Abstract
Objectives. We evaluated the impact of exposure to emotional, physical, or sexual abuse on contraceptive method selection and discontinuation.
Methods. We performed a secondary analysis of 7170 women enrolled in the Contraceptive CHOICE Project in St. Louis, Missouri, a prospective cohort study in which 9256 women were provided their preferred method of contraception at no cost from 2007 to 2011. We defined contraceptive discontinuation as device removal or nonuse for at least 4 weeks within the first 12 months after initiation.
Results. One third of women experienced some abuse in their lifetimes. Women with an abuse history were as likely as those without to select a long-acting reversible contraceptive method and more likely to choose a contraceptive injection, the patch, or the ring. When we compared women who were abused to those who were not, rates of discontinuation at 12 months were higher among women who selected long-acting reversible contraception (17% vs 14%; P = .04) and significantly higher among women who selected non–long-acting methods (56% vs 47%; P < .001). Type of abuse did not alter the association between abuse and contraceptive continuation.
Conclusions. Previous experiences of abuse are associated with both contraceptive method selection and continuation.
Research has shown that violence against women is disturbingly common.1,2 A 2000 Centers for Disease Control and Prevention nationally representative survey of 8000 women aged 18 years and older found that the lifetime prevalence of physical intimate partner violence was 25%, and 56% of women reported at least 1 incident of physical or sexual assault.1 A 2010 survey conducted by the National Center for Injury Prevention and Control found that 36% of women reported intimate partner violence during their lifetime, 18% of women had been raped, and 45% of women reported some other form of sexual violence.2
A developing body of evidence suggests that childhood and adulthood violence has far-reaching effects on women’s lives.1,3,4 Women with a history of violence report more high-risk health behaviors, such as early age at first intercourse or more lifetime sexual partners,5,6 more psychological effects including posttraumatic stress disorder and depression, higher rates of physical injury, and decreased access to social networks than women with no history of violence.1,7 In addition, women with current or past histories of violence may face unwanted or mistimed pregnancies, are at an increased risk of acquiring sexually transmitted infections (STIs), and are more likely to undergo repeat abortions.1,8–14
Exposure to all forms of violence may influence the choices that women make regarding contraceptive use.10,12,15,16 Women’s perceptions and experience of loss of reproductive control may affect their decisions to use contraception, lead to decreased conviction to use condoms, or result in partner control over administration and type of contraception used.11,16 Gee et al. demonstrated that, because of difficulties imposed by their partners, women with exposure to intimate partner violence were less likely than nonexposed women to use birth control.9 Compared with women without violence exposure, women with a history of intimate partner violence reported that their male partners were more likely to refuse to use condoms (21% vs 7%; P < .001) and to refuse to allow contraception (5% vs 1%; P < .001).15 Women exposed to violence were also less likely than their nonexposed peers to ask their partners to wear condoms (35% vs 56%; P < .001).15 Finally, previous experiences of abuse, particularly those occurring in childhood, might have an impact on contraceptive choices via alternate pathways including depression, substance abuse, and alcohol use.17–19
In light of these findings, women who experience histories of abuse may benefit from contraceptive methods that are independent of their partners. In this analysis, we sought to estimate the association of childhood, adult, and lifetime exposure to physical, emotional, or sexual abuse with contraceptive method selection and duration of use for both long-acting reversible contraception (LARC; intrauterine devices and hormonal implant) and non–long-acting methods of contraception (non-LARC; birth-control pill, injection, ring, or patch) in the Contraceptive CHOICE Project (CHOICE).
METHODS
We performed a secondary analysis of data collected for CHOICE, an ongoing prospective cohort study. CHOICE enrolled women in the St. Louis, Missouri, region from August 2007 through September 2011. A primary objective of CHOICE is to promote the use of LARC by providing women with comprehensive contraceptive counseling and the method of reversible contraception of their choice at no cost to them for up to 3 years. Women were eligible to participate if they were aged 14 to 45 years; resided in St. Louis or sought clinical services at designated recruitment sites; had been sexually active with a male partner in the past 6 months or anticipated sexual activity in the next 6 months; did not have a tubal ligation or hysterectomy; did not desire pregnancy in the next year; and were interested in starting a new reversible contraceptive method.
