‘I feel like a person has a right to use a product to protect themselves…’: a qualitative study of the risk–benefit calculus on women’s contraceptive use and choice

Abstract

Background:

Reducing pregnancy risk requires a multidimensional approach to sexual and reproductive health product development. The purpose of this analysis is to identify, compare, and contrast women’s pre-use beliefs and attitudes about three different forms of contraceptives: intravaginal rings; spermicide in conjunction with condoms; and oral contraceptive pills – and explore how those attitudes and beliefs, along with actual method-use experience, may affect potential choices in contraceptive method moving forward. The relationship of beliefs and attitudes to their risk–benefit calculations when using these methods was also considered.

Methods:

Women used one or more contraceptive methods, each for 3–6 months. Qualitative data from individual in-depth interviews completed after each 3-month use period were analysed using a summary matrix framework. Data were extracted and summarised into themes. Each woman’s experiences were compared among the methods she used; comparisons were also made across participants.

Results:

The data consist of 33 90–120 min in-depth qualitative interviews from 16 women aged 20–34 years, in which they discussed various elements of their method use experience. One prominent theme was identified: the influence of attitudes and beliefs on the risk–benefit calculus. There were six key elements within the theme: pregnancy prevention; dosing and the potential for user error; side-effects; familiarity; disclosure; and sexual partnerships.

Conclusions:

Women weighed perceived risks and benefits in their decision-making and, ultimately, their contraception choices. Understanding women’s beliefs and attitudes that contribute to a calculation of risk–benefit can inform the development of sexual and reproductive health products.

Introduction

Women^A should be able to choose a contraceptive product that aligns with their personal values throughout their contraception decision-making journey.^1,2 Many women prioritise context (e.g. culture and social networks) and user experiences³ over textual or medical knowledge when gathering information about contraception, shaping their values, perceptions of product attributes and meaning-making.^4–6 Thus, method choice is a risk–benefit calculus, as women weigh their sexual and reproductive health priorities given their unique beliefs and attitudes, and determine which product best fits their current lifestyle.⁷ The risk–benefit calculus is an assessment of the risks of a situation and its benefits, which includes the embodied nature of contraceptives. For example, women may choose to use a product for its unilateral, non-negotiable qualities (e.g. covert/discreet) or for its characteristics that affect the sexual experience, while considering side-effects and ongoing maintenance.^5,7–10

Women may not properly adhere to a short-term sexual and reproductive health product regimen when they are dissatisfied with the method, thereby decreasing product effectiveness.⁴ Capturing women’s beliefs and attitudes to address their needs and wants accurately and individually, within sexual partnerships and in social networks, allows for a multidimensional approach to understand contraceptive acceptability and use.¹¹ Acceptability is defined in the related microbicide literature as ‘the voluntary and sustained use of a method in the context of alternatives’.¹² In contraceptive use, a lack of acceptability can result in inconsistent adherence (or non-adherence) and unplanned pregnancy, which can require altering decisions about educational or career trajectories, financial stability and relationships.¹³

Drawing on data from a longitudinal observational study, this analysis identifies, compares and contrasts women’s pre-use beliefs and attitudes about using three currently available contraceptive methods: the intravaginal ring (IVR); spermicide in conjunction with condom (S+C); and oral contraceptive pill (OCP). To understand the factors that influence contraceptive method choice and use the most, we explored women’s beliefs and attitudes in the context of their actual experiences with contraceptive methods, both in uptake and long-term use of contraceptive methods with varying attributes.

Methods

Project WISH (Women’s Input on Sexual Health) was a two-arm prospective study utilising a mixed-method integrative design.⁸ The study was designed to capture data related to users’ experiences of sexual lubricants and contraceptives to determine which experiences are important to effective use. The current analysis focuses on qualitative data from the contraceptive arm, exploring women’s experiences with OCPs, IVRs, and S+C. The number and type of contraceptive methods were chosen in order to explore ‘Effective Use’. The concept of ‘Effective Use’ posits that consistent product use is a function of a ‘best user experience’ and is driven by biophysical properties, use parameters and other more conventional ‘acceptability’ variables, which combine to allow the user to evaluate method ‘fit’ (K. M. Guthrie and R. E. Berry, unpublished manuscript).

