Postpartum Contraceptive Decision-Making of Parous Teens – A Qualitative Study

Abstract

Study Objective:

Approximately 25% of teens in the U.S. will become pregnant before the age of 18 and within two years, more than 31% will have a repeat pregnancy. Acknowledging that some adolescents may seek or be ambivalent towards rapid repeat pregnancy, compared to their counterparts, not using a LARC method increases a teens’ risk of another pregnancy in two years by more than 35 times. We seek to better understand the influences and factors surrounding adolescent postpartum contraceptive decision-making following the index delivery.

Design:

We completed a qualitative study via focused, semi-structured interviews during the inpatient postpartum course. The interview guide was modeled after those used in other studies of adolescent contraceptive decision-making, beta-tested, and developed iteratively. Interviews were completed, transcribed, coded, and analyzed with the assistance of Dedoose.

Setting:

The study was conducted at MetroHealth Medical Center in Cleveland, OH.

Participants:

Parous adolescents aged 13-19

Results:

We performed twelve interviews prior to reaching theoretical saturation. Themes were identified related to the participants’ prior experiences with contraception and prior and current pregnancies. The participants’ contraceptive choices were influenced by personal relationships, varying levels of autonomy, misperceptions, and changing contraceptive needs.

Conclusions:

We found adolescents’ contraceptive decision-making was influenced by their social networks and community, including their parents and friends. Mothers played a key role as adolescents transitioned to gaining more autonomy over their reproductive decisions. Providers should consistently present adolescents with comprehensive contraceptive options as a component of preventive health care.

Introduction

Approximately one quarter of teens in the United States will become pregnant before the age of 18 and within two years, more than 31% will have a repeat pregnancy.^1-3 While some adolescents seek or are ambivalent towards another pregnancy, pregnant teens face a higher risk of complications, such as preterm delivery, and lower levels of educational attainment and income.^3-5 The burden of teenage pregnancy falls disproportionately on Black and Latinx populations with 57% of teen births in these communities, despite the fact they comprise 35% of the population of girls between 15 and 19 years old.^6,7

Recent declines in pregnancy rates have been attributed to increases in the use of contraception, however, teens often select contraceptive methods that are known to be less reliable, including condoms (55%), oral contraceptive pills (35%), and withdrawal (20%) rather than the more effective alternative of long-acting reversible contraception (LARC) (4.5%).^2,8,9 Not using a LARC method increases a teens’ risk of another pregnancy in two years by more than 35 times.³ Studies have shown that when barriers of cost, knowledge, health care providers, and logistics are eliminated adolescents were more likely to choose LARC over other methods of contraception and that rates of LARC use has increased in recent years.^7,10 In the postpartum adolescent population specifically, availability of immediate postpartum LARC is associated with both increased utilization as well as reduction in repeat teen pregnancies.^11,12 However, racial/ethnic disparities in adolescent postpartum contraceptive use and interpregnancy intervals exist.¹³ While prior studies have examined the contraceptive choices of parous adolescents, less research has focused on contraceptive decision-making in the immediate postpartum period.^14,15 We seek to better understand the influences and factors surrounding contraceptive decision-making in adolescents following the index delivery.

Materials and Methods

We performed a semi-structured, qualitative interview study of English or Spanish-speaking female patients between 13 and 19 years of age who were admitted for labor and delivery at MetroHealth Medical Center between October 15, 2017 and May 1, 2018. MetroHealth Medical Center is a tertiary-care, academic county hospital which cares for primarily an underserved population in Cleveland, Ohio. Prenatal, delivery, and postpartum care is provided by resident, fellow, and attending physicians in Obstetrics and Gynecology and Family Medicine as well as certified nurse midwives, nurse practitioners, and physician assistants. Study subjects were identified prospectively via review of the medical record. A convenience sample based on interviewer availability was used. Potential subjects were excluded if they did not deliver a live-born infant. Approval from the Institutional Review Board (IRB) was obtained.

Consent to participate in audio-record structured interviews was obtained from participants. A waiver of parental consent was approved by the IRB. Consent from a parent/guardian was not sought from those subjects under the age of 18 years given the private nature of sexual health including contraception. If parents/guardians were in the room when the potential study subject was approached and declined to leave the room, another time was sought to conduct the interview.