At entry into the study, each participant completed a comprehensive enrollment visit that included contraceptive counseling, a staff-administered questionnaire, and clinical consultation for the provision of the participant’s chosen contraceptive method. The questionnaire included questions regarding demographic characteristics; medical, contraceptive, and reproductive history; risk behaviors; and history of violence.
Baseline demographic information included age, self-reported race and ethnicity, highest level of education, and body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) at enrollment. Indicators of socioeconomic status included type of medical insurance and receipt of public assistance or difficulty paying for basic needs such as food or transportation.
Reproductive history included age of first pregnancy, parity, history of unintended pregnancies and elective abortions, timing of elective abortions relative to study enrollment, previous use of contraceptive methods, and history of STIs (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, genital warts, or HIV). Sexual history included current condom use, number of lifetime sexual partners, participant’s impression of her partner’s willingness to use condoms, and confidence in condom use. We calculated a confidence in condom use score, ranging from 5 (low confidence) to 25 (high confidence), from a woman’s self-reported confidence in her ability to use a condom in 5 situations: under the influence of alcohol or drugs, when her partner is annoyed, during sexual excitement, when depressed, or when perceived risk is low.20 We assessed depressive symptoms by using the 10-item Center for Epidemiologic Studies of Depression scale.21
We evaluated potential confounders for univariate associations with history of abuse (Table 1) and time to method discontinuation stratified by LARC method use (data not shown).
TABLE 1—
Overview of Participant Demographic and Reproductive Characteristics by Lifetime Exposure to Abuse: Contraceptive CHOICE Project, St. Louis, MO, 2007–2011
| Any Abuse |
||||
| Characteristics | All Participants (n = 7170), No., No. (%), or Mean ±SD | No (n = 5078), No., No. (%), or Mean ±SD | Yes (n = 2092), No., No. (%), or Mean ±SD | P |
| Age, y | 25.2 ±5.9 | 24.8 ±5.7 | 26.1 ±6.2 | <.001 |
| Race | ||||
| Black/African American | 3545 (49) | 2587 (73) | 958 (27) | <.001 |
| White | 3068 (43) | 2108 (69) | 960 (31) | |
| Other or multiracial | 556 (8) | 382 (69) | 174 (31) | |
| Hispanic | ||||
| No | 6808 (95) | 4817 (71) | 1991 (29) | .58 |
| Yes | 362 (5) | 261 (72) | 101 (28) | |
| Education | ||||
| ≤ high school | 913 (13) | 650 (71) | 263 (29) | .03 |
| High school or GED | 1574 (22) | 1083 (69) | 491 (31) | |
| Some college, vocational, or technical school | 3021 (42) | 2125 (70) | 896 (30) | |
| College degree | 1659 (23) | 1219 (73) | 440 (27) | |
| Government assistance or trouble paying for basic expensesa | ||||
| No | 3054 (43) | 2387 (78) | 667 (22) | <.001 |
| Yes | 4116 (57) | 2691 (65) | 1425 (35) | |
| Medical insurance | ||||
| None | 2995 (42) | 2023 (68) | 972 (32) | <.001 |
| Medicaid or Medicare | 1030 (14) | 711 (69) | 319 (31) | |
| Private | 1997 (28) | 1441 (72) | 556 (28) | |
| Other | 1098 (15) | 860 (78) | 238 (22) | |
| Body mass index, kg/m2 | 27.8 ±7.2 | 27.5 ±7.0 | 28.3 ±7.6 | <.001 |
| Depressive symptom score ≥ 10 | ||||
| No | 5419 (77) | 4055 (81) | 1364 (66) | <.001 |
