Abstract
Background: Intimate partner violence and differential power dynamics are associated with contraceptive behaviors. This study examines the role of reproductive coercion (RC) by an intimate partner in women's decisions about contraceptive use.
Materials and Methods: A self-report survey was administered to a probability sample of a diverse group of women of reproductive age in Delaware's Title X health care facilities. Currently used contraceptive methods were categorized into three effectiveness levels based on typical use failure rates: no method or low effectiveness (>10% failure), moderate effectiveness (>1% and <10% failure), and high effectiveness (<1% failure). The short-form RC scale was used to categorize RC experiences: no RC, verbal only, or behavioral. We conducted multinomial logistic regression to examine the association between types of RC and effectiveness level of current contraceptive method, taking our sampling design into account and adjusting for covariates.
Results: Among 240 women (weighted n = 6529) included in the sample, 13.9% reported experiencing only verbal RC, and 16.1% reported behavioral RC. Women who reported behavioral RC were more likely to currently be using highly versus moderately (adjusted relative risk ratio [aRRR]: 26.71, 95% confidence interval [CI]: 4.59–156.0) and low effective methods (aRRR: 3.08, 95% CI: 0.97–9.82), but less likely to be using moderately (aRRR: 0.12, 95% CI: 0.02–0.77) than low effective methods.
Conclusions: Using highly and low effective methods may indicate two opposing ways of managing behavioral RC experiences: controlling fertility by choosing less detectable but highly effective methods or feeling disempowered and using no or low effective partner-dependent methods.
Keywords: reproductive coercion, contraception, contraceptive use, contraceptive behaviors, intimate partner violence
Introduction
Almost half of all pregnancies in the United States are unintended.1 Delaware had the highest rate of unintended pregnancy of all the states in 2010, 62 per 1000 women aged 15–44, accounting for 57% of all pregnancies in the state.2 Unintended pregnancies are associated with negative health outcomes and adverse economic consequences for both mother and child.3–6 The type of contraceptive method being used (or not used) is directly linked to the likelihood of an unintended pregnancy.7,8
Contraceptive methods are commonly classified into four effectiveness levels, based on typical failure rates: (1) no method (failure rate of 85% and includes no method and abstinence), (2) low effective methods (10% to 25% failure rate and include withdrawal, natural family planning methods, emergency contraception, male condoms, and other barrier methods), (3) moderately effective methods (between 1% and 9% failure rate and include pills, patch, ring, and shot), and (4) highly effective methods (<1% failure rate and include intrauterine devices, implants, and male and female sterilization).9
Identifying factors associated with the effectiveness level of contraceptive methods being used may contribute to the reduction of unintended pregnancy, and can inform policies and practices. For instance, the power dynamic between individuals engaging in sexual intercourse has been shown to affect contraceptive behaviors.10 Specifically, some studies have found that women who are experiencing intimate-partner violence (IPV) are more likely to use no contraception or less effective methods,10,11 whereas other studies have found that experiencing IPV is associated with using more effective methods.12–16 A study using the nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) data found that women who reported IPV in the past year by current or former partner were significantly less likely to report contraceptive use after childbirth.17
Reproductive coercion (RC), a close correlate of IPV,18 entails a partner tampering with or otherwise discouraging contraceptive use, behaving in ways that promote a pregnancy, or controlling a pregnancy outcome.19,20 Based on the National Intimate Partner and Sexual Violence Survey (NISVS), ∼8.4% (10.1 million) women aged 18 and older in the United States have ever experienced RC.21 Women aged 16–29 years visiting family planning clinics have reported a lifetime experience of 25%.18 In addition to the difference in the age range of the sample, the latter study used a more expansive definition of RC than was used in the NISVS.18,21
Prior research has examined the prevalence of lifetime experience of RC in a nationally representative sample and in women seeking family planning services in California. To our knowledge, no study has examined RC experiences of Title X patients in a state with one of the highest rates of unintended pregnancy. The current study aimed at further contributing to these prevalence estimates with a sample of Title X patients in Delaware, which, in 2014, was the state with the highest percentage of pregnancies that were unintended.22 We then examined the association between RC and current contraceptive use in this sample. Understanding these relationships may aid in efforts to reduce unintended pregnancy by informing how interventions, practices, or programs aimed at reducing unintended pregnancy should address RC and the effects that they may have on women's contraceptive behaviors and experiences.