Volunteers in Rhode Island and southeastern Massachusetts received a description of the study by phone.⁸ Interested volunteers completed a brief prescreening questionnaire, which collected basic eligibility data (e.g. age, self-reported need/desire for either lubricants or contraceptives). If deemed initially eligible, we scheduled volunteers in the contraceptive arm for a clinical screening visit with a study clinician. Lu et al. discuss recruitment procedures and eligibility requirements further.⁸ Participants received study contraceptives at no cost and were compensated for their time to complete research activities.

Once enrolled, participants completed a baseline demographic and sexual and reproductive health history survey, inclusive of use of previous products.⁸ Initially, all participants were expected to complete three 3-month use periods, one product per use period, with the order of product use assigned randomly. At the beginning of each use period, trained study staff and clinicians oriented participants to the proper use of each product and provided a 3-month supply.⁸

Difficult recruitment required the protocol (version 1) to be altered, such that women were enrolled for two 3-month use periods only (version 2).⁸ In addition, rather than full random assignment to the order of each contraceptive method used, in protocol version 2, we opted to further explore the decision-making process by providing choice: once women completed their first randomly assigned method, they could then choose to remain on their first method or switch to the next randomly assigned method for the second 3-month use period.

There were three primary data sources: (1) daily automated phone surveys; (2) monthly web-based behavioural and user sensory perception and experience (USPE) surveys; and (3) in-person, in-depth interviews after each 3-month product use period.⁸ The in-depth interviews followed a semi-structured interview guide, which was developed to elucidate the women’s narrative experiential data, adherence behaviours, and, ultimately, decision-making about potential future use. The guide contained open-ended questions; probes were cued and contextualised by the data from the daily phone surveys, which included calendars that presented their product use, sexual behaviour and menstrual cycles.⁸ The interviews established an understanding of the relationship between salient contraceptive method characteristics and an ‘Effective Use’ framework, and articulated women’s perceptions of sexual and reproductive health products, generally allowing women to reflect on product function in relationship to fit (K. M. Guthrie and R. E. Berry, unpublished manuscript).

A team of eight researchers reduced and analysed all qualitative data derived from the in-depth interviews using a summary matrix framework.⁸ A coding structure was developed iteratively, beginning with the constructs and aims of the interview guide, and further refined based on emergent data including the understanding of a risk–benefit calculus reported below. At least two members of the coding team independently coded data from each transcript and summarised data into applicable conceptual and/or thematic cell(s).⁸ The two researchers then reviewed and compared each summary per code and discussed discrepancies. A third trained analyst was consulted if resolutions could not be agreed upon. The first author extracted data from contraceptive product matrices to explore each participant’s beliefs and attitudes before and following method use, previous history of use of other sexual and reproductive health products, and discussion of future method use to identify risk–benefit calculations. A major, unifying theme was identified, and key elements of the theme were considered.

Results

Twenty-four participants enrolled in the study: six were immediately withdrawn following clinical screening at visit 1 due to hypertension (2), history of migraines (1) and body mass index (BMI; 3). Two were withdrawn before visit 2: one withdrew immediately upon inserting, then removing, the IVR due to anxiety about the ring in her body; and one did not have the ability to use the study product during sex. A total of 16 women aged 20–34 years completed study activities. Selected demographic characteristics are shown in Table 1. The women (n = 33) completed 90 to 120 min interviews: seven for S+C, 12 for OCP and 14 for IVR. Eighteen (18) transcripts capture in-depth data from women enrolled in the version 1 protocol and 15 from women enrolled in the version 2 protocol.

Table 1.

Selected demographic characteristics of participants who used up to three contraceptive methods (n = 16)

