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Why women risk unintended pregnancy
Background To reduce unintended pregnancy, it is necessary to understand why women have unprotected intercourse when they do not desire pregnancy.
Methods We devised a survey of 42 potential reasons why women have unprotected intercourse based on the responses of a focus group we had previously convened. We administered the survey to women between the ages of 18 and 39 years who were visiting primary care clinics and were not trying to get pregnant.
Results Of the 151 respondents, 84 (56%) were having unprotected intercourse. Women gave an average of 9 reasons for having unprotected intercourse. The most common reasons fell into 3 categories: lack of thought/preparation (87% of respondents), being in a long-term or strong relationship (70%), and concerns about side effects of contraception (80%). Eighty-three of the 84 women (99%) chose at least 1 of these categories.
Conclusion Basing survey questions on focus group responses provided important insights into the reasons women risk unintended pregnancy. A deeper understanding of this issue is critical to reducing unintended pregnancy.
What are the reasons women ordinarily give for unintended pregnancy? The results of our study show that some of the more common ones are not included on standard risk-assessment surveys. If we hope to offer patients a meaningful course of intervention, it would help to understand the issues these women contend with.
Despite the availability of effective contraception, many women have unprotected intercourse that puts them at risk for unintended pregnancy. Among women in the United States who are age 18 or older, slightly more than 40% of live births result from unintended conception.1 The reasons women have unprotected intercourse have not been clear. Of the few studies that have addressed this issue,2 some have restricted their investigation to a few potential reasons2-4 or have limited exploration to the reasons associated with a single episode of intercourse.5 The latter type of investigation is too narrow. A more comprehensive approach is needed because risk-taking is likely to be a complex phenomenon, with reasons changing as the context changes or as women try different forms of contraception.
We conducted focus groups with women who were risking unintended pregnancy.6 With results from the focus groups, we developed a survey to determine the relative prevalence of reasons given, and thereby direct future interventions at those that are most common.
Methods
We recruited participants from local primary care clinics serving financially disadvantaged populations. Flyers describing the study were posted, and interested women approached a research assistant stationed in the clinic. We explained the survey and reviewed eligibility criteria with those who inquired. Women who wished to participate gave verbal consent and were taken to a private area, where a research assistant administered the survey. The study was approved by the local institutional review board. We waived written consent because the survey was anonymous and we collected no identifiers.
Eligibility required that a woman be between the ages of 18 and 39 years, unmarried, and not be pregnant or trying to get pregnant. Women who reported having had a hysterectomy or tubal ligation or being menopausal were ineligible. We defined unprotected intercourse as vaginal intercourse with a fertile male without using a condom, hormonal method, diaphragm, intrauterine device (IUD), vaginal ring, Lea’s shield (a vaginal barrier contraceptive), emergency contraception, vaginal sponge, or cervical cap. These eligibility requirements were identical to those of the focus groups that had provided input for our survey questions.
Women who reported having unprotected sex in the past year were asked to choose from 42 possible reasons (foils) adapted from responses offered in the focus groups.6 When possible, we used the exact words uttered by focus group participants (eg, “I just went with the flow”). We asked women to select all the reasons that applied to them over the past year. The survey also included questions about previous pregnancies, use of home pregnancy test kits, and medical conditions that could affect an unintended pregnancy or fetus (preconceptual health status).
Analysis
We performed univariate analysis using the chi square test in the Statistical Analysis System package (SAS version 8.0, SAS Institute, Inc., Cary, NC). Age was evaluated as a dichotomous variable compared to the median.
Results
Demographics and health
The 151 respondents had a median age of 24 years, and a median household income of <$20,000 per year. Eighty-four women (56%) had unprotected intercourse in the past year. Of the 151 respondents, 56% were white and 41% were black. Twenty-two percent had not graduated from high school. Ten percent had recently been homeless, 9% had recently been jailed, 7% had a recent sexually transmitted disease, and 4% had traded sex for gain.
Median body mass index was 26. Fifty-one percent were smokers, 19% were binge drinkers, 11% had hypertension, and 5% had diabetes. Ninety-four (62%) of the respondents had at least 1 previous pregnancy (average of 2 live births), and 39% of them had used a home pregnancy test kit to diagnose their last pregnancy.
Reasons for unprotected intercourse
Of the 84 women who reported having unprotected intercourse in the past year, 1 woman selected all 42 of the reasons on the survey, with a single exception (“I don’t know where to get birth control/contraception”). On average, the women selected 9 reasons each. The most common reasons for having unprotected intercourse appear in the TABLE.
Lack of concern. Seventy-three women (87%) cited at least 1 of the following reasons: “just not thinking about birth control,” “not planning to have sex,” getting caught up in the “heat of the moment,” or “just went with the flow.” We categorized these reasons as lack of thought/preparation.6
Beliefs about relationship. Fifty-nine women (70%) cited relationship-related reasons: their partner would “be there” for them if they did get pregnant, or they were “in a long-term relationship and it was too much of a hassle to keep using birth control/condoms.”