Materials and Methods
Sampling and recruitment
The probability-based sample consisted of women aged 15 to 45, who came to Title X clinics in Delaware between June and December 2017 to receive care for themselves. To ensure a probability-based sample representative of the entire Delaware Title X system, sampling was done at three levels: the clinic level, the interview time level, and the patient level.
For the analyses presented here, we excluded women who had never had sexual intercourse with a man, were pregnant, were seeking prenatal care, had been told by a doctor that they are infertile, had a hysterectomy, or came to the clinic because they were trying to get pregnant. Therefore, our study sample also includes women who, on the day of recruitment, were seeking services other than family planning. We further excluded women missing on any study variables, which left us with a sample size of 248. Another eight women were missing information necessary to create their sampling weights (see Analysis section for a description of weighting procedures); thus, our weighted sample size for analysis in this study was 240.
Procedure
The data were collected by a team of 30 recruiters (all women) through a questionnaire survey administered to women in nine health care facilities receiving Title X funds and participating in the Delaware CAN (Contraceptive Access Now) initiative in the state of Delaware. These data were collected as part of a larger, multi-component longitudinal evaluation of that initiative.23
Women were surveyed at two points during their clinic visit. The first part of the survey was self-administered in the clinic waiting rooms before the woman's visit with her health provider (pre-visit), and the second part of the survey was self-administered after the visit. If a participant did not wish to fill out the survey herself, the recruiter read and input the answers on behalf of the participant. This study used only the pre-visit data, because they reflect women's contraceptive choices before meeting with a health provider who had recently been trained to deliver contraceptive counseling focused on more effective methods. All participants provided informed consent. Study procedures were approved by the Institutional Review Board (IRB) of the University of Maryland, College Park.
Measures
Effectiveness level of current contraceptive method use
In the survey, women's current contraceptive use was measured with the question, “Do you currently use any of these birth control methods?” followed by a list of 13 methods that women could mark with a “yes” or a “no.” Our outcome of interest was the highest effectiveness level of contraception a participant was currently using. If a participant reported using more than one method, she was categorized into the higher effectiveness method. In line with the literature, contraceptive methods were classified into four groups, based on typical failure rates. Because <10% of our sample reported using no method of contraception, we combined no method and low effective methods into one category, which is similar to the categories used in other studies.11,24
Lifetime RC
In the survey, RC was measured with the short-form RC scale.25 This is a five-item questionnaire to which women respond “yes,” “no,” or “I don't know.” All the questions began with: “In your lifetime, has a sexual partner or someone you were dating or going out with…” and continued with: (1) “Told you not to use any birth control (like the pill, shot, ring, etc.),” (2) “Taken your birth control (like pills) away from you or kept you from going to the clinic to get birth control,” (3) “Made you have sex without a condom so you would get pregnant,” (4) “Taken off the condom while you were having sex, so you would get pregnant,” and (5) “Put holes in the condom or broken the condom on purpose so you would get pregnant.”
Women's answers to these five questions were recoded into a single variable to assess the prevalence and type of lifetime RC. If a woman answered “yes” to the first question only, she was categorized into the verbal-only group. If a woman answered “yes” to any of the other four types of RC, she was categorized into the behavioral group. If a woman answered “no” to all five questions, she was categorized in the no-RC group. Seven women who answered “I don't know” to one question and answered “yes” or “no” to the other four questions were categorized as if the “I don't know” were a “no” because they could not say for certain that they had experienced it. One woman who answered “I don't know” to two questions was excluded from this study.