Basic demographic information including age, parity, and race/ethnicity was collected. A semi-structured interview guide was used to guide the conversation. The interview guide had been previously pilot-tested with three participants and subsequently revised. The interviews explored participant’s sexual history, past contraceptive experiences, sources of influence for contraceptive decisions, reproductive goals, and impact of pregnancy and delivery on goals and contraceptive choice. All interviews were conducted by the same trained qualitative interviewer (C.R.) to promote consistency following the semi-structured interview guide (Appendix 1). After the interviews, subjects were given a publication with frequently asked questions about contraception targeted to teens from the American College of Obstetricians and Gynecologists. Interviews were conducted in-person inside the patient’s hospital room on postpartum days one through four.

The interviews were transcribed verbatim. Transcriptions were reviewed for accuracy and coded and analyzed with Dedoose, a cloud-based qualitative data analysis tool. Two authors conducted coding. At time of the study, C.R. was a resident physician in obstetrics and gynecology. L.M. is a project manager with expertise in qualitative research. Both authors independently reviewed the first few transcripts to develop an initial codebook. This codebook was then discussed and revised by all study authors. Transcripts and the codebook were then reviewed by C.R. and L.M. in an iterative process consistent with constant comparative methods.¹⁶ It was determined that theoretical saturation, or the point at which no new themes emerged, was reached after the completion of twelve interviews and thus further interviews were not conducted.¹⁷

Results

Participants ages ranged from 16 to 19 years old (Table 1). The majority of participants were Black and either 18 or 19 years old. Half of the participants (n=6) were primiparous whereas the other half (n=6) had delivered prior to the index pregnancy. Seven of 12 participants were either breastfeeding or both breast and bottle feeding. We did not have breastfeeding data for 3 participants. Themes were identified related to the participant’s prior experiences with contraception and prior and current pregnancies. The participants’ contraceptive choices were influenced by personal relationships, varying levels of autonomy, misperceptions, and changing contraceptive needs. A schematic of contraceptive decision-making of parous teens based on these interviews is depicted in Figure 1.

Table 1.

Demographics and Adolescents’ Contraceptive Choices.

Interviewee	Age	Gravidity/ Parity	Race/ Ethnicity	Coitarche	Prior Contraceptive Methods	Planned Contraceptive Method
1	19	G2P1011	Hispanic	16	None, Depo-Provera, condoms	IUD
2	19	G3P3003	Black	14	Condoms, pills	IUD
3	16	G1P1	Black	14	Condoms, pills	IUD
4	17	G1P1	Hispanic	16	Condoms	Depo-Provera
5	19	G2P1103	Black	17	Pills, Depo-Provera, none	IUD
6	19	G1P1	Black	16	Pills, Depo-Provera, none	Pills
7	17	G1P1	White	14	Condoms	Depo-Provera → Implant
8	18	G2P2	Hispanic	15	Pills, Depo-Provera, none	Implant
9	18	G2P1011	Black	15	Depo-Provera, none	IUD
10	19	G1P1	Black	17	Depo-Provera, pills, condoms	Pills (IUD initially desired postplacentally)
11	18	G1P1	Black	14	Depo-Provera, none, pills	Pills
12	19	G3P2012	White	14	Depo-Provera, pills, none	Depo-Provera

Figure 1.

Factors Influencing Adolescents’ Contraceptive Decision-Making Schematic

Influence of Others

Mothers

Most participants (n= 9) reported turning to their parents, particularly mothers, for advice regarding contraception. Discussion with mothers centered around both the decision to use contraception as well as method choice. One participant stated, “Honestly, my mom helped me. She's been there for me a long time. She knows my body and she knows how I act on different things. It kinda scares her when I go onto sometimes when I go onto something different and I don't know the consequences of those. She helps me decide what is best, because sometimes I can't think for myself being a young, dumb teenager.” The prior contraceptive experiences of a participant’s mother were also heavily considered. Participants reported being encouraged by their mothers to pursue similar contraceptive methods as their mother had used herself. “She’s like, ‘Do the Mirena.’ ‘Cause she got the Mirena.”