| Yes | 1642 (23%) | 946 (19) | 696 (34) | |
| Age at first pregnancy | 19.6 ±4.0 | 19.6 ±3.9 | 19.5 ±4.2 | .29 |
| Parity, median | 1 | 1 | 1 | <.001 |
| 0b | 3388 (47) | 2463 (73) | 925 (27) | <.001 |
| 1 | 1759 (25) | 1262 (72) | 497 (28) | |
| 2 | 1235 (17) | 839 (68) | 396 (32) | |
| ≥ 3 | 788 (11) | 514 (65) | 274 (35) | |
| No. of unintended pregnancies, median | 2 | 2 | 2 | <.001 |
| History of abortion, median | 0 | 0 | 0 | <.001 |
| 0b | 4566 (64) | 3306 (72) | 1260 (28) | <.001 |
| 1 | 1662 (23) | 1157 (70) | 505 (30) | |
| ≥ 2 | 942 (13) | 615 (65) | 327 (35) | |
| Timing of abortion in relation to study enrollment | ||||
| Never | 3917 (55) | 2841 (56) | 1076 (51) | <.001 |
| Before study enrollment | 2023 (28) | 1358 (27) | 665 (32) | |
| At time of study enrollment | 1229 (17) | 879 (17) | 350 (17) | |
| History of STIc | ||||
| No | 4525 (63) | 3361 (74) | 1164 (26) | <.001 |
| Yes | 2645 (37) | 1717 (65) | 928 (35) | |
| Any STI at baselined | ||||
| No | 6417 (93) | 4553 (71) | 1864 (29) | .19 |
| Yes | 490 (7) | 334 (68) | 156 (32) | |
| Current condom use at enrollment | ||||
| No | 5155 (72) | 3650 (71) | 1505 (29) | .96 |
| Yes | 2015 (28) | 1428 (71) | 587 (29) | |
| Condom confidence score | 18.8 ±5.4 | 19.1 ±5.3 | 18.3 ±5.6 | <.001 |
| Perception that partner is willing to use condomse | ||||
| Not willing | 1495 (27) | 980 (66) | 515 (34) | <.001 |
| Willing | 4041 (73) | 2905 (72) | 1136 (28) | |
| Total lifetime sexual partners | 8.9 ±11.8 | 7.4 ±9.2 | 12.3 ±16.0 | <.001 |
Note. GED = general equivalency diploma; STI = sexually transmitted infection.
Receives public assistance (current receipt of food stamps; Special Supplemental Nutrition Program for Women, Infants, and Children; welfare; or unemployment) or has trouble paying basic expenses (transportation, housing, health or medical care, or food).
P value estimated by using Cochran-Armitage test of trend.
History of STI: self-reported history of chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, or human immunodeficiency virus.
Any STI at baseline: positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis.
The sample size was n = 5536 because not all participants had current sexual partners.
We ascertained assessment of physical, sexual and emotional abuse via a survey based on the Conflict Tactics Scale22 and the Abuse Assessment Screen.23 Participants were asked to recall experiences of abuse during 2 distinct time periods: childhood (abuse by an adult while aged ≤13 years) and adulthood (abuse by any individual while aged ≥14 years). We defined physical abuse as physical force used against the woman. Specifically, women were asked how often anyone hit, kicked, or beat them or seriously threatened their lives. We defined emotional abuse as behaviors or language perpetrated toward the woman to emotionally hurt her. Specifically, we asked women how often anyone emotionally abused, humiliated, or insulted them. For physical and emotional abuse, we classified a woman as exposed to abuse if she had had more than 1 such experience. Finally, we defined sexual violence as any sexual act that the woman was forced to participate in without her consent. Each woman was asked whether anyone exposed his or her sex organs to her, touched her in an inappropriately sexual manner, or forced her to perform sexual acts or have intercourse with him or her. Any experience of sexual abuse was classified as exposed.