Covariates
Based on previous literature, we included demographic variables, future pregnancy desire, and lifetime experience of unintended pregnancy.26–31
Demographic variables included race/Hispanic ethnicity, age, marital/relationship status, insurance type, education level, and nativity. The future pregnancy desire variable was based on the survey question, “How do you feel about having a child now or sometime in the future?”; women's answers were recoded into four categories: (1) wanting a child in the next 2 years, (2) wanting a child sometime after 2 years, (3) wanting a child but not sure when or unsure about wanting a child, and (4) not wanting a(nother) child. Lifetime experience of unintended pregnancy was measured with the survey question, “Have you ever gotten pregnant when you were not planning or wanting to become pregnant (please include pregnancies that ended in miscarriage or abortion, in addition to births)?”; possible answers were “yes” or “no.” All covariates were collected through the self-report survey.
Analysis
We conducted multinomial logistic regression analyses to test the association between RC and the effectiveness level of contraceptive method currently used by participants, first unadjusted and subsequently adjusted for all covariates. We examined both multinomial logistic regression models that did and did not take weights of the sample into account.
Weights were created that were equal to the inverse of the probability of selection. They accounted for the differential probability of selection that varied across sampling strata that were determined by clinic size, and they accounted for differential non-response across clinic sites. Because findings were similar when taking the complex sample design into account and when not, findings presented below take the sampling design described above into account and all analyses were conducted in the Complex Sample Design feature of SPSS Version 25. We present relative risk ratios below for the association between RC and the effectiveness level of current contraceptive method being used.
Results
The analytic sample consisted of a diverse demographic sample of 240 women (weighted n = 6529) who visited a Title X clinic in the state of Delaware in 2017. As presented in Table 1, 6.8% were using no method of contraception, and 22.8%, 37.1%, and 33.4% were using low, moderately, and highly effective methods respectively.
Table 1.
Unweighted and Weighted Percent Distribution of Participant Reports of Most Effective Current Contraceptive Methods Being Used, Measured Before Their Medical Visit (Unweighted n = 240; Weighted n = 6529)
| Contraception method of highest effectiveness currently using | ||
|---|---|---|
| Unweighted % | Weighted % | |
| No method or low | 34.5 | 29.5 |
| None | 7.9 | 6.8 |
| Emergency contraceptives | 0.4 | 0.4 |
| Withdrawal | 4.6 | 3.7 |
| Natural family planning methods | 0.8 | 0.7 |
| Male condoms | 20.8 | 18.0 |
| Moderate | 35.4 | 37.1 |
| Birth control pills | 18.3 | 14.8 |
| The patch | 0.8 | 0.6 |
| Vaginal ring | 1.7 | 1.4 |
| The shot (or injection) | 14.6 | 20.3 |
| High | 30.0 | 33.4 |
| Intrauterine devices (IUDs) | 12.9 | 10.0 |
| Subdermal implant | 10.4 | 18.2 |
| Female sterilization | 5.8 | 4.5 |
| Male sterilization | 0.8 | 0.7 |
| Total | 100 | 100 |
Table 2 presents information on the total sample and by experience of RC. Our sample was racially and ethnically diverse: 50.1% identified as Black, non-Hispanic, 27.8% as White, non-Hispanic, 19.1% as Hispanic, and 2.9% as other races or ethnicities. Women's ages ranged from 16 to 45, in line with the study's eligibility criteria. Women aged 20 to 29 made up 50.5% of our sample, with 13.2% aged 16 to 19 and 36.3% aged 30 to 45. Almost half (43.2%) of our sample were either currently married or cohabitating with a romantic partner. The sample represented a wide range of women's health insurance status: half had public, 25.5% had private, and 24.2% had no insurance. Half the sample held a high school degree or less, 33.3% had some college or vocational training, and only 15.9% of the women held bachelor's or more advanced degrees. The vast majority (83.0%) of the women were born in the United States.
