Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
The Role of Previous Contraception Education and Moral Judgment in Contraceptive Use Valerie Bader, CNM, MN, Patricia J. Kelly, PhD, RN, An-Lin Cheng, PhD, Jackie Witt, PhD, WHCNP
Introduction: The knowledge and attitudes that lead to nonuse of contraception are not well understood. The goal of this study was to determine whether an association exists between contraceptive use and specific knowledge and attitudinal factors. Methods: We conducted a secondary analysis of data from a nationally representative telephone survey of 897 unmarried women aged 18 to 29 years to examine the relationship between contraceptive use and comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, distrust toward the health care system or contraception, and moral attitude toward contraception. Results: Both ever having made a visit to a physician or clinic for women’s health care and ever having used any method of contraception to prevent pregnancy were significantly impacted by more comprehensive sex education and less likelihood to view contraception as morally wrong. Consistent with other research, we found no association between the desire to avoid pregnancy and contraceptive use. We found an association between health system distrust and contraceptive use, but health system distrust did not predict contraceptive use. Discussion: Our findings show that contraceptive use among a sample of young women is influenced by previous contraceptive education and moral attitudes toward contraception. Clinicians should be cognizant of these realities, which may need to be addressed in both clinical and nonclinical venues. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:447–451 Keywords: attitude to health, contraception, morals, pregnancy, pregnancy unplanned, pregnancy unwanted, professional–patient relations, sex education, unplanned, unwanted
INTRODUCTION
Address correspondence to Valerie Bader, CNM, MN, S 424 Sinclair School of Nursing, University of Missouri, Columbia, MO 65211. E-mail: [email protected]
Unintended pregnancy occurs when couples do not use contraception consistently and correctly or due to technical failure of a contraceptive method. Reasons for contraceptive nonuse are not well understood. Factors that may contribute include comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, health system distrust, and moral judgment toward contraception. Many clinicians, health educators, and lay people assume that unintended pregnancy can be reduced through comprehensive sex education. Comprehensive sex education is targeted toward adolescents and usually consists of information about healthy relationships, abstinence from sexual intercourse, and effective use of contraception.6 Current evidence suggests that comprehensive sex education reduces unintended pregnancy among adolescents, especially if implemented along with policies that provide convenient access to contraception.6, 7 How comprehensive sex education in adolescence affects a woman’s reproductive experiences in adulthood remains unexplored. Pregnancy intention and contraceptive use do not always correspond. In Jones et al’s study of more than 10,000 women seeking abortion, 46% reported not using any form of contraception in the month of conception.8 In The Fog Zone study, 20% of sexually active participants aged 18 to 29 years (N = 1800) reported not using contraception despite not wanting to become pregnant.9 In a study of 311 US women who presented to health departments for a pregnancy test and reported that their pregnancy would be unintended, 46% of participants used contraception inconsistently, if at all.10 It appears as though the desire to avoid pregnancy does not always cause women to use contraception effectively, although this paradox is not well understood.
1526-9523/09/$36.00 doi:10.1111/jmwh.12149
c 2014 by the American College of Nurse-Midwives
Family planning represents one of the most important public health accomplishments of the 20th century.1 The ability of individuals to determine when they will have children and how many children they will have has improved the health of infants, children, and women. Yet more work remains to be done: The latest demographic data indicate that 49% of pregnancies in the United States are unintended.1, 2 During 2006, approximately 5% of women of reproductive age (15-44 years) experienced an unintended pregnancy.2 The cost to federal and state governments of births from unintended pregnancies in the United States was estimated at $11.1 billion in 2006.3 Poor health and lower educational and economic achievement for women and their children occur more frequently during and following an unintended pregnancy.2, 4 Substantial evidence documents that racial and income disparities exist among US women who experience an unintended pregnancy. African American women have higher rates (67%) of unintended pregnancy than both Hispanic (53%) and white (40%) women.2 These racial disparities are even more pronounced among low-income women: Fifty percent more Hispanic women with incomes at or below the federal poverty level experience unintended pregnancy compared with white women with the same income level.5
447
✦ Contraceptive nonuse is common, even among women who say they do not want to become pregnant. ✦ More comprehensive sex education and viewing contraception as morally acceptable increases a woman’s likelihood of
seeking health care and using contraception. ✦ More research is needed to determine factors that contribute to women’s ongoing, effective use of contraception.