Age	Mean	Standard deviation
20–34 years	26.94	4.16
Race	n	%
Black	2	13
White	8	50
Asian	0	0
American Indian/Alaska Native	0	0
More than one raceA	5	31
Refused to answer	1	6
Ethnicity	n	%
Hispanic/Latina	4	25
Marital status	n	%
Never married	14	88
Married	0	0
Separated	0	0
Divorced	1	6
Widowed	1	6
Financial situation	n	%
Comfortable, with ‘extras’	6	38
Enough to pay bills without cutting	7	44
Enough to pay bills but have to cut back	1	6
Not enough to pay bills	2	13
Annual income (US$)	n	%
<$15000	3	19
$15000–$36000	9	56
>$36000	4	25
Health insurance coverage	n	%
Employer-sponsored	5	31
Direct from insurance company	1	6
Government-sponsored	5	31
OtherB	1	6
No insurance	4	25
Highest educational level	n	%
Some high school	1	6
High school diploma/GEDC	2	13
Some college	5	31
College degree	6	38
Graduate/professional degree	2	13
Body mass index (BMI)	Mean	Standard deviation
	24.75	4.75
Sexual history: male partners	Mean	Standard deviation
Any sex, # past month	1.06	0.24
Vaginal sex, # past month	1.06	0.24
Received oral sex, # past month	0.75	0.43
Gave oral sex to, # past month	0.88	0.48
Anal sex, # past month	0.25	0.43
Pregnancy history	n	%
Ever pregnant	5	31%
Ever gave birth to a child	3	19
Vaginal delivery	3	19
Sexually transmitted disease (STD) history	n	%
Ever diagnosed with an STD	5	31
Sexual lubricant history	n	%
Ever used vaginal lubricants	10	63
Vaginal lubricants in last 6 months	5	32
Ever used anal lubricants	4	25
Anal lubricants in last 6 months	4	25
Desiccants	0	0
Menstrual product history	n	%
Ever used tampon	15	94
Typically uses tampons	9	56
Ever used menstrual cup	2	13
Typically uses menstrual cup	2	13
Contraceptive history	n	%
Male condoms	15	94
Female condoms	0	0
Non-hormonal intrauterine device	3	19
Hormonal contraception	11	69
Oral contraceptive pills (OCP)	11	69
Patch	2	13
Intravaginal ring (IVR)	4	25
Injection	4	25
Implant	0	0
Hormonal intrauterine device	2	13
Emergency contraception (EC)	9	56
EC in last 12 months	3	19
Never used contraception	0	0

^AMore than one race: n = 5; 2 American Indian/Alaska Native and Black; 1 American Indian/Alaska Native, Black and White; 1 Asian and White; 1 Cape Verdean and White.

^BParent’s insurance.

^CGED, General Educational Development (high school diploma equivalent).

One unifying theme emerged from this analysis: the influence of attitudes and beliefs on the risk–benefit calculus. Six elements of the theme were particularly prominent: pregnancy prevention; dosing and the potential for user error; side-effects; familiarity; disclosure; and sexual partnerships. Illustrative quotations are matched with each woman by age and any prior experience with the study’s contraceptive method(s) used during their participation in the study (e.g. age 24 years; new experience; age 34a years; prior experience: OCP, IVR). The letters ‘a’, ‘b’, and ‘c’ are used to differentiate between women who were the same age.

Pregnancy prevention

Pregnancy prevention was often the benefit that participants weighed against the risks. Data revealed both historic fluctuations in levels of contraception benefits across different periods in life, as a function of the participant’s journey through their reproductive readiness, as well as clear determinations that contraceptive benefits were stable and long-lasting (i.e. having children was not at all in some participants’ long-term plans). This attitude was illustrated by a woman who used all three methods in the study and revealed having used more than one form of contraception (i.e. dual methods) to make sure she did not get pregnant, saying ‘I feel like it [getting pregnant] will prevent me from doing all the other stuff that I want to do and I’m supposed to do.’ (age 34a years; prior experience: OCP, IVR)

Another woman who used the IVR and OCP in the study also noted that her choice of contraceptive was integral to her choice not to have children. Despite her friends expressing fear that long-term contraceptive use might negatively affect fertility in the future, her determination not to have children at this time in her life outweighed the perceived potential of contraceptive-induced infertility. Her drive to not have children motivated her specifically to use hormonal contraceptive methods due to her belief and confidence in their efficacy.

Other women placed greater emphasis on their short-term plans, viewing the risk of having a child as an interruption in their current life trajectory. This desire to prevent pregnancy in the foreseeable future also framed hormonal contraception use as a benefit. For example, one woman who experienced an unplanned teen pregnancy discussed her motivation to take OCPs correctly to prevent a ‘difficult situation’ (age 33 years; prior experience: OCP) from occurring. She explained that she did not want to disrupt her current life course, which she described as comfortable and stable financially, emotionally and in her relationship. Similarly, another woman who used all three methods in the study said she was fully committed to the OCP and fully committed to a contraceptive regimen in general, because she felt she could not afford children right now.