Unacceptable side effects. Sixty-seven women (80%) cited method-related side effects, including weight gain, discomfort with condoms, and reduced pleasure. Of note, the most commonly cited reason was that condoms gave the woman discomfort.
Categories not mutually exclusive. These 3 categories—lack of thought/preparation, relationship-related reasons, and side effects—overlapped significantly, with 72 women (86%) choosing more than 1 of these categories, and 44 (52%) choosing all 3. Eighty-three of the 84 women (99%) chose at least 1 of these categories.
As stated, 55 women (65%) believed their partner would “be there” for them, and 43 of these had a previous pregnancy. Of the 43, 58% said their partner actually “was there” for them during the last pregnancy. The remainder had not had partner support during the last pregnancy, but believed their current partner would support them in the event of a future pregnancy.
Additional volunteered reasons. Beyond the reasons given in the TABLE, 23% said they forgot to take their pill, and 20% said they would not really mind that much if they got pregnant.
Between 10% and 18% of women cited each of the following reasons: judgment clouded by alcohol or drugs, thinking they could always get an abortion if they conceived, not wanting to ask their partner to use a condom, being scared of needles, being worried about vaginal bleeding, having a medical condition (smoking, obesity, etc.) that limited their choice of contraception, having a partner who objected to her using contraception, or feeling that contraception was unnatural.
Less than 10% of women cited the following reasons: problems with transportation to get to clinic, insurance that did not cover contraception or a preferred method of contraception, not liking the clinic or clinic personnel, inability to understand explanations by clinic personnel, cost, forced sex, a preference for rhythm method, feeling that a method was messy, family/friends being against her using contraception, religious objections, being embarrassed to buy contraception, or being unsure how to use contraception.
Few age or race differences. There was little difference in response between races, with the exception of being uncomfortable asking a partner to use condoms, which was noted by 23% of blacks and 2% of whites (P=.006). There were no significant differences by age.
Among the women who had unprotected intercourse, 79 (94%) had used some form of birth control at least once during the past year. Of these, 90% had used condoms, 34% had taken the Pill, 22% had used medroxyprogesterone acetate injectable suspension (Depo Provera), and 20% had used the norelgestromin/ethinyl estradiol transdermal system (Ortho Evra/“the patch”). Eighteen percent had used emergency contraception in the past year.
TABLE
Reasons women most commonly cited for unprotected intercourse
| REASON | PERCENT (N=84) |
|---|---|
| “Heat of the moment”/“just went with the flow” | 70% |
| Partner would “be there” if pregnancy occurred | 65% |
| Not planning to have sex | 54% |
| Not thinking about using birth control at the time | 52% |
| Condoms are uncomfortable for woman | 49% |
| Weight gain with hormonal methods | 43% |
| Partner does not like condoms | 43% |
| Ran out of birth control method | 37% |
| In a long-term relationship and it was too much of a hassle to keep using contraception | 37% |
| Thought pregnancy was unlikely to occur | 36% |
| Contraception reduces pleasure | 36% |
| Forgot to use birth control method | 32% |
| Prefer to use withdrawal | 30% |
Discussion
The most common reasons for having unprotected intercourse reflected lack of thought/preparation, relationship issues, and concerns about side effects. Most women expressed reasons from more than 1 of these categories, suggesting they are interrelated.7
Preparation issues. Most women used contraception inconsistently rather than not at all. At times they were motivated to use contraception; at times they were not.
Relationship issues. Women in our study cited several relationship-related reasons that might explain inconsistent use of contraception. Many women felt that regular contraception became a “hassle” in long-term relationships. This is supported by studies showing that condoms may be reserved for partners who are considered at risk for disease, or that condom use may be thought to imply a lack of trust antithetical to a long-term relationship.8 Others believed their partner would “be there” for them if a pregnancy occurred and gave this as a reason for having unprotected intercourse. Regarding this belief, past experience to the contrary did not appear to dampen optimism about the future.
Side effect issues. Interestingly, the most commonly cited method-related side effect was that male condoms made the woman uncomfortable during intercourse. They cited discomfort for the man less frequently. Female discomfort has also been identified as a reason college women avoid condom use.9 Others have shown that women have difficulties with condom lubrication,10 although it is less of an issue for men.11 This suggests that education about condoms should include informing women about lubrication options. However, education alone may not resolve this issue, and it is important to inform women about alternative contraceptive choices.
Our extensive list of reasons facilitated responses. On average, each woman identified 9 reasons why she had unprotected intercourse. This was likely a result of the large number of foils presented in the survey, which allowed women to give a fuller picture of their reasons than a more limited number of choices might allow.
