Understanding contraceptive failure: an analysis of qualitative narratives.

Most American women wanting to avoid pregnancy use contraception, yet contraceptive failures are common. Guided by the Health Belief Model (HBM), we conducted a secondary qualitative analysis of interviews with women who described experiencing a contraceptive failure (n=69) to examine why and how this outcome occurs. We found three primary drivers of contraceptive failures (health literacy and beliefs, partners and relationships, and structural barriers), and we identified pathways through which these drivers led to contraceptive failures that resulted in pregnancy. These findings have implications for how individuals can be better supported to select their preferred contraception during clinical contraceptive discussions.

"Adoption is just not for me": How abortion patients in Michigan and New Mexico factor adoption into their pregnancy outcome decisions.

Objectives: In public discourses in the United States, adoption is often suggested as a less objectionable, equal substitute for abortion, despite this pregnancy outcome occurring much less frequently than the outcomes of abortion and parenting. This qualitative study explores whether and how abortion patients weighed adoption as part of their pregnancy decisions and, for those who did, identifies factors that contributed to their ultimate decision against adoption. Study design: We interviewed 29 abortion patients from 6 facilities in Michigan and New Mexico in 2015. We conducted a thematic analysis using both deductive and inductive approaches to describe participants' perspectives, preferences, and experiences regarding the consideration of adoption for their pregnancy. Results: Participants' reasons why adoption was not an appropriate option for their pregnancy were grounded in their ideas of the roles and responsibilities of parenting and fell into three themes. First, participants described continuing the pregnancy and giving birth as inseparable from the decision to parent. Second, choosing adoption would represent an irresponsible abnegation of parental duty. Third, adoption could put their child's safety and well-being at risk. Conclusions: Adoption was not an equally acceptable substitute for abortion among abortion patients. For them, adoption was a decision that represented taking on, and then abdicating, the role of parent. This made adoption a particularly unsuitable choice for their pregnancy. Implications: Rhetoric suggesting that adoption is an equal alternative to abortion does not reflect the experiences, preferences, or values of how abortion patients assess what options are appropriate for their pregnancy.

A Content Analysis of Reddit Users' Posts about Challenges to Contraceptive care-seeking during COVID-19-related Restrictions in the United States.

The COVID-19 pandemic in the United States caused disruptions in care seeking and delivery during the spring of 2020, including for contraceptive care. We examined how some individuals experienced and responded to barriers to accessing contraceptive care by conducting a content analysis of relevant Reddit posts. We collected 2666 posts by scraping relevant subreddits from February 1, 2020, to April 15, 2020, and filtering by selected keywords. Among the 101 posts on contraception and the COVID-19 pandemic, we explored three main themes: barriers to accessing general healthcare during the early pandemic, problems and concerns specific to contraceptive use, and attempts to navigate the obstacles to contraceptive care or use-related concerns. The Reddit posts demonstrated the disruptive force the early pandemic had on contraceptive care and provided a unique window into the concerns posters expressed on Reddit during this time. Many posters asked questions related to accessing contraception and side effects and sought reassurance from these online forums. Our results suggest that there were barriers to accessing reliable, high-quality, and evidence-based information about contraception during this disruption in care. The findings also underscore that conversational and interactive means of seeking out information are important modes for learning about and discussing contraception for some and may be especially helpful during clinic closures and other restrictions on access.

Access to Preferred Contraceptive Strategies in Iowa: A Longitudinal Qualitative Study of Effects of Shifts in Policy and Healthcare Contexts.

People's ability to use their desired contraception is necessary for reproductive autonomy. We conducted longitudinal in-depth interviews over two years with 34 women in Iowa who sought contraceptive and related care at publicly supported sites in 2018/2019 to understand how state-level shifts in funding for these services affected their access to contraception. Twenty-seven of 34 respondents faced cost, access, and quality barriers relevant to policy and health care contexts, and we assessed the overall level of impact of these on access to preferred contraception over the study period. Cost barriers such as high fees for visits and methods as well as restrictive or inadequate insurance coverage, and access barriers such as long appointment wait times were most common; barriers compounded one another. Policies that support funding for contraceptive care, and that limit the need to interact with health systems for routine care, can decrease vulnerability to barriers and increase reproductive autonomy.

Exploring experience of and engagement in coercive pregnancy behaviors among sexually active young men from five clinics in Baltimore, MD.

