Personal and Interpersonal Determinants of Contraceptive Use
The previous chapter concluded that one of the reasons that the United States has high levels of unintended pregnancy is that both knowledge about and access to contraception may be insufficient. The point was also made, however, that the determinants of contraceptive use and of unintended pregnancy are not limited to knowledge and access alone.
In fact, there is persuasive evidence that personal and emotional factors are closely connected to inadequate contraceptive vigilance and therefore unintended pregnancy. For example, in a series of telephone interviews with 760 women aged 18–35 at risk of unintended pregnancy, researchers learned that 23 percent of the women interviewed were sexually active but using no contraception, despite no apparent desire to become pregnant. Most of the reasons given for not using contraception involved feelings about and experiences with specific methods of contraception, issues involving relationships with their partner, and a general discomfort with contraception—all of which have more to do with emotion, attitude, and belief than with the availability of contraception or specific knowledge about individual methods (Silverman et al., 1987). As every current or former dieter or smoker knows, the gap between knowledge and behavior change in particular can be very great. Accordingly, this chapter addresses personal and interpersonal attitudes, feelings, and beliefs that can affect contraceptive use and therefore the risk of unintended pregnancy. It begins with a brief note on some theoretical and methodological problems that burden research in this field and then discusses several cross-cutting themes. Later sections summarize research on how contraceptive use is influenced by several specific attitudes and personality dimensions, and by selected situational factors.
A Comment on Available Data
It is sometimes difficult to draw broad conclusions from research on the relative importance and interaction of the personal and interpersonal factors that affect contraceptive use and unintended pregnancy because the data available are of such variable quality and limited generalizability. For example, the literature often fails to distinguish between those who experience unintended pregnancies despite some attempt to use contraception versus those who use no contraception at all, and rarely is consistent nonuse of contraception distinguished from briefer episodes of nonuse. Few studies have been replicated, and sample sizes tend to be small. Moreover, most of the individual studies in this area do not share the same theoretical orientation or use the same test instruments to probe various personal dimensions related to unintended pregnancy and contraceptive use, thereby impeding the development of a coherent body of theory or data.
Perhaps the biggest problem of all, however, is the over-representation of urban black adolescent girls and white female (and some male) college students. As the balance of this chapter demonstrates, little if anything is known about, for example, the motivational issues surrounding poor contraceptive use in women or couples over age 35, even though their rates of unintended pregnancy are relatively high (Chapter 2). Although there is new interest in contraceptive use by men, the majority of relevant behavioral research is focused on their use of condoms and rarely on their support of or participation in their partner's use of various methods. As such, the picture of the psychology of contraceptive use provided by the available data is often incomplete.
Although not often explicitly stated, much of the research on the psychology of contraceptive use views efforts to avoid unintended pregnancy as being based on a ''benefit:burden ratio"—the notion that sexually active individuals and couples carry within themselves a complicated equation balancing the benefits and burdens of becoming pregnant (or causing pregnancy) and having a child versus the benefits and burdens of not becoming pregnant (or causing pregnancy) (Furstenberg, 1980). At different stages of life, these factors are weighted differently: sometimes the scales tip in favor of pregnancy, sometimes against it. In the language of behavioral theories of fertility, contraceptive decisions are influenced by the perceived costs of a pregnancy and the perceived costs of obtaining and using different contraceptive methods (Bulatao and Lee, 1983). The higher the costs of an unintended pregnancy, the more likely couples are to use an effective method; conversely, the perception of low costs attached to an unintended pregnancy will reduce the likelihood of using an effective method. One important value of this perspective is its recognition that pregnancy and
childbearing can be very rewarding experiences and that, in addition, using contraception can be an intrusive, complicated undertaking requiring considerable skill and knowledge; it may be expensive as well.
Luker (1975) was one of the first to articulate this perspective in her theory of contraceptive risk taking, which argued that both pregnancy and pregnancy prevention have pluses and minuses and that it is the net effect of how each of these variables is valued, by the individual and couple, that determines ultimate outcome (i.e., use of contraception or the occurrence of unintended pregnancy). Zabin (1994) has referred to this as the "personal calculus of choice." And Miller (1986) has argued that a woman's contraceptive vigilance and her actual use of birth control on any given occasion frequently depend on where the internal balance lies among her positive and negative feelings toward getting pregnant and toward her contraceptive method. Other models that are consistent with this general approach and that have been variously applied to studies of contraceptive use include the health belief model (Rosenstock et al., 1988), the theory of reasoned action (Fishbein and Ajzen, 1980), and the theory of planned behavior (Ajzen, 1991). Related investigations of adolescent risk taking (of which unprotected intercourse is a good example) increasingly suggest that although some risky behaviors may seem totally irrational to adults, they derive from the adolescent's own weighing of the benefits and costs of various courses of action (Furby and Beyth-Marom, 1990).