For example, the Pregnancy Risk Assessment Monitoring System (PRAMS) survey offers just 6 foils, and they do not include the common thought/preparation and relationship issues. Broad surveys like PRAMS are necessarily concise about single issues. Free-text responses to the PRAMS survey show that respondents endorse reasons not reflected in the few foils.4
Moreover, we used the exact phrasing given by focus group participants whenever possible, which could increase selection of appropriate foils. This is why we included reasons such as wanting to “go with the flow.” We also included reasons that were cited by the focus groups, but which have rarely been included in surveys, such as condoms creating discomfort for women.
Implications of our findings. Slightly more than half of the women in the study were having unprotected intercourse and were at risk for unintended pregnancy. Although “unintendedness” is a concept that may not be widely recognized by individual women,7 it is a useful epidemiological construct that serves as a marker for adverse outcomes, such as low birth weight or premature labor.12 In our study, women at risk for unintended pregnancy had a variety of medical conditions and health behaviors that could affect a pregnancy. Moreover, slightly more than one-third of participants thought they were unlikely to get pregnant despite having unprotected intercourse. This argues for improved preconceptional care in this population.13 Education may improve understanding of fertility, contraceptive options, risk reduction strategies, and communication techniques.
Limitations. The study is subject to several limitations. All responses were self-reported and subject to recall bias. The population was a convenience sample of financially disadvantaged women visiting outpatient clinics, and is not representative of other populations. Women attending a clinic might reasonably be expected to have access to health care and contraception, which might not be true of other populations. Thus, few women in our study cited cost or access to care as a reason for having unprotected intercourse.
Funding
This study was funded in part by the Michigan Department of Community Health.
Correspondence
Mary D. Nettleman, MD, MS, B 427 Clinical Center, East Lansing, MI 48824; [email protected]
1. Ahluwalia IB, Whitehead N, Bensyl D. Pregnancy intention and contraceptive use among adult women. Matern Child Health J. 2007;11:347-351.
2. Ayoola A, Brewer J, Nettleman M. Reasons why women have unprotected sex: a review. J Womens Health. 2007;16:302-310.
3. Project Choices Epidemiologic Survey Group. Alcohol-exposed pregnancy: Characteristics associated with risk. Am J Prev Med. 2002;23:166-173.
4. Nettleman MD, Chung H, Brewer J, et al. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception. 2007;75:361-366.
5. Centers for Disease Control and Prevention. Monitoring progress toward achieving Maternal and Infant Healthy People 2010 objectives—19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. MMWR Surveill Summ. 2006;55:1-11.
6. Nettleman M, Brewer J, Ayoola A. Reasons for unprotected intercourse in adult women: a qualitative study. J Midwifery Womens Health. 2007;52:148-152.
7. Santelli J, Rochat R, Hatfield-Timajchy K, et al. Unintended Pregnancy Working Group. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health. 2003;35:94-101.
8. Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic review. Lancet. 2000;368:1581-1586.
9. Crosby R, Yarber WL, Sanders SA, et al. Condom discomfort and associated problems with their use among university students. J Am Coll Health. 2005;54:143-147.
10. Sanders SA, Graham CA, Yarber WL, et al. Condom use errors and problems among young women who put condoms on their male partners. J Am Med Womens Assoc. 2003;58:95-98.
11. Crosby RA, Sanders SA, Yarber WL, et al. Condom use errors and problems among college men. Sex Transm Dis. 2002;29:552-557.
12. Centers for Disease Control and prevention. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR. 2006;55(RR- 6):1-15.
13. Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect. 1998;30:223.
Background To reduce unintended pregnancy, it is necessary to understand why women have unprotected intercourse when they do not desire pregnancy.
Methods We devised a survey of 42 potential reasons why women have unprotected intercourse based on the responses of a focus group we had previously convened. We administered the survey to women between the ages of 18 and 39 years who were visiting primary care clinics and were not trying to get pregnant.
Results Of the 151 respondents, 84 (56%) were having unprotected intercourse. Women gave an average of 9 reasons for having unprotected intercourse. The most common reasons fell into 3 categories: lack of thought/preparation (87% of respondents), being in a long-term or strong relationship (70%), and concerns about side effects of contraception (80%). Eighty-three of the 84 women (99%) chose at least 1 of these categories.
Conclusion Basing survey questions on focus group responses provided important insights into the reasons women risk unintended pregnancy. A deeper understanding of this issue is critical to reducing unintended pregnancy.
What are the reasons women ordinarily give for unintended pregnancy? The results of our study show that some of the more common ones are not included on standard risk-assessment surveys. If we hope to offer patients a meaningful course of intervention, it would help to understand the issues these women contend with.
Despite the availability of effective contraception, many women have unprotected intercourse that puts them at risk for unintended pregnancy. Among women in the United States who are age 18 or older, slightly more than 40% of live births result from unintended conception.1 The reasons women have unprotected intercourse have not been clear. Of the few studies that have addressed this issue,2 some have restricted their investigation to a few potential reasons2-4 or have limited exploration to the reasons associated with a single episode of intercourse.5 The latter type of investigation is too narrow. A more comprehensive approach is needed because risk-taking is likely to be a complex phenomenon, with reasons changing as the context changes or as women try different forms of contraception.