Contraceptive use requires an understanding of fertility. The Fog Zone participants inaccurately judged the risk of becoming pregnant with each act of unprotected intercourse. More than 22% of participants assume that pregnancy will occur after just one act of unprotected intercourse, but the actual risk is between 3% and 5%.9 Individuals who believe that the chance of becoming pregnant is high with unprotected intercourse, but who have experienced unprotected intercourse and have not gotten pregnant, may incorrectly conclude that they are infertile. Among the more than 10,000 women that Jones et al surveyed, 33% reported that they were not using contraception because they thought they were at low risk for pregnancy, but only 6% reported believing that they or their partner were sterile.8 Distrust of the health care system is another potential contributor to the nonuse of contraception that has been minimally studied. If a woman distrusts the values or competency of the health care system, she may dismiss the advice and reassurance offered by health care providers. Although this hypothesis has not been studied in relation to contraceptive behavior, a study of 5268 women in Pennsylvania found that distrust of the health care system was associated with a lower rate of participation in breast and cervical cancer screening.11 The hypothesis that health system distrust affects use of the health care system has also been examined among people with HIV. In a study of 611 people who were HIV-positive, 10% of participants did not trust their physicians or clinics to take care of them, and 50% believed that information about HIV/AIDs was being withheld from them.12 Participants who scored higher in health care system trust reported better health, more appropriate clinic visits, fewer emergency room visits, and better adherence to antiretroviral medications. Moral uncertainty surrounding contraception has existed for centuries.13 Multiple studies on the moral beliefs of health care professionals indicate that moral judgment impacts prescribing practices and provision of contraception, especially emergency contraception.13, 14 But whether contraceptive use represents an untenable moral situation for sexually active women has not been fully explored in the scientific literature. The Fog Zone survey found that very few respondents viewed contraception as morally wrong.8 The knowledge and attitudes that lead so many women to not use contraception remain unknown to researchers and clinicians. With a better understanding of the components of contraceptive decision making, interventions to improve acceptance and correct use of contraceptives can be developed and tested. The purpose of this study is to determine whether an association exists between contraceptive use and the following specific factors: comprehensive sex 448
education, attitude toward pregnancy prevention, perceived infertility, health system distrust, and moral judgment toward contraception. METHODS
We conducted a secondary analysis of The Fog Zone dataset. Briefly, The Fog Zone survey sought to describe the following: participants’ knowledge, attitudes, and expectations of contraceptives; their perceptions of the relative benefits and risks associated with a variety of contraceptives; whether their perception of benefits and risks influences contraceptive use; and whether misperceptions or myths may be a significant barrier to preventing unintended pregnancy. The telephone survey was administered to a nationally representative sample of 1800 unmarried men and women aged 18 to 29 years; African American and Hispanic participants were oversampled in order to conduct a subgroup analysis of race and ethnicity. Data collection for The Fog Zone is described in detail elsewhere.8 Our secondary analysis includes only the female participants because women may make contraceptive decisions without their male partners’ knowledge.15 Because this analysis derives from de-identified data, the University of Missouri–Kansas City institutional review board did not require a review. We conducted a multivariate analysis to determine whether contraceptive use was influenced by 5 factors: comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, distrust of the health care system, and moral attitude toward contraception. Three questions were used to measure contraceptive use: 1) Have you ever made a visit to a physician or clinic for women’s health care? 2) Have you ever used any method to prevent pregnancy? and 3) In the past one month, have you used any method to prevent pregnancy? All 3 questions have bivariate yes/no answers. To measure participants’ exposure to comprehensive sex education, they scored the amount of their sex education by answering from 0 to 5, with 5 reflecting participation in sex education that covered all 5 of the following topics: the importance of using birth control if you have sex, a demonstration on how to use a condom, how to say “no” to sex, the importance of waiting until marriage to have sex, and the availability of many types of birth control methods. Participants’ attitude toward pregnancy prevention was measured with the following item, “Thinking about your life right now, how important is it to you to avoid becoming pregnant?” Possible responses ranged from one to 4, with one equaling very important and 4 equaling not at all important. Perceived infertility was measured with the item, “How likely do you think it is that you are infertile or will have difficulty getting Volume 59, No. 4, July/August 2014
