Objective
Contraceptive methods have differing attributes. Women’s preferences for these attributes may influence contraceptive decision making. Our objective was to identify women’s contraceptive preferences among women initiating a new contraceptive method.
Study Design
We conducted a cross-sectional, self-administered survey of women’s contraceptive preferences at the time of enrollment into the Contraceptive CHOICE Project. Participants were asked to rank the importance of 15 contraceptive attributes on a 3-point scale (1 = not at all important, 2 = somewhat important, and 3 = very important) and then to rank the 3 attributes that were the most important when choosing a contraceptive method. The survey also contained questions about prior contraceptive experience and barriers to contraceptive use. Information about demographic and reproductive characteristics was collected through the CHOICE Project baseline survey.
Results
There were 2590 women who completed the survey. Our sample was racially and socioeconomically diverse. Method attributes with the highest importance score (mean score [SD]) were effectiveness (2.97 [0.18]), safety (2.96 [0.22]), affordability (2.61 [0.61]), whether the method is long lasting (2.58 [0.61]), and whether the method is “forgettable” (2.54 [0.66]). The attributes most likely to be ranked by respondents among the top 3 attributes included effectiveness (84.2%), safety (67.8%), and side effects of the method (44.6%).
Conclusion
Multiple contraceptive attributes influence decision making and no single attribute drives most women’s decisions. Tailoring communication and helping women make complex tradeoffs between attributes can better support their contraceptive decisions and may assist them in making value-consistent choices. This process could improve continuation and satisfaction.
Contraceptive use is widespread in the United States with 62% of reproductive-aged women currently using a contraceptive method. Like many preference-sensitive health care decisions, contraceptive methods have both desirable and undesirable attributes that require the patient to make tradeoffs between potential benefits and disadvantages of options. However, many women lack knowledge or support for contraceptive decision making or have unrealistic expectations, unclear values, or social pressures that can complicate decisions. For example, multiple prior studies have shown that effectiveness is an important attribute to women when choosing contraception. Yet many women remain uninformed about highly effective contraceptive methods such as intrauterine devices (IUDs) and implants, and use remains low compared to oral contraceptive pills (OCPs) and condoms, methods that have lower rates of effectiveness. Contraceptive decision making is complex, and women who select methods inconsistent with their preferences may be less likely to adhere or continue the method. Effective contraceptive counseling should assist women in identifying important method attributes. This, in turn, can help women choose the contraceptive method most consistent with her preferences, which may lead to improved continuation and satisfaction.
Given that contraceptive decision making is a highly personal process, our primary objective in this analysis was to evaluate the importance of specific contraceptive attributes among participants of the Contraceptive CHOICE Project who were choosing a new contraceptive method. We also explored associations between contraceptive preferences and women’s choice of method as well as women’s past experiences with contraception.
Materials and Methods
This study was a cross-sectional survey of a subset of women enrolling into the Contraceptive CHOICE Project, which was a prospective cohort study of 9256 women designed to promote the use of long-acting reversible contraception and remove financial and access barriers to contraception. Participants were recruited through referral from word-of-mouth, community-based medical providers, and study flyers. Participants underwent comprehensive contraceptive counseling and were provided with their reversible contraceptive method of choice at no cost. We developed a self-administered written survey that asked about prior contraceptive experience, including prior contraceptive use, experience of side effects with a prior method, and barriers to using contraception. Women were eligible to participate in the CHOICE Project if they were between 14-45 years of age, English or Spanish speaking, at risk of unintended pregnancy (ie, no prior tubal sterilization or hysterectomy), currently sexual active or planning to become sexually active with a male partner in the next 6 months, and willing to start a new contraceptive method. There were no additional eligibility requirements for this study. The survey was administered to all CHOICE participants who enrolled from January 2010 through March 2011. Approval was obtained from the human research protection office prior to administration of the survey.
The survey included the following contraceptive method attributes potentially important to women when selecting a contraceptive method: effectiveness, safety, side effects, long acting, “forgettable” (do not have to remember to take or use the method regularly), affordability, protects against sexually transmitted infections (STIs), having a monthly period, not having irregular bleeding, privacy, and opinion of health care provider, partner, family, friend, or religious community. We developed this list using qualitative data from patients, expert opinion, and a review of the current scientific literature. Participants were asked to score the importance of the attribute in making a decision about contraception on a 3-point scale: 1 = not at all important, 2 = somewhat important, and 3 = very important. Next, participants were asked to choose from the same list of attributes, the 3 attributes that would be most important to them when making a decision about contraception and to rank them from 1-3. Participants completed the survey prior to undergoing contraceptive counseling and enrollment into CHOICE. Demographic characteristics and contraceptive method chosen were extracted from the baseline CHOICE Project survey that was administered in-person to the participant at the time of enrollment into the parent study.