The risk of unwanted consequences of childbearing and rearing that could affect the women and other people in their life, seemed to outweigh the day-to-day hassle of taking OCPs. One woman, who used the OCP in the study, stated that she would take every precaution possible to prevent pregnancy because she did not want to use Plan B^® or get an abortion (despite the fact that she is pro-choice):

‘I don’t want to say, ‘oh, my God. I’m pregnant. I didn’t do - didn’t use any of the resources and anything that’s out there for me to use to avoid this [pregnancy]’.’

(age 24 years; new experience)

Similarly, one woman who used the OCP in the study believed that while not everyone’s beliefs and values align with contraception, it is a greater benefit than having to decide whether to have an abortion, which would affect many other aspects of her life, including her partner, child, family and career.

Dosing and the potential for user error

Efficacy is an important factor in the risk–benefit calculus, as women’s perception of a contraceptive method’s effectiveness was a function of their perceived product efficacy, and also their confidence in their own dosing behaviours and the potential for user error. This was especially true of the OCP, a method that requires consistent daily administration. Self-efficacy to successfully comply with OCP dosing played a critical role; one woman felt enough confidence in the efficacy of OCPs and her compliance behaviours to note that she prefers to only use OCPs for pregnancy prevention (i.e. without a condom as a second method). Another described a more nuanced confidence in OCPs because of her perceived increased susceptibility to user error (i.e. forgetting to consistently take her pills) compared with the S+C. She explained that although OCPs might be more effective than the S+C, she had more confidence in the S+C effectiveness because of decreased personal user error with a peri-coital method, in contrast to a daily dose of OCP that she might sometimes forget. Similarly, another woman’s choice of the IVR over OCPs was associated with the fact that the IVR resides in the vagina for an extended period of time and does not rely on timely, consistent dosing; she said, ‘I feel a little bit better knowing that there’s less of, like, my human error in it.’ (age 25a years; prior experience: OCP)

Given the presumption of human error, women weighed their confidence in a product’s effectiveness with beliefs and attitudes regarding their own potential for compliance. For instance, although product instructions state that the IVR can be removed for up to 3 h, some women believed that if they did not comply with contraceptive instructions strictly, they would get pregnant. Similarly, with the S+C, one woman suggested that someone who never uses a condom could get nervous about the hour expiration of the spermicide (when using it without a condom). Another characterised herself as forgetful and felt stressed about remembering to reinsert the ring despite, as another put it, the ‘grace period’ (age 31 years; prior experience: IVR). Thus, she decided to err on the side of strict compliance and never remove the IVR. This attitude is further illustrated by another woman:

‘If you’re supposed to use it [IVR] for those three weeks, then it has to stay in there… Oh my god, in that one hour, I could get pregnant… I’m gonna do what I’m supposed to do and take it when I’m supposed to or use it how I’m supposed to.’

(age 29 years; new experience)

Similarly, one woman opted not to remove the IVR ‘without a good reason’ (age 25a years; prior experience: OCP); she would only remove it during sex and only if she or her partner felt it.

Side-effects

Women who used the IVR and OCP discussed side-effects and safety concerns associated with hormonal methods and weighed those against perceived benefits. Several women noted being more comfortable using OCPs because this method has been in use for a long time, with a perceived greater body of research on side-effects, compared with newer methods like the IVR. Nonetheless, women discussed the risks of hormonal birth control, specifically concerns of stroke, which was believed, by some, to be common:

‘Hormones always pose a risk… it’s a chemical you’re putting in your body, and that’s a thing…nothing that is particularly felt… that’s always there, and the risk of stroke or whatnot.’