The policy debate about welfare reform rests in large part on this benefit:burden notion. Those who advocate reducing or eliminating welfare benefits for unmarried women who conceive and bear children while on welfare suggest that without such measures there are no disincentives (or only weak disincentives) to avoid childbearing while receiving public assistance; furthermore, some suggest that welfare is actually a positive incentive for childbearing (Chapter 7) and that welfare reduces incentives for men to avoid causing pregnancy or, once a child is born, to participate in the child's support.
Closely related to this idea of the benefit:burden ratio is the importance of motivation in contraceptive use. In truth, using the reversible methods of contraception carefully to avoid pregnancy can be a complicated, challenging task that requires consistent dedication over an extended period of time, often from both partners; even a fleeting step off the straight and narrow can result in pregnancy. Absent the utmost contraceptive vigilance, the human organism is designed to reproduce under even adverse biological circumstances, including famine—an evolutionary inheritance that was designed for species survival. This theme of motivation to avoid unintended pregnancy—that it must be powerful if pregnancy is to be prevented—bubbles to the surface from widely different data sets and forms a common theme among disparate investigations.
Several studies have looked at contraceptive use from this motivational perspective, and their findings offer important insights into why some women become pregnant even when they do not intend to. Over a two-year period,
Zabin and colleagues (1993), for example, studied a sample of 313 inner-city girls 17 years of age and under to learn how their attitudes toward childbearing, contraception, and abortion and their beliefs about their partners' views of these same issues affected their use of contraception and their rates of both pregnancy and child bearing. Like many other students of adolescent pregnancy, the investigators were struck by the fact that although few girls say they want to be pregnant, many conceive nonetheless. They found that simple measures of intent—for example, did you plan to become pregnant?—fail to capture the complexity of motivations that surround the use of contraception or attitudes toward the desirability (or lack of desirability) of pregnancy. Zabin (1994:94–95) summarized this seminal work:
We … explored the concept of "wantedness" in some depth and [found that] although few want to conceive, there is considerable ambivalence on that issue and, surprisingly, those who are ambivalent about childbearing are at just as high risk of having a child as those who positively desire to conceive. In this research we defined "wantedness" not by the single variable most surveys use: "Did you want to get pregnant," but by three variables [questions] that also tapped how they would feel if they became pregnant and whether they saw a pregnancy as problematic at this stage in their lives. Following this study group for two years, we compared childbearing rates of those whose answers to all three questions suggested that they unequivocally wanted to avoid pregnancy (47%), those who unequivocally wanted to conceive (only 5%), and those whose answers to the three questions suggested some ambivalence (48%). Rather than falling midway between the other two groups, the ambivalent girls were just as likely to become mothers in the next two years as the few who unequivocally wanted to conceive [emphasis added]. Furthermore, the same research showed that to use contraception and reduce the probability of childbearing, the same kind of unambivalent attitude had to support its use. … Ambivalence put these girls at risk; when engaging in coital activity, it is hard to avoid conception. The motivation for contraception is not easy to maintain, and negative attitudes toward it abound in the United States—not merely among teenagers. … Here one might legitimately ask: What kind of identity, what view of self, what view of the future, might provide strong enough motivation to stay the course?
The findings of Zabin and colleagues are highly consistent with the eloquent ethnographic writings of several authors regarding pregnancy among poor adolescents (Quint et al., 1994; Anderson, 1994; Musick, 1993; Dash, 1989). Anderson, for example, has written about differing male and female orientations to sex and childbearing as one explanation for unintended pregnancy among very poor inner-city adolescent girls in particular. He describes the important role for young men and boys that sexual activity itself may play in building and sustaining self-esteem and a sense of self-worth. He argues that, largely in response to profound poverty and absent opportunities, young men and boys may
become absorbed into powerful peer groups that emphasize "sexual prowess as proof of manhood, with babies as evidence." The girls, by contrast, may engage in sex to secure the attentions of a young man, hoping that some better future will come from the liaison—that is, "the girls have a dream, the boys a desire" (Anderson, 1994:11). Although Anderson reports that "an overwhelming number [of the girls] are not trying to have babies," their hopes for attachment and closeness, as well as a generally positive orientation toward the rewards and sense of maturity and status that childbearing may bring, overpower short-term resolve to use contraception and avoid pregnancy. "With the dream of a mate, a girl may be indifferent to the possibility of pregnancy'' (Anderson, 1994:9–10). He thus characterizes sexual conduct among this especially impoverished group as a contest, with the boys seeking conquest, status, and control over the girls, and the girls hoping that a sexual relationship will begin a journey into a secure, middle-class future with a house and husband. Given such differing orientations to sex and pregnancy, it is not surprising that contraceptive vigilance may be poor and that unintended pregnancy is a common occurrence.
