Contraceptive practices and attitudes among immigrant and nonimmigrant women in Canada

Abstract

Objective

To compare experiences, attitudes, and beliefs of immigrant and nonimmigrant women presenting for abortion with regard to contraception, and to identify difficulties involved in accessing contraception in Canada.

Design

A survey of immigrant and nonimmigrant women asking about women’s experiences with and attitudes toward contraceptives and any barriers to contraceptive access they have encountered. Demographic data including ethnicity, country of origin, and length of residence in Canada were collected.

Setting

Two urban abortion clinics.

Participants

Women presenting for first-trimester abortion.

Main outcome measures

Type of contraception used when the unwanted pregnancy was conceived, attitudes to contraceptives, and barriers to access of contraceptives.

Results

A total of 999 women completed questionnaires during the study period (75.9% response rate); 466 of them (46.6%) were born in Canada. Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant (12.5% vs 23.5%, P < .001) and had more negative attitudes toward hormonal contraception (62.6% vs 51.6%, P < .003). They reported having more difficulties accessing contraception before the abortion (24.8% vs 15.3%, P < .001) than nonimmigrant women did. About half of all the women expressed fear about intrauterine device use. The longer immigrant women had lived in Canada, the more likely they were to have similar responses to those of Canadian-born women.

Conclusion

The information provided by this study might be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps and other culturally relevant concerns. As about half of all women presenting for abortion expressed negative attitudes toward the more effective methods of contraception, it is important that family doctors educate all women at risk for unintended pregnancies.

Three previous studies of contraception and ethnicity^1–3 found that the contraceptive practices and attitudes of immigrant women differed from those reported by other Canadian women.^4,5 Specifically, they found that among Chinese and Korean immigrant groups in Vancouver, BC, women expressed a deep suspicion toward hormonal methods of contraception, such as birth control pills, and were reluctant to use them. Most couples reported using a mix of condoms, the rhythm method, and the withdrawal method. Additionally, it was necessary to ask up to 5 questions to identify what types of contraception immigrant couples were using. Anecdotally, a similar attitude toward hormonal contraception seems to be shared by many patients who have emigrated from countries other than China and Korea.

According to the 2006 census, approximately half of the population of greater Vancouver comprised immigrants.⁶ This ethnocultural distribution is reflected in the demographic characteristics of the patients presenting for abortion. In a previous chart-review study of 993 patients in a Vancouver abortion clinic in 2008, 50.1% of patients were white or Caucasian, 29.7% were East Asian, 15.4% were South Asian, and 4.8% were of other ethnicities (ethnicity was determined by surname only).⁷ Census data show that about one-third of immigrants have lived in Canada for less than 5 years.⁶ The most recent census in 2011 indicated that only 47.7% of women in Vancouver spoke English as a first language and 36.3% mostly spoke another language at home.⁸

The purpose of this study was to compare experiences, attitudes, and beliefs of immigrants and nonimmigrants presenting for abortion with regard to contraception, and to identify difficulties involved in accessing contraception in Canada. As women presenting for abortions are those whose contraceptive needs are not being adequately met, this sample might provide insight into the knowledge gaps and problems of accessibility that should be addressed.

METHODS

This study surveyed women presenting for abortion at 2 urban abortion clinics. The questionnaire asked about women’s usage and experiences of both hormonal contraceptives and natural family planning methods, their attitudes toward medical contraceptive methods (hormonal and intrauterine), any barriers to contraceptive access they encountered, and the sources of information they relied on to make their contraceptive decisions. Demographic data, including ethnicity, country of origin, and length of residence in Canada, were collected. This questionnaire was pilot–tested and edited before the study began.

The questionnaires were given to all women upon arrival for an initial appointment for a medical or surgical abortion. It was made clear by reception staff which forms were mandatory and which were optional. A confidential dropbox was placed in the waiting room for completed questionnaires. The questionnaires were available in English, Chinese, and Punjabi (the 3 most common languages in the area). The translations were done by certified translators and checked for readability by clinic staff fluent in those languages. There were no exclusion criteria. This study was approved by the Behavioural Research Ethics Board of the University of British Columbia.