To describe demographic characteristics of the study participants, frequencies, percentages, means, and SD were used for appropriate data type. We calculated mean importance scores for contraceptive attributes. We then identified the attributes most commonly ranked among 3 most important attributes. We used multinomial logistic regression to investigate associations between the top 3 ranked attributes and the contraceptive method chosen at the time of enrollment. We calculated odds ratios (ORs) and 95% confidence intervals (CIs). We tested for confounding by including demographic factors in the regression model. None of the demographic factors confounded the relationship between attributes and method selection. The OR was considered to be statistically significant if the 95% CI did not cross 1. Statistical analyses were performed using STATA 11 (StataCorp, College Station, TX).
Results
There were 2902 women who completed the survey; 312 women did not answer any questions about contraceptive preferences and were excluded from the analysis leaving 2590 respondents. The demographic and reproductive characteristics of the respondents are shown in Table 1 . Prior contraceptive use was prevalent with 99.6% of respondents reporting any prior contraceptive use. The most common methods that women had used in the past were OCPs (80%) and condoms (53%). Eight percent of women reported ever using an IUD or an implant. Participants’ current contraceptive method use and the method chosen at the time of enrollment into the CHOICE Project are also shown in Table 1 .
| Characteristic | n | % |
|---|---|---|
| Age (y), mean (SD) | 25.6 (5.9) | |
| Race (missing, n = 6) | ||
| Black | 1349 | 52.1 |
| White | 1044 | 40.3 |
| Other | 191 | 7.4 |
| Hispanic ethnicity (missing, n = 1) | 135 | 5.2 |
| Education | ||
| ≤High school | 801 | 30.9 |
| Some college | 1122 | 43.3 |
| ≥College | 667 | 25.8 |
| Insurance (missing, n = 6) | ||
| None | 1011 | 39.0 |
| Commercial | 1068 | 41.2 |
| Public | 505 | 19.5 |
| Marital status (missing, n = 1) | ||
| Single | 1495 | 57.7 |
| Married/living with partner | 909 | 35.1 |
| Separated/divorced/widowed | 185 | 7.1 |
| Low SES a | 1596 | 61.6 |
| Any prior pregnancy | 1786 | 69.0 |
| Prior unintended pregnancy | 1546 | 56.7 |
| Contraceptive method | At time of enrollment, b n (%) | Chosen at enrollment, b n (%) |
| None | 784 (30.3) | 0 |
| LNG-IUS | 32 (1.2) | 1215 (46.9) |
| Copper IUD | 7 (0.3) | 378 (14.6) |
| Implant | 27 (1.0) | 505 (19.5) |
| DMPA | 135 (5.2) | 194 (7.5) |
| OCP | 458 (17.7) | 173 (6.7) |
| Ring | 109 (4.2) | 97 (3.8) |
| Patch | 18 (0.7) | 28 (1.1) |
| Condoms | 890 (34.4) | 0 |
| Other barrier | 6 (0.2) | 0 |
| Withdrawal | 68 (2.6) | 0 |
| Natural family planning | 3 (0.1) | 0 |
| Abstinence | 53 (2.0) | 0 |
a Defined as receipt of public assistance or reported difficulty paying for transportation, housing, medical expenses, or food in past 12 mo
b Reported contraceptive method use at time of enrollment into Contraceptive CHOICE Project–if respondents reported using >1 method, most effective method is listed.
Table 2 shows the mean importance score for each contraceptive attribute. Effectiveness and safety had the highest mean scores. Cost of the method, whether the method is long lasting, whether the method is forgettable, health care providers’ recommendation, avoiding irregular bleeding, whether the method protects against STI, and side effects all had mean scores >2 (on a 3-point scale). Women did not rate the influence of partner, family, friends, and religious community highly in their contraceptive decision making with mean scores of <1.6.
