Knowledge and attitudes about long-acting reversible contraception among Latina women who desire sterilization

Abstract

Background

There is growing interest in increasing the use of long-acting reversible contraception (LARC), and suggestions that such methods may serve as an alternative to sterilization. However, there is little information about whether women who do not want more children would be interested in using LARC methods.

Methods

We conducted semi-structured interviews with 120 parous Latina women in El Paso, Texas who wanted a sterilization but had not obtained one. We assessed women’s awareness of and interest in using the copper intrauterine device (IUD), levonorgestrel intrauterine system (LNG-IUS), and etonogestrel implant.

Findings

Overall, 51%, 23% and 47% of women reported they had heard of the copper IUD, LNG-IUS and implant, respectively. More women stated they would use the copper IUD (24%) than the LNG-IUS (14%) or implant (9%). Among women interested in LARC, the most common reasons were that, relative to their current method, LARC methods were more convenient, effective, and provided longer-term protection against pregnancy. Those who had reservations about LARC were primarily concerned with menstrual changes. Women also had concerns about side effects and the methods' effectiveness in preventing pregnancy, preferring to use a familiar method.

Conclusions

Although these findings indicate many Latina women in this setting do not consider LARC an alternative to sterilization, they point to an existing demand among some who wish to end childbearing. Efforts are needed to improve women’s knowledge and access to a range of methods so they can achieve their childbearing goals.

Introduction

There is growing interest in increasing women’s use of long-acting reversible contraception (LARC), such as the intrauterine device (IUD) and subdermal implant, in order to reduce rates of unintended pregnancy in the United States (US) (Allen, Goldberg, & Grimes, 2009; Finer & Zolna, 2011; Speidel, Harper, & Shields, 2008). In addition, some have suggested that the IUD could serve as an alternative to female sterilization given the method’s comparable efficacy and lower cost (Grimes & Mishell, 2008; Trussell et al., 2009). Others also note that greater IUD use among women who wish to end childbearing may reduce the incidence of post-sterilization regret (Allen, et al., 2009). However, use of LARC remains low in the US, particularly compared to the prevalence of female sterilization. Just over five percent of reproductive aged women report using an IUD and less than one percent use implants, while female sterilization accounts for 27% of current contraceptive use (Mosher & Jones, 2010). Additionally, despite increases in LARC use in the last several years, the prevalence of sterilization has declined only slightly (Finer, Jerman, & Kavanaugh, 2012).

The low use of LARC has been attributed, in part, to women’s lack of familiarity with these methods (Fleming, Sokoloff, & Raine, 2010), as well as their misperceptions about them. For example, women tend to underestimate the effectiveness of IUDs, believe they are unsafe and can increase one’s risk of cancer and sexually transmitted infections (Forrest, 1996; Hladky, Allsworth, Madden, Secura, & Peipert, 2011). Women also express concerns about the insertion and removal of LARCs and menstrual changes associated with use (Fleming, et al., 2010; Whitaker et al., 2008). In one study, one-quarter to one-half of women said heavier periods and cramping, spotting between periods, and IUD-related amenorrhea would bother them enough that they would not use the IUD (Fleming, et al., 2010).

Most of these studies have focused on women age 25 years or younger who are likely interested in delaying or spacing their future pregnancies. Much less is known about use of or interest in LARC among women who do not want additional children. A recent analysis of the National Survey of Family Growth (NSFG) found that women who do not want more children are just as likely to be using an IUD as women who intend to have additional children (Kavanaugh, Jerman, Hubacher, Kost, & Finer, 2011). Baldwin et al (2012) interpreted publicly insured women’s low rates of postpartum IUD insertion compared to female sterilization as due to system barriers. However, Borrero et al. (2011) found that although the majority of women who obtained a postpartum sterilization had heard of the IUD, over one-third reported choosing sterilization because they did not want a foreign object in their body or were concerned about long-term hormonal method use. These studies did not specifically assess whether women would consider using an IUD instead of sterilization, nor did they distinguish between the different IUDs available. The latter distinction is important as the characteristics of these methods may affect potential users’ interest in adopting LARC.