Participants included in this analysis had information on previous exposure to violence and data on contraceptive continuation through 12 months of observation. We excluded women who did not start their chosen method within 3 months or who had not reached 12 months of follow-up. Those included in this analysis were similar to the overall CHOICE cohort in baseline demographic characteristics, current contraceptive at enrollment, and history of violence.
We examined exposure to violence in relation to the type of contraceptive method chosen at enrollment. LARC methods included the levonorgestrel intrauterine system, the copper intrauterine device, and the etonogestrel implant. Non-LARC methods included oral contraceptive pills, vaginal ring, contraceptive patch, and depot medroxyprogesterone acetate (DMPA) injection. Non-LARC methods were further broken down into 2 categories: pill, patch, and ring (PPR) or DMPA. We stratified analyses in this manner because of the opportunity for differential influence in use and continuation by partners and because of marked differences in rates of selection and continuation.24–26
Methods describing contraceptive continuation in CHOICE are described elsewhere.24 In brief, we estimated time to discontinuation of a chosen contraceptive method within 12 months from survey, pharmacy, and clinical research records. Women who reported discontinuation in the 3-, 6-, or 12-month surveys provided month and year of discontinuation. For women who did not complete these surveys, we used clinical research records (contraceptive method distribution and removal logs) and pharmacy records to estimate time of discontinuation. We censored women who were lost to follow-up at their last survey date and we censored continuing users at 12 months.
We used descriptive statistics to determine the relationship between abuse and contraceptive method selected at enrollment. We used χ2 tests to test for differences in categorical variables, t tests for continuous variables, and Cochran-Armitage tests of trend for ordinal data. We estimated time to discontinuation at 12 months from enrollment by using survival analysis. We constructed Cox proportional hazards regression models to estimate the hazard rate ratios with adjustment for potential confounders. We examined potential confounders for their relationship to history of violence (Table 1) and association to time to discontinuation between LARC and non-LARC users separately. Models adjusted for variables significant (P < .05) in both comparisons, including age, race, Hispanic ethnicity, baseline BMI, and history of STI. Because of the potential association with timing of abortion in relation to study enrollment and method discontinuation, we forced this variable into the model despite its not meeting traditional criteria for confounding. We analyzed data with Stata version 12 (StataCorp LP, College Station, TX).
RESULTS
This analysis included 7170 participants enrolled in CHOICE (Table 1). The population was diverse and included a majority of women with low socioeconomic position as determined by insurance status, receipt of public assistance, and self-reported ability to pay for basic expenses. Overall, exposure to physical, sexual, and emotional abuse was common among CHOICE participants (see information available as a supplement to the online version of this article at http://www.ajph.org). Nearly 1 in 3 women (29%) reported some lifetime exposure to abuse, 19% first reported abuse during childhood, and 10% first reported it in adolescence or adulthood. Approximately 8% of the cohort reported abuse in childhood and later in life. Fifteen percent of women reported sexual abuse at some point in their lives with 11% first reporting abuse in childhood and 4% first reporting it later in life. When we loosened our criteria for abuse to include a single occurrence of emotional or physical abuse, 54% of women in our cohort were counted as exposed.
Contraceptive method selected at baseline differed with childhood or lifetime exposure to abuse (Table 2). Exposure to emotional, physical, or sexual abuse before the age of 14 years was associated with modest shifts in method of contraception selected. Women reporting emotional, physical, or sexual abuse were as likely to choose a long-acting method as women without an exposure to childhood abuse. Among women who chose a non-LARC method, those with histories of childhood abuse were more likely than women without such history to select DMPA over PPR. There were no significant associations between experiences of any type of abuse after the age of 14 years with method of contraception selected.