pregnant when you want to?” The answers ranged from one to 4, with one equaling not at all likely and 4 equaling extremely likely. Distrust of the health care system or contraception was measured with 4 items: “The government makes certain that birth control methods are safe before they come onto the market”; “The government and public health institutions use poor and minority people as guinea pigs to try out new birth control methods”; “The government is trying to limit blacks and other minority populations by encouraging the use of birth control”; and “Drug companies don’t care if birth control is safe, they just want people to use it so that can make money.” Possible responses ranged from one to 5, with one equaling strongly agree and 5 equaling strongly disagree. The second, third, and fourth of the 4 items related to distrust of the health care system or contraception were reverse scored before totaling the score on this subscale. Possible total scores were from 4 to 20, with higher scores equaling more suspicion of family planning services. Moral attitude toward contraception was measured with the item, “Using birth control is morally wrong.” Possible responses ranged from one to 5, with one equaling strongly agree and 5 equaling strongly disagree. Bivariate association between the 5 predictor variables and contraceptive use were determined by independent samples t tests. Separate logistic regression models for each question that measured the outcome variable were conducted with predictors achieving bivariate significance. Model selection procedure was applied to the logistic regression and only included retained predictors that reached statistical significance. Significant covariates such as age, level of education, ethnicity, and number of topics covered in sex education classes were considered and adjusted in the model. IBM SPSS V. 19 (Armonk, NY) was used to conduct the statistical analysis. Statistical significance was set at .05. RESULTS
Demographic characteristics of the 897 participants are presented in Table 1. Women were most commonly aged 20 to 24 years (45%), white (48%), and had attended some college (44%). One-quarter had never received sex education. Most of the women had visited a clinic for women’s health care (84%), used any contraceptive method to prevent pregnancy (82%), and used a method to prevent pregnancy in the past month (70%). The bivariate analysis (Table 2) showed that ever having made a visit to a physician or clinic for women’s health care was significantly associated with having more comprehensive sex education and being less likely to view contraception as morally wrong. Having ever used any method of contraception to prevent pregnancy was associated with having more comprehensive sex education, being less likely to view using contraception as morally wrong, and having less distrust of the health care system or contraception. None of the predictor variables were significantly associated with use of contraception in the last month. The logistic regression analyses (Table 3) showed that the significant predictors for not ever visiting a physician or clinic for women’s health care were the attitude that contraception is morally wrong and less comprehensive sex education. For each unit increase in the belief that contraception Journal of Midwifery & Women’s Health r www.jmwh.org
Table 1. Demographic Characteristics of Women in a Nationally Representative Telephone Survey (N = 897)
Participant Characteristics
n ()
Age, y 18-19
231 (25.8)
20-24
403 (44.9)
25-29
263 (29.3)
Race/Ethnicity White
432 (48.2)
African American
220 (24.5)
Hispanic
186 (20.7)
Asian/other
59 (6.6)
Education ⬍High school graduate
112 (12.5)
High school graduate or GED
218 (24.3)
Some college
397 (44.3)
College graduate
123 (13.7)
Graduate or professional degree
39 (4.3)
Vocational or technical training
8 (0.9)
Number of topics covered in sex education class 0 (no sex education)
211 (23.5)
1
44 (4.9)
2
95 (10.6)
3
151 (16.8)
4
192 (21.4)
5
204 (22.7)
Ever visited clinic for women’s health carea
753 (84.0)
Ever used any contraceptive method to prevent
729 (81.5)
pregnancyb In past month, used any contraceptive method to
511 (70.1)
prevent pregnancyc Abbreviation: GED, general educational development (for high school equivalency). a Data available for 896 participants. b Data available for 894 participants. c Data available for 729 participants.
is not morally wrong, young adults were about 0.66 times as likely to not visit a physician or clinic. Restated, young adults who judged contraception as moral were more likely to visit a physician or clinic. For each unit increase in the amount of comprehensive sex education, young adults were about 12% more likely to visit a physician or clinic. Significant predictors for never having used any contraceptive method to prevent pregnancy were less comprehensive sex education and the attitude that contraception is morally wrong. For each one unit increase in the amount of comprehensive sex education, young women were about 16% more likely to have used any method to prevent pregnancy. For each one unit increase in the score of attitude that contraception is not morally wrong, young women were about 0.66 times as likely to have never used any method to prevent pregnancy. All models were statistically significant (P ⬍ .001) and demonstrated adequate model fit using Hosmer–Lemeshow 449
Table 2. Bivariate Association Between Predictor Variables and Contraceptive Use
Have Ever Visited a
Have Ever Used
Used Contraception
Physician or Clinic
Contraception to
to Prevent Pregnancy
for Women’s Health Care
Prevent Pregnancy
in the Last Month
Mean
Mean
Mean
Predictor
Yes
No
P
Yes
No
P
Yes
No
P
Comprehensive sex educationa
2.85
2.31
.002
2.88
2.21
⬍.001
2.90
2.85
.74
Attitude toward pregnancy preventionb
1.35
1.26
.16
1.33
1.35
.81
1.30
1.42
.09
Perceived infertilityb
1.82
1.88
.44
1.82
1.89
.33
1.81
1.85
.58
8.93
9.58
.05
8.92
9.58
.04
8.79
9.26
.12
4.61
4.01
⬍.001
4.62
4.03
⬍.001
4.66
4.53
.10
Distrust of the health care system or contraception Moral attitude toward contraceptionb
c
a Scale 0-5. b Scale 1-4. c
Scale 4-20.
Table 3. Final Logistic Regression Model for Predictors of Contraceptive Use
Have Visited Physician or Clinic
Have Ever Used
for Women’s
Contraception to
Health Care
Prevent Pregnancy
Predictor
OR ( CI)a
OR ( CI)b
Comprehensive
0.88 (0.80-0.97)
0.84 (0.77-0.92)
0.66 (0.58-0.76)
0.66 (0.58-0.76)
sex education Moral attitude toward contraception Abbreviations: CI, confidence interval; OR, odds ratio. a Event modeled in the logistic regression is not visited physician or clinic for women’s health care. b Event modeled in the logistic regression is have ever used contraception to prevent pregnancy.
