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; mary.nettleman@ht.msu.edu