However, a minority of participants (n= 3) reported not feeling comfortable discussing contraception with their mother. For one participant, it was difficult to develop a deep connection with her mother. “Me and my mom were never close. She was always too high to do anything or talk. She was really bad addicted to drugs.” Religious convictions also influenced discussions about sex: “Our mom is really religious, so she didn’t want us having sex talks. She didn’t want us having sex period. We didn’t really have a sex talk with our mom until we got older and we were grown and already had our kids and stuff… She didn’t believe in birth control and stuff. It was use protection, use condoms… She looked at birth control as abortion. It took for her after she was coming to our doctor’s appointments with us and stuff and actually hearing what birth control do, that was when she was like, ‘Ok, birth control. Use birth control to prevent yourself from having another child’”.

Siblings/Friends

Sisters (n=8) tended to be an important influence for teens. Many teens noted that similar conversations and decisions had occurred between older sisters and their mothers. One teen described how she chose Depo “cause my mom had my sister in the Depo.” Sisters were also independent sources of influence due to their own positive and negative experiences with contraception. One teen described choosing the oral contraceptive pill because “I think my sister was telling me about it, and I wanted to—I wanted to try it out because she was saying it was working for her.” Another described being swayed from an option due to her sister’s experience. “One sister have (sic) three kids and got pregnant on depo with all three of her kids. The only reason that I know and believe this for a fact is because I was there seeing her going to her doctor’s appointments and scheduling her appointments…I was like, ‘Ok. I might not do that for me.’”

When discussing with friends (n = 7) conversations tended to center around choice of method, rather than whether contraception was needed (as this discussion occurred primarily with mothers). Decision-making was influenced by both the positive and negative experiences of their friends and teens tended to choose similar methods as their friends. “I was young and a lot of my friends kind of influenced. They were on the shot and they were said like, ‘Oh, I don’t have a period. I can run around and do cartwheels all day’. So, it just seemed like an easier thing. I wasn’t even thinking about sex or consequences of birth control. I was just thinking, ‘Ooh, I want it.’” One teen recounted how hearing her friends’ negative experience with the implant discouraged her from considering it. “She didn’t like it [implant]. She said it was irritating her arm. I’m like, yeah, it’s not for me.”

In general, teens were selective about with which friends they discussed these topics. “I talked to my friend. It was only one friend that was on birth control, one of my friends that I hung out with. Anybody else, people didn't really want to say or wasn't too open about it. I guess kinda embarrassed or just not really wanting to talk about it. I don’t really have many [friends], and I’m not comfortable talking to people about that. That’s more my business and more I want to do what I want to do.”

Providers

Only a minority (n = 3) of teens felt their healthcare providers played a key role in counseling about contraception. One teen stated, “I always go to the doctor… I love it. She always talk to me about sex and being on birth control, protecting myself, and stuff like that.” Admission to Labor and Delivery was another key time of contact with medical providers, however, as one participant reported, maternal and fetal concerns and labor discomfort can preclude a thorough discussion of contraceptive options. Upon arrival to Labor and Delivery, “I was too much in pain and they were just trying to make sure that my son was going to be ok. Then after I had him, that's when they started to ask me [about contraception].” On the other hand, some teens were sure about their desired contraceptive method and had decided well in advance of their delivery. Eight participants reported deciding on their contraceptive method prior to arriving to Labor and Delivery. As one participant related, “They said I need to get on some kind of form of birth control… I said the pill. I didn’t want to talk about other stuff… I had already made up my mind”.

Five teens reported feeling disappointed regarding their provider’s reluctance to discuss contraception during their prenatal care. One participant relayed, “She [provider] was like, “When we get to that time we’ll talk about it.” Like, what do you mean? ‘Get to that time?’ Hello! Can you not see?… She be like, “This is more important today. We get on this subject another moment.” … Like you didn’t care about my wants at all. You just cared about that moment.” One participant expressed a disconnect with her provider, “He kinda kept me in the dark about a lot of things. He didn’t even tell me. I was just like why, why wouldn't he tell me that when I'm sitting in the room with him the whole time? He didn’t say anything. I guess he didn't want to worry me, but I feel like that's something I needed to be directly told.” The lack of guidance inspired one teen to change providers.