test (P ⬎ .05). No significant covariate was found for any of the models. DISCUSSION
In our analysis, comprehensive sex education predicted ever using contraception but did not predict contraceptive use in the previous month. Abstinence-only education may have left young people with a distorted view of the risks of contraception and without an accurate view of the benefits of the correct use of contraception.17 The development of a thorough understanding of what comprehensive sex education should include, coupled with an effective delivery method, may lead to sex education that affects ongoing contraceptive use. However, effective comprehensive sex education currently is not widely available. The inability of comprehensive sex education to predict using contraception in the previous month to prevent pregnancy is a finding that deserves attention in both the clinical and community settings. In order to be effective, contraceptive use must be ongoing, especially if sexual encounters are ongoing. Comprehensive sex education must include instruction on how to maintain contraceptive use, as well as instruction on how to begin contraceptive use. 450
Consistent with other studies, we found that a lower desire for pregnancy was not associated with an increased use of contraception. Further research is needed to fully explore the antecedents to this paradoxical attitude. Some authors have suggested that intimate partner violence is associated with an inconsistent use of contraception10 ; others have shown an association between childhood adversity and repeat induced abortion.16 In addition, we found that a perception of infertility does not predict the use of contraception. Since more pragmatic explanations for contraceptive behavior fail to predict contraceptive use, it is important to understand the influence of health system distrust and moral concerns on contraceptive behavior. Even though distrust of the health care system was associated with not using contraception, our regression analysis did not show that health care system distrust predicted having used contraception or visiting a women’s health care physician or clinic. However, health care system distrust is emerging in other health care settings as a significant predictor of perceived well-being and appropriate health care system use.11, 12 Additional questions regarding health system distrust should be included in future surveys on contraceptive use and unintended pregnancy. Our findings indicated that among a lay population of young women, one’s moral attitude toward contraception is a significant predictor for both visiting a physician or clinic for women’s health care as well as for ever using any method of contraception to prevent pregnancy. The moral judgments of the public are poorly understood, and we were unable to identify published research on the moral judgments of the public toward contraception. Further research that clarifies the moral judgments that people have toward contraception will help clinical practitioners and education program planners address women’s moral concerns. Meanwhile, clinicians can ask men and women seeking family planning advice about their moral and ethical beliefs surrounding contraception. Doing so allows clinicians to help clients select a contraception that respects their client’s values. As a secondary analysis of data obtained by telephone interview, our study contains limitations that are similar to all cross-sectional research. Survey questions can only elicit superficial descriptive information from respondents, Volume 59, No. 4, July/August 2014
leaving questions that illuminate the rationale for their responses unanswered. For example, in our findings some participants agreed that using contraception was morally wrong, but our results do not describe how participants arrived at this conclusion or what exactly was immoral about contraceptive use. Likewise, although our findings support other research showing that a lower desire for pregnancy is not associated with contraceptive use, we offer no new information on why this paradox exists. In addition, our study has only found minor contributing attitudes to contraceptive use. Moral judgment and comprehensive sex education explained less than 10% of the variance for ever having visited a physician or clinic for women’s health care and ever using contraception. Finally, although this survey assessed whether or not women have visited a physician or clinic for women’s health care, more detailed information about the subject of that visit, including whether or not contraception was addressed, is not available. Preventing unintended pregnancies provides a broad range of societal benefits. Because of provisions in the Affordable Care Act, more young adults than ever in the United States will have access to contraception and have the ability to plan their families. Health care providers and health educators must be ready to provide contraception and sex education that is sensitive to moral concerns and values as well as accurate. Sex education must instruct women on initiating and continuing contraceptive use. Because there are few other efforts that lead to a healthier future than family planning, continued examination of factors that influence contraceptive use is necessary.
AUTHORS
Valerie Bader, CNM, MN, is a doctoral student at the University of Missouri, Kansas City, School of Nursing, and a clinical instructor at the University of Missouri, Sinclair School of Nursing in Columbia, MO. Patricia J. Kelly, PhD, RN, is Professor and Associate Dean for Research at the University of Missouri–Kansas City, School of Nursing. Her research focuses on women’s health issues in community settings. An-Lin Cheng, PhD, is Associate Professor at the University of Missouri–Kansas City, School of Nursing. She develops analytic strategies for a variety of research designs. Jacki Witt, PhD, WHCNP, is Associate Clinical Professor at the University of Missouri–Kansas City, School of Nursing. She is the Director of the Department of Health and Human Services’ funded Clinical Training Center for Family Planning.
Journal of Midwifery & Women’s Health r www.jmwh.org
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. REFERENCES 1.Centers for Disease Control. Achievements in public health, 1900– 1999: Family planning. MMWR. 1999;48(47):1073-1080. http://www. cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm Accessed May 10, 2013. 2.Finer LB, Zolna MR. Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception. 2011;84(5):478485. 3.Sonfield A, Kost K, Benson R, et al. The public costs of births resulting from unintended pregnancies: National and state level estimates. Perspect Sex Reprod Health. 2011;2(43):94-102. 4.Cheng D, Schwarz EB, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009;79(3):194-198. 5.Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96. 6.Brindis CD, Geierstanger SP, Faxio A. The role of policy advocacy in assuring comprehensive family life education in California. Health Education & Behavior. 2010;36(6):1095-1108. 7.Levels M, Need A, Nieuwenhuis R, Sluiter R, Ultee W. Unintended pregnancy and induced abortion in the Netherlands 1954–2002. European Sociological Review. 2012;28(3):301-318. 8.Jones RK, Darroch JE, Henshaw SK. Contraceptive use among US women having abortions in 2000–2001. Perspect Sex Reprod Health. 2002;34(6):294-303. 9.Kaye K, Suellentrop K, Sloup C. The Fog Zone: How Misperceptions, Magical Thinking and Ambivalence Put Young Adults at Risk for Unplanned Pregnancy. 2009. The National Campaign to Prevent Teen and Unplanned Pregnancy: Washington, DC. http://www. thenationalcampaign.org/fogzone/ Accessed May 10, 2013. 10.Sable MR, Libbus MK. Pregnancy intention and pregnancy happiness: Are they different? Matern Child Health J. 2000;4(3):191195. 11.Yang TC, Matthews SA, Hillemeier MM. Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania. Am J Public Health. 2011;101(7):1297. 12.Whetten K, Leserman J, Whetten R, et al. Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health. 2006;96(4):716-721. 13.Lawrence RE, Rasinski KA, Yoon JD, et al. Obstetrician-gynecologists’ views on contraception and natural family planning: A national survey. Am J Obstet Gynecol. 2011;204:124.e1-124.e7. 14.Mackin ML, Clark K. Emergency contraception in Iowa pharmacies before and after over-the-counter approval. Public Health Nurs. 2011;28(4):317-324. 15.Melchionne K. Eight indicators of unilateral pregnancy. Am J Mens Health. 2010;4(4):323-333. 16.Bleil ME, Adler NE, Pasch LA, et al. Adverse childhood experiences and repeat induced abortion. Am J Obstet Gynecol. 2011;204(2):122.e1-122.e6. 17.Kirby D. The impact of programs to increase contraceptive use among adult women: A review of experimental and quasi-experimental studies. Perspect Sex Reprod Health. 2009;40(1):34-41.