TABLE 2—
Method of Contraception Chosen at Baseline by Women: Contraceptive CHOICE Project by Lifetime History of Abuse, St. Louis, MO, 2007–2011
| Prevalence of Baseline Chosen Contraceptive Method, % |
||||||
| Type of Abuse | No. | LARC | PPR | DMPA | LARC vs non-LARC, RR (95% CI) | DMPA vs PPR, RR (95% CI) |
| Childhood (aged < 14 y) | ||||||
| None | 5631 | 72 | 20 | 7 | 1.00 (Ref) | 1.00 (Ref) |
| Any | 1532 | 75 | 16 | 8 | 1.04 (1.01, 1.08) | 1.28 (1.09, 1.51) |
| Emotionala | 896 | 76 | 17 | 8 | 1.04 (1.00, 1.09) | 1.18 (0.96, 1.45) |
| Physicala | 641 | 78 | 14 | 8 | 1.08 (1.03, 1.13) | 1.37 (1.09, 1.73) |
| Sexual | 763 | 75 | 15 | 10 | 1.03 (0.99, 1.08) | 1.47 (1.21, 1.78) |
| ≥ 2 types | 609 | 78 | 13 | 8 | 1.08 (1.03, 1.13) | 1.42 (1.13, 1.78) |
| Adult (aged ≥ 14 y) | ||||||
| None | 5854 | 73 | 20 | 7 | 1.00 (Ref) | 1.00 (Ref) |
| Any | 1307 | 74 | 18 | 8 | 1.02 (0.98, 1.06) | 1.14 (0.95, 1.36) |
| Emotionala | 964 | 74 | 18 | 8 | 1.03 (0.98, 1.07) | 1.11 (0.91, 1.36) |
| Physicala | 453 | 74 | 18 | 8 | 1.02 (0.97, 1.08) | 1.12 (0.85, 1.49) |
| Sexual | 484 | 73 | 18 | 9 | 1.00 (0.94, 1.06) | 1.22 (0.94, 1.57) |
| ≥ 2 types | 496 | 74 | 18 | 9 | 1.01 (0.96, 1.07) | 1.20 (0.93, 1.55) |
| Lifetime | ||||||
| None | 5078 | 72 | 20 | 7 | 1.00 (Ref) | 1.00 (Ref) |
| Any | 2092 | 74 | 18 | 8 | 1.03 (0.99, 1.06) | 1.22 (1.04, 1.41) |
| Emotionala | 1353 | 75 | 17 | 7 | 1.04 (1.00, 1.07) | 1.10 (0.91, 1.31) |
| Physicala | 898 | 76 | 16 | 8 | 1.05 (1.01, 1.09) | 1.28 (1.05, 1.56) |
| Sexual | 1044 | 74 | 16 | 10 | 1.02 (0.98, 1.06) | 1.39 (1.16, 1.65) |
| ≥ 2 types | 931 | 76 | 16 | 8 | 1.05 (1.01, 1.10) | 1.28 (1.05, 1.56) |
Note. CI = confidence interval; DMPA = depot medroxyprogesterone acetate contraceptive injection; LARC = long-acting reversible contraception (intrauterine device or hormonal implant); non-LARC = contraceptive pill, patch, ring, or injection; PPR = contraceptive pill, patch, or ring; RR = relative risk. The sample size was n = 7170.
Emotional and physical abuse classified as abuse if more than a single occurrence of abuse.
We examined the impact of history of childhood experiences of abuse on contraceptive method discontinuation. Compared with nonabused women, women with histories of childhood abuse had faster rates of discontinuation for both LARC and non-LARC methods (Figure 1 and Table 3) after adjustment for age, race/ethnicity, baseline BMI, history of STI, and timing of abortion. After 12 months, 48% of women not exposed to childhood abuse had discontinued their non-LARC method whereas 55% of abuse-exposed women had discontinued their non-LARC method (adjusted hazard ratio [AHR] = 1.24; 95% confidence interval [CI] = 1.06, 1.45). We examined specific type of abuse and found that, among non-LARC users, reported emotional or sexual abuse was associated with increased rates of discontinuation. Although the rates of discontinuation of LARC methods were significantly lower than those found for non-LARC methods, we found that childhood abuse was also associated with faster discontinuation of LARC methods of contraception (AHR = 1.32; 95% CI = 1.11, 1.56). Within 12 months, 14% of women with no childhood abuse discontinued their LARC methods whereas 18% of women with a history of abuse discontinued their LARC methods.