In the present study, we assess whether LARC is viewed as an acceptable contraceptive option by women who wish to end childbearing. Specifically, we examine awareness of three different LARC methods, interest in LARC and motivations for and concerns about using these methods among parous Latina women who do not want more children and would like a sterilization. Our focus on Latina women stems from our finding that, despite a high prevalence of sterilization, low-income Latinas are often unable to get a desired tubal ligation due to lack of public funding, problems associated with the Medicaid consent form and providers’ ad hoc criteria surrounding age and parity – barriers that have been reported in other studies with ethnic minority women (Potter et al., 2012; Thurman, Harvey, & Shain, 2009; Zite, Wuellner, & Gilliam, 2005). Latinas may consider LARC an acceptable contraceptive option since they are more likely than women in other racial/ethnic groups to use these methods and may be more familiar with them due to the high prevalence of LARC use in countries that are the main sources of migrants to the US (Palma Cabrera & Palma, 2007; Thompson, Greene Foster, & Harper, 2011). However, much of the published literature has not assessed Latina women’s knowledge of and interest in LARC separately from women in other racial/ethnic groups.

Methods

Study Setting and Sample

This study was conducted in El Paso, Texas. The majority of the city’s residents are Latino, nearly one-third of adults live below poverty, and a large percentage of the population lacks health insurance (Law & VanDerslice, 2010; U.S. Census Bureau, 2010). For low-income and uninsured reproductive aged women in El Paso, contraception is available for free or low-cost in US clinics and health centers through the state’s Medicaid family planning waiver and other state-administered federally funded programs, like Title X. In recent years, state budget cuts and restructuring of family planning funding streams have restricted the range and availability of contraceptive options for low-income women. As a result, organizations increasingly rely on providing contraceptive methods with lower upfront costs, such as oral contraceptive pills and injections, in order to stretch limited financial resources.

In a recent prospective cohort study of oral contraceptive users in El Paso, we found a large number of women who did not want more children and wanted a sterilization (Potter, et al., 2012). Between July 2009 and June 2010, we contacted a sub-sample of these women to better understand their barriers to getting a sterilization. Women were eligible for the sub-sample if they were age ≥21 years, had two or more children, reported at the last interview of the prospective study that they did not want additional children, and wanted a sterilization but were not using a permanent contraceptive method (n=337). In order to obtain a target sample of 120 women who still wanted a sterilization but had not obtained one, we attempted to reach 285 eligible women from the prospective study who had provided written informed consent to be contacted for future interviews and whose names were drawn from a list generated through random number assignment. We were unable to contact 132 women, and one woman declined to participate. Of the 152 women who agreed to be interviewed, we completed 120 interviews with women who still wanted a sterilization, as well as additional interviews with seven women using a permanent method (5 female sterilization, 2 whose partner had a vasectomy), and one woman who was pregnant. Here, we focus on our interviews with the 120 women who still wanted a sterilization but had not obtained one.

Data collection

The semi-structured interview guide contained a series of close- and open-ended questions that focused on women’s motivations for ending childbearing and interest in and barriers to obtaining a sterilization, findings which we reported on elsewhere (Potter, et al., 2012). Of relevance to the present study, we also asked women to report their current contraceptive method and if they were considering using another method besides sterilization. In addition, women were shown a picture and read a short description of each of the following methods, which we referred to by their trade names: the copper IUD, levonorgestrel intrauterine system (LNG-IUS) and etonogestrel implant. Women were told each method was very effective at preventing pregnancy, very safe and could be used by most women without problems (see appendix for method-specific descriptions). For each method, we asked women if they had ever heard of the method prior to the interview, if they would consider using the method if it were available for free or low-cost, and the reasons they would or would not use the method or why they were unsure. If a woman was using a LARC method at the time of the interview, she was not asked the questions about her specific method.

Prior to the interview, women provided verbal consent and were asked for their permission to record the interview; all women agreed to have their interview recorded. All interviews were conducted in Spanish by a native Spanish-speaking female interviewer. Women received a $30 gift card for completing the interview. This study was approved by the Institutional Review Boards at the appropriate institutions.