We conducted focus groups with women who were risking unintended pregnancy.6 With results from the focus groups, we developed a survey to determine the relative prevalence of reasons given, and thereby direct future interventions at those that are most common.
Methods
We recruited participants from local primary care clinics serving financially disadvantaged populations. Flyers describing the study were posted, and interested women approached a research assistant stationed in the clinic. We explained the survey and reviewed eligibility criteria with those who inquired. Women who wished to participate gave verbal consent and were taken to a private area, where a research assistant administered the survey. The study was approved by the local institutional review board. We waived written consent because the survey was anonymous and we collected no identifiers.
Eligibility required that a woman be between the ages of 18 and 39 years, unmarried, and not be pregnant or trying to get pregnant. Women who reported having had a hysterectomy or tubal ligation or being menopausal were ineligible. We defined unprotected intercourse as vaginal intercourse with a fertile male without using a condom, hormonal method, diaphragm, intrauterine device (IUD), vaginal ring, Lea’s shield (a vaginal barrier contraceptive), emergency contraception, vaginal sponge, or cervical cap. These eligibility requirements were identical to those of the focus groups that had provided input for our survey questions.
Women who reported having unprotected sex in the past year were asked to choose from 42 possible reasons (foils) adapted from responses offered in the focus groups.6 When possible, we used the exact words uttered by focus group participants (eg, “I just went with the flow”). We asked women to select all the reasons that applied to them over the past year. The survey also included questions about previous pregnancies, use of home pregnancy test kits, and medical conditions that could affect an unintended pregnancy or fetus (preconceptual health status).
Analysis
We performed univariate analysis using the chi square test in the Statistical Analysis System package (SAS version 8.0, SAS Institute, Inc., Cary, NC). Age was evaluated as a dichotomous variable compared to the median.
Results
Demographics and health
The 151 respondents had a median age of 24 years, and a median household income of <$20,000 per year. Eighty-four women (56%) had unprotected intercourse in the past year. Of the 151 respondents, 56% were white and 41% were black. Twenty-two percent had not graduated from high school. Ten percent had recently been homeless, 9% had recently been jailed, 7% had a recent sexually transmitted disease, and 4% had traded sex for gain.
Median body mass index was 26. Fifty-one percent were smokers, 19% were binge drinkers, 11% had hypertension, and 5% had diabetes. Ninety-four (62%) of the respondents had at least 1 previous pregnancy (average of 2 live births), and 39% of them had used a home pregnancy test kit to diagnose their last pregnancy.
Reasons for unprotected intercourse
Of the 84 women who reported having unprotected intercourse in the past year, 1 woman selected all 42 of the reasons on the survey, with a single exception (“I don’t know where to get birth control/contraception”). On average, the women selected 9 reasons each. The most common reasons for having unprotected intercourse appear in the TABLE.
Lack of concern. Seventy-three women (87%) cited at least 1 of the following reasons: “just not thinking about birth control,” “not planning to have sex,” getting caught up in the “heat of the moment,” or “just went with the flow.” We categorized these reasons as lack of thought/preparation.6
Beliefs about relationship. Fifty-nine women (70%) cited relationship-related reasons: their partner would “be there” for them if they did get pregnant, or they were “in a long-term relationship and it was too much of a hassle to keep using birth control/condoms.”
Unacceptable side effects. Sixty-seven women (80%) cited method-related side effects, including weight gain, discomfort with condoms, and reduced pleasure. Of note, the most commonly cited reason was that condoms gave the woman discomfort.
Categories not mutually exclusive. These 3 categories—lack of thought/preparation, relationship-related reasons, and side effects—overlapped significantly, with 72 women (86%) choosing more than 1 of these categories, and 44 (52%) choosing all 3. Eighty-three of the 84 women (99%) chose at least 1 of these categories.
As stated, 55 women (65%) believed their partner would “be there” for them, and 43 of these had a previous pregnancy. Of the 43, 58% said their partner actually “was there” for them during the last pregnancy. The remainder had not had partner support during the last pregnancy, but believed their current partner would support them in the event of a future pregnancy.
Additional volunteered reasons. Beyond the reasons given in the TABLE, 23% said they forgot to take their pill, and 20% said they would not really mind that much if they got pregnant.
Between 10% and 18% of women cited each of the following reasons: judgment clouded by alcohol or drugs, thinking they could always get an abortion if they conceived, not wanting to ask their partner to use a condom, being scared of needles, being worried about vaginal bleeding, having a medical condition (smoking, obesity, etc.) that limited their choice of contraception, having a partner who objected to her using contraception, or feeling that contraception was unnatural.
Less than 10% of women cited the following reasons: problems with transportation to get to clinic, insurance that did not cover contraception or a preferred method of contraception, not liking the clinic or clinic personnel, inability to understand explanations by clinic personnel, cost, forced sex, a preference for rhythm method, feeling that a method was messy, family/friends being against her using contraception, religious objections, being embarrassed to buy contraception, or being unsure how to use contraception.