Musick's observations, consistent with those of Anderson, focus especially on young girls in poverty. She describes a broad array of psychological, developmental, and situational factors that may interfere with careful contraceptive use. She argues that many young girls enter adolescence with unresolved issues of identity and security, limited vocational or professional aspirations (largely because of the absence of mentors and role models), and a personal history—often involving childhood sexual abuse—that leaves them powerless and vulnerable to early sexual activity and childbearing. Histories of dysfunctional relationships with largely absent fathers set the stage for unhealthy relationships with other males who may easily draw them into destructive sexual liaisons. She suggests that in order to understand adolescent pregnancy and childbearing, one must recognize the troubled childhoods and families that shape the development of girls who then go on to become teenage mothers. She notes, in particular, a puzzling phenomenon that has been observed by many who have worked in teenage pregnancy prevention programs: that, just on the brink of advancement and new opportunities, young adolescent girls are particularly likely to become pregnant. Such pregnancies, although usually not fully intended, are portrayed by Musick as a complex response to fear of major life changes, of differentiating oneself from peers and relatives, and of separation from the mother especially.
Like Zabin, Musick finds that although many adolescents are not motivated to become pregnant—i.e., they may not fully "intend" to become pregnant—they are insufficiently motivated to avoid pregnancy. As Maynard (1994:10) has observed, "most teens on welfare do use contraception (83 percent)—and most often they use a relatively effective method like the pill or an IUD (75 percent). However, most are also pregnant again within a relatively short time. … The clear implication is that many who are using 'effective' contraception are not using them 'effectively' A pregnant teenager captured the essence of this dynamic:
'I didn't plan it, and then again I kind of knew what was going to happen because I wasn't like really taking the pills like I was supposed to. I couldn't remember every day to take the pill. And I still don't' (Polit, 1992:69)."
Musick notes the enormous attraction and fulfillment that childbearing can offer to young women with few alternatives and little hope for personal economic betterment through the conventionally touted avenues of high school graduation and full-time employment. A baby offers the promise of unconditional love, a chance to feel needed and valued, and a feeling of accomplishment and achievement. Moreover, the urge and presumed benefits of having a child and being a mother are rarely countered by equally powerful forces to take a different life course.
This body of information is important to ponder in the context of public policy discussions regarding adolescent childbearing. It has been suggested that most teenage mothers get pregnant and bear children purposefully, perhaps to get on welfare, to get away from home, to hold onto a boyfriend, etc. Yet survey data show that more than 85 percent of births to unmarried women less than 20 years old are unintended at the time of conception (Chapter 2); in Zabin's small sample, described above, the figure is arguably higher. It is puzzling that these two images are so out of sync with each other—the belief that teenagers are having babies largely as the result of conscious choice, versus survey data saying that the vast majority of births to teenagers are unintended at conception. The explanation may be that, in some sense, both are right. On the one hand, few teenagers "intend" their pregnancy in the sense of actively planning and wanting a child as might a 30-year-old married couple. This strict definition of intended pregnancy is consistent with the survey data showing that few births to teenagers are the product of intended pregnancies. But that does not mean that they are fully unintended either. Zabin uses the term "ambivalence" to describe the underlying dynamic. Because the reasons to delay childbearing may not seem very persuasive to some adolescents, especially those who are poor, there may be appreciable ambivalence—even confusion—about pregnancy and contraception. These feelings are not consistent with the strong motivation required to use reversible methods carefully and consistently over an extended period of time. The result can often be pregnancy—not really intended, not really unintended, but caught somewhere in between.
This dynamic of ambivalence and related psychological issues is directly relevant to many of the measurement issues and caveats discussed in both Chapters 2 and 3 as well as in Appendix G. These various sections argue that "intendedness" is often more complicated than is suggested by such measures as those used in the National Survey of Family Growth (NSFG) or other investigations. Consistent with this view, the NSFG plans to use more elaborate measures of intendedness in the 1995 cycle, as detailed in Appendix C. Miller (1992), in
particular, has directly addressed this issue of ambivalence by proposing a seven-point continuum of intendedness that helps to capture the complexities described by Zabin and others. This scale may be particularly useful in that it was developed on the basis of extensive interviews with both adolescents and adults and with both married and unmarried women.