Table 2.
Unweighted and Weighted Percent Distribution of Participants' Select Characteristics and Percentages of Association Between Lifetime Experience of Reproductive Coercion and Select Covariates (Unweighted n = 240; Weighted n = 6529)
| Unweighted % | Weighted % | Reproductive coercion % |
Chi-square | |||
|---|---|---|---|---|---|---|
| None |
Verbal only |
Behavioral |
||||
| (unweighted n = 197) |
(unweighted n = 18) |
(unweighted n = 25) |
||||
| (weighted n = 4575) | (weighted n = 906) | (weighted n = 1048) | ||||
| 70.1% | 13.9% | 16.1% | ||||
| Race/Hispanic Ethnicity | 0.010 | |||||
| White, non-Hispanic | 32.5 | 27.8 | 32.7% | 20.1% | 13.0% | |
| Black, non-Hispanic | 40.0 | 50.1 | 40.0% | 70.5% | 76.8% | |
| Hispanic | 23.8 | 19.1 | 23.6% | 9.4% | 8.0% | |
| Other, non-Hispanic | 3.8 | 2.9 | 3.6% | 0.0% | 2.2% | |
| Age | <0.001 | |||||
| 16–19 | 15.4 | 13.2 | 16.8% | 4.6% | 4.6% | |
| 20–29 | 50.0 | 50.5 | 51.5% | 83.5% | 17.6% | |
| 30–45 | 34.6 | 36.3 | 31.6% | 11.9% | 77.8% | |
| Marital/relationship status | 0.078 | |||||
| Never married or Divorced/widowed /separated | 48.3 | 56.9 | 48.9% | 72.2% | 78.5% | |
| Currently married | 24.6 | 20.2 | 25.0% | 6.9% | 10.5% | |
| Currently cohabitating | 27.1 | 23.0 | 26.1% | 20.9% | 11.0% | |
| Insurance type | 0.008 | |||||
| Public | 37.9 | 50.3 | 41.9% | 69.0% | 71.2% | |
| Private | 31.7 | 25.5 | 19.9% | 15.3% | 25.5% | |
| None | 30.4 | 24.2 | 29.2% | 11.2% | 13.5% | |
| Education level | 0.142 | |||||
| High school or less | 40.4 | 50.9 | 47.0% | 60.1% | 59.6% | |
| Some college/vocational | 39.6 | 33.3 | 35.8% | 23.1% | 31.1% | |
| Bachelor's degree or more | 20.0 | 15.9 | 17.2% | 16.7% | 9.2% | |
| Nativity | 0.045 | |||||
| U.S.-born | 79.2 | 83.0 | 78.6% | 94.6% | 92.2% | |
| Foreign-born | 20.8 | 17.0 | 21.4% | 5.4% | 7.8% | |
| Future pregnancy desire | 0.001 | |||||
| In the next 2 years | 9.2 | 7.6 | 8.3% | 7.6% | 4.4% | |
| Sometime after 2 years | 35.4 | 29.7 | 37.1% | 12.8% | 11.9% | |
| Unsure & yes, but not sure when | 27.9 | 25.5 | 31.5% | 7.2% | 15.1% | |
| No (more) children | 27.5 | 37.3 | 23.1% | 72.4% | 68.5% | |
| Unintended pregnancy—ever | 0.040 | |||||
| No | 48.3 | 47.6 | 50.2% | 23.5% | 57.0% | |
| Yes | 51.7 | 52.4 | 49.8% | 76.5% | 43.0% | |
Very few women (7.6%) wanted to have a child in the next 2 years, with 29.7% wanting a child sometime after 2 years, 25.5% unsure about wanting a child or the timing, and 37.3% not wanting a(nother) child. Half of the women (52.4%) reported that they had experienced a prior unintended pregnancy. Almost one-third (30.0%) of the sample had experienced some form of RC in their lifetime; 13.9% reported verbal-only RC and 16.1% reported at least one of the behavioral types of RC. Of the people who experienced behavioral coercion, 19% also experienced verbal RC (data not shown).