Few age or race differences. There was little difference in response between races, with the exception of being uncomfortable asking a partner to use condoms, which was noted by 23% of blacks and 2% of whites (P=.006). There were no significant differences by age.
Among the women who had unprotected intercourse, 79 (94%) had used some form of birth control at least once during the past year. Of these, 90% had used condoms, 34% had taken the Pill, 22% had used medroxyprogesterone acetate injectable suspension (Depo Provera), and 20% had used the norelgestromin/ethinyl estradiol transdermal system (Ortho Evra/“the patch”). Eighteen percent had used emergency contraception in the past year.
TABLE
Reasons women most commonly cited for unprotected intercourse
| REASON | PERCENT (N=84) |
|---|---|
| “Heat of the moment”/“just went with the flow” | 70% |
| Partner would “be there” if pregnancy occurred | 65% |
| Not planning to have sex | 54% |
| Not thinking about using birth control at the time | 52% |
| Condoms are uncomfortable for woman | 49% |
| Weight gain with hormonal methods | 43% |
| Partner does not like condoms | 43% |
| Ran out of birth control method | 37% |
| In a long-term relationship and it was too much of a hassle to keep using contraception | 37% |
| Thought pregnancy was unlikely to occur | 36% |
| Contraception reduces pleasure | 36% |
| Forgot to use birth control method | 32% |
| Prefer to use withdrawal | 30% |
Discussion
The most common reasons for having unprotected intercourse reflected lack of thought/preparation, relationship issues, and concerns about side effects. Most women expressed reasons from more than 1 of these categories, suggesting they are interrelated.7
Preparation issues. Most women used contraception inconsistently rather than not at all. At times they were motivated to use contraception; at times they were not.
Relationship issues. Women in our study cited several relationship-related reasons that might explain inconsistent use of contraception. Many women felt that regular contraception became a “hassle” in long-term relationships. This is supported by studies showing that condoms may be reserved for partners who are considered at risk for disease, or that condom use may be thought to imply a lack of trust antithetical to a long-term relationship.8 Others believed their partner would “be there” for them if a pregnancy occurred and gave this as a reason for having unprotected intercourse. Regarding this belief, past experience to the contrary did not appear to dampen optimism about the future.
Side effect issues. Interestingly, the most commonly cited method-related side effect was that male condoms made the woman uncomfortable during intercourse. They cited discomfort for the man less frequently. Female discomfort has also been identified as a reason college women avoid condom use.9 Others have shown that women have difficulties with condom lubrication,10 although it is less of an issue for men.11 This suggests that education about condoms should include informing women about lubrication options. However, education alone may not resolve this issue, and it is important to inform women about alternative contraceptive choices.
Our extensive list of reasons facilitated responses. On average, each woman identified 9 reasons why she had unprotected intercourse. This was likely a result of the large number of foils presented in the survey, which allowed women to give a fuller picture of their reasons than a more limited number of choices might allow.
For example, the Pregnancy Risk Assessment Monitoring System (PRAMS) survey offers just 6 foils, and they do not include the common thought/preparation and relationship issues. Broad surveys like PRAMS are necessarily concise about single issues. Free-text responses to the PRAMS survey show that respondents endorse reasons not reflected in the few foils.4
Moreover, we used the exact phrasing given by focus group participants whenever possible, which could increase selection of appropriate foils. This is why we included reasons such as wanting to “go with the flow.” We also included reasons that were cited by the focus groups, but which have rarely been included in surveys, such as condoms creating discomfort for women.
Implications of our findings. Slightly more than half of the women in the study were having unprotected intercourse and were at risk for unintended pregnancy. Although “unintendedness” is a concept that may not be widely recognized by individual women,7 it is a useful epidemiological construct that serves as a marker for adverse outcomes, such as low birth weight or premature labor.12 In our study, women at risk for unintended pregnancy had a variety of medical conditions and health behaviors that could affect a pregnancy. Moreover, slightly more than one-third of participants thought they were unlikely to get pregnant despite having unprotected intercourse. This argues for improved preconceptional care in this population.13 Education may improve understanding of fertility, contraceptive options, risk reduction strategies, and communication techniques.
Limitations. The study is subject to several limitations. All responses were self-reported and subject to recall bias. The population was a convenience sample of financially disadvantaged women visiting outpatient clinics, and is not representative of other populations. Women attending a clinic might reasonably be expected to have access to health care and contraception, which might not be true of other populations. Thus, few women in our study cited cost or access to care as a reason for having unprotected intercourse.
Funding
This study was funded in part by the Michigan Department of Community Health.
Correspondence
Mary D. Nettleman, MD, MS, B 427 Clinical Center, East Lansing, MI 48824; [email protected]
Background To reduce unintended pregnancy, it is necessary to understand why women have unprotected intercourse when they do not desire pregnancy.