The work of Zabin, Anderson, Musick, and others as well (see, for example, Klerman, 1993; Furstenberg, 1987) suggests that, particularly for low-income teens in urban settings, preventing unintended pregnancy will require strengthening the familial, social, educational, and employment environment of children and youth such that both boys and girls reach adolescence with a greater sense of self-worth and a vision of the future in which pregnancy and childbearing before schooling is completed and employment secured are seen as significantly less desirable than other life options. These investigators suggest that hopes and plans for a better adult life—and reason to believe that the plans are realistic—may provide critical energy for overcoming all the other obstacles to preventing pregnancy that this report and many others have detailed. Absent such countervailing forces, the motivation to be abstinent or use contraception carefully and consistently may be too weak to avoid conception; pregnancy, although not fully intended, will probably continue to characterize the adolescence of disadvantaged, poor girls.
Are these same forces at work among older men and women? Unfortunately, an equally rich body of research on motivation to use contraception and avoid pregnancy does not exist for older women, for couples, or for men, although there are some important exceptions (see, for example, Miller, 1986). It is reasonable to believe that motivational issues are powerful at all stages of reproductive life, not just adolescence, but the ethnographic and behavioral research available to help in understanding these other periods is thin.
Single Factor Investigations
Many researchers have investigated the effect on contraceptive use of more specific issues than the broad motivational ones noted above. These include personality characteristics, feelings about sexuality and fertility and about specific contraceptive methods themselves, such behavioral factors as alcohol and substance abuse, family and peer interactions, and the quality of a couple's relationship. These are reviewed briefly in this section.
The influence of specific personality characteristics on the use, nonuse, or poor use of contraception has been a particular focus of several investigators. In studying contraceptive use among adolescents, most of this research has focused on self-esteem, self-efficacy, and locus of control. Several studies have examined the association between self-esteem and events (e.g., sexual intercourse, nonuse of contraception, pregnancy) that lead to nonmarital childbearing. Herold et al. (1979), for example, found that high self-esteem was associated with more positive attitudes toward contraception and more effective contraceptive use among adolescent clients of family planning clinics. In another study, for both men and women, positive descriptions of one's self and body image were significantly associated with more consistent contraceptive use (McKinney et al., 1984). And both Neel et al. (1985) and Rosen and Ager (1981) found that a favorable self-concept, variously defined, was positively associated with contraceptive use. However, other studies on this issue, including prospective studies, have shown inconsistent results (see, for example, Plotnick, 1992; Plotnick and Butler, 1991; Durant et al., 1990; Burger and Inderbitzen, 1985).
The failure to find a consistent relationship between contraceptive behavior and self-esteem may stem from the possibility that the measure of self-esteem is too general to capture the direct effect that it has on contraceptive use. A more situation-specific concept of self-esteem—self-efficacy—has been used by many researchers with more consistent results. Self-efficacy refers to an individual's belief that he or she has the skills to control his or her own behavior to achieve the desired outcome or goal (Bandura, 1982, 1977). Hence, individuals with higher self-efficacy would be more likely to use contraception to avoid an unintended pregnancy. Several investigations of this notion support the importance of self-efficacy in the careful use of contraception (Heinrich, 1993; Brafford and Beck, 1991; Levinson, 1986).
Another body of work has explored the concept of "locus of control," that is, individuals' belief that they can control what happens to them. The evidence is mixed, however, on the relationship between contraceptive behavior and various measures of locus of control (see, for example, Sandler et al., 1992; Visher, 1986; McKinney et al., 1984; Lieberman, 1981), possibly because of the general nature of the measure. But even when a measure more specific to contraceptive use was studied in relationship to consistency of condom use among a sample of clients at a family planning clinic, no significant association was found (Jaccard et al., 1990).
Attitudes and Feelings About Sexuality and Fertility
Another set of factors studied in relationship to contraceptive use is feelings about sexuality generally, as well as the guilt, fear, or embarrassment that the subjects of sexuality and contraception (and even the process of obtaining contraception) may engender. Concerns about one's fertility have also been studied in relationship to contraceptive use.
The theory of sexual behavior sequence, for example, hypothesizes that an individual's emotional response to sexuality may influence and mediate the avoidance of or approach to contraception because using contraception is a behavior with important sexual overtones (Byrne, 1983). Consequently, the theory states, persons with negative feelings about sexuality may find it difficult to learn contraceptive information, may avoid public acquisition of contraceptives, and may therefore be inconsistent users of contraception. A test of this hypothesis among sexually active college men showed a moderate relationship between feelings about sexuality and contraception: those with more positive feelings were more likely to report condom use (Fisher, 1984). Similarly, Winter extended the psychological notion of self-concept to include one's evaluation of one's own sexuality and defined it as the "sexual self-concept"—an individual's evaluation of his or her own sexual thoughts, feelings, and actions. In an exploratory analysis among college students, positive sexual self-concept was found to be associated with frequency of contraceptive use, with use at most recent intercourse, and with choice of method. Students who had used prescription methods at last intercourse scored higher on the sexual self-concept than did students who had used nonprescription methods or no method at all (Winter, 1988).