Many covariates were significantly associated with type of lifetime RC. Black, non-Hispanic women, those with public health insurance, and those born in the United States were more likely to report both the verbal only and behavioral types of RC (p < 0.05). Women aged 20 to 29 were most likely to report the verbal-only type, whereas women aged 30 and older were more likely to report a behavioral form of RC compared with women in the other two age categories (p < 0.001). Women who did not want a(nother) child were more likely to report both forms of RC (p = 0.001). Women who had a prior unintended pregnancy were more likely to have experienced the verbal-only form of RC (p = 0.04).
Table 3 presents the bivariate associations between the effectiveness level of contraceptive methods that participants reported currently using, the type of RC they experienced, and the covariates. Women who had experienced behavioral types of RC were more likely to use highly effective contraceptive methods relative to women who experienced none or the verbal-only type of RC (p < 0.001). In addition, adolescents were more likely to use no or low effective methods, women in their 20s were more likely to use moderately effective methods, and women 30 and older were more likely to use highly effective methods, compared with the other age groups (p = 0.03). Women who wanted to become pregnant in the next 2 years or sometime after 2 years were significantly more likely to use no or low effective methods, whereas women who did not want a(nother) child were more likely to be using highly effective methods (p = 0.02).
Table 3.
Association Between Participant Reports of Most Effective Contraceptive Method Currently Being Used and Lifetime Experience of Reproductive Coercion and the Covariates (Unweighted n = 240; Weighted n = 6529)
| Weighted % | Effectiveness of currently used contraceptive methods |
Chi-square | |||
|---|---|---|---|---|---|
| None & low (weighted n = 1925) | Moderate (weighted n = 2421) | High (weighted n = 2183) | |||
| Reproductive coercion | <0.001 | ||||
| None | 70.1 | 86.1% | 68.1% | 58.2% | |
| Verbal only | 13.9 | 3.3% | 30.0% | 5.3% | |
| Behavioral | 16.1 | 10.6% | 1.9% | 36.5% | |
| Race/Hispanic ethnicity | 0.291 | ||||
| White, non-Hispanic | 27.8 | 26.9% | 29.0% | 27.4% | |
| Black, non-Hispanic | 50.1 | 45.8% | 51.4% | 52.6% | |
| Hispanic | 19.1 | 26.5% | 14.2% | 18.1% | |
| Other, non-Hispanic | 2.9 | 0.9% | 5.4% | 1.9% | |
| Age | 0.032 | ||||
| 16–19 | 13.2 | 18.9% | 14.4% | 6.7% | |
| 20–29 | 50.5 | 46.3% | 65.3% | 37.8% | |
| 30–45 | 36.3 | 34.8% | 20.2% | 55.5% | |
| Marital/relationship status | 0.098 | ||||
| Never married or Divorced/widowed /separated | 56.9 | 46.2% | 67.6% | 54.5% | |
| Currently married | 20.2 | 24.7% | 11.5% | 25.8% | |
| Currently cohabitating | 23.0 | 29.1% | 21.0% | 19.7% | |
| Insurance type | 0.151 | ||||
| Public | 50.3 | 41.5% | 48.5% | 60.2% | |
| Private | 25.5 | 31.4% | 26.2% | 19.5% | |
| None | 24.2 | 27.0% | 25.4% | 20.3% | |
| Education level | 0.093 | ||||
