelical Protestants less likely to consistently use contraceptives? We are confident that the answer to this question lies in the precise measurement of specific evangelical Protestant beliefs concerning sexuality, fertility, and contraceptive use. In the process of addressing these issues, it is important for future research to confront the limitations of the current study. First and foremost, the cross-sectional nature of the data makes it impossible to establish any causal priorities. Our study has merely identified statistically significant associations among personal religiosity, perceived infertility, and inconsistent contraceptive use. Second, the data for this investigation were restricted to perceptions of infertility. Direct measures of biological infertility would clearly improve upon previous work. Finally, our measure of inconsistent contraceptive use (and associated unplanned pregnancy risk) was also limited because we were unable to categorize roughly 18% of the sample, owing to the inconsistent follow-up protocol for specific contraceptive methods. Although ancillary analyses showed no religious differences in the categorization of protection status, this limitation remains a major drawback of the current study. Despite these limitations, our study uniquely contributes to previous research by examining the link between personal religiosity and perceived infertility among young adults, a group that is characterized by especially high rates of unintended pregnancy. Whereas most studies of religion and health emphasize
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the salubrious role of personal religiosity, our results suggest that evangelical Protestants may be especially likely to hold misconceptions about their fertility. Because these misconceptions fail to explain higher rates of inconsistent contraception use among evangelical Protestants, additional research is needed to understand the principles and motives of this unique religious community. Funding Sources There were no sources of funding, either direct or indirect, for this study. References [1] Finer LB, Kost K. Unintended pregnancy rates at the state level. Perspect Sex Reprod Health 2011;43:78e87. [2] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38: 90e6. [3] Boonstra HD. The challenge in helping young adults better manage their reproductive lives. Guttmacher Pol Rev 2009;12:13e8. [4] Raine T, Minnis AM, Padian NS. Determinants of contraceptive method among young women at risk for unintended pregnancy and sexually transmitted infections. Contraception 2003;68:19e25. [5] Miller WB. Why some women fail to use their contraceptive method: A psychological investigation. Fam Plann Perspect 1986;18:27e32. [6] Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;25:1e160. [7] Polis CB, Zabin LS. Missed conceptions or misconceptions: Perceived infertility among unmarried young adults in the United States. Perspect Sex Reprod Health 2012;44:30. [8] Downs JS, Bruine de Bruin W, Murray PJ, Fischhoff B. When “it only takes once” fails: Perceived infertility predicts condom use and STI acquisition. J Pediatric Adolesc Gynecol 2004;17:224. [9] Kinsella EO, Crane LA, Ogden LG, Stevens-Simon C. Characteristics of adolescent women who stop using contraception after use at first sexual intercourse. J Pediatric Adolesc Gynecol 2007;20:73e81. [10] Higgins JA, Popkin RA, Santelli JS. Pregnancy ambivalence and contraceptive use among young adults in the United States. Perspect Sex Reprod Health 2012;44:236e43. [11] Smith C, Snell P. Souls in transition: the religious and spiritual lives of emerging adults. New York: Oxford Univ Press; 2009. [12] Regnerus MD. Forbidden fruit: sex and religion in the lives of American teenagers. New York: Oxford Univ Press; 2007.
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