Analysis

We computed frequencies of women’s sociodemographic characteristics and awareness of and interest in using each LARC method. Responses to the open-ended questions about why a woman would or would not use each method were transcribed in Spanish, and the transcripts reviewed against the recordings for accuracy; errors or omissions in the transcripts were corrected. Constant comparison and content analysis were used to code and analyze the transcripts (Glaser & Strauss, 1967). The first and second authors read through the transcribed responses and then, based on common themes in the data, developed two preliminary coding schemes: one for women’s responses about interest in using a particular method and another for responses about lack of interest in the method. They then independently coded half of the transcribed responses and met to review their coding for consistency and discuss discrepancies in assigning codes to text to reach a consensus. Once they finalized the coding schemes, the lead author coded the remaining open-ended responses and conferred with the second author in cases where she was uncertain of the most appropriate code. When a woman said she was unsure about whether she would use a particular method, codes for interest or lack of interest were assigned based on the main ideas in her response. In the final stage of analysis, we assessed similarities and differences in women’s reasons for being interested in (or unwilling to use) each of the LARC methods. Representative quotes, translated from the original Spanish, are presented here.

Results

Participant characteristics

The majority of women in the sample were age 35 years or older, had three or more children, were married, had less than a high school level education, and were born in Mexico (Table 1). Few women had health insurance. One-third of the sample had previously used an IUD or implants. At the time of the survey, 94% were using some form of contraception, and most were still using oral contraceptive pills. Twelve women (10%) said they were using an IUD, of which four reported using the copper IUD, four the LNG-IUS, and the others did not know which type of IUD they had.

Table 1.

Characteristics of women who would like a sterilization (n=120)

	n	(%)
Age, years
25 – 34	33	(28)
35 – 39	41	(34)
40 – 48	46	(38)
Parity
2 children	27	(23)
3 children	52	(43)
4 children or more	41	(34)
Marital Status
Not currently married	19	(16)
Currently married/cohabiting	101	(84)
Educational attainment
Less than high school	75	(63)
High school or more	45	(37)
Nativity/education
Born in US, Educated in US	7	(6)
Born in Mexico, Educated in US	45	(37)
Born in Mexico, Educated in Mexico	68	(57)
Language proficiency
Spanish better than English	104	(87)
No difference, English somewhat better	16	(13)
Health insurance
No health insurance	108	(90)
Has health insurance	12	(10)
History of LARC use
No past use of IUD/Implants	80	(67)
Previously used IUD/Implants	40	(33)
Current contraceptive use
Oral contraceptive pills	76	(63)
Condoms	13	(11)
IUD	12	(10)
Injectables	6	(5)
Patch	2	(2)
Other methods1	4	(3)
No method	7	(6)

LARC – long-acting reversible contraception; IUD – intrauterine device

^1.Other methods included rhythm, withdrawal and spermicides.

Interest in LARC

Before hearing the brief description of the specific LARC methods, 14 women said they were considering another method besides sterilization; of these, six said they were considering an IUD and none were considering the implant (Table 2). Following the description, half of women said that they had heard of the copper IUD and implant, while only 23% had heard of the LNG-IUS. When specifically queried about their interest in each method, 26 women said they would use the copper IUD, and 15 would use the LNG-IUS if it were available for free or low-cost; ten women said they would use the implant. Overall, 32% said they would be interested in using at least one LARC method, and results were similar for women who had previously used and never used LARC (29% and 34%, respectively).

Table 2.

Awareness of and interest in LARC methods among women who would like a sterilization and were not using a LARC method (n=108)

	n	(%)
Considering use of another method besides sterilization, unprompted
IUD	6	(6)
Oral contraceptive pills	4	(4)
Injectables	1	(1)
Patch	1	(1)
Condoms	1	(1)
Other methods1	1	(1)
Not considering another method	94	(87)
Has heard of LARC methods2:
Heard of copper IUD	55	(51)
Heard of levonorgestrel IUS	25	(23)
Heard of etonogestrel implant	51	(47)
Would consider using LARC methods if available free or low-cost, prompted2:
Would consider copper IUD	26	(24)
Would consider levonorgestrel IUS	15	(14)
Would consider etonogestrel implant	10	(9)

LARC – long-acting reversible contraception; IUD – intrauterine device; IUS – intrauterine system

^1.Other methods included diaphragm.