| High school or less | 50.9 | 46.4% | 43.4% | 63.0% | |
| Some college/vocational | 33.3 | 32.8% | 39.0% | 27.4% | |
| Bachelor's degree or more | 15.9 | 20.7% | 17.6% | 9.6% | |
| Nativity | 0.199 | ||||
| U.S.-born | 83.0 | 76.8% | 88.5% | 82.4% | |
| Foreign-born | 17.0 | 23.2% | 11.5% | 17.6% | |
| Future pregnancy desire | 0.017 | ||||
| In the next 2 years | 7.6 | 13.5% | 1.8% | 8.7% | |
| Sometime after 2 years | 29.7 | 42.6% | 28.2% | 19.8% | |
| Unsure & yes, but not sure when | 25.5 | 28.5% | 26.6% | 21.7% | |
| No (more) children | 37.3 | 15.4% | 43.3% | 49.8% | |
| Unintended pregnancy—ever | 0.141 | ||||
| No | 47.6 | 50.6% | 38.4% | 55.0% | |
| Yes | 52.4 | 49.4% | 61.6% | 45.0% | |
In the multinomial logistic regression analyses presented in Table 4, unadjusted and adjusted for all the covariates, women who experienced behavioral types of RC were more likely to currently be using highly versus moderately effective methods (RRR: 22.34, 95% confidence interval [CI]: 3.16–157.93, p = 0.002; adjusted relative risk ratio [aRRR]: 26.70, 95% CI: 4.59–156.02, p < 0.001) and marginally more likely to be using highly versus low effective contraception (RRR = 5.10, 95% CI: 1.11–23.40, p = 0.04; aRRR = 3.08, 95% CI: 0.97–9.82, p = 0.06). In addition, women who experienced behavioral types of RC were less likely to use moderately compared with low effective methods (RRR: 0.23, 95% CI: 0.05–1.11, p = 0.07; aRRR: 0.12, 95% CI: 0.02–0.77, p = 0.03). In contrast, women who experienced the verbal-only form of RC were more likely to be using moderately (RRR: 11.38, 95% CI: 1.75–73.78, p = 0.01; aRRR: 9.90, 95% CI: 1.63–60.30, p = 0.01) versus low effective methods.
Table 4.
Relative Risk Ratios from the Multinomial Logistic Regression Models Showing the Relationship Between Reproductive Coercion and the Effectiveness Level of Contraceptive Method Currently Being Used (Unweighted n = 240; Weighted n = 6529)
| High versus moderate |
High versus low |
Moderate versus low |
||||
|---|---|---|---|---|---|---|
| Unadjusted | Adjusteda | Unadjusted | Adjusteda | Unadjusted | Adjusteda | |
| Reproductive coercion | ||||||
| None | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Verbal only | 0.21 (0.04–1.17) | 0.25 (0.05–1.32) | 2.33 (0.51–10.6) | 2.51 (0.43–14.56) | 11.38* (1.75–73.78) | 9.90* (1.63–60.30) |
| Behavioral | 22.34** (3.16–157.93) | 26.70*** (4.59–156.02) | 5.10* (1.11–23.40) | 3.08 (0.97–9.82) | 0.23 (0.05–1.11) | 0.12* (0.02–0.77) |
| Race/Hispanic ethnicity | ||||||
| White, non-Hispanic | 1.00 | 1.00 | 1.00 | |||
| Black, non-Hispanic | 0.54 (0.20–1.45) | 0.59 (0.23–1.51) | 1.10 (0.46–2.63) | |||
| Hispanic | 0.42 (0.09–1.92) | 0.32 (0.08–1.28) | 0.77 (0.23–2.56) | |||
| Other, non-Hispanic | 0.03** (0.01–0.32) | 3.11 (0.19–50.71) | 90.79*** (5.72–1440.54) | |||
| Age | ||||||
| 16–19 | 1.00 | 1.00 | 1.00 | |||
| 20–29 | 2.65 (0.75–9.43) | 2.75 (0.79–9.60) | 1.04 (0.38–2.86) | |||
| 30–45 | 7.14** (1.72–29.7) | 2.51 (0.61–10.27) | 0.35 (0.10–1.26) | |||