Despite having received some counseling in the antepartum period, some participants noted that contraceptive counseling should have been provided earlier and more proactively. One participant asserted a desire for comprehensive counseling at an earlier age. One teen stated, “I wish when I was younger that they would have talked to me about it more…I just wish when I was younger that they would take more consideration and talk to younger kids about birth control.”

Partners

Male partners did not play a large role in contraceptive decision-making. Of the two participants who reported soliciting their partners’ opinion, one partner deferred the question to the participant’s mother and close friends, stating “He didn’t really know what to say ‘cause he’s like, ‘I don’t do this stuff.’ That’s when he was like, ‘Can you ask your best friend or your mom?’” If the topic of contraception was raised, it was usually in the context of condom use: “We've talked about using condoms when I was younger. We did for a few days, then we just stopped because it wasn't the same way. It didn't feel right. Then, going up with partners we just stopped talking about it, because they were like, “I don't want to hear about it. It's not my choice, it's yours.” Another participant’s partner turned to the recommendations of his mother and sister to provide encouragement regarding a specific method.

Misperceptions

Although the teens had avenues of influence and information from various sources, not all the information they received was correct. They also had misperceptions about their ability to conceive. Four teens did not consider the possibility of pregnancy at the time of conception. One stated, “I didn’t really think I was gonna get pregnant. I guess every other teen who had pregnant, they don’t really think it’s gonna happen, and then it happens.”

Several teens demonstrated an incomplete and/or inaccurate knowledge of how contraceptive methods work and female reproductive anatomy even after explanations by their providers. “She [Ob/Gyn] told me about the implant, but she says it doesn't really work half the time, and then she also said with the implant…it can cause infertility. Then, she went over the feel of the thing that goes in your ovaries. She says a lot of people don't like those and they get irritated with them.” This misunderstanding was also still seen after initiating a contraceptive method. One teen believed she was still receiving the effects of her contraception months after it had been discontinued.

“I think when I got pregnant… I [was] kinda being a little bit more risky 'cause I'm like, ‘Well, my period, it came back, and I just, I don't know’. For a while, Depo made me think that I couldn't get pregnant 'cause I would have unprotected sex sometimes and not be scared that I was pregnant. I was like, ‘I'm pretty sure the Depo is still in me, even though my period is here’; but it wasn't. It was a year; and that's when I realized it was a year without me taking it, and that's when I thought that I was pregnant.”

Three participants associated contraceptive methods with future infertility. One teen believed, “my friend used an Implant. She had it for, like, 6 years. She was using it and she was fine, and then, she couldn't have no kids because of how long she used it.” Another participant associated Plan B with infertility, “My friend, she’s taken like 5 already [Plan B]… Everybody’s like, ‘Stop. You won’t probably have kids if you keep taking that pill. Make you sterile or something like that.’

Increasing Autonomy

While the majority of participants reported benefiting from conversations with others and that input from their mother was especially valuable, some (n=3) participants noted that the decision-making process was not collaborative but rather a decision-made for them by their mothers. One teen stated, “yeah, she [mother] didn’t really try to talk to me about what other things that they had at all… she just said the shot made her gain weight, so she didn’t want me to gain weight, and I really wanted to gain weight back then, ‘cause I was small.” One interviewee explained her mother’s motivations in choosing Depo-Provera over pills this way: “She didn't want us to get on the pill. She wanted us to get the shot, because she knew she was going to take us to our doctor's appointment every 30 days.” Four of the twelve felt their healthcare provider did not ensure that the contraceptive method chosen reflected their wishes and not their mothers’. While it may not have been what she preferred, one adolescent simply acquiesced, “My mom was already set at that time. I thought, might as well. I didn’t feel like going back and changing and filling out. I already had my appointments set up. It was like, this date, this date. Ok. We’re here. We’re on it. So, I feel like there was no point at that time.” They were started on pills or Depo-Provera by their mothers and participated very little in discussions with providers. One teen explained: “They let my parents choose and they chose the depo shot. I didn't have a choice.”