Negative emotions about nonmarital sex, such as fear or guilt, may inhibit sexual intercourse. When these emotions are not strong enough to deter intercourse, however, there is strong evidence that they may actually reduce the individual's ability to use contraception (Strassberg and Mahoney, 1988; Gerrard, 1987, 1982; Burger and Inderbitzen, 1985; Mosher and Vonderheide, 1985; Gerrard et al., 1983; Herold and McNamee, 1982). For example, the reasons given by sexually active college women for not using contraception show a tendency for denial and guilt over their sexuality (Sawyer and Beck, 1988), and high levels of guilt about sexual issues further predispose adolescents to taking contraceptive risks (Morrison and Shaklee, 1990). Similarly, among 13-to 20-year-old sexually active single females attending family planning clinics, significant relationships were found between guilt over premarital sex and both consistency of contraceptive use and contraceptive method choice at last intercourse (Herold and Goodwin, 1981). "High-guilt" women were significantly more embarrassed attending the clinic and having an internal examination than "low-guilt" women. High-guilt women were also more likely to perceive barriers to obtaining birth control information and contraceptives. A similar relationship
between guilt about premarital sexual activity and contraceptive use among never-married female college students was shown by Keller and Sack (1982). The findings of these various investigations support the hypothesis that acceptance of one's own sexuality is positively related to the consistent use of a reliable form of contraception. Furthermore, the hypothesized relationship seems to hold regardless of whether a female or a male contraceptive method is used.
Focus groups designed to learn more about how adolescents feel about obtaining contraception at clinics confirm the importance of shame, embarrassment, and fear related to the medical examinations; embarrassment about being sexually active; and concern about confidentiality (Silverman and Singh, 1986). Pelvic examinations are often required before securing such prescription-based methods as oral contraceptives or diaphragms. In some clinics, such examinations are also required before nonprescription contraceptive methods are supplied. Consequently, among adolescents, in addition to the fear that their families will find out, another important factor in delaying a visit to a family planning clinic can be the fear of medical examination (Zabin and Clark, 1981). As noted in Chapter 5, this finding has led some groups to experiment with providing the first several cycles of oral contraceptives to adolescents without first requiring a pelvic exam.
Similarly, one of the major reasons given by men for not using condoms is because of embarrassment involved in obtaining them. Among a sample of adult males between the ages of 20 and 39 interviewed in 1991, 27 percent stated that it was embarrassing to buy condoms, and 20 percent stated that discarding condoms was embarrassing (Grady et al., 1993). The television comedian Jerry Seinfeld captured the essence of the embarrassment factor in a recent monologue (Seinfeld, 1993):
Which brings us to the condom. There's nothing wrong with the condom itself. The problem with condoms is still buying them. I think we should have like a secret signal with the druggist. You just walk into the drugstore, you go up to the counter, he looks at you and if you nod slowly, he puts them in the bag for you. That's it.
You show up there, you put your little shaving cream, you little toothpaste at the counter.
How are you today? (You nod.)
Not bad. Yourself? (He puts them in.)
Oh, pretty good.
And you've got them.
There is also a small but important body of data suggesting that fears of being infertile, as well as inaccurate assessments of the risk of pregnancy in a variety of circumstances, may limit the careful and consistent use of contraception.
Perceived fertility has been found to affect contraceptive use, with those women who perceived themselves as less fertile being more likely not to use contraception (Rainey et al., 1993). Other studies, too, have found a lower perceived probability of pregnancy to be associated with less effective contraceptive use (Burger and Burns, 1988; Tsui et al., 1991), although this has not been found consistently (Whitley and Hern, 1991).
One final attitude toward sexuality merits mention—the capacity to plan for intercourse and for contraception. For many individuals, especially those who are young or who are in the early weeks and months of sexual activity, intercourse is often unplanned. And because contraceptive devices must be obtained before intercourse, lack of planning for the event is closely associated with either the failure to use any method of birth control at all or use of such poor methods as withdrawal. In a 1994 survey of more than 500 high school students, three-fourths of those who were sexually active said that their first sexual experience "just happened" (SIECUS/Roper poll, 1994), and a recent study of young adults aged 17–23 found that 79 percent of those who did not use contraception at first intercourse said that they "did not expect to have sex" (Winter, 1988). Despite such findings, National Survey of Family Growth data and smaller studies confirm that the use of contraception at first intercourse has risen appreciably in recent years, almost entirely because of greater reliance on condoms.