^2.Women could report hearing of and considering multiple LARC methods.

Women who were interested in the copper IUD, LNG-IUS or implant most frequently mentioned the effectiveness and convenience of the method, particularly relative to their current form of contraception, as reasons for interest in use. Women using oral contraceptive pills said they liked that they would not have to remember the method every day or worry about missing pills. These themes were common for all three methods, as the following quotes illustrate:

It’s more convenient because you don’t have to take a pill every day and wonder if you’ve forgotten to take it. (39 years old, 2 children, interested in the copper IUD)

I see it as effective … because you have it inside your body, and in a place where you can see and feel it. (26 years old, 2 children, interested in the implant)

With respect to the copper IUD and LNG-IUS, women often said they would be interested in these methods because they prevent pregnancy for long periods of time. However, duration of use was not mentioned as an advantage of the implant. On the other hand, several women stated that they would use the implant because they believed it would be comfortable to use:

Well, for me it’s more comfortable that they put something in my arm than in my uterus. (36 years old, 4 children)

Other reasons women gave for being interested in LARC were that they could have it inserted or removed at any routine visit and had a positive past experience using one of the methods. Only a few women specifically mentioned the lack of hormones (copper IUD), absence of menstruation (LNG-IUS), and being able to see and feel the method (implant) as reasons they would consider use.

Reasons for lack of interest in LARC

Women’s reasons for not being interested in using the copper IUD, LNG-IUS or implant fell into four main categories: concerns about menstrual changes, uncertainty about effectiveness, other health risks of using LARC, and insertion and removal.

Concerns about menstrual changes

The most common reason women gave for not wanting to use a LARC method was that it may alter their menstrual cycle. Women liked knowing the timing and duration of their cycles and did not want to switch to a method that would affect either of these.

Because bleeding a little or a lot … it’s not normal, because I am very … regular on my period, it comes this day and stops that day, and I know my periods and [if] it’s a different color or something, I know my system. And, well, to get familiar with another method … it would scare me. It’s better that I stay on the same one that I [have used] up until now. (29 years old, 2 children)

The possibility of experiencing heavier bleeding or cramping while using the copper IUD was frequently mentioned by women who did not want to use this method. This concern was raised not only by women hearing of the method for the first time, but also previous users who recalled their negative experiences with the method. These past experiences also affected several women’s attitudes toward using the LNG-IUS, as they expected all IUDs to have similar effects on their menstrual cycle.

Irregular or absent periods associated with the use of the LNG-IUS or implant were also a concern. Women frequently stated they would worry that they had gotten pregnant. In addition, women said that irregular periods or bleeding between periods was ‘inconvenient.’ Some women also mentioned that not having a regular period would be detrimental to their health:

It’s very …risky … Think about it, if I didn’t get my period for such a long time it would harm my health. (45 years old, 4 children)

Uncertainty about LARC’s effectiveness preventing pregnancy

A second major reason women did not want to use LARC related to their feelings of uncertainty about how well these methods protect against pregnancy. Even after hearing that a particular LARC method was very effective in preventing pregnancy, women often stated that since they did not know much about the method or did not know other women who had used it, they would not consider the method themselves. In discussing why she would not use the implant, one woman said she did not think it would be effective ‘because you can’t prevent pregnancy [with something] in your arm.’

Other women, however, stated that they did not believe the methods were effective due to their own or others’ experiences becoming pregnant while using one of these methods. Because of such experiences, one woman said she would recommend the copper IUD to women who wanted to have more children, but for herself, sterilization would be a safer option. This anecdotal information was more common among women who described why they would not use the copper IUD, but was also mentioned by women who were not interested in the LNG-IUS and implant.