Many participants (n=8) felt that pregnancy was a turning point in that they embraced the opportunity to have a greater voice in their contraceptive choices. “I had already decided, because I been talking about it my whole pregnancy, well, since I found out I was pregnant. I was talking about what birth control I was going to get.” When asked what her mother thought of her using pills, another participant responded, “She didn’t have a say-so…She can’t tell me what to do.”

However, not all participants felt so empowered:

I didn’t want to be back on birth control, because I don’t like—I just don’t like taking a lot of stuff. I wanted to wait a little bit, not get it right after, because I was really upset, because my mom speaks for me half the time, and I don’t really get to speak for myself. I don’t know, my OBGYN, she was asking me questions, and when I would answer, then my mom would say, “No, that’s not what happened.” She would say what she thought would happen. I don’t really get to speak for myself half the time about it, or when I would think about it. I really didn’t want it.

One adolescent felt overwhelmed when asked about contraception on Labor and Delivery: “She [provider] was trying to tell me a bunch of them, but I was in too much pain to really pay attention. I just told her the shot or the pill. Ask my mom.”

Change in Contraceptive Goals

Prior to the index pregnancy, participants had used a variety of methods of contraception, from no method (8) to condoms (6), pills (8), and Depo-Provera (8). Eight participants were not using a contraceptive method at the time of conception. Two interviewees had condoms break and two reported intermittent condom use. Following delivery, eight interviewees elected to use a new contraceptive method than they had previously tried. Seven participants had either already received or planned to receive a LARC at their postpartum visit with five selecting an IUD. One participant, planning to restart pills, expressed regret that she was unable to have an IUD placed at the time of her cesarean section as she feared insertional pain. Participants with pregnancies prior to the index pregnancy elected for LARC more often than those following their first pregnancy.

Discussion

The goal of this study was to explore adolescents’ contraceptive decision-making in the immediate postpartum period. We found adolescents were influenced by their social networks and community, including their parents and friends with mothers playing a key role. Contraceptive decision-making was often collaborative with adolescents valuing opinions of their mothers, sisters, and friends. However, ultimately, after the index delivery, adolescents had a stronger sense of autonomy and relied more upon themselves – rather than maternal influence – to make the final decision regarding contraception. In addition, most participants selected a contraceptive method they had not previously tried.

Study participants also reported being disappointed in health care providers for missed opportunities to discuss contraceptive options both prior to and during their index pregnancy. Health care providers can better serve teens going forward by addressing contraceptive needs early in their primary care and throughout prenatal care. The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the Society for Adolescent Health and Medicine (SAHM) recommend incorporating reproductive care into visits between 13 and 15 years of age and providing counseling based on the principles of reproductive justice, centered around patient choice.^18-20 Given that teens value input from multiple sources and decision-making is a fluid process, discussing contraceptive options together with teens and their support system (especially mothers if desired by the teen) could serve as an opportunity to dispel any misperceptions regarding contraceptives and encourage teens to feel empowered to make their own choice. While including those potential influencers and supporters (if desired by the teen) as a component of the decision-making process can be helpful, it is also important to ensure an opportunity to discuss sexual and reproductive health in privacy with the teen to ensure autonomy in decision-making.

Consistent with other studies, adolescents in our study harbored misperceptions regarding LARCs including side effects or impact on future fertility.^24,25 Therefore, specifically inviting adolescents to share such concerns during comprehensive contraceptive counseling is important to ensure fully informed decision-making. Our findings are consistent with prior studies which demonstrate that teens lack a comprehensive knowledge of contraceptive methods, especially regarding LARCs.^21,22 Studies show that only between 20 and 50% of adolescents identified LARCs as contraceptives.²² Although before the index pregnancy none of the adolescents had tried a LARC, following delivery more adolescents elected for IUDs and contraceptive implants. Overall, the postpartum contraceptive method selected tended to be more effective than the method previously used; thus, it is possible that index delivery brings increased motivation to postpone future pregnancies and increased opportunities for contraceptive counseling during prenatal and postnatal care. However, the exact reason for this trend is not able to be elucidated in this study. This finding is similar to a study by Kokanali et al who found greater uptake of more effective contraceptive methods following a voluntary abortion.¹⁵ Offering adolescents the full breadth of contraceptive options, including LARCs, is in agreement with the positions of multiple professional organizations, including ACOG, the AAP, the Centers for Disease Control and Prevention, and the Society of Family Planning.²³