OBJECTIVES: To explore young men's perceived experience of coercive pregnancy behaviors by female partners, and engagement in and behavioral overlap of these occurrences in this sample. STUDY DESIGN: Heterosexually active young men aged 15 to 24 (n = 39), recruited from 3 primary care and 2 sexually transmitted disease clinics in Baltimore, MD city over a 2-week period, were surveyed on their perceived experience of and engagement in coercive pregnancy behaviors, attitudes about women, and background characteristics. RESULTS: Of 130 invited, 66 (51%) agreed to participate, 39 of whom were heterosexual young men; 87% were non-Hispanic Black and 59% were aged 20 to 24. Eleven (28%) perceived one or more coercive pregnancy behaviors by a partner and nine (23%) engaged in one or more coercive behavior. Most (58%) agreed women are responsible for birth control decisions, but 55% believed women could not be trusted to tell the truth about contraceptive use and 68% believe women would like to get pregnant. CONCLUSIONS: Over one-third of young men in this sample perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings have implications for promoting healthy relationships among young people. IMPLICATIONS: This study found over one-third of young men perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings highlight the need for research to include young men in examining coercive pregnancy behaviors. Findings also highlight the need to develop strategies to support educational and clinical approaches to address young men's role as partners in healthy contraceptive practices.

"It's not something you talk about really": information barriers encountered by women who travel long distances for abortion care.

OBJECTIVE: For individuals traveling significant distances for time-sensitive abortion care, accurate information about service options and locations is critical, but little is known regarding information barriers that individuals may encounter and strategies for circumventing these barriers. STUDY DESIGN: In early 2015, we conducted in-depth interviews with 29 patients who had traveled for abortion care at six facilities in Michigan and New Mexico. We identified information-related barriers that respondents encountered in understanding their pregnancy options and/or where to obtain an abortion between the time of pregnancy discovery, including any contact with a crisis pregnancy center, to the day of the abortion procedure through inductive and deductive analysis. RESULTS: We identified two logistical information-related barriers - a general lack of reproductive-related knowledge and unhelpfulness on the part of perceived members of the healthcare community - and one broader barrier of perceived stigma within respondents' narratives. Of the seven respondents who did not encounter a logistical information-related barrier, having previous personal or close experience with abortion and internet savviness were both identified as strategies enabling them to circumvent the barriers. CONCLUSION: Lack of clear, easy-to-find and accurate information about abortion services and availability represents a key barrier to obtaining an abortion; health care providers play a crucial role in ensuring pregnant patients' right to informed consent within reproductive health care delivery. IMPLICATIONS: Women's health care providers should provide their patients with the full spectrum of resources and referrals for pregnancy and abortion care; recent federal guidelines proposing to restrict abortion counseling and referral at Title X-funded facilities would only exacerbate the current challenges that pregnant patients encounter when seeking abortion-related information and further decrease linkages to timely, desired abortion care.

Managing Religion and Morality Within the Abortion Experience: Qualitative Interviews With Women Obtaining Abortions in the U.S.

Most women in the United States are religious, and most major religions in the United States doctrinally disapprove of abortion. A substantial proportion of U.S. women have abortions. Although relationships among religious beliefs, abortion attitudes, behaviors, and stigma have been found in previous research, the relationship between stigma and religion is understudied. In-depth interviews conducted with 78 women having abortions at nine sites in the United States found religion to permeate abortion stigma manifestations and management strategies identified in previous research, for religious and religiously affiliated respondents as well as those who did not claim a religious affiliation. Health-care providers, religious leaders, researchers, and advocates need to recognize the influence religion has on the experience of obtaining an abortion for all women in the United States.

Barriers to Abortion Care and Their Consequences For Patients Traveling for Services: Qualitative Findings from Two States.

CONTEXT: Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is known about the experience of travel to obtain abortion. METHODS: In January and February 2015, in-depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis. RESULTS: Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self-induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion. CONCLUSION: The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.

Parents' experience of unintended childbearing: A qualitative study of factors that mitigate or exacerbate effects.

Births resulting from an unintended pregnancy affect individuals differentially, and some may experience more negative consequences than others. In this study, we sought to describe the mechanisms through which the severity of effects may be mitigated or exacerbated. We conducted in-depth interviews with 35 women and 30 men, all with a youngest child born resulting from an unintended pregnancy, in two urban sites in the United States. Respondents described both negative and positive effects of the child's birth in the areas of school; work and finances; partner relationships; personal health and outlook on life trajectories. Mechanisms through which unintended pregnancies mitigated or exacerbated certain effects fell at the individual (e.g. lifestyle modification), interpersonal (e.g. partner support) and structural (e.g. workplace flexibility) levels. These qualitative findings deepen understanding of the impact of unintended childbearing on the lives of women, men and families.

The Complexity of Multiple Contraceptive Method Use and the Anxiety That Informs It: Implications for Theory and Practice.