Because, I used it and got pregnant. And it didn’t move or anything, it was … in its place where it should have been … And there were two of us that got pregnant that way, my sister and me. (36 years old, 3 children)

Because I had it put in 16 years ago and it came out, and that was when I got pregnant with my son, the one that is 16 years old. (42 years old, 4 children)

The second statement above also highlights women’s concerns that LARC would not stay in place after insertion. Not only did women talk about how a method could be expelled, but they also feared that the method would become stuck or embedded or even move to other parts of the body. This was mentioned primarily with respect to the copper IUD and LNG-IUS, but a few women also expressed this concern about the implant.

Other health risks of using LARC

Some women did not want to use LARC because they thought it was unnatural to have a contraceptive device inside their body. Women expressed concerns about having metal in their body for 10 years, being able to feel the implant in their arm, and believing that just having the device in their body would be uncomfortable. These types of concerns emerged for all three methods.

Furthermore, women were worried about potential side effects that would result from using these methods. These ranged from physical discomforts (e.g. headaches, nausea), weight gain, and the development of ailments (e.g. ulcers, inflammation and cysts) to perceptions of serious health consequences, such as uterine cancer. Some women cited their own experiences or those of others to support these claims. One woman, however, relayed her account of a conversation with her doctor to explain why she would not use the implant:

The doctor told me that … because I’ve used the pill for so many years, anything else would give me uterine cancer, because now my body is filled with medicine, filled with pills. He said “Now, if you change from pills it would be very risky … but no other method of birth control would suit you because of your weight, because you’ve been taking the pill for years,” he said. “If you want my advice, it’s to get your tubes tied.” (34 years old, 4 children)

This statement also highlights women’s concerns with continued use of hormonal contraception, which was mentioned by several women who were not interested in the LNG-IUS or implant. Although some women linked the hormones in these methods to side effects such as headaches, many others, like the woman above, believed that long-term hormonal use was unsafe and would cause health problems. As such, they believed that use of LARC containing hormones would be no different than continued use of oral contraceptive pills. One woman also feared that, compared to the pill, these methods had higher, concentrated doses of hormones which could provoke adverse health effects.

Insertion and removal concerns

Women’s reluctance to use LARC also reflected their specific concerns about insertion and removal. These concerns were mentioned primarily for the implant, but a couple of women discussed these issues for the copper IUD and LNG-IUS as well. A number of women stated that they would not consider using the implant because they did not like needles or injections or were afraid of having anesthesia or ‘surgery,’ as illustrated in the following quotes:

I don’t like operations or injections or anything … No, the fact that they cut me, no. (35 years old, 3 children)

Well, I am a little afraid of the way they put it in, the anesthesia. (36 years old, 2 children)

Several women also mentioned that they did not want LARC because they were told the device could not be removed early. Most reported being told that they would have to use the method for a year before their provider would consider removing it. In discussing the copper IUD, one woman added that this requirement was related to the cost of the method:

They told me that since it is very expensive, they were going to give it to me and they were not going to remove it. (37 years old, 5 children)

Women also noted that they could not have the method removed, even if they had side effects. However, one woman commented that her doctor told her “if I started to have problems, they would charge me to take it [implant] out.”

Other reasons

A number of women stated that they would not use LARC because they were committed to getting a sterilization as it was ‘100% effective.’ In lieu of obtaining a sterilization, women preferred to use their current method since they had not experienced any problems and did not want to risk experiencing unexpected changes to their body or menstrual cycle.

Additional reasons that women gave for not wanting to use LARC were fears of harming the baby if a pregnancy were to occur while using an IUD, infrequent intercourse, or believing that the IUD caused abortions. These reasons, however, were not frequently mentioned. Five women said a health provider did not consider them an appropriate candidate due to reasons such as uncontrolled diabetes, obesity, family history of cancer, or metal allergies. Only two women mentioned concerns that their partner could feel the IUD strings or be injured during intercourse.