There are several potential limitations of this study. While the small sample size is appropriate for hypothesis-generating qualitative research, further quantitative analysis is warranted to address the questions raised in this study. Our study population broadly reflects the demographic population served by MetroHealth Medical Center, however, the findings may not be applicable to settings serving different populations. For example, less than 10% of our general patient population exclusively breastfeeds at the time of the outpatient six-week postpartum visit, which may impact contraceptive decision-making. In addition, our results were limited to information gleaned from interviews, but could have been strengthened by data regarding socioeconomic status and barriers to access to care, especially prior to pregnancy. Finally, while our qualitative interviewer (C.R.) had racial concordance with many of the participants, her positionality as within the healthcare infrastructure may also have impacted participant responses.

In conclusion, adolescents face many challenges in navigating their contraceptive options. They often turn to trusted sources around them, namely family, friends, and providers for advice and recommendations. After index delivery, adolescents often exerted more autonomous decision-making rather than relying on maternal delivery. This translated often to choosing a different and more effective method of contraception. By providing early comprehensive contraceptive counseling within the framework of reproductive justice, providers can better meet the reproductive needs of adolescent patients. These steps could help dispel misperceptions and further promote adolescents’ self-determination in decision-making.

Table 2.

Theme Quotes of Adolescents’ Contraceptive Influences.