Despite clinical guidelines and national data describing the use of one contraceptive method as the best and most common way to prevent unintended pregnancy, limited evidence indicates a more complex picture of actual contraceptive practice. Face-to-face in-depth interviews were conducted in November of 2013 with a sample of women from two cities in the United States (n = 52). The interviews explored the ways participants used contraception to protect themselves from unintended pregnancy over the past 12 months. Most respondents reported using multiple methods, many of which are considered to be less-effective, within this timeframe. The practice of combining methods in order to increase one's level of protection from pregnancy was prevalent, and was mainly enacted in two ways: by backing up inconsistent method use with other methods and by "buttressing" methods. These practices were found to be more common, and more complex, than previously described in the literature. These behaviors were mainly informed by a deep anxiety about both the efficacy of contraceptive methods, and about respondents' own perceived ability to prevent pregnancy. These findings challenge prevailing assumptions about women's contraceptive method use and have implications for clinical contraceptive counseling practice.

"If I know I am on the pill and I get pregnant, it's an act of God": women's views on fatalism, agency and pregnancy.

OBJECTIVES: Fatalism is the idea that outside forces have control over events. Pregnancy and pregnancy prevention play a prominent role in many women's lives, and we sought to understand if and how fatalism informed their thinking about these issues. STUDY DESIGN: We conducted in-depth interviews with 52 unmarried women between the ages of 18 and 30. We used NVivo to analyze the transcripts. The current analysis focuses on the ways that women discussed fatalism and pregnancy both in response to a direct question and as it came up spontaneously. RESULTS: The majority of respondents expressed a mix of fatalistic and non-fatalistic views about pregnancy. Many related that "fate," "destiny" and/or God play a role in pregnancy, but most also asserted that pregnancy risk could be substantially reduced, most commonly by using contraception. Fatalism sometimes served a positive function, for example as a mechanism to deal with an unintended pregnancy. Having a fatalistic outlook did not preclude contraceptive use. Rather, some women using highly effective methods related that if they were to become pregnant, they would interpret it as a sign that the pregnancy was "meant to happen." Finally some women related that there was no guarantee a woman could get pregnant when she wanted to, suggesting that some degree of fatalism may be inevitable when it comes to pregnancy. CONCLUSIONS: Fatalism and agency should not be viewed as opposing outlooks when it comes to pregnancy and pregnancy prevention; having fatalistic views about pregnancy does not preclude contraceptive use. IMPLICATIONS: Given that women do not have total control over attainment of a wanted pregnancy or even prevention of pregnancy, some amount of fatalism about fertility is a logical and pragmatic response. Both research and clinical practice need to recognize that fatalism and contraceptive use are often not in conflict.

Perceptions of susceptibility to pregnancy among U.S. women obtaining abortions.

More than half (52%) of unintended pregnancies in the United States (U.S.) occur among the 10.7% of women using no contraceptive method. We interviewed a sample of women obtaining abortions in the U.S. in 2008 (n = 49) and explored their attitudes toward and beliefs about their risk of pregnancy. We found that most respondents perceived themselves to have a low likelihood of becoming pregnant at the time that the index pregnancy occurred. Respondents' reasons for this perceived low likelihood fell into four categories: perceived invulnerability to pregnancy without contraceptive use, perceptions of subfecundity, self-described inattention to the possibility of conception and perceived protection from their current use of contraception (although the majority in this subgroup were using contraception inconsistently or incorrectly). About half of the women discussed more than one reason when explaining why they perceived themselves to have a low risk of pregnancy at that time. We propose a modified Health Belief Model to account for women's low perceived susceptibility to pregnancy based on our results. Further research is needed to quantify the proportion of women who are at risk of pregnancy who do not believe they are at risk and their reasons why, so as to be able to better address women's misconceptions about fecundity and conception with the goal of preventing unintended pregnancy.

Long-acting reversible contraception for adolescents and young adults: patient and provider perspectives.

STUDY OBJECTIVE: To describe and explore provider- and patient-level perspectives regarding long-acting reversible contraception (LARC) for teens and young adults (ages 16-24). METHODS: Data collection occurred between June and December 2011. We first conducted telephone interviews with administrative directors at 20 publicly funded facilities that provide family planning services. At 6 of these sites, we conducted a total of 6 focus group discussions (FGDs) with facility staff and 48 in-depth interviews (IDIs) with facility clients ages 16-24. RESULTS: Staff in the FGDs did not generally equate being a teen with ineligibility for IUDs. In contrast to staff, one-quarter of the young women did perceive young age as rendering them ineligible. Clients and staff agreed that the "forgettable" nature of the methods and their duration were some of LARC's most significant advantages. They also agreed that fear of pain associated with both insertion and removal and negative side effects were disadvantages. Some aspects of IUDs and implants were perceived as advantages by some clients but disadvantages by others. Common challenges to providing LARC-specific services to younger patients included extra time required to counsel young patients about LARC methods, outdated clinic policies requiring multiple visits to obtain IUDs, and a perceived higher removal rate among young women. The most commonly cited strategy for addressing many of these challenges was securing supplementary funding to support the provision of these services to young patients. CONCLUSION: Incorporating young women's perspectives on LARC methods into publicly funded family planning facilities' efforts to provide these methods to a younger population may increase their use among young women.