Analysis

The data from the questionnaires were entered into an SPSS (PASW 18) database for statistical analysis. I compared 3 groups: women born in Canada, immigrant women who had lived in Canada for less than 5 years, and immigrant women who had lived in Canada for 5 or more years. Using χ² analysis, I compared those 3 groups with respect to demographic characteristics, contraceptive practices, and attitudes toward contraceptives. The sample size of 1000 was chosen to be larger than that required by the main outcome measures to allow for a description of a wider range of women requiring contraception.

RESULTS

A total of 999 questionnaires were completed between April and September 2010. During this time 1316 women presented for abortion at our clinic, giving a response rate of 75.9%. They had been born in 75 different countries, with 46.6% born in Canada and 38.1% in Asia (Table 1). When they conceived, immigrants were less likely to have been using hormonal contraception (n = 58, 12.5% vs n = 103, 23.5%; P < .001) and more likely to have been using the “counting safe days” method (n = 128, 27.6% vs n = 64, 14.6%; P < .001; Table 2). Immigrants had less experience using hormonal contraception (60.2% vs 92.9%, P < .001) and more negative attitudes toward it; 62.6% compared with 51.6% agreed with the statement, “I am concerned that this kind of birth control is not healthy for my body” (Table 3). A similar number had used intrauterine devices in the past (12.9% vs 13.4%), but more immigrants (57.4% vs 48.9%, P = .027) agreed with the statement, “I am afraid to use this type of birth control.” Women who had been in Canada for less than 5 years had more negative attitudes to contraception and were less likely to be using more effective methods of contraception than women who had immigrated 5 or more years ago. Of the 741 women who had used hormonal contraception in the past, immigrants were less likely to complain of side effects than nonimmigrants were (Table 4). More immigrants said they had problems getting birth control (24.8% vs 15.3%, P < .001; Table 5). Immigrants were more likely to not know about birth control or not know where to get it. The most common problem nonimmigrants reported was not having enough money to buy birth control.

Table 1.

Location of birth of respondents

COUNTRY OR CONTINENT	RESPONDENTS, N (%)
North America	474 (47.4)
China	119 (11.9)
India	136 (13.6)
Other part of Asia	126 (12.6)
Africa	15 (1.5)
Europe	56 (5.6)
Latin America	19 (1.9)
Oceania, Australia, or New Zealand	15 (1.5)
Middle East	36 (3.6)
Unknown	3 (0.3)
Total	999 (100.0)

Table 2.

Use of contraception in the month of conception in immigrant and nonimmigrant women presenting for abortion: N = 903; not every question was answered by every woman.

CONTRACEPTION METHOD	IMMIGRANTS, BY LENGTH OF TIME RESIDING IN CANADA, N (%)		NONIMMIGRANTS (N = 439), N (%)	P VALUE
	< 5 Y (N = 174)	≥ 5 Y (N = 290)
Hormonal contraception	20 (11.5)	38 (13.1)	103 (23.5)	< .001
Condoms	52 (29.9)	88 (30.3)	131 (29.8)	.9
Withdrawal	56 (32.2)	93 (32.1)	146 (33.3)	.9
Counting safe days	55 (31.6)	73 (25.2)	64 (14.6)	< .001
Intrauterine devices	2 (1.1)	4 (1.4)	10 (2.3)	.5
Nothing	41 (23.6)	69 (23.8)	100 (22.8)	.74

Table 3.

Use of and attitudes toward hormonal and intrauterine contraception among immigrants and nonimmigrants: N = 840; not every question was answered by every woman.

QUESTION	IMMIGRANTS, BY LENGTH OF TIME RESIDING IN CANADA, N (%)		NONIMMIGRANTS (N = 466), N (%)	P VALUE
	< 5 Y (N = 127)	≥ 5 Y (N = 247)
Ever used hormonal contraception	94 (50.3)	219 (65.6)	433 (92.9)	< .001
Concerned that hormonal contraception is not healthy	86 (67.7)	148 (59.9)	210 (51.6)	< .003
Ever used intrauterine device	16 (9.2)	47 (14.6)	62 (13.4)	.22
Fear of intrauterine device	66 (55.5)	139 (57.4)	184 (48.9)	.10
Problems obtaining contraception	43 (26.9)	67 (23.7)	68 (15.3)	.001

Table 4.

Problems with previous use of hormonal contraception: N = 741; this only includes those women with hormonal contraceptive experience.