(age 25b years; prior experience: OCP)

In contrast, others believed there was low risk for adverse effects from the OCP, especially for those who are healthy and use the OCP as prescribed, saying ‘it [hormonal contraception] seems… relatively safe unless you have other… undiagnosed health problems.’ (age 23 years; prior experience: OCP)

Familiarity

Prior to study use, women’s evaluations were heavily reliant on beliefs and attitudes. For instance, with respect to the IVR, comparative knowledge was lacking. Interestingly, familiarity with a product (or not) could work to the method’s advantage – or not. For instance, one of the women with no previous knowledge of the IVR, as well as the woman who had used the IVR for several years before the study, noted strong perceptions of efficacy regarding the IVR. While one derived her confidence from years of experience, the other did not explain how she specifically came to her sense of confidence, though she did note a general belief in the efficacy of hormonal methods. Several women noted that they would likely use OCPs in the future, though it was difficult to discern which aspect of familiarity was most impactful: the years of OCP use, research and experience (whether personal or otherwise) or the familiarity of a pill over an intravaginal device.

Familiarity with a particular method was not only impactful for the user herself, but also considered in the context of her sexual partner’s familiarity. Women noted that the general population is more familiar with the OCP compared with other forms of contraception. This familiarity influenced their ability to use them discreetly within the context of ongoing relationships. Two women specifically noted that a conversation with their sexual partners regarding the OCP used in the context of the study was unnecessary because of this generalised familiarity and the fact that the OCP does not reside in the vagina. However, using either the IVR or S+C was not normative for most women and their partners. Additionally, the idea of using a topical birth control method rather than a condom alone in the context of sex was a novel idea for most participants.

Disclosure

Women assessed the risks and benefits of disclosing contraceptive use to sexual partners, relying heavily on the attitudes and beliefs that varied in timing, relationship length and the method’s perceived level of covertness and/or discreetness. Some women were comfortable initiating conversations about contraception with short-term sexual partners before vaginal sex or during foreplay, and many stressed the importance of contraceptive disclosure:

‘I don’t wanna have sex with someone that I’m not comfortable with disclosing that information [method use] to. You know, if I don’t feel like I can talk to that person, I probably shouldn’t have sex with them… I don’t really wanna be with anybody that… took issue with my preferred method, unless it was something crazy. Like, if I was a staunch believer in pulling out, then yeah… or if it affects him a lot more. I don’t think that that should be an issue.’

(age 26a years; new experience)

Interestingly, when using an OCP with a new sexual partner, women did not feel it was necessary to disclose OCP use. This is attributed to the fact that the partner doesn’t see the pill, and, for some women, that protection is granted to him by using a condom in conjunction with the OCP, as the condom is a visible method. OCPs could also be hidden from long-term partners, with one participant stating that long-term partners may notice a difference with the response of a woman’s body to OCPs, but they would not necessarily connect those changes to the hormonal side-effects of OCPs, saying: ‘They would just, you know, say, ‘What’s your problem… are you on your period? They don’t have that recognition.’ (age 34b years; new experience).

Women who used S+C believed they had to be open with their partner about S+C use, because spermicide would be harder to use discreetly, especially with a long-term partner. One added that she would want him to know what is coming into contact with his body. Similarly, another woman noted that she did tell new partners she was using an IVR and added that she provided more detail than she would with an OCP as a forewarning because it is physically in the vagina, and she could feel it. Relationship factors like communication and commitment can facilitate conversations about IVRs:

‘I did tell him because we were [in] a relationship for so long, and because, if he could feel it [IVR] or it felt uncomfortable, then I wanted to know.’

(age 29 years; new experience)

In contrast, some women stated they would feel comfortable using the IVR without telling a sexual partner, which seemed to stem from varying beliefs and attitudes regarding their sensory awareness of the IVR post-insertion in the context of day-to-day use. For example, several women discussed having forgotten that the IVR was in their body unless they felt it or had issues with it. Others felt that awareness of the IVR was inevitable because it is an object that is not part of their own body. Individual sensations or anticipations, therefore, spoke to their ability to use the IVR covertly/discreetly, and, therefore, decisions to disclose use.

Women agreed that disclosing information about contraceptive use was optional; that is, women should tell their partner if they feel able, but it’s not necessary if they have a reason not to disclose, with one saying, ‘I feel like a person has a right to use a product to protect themselves without their partner knowing.’ (age 25b years; prior experience: OCP). Aside from relationship commitment and personal motivations, little or no disclosure of contraception seemed most attributed to the belief that men are not aware of diverse methods like the IVR, and generally assume women use OCPs:

‘I don’t know if men know about the different types of birth control. I don’t think they do… He thinks I’m on the pill or whatever.’