451
www.jmwh.org
Original Research
The Role of Previous Contraception Education and Moral Judgment in Contraceptive Use Valerie Bader, CNM, MN, Patricia J. Kelly, PhD, RN, An-Lin Cheng, PhD, Jackie Witt, PhD, WHCNP
Introduction: The knowledge and attitudes that lead to nonuse of contraception are not well understood. The goal of this study was to determine whether an association exists between contraceptive use and specific knowledge and attitudinal factors. Methods: We conducted a secondary analysis of data from a nationally representative telephone survey of 897 unmarried women aged 18 to 29 years to examine the relationship between contraceptive use and comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, distrust toward the health care system or contraception, and moral attitude toward contraception. Results: Both ever having made a visit to a physician or clinic for women’s health care and ever having used any method of contraception to prevent pregnancy were significantly impacted by more comprehensive sex education and less likelihood to view contraception as morally wrong. Consistent with other research, we found no association between the desire to avoid pregnancy and contraceptive use. We found an association between health system distrust and contraceptive use, but health system distrust did not predict contraceptive use. Discussion: Our findings show that contraceptive use among a sample of young women is influenced by previous contraceptive education and moral attitudes toward contraception. Clinicians should be cognizant of these realities, which may need to be addressed in both clinical and nonclinical venues. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:447–451 Keywords: attitude to health, contraception, morals, pregnancy, pregnancy unplanned, pregnancy unwanted, professional–patient relations, sex education, unplanned, unwanted
INTRODUCTION
Address correspondence to Valerie Bader, CNM, MN, S 424 Sinclair School of Nursing, University of Missouri, Columbia, MO 65211. E-mail: [email protected]
Unintended pregnancy occurs when couples do not use contraception consistently and correctly or due to technical failure of a contraceptive method. Reasons for contraceptive nonuse are not well understood. Factors that may contribute include comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, health system distrust, and moral judgment toward contraception. Many clinicians, health educators, and lay people assume that unintended pregnancy can be reduced through comprehensive sex education. Comprehensive sex education is targeted toward adolescents and usually consists of information about healthy relationships, abstinence from sexual intercourse, and effective use of contraception.6 Current evidence suggests that comprehensive sex education reduces unintended pregnancy among adolescents, especially if implemented along with policies that provide convenient access to contraception.6, 7 How comprehensive sex education in adolescence affects a woman’s reproductive experiences in adulthood remains unexplored. Pregnancy intention and contraceptive use do not always correspond. In Jones et al’s study of more than 10,000 women seeking abortion, 46% reported not using any form of contraception in the month of conception.8 In The Fog Zone study, 20% of sexually active participants aged 18 to 29 years (N = 1800) reported not using contraception despite not wanting to become pregnant.9 In a study of 311 US women who presented to health departments for a pregnancy test and reported that their pregnancy would be unintended, 46% of participants used contraception inconsistently, if at all.10 It appears as though the desire to avoid pregnancy does not always cause women to use contraception effectively, although this paradox is not well understood.
1526-9523/09/$36.00 doi:10.1111/jmwh.12149
c 2014 by the American College of Nurse-Midwives
Family planning represents one of the most important public health accomplishments of the 20th century.1 The ability of individuals to determine when they will have children and how many children they will have has improved the health of infants, children, and women. Yet more work remains to be done: The latest demographic data indicate that 49% of pregnancies in the United States are unintended.1, 2 During 2006, approximately 5% of women of reproductive age (15-44 years) experienced an unintended pregnancy.2 The cost to federal and state governments of births from unintended pregnancies in the United States was estimated at $11.1 billion in 2006.3 Poor health and lower educational and economic achievement for women and their children occur more frequently during and following an unintended pregnancy.2, 4 Substantial evidence documents that racial and income disparities exist among US women who experience an unintended pregnancy. African American women have higher rates (67%) of unintended pregnancy than both Hispanic (53%) and white (40%) women.2 These racial disparities are even more pronounced among low-income women: Fifty percent more Hispanic women with incomes at or below the federal poverty level experience unintended pregnancy compared with white women with the same income level.5
447
✦ Contraceptive nonuse is common, even among women who say they do not want to become pregnant. ✦ More comprehensive sex education and viewing contraception as morally acceptable increases a woman’s likelihood of
seeking health care and using contraception. ✦ More research is needed to determine factors that contribute to women’s ongoing, effective use of contraception.