FIGURE 1—
Cumulative discontinuation rates by contraceptive method and experience of abuse for (a) childhood abuse and (b) adult abuse: Contraceptive CHOICE Project, St. Louis, MO, 2007–2011.
Note. LARC = long-acting reversible contraception (intrauterine device or hormonal implant); non-LARC = contraceptive pill, patch, ring, or injection.
TABLE 3—
Contraceptive Discontinuation Rates and Adjusted Hazard Ratio for Types of Abuse and First Experience of Abuse Among Women: Contraceptive CHOICE Project, St. Louis, MO, 2007–2011
| PPR or DMPA |
LARC |
|||||
| Discontinuation Rate, % |
Discontinuation Rate, % |
|||||
| Type of Abuse | 6 Months | 12 Months | AHRa (95% CI) | 6 Months | 12 Months | AHRa (95% CI) |
| Childhood (aged < 14 y) | ||||||
| None | 34.3 | 47.7 | 1.00 (Ref) | 7.2 | 14.2 | 1.00 (Ref) |
| Any | 41.1 | 55.1 | 1.24 (1.06, 1.45) | 9.3 | 18.1 | 1.32 (1.12, 1.56) |
| Emotionalb | 40.8 | 57.7 | 1.31 (1.08, 1.59) | 9.9 | 17.9 | 1.29 (1.05, 1.58) |
| Physicalb | 34.9 | 44.9 | 0.92 (0.71, 1.20) | 10.3 | 18.5 | 1.29 (1.03, 1.61) |
| Sexual | 45.3 | 58.3 | 1.33 (1.08, 1.63) | 9.7 | 18.9 | 1.36 (1.10, 1.69) |
| ≥ 2 types | 40.7 | 53.1 | 1.18 (0.92, 1.51) | 11.1 | 18.8 | 1.35 (1.08, 1.70) |
| Adulthood (aged ≥ 14 y) | ||||||
| None | 33.3 | 47.0 | 1.00 (Ref) | 7.6 | 15.0 | 1.00 (Ref) |
| Any | 46.3 | 59.3 | 1.47 (1.25, 1.73) | 7.9 | 14.9 | 1.03 (0.86, 1.25) |
| Emotionalb | 43.9 | 58.4 | 1.40 (1.16, 1.69) | 8.9 | 15.0 | 1.06 (0.86, 1.31) |
| Physicalb | 50.2 | 66.3 | 1.67 (1.30, 2.14) | 9.6 | 17.0 | 1.21 (0.91, 1.60) |
| Sexual | 49.5 | 56.0 | 1.35 (1.06, 1.72) | 5.3 | 13.8 | 0.92 (0.68, 1.25) |
| ≥ 2 types | 47.5 | 59.0 | 1.43 (1.12, 1.83) | 9.2 | 15.2 | 1.09 (0.82, 1.45) |
| Lifetime | ||||||
| None | 32.8 | 46.6 | 1.00 (Ref) | 7.3 | 14.4 | 1.00 (Ref) |
| Any | 42.9 | 55.9 | 1.34 (1.16, 1.54) | 8.6 | 16.6 | 1.20 (1.03, 1.40) |
| Emotionalb | 43.4 | 57.9 | 1.39 (1.17, 1.64) | 9.2 | 16.0 | 1.15 (0.96, 1.38) |
| Physicalb | 41.7 | 54.3 | 1.22 (1.00, 1.49) | 9.3 | 17.1 | 1.20 (0.97, 1.47) |
| Sexual | 45.2 | 56.4 | 1.31 (1.09, 1.57) | 8.5 | 17.3 | 1.23 (1.01, 1.49) |
| ≥ 2 types | 44.2 | 56.1 | 1.30 (1.07, 1.58) | 9.8 | 16.8 | 1.21 (0.99, 1.49) |
Note. AHR = adjusted hazard ratio; CI = confidence interval; DMPA = depot medroxyprogesterone acetate contraceptive injection; LARC = long-acting reversible contraception (intrauterine device or hormonal implant); PPR = contraceptive pill, patch, or ring. The sample size was n = 7170.