Mothers
	“All of this happened after the fact, because our mom is really religious, so she didn’t want us having sex talks. She didn’t want us having sex period. We didn’t really have a sex talk with our mom until we got older and we were grown and already had our kids and stuff. I: So when you were younger it was just, ‘Don’t have sex.’… She looked at birth control as abortion. It took for her after she was coming to our doctors appointments with us and stuff and actually hearing what birth control do, that was when she was like, ‘Ok, birth control. Use birth control to prevent yourself from having another child.” That’s how that was.”
	“When I first started having sex, it was only a one-time thing, but she thought I was gonna do it more than one time, so she put me on the pills herself.”
	“We [participant and mother] went to Planned Parenthood together and we got it done. She just was happy that I felt comfortable enough to tell her and not sneak behind her back and just try to do it the easy way, which was just go have sex. She was happy that I actually was being mature about it and wanted to do something to prevent myself.”
Siblings/Friends
	“I would say my sister and my friend [influenced me] 'cause they had more experience than me in that area.”
	“I was just thinking maybe it wouldn't happen the same way because my sister—she's my sister, but all bodies are different.”
	“All my friends talk to me about it. So that’s why I choose depo, ‘cause they was on depo.”
	“No, I didn’t talk to them because—I don’t know, I just didn’t. I don’t know. I didn’t really talk to anybody about it. I just thought it was awkward.”
	“One of my friends had a patch. She has a patch. She took that. It just looked ridiculous, so I didn’t really… Patches on you and stuff. Sticky stuff…I don’t know.”
	“A couple of my friends are pregnant that were on the shot. They had the same complaint about weight gain. One of them, I said the stick broke in her arm, she was probably picking and playing with it. […] Yeah. They didn’t get pregnant on the shot. They must have stopped it, because of weight gain or something, but I knew that was a problem too.”
	“Some of my friends took the pills, but a lot of them forgot. Some of them got pregnant.”
	“My best friend had it [implant]. It didn’t work out for her, though…She bled for three months straight.”
Providers
	“We only talked about it at one visit, then, when I got here [L&D] my nurse talked to me about it. She talked to me about different types of birth control, because she asked if I was interested in taking it this time. Then, she told me that woulda been the best one. So, I just took it because my doctor said it would be the best one and my nurse did too.”
	“She just said we’re gonna talk about it [contraception] when we get closer to my due date. She just asked me did I have any preferences on which one I wanted. I said no, so she just… you know. My doctor wasn’t a really good doctor this pregnancy. She didn’t really help me with the things I needed.”
	“He [Ob/Gyn during pregnancy] never brought it up to me. Nope. I don't know. I felt like some—even though they know my information and how old I am and stuff like that, I think people assume or get confused and maybe think I have more than one baby already so they just—it's just another, okay, yeah, you're pregnant. Okay. We'll just deal with it. You'll be my patient or whatever. No, he didn't suggest it at all, no, not at all.”
	“I didn't actually choose the person [Ob/Gyn]. He was the first one, and I just didn't really care 'cause he was a nice person. My mother had said she liked him because he was older, and she knew that he had been doing it for a while probably. That was a plus as well. I didn't really mind not having a relationship, but now looking back on it now, I feel like a lot of stuff would have been different if I would have had a woman doctor. She probably would have been more talkative and telling me more stuff. He kinda kept me in the dark about a lot of things. … I guess he didn't want to worry me, but I feel like that's something I needed to be directly told.”
	“At that point [after spontaneous abortion] I would have [been open to options counseling], because I wouldn't want to lose another child. With me being a borderline diabetic and having children, it's a risk I'm taking. I can lose the child. I can lose my life or I can lose both. It's very scary to do it, so back then if I would have heard about different implants and stuff like that I would have probably chose it.”
Partners
	“He said depo,… […] He’s just a male figure so he thinks, my mama said you don’t have to have a period. It just don’t work like that. Like, no… He feels like it’s better in his mind, because it works for his mother and sister, but it don’t work for me.”
	“Before I got pregnant, we wouldn't talk about condoms, but I didn't think I could get pregnant.”
Misperceptions
	“I have to worry about that [infertility] with all birth control, because that is a side effect of birth control.”
	“She [friend] said there have been cases where it [implant] burns the skin.”
Autonomy
	“I didn’t want to be back on birth control, because I don’t like—I just don’t like taking a lot of stuff. I wanted to wait a little bit, not get it right after, because I was really upset, because my mom speaks for me half the time, and I don’t really get to speak for myself. I don’t know, my OBGYN, she was asking me questions, and when I would answer, then my mom would say, ‘No, that’s not what happened.’ She would say what she thought would happen. I don’t really get to speak for myself half the time about it, or when I would think about it. I really didn’t want it.”
	“Even though I didn’t like the pills, I would have still taken them. I had an alarm set and everything, but I don’t know. Whenever my mom gets—‘cause that’s how I would always keep track of everything. I had everything in my phone, but I feel like whenever she gets upset, she just takes everything away. She thinks cutting off communication is best, and whenever I had to get a new prescription, I would have to call ‘em, and I didn’t have my phone, or she wouldn’t be at home. I have to remind her, or she’ll forget. The other medicines that I take, she would get those instead of my birth control.”
	“I didn’t never ask questions, because of the type of mother she is. You don’t ask questions. That’s an argument and a beat down. Don’t ask questions. So, ok! That’s what I did!”
	“I go and I do what I have to do for myself. If I read upon something, I’m like, ‘Oh, ok’ and keep it pushing. I don’t need to have anyone else’s opinion on this. If I try it and it works for me, then that’s what we gonna stick with. Uh uh.”

Appendix 1. Interview Guide

Interview Guide

1. How old are you?

2. How many times have you been pregnant and at what age?

3. Have you had any miscarriages or abortions?

4. What methods of birth control have you heard of?

5. Do you talk to your parents about birth control? Tell us about that conversation. When did you start talking to them? What methods do they recommend?

6. Do you talk to other family members about birth control. Tell us about that conversation. What methods do they recommend?

7. Do you talk to your friends about birth control options? Tell us about that conversation. What methods do they use? What methods do they recommend?

8. What methods have you tried in the past? What was your experience like? Did you choose to stop that method before becoming pregnant? Did your parents/guardians know you were on birth control?

9. What do you think you would like to use for birth control now?

10. What led you to choose (particular method of birth control)? What led you to not choose other methods of birth control?

11. Was your partner involved in the discussion? What did your partner(s) think of your chosen method?

12. When would you like to have your next child?