Objective
The objective of the study was to characterize beliefs about contraception among obstetrician-gynecologists.
Study Design
National mailed survey of 1800 US obstetrician-gynecologists. Criterion variables were whether physicians have a moral or ethical objection to, and whether they would offer, 6 common contraceptive methods. Covariates included physician demographic and religious characteristics.
Results
One thousand one hundred fifty-four of 1760 eligible obstetrician-gynecologists responded (66%). Some obstetrician-gynecologists object to intrauterine devices (4.4% object, 3.6% would not offer), progesterone implants and/or injections (1.7% object, 2.1% would not offer), tubal ligations (1.5% object, 1.5% would not offer), oral contraceptive pills (1.3% object, 1.1% would not offer), condoms (1.3% object, 1.8% would not offer), and the diaphragm or cervical cap with spermicide (1.3% object, 3.3% would not offer). Religious physicians were more likely to object (odds ratio, 7.4) and to refuse to provide a contraceptive (odds ratio, 1.9).
Conclusion
Controversies about contraception are ongoing but among obstetrician-gynecologists, objections and refusals to provide contraceptives are infrequent.
May 2010 marked the 50th anniversary of the Food and Drug Administration’s approval of the oral contraceptive pill. These 5 decades of use are marked by widespread popularity, with the pill being used at some point by 82% of sexually experienced US women (aged 15-44 years). There has also been much controversy, ranging from legal and political battles about contraception access, to concern about the pill’s effect on marriage, families, and sexual morés.
Debates about contraception are by no means limited to the oral contraceptive pill, nor are they limited to the past 50 years but have spanned many centuries and cultures. Ongoing loci of controversy are readily found, such as the Bush Administration’s decision to shift funding away from family-planning programs to abstinence-only education or criticism of health insurance providers that provide reimbursements for sildenafil but not for contraceptives.
Although contraception has both advocates and opponents, there has been relatively little study of physicians’ beliefs about contraception, an important topic because most contraceptive methods must be obtained from a physician. Previously we reported significant variability in obstetrician-gynecologist physicians’ beliefs about emergency contraception and their willingness to offer it.
This study considers contraception more broadly, using survey data to quantify how many obstetrician-gynecologist physicians object to any of 6 common contraceptive methods, whether they would provide it if asked, and what they think of natural family planning (the chief alternative to medical or barrier contraception). Because religious issues are prominent in many debates about reproductive medicine, we also examined associations with physicians’ religious characteristics.
Materials and Methods
From October 2008 until January 2009, we mailed a confidential self-administered questionnaire to a stratified random sample consisting of 1800 US general obstetrician-gynecologist physicians 65 years old or younger. The sample was generated from the American Medical Association Physician Masterfile, a database intended to include all practicing US physicians.
To increase minority representation (especially minority religious perspectives), we used validated surname lists to create 4 strata. We randomly sampled the following: (1) 180 physicians with typical south Asian surnames, (2) 225 physicians with typical Arabic surnames, (3) 180 physicians with typical Jewish surnames, and (4) 1215 other physicians (from all those whose surnames were not on 1 of these ethnic lists). Physicians received up to 3 separate mailings of the questionnaire; the first included a $20 bill, and the third offered an additional $30 for participating.
Physicians also received an advance letter and a postcard reminder after the first questionnaire mailing. All data were double keyed, cross-compared, and corrected against the original questionnaire. The study was approved by the institutional review board of the University of Chicago.
Questionnaire
Primary criterion variables were whether the physician has a moral or ethical objection to any of 6 common contraceptives (oral contraceptive pills, progesterone implants and/or injections, intrauterine devices, diaphragms/cervical cap with spermicide, condoms, or tubal ligation); and whether the physician would offer the method if a patient requested it. Response options were yes or no. Responses were analyzed for each method individually; then to simplify the presentation, we pooled all objections into a single variable indicating the physician objected to 1 or more contraceptive methods.
Inasmuch as many consider natural family planning (the use of cervical mucus and/or basal body temperature assessment to prevent pregnancy) to be the principal alternative to contraception, we hypothesized that physicians who object to contraceptives would have more favorable views toward natural family planning. To assess this we asked a free response question, “Of 100 couples who use natural family planning, how many do you think will get pregnant over a year?” We also asked: As a method of family planning, would you say that natural family planning is: (1) the best option for most women, (2) the best option for some women, or (3) a poor option for most women?