Contraceptive use requires an understanding of fertility. The Fog Zone participants inaccurately judged the risk of becoming pregnant with each act of unprotected intercourse. More than 22% of participants assume that pregnancy will occur after just one act of unprotected intercourse, but the actual risk is between 3% and 5%.9 Individuals who believe that the chance of becoming pregnant is high with unprotected intercourse, but who have experienced unprotected intercourse and have not gotten pregnant, may incorrectly conclude that they are infertile. Among the more than 10,000 women that Jones et al surveyed, 33% reported that they were not using contraception because they thought they were at low risk for pregnancy, but only 6% reported believing that they or their partner were sterile.8 Distrust of the health care system is another potential contributor to the nonuse of contraception that has been minimally studied. If a woman distrusts the values or competency of the health care system, she may dismiss the advice and reassurance offered by health care providers. Although this hypothesis has not been studied in relation to contraceptive behavior, a study of 5268 women in Pennsylvania found that distrust of the health care system was associated with a lower rate of participation in breast and cervical cancer screening.11 The hypothesis that health system distrust affects use of the health care system has also been examined among people with HIV. In a study of 611 people who were HIV-positive, 10% of participants did not trust their physicians or clinics to take care of them, and 50% believed that information about HIV/AIDs was being withheld from them.12 Participants who scored higher in health care system trust reported better health, more appropriate clinic visits, fewer emergency room visits, and better adherence to antiretroviral medications. Moral uncertainty surrounding contraception has existed for centuries.13 Multiple studies on the moral beliefs of health care professionals indicate that moral judgment impacts prescribing practices and provision of contraception, especially emergency contraception.13, 14 But whether contraceptive use represents an untenable moral situation for sexually active women has not been fully explored in the scientific literature. The Fog Zone survey found that very few respondents viewed contraception as morally wrong.8 The knowledge and attitudes that lead so many women to not use contraception remain unknown to researchers and clinicians. With a better understanding of the components of contraceptive decision making, interventions to improve acceptance and correct use of contraceptives can be developed and tested. The purpose of this study is to determine whether an association exists between contraceptive use and the following specific factors: comprehensive sex 448
education, attitude toward pregnancy prevention, perceived infertility, health system distrust, and moral judgment toward contraception. METHODS
We conducted a secondary analysis of The Fog Zone dataset. Briefly, The Fog Zone survey sought to describe the following: participants’ knowledge, attitudes, and expectations of contraceptives; their perceptions of the relative benefits and risks associated with a variety of contraceptives; whether their perception of benefits and risks influences contraceptive use; and whether misperceptions or myths may be a significant barrier to preventing unintended pregnancy. The telephone survey was administered to a nationally representative sample of 1800 unmarried men and women aged 18 to 29 years; African American and Hispanic participants were oversampled in order to conduct a subgroup analysis of race and ethnicity. Data collection for The Fog Zone is described in detail elsewhere.8 Our secondary analysis includes only the female participants because women may make contraceptive decisions without their male partners’ knowledge.15 Because this analysis derives from de-identified data, the University of Missouri–Kansas City institutional review board did not require a review. We conducted a multivariate analysis to determine whether contraceptive use was influenced by 5 factors: comprehensive sex education, attitude toward pregnancy prevention, perceived infertility, distrust of the health care system, and moral attitude toward contraception. Three questions were used to measure contraceptive use: 1) Have you ever made a visit to a physician or clinic for women’s health care? 2) Have you ever used any method to prevent pregnancy? and 3) In the past one month, have you used any method to prevent pregnancy? All 3 questions have bivariate yes/no answers. To measure participants’ exposure to comprehensive sex education, they scored the amount of their sex education by answering from 0 to 5, with 5 reflecting participation in sex education that covered all 5 of the following topics: the importance of using birth control if you have sex, a demonstration on how to use a condom, how to say “no” to sex, the importance of waiting until marriage to have sex, and the availability of many types of birth control methods. Participants’ attitude toward pregnancy prevention was measured with the following item, “Thinking about your life right now, how important is it to you to avoid becoming pregnant?” Possible responses ranged from one to 4, with one equaling very important and 4 equaling not at all important. Perceived infertility was measured with the item, “How likely do you think it is that you are infertile or will have difficulty getting Volume 59, No. 4, July/August 2014