| Marital/relationship status | ||||||
| Never married or Divorced/widowed/separated | 1.00 | 1.00 | 1.00 | |||
| Currently married | 4.34* (1.30–14.5) | 1.83 (0.65–5.15) | 0.42 (0.14–1.26) | |||
| Currently cohabitating | 2.04 (0.73–5.66) | 0.89 (0.35–2.27) | 0.44 (0.17–1.14) | |||
| Insurance type | ||||||
| Public | 1.00 | 1.00 | 1.00 | |||
| Private | 0.91 (0.33–2.53) | 0.51 (0.20–1.30) | 0.56 (0.21–1.50) | |||
| None | 0.56 (0.21–1.50) | 0.80 (0.33–1.91) | 1.42 (0.58–3.50) | |||
| Education level | ||||||
| High school or less | 1.00 | 1.00 | 1.00 | |||
| Some college/vocational | 0.22** (0.08–0.67) | 0.53 (0.21–1.31) | 2.37 (0.96–5.86) | |||
| Bachelor's or higher | 0.18** (0.05–0.64) | 0.30* (0.10–0.91) | 1.61 (0.53–4.91) | |||
| Nativity | ||||||
| U.S.-born | 1.00 | 1.00 | 1.00 | |||
| Foreign-born | 0.82 (0.19–3.54) | 0.67 (0.19–2.40) | 0.82 (0.24–2.81) | |||
| Future pregnancy desire | ||||||
| In the next 2 years | 1.00 | 1.00 | 1.00 | |||
| Sometime after 2 years | 0.15 (0.02–1.12) | 1.18 (0.32–4.28) | 7.99* (1.14–56.2) | |||
| Unsure & yes, but not sure when | 0.08* (0.01–0.67) | 1.42 (0.38–5.34) | 16.86** (2.29–124.07) | |||
| No (more) children | 0.07** (0.01–0.51) | 3.78* (1.04–13.8) | 58.32*** (7.79–436.51) | |||
| Unintended pregnancy—ever | ||||||
| No | 1.00 | 1.00 | 1.00 | |||
| Yes | 0.46 (0.21–1.01) | 0.89 (0.42–1.91) | 1.95 (0.87–4.36) | |||
p ≤ 0.05. **p ≤ 0.01. ***p ≤ 0.001.
Adjusts for all the variables in the table: race/Hispanic ethnicity, age, marital/relationship status, insurance type, education level, nativity, future pregnancy desire, and unintended pregnancy (ever).
Discussion
To our knowledge, this is the first study to examine the association between lifetime experiences of RC and the effectiveness level of current contraceptive use in the United States. There are three findings from this study to highlight. First, those who had experienced behavioral types of RC (i.e., where the partner actively interferes with contraceptive use) were more likely to be currently using highly effective methods. Second, those who had experienced behavioral types of RC were less likely to use moderately effective methods. And third, those who had experienced the verbal-only type of RC (i.e., only being told not to use birth control) were (or tended to be) more likely to use moderately effective methods.
Only one study to date, to our knowledge, has examined RC and the effectiveness level of contraceptive method selected to use, though it was not the study's primary focus, and the study included only women seeking an abortion and different measures of RC.11 The Vafai and Steinberg11 study measured experiences of RC in the past 6 months, whereas we measured lifetime experiences of RC with the short form of the validated RC scale; further, we distinguished between the verbal-only and behavioral types of RC. Nevertheless, Vafai and Steinberg's results,11 although not statistically significant, are in line with one of our findings; women reporting RC were more likely to use highly effective methods.