Adjusted for age, race, Hispanic ethnicity, baseline body mass index (defined as weight in kilograms divided by the square of height in meters), history of sexually transmitted infection, and timing of abortion.
Emotional and physical abuse classified as abuse if more than a single occurrence of abuse.
We explored the relationship between exposure to adult abuse and discontinuation of contraception. Women exposed to adult abuse were no more likely than nonabused women to discontinue LARC methods (AHR = 1.03; 95% CI = 0.86, 1.25; Figure 1 and Table 3). In contrast, abuse was significantly linked to faster discontinuation (AHR = 1.47; 95% CI = 1.25, 1.73) among non-LARC users. For example, 47% of women who reported no adult abuse discontinued their non-LARC method within 12 months, whereas 59% of women who reported adult abuse discontinued their non-LARC method in this same timeframe. Furthermore, emotional, physical, and sexual abuse was each independently associated with increased risk of discontinuation of non-LARC methods.
DISCUSSION
With the goal of both decreasing unintended pregnancies and preventing STIs, one key strategy is to empower women with information on how they may best protect themselves. To our knowledge, this is the first published study to examine the relationship between abuse history and selection and continuation of reversible contraceptive methods. Consistent with national estimates,1 reports of exposure to violence and abuse were common in our cohort. Half of women in CHOICE reported some exposure to abuse during their lifetimes, and almost 1 in 3 women met our definition of abuse (single experience of sexual abuse or repeated experiences of physical or emotional abuse). Among CHOICE participants selecting a non-LARC method, women exposed to abuse were more likely to choose DMPA over PPR than women without exposure to abuse. This finding was welcome, because women with histories of violence benefit greatly from highly effective contraceptive methods that do not require partner consent or cooperation.
Abuse exposure was associated with more rapid discontinuation of contraception, particularly among non-LARC users. Women who reported abuse during childhood were significantly more likely to discontinue non-LARC methods than were never-abused women; at 12 months, 55% of women abused in childhood had discontinued their method, whereas 48% in the never-abused group had done so. Women reporting childhood abuse were also more likely to discontinue LARC methods (18% vs 14%) at 12 months than were nonabused women. In a similar way, abuse exposure in adulthood was associated with increased rates of non-LARC discontinuation at 12 months (59% vs 47%). Moreover, we noted that the effect of adult abuse was greatest on women using PPR or DMPA as their contraceptive method, a pattern not observed among LARC users reporting adult abuse. When we examined types of abuse reported throughout a woman’s lifetime, it was clear that emotional, physical, and sexual abuse may each have an impact on contraceptive continuation.
Women exposed to abuse are particularly vulnerable to suffering from decreased power and confidence in their abilities to assert themselves (self-efficacy) in their sexual lives. First, although they are at increased risk of unintended pregnancy,27 effective contraception may be difficult for this population if it requires male willingness (e.g., condoms) or can be observed and controlled by male partners (e.g., PPR).11,28,29 This may explain why we observed that previous experiences of abuse lead to faster discontinuation of non-LARC contraception. Second, abuse-exposed women are at increased risk of STIs. In a previous study, we found that women exposed to physical violence in the past year had a 2-fold increased risk for developing an incident STI.30 In our study, 55% of abused women had a history of STIs, whereas 34% of nonabused women did.