Lack of planning for intercourse may be partly due to a general disinclination to plan ahead on a wide variety of issues in daily life, and as such may be a basic personality trait. It may also be due to the well-recognized "swept away" phenomenon—the passion and desire that can accompany sexual contact and that are among the most powerful and often pleasurable human sensations. Indeed, some would say that satisfaction from sexual activity is enhanced by spontaneity and that deliberate planning for such activity (including securing contraception) detracts from the experience. However, failure to anticipate sexual intercourse and to secure contraception may also reflect guilt, ambivalence, or denial regarding sexual activity, as discussed above. It has been suggested that one consequence of the residual squeamishness in the United States about sex (Chapter 7) is that too many individuals begin their sexual careers with a high level of discomfort regarding sexual feelings and behavior, and that this discomfort in turn impedes planning for both intercourse and for using contraception (Haffner, 1994). It is also important to acknowledge, however, that some sexual encounters are nonconsensual; in these situations contraceptive use is obviously precluded (Chapter 7).
Attitudes and Feelings About Contraceptive Methods
The 1987 study by Silverman and colleagues noted in the introduction to this chapter underscores how opinions and feelings about contraceptive methods themselves can affect the use of contraception and therefore the risk of unintended pregnancy. A wide variety of studies confirm that attitudes toward contraception and feelings about specific methods are strong predictors of contraceptive behavior and patterns of contraceptive use (Balassone, 1989; Morrison, 1989; Grady et al., 1988; Miller, 1986; Tanfer and Rosenbaum, 1986; Houser and Beckman, 1978).
As noted briefly in Chapter 5, one reason women often give for not using contraceptives is that they are concerned about the side effects or health risks of contraception in general and of specific methods in particular (Zabin et al., 1991; Sawyer and Beck, 1988; Forrest and Henshaw, 1983). Overall, it appears that both nonuse and the use of less effective methods derive at least in part from method-related fears and dislikes and from a general negative feeling about contraception.
All barrier methods and other "ad hoc" methods (such as withdrawal) must be used at the time of intercourse, and they require a definite decision and some type of a specific action at each sexual intercourse, whereas methods such as the pill and the IUD are used independent of coital activity. Not suprisingly, when compared to women who use coitus-independent methods, women who rely on coitus-dependent methods have been found to be more likely to forget to use or fail to use their method, more likely to discontinue their method in favor of no method at all, and more likely to switch methods altogether. For example, among a nationally representative sample of 15- to 44-year-old married women, Grady et al. (1988) found that those who used coitus-dependent methods were more likely to discontinue contraceptive use or to switch to a different method than users of coitus-independent methods. User failure was also found to be higher among users of coitus-dependent methods than it was among pill or IUD users. The researchers speculate that differences in user satisfaction with different methods may underlie both method discontinuation and user failures (Grady et al., 1989, 1988). Miller (1986) also reports more discontinuation among women who were using coitus-dependent methods, regardless of women's marital status.
The effect of user-method interaction has gained new significance with the spread of HIV infection. The condom is the only reversible male method of contraception that also is a very effective prophylactic against sexually transmitted diseases (STDs), including HIV. With the increase in the incidence of STDs and the spread of HIV into the heterosexual population, a small but growing segment of the literature on contraceptive use has focused on the determinants of condom use and individuals' perceptions of the advantages and disadvantages of this method (Brafford and Beck, 1991; Kegeles et al., 1988;
Brown, 1984). Although the condom's effectiveness in reducing the risk of an unintended pregnancy as well as the risk of an STD is widely appreciated (Boyd and Wandersman, 1991; Bernard et al., 1989; Strader and Beamen, 1989), men generally report overwhelmingly negative views of condoms, focussing on such disadvantages as embarrassment in purchasing or using them (noted earlier), reduction in physical pleasure or sensation, and the intrusiveness of the method (Boyd and Wandersman, 1991; Brafford and Beck, 1991; Pleck et al., 1991; Bernard et al., 1989; Strader and Beamen, 1989).
Another very important but less commonly cited disadvantage of condom use is fear of breakage and slippage (Grady and Tanfer, 1994; Beaman and Strader, 1989; Consumers Union, 1989). In a nationally representative sample of 20- to 39-year-old men, three-fourths of the respondents agreed that condoms reduce sensation, 64 percent mentioned that condom users must be careful or the device may break, and 43 percent were concerned that a man must withdraw quickly when he is using a condom. Also mentioned were slippage (22 percent) and difficulty in putting it on (24 percent), with 13 percent indicating that condoms cost too much (Grady et al., 1993).
Substance Abuse, Peer Influences and Family Relationships
Two sets of factors that may affect the use of contraception have attracted some analysis: the effects of alcohol and/or drugs, and the effects of both family and peer relationships.