Methods We devised a survey of 42 potential reasons why women have unprotected intercourse based on the responses of a focus group we had previously convened. We administered the survey to women between the ages of 18 and 39 years who were visiting primary care clinics and were not trying to get pregnant.
Results Of the 151 respondents, 84 (56%) were having unprotected intercourse. Women gave an average of 9 reasons for having unprotected intercourse. The most common reasons fell into 3 categories: lack of thought/preparation (87% of respondents), being in a long-term or strong relationship (70%), and concerns about side effects of contraception (80%). Eighty-three of the 84 women (99%) chose at least 1 of these categories.
Conclusion Basing survey questions on focus group responses provided important insights into the reasons women risk unintended pregnancy. A deeper understanding of this issue is critical to reducing unintended pregnancy.
What are the reasons women ordinarily give for unintended pregnancy? The results of our study show that some of the more common ones are not included on standard risk-assessment surveys. If we hope to offer patients a meaningful course of intervention, it would help to understand the issues these women contend with.
Despite the availability of effective contraception, many women have unprotected intercourse that puts them at risk for unintended pregnancy. Among women in the United States who are age 18 or older, slightly more than 40% of live births result from unintended conception.1 The reasons women have unprotected intercourse have not been clear. Of the few studies that have addressed this issue,2 some have restricted their investigation to a few potential reasons2-4 or have limited exploration to the reasons associated with a single episode of intercourse.5 The latter type of investigation is too narrow. A more comprehensive approach is needed because risk-taking is likely to be a complex phenomenon, with reasons changing as the context changes or as women try different forms of contraception.
We conducted focus groups with women who were risking unintended pregnancy.6 With results from the focus groups, we developed a survey to determine the relative prevalence of reasons given, and thereby direct future interventions at those that are most common.
Methods
We recruited participants from local primary care clinics serving financially disadvantaged populations. Flyers describing the study were posted, and interested women approached a research assistant stationed in the clinic. We explained the survey and reviewed eligibility criteria with those who inquired. Women who wished to participate gave verbal consent and were taken to a private area, where a research assistant administered the survey. The study was approved by the local institutional review board. We waived written consent because the survey was anonymous and we collected no identifiers.
Eligibility required that a woman be between the ages of 18 and 39 years, unmarried, and not be pregnant or trying to get pregnant. Women who reported having had a hysterectomy or tubal ligation or being menopausal were ineligible. We defined unprotected intercourse as vaginal intercourse with a fertile male without using a condom, hormonal method, diaphragm, intrauterine device (IUD), vaginal ring, Lea’s shield (a vaginal barrier contraceptive), emergency contraception, vaginal sponge, or cervical cap. These eligibility requirements were identical to those of the focus groups that had provided input for our survey questions.
Women who reported having unprotected sex in the past year were asked to choose from 42 possible reasons (foils) adapted from responses offered in the focus groups.6 When possible, we used the exact words uttered by focus group participants (eg, “I just went with the flow”). We asked women to select all the reasons that applied to them over the past year. The survey also included questions about previous pregnancies, use of home pregnancy test kits, and medical conditions that could affect an unintended pregnancy or fetus (preconceptual health status).
Analysis
We performed univariate analysis using the chi square test in the Statistical Analysis System package (SAS version 8.0, SAS Institute, Inc., Cary, NC). Age was evaluated as a dichotomous variable compared to the median.
Results
Demographics and health
The 151 respondents had a median age of 24 years, and a median household income of <$20,000 per year. Eighty-four women (56%) had unprotected intercourse in the past year. Of the 151 respondents, 56% were white and 41% were black. Twenty-two percent had not graduated from high school. Ten percent had recently been homeless, 9% had recently been jailed, 7% had a recent sexually transmitted disease, and 4% had traded sex for gain.
Median body mass index was 26. Fifty-one percent were smokers, 19% were binge drinkers, 11% had hypertension, and 5% had diabetes. Ninety-four (62%) of the respondents had at least 1 previous pregnancy (average of 2 live births), and 39% of them had used a home pregnancy test kit to diagnose their last pregnancy.
Reasons for unprotected intercourse
Of the 84 women who reported having unprotected intercourse in the past year, 1 woman selected all 42 of the reasons on the survey, with a single exception (“I don’t know where to get birth control/contraception”). On average, the women selected 9 reasons each. The most common reasons for having unprotected intercourse appear in the TABLE.
Lack of concern. Seventy-three women (87%) cited at least 1 of the following reasons: “just not thinking about birth control,” “not planning to have sex,” getting caught up in the “heat of the moment,” or “just went with the flow.” We categorized these reasons as lack of thought/preparation.6
Beliefs about relationship. Fifty-nine women (70%) cited relationship-related reasons: their partner would “be there” for them if they did get pregnant, or they were “in a long-term relationship and it was too much of a hassle to keep using birth control/condoms.”
