One challenge in counseling women about contraception is that any single patient’s feelings about pregnancy and using contraception could be nuanced and not solidly in a “yes” or “no” category.
New research into pregnancy preferences and contraceptive use among women in the Southeastern United States shows that a woman’s pregnancy preferences strongly influenced the likelihood of contraceptive use. Researchers concluded that contraceptive care and counseling should be delivered in a way that respects patients’ feelings and desires regarding pregnancy. It also should take into account that many people hold a range of feelings.1
“It’s fascinating. We had a broad question about contraceptive use and [pregnancy] desire. We looked at the distribution, and people fall across the entire spectrum,” says Corinne Rocca, PhD, MPH, study co-author and a professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco.
The answers were skewed slightly toward desiring to avoid pregnancy, but people also were in the middle of the scale. “It can mean you land there if you feel ambivalent — if you feel you’d like to have a child, but it’d be hard to achieve other things if you have a child,” Rocca says. “You can fall in the middle if you are indifferent and don’t care one way or the other, or if you are uncertain and don’t know what you feel.”
The information came from a data set of statewide surveys of women of reproductive age across nine states. “What’s unique and cool about these data is these are the first surveillance data collected that are focused on contraceptive use, in-depth pregnancy measures, and contraceptive experiences with the system,” Rocca says. “It’s really rich data.”
One of the goals was to study how unintended pregnancy and contraceptive use are affected by pregnancy desires and preferences. “Unintended pregnancy has remained quite high in the United States,” Rocca notes.
Studying this issue has been challenging because of a misconception that people hold fixed pregnancy intentions of “Yes, I want to become pregnant,” or “No, I don’t want to become pregnant” — a clear binary, Rocca explains. “But qualitative research shows people don’t think this way,” she says. “Maybe they want to become pregnant, but want to wait until they have enough money for it.”
Some women may not desire to become pregnant until they are pregnant. “The measures we have used to measure pregnancy intention have typically been, ‘Do you want to become pregnant in the next year?’” Rocca says. “There is such a range of things people could feel, even if they answer ‘no’ to that question.”
Rocca and colleagues used a rigorously developed measure with 14 items to catch participants’ cognitive perception about whether they feel pregnancy would be good for their lives. It asks how they would feel if they were to become pregnant and asks about the practical consequences, such as a loss of freedom. Answers ranged from zero, if they were open to pregnancy, to four — a strong desire to avoid pregnancy.
Using the pregnancy intention measure, researchers studied how women’s intentions were connected to contraception use. “This is essential for policies and for understanding what are the true reasons for contraception non-use among people who really want to prevent pregnancy,” Rocca says.
Rocca described these important findings:
• As a person’s desire to avoid pregnancy increases, their likelihood of contraception use increases.
“That makes perfect sense,” Rocca notes. “Based on our model, about 45% of people who had a score of zero used contraception, whereas those who had a score of four, about 86% of them used contraception.”
As respondents’ pregnancy avoidance score increased, their likelihood of contraception use also increased.
• The contraceptive methods people chose to use did not change, depending on their commitment to pregnancy avoidance. In other words, people who most wanted to avoid pregnancy were not more likely to use long-acting reversible contraceptives.
“The method mix looks the same, regardless of their [pregnancy desire] level,” Rocca says. “This suggests that people select contraceptive methods based on features other than how effective the method is regarding preventing pregnancy.”
• Some people who strongly desire to prevent pregnancy do not use contraception. Their two primary reasons for non-use were concerns about contraception side effects and simply not wanting to use a contraceptive method. It was not about inability to obtain or afford the method they wanted, Rocca says.
About 30% of participants who were not using a method also said they were not having sex. This group may be open to emergency contraception.
“These are attitudinal features, and we have to appreciate that there are legitimate [psychosocial] reasons why people may not use a method,” Rocca says. “Side effects are real and may prevent some people from using them, and there are maybe cultural issues that cause rejection of contraception.”
The findings have challenging implications for the new era of abortion bans and decreased access to all forms of contraception. “I imagine that in this post-Roe era, we’ll have improved efforts to provide access to contraception,” Rocca says. “That access to abortion will remain essential to people who don’t use contraception.”
Also, it suggests that despite a greater urgency in the reproductive health community to provide patients with access to highly effective contraception, there remain reasons why some people will not use contraception. Contraceptive counseling should be patient-centered and take those views into consideration.
“The way I think about contraceptive decision-making is that people balance their need for a method with their perceived drawbacks about using a method, and those factors interact with one another,” Rocca says. “It’s important to understand a person’s reasons for not wanting to use a method. We need to be a partner in the decision-making process, particularly among communities of color and women with a history of coercion that could be a part of people’s unwillingness to use a method.”
REFERENCE
- Harper CC, Rao L, Munoz I, et al. Agency in contraceptive decision-making in patient care: A psychometric measure. J Gen Intern Med 2022 Sep 7. doi: 10.1007/s11606-022-07774-0. [Online ahead of print].
New research into pregnancy preferences and contraceptive use among women in the Southeastern United States shows that a woman’s pregnancy preferences strongly influenced the likelihood of contraceptive use. Researchers concluded that contraceptive care and counseling should be delivered in a way that respects patients’ feelings and desires regarding pregnancy. It also should take into account that many people hold a range of feelings.
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