Alcohol and Substance Use
Nonuse or poor use of contraception may sometimes be linked to the use of alcohol or drugs. Nonconsensual sex, such as "date rape," may be linked to substance abuse as well (see Chapter 7 also). Consistent with this view, an exploratory study based on interviews with unmarried, young women drawn from a family planning clinic found a clear association between unplanned sex, alcohol consumption, and nonuse of contraception (Flanigan and Hitch, 1986). More than two-thirds of the respondents had their first sexual experience by age 17, and one-half of these women reported alcohol (43 percent) or drug (7 percent) use at the time of that first intercourse. For a majority of these women the first sexual intercourse was unplanned, more than one-half of these women used alcohol before intercourse, and more than 80 percent did not use a method of birth control. Similarly, a correlation between general substance use and poor contraceptive use among adolescents has also been documented (Ford and Norris, 1994; Mott and Haurin, 1988; Ensminger, 1987).
However, some studies suggest a more complicated picture (Flanigan et al., 1990; Harvey and Beckman, 1986; Donovan and Jessor, 1985; Zabin, 1984). For example, in one study that examined substance use and other factors associated with risky sexual behavior within a target group of urban, unmarried pregnant adolescents aged 17 and younger, cigarettes and alcohol in general, and alcohol and drug use during sex in particular, were found to be positively associated with risky sexual behavior, including the nonuse or poor use of contraception. The effect of substance use, however, disappeared when the confounding effects of family bonding, parental monitoring, commitment to conventional values, peer associations, self-esteem, and delinquent activities were controlled (Gillmore et al., 1992). Such findings suggest that both substance use and behaviors that increase the risk of pregnancy may be part of a more general syndrome of risk-taking behavior and troubled life circumstances.
Parents and Peers
The fear of their sexual activity being detected by their family and meeting with strong disapproval can be a potent barrier to teenagers' use of effective contraception (Zabin et al., 1991), and improving communication about sex and birth control between parents and their children has therefore often been cited as a means to encourage young people to use contraceptives more effectively. However, much of the research in this area suggests that parent-child communication is not as powerful an influence on adolescent contraceptive use as common sense would suggest.
Furstenberg and colleagues (1984) found, for example, that family communication about sex and birth control appeared to count for very little with regard to levels of contraceptive use among sexually active teenagers. Similarly, using data collected over a period of two years from teenagers and their mothers, Newcomer and Udry (1985) found that neither parental attitudes toward premarital sex nor parent-child communication about sex and contraception affects teenagers' subsequent sexual and contraceptive behavior. Not only were the teenagers often ignorant of their parents' attitudes toward sex-related issues but also they and their parents often contradicted one another in describing the kinds of sex-related conversations that they had had. In only two cases was a significant relationship found between communication and subsequent behavior: adolescents whose mothers reported that they had discussed sex with them were less likely to subsequently initiate coitus, and adolescents who reported that their mothers had discussed birth control with them were more likely to use effective contraceptives. However, the former association disappeared when it was the daughters who reported the communication, and the latter association disappeared when it was the mothers who reported it.
One other aspect of parent-child interaction that should be noted is the possibility that some pregnancies among young adolescents occur during intervals of inadequate adult supervision, such as the unstructured hours between school dismissal and the return of parents from work in the early evening. Unfortunately, there are no data available to judge the merits or magnitude of this explanation, although it is intuitively appealing. This issue of supervision is also addressed in Chapter 7, in the context of preventing nonconsensual sexual activity.
Peer influences on contraceptive use have also been studied (see, for example, Whitley, 1991). Using data obtained in the 1982 National Survey of Family Growth, Mosher and Horn (1988) found that among sexually active women aged 15–24, friends and parents were the main sources of referral for first family planning visits. More specifically, friends were the leading referral source for women who attended clinics, and parents were the leading referral source for those who went to private physicians. Despite the importance of confidentiality to many teenagers, women who made their first family planning visit before the age of 17 were more likely to be referred by their parents than were those whose first visit occurred when they were age 17 or older. Since the analysis by Mosher and Horn is confined to those who made a family planning visit, these findings do not necessarily contradict the findings of other research (reported above) showing a lack of communication about sex and birth control between parents and their daughters or the findings indicating that family communication about these matters count for very little in explaining contraceptive behavior among sexually active teenagers. More recent research by Laumann and colleagues (1994) confirms that peers exert a significant influence on both sexual activity and contraceptive use.