pregnant when you want to?” The answers ranged from one to 4, with one equaling not at all likely and 4 equaling extremely likely. Distrust of the health care system or contraception was measured with 4 items: “The government makes certain that birth control methods are safe before they come onto the market”; “The government and public health institutions use poor and minority people as guinea pigs to try out new birth control methods”; “The government is trying to limit blacks and other minority populations by encouraging the use of birth control”; and “Drug companies don’t care if birth control is safe, they just want people to use it so that can make money.” Possible responses ranged from one to 5, with one equaling strongly agree and 5 equaling strongly disagree. The second, third, and fourth of the 4 items related to distrust of the health care system or contraception were reverse scored before totaling the score on this subscale. Possible total scores were from 4 to 20, with higher scores equaling more suspicion of family planning services. Moral attitude toward contraception was measured with the item, “Using birth control is morally wrong.” Possible responses ranged from one to 5, with one equaling strongly agree and 5 equaling strongly disagree. Bivariate association between the 5 predictor variables and contraceptive use were determined by independent samples t tests. Separate logistic regression models for each question that measured the outcome variable were conducted with predictors achieving bivariate significance. Model selection procedure was applied to the logistic regression and only included retained predictors that reached statistical significance. Significant covariates such as age, level of education, ethnicity, and number of topics covered in sex education classes were considered and adjusted in the model. IBM SPSS V. 19 (Armonk, NY) was used to conduct the statistical analysis. Statistical significance was set at .05. RESULTS
Demographic characteristics of the 897 participants are presented in Table 1. Women were most commonly aged 20 to 24 years (45%), white (48%), and had attended some college (44%). One-quarter had never received sex education. Most of the women had visited a clinic for women’s health care (84%), used any contraceptive method to prevent pregnancy (82%), and used a method to prevent pregnancy in the past month (70%). The bivariate analysis (Table 2) showed that ever having made a visit to a physician or clinic for women’s health care was significantly associated with having more comprehensive sex education and being less likely to view contraception as morally wrong. Having ever used any method of contraception to prevent pregnancy was associated with having more comprehensive sex education, being less likely to view using contraception as morally wrong, and having less distrust of the health care system or contraception. None of the predictor variables were significantly associated with use of contraception in the last month. The logistic regression analyses (Table 3) showed that the significant predictors for not ever visiting a physician or clinic for women’s health care were the attitude that contraception is morally wrong and less comprehensive sex education. For each unit increase in the belief that contraception Journal of Midwifery & Women’s Health r www.jmwh.org
Table 1. Demographic Characteristics of Women in a Nationally Representative Telephone Survey (N = 897)
Participant Characteristics
n ()
Age, y 18-19
231 (25.8)
20-24
403 (44.9)
25-29
263 (29.3)
Race/Ethnicity White
432 (48.2)
African American
220 (24.5)
Hispanic
186 (20.7)
Asian/other
59 (6.6)
Education ⬍High school graduate
112 (12.5)
High school graduate or GED
218 (24.3)
Some college
397 (44.3)
College graduate
123 (13.7)
Graduate or professional degree
39 (4.3)
Vocational or technical training
8 (0.9)
Number of topics covered in sex education class 0 (no sex education)
211 (23.5)
1
44 (4.9)
2
95 (10.6)
3
151 (16.8)
4
192 (21.4)
5
204 (22.7)
Ever visited clinic for women’s health carea
753 (84.0)
Ever used any contraceptive method to prevent
729 (81.5)
pregnancyb In past month, used any contraceptive method to
511 (70.1)
prevent pregnancyc Abbreviation: GED, general educational development (for high school equivalency). a Data available for 896 participants. b Data available for 894 participants. c Data available for 729 participants.
is not morally wrong, young adults were about 0.66 times as likely to not visit a physician or clinic. Restated, young adults who judged contraception as moral were more likely to visit a physician or clinic. For each unit increase in the amount of comprehensive sex education, young adults were about 12% more likely to visit a physician or clinic. Significant predictors for never having used any contraceptive method to prevent pregnancy were less comprehensive sex education and the attitude that contraception is morally wrong. For each one unit increase in the amount of comprehensive sex education, young women were about 16% more likely to have used any method to prevent pregnancy. For each one unit increase in the score of attitude that contraception is not morally wrong, young women were about 0.66 times as likely to have never used any method to prevent pregnancy. All models were statistically significant (P ⬍ .001) and demonstrated adequate model fit using Hosmer–Lemeshow 449
Table 2. Bivariate Association Between Predictor Variables and Contraceptive Use
Have Ever Visited a
Have Ever Used
Used Contraception
Physician or Clinic
Contraception to
to Prevent Pregnancy
for Women’s Health Care
Prevent Pregnancy
in the Last Month
Mean
Mean
Mean
Predictor
Yes
No
P
Yes
No
P
Yes
No
P
Comprehensive sex educationa
2.85
2.31
.002
2.88
2.21
⬍.001
2.90
2.85
.74
Attitude toward pregnancy preventionb
1.35
1.26
.16
1.33
1.35
.81
1.30
1.42
.09
Perceived infertilityb
1.82
1.88
.44
1.82
1.89
.33
1.81
1.85
.58
8.93
9.58
.05
8.92
9.58
.04
8.79
9.26
.12
4.61
4.01
⬍.001
4.62
4.03
⬍.001
4.66
4.53
.10
Distrust of the health care system or contraception Moral attitude toward contraceptionb
c
a Scale 0-5. b Scale 1-4. c
Scale 4-20.