Discussion

In this sample of low-income parous Latina women who did not want more children, we found that awareness of LARC was relatively low compared to several other studies of reproductive aged women in the US (Borrero, et al., 2011; Fleming, et al., 2010; Hladky, et al., 2011). Only one-quarter to one-half of women in this sample had heard of the different LARC methods. Women’s limited awareness of the LNG-IUS and implant may be due to the infrequent use of these methods in Mexico, where a large percentage of our sample was born and educated; however, comparatively low awareness of the copper IUD is surprising since this method is well-known and widely used among Mexican women (Palma Cabrera & Palma, 2007).

Even though many women in our study were not initially aware of the different methods, we found that almost one-third would be willing to use at least one LARC method if it were available for free or low cost. This percentage is substantially higher than current use reported in other studies, including among foreign-born and Latina women for whom prevalence of LARC use is highest (Finer, et al., 2012; Thompson, et al., 2011). Participants who were interested in LARC emphasized the methods’ relative convenience and efficacy compared to their current form of contraception, as well as the long-term protection against pregnancy that these methods provide. These reasons are similar to those noted in other studies (Fleming, et al., 2010; Hladky, et al., 2011; Xu et al., 2011). Although women’s interest in LARC may not reflect their future contraceptive practice, these results provide further evidence regarding the acceptability of these methods among older reproductive aged women, whose attitudes have received less attention.

However, despite these findings, the majority of women reported that they did not want to use these methods. Similar to results reported elsewhere (Borrero et al., 2009; Fleming, et al., 2010), women in our sample were not interested in using LARC methods because of fears and misperceptions about method insertion and removal, concerns that having a contraceptive device in their body is not normal, and that the device would not stay in place. Some concerns differed for the specific methods, but, overall, women offered similar reasons for their lack of interest in LARC. For example, concerns that the device would stay in place was more common for both types of IUD than the implant, but menstrual changes of any kind were a key reason women gave for not wanting to use any of the LARC methods. A recent survey documented women’s interest in a self-removable IUD (Foster, Karasek, Grossman, Darney, & Schwarz, 2012), which might address some of the concerns raised by women in our study.

Other reasons offered may be unique to women who wish to end childbearing and for this sample in particular. Women who do not want more children may be reluctant to switch to a LARC method due to misperceptions about effectiveness, as well as their personal experiences or anecdotal evidence about pregnancy while using these methods. Furthermore, they may be less tolerant of irregular or absent periods which they associate with pregnancy.

Additionally, some women’s responses about why they would not use LARC reflected a limited understanding of reproductive physiology and hormonal methods’ mode of action. Women expressed concerns that not having menstrual periods or using hormonal methods for many years would harm their health. Similar concerns have been noted in other studies with Mexican-origin women (Grossman, Fernandez, Hopkins, Amastae, & Potter, 2010; Guendelman, Denny, Mauldon, & Chetkovich, 2000; Rivera, Mendez, Gueye, & Bachmann, 2007). In our cohort study of oral contraceptive users, half of participants stated that it was necessary to take a break from the pill to let your body rest, and many commented that long term use would lead to cancer or other health problems (Potter, et al., 2012; Shedlin, Amastae, Potter, Hopkins, & Grossman, 2013). These ideas likely also shape women’s reasoning about the LNG-IUS and implant; since both contain hormones, they may be viewed as equivalent to the pill and as such similarly ‘unsafe.’ While a combined versus progestin-only method is a significant clinical distinction, as is the primarily local hormonal effect of the LNG-IUS, most women are likely unaware of these differences which, in turn, affects their perception of safe and effective contraceptive options. This limited knowledge of reproductive physiology and method characteristics may also help explain the fact that women in this study who had previously used LARC did not express greater interest in using these methods.

Our finding that many women, including previous users, were not interested in using a LARC method may also be due to social norms and preferences surrounding contraceptive use among Mexican-born women. The copper IUD is often used for spacing births in Mexico, whereas sterilization is the prevailing method among women who do not want more children (Potter, 1999). As we previously reported, women in this sample had clear motivations for ending childbearing and using sterilization (Potter, et al., 2012). The influence of these norms and preferences on women’s contraceptive use is further reinforced by our results that, before being prompted about LARC, 87% of women said they were not considering another method besides sterilization, and many reiterated their commitment to getting sterilized in their responses.