(age 20 years; prior experience: IVR)

Sexual partnerships

The data suggest that women also included the concept of gender roles within sexual partnerships when weighing risks and benefits of contraception decisions. One woman emphatically stated that her role as a woman means being in control of contraception, otherwise sex was out of the question. With respect to the sexual partnership, contraceptive choice and use was not always one sided; one woman said her partner’s potential dislike for a contraceptive method would be a factor to weigh in her contraceptive choice and would not be forced on him. For another, while using a condom did not make a difference in her own sensations, her long-term partner disliked condoms because sex felt different for him; she added that she had to negotiate condom use with him during the study. She also noted that she believed condoms were more for STD and HIV prevention, thus leading to her weighing condom use less with respect to pregnancy prevention:

‘I know that it probably sounds weird… when I think of like using a condom, that’s more for like – in my mind anyway – someone that you’re not normally having sex with., especially if it’s someone you’re just meeting, then that’s [not using a condom] not smart.’

(age 26b years; new experience)

Finally, one woman noted that her partner viewed female-controlled methods as more convenient, whereas other participants’ partners liked being in control of contracepting, wanted the responsibility to be in their hands and had positive attitudes towards condom use. One woman noted that her partner thinks condoms are the best form of contraception because he can control it; using a condom or not is ‘like life or death for him.’ (age 26c years; new experience).

Discussion

The current study presents qualitative data regarding pre-study beliefs and attitudes of women who then experienced IVRs, OCPs and/or S+Cs, and used those beliefs and attitudes, along with their actual short-term use experiences, in a risk–benefit calculation of future contraceptive method use. The value of the current analysis is in the ability to explore these processes within the context of actual use experience in real time, mimicking the process of method initiation and switching seen in the literature and clinical practice.

As in prior work, our data show that women begin using a product with existing attitudes, beliefs and (sometimes) experiences with those or similar products.⁶ Thus, they weigh the risks and benefits of a current product through the lens of those attitudes, beliefs and expectations, and choose a product as a function of past and present experiences and the meanings they derive from those experiences. Unique to this study, we specifically discussed participants’ experiences with products’ biophysical/biomechanical properties, which provided women with additional and tangible evidence to confirm or deny their attitudes, beliefs and expectations, and influence the calculus of risks and benefits of contraceptives, ultimately influencing acceptability, use and adherence.⁶

Pregnancy prevention, and the benefit of being proactive rather than reactive and self-efficacious with dosing behaviours, was a personal and primary value. This desire was emphasised as a salient need; avoiding pregnancy risk as the most non-negotiable of both short- and long-term outcomes. Studies suggest that using contraception leads to social and economic benefits for women, which in turn sustain motivations to prevent pregnancy at their current stage in life; for example, by being able to maintain financial stability and continue to foster current relationships.^13,14

Participants confirmed that side-effects could result in adverse health outcomes and social consequences, or method dissatisfaction and non-use. Our data regarding women’s evaluation with the covert qualities of the IVR and/or S+C, including their sensory experiences, should be considered and leveraged – or mitigated – to optimise long-term use. Women considered the weight of research and other women’s experiences regarding potential side-effects from hormonal methods, but it was only one of several considerations. Participants expressed primacy of pregnancy prevention in their risk–benefit calculous, which is consistent with findings by Nelson et al. that women continued to use contraception despite perceived side-effects because it outweighed pregnancy risk.¹⁵ Creating a balance between the biophysical properties needed for drug delivery and efficacy and understanding women’s risk–benefit calculations regarding sexual and reproductive health products can enhance product uptake and adherence.^6,16