Partner and Couple Issues
Numerous studies support the notion that a woman's partner may have a major impact on her use or nonuse of a contraceptive method; this may be especially true for young adolescent girls, given their relatively greater reliance on male contraceptive methods, especially condoms and withdrawal. For example, partner encouragement to use contraception had a direct effect on the contraceptive behavior of a sample of female high school and college students (Herold and McNamee, 1982). And in a prospective study among a sample of adolescent family planning clinic patients who were followed for six months after they were prescribed oral contraceptives, women's perception of partner support was the best predictor of compliance. Similarly, perceived partner support was also a good predictor of condom use for disease prevention among adolescent users of oral contraceptives (Weisman et al., 1991). Pleck et al. (1991) reported that among adolescent males, the anticipation that a partner
would appreciate the respondent's willingness to use condoms was significantly associated with consistency of condom use.
However, couples may often disagree on various aspects of contraceptive choice and practice. In a study of married couples, for example, Severy (1984) found that appreciable differences between the fertility values of husbands and wives occurred one-fourth of the time, and that one spouse's perceptions of the other's values were at variance one-half of the time. Miller (1986) showed that, among married women, dislike by the husband of the method being used was significantly associated with an increased incident of subsequent nonuse. More recently, Severy and Silver (1993) showed that in light of the substantial misperception of one spouse's attitudes and intentions by the other spouse, joint decision-making was indeed an important factor for effective contraceptive behavior.
Many studies confirm that the nature and quality of a couple's relationship affect contraceptive use (Miller, 1986), particularly the use of coitus-dependent methods, because they generally require partner cooperation and support. The length of the relationship, for example, has been confirmed as an important factor in the contraceptive behavior of unmarried couples (Foreit and Foreit, 1981). Cvetkovich and Grote (1981) found that contraceptive use was positively associated both with the duration of the relationship and with trust in the partner. The authors suggest that men in stable relationships are more likely to care about the well-being of their partners and to actively encourage contraceptive use. Similarly, in a study of sexually active adolescent couples, those with good communication patterns were found to be significantly more likely to practice effective contraception; the risk of an unintended pregnancy was highest among couples who felt that contraception had not been adequately discussed (Polit-O'Hara and Kahn, 1985). Many other studies confirm these general themes (O'Campo et al., 1993; Adler and Hendrick, 1991; Pleck et al., 1988; Sawyer and Beck, 1988; Burger and Inderbitzen, 1985; Sack et al., 1985; Foreit and Foreit, 1978).
Some investigators have explored the relative influence of partners versus peers on contraceptive use. Whitley (1991, 1990) examined the sources and effect of social support on contraceptive use in a small survey of sexually active female and male college students. Although friends and partners were identified as equally supportive, only partner support was found to be related to contraceptive use. Furthermore, the nature and the quality of the relationship between the partners was a major factor in contraceptive use; contraceptive use increased with the intimacy of the relationship. Students also reported more motivation to comply with the views of their partners than with their friends, and this was more so among women than it was among men. Young men were willing to use condoms when they were encouraged by their partner, despite widespread dislike of this method. The finding that parental support was not an important factor suggests that contraceptive use may best be promoted through
the self-disclosure and open discussion young adults enjoy with peers, and that a desire to please one's sexual partner seems to outweigh advice provided by a best friend. The findings of Cohen and Rose (1984) also indicate that for adolescent males, like females, sexual partners are the primary direct social influence with regard to contraceptive use.
Personal attitudes and feelings, both within males and females individually and through their connections as couples, clearly exert a major influence on contraceptive use and therefore unintended pregnancy. The concepts of personal motivation, the ''benefit:burden ratio," and ambivalence, in particular, provide an integrating framework for numerous investigations of more limited concepts such as self-efficacy. Partner influence, and particularly the depth and quality of a couple's relationship, is an important influence on contraceptive use and therefore unintended pregnancy, underscoring the need to include men and couples in research on unintended pregnancy, as well as in interventions to reduce such pregnancies.
Overall comfort with sexuality and an absence of shame, embarrassment, guilt, or fear about sexual issues appear to support the careful use of contraception among both men and women. Data are also persuasive that feelings about contraceptive devices themselves—both overall and with regard to specific methods—can influence the choice of methods and the success with which they are used. Although sometimes associated with unprotected sex, alcohol or substance abuse are often not isolated influences explaining poor contraceptive use (or nonuse), but may rather be part of more general patterns of problem behavior and risk-taking.
Unfortunately, the research that lies behind many of these observations rests largely on samples of low-income black urban teenagers and white college students, even though a large portion of unintended pregnancies occurs among other groups. Too few investigations include older women and men or couples, and the racial and ethnic diversity of the populations studied, taken as a whole, is very narrow. Thus, available research is limited in its ability to explain the personal and interpersonal issues that affect contraceptive use and the risk of an unintended pregnancy among all of the populations in whom unintended pregnancy occurs. Finally, the lack of common theory and measurement instruments across the many investigations noted in this chapter makes it difficult to pool results or to integrate them with other bodies of information, especially material reviewed earlier on contraceptive knowledge and access (Chapter 5).
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