This study also adds to the small body of research exploring the prevalence of RC among a diverse sample of patients at family planning clinics. Miller et al.18 found a lifetime prevalence of 25% among 16–29 year-old patients. Our weighted results demonstrate a prevalence of 30.1%, which is in line with Miller et al.'s findings, considering that our sample consists of women 16–45 and older women have had more time to experience RC. Examining the prevalence of lifetime RC in patients seeking services at Title X clinics in Delaware, a state with high rates of unintended pregnancy, is important in and of itself considering the lack of studies investigating RC in Title X clinics, and the lack of published analyses from the NISVS beyond the data collected in 2012.21,32,33
We categorized our measure of RC, a validated measure,25 into behavioral and verbal-only experiences to examine the effects of each on the effectiveness level of current contraceptive use. Those who experienced behavioral types of RC over their lifetime were more likely to be using highly effective methods and avoiding moderately effective ones. Women who have experienced behavioral RC may be using highly effective methods to control their own fertility with less detectable methods. Women who have experienced behavioral RC more recently, or are currently experiencing it, may avoid moderately effective methods such as the pill, patch, ring, or shot if their partner may see these methods and take them away, has previously taken them away, or has prevented her from going to the clinic to get them. Women who reported experiencing only the verbal-only type of RC (i.e., only being told not to use contraception) may still want to prevent pregnancy, but may not feel threatened (enough) to opt for the less visible and more effective methods or none or low effective methods.
Limitations
Several limitations should be considered in interpreting the results of this study. First, although our results should generalize to women seeking services at Title X clinics in Delaware due to the sample design and weighting in our analyses, they may not. We had a relatively small number of women who were included in our study (n = 240), creating large CIs around our relative risk ratios, and there was an error in the study's skip pattern that excluded some women (up to n = 76) from our study who would otherwise have been included. These 76 women were missing data on current contraceptive use, but not on their experiences of RC. They had a similar frequency distribution of RC experiences as the 240 women included in our study, increasing our confidence in the generalizability of our findings.
Second, our data do not permit us to know why women who experienced different types of RC were more likely to be using different effectiveness levels of methods. Related, we do not know when the experiences of RC occurred relative to the interview date, and how the timing might be related to participants' current contraceptive choice use.
Future research should include measures of women's recent and past experiences of RC and seek to understand the role that RC experiences may play in influencing contraceptive choices. Third, although we used a validated measure of RC, another measure that delineates the types of contraceptive methods for which women have experienced RC (e.g., pills only or condoms only) may further illuminate the ways in which experiences of RC are associated with contraceptive behaviors. Further, discerning the contexts in which the verbal-only type of RC occurs, when a woman is told not to use contraception, would help in understanding how this affects women's contraceptive behaviors.
Conclusions
This study is among the first to investigate an association between RC and the effectiveness level of the contraceptive method. Those experiencing behavioral types of RC (i.e., a partner interfering with contraceptive use) were more likely to be using highly effective methods, and less likely to be using moderately effective methods. Those experiencing verbal-only types of RC (i.e., only being told not to use birth control) were more likely to be using moderately effective methods.
Using highly and low effective methods may indicate two opposing ways of managing behavioral RC experiences: controlling fertility by choosing less detectable but highly effective methods or feeling disempowered and using no or low effective partner-dependent methods. Programs and practices that seek to reduce unintended pregnancies should assess women's experiences of RC, but they should not assume that women who have experienced or are experiencing RC will use no or low effective methods. Women experiencing RC may be particularly interested in the harm reduction strategy of using highly effective methods.34
Authors' Contributions
I.S., A.B.L., and J.R.S. designed the study. I.S. and J.R.S. performed the data analysis. I.S., A.B.L., and J.R.S. interpreted the findings. I.S. wrote the article with the help of A.B.L. and J.R.S. All authors contributed extensively to the study presented in this article.
Author Disclosure Statement
No competing financial interests exist.
Funding Statement
This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, population research infrastructure grant P2C-HD041041, and a research grant from a private philanthropic foundation. Neither organization had any involvement in the analysis and interpretation of the data, nor on the decision to submit the article for publication.
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