Contraceptive use disclosure was often weighed against relationship type and the participant’s sense of commitment in the relationship. Disclosure also appeared to be influenced by women’s perceptions of her partner’s knowledge of contraceptive methods, and her sense of personal autonomy in not disclosing contraceptive use to a partner. Overall, women believed it was important to have conversations about condoms with short-term partners to prevent STIs, including HIV, but similar conversations about pregnancy prevention were not as important. In addition to relationship type, gender dynamics between the women and their sexual partners also influenced their beliefs and attitudes regarding contraceptive use, choice and disclosure. While this could be considered related to partner dominance, gender norms (i.e. men assuming the burden of contraception will be on the women) or biotechnological constraints,^17–19 our findings emphasise compromise and understanding of partner preferences. This difference could potentially be attributed to the fact that all women in the contraceptive arm described their sexual partnerships as ‘main’ partnerships and half lived with their partners. However, it is important to note that women in our study also emphasised that the benefit of contraceptive decisions is that it is theirs only, aside from partner preferences or input. The perceived benefit of autonomous contraceptive decisions is consistent with the principle of women’s autonomous control of their bodies.²⁰

Women also weighed their personal knowledge and general familiarity when considering the IVR and S+C as viable contraceptive choices within their sexual partnerships. Limited knowledge and familiarity of the IVR can be perceived as a risk that deters method initiation or adherence.²¹ Meanwhile, condom use is a benefit for STI risk reduction with casual partners, given its historical implementation as a behavioural strategy to prevent HIV transmission and ‘feminization of contraception’ that deters use of male-body based methods.^22,20 Thus, condoms are not perceived as the primary choice for pregnancy prevention,²³ despite 98% efficacy when used correctly²⁴ and the concept dating back to ~3000 B.C.²⁵

Conversations regarding contraception use were not limited to pregnancy prevention. The literature suggests that conversations with partners regarding condom use could be influenced by public health programs that teach heterosexual women to initiate sexual risk reduction²⁶ and ongoing gendered division of reproductive labour,²⁰ even though they are not the ones onto whom the product is applied. This highlights the varied reasons why women in our study may have initiated conversations regarding S+C with partners. When using S+C, the conversation could have been a function of: (1) the potential for the partner to feel the physical qualities of the spermicide; (2) the need to use a condom to achieve desired efficacy; (3) the desire to prevent STIs. Additionally, as suggested in findings by Lu et al. the potential for the partner to feel the physical characteristics of the IVR led some women to discuss IVR use, not with respect to risk reduction, but rather, within the context of sex as an experience and desire to forewarn their partner that they may potentially feel the IVR.⁸

Invariably, each woman has her own risk–benefit algorithm that conforms to which factors are important to her and how she weighs each of them. In fact, the internal scale in each woman shifts weight throughout her sexual and reproductive health journey. Pregnancy prevention is the consistent goal, but even the ‘constant’ applied will vary by woman and circumstance. While side-effects and familiarity are known factors in women’s contraceptive choices, the study’s opportunity to set each method experience back-to-back and reflect during the in-depth interviews across methods, allowed women to consider important reflections on their own behaviours, including propensities to manage appropriate dosing behaviours (or not) and to consider how sexual partnerships (albeit in the context of a research study) affect disclosure and choice.

We understand that the effect of these contraceptive beliefs and attitudes in which these risk–benefit calculations are based may be limited to populations of women similar to those in our study sample and can change in the context of varying indentities, including gender identities (e.g. transgender, gender-expansive individuals)²⁷ and cisgender queer women.²⁸ Indeed, we recognise that understanding these risk–benefit calculations can inform patient communications and support, as well as development and acceptability of different contraceptive methods for diverse populations in the United States and globally. Exploring judgments derived from different experiences and their resulting meanings is paramount to determining which contraceptive method might be most beneficial for each person.⁶

The understanding achieved with in-depth data collection and analyses illustrates that attitudes and beliefs vary across products and contribute uniquely to each woman’s risk–benefit calculus. More comprehensive understandings of women’s risk–benefit calculations regarding contraceptive methods and experiences can allow healthcare providers to consider the factors that determine which product best fits into the patient’s lifestyle through shared decision-making²⁹ (where a provider contributes their medical knowledge and a patient provides their values and preferences); advance contraception counselling through sex education programs;^30,31 and enhance online interventions.^32,33 Finally, while contraceptive agents were at the centre of the current analysis, the results are applicable to other forms of sexual and reproductive health products, from gynaecological treatments to multipurpose prevention technologies (MPTs) currently being developed to prevent unplanned pregnancy and STIs, including HIV.^21,34 By contributing to knowledge of how women weigh risks and benefits of reproductive health methods, we hope to inform innovation in contraception development, delivery and care.