We found that participants reporting lifetime exposure to abuse did not differ from never-abused women in rates of self-reported condom use at baseline. However, women with abuse histories did report lower conviction that they would use condoms when depressed, sexually excited, under the influence of alcohol or drugs, or when their partner seemed annoyed about using condoms. This confirms recent findings by Swan and O’Connell that incarcerated women with a history of intimate partner violence reported decreased confidence in their abilities to negotiate condom use.31
Our study had a number of strengths. The size and diversity of the study population allowed us to make meaningful comparisons to urban populations of women at risk for unintended pregnancy. We used a structured interview to measure history of childhood and adolescent or adult abuse and condom confidence.20,22,23,32 Moreover, we addressed situation-dependent conviction to use condoms and history of and current STI.
This is a secondary analysis of an ongoing prospective cohort study on contraceptive choice and may have limitations, which we have tried to mitigate where possible. First, participant recall of abuse may be underreported. In particular, there may be differences in willingness to report current versus past experiences of violence, resulting in underreporting of current adult exposure to abuse.8 To alleviate this problem, our analysis examined only baseline history of violence and inquired broadly on life stages (childhood vs adulthood), but did not inquire about recency of reported abuse.
Second, because the identification of violence may be subjective, questions aimed at differentiating emotional, physical, or sexual acts focused on specific actions (e.g., hitting, punching, threatening) to minimize misclassification. Variability in definitions of violence and abuse across surveys limit the comparisons we are able to make. For example, Kazi et al. found that 18% of participants in abortion, contraceptive, or gynecologic research studies reported domestic abuse, whereas 18% of CHOICE participants reported any adolescent or adult abuse regardless of perpetrator. CHOICE participants also report slightly lower lifetime rates of sexual violence (15% vs 18%–21%), but it is not clear whether this is attributable to differences in study design and setting or the relative youth of the CHOICE cohort.2,33 Furthermore, the Contraceptive CHOICE Project did not inquire about ongoing abuse, so it was not possible to dissect the effects of ongoing versus past experience of abuse.
Finally, it is possible that the unique environment of the Contraceptive CHOICE Project, which actively seeks to promote the most effective and appropriate methods for individual women and provides direct contraceptive counseling and contraception at no cost, could have resulted in selection bias in participant enrollment and increased selection of the most effective methods of contraception. The study enrolled women seeking to start a method of contraception, recent initiators of a new method (within the past month), or those interested in initiating a new method, which may have had an impact on generalizability. A previous comparison of the CHOICE cohort with state and nationally representative surveys found that, despite differences in sampling strategies, contraceptive prevalence estimates were largely similar with the exception that CHOICE participants were more likely to report condom use and less likely to report oral contraceptive use or withdrawal.34
In this study of women seeking contraception, almost 1 in 3 women reported a history of sexual abuse or repeated experiences of emotional or physical abuse. Our findings highlight the large proportion of women who have experienced abuse in their lifetimes and the association of abuse with contraceptive method selection and discontinuation. Women with histories of abuse who select non-LARC methods may benefit from enhanced counseling as significant differences in contraceptive continuation existed by 6 months after initiation. Differences in continuation of LARC methods were modest and our data support current recommendations that LARC should be offered as first-line contraceptive methods.35 A health care provider who identifies a woman with a history of abuse should consider the patient’s ability to maintain ongoing use, discuss LARC methods as the most effective contraceptive options to prevent pregnancy,36 and provide optimal contraceptive management in a manner that is effective, private, and safe.
Acknowledgments
The Contraceptive CHOICE Project is supported by the Susan Thompson Buffett Foundation.
We thank the 9256 women who participated in the Contraceptive CHOICE Project and the stellar CHOICE research team whose dedication and hard work has made this research possible. Jessica Kenerson, MD, and Kimberly A. Roehl, MPH, contributed to an early version of this article. Thank you to Deborah J. Frank, PhD, for a detailed review of the article.
Human Participant Protection
The Contraceptive CHOICE Project study was approved by the Human Research Protection Office of Washington University in St. Louis.
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