Yet, it is also important to recognize that providers and systems issues also influence women’s contraceptive use. Publicly funded clinics may have limited supplies of LARC methods due to their higher initial cost (Lindberg, Frost, Sten, & Dailard, 2006), leading providers to impose their own guidelines around insertion and removal. This may be particularly salient in Texas, where public funding for family planning has been curtailed in recent years (White, Grossman, Hopkins, & Potter, 2012). A recent study of publicly funded clinics in Texas found that providers were less likely to recommend LARC methods to older women (Vaaler, Kalanges, Fonseca, & Castrucci, 2012). Our results suggest that providers may also restrict access by telling women they cannot have the method removed if they are dissatisfied with it. Therefore, women who already have concerns about potential side effects might be especially reluctant to choose LARC methods. Access may be further limited by providers’ lack of familiarity with the medical eligibility criteria for LARC use; several statements from women in our study, as well as a survey of Texas providers (Vaaler, et al., 2012), indicated that misperceptions about LARC are common.

Our findings should be interpreted in the context of the study’s limitations. Participants were drawn from a sample of oral contraceptive users, and their attitudes about LARC may not be representative of women in the general population who wish to end childbearing. Additionally, only those who reported that they both did not want more children and wanted a sterilization were eligible for this study, and therefore, women with interest in a broader range of methods, including LARC, may not have participated. Despite these inclusion criteria, we found that a considerable proportion of the sample would consider using at least one LARC method. In addition, women in this sample were of Mexican origin and may be less willing to use an IUD or implant as these methods are often used for spacing births in Mexico. As such, LARC methods may be more acceptable to women in other racial/ethnic groups or from countries with different contraceptive norms, and therefore interest would be greater than that observed here.

Implications for Policy and Practice

These findings suggest that many low-income Latina women do not consider LARC an alternative to sterilization, but point to an existing demand among some who wish to end childbearing. The limited awareness of and common misperceptions about these methods indicate that additional education about LARC is needed in this setting. Such efforts should be culturally tailored and address women’s understandings of reproductive physiology – as well as providers’ knowledge about appropriate method use. Additionally, increased funding for family planning services for low-income women is needed such that a range of contraception options is available and accessible, thereby enabling women to achieve their reproductive goals.

Appendix

Interview script describing specific LARC methods

Now I would like to ask you some questions about other long-term methods that couples can use to prevent pregnancy. All of the methods I am going to talk to you about are very effective at preventing pregnancy, very safe, and most women are able to use them without any problems.

The IUD is a small plastic or metal device that is inserted into the uterus to prevent pregnancy. It can be used for 5 to10 years, depending on the type of IUD. There are two types of IUDs available in the US. The ParaGard IUD, also known as the Copper T, is made of plastic and copper, and it does not have any hormones. A doctor can insert the ParaGard IUD during a routine visit and remove it at any time. Women that use the ParaGard IUD continue having periods each month and sometimes their periods may become heavier and more painful. The ParaGard IUD can be used for up to 10 years. Have you heard of the ParaGard IUD?

The other IUD is called the Mirena. This IUD is similar to the ParaGard but it is made of only plastic and it releases a low dose of progesterone hormones into the uterus to prevent pregnancy. Like the ParaGard IUD, a doctor can insert the Mirena IUD during a routine visit and remove it at any time. Women using the Mirena IUD have irregular periods at the beginning and often do not have periods at all while using Mirena. The Mirena IUD can be used for up to 5 years. Have you heard of the Mirena IUD?

Finally, Implanon is not an IUD. It is a small matchstick-size rod that is inserted under the skin in your arm and releases hormones to prevent pregnancy. A doctor can insert Implanon using local anesthetic during a routine visit and can remove it any time. Women using Implanon often have irregular periods and may have bleeding between periods. It can be used for up to 3 years. Have you heard of Implanon?