Table 3. Final Logistic Regression Model for Predictors of Contraceptive Use
Have Visited Physician or Clinic
Have Ever Used
for Women’s
Contraception to
Health Care
Prevent Pregnancy
Predictor
OR ( CI)a
OR ( CI)b
Comprehensive
0.88 (0.80-0.97)
0.84 (0.77-0.92)
0.66 (0.58-0.76)
0.66 (0.58-0.76)
sex education Moral attitude toward contraception Abbreviations: CI, confidence interval; OR, odds ratio. a Event modeled in the logistic regression is not visited physician or clinic for women’s health care. b Event modeled in the logistic regression is have ever used contraception to prevent pregnancy.
test (P ⬎ .05). No significant covariate was found for any of the models. DISCUSSION
In our analysis, comprehensive sex education predicted ever using contraception but did not predict contraceptive use in the previous month. Abstinence-only education may have left young people with a distorted view of the risks of contraception and without an accurate view of the benefits of the correct use of contraception.17 The development of a thorough understanding of what comprehensive sex education should include, coupled with an effective delivery method, may lead to sex education that affects ongoing contraceptive use. However, effective comprehensive sex education currently is not widely available. The inability of comprehensive sex education to predict using contraception in the previous month to prevent pregnancy is a finding that deserves attention in both the clinical and community settings. In order to be effective, contraceptive use must be ongoing, especially if sexual encounters are ongoing. Comprehensive sex education must include instruction on how to maintain contraceptive use, as well as instruction on how to begin contraceptive use. 450
Consistent with other studies, we found that a lower desire for pregnancy was not associated with an increased use of contraception. Further research is needed to fully explore the antecedents to this paradoxical attitude. Some authors have suggested that intimate partner violence is associated with an inconsistent use of contraception10 ; others have shown an association between childhood adversity and repeat induced abortion.16 In addition, we found that a perception of infertility does not predict the use of contraception. Since more pragmatic explanations for contraceptive behavior fail to predict contraceptive use, it is important to understand the influence of health system distrust and moral concerns on contraceptive behavior. Even though distrust of the health care system was associated with not using contraception, our regression analysis did not show that health care system distrust predicted having used contraception or visiting a women’s health care physician or clinic. However, health care system distrust is emerging in other health care settings as a significant predictor of perceived well-being and appropriate health care system use.11, 12 Additional questions regarding health system distrust should be included in future surveys on contraceptive use and unintended pregnancy. Our findings indicated that among a lay population of young women, one’s moral attitude toward contraception is a significant predictor for both visiting a physician or clinic for women’s health care as well as for ever using any method of contraception to prevent pregnancy. The moral judgments of the public are poorly understood, and we were unable to identify published research on the moral judgments of the public toward contraception. Further research that clarifies the moral judgments that people have toward contraception will help clinical practitioners and education program planners address women’s moral concerns. Meanwhile, clinicians can ask men and women seeking family planning advice about their moral and ethical beliefs surrounding contraception. Doing so allows clinicians to help clients select a contraception that respects their client’s values. As a secondary analysis of data obtained by telephone interview, our study contains limitations that are similar to all cross-sectional research. Survey questions can only elicit superficial descriptive information from respondents, Volume 59, No. 4, July/August 2014
leaving questions that illuminate the rationale for their responses unanswered. For example, in our findings some participants agreed that using contraception was morally wrong, but our results do not describe how participants arrived at this conclusion or what exactly was immoral about contraceptive use. Likewise, although our findings support other research showing that a lower desire for pregnancy is not associated with contraceptive use, we offer no new information on why this paradox exists. In addition, our study has only found minor contributing attitudes to contraceptive use. Moral judgment and comprehensive sex education explained less than 10% of the variance for ever having visited a physician or clinic for women’s health care and ever using contraception. Finally, although this survey assessed whether or not women have visited a physician or clinic for women’s health care, more detailed information about the subject of that visit, including whether or not contraception was addressed, is not available. Preventing unintended pregnancies provides a broad range of societal benefits. Because of provisions in the Affordable Care Act, more young adults than ever in the United States will have access to contraception and have the ability to plan their families. Health care providers and health educators must be ready to provide contraception and sex education that is sensitive to moral concerns and values as well as accurate. Sex education must instruct women on initiating and continuing contraceptive use. Because there are few other efforts that lead to a healthier future than family planning, continued examination of factors that influence contraceptive use is necessary.
AUTHORS
Valerie Bader, CNM, MN, is a doctoral student at the University of Missouri, Kansas City, School of Nursing, and a clinical instructor at the University of Missouri, Sinclair School of Nursing in Columbia, MO. Patricia J. Kelly, PhD, RN, is Professor and Associate Dean for Research at the University of Missouri–Kansas City, School of Nursing. Her research focuses on women’s health issues in community settings. An-Lin Cheng, PhD, is Associate Professor at the University of Missouri–Kansas City, School of Nursing. She develops analytic strategies for a variety of research designs. Jacki Witt, PhD, WHCNP, is Associate Clinical Professor at the University of Missouri–Kansas City, School of Nursing. She is the Director of the Department of Health and Human Services’ funded Clinical Training Center for Family Planning.
Journal of Midwifery & Women’s Health r www.jmwh.org
CONFLICT OF INTEREST
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