| Variable | Mean importance score (SD) (n = 2590) | Most important attribute, n (%) (n = 2476) a | Ranked among top 3 most important attributes, n (%) (n = 2476) a |
|---|---|---|---|
| Effectiveness | 2.97 (0.18) | 1093 (44.1) | 2084 (84.2) |
| Safety | 2.96 (0.22) | 944 (38.1) | 1679 (67.8) |
| Affordability | 2.61 (0.61) | 77 (3.1) | 649 (26.2) |
| Method is long lasting | 2.58 (0.61) | 38 (1.5) | 421 (17.0) |
| Forgettable | 2.54 (0.66) | 75 (3.0) | 461 (18.6) |
| Health care provider’s recommendation | 2.37 (0.67) | 21 (0.8) | 147 (5.9) |
| Not having irregular or unpredictable bleeding | 2.32 (0.68) | 21 (0.8) | 231 (9.3) |
| Whether it protects against sexually transmitted infections | 2.20 (0.83) | 46 (1.9) | 300 (12.1) |
| Side effects | 2.20 (0.83) | 128 (5.2) | 1105 (44.6) |
| Having regular period every month | 1.99 (0.78) | 23 (0.9) | 217 (8.8) |
| Partner’s opinion | 1.56 (0.71) | 5 (0.2) | 59 (2.4) |
| Nobody knows that you are using birth control method | 1.38 (0.66) | 1 (0.0) | 30 (1.2) |
| Family’s opinion | 1.33 (0.60) | 2 (0.1) | 16 (0.6) |
| Religious community’s opinion | 1.22 (0.52) | 1 (0.0) | 15 (0.6) |
| Friend’s opinion | 1.21 (0.49) | 0 (0.0) | 10 (0.4) |
a Data missing for 114 participants who did not complete this question.
When asked to identify the top 3 most important attributes when choosing a contraceptive method, respondents most frequently ranked effectiveness (44%) and safety (38%) as their top most preference ( Table 2 ). Other attributes that were frequently ranked among the top 3 included side effects, cost, not having to remember to take or use the method regularly, that the method was long lasting, and that the method protected against STIs.
For our multinomial regression model, we evaluated a number of potential confounders we believed could be associated with the top-ranked attributes and the contraceptive method chosen, including age, race, education level, parity, markers of socioeconomic status, and history of unintended pregnancy. None of these variables made a significant (>10%) change in the effect estimate. Therefore, we present unadjusted ORs shown in Table 3 . We found that ranking certain contraceptive attributes among the top 3 attributes was associated with contraceptive method choice. Women who ranked either the “method is long lasting” or “forgettable” were more likely to choose the IUD, implant, depot medroxyprogesterone acetate, contraceptive ring, or contraceptive patch compared to women who chose OCPs. Women who ranked “wanting to have a regular period every month” and “avoiding irregular bleeding” were less likely to choose the IUD or the implant than OCPs. Ranking effectiveness as a top factor was associated with increased choice of the levonorgestrel intrauterine system only, although the effect size was modest (OR, 1.54; 95% CI, 1.04–2.28). Concerns about safety were not associated with the choice of any specific contraceptive method.
| Variable | LNG-IUS | Copper IUD | Implant | DMPA | Ring | Patch |
|---|---|---|---|---|---|---|
| Effectiveness | 1.54 (1.04–2.28) a | 1.34 (0.85–2.10) | 1.40 (0.91–2.16) | 1.09 (0.64–1.86) | 1.39 (0.72–2.67) | 0.51 (0.21–1.23) |
| Safety | 0.85 (0.61–1.18) | 0.86 (0.59–1.26) | 1.13 (0.78–1.64) | 1.12 (0.71–1.78) | 1.02 (0.60–1.74) | 0.88 (0.37–2.09) |
| Side effects | 0.63 (0.46–0.86) a | 0.84 (0.59–1.20) | 0.51 (0.36–0.72) a | 0.68 (0.45–1.04) | 0.82 (0.50–1.35) | 0.66 (0.29–1.48) |
| Method is long lasting | 3.88 (2.02–7.47) a | 4.40 (2.21–8.75) a | 4.43 (2.26–8.71) a | 3.34 (1.56–7.16) a | 0.19 (0.02–1.47) | 4.00 (1.25–12.78) a |
| Forgettable | 8.69 (3.80–19.82) a | 6.86 (2.88–15.92) a | 6.60 (2.83–15.38) a | 4.92 (1.95–12.43) a | 4.29 (1.56–11.81) a | 6.82 (1.92–24.20) a |
| Whether it protects against sexually transmitted infections | 0.67 (0.43–1.06) | 0.55 (0.32–0.96) a | 1.22 (0.76–1.90) | 1.27 (0.72–2.26) | 0.61 (0.27–1.35) | 0.47 (0.11–2.10) |
| Not having irregular or unpredictable bleeding | 0.69 (0.43–1.10) | 0.46 (0.25–0.83) a | 0.56 (0.32–0.95) a | 0.90 (0.48–1.69) | 0.75 (0.34–1.63) | 0.25 (0.03–1.91) |
| Having regular period every month | 0.35 (0.22–0.54) a | 0.52 (0.31–0.86) a | 0.40 (0.24–0.66) a | 0.24 (0.11–0.53) a | 0.86 (0.44–1.67) | 1.32 (0.50–3.54) |
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