In addition to demographic information, religious characteristics were included as covariates. Religious affiliation was categorized as Nonevangelical Protestant, Evangelical Protestant, Catholic (includes Roman Catholic [n = 237] and Eastern Orthodox [n = 25]), Muslim, Jewish, Hindu, other religion (includes 9 Buddhists), and no religion. The importance of religion was assessed by asking: How important would you say your religion is in your own life? Response options were dichotomized as “not very important in my life/fairly important in my life” and “very important in my life/the most important part of my life.” Attendance at religious services was categorized as twice a year or less, 3 times a year to monthly, and twice a month or more.
We also asked whether respondents work primarily in an academic medical center or teaching hospital and whether they are members of the American College of Obstetricians and Gynecologists (ACOG).
Statistical analysis
Case weights were incorporated to account for the oversampling strategy (the design weight) and to correct for differences in response rates among the surname categories, and between US vs foreign medical school graduates (the poststratification adjustment weight). Weights were the inverse probability of a person with the relevant characteristic being in the final dataset. The final weight for each case/respondent was the product of the design weight and the poststratification adjustment weight.
This method of case weighting, widely used in population-based research, enabled us to adjust for sample stratification and variable response rates to generate estimates for the population of US obstetrician-gynecologists. We used the χ 2 test to examine the associations between each background variable and physicians’ beliefs about contraception and natural family planning.
We then conducted multivariable logistic regression using physicians’ sex, race, region, and age as covariates. When analyzing physicians’ estimates of the natural family planning failure rate, we used ordinary least-squares regression analysis. All analyses were conducted using the survey-design–adjusted commands of Stata SE statistical software (version 10.0; Stata Corp, College Station, TX).
Results
The response rate was 66% (1154/1760), after excluding 40 potential respondents who were retired or had invalid addresses. The response rate varied by sample; 68% (807/1188) of the primary sample responded, 54% (120/221) of those with Arabic surnames responded, 61% (107/175) of those with South Asian surnames responded, and 68% (120/176) of those with Jewish surnames responded. Graduates of foreign medical schools were less likely to respond than graduates of US medical schools (58% vs 68%; P = .001). These differences were accounted for by calculating poststratification adjustment case weights. Response did not differ significantly by age, sex, region, or board certification. Demographic characteristics of respondents are reported in Table 1 .
| Variable | n | % |
|---|---|---|
| Sex | ||
| Female | 537 | 47 |
| Male | 617 | 53 |
| Race | ||
| White, non-Hispanic | 774 | 69 |
| Black, non-Hispanic | 67 | 6 |
| Asian | 202 | 18 |
| Hispanic/Latino | 64 | 6 |
| Other | 22 | 2 |
| Age, y | ||
| 25-40 | 291 | 25 |
| 41-47 | 305 | 26 |
| 48-55 | 281 | 24 |
| 56-65 | 277 | 24 |
| Region | ||
| South | 373 | 32 |
| Midwest | 249 | 22 |
| Northeast | 288 | 25 |
| West | 242 | 21 |
| Medical education | ||
| US medical graduate | 932 | 81 |
| International medical graduate | 222 | 19 |
| Religious affiliation | ||
| Nonevangelical Protestant | 300 | 27 |
| Evangelical Protestant | 91 | 8 |
| Catholic | 262 | 23 |
| Muslim | 54 | 5 |
| Jewish | 160 | 14 |
| Hindu | 91 | 8 |
| Other religion | 48 | 4 |
| No religion | 119 | 11 |
| Importance of religion | ||
| Not very important | 272 | 24 |
| Fairly important | 321 | 28 |
| Very important | 385 | 34 |
| The most important part | 157 | 14 |
| Attendance at services | ||
| ≤2 per year | 380 | 33 |
| 3 per year to monthly | 290 | 26 |
| Twice a month or more | 466 | 41 |
| Practice characteristics | ||
| ACOG member | 1052 | 92 |
| Work primarily in academic center | 305 | 27 |
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