PROBLEM	IMMIGRANTS (N = 308), N (%)	NONIMMIGRANTS (N = 433), N (%)	P VALUE
Weight gain	95 (30.8)	208 (47.8)	< .001
Irritable or moody	89 (28.9)	191 (43.9)	< .001
Headaches	53 (17.2)	110 (25.3)	.008
Nausea	54 (17.5)	103 (23.7)	.043
Decreased interest in sex	51 (16.6)	103 (23.7)	.018
Irregular bleeding	40 (13.0)	91 (20.9)	.006

Table 5.

Barriers to accessing contraception: N = 895; not every question was answered by every woman.

BARRIER	IMMIGRANTS (N = 451), N (%)	NONIMMIGRANTS (N = 444), N (%)	P VALUE
Any problems getting birth control	112 (24.8)	68 (15.3)	< .001
Did not know about it	31 (29.5)	4 (5.9)	< .001
Did not know where to get it	10 (9.5)	5 (7.4)	.62
Not enough money to buy it	11 (10.5)	43 (63.2)	< .001
No doctor for prescriptions	12 (11.4)	10 (14.7)	.64
Too busy (inconvenient to get it)	36 (34.3)	27 (39.7)	.519

DISCUSSION

Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant, had more negative attitudes toward hormonal contraception, and had more difficulties accessing contraception before the abortion than nonimmigrant women had. The length of time spent in Canada was related to use of and attitudes toward contraception—this is likely owing to cultural differences becoming less strong over time. It is natural that living in a new country and using a second language would make access to contraceptives more of a problem.

One of the most striking findings of this study is that half of the women born in Canada had negative attitudes to intrauterine and hormonal contraception. As these were all women who had had unwanted pregnancies and therefore had a need for very effective contraception, it helps explain the one-quarter of women who were not using any method of contraception when they conceived. It also helps us understand why we can expect half of women who need contraception to quit their hormonal methods within a year.⁹

Limitations

The main limitation of this study is that this particular group of women in 2 Vancouver abortion clinics cannot represent all Canadian women needing contraception. Each family doctor knows the mix of immigrants and nonimmigrants in his or her practice, but might not be aware of how this affects the knowledge of, attitudes toward, and access to contraception for these patients. Further research should be done with other groups and in more depth using qualitative methodology.

Conclusion

The information provided by this study might be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps and other culturally relevant concerns. As about half of all women presenting for abortion expressed negative attitudes to the more effective methods of contraception, it is important that family doctors educate all women at risk of unintended pregnancies.

EDITOR’S KEY POINTS

• Immigrant women presenting for abortion were less likely to be using hormonal contraception when they got pregnant, had more negative attitudes toward hormonal contraception, and had more difficulties accessing contraception before the abortion than nonimmigrant women did.

• As about half of all women presenting for abortion expressed negative attitudes to the more effective methods of contraception, it is important that family doctors educate all women at risk of unintended pregnancies.

• The information provided by this study might be valuable for family doctors and other clinicians to improve contraceptive information resources for immigrants to address existing knowledge gaps and other culturally relevant concerns. Further research should be done with other groups and in more depth using qualitative methodology.

POINTS DE REPÈRE DU RÉDACTEUR

• Par rapport aux femmes non immigrantes, les immigrantes demandant un avortement étaient moins susceptibles d’utiliser une contraception hormonale au moment de devenir enceintes, avaient une attitude moins favorable envers ce type de contraception et avaient plus de difficulté à avoir accès à une méthode contraceptive avant l’avortement.

• Comme environ la moitié de toutes les femmes demandant un avortement disaient avoir une attitude plus négative envers les méthodes contraceptives les plus efficaces, il importe que les médecins de famille renseignent toutes les femmes qui risquent d’avoir une grossesse non désirée sur ces méthodes.

• Les informations recueillies dans cette étude pourraient être utiles aux médecins de famille et autres intervenants cliniciens afin qu’ils rendent l’information sur la contraception plus accessible aux immigrantes de manière à combler un manque de connaissances tout en tenant compte de leurs préoccupations d’ordre culturel. Il faudrait entreprendre d’autres études plus en profondeur avec d’autres groupes en utilisant une méthodologie qualitative.