Unacceptable side effects. Sixty-seven women (80%) cited method-related side effects, including weight gain, discomfort with condoms, and reduced pleasure. Of note, the most commonly cited reason was that condoms gave the woman discomfort.
Categories not mutually exclusive. These 3 categories—lack of thought/preparation, relationship-related reasons, and side effects—overlapped significantly, with 72 women (86%) choosing more than 1 of these categories, and 44 (52%) choosing all 3. Eighty-three of the 84 women (99%) chose at least 1 of these categories.
As stated, 55 women (65%) believed their partner would “be there” for them, and 43 of these had a previous pregnancy. Of the 43, 58% said their partner actually “was there” for them during the last pregnancy. The remainder had not had partner support during the last pregnancy, but believed their current partner would support them in the event of a future pregnancy.
Additional volunteered reasons. Beyond the reasons given in the TABLE, 23% said they forgot to take their pill, and 20% said they would not really mind that much if they got pregnant.
Between 10% and 18% of women cited each of the following reasons: judgment clouded by alcohol or drugs, thinking they could always get an abortion if they conceived, not wanting to ask their partner to use a condom, being scared of needles, being worried about vaginal bleeding, having a medical condition (smoking, obesity, etc.) that limited their choice of contraception, having a partner who objected to her using contraception, or feeling that contraception was unnatural.
Less than 10% of women cited the following reasons: problems with transportation to get to clinic, insurance that did not cover contraception or a preferred method of contraception, not liking the clinic or clinic personnel, inability to understand explanations by clinic personnel, cost, forced sex, a preference for rhythm method, feeling that a method was messy, family/friends being against her using contraception, religious objections, being embarrassed to buy contraception, or being unsure how to use contraception.
Few age or race differences. There was little difference in response between races, with the exception of being uncomfortable asking a partner to use condoms, which was noted by 23% of blacks and 2% of whites (P=.006). There were no significant differences by age.
Among the women who had unprotected intercourse, 79 (94%) had used some form of birth control at least once during the past year. Of these, 90% had used condoms, 34% had taken the Pill, 22% had used medroxyprogesterone acetate injectable suspension (Depo Provera), and 20% had used the norelgestromin/ethinyl estradiol transdermal system (Ortho Evra/“the patch”). Eighteen percent had used emergency contraception in the past year.
TABLE
Reasons women most commonly cited for unprotected intercourse
| REASON | PERCENT (N=84) |
|---|---|
| “Heat of the moment”/“just went with the flow” | 70% |
| Partner would “be there” if pregnancy occurred | 65% |
| Not planning to have sex | 54% |
| Not thinking about using birth control at the time | 52% |
| Condoms are uncomfortable for woman | 49% |
| Weight gain with hormonal methods | 43% |
| Partner does not like condoms | 43% |
| Ran out of birth control method | 37% |
| In a long-term relationship and it was too much of a hassle to keep using contraception | 37% |
| Thought pregnancy was unlikely to occur | 36% |
| Contraception reduces pleasure | 36% |
| Forgot to use birth control method | 32% |
| Prefer to use withdrawal | 30% |
Discussion
The most common reasons for having unprotected intercourse reflected lack of thought/preparation, relationship issues, and concerns about side effects. Most women expressed reasons from more than 1 of these categories, suggesting they are interrelated.7
Preparation issues. Most women used contraception inconsistently rather than not at all. At times they were motivated to use contraception; at times they were not.
Relationship issues. Women in our study cited several relationship-related reasons that might explain inconsistent use of contraception. Many women felt that regular contraception became a “hassle” in long-term relationships. This is supported by studies showing that condoms may be reserved for partners who are considered at risk for disease, or that condom use may be thought to imply a lack of trust antithetical to a long-term relationship.8 Others believed their partner would “be there” for them if a pregnancy occurred and gave this as a reason for having unprotected intercourse. Regarding this belief, past experience to the contrary did not appear to dampen optimism about the future.
Side effect issues. Interestingly, the most commonly cited method-related side effect was that male condoms made the woman uncomfortable during intercourse. They cited discomfort for the man less frequently. Female discomfort has also been identified as a reason college women avoid condom use.9 Others have shown that women have difficulties with condom lubrication,10 although it is less of an issue for men.11 This suggests that education about condoms should include informing women about lubrication options. However, education alone may not resolve this issue, and it is important to inform women about alternative contraceptive choices.
Our extensive list of reasons facilitated responses. On average, each woman identified 9 reasons why she had unprotected intercourse. This was likely a result of the large number of foils presented in the survey, which allowed women to give a fuller picture of their reasons than a more limited number of choices might allow.
For example, the Pregnancy Risk Assessment Monitoring System (PRAMS) survey offers just 6 foils, and they do not include the common thought/preparation and relationship issues. Broad surveys like PRAMS are necessarily concise about single issues. Free-text responses to the PRAMS survey show that respondents endorse reasons not reflected in the few foils.4
Moreover, we used the exact phrasing given by focus group participants whenever possible, which could increase selection of appropriate foils. This is why we included reasons such as wanting to “go with the flow.” We also included reasons that were cited by the focus groups, but which have rarely been included in surveys, such as condoms creating discomfort for women.
Implications of our findings. Slightly more than half of the women in the study were having unprotected intercourse and were at risk for unintended pregnancy. Although “unintendedness” is a concept that may not be widely recognized by individual women,7 it is a useful epidemiological construct that serves as a marker for adverse outcomes, such as low birth weight or premature labor.12 In our study, women at risk for unintended pregnancy had a variety of medical conditions and health behaviors that could affect a pregnancy. Moreover, slightly more than one-third of participants thought they were unlikely to get pregnant despite having unprotected intercourse. This argues for improved preconceptional care in this population.13 Education may improve understanding of fertility, contraceptive options, risk reduction strategies, and communication techniques.
Limitations. The study is subject to several limitations. All responses were self-reported and subject to recall bias. The population was a convenience sample of financially disadvantaged women visiting outpatient clinics, and is not representative of other populations. Women attending a clinic might reasonably be expected to have access to health care and contraception, which might not be true of other populations. Thus, few women in our study cited cost or access to care as a reason for having unprotected intercourse.
Funding
This study was funded in part by the Michigan Department of Community Health.
Correspondence
Mary D. Nettleman, MD, MS, B 427 Clinical Center, East Lansing, MI 48824; [email protected]
1. Ahluwalia IB, Whitehead N, Bensyl D. Pregnancy intention and contraceptive use among adult women. Matern Child Health J. 2007;11:347-351.
2. Ayoola A, Brewer J, Nettleman M. Reasons why women have unprotected sex: a review. J Womens Health. 2007;16:302-310.
3. Project Choices Epidemiologic Survey Group. Alcohol-exposed pregnancy: Characteristics associated with risk. Am J Prev Med. 2002;23:166-173.
4. Nettleman MD, Chung H, Brewer J, et al. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception. 2007;75:361-366.
5. Centers for Disease Control and Prevention. Monitoring progress toward achieving Maternal and Infant Healthy People 2010 objectives—19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. MMWR Surveill Summ. 2006;55:1-11.
6. Nettleman M, Brewer J, Ayoola A. Reasons for unprotected intercourse in adult women: a qualitative study. J Midwifery Womens Health. 2007;52:148-152.
7. Santelli J, Rochat R, Hatfield-Timajchy K, et al. Unintended Pregnancy Working Group. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health. 2003;35:94-101.
8. Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic review. Lancet. 2000;368:1581-1586.
9. Crosby R, Yarber WL, Sanders SA, et al. Condom discomfort and associated problems with their use among university students. J Am Coll Health. 2005;54:143-147.
10. Sanders SA, Graham CA, Yarber WL, et al. Condom use errors and problems among young women who put condoms on their male partners. J Am Med Womens Assoc. 2003;58:95-98.
11. Crosby RA, Sanders SA, Yarber WL, et al. Condom use errors and problems among college men. Sex Transm Dis. 2002;29:552-557.
12. Centers for Disease Control and prevention. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR. 2006;55(RR- 6):1-15.
13. Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect. 1998;30:223.
1. Ahluwalia IB, Whitehead N, Bensyl D. Pregnancy intention and contraceptive use among adult women. Matern Child Health J. 2007;11:347-351.
2. Ayoola A, Brewer J, Nettleman M. Reasons why women have unprotected sex: a review. J Womens Health. 2007;16:302-310.
3. Project Choices Epidemiologic Survey Group. Alcohol-exposed pregnancy: Characteristics associated with risk. Am J Prev Med. 2002;23:166-173.
4. Nettleman MD, Chung H, Brewer J, et al. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception. 2007;75:361-366.
5. Centers for Disease Control and Prevention. Monitoring progress toward achieving Maternal and Infant Healthy People 2010 objectives—19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. MMWR Surveill Summ. 2006;55:1-11.
6. Nettleman M, Brewer J, Ayoola A. Reasons for unprotected intercourse in adult women: a qualitative study. J Midwifery Womens Health. 2007;52:148-152.
7. Santelli J, Rochat R, Hatfield-Timajchy K, et al. Unintended Pregnancy Working Group. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health. 2003;35:94-101.
8. Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic review. Lancet. 2000;368:1581-1586.
9. Crosby R, Yarber WL, Sanders SA, et al. Condom discomfort and associated problems with their use among university students. J Am Coll Health. 2005;54:143-147.
10. Sanders SA, Graham CA, Yarber WL, et al. Condom use errors and problems among young women who put condoms on their male partners. J Am Med Womens Assoc. 2003;58:95-98.
11. Crosby RA, Sanders SA, Yarber WL, et al. Condom use errors and problems among college men. Sex Transm Dis. 2002;29:552-557.
12. Centers for Disease Control and prevention. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR. 2006;55(RR- 6):1-15.
13. Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect. 1998;30:223.