More than poverty: disruptive events among women having abortions in the USA.

BACKGROUND: In the USA, abortion has become increasingly concentrated among poor women. For many, poverty represents difficulties meeting financial obligations, but the authors expect it is also associated with a range of potentially difficult life circumstances that may influence women's pregnancy decisions. METHODS: This mixed methods study relied on two data sources. Quantitative data came from a national sample of 9493 women obtaining abortions in 2008 and examined exposure to 11 potentially disruptive events. The authors also examined associations between disruptive events, poverty status and contraceptive use. Qualitative information from 49 in-depth interviews was used to provide insights into patterns that emerged from the quantitative analysis. RESULTS: More than half (57%) of the women obtaining abortions experienced a potentially disruptive event within the last year, most commonly unemployment (20%), separation from a partner (16%), falling behind on rent/mortgage (14%) and/or moving multiple times (12%). Poverty status was significantly associated with several of the events, particularly those that could directly impact on a family's economic circumstances, for example losing a job or having a baby. Information from the in-depth interviews suggested that disruptive events interfered with contraceptive use, but the quantitative survey found no difference in contraceptive use by exposure to disruptive life events, even after controlling for poverty status. CONCLUSION: Many abortion patients make decisions about their pregnancies in the midst of complex life circumstances.

What women want from abortion counseling in the United States: a qualitative study of abortion patients in 2008.

Abortion counseling, including informed consent laws specifying what a woman must be told to obtain an abortion, have been the subject of a great deal of social policy. Using a qualitative sample of 49 women seeking abortions in 2008, we asked women whether they had their mind made up when they called the clinic to make their appointment as well as what they wanted from abortion counseling. The majority of women contacting the abortion clinic had already made up their minds to have an abortion and were therefore not seeking options counseling. Neither were they seeking to emotionally confide in their abortion counselors: They anticipated that the counselor would try to discourage them from having an abortion, they stated that they had met their emotional needs elsewhere, and they feared that confiding in the counselor might endanger their ability to obtain an abortion. They perceived other women needed counseling, though, to help them make a responsible decision. A cafeteria-style approach to counseling that allows women to specify what their needs are would better match abortion counseling with women's stated needs. These data have the potential to inform public policy to better suit abortion-related counseling with women's needs.

Perceptions of male knowledge and support among U.S. women obtaining abortions.

PURPOSE: At least one national study has shown that most women having abortions have consulted with male partners before terminating a pregnancy. However, little is known about the extent to which women perceive men to be supportive of their abortion decisions or which relationship characteristics are associated with male knowledge of and support for the abortion. METHODS: We used data from a nationally representative sample of 9,493 women obtaining abortions to examine perceptions of male knowledge and support for the abortion according to three relationship characteristics: Union status, length of relationship, and exposure to intimate partner violence (IPV). MAIN FINDINGS: The overwhelming majority of women reported that the men with whom they got pregnant knew about the abortion, and most perceived these men to be supportive. Cohabiting and, to a lesser extent, married women as well as those in longer relationships were more likely to report both of these outcomes, even after controlling for demographic characteristics. Exposure to IPV by the man involved in the pregnancy, reported by 7% of abortion patients, substantially reduced the likelihood that women perceived the men to know about or to be supportive of the abortion. CONCLUSION: Our results suggest that most women obtaining abortions are able to rely on male partners for social support. Education and counseling efforts that incorporate or reach out to male partners may increase support for women obtaining abortions. However, this strategy may not be appropriate for all women, especially those exposed to IPV.

Male reproductive control of women who have experienced intimate partner violence in the United States.

Women who have experienced intimate partner violence (IPV) are consistently found to have poor sexual and reproductive health when compared to non-abused women, but the mechanisms through which such associations occur are inadequately defined. Through face-to-face, semi-structured in-depth interviews, we gathered full reproductive histories of 71 women aged 18-49 with a history of IPV recruited from a family planning clinic, an abortion clinic and a domestic violence shelter in the United States. A phenomenon which emerged among 53 respondents (74%) was male reproductive control which encompasses pregnancy-promoting behaviors as well as control and abuse during pregnancy in an attempt to influence the pregnancy outcome. Pregnancy promotion involves male partner attempts to impregnate a woman including verbal threats about getting her pregnant, unprotected forced sex, and contraceptive sabotage. Once pregnant, male partners resort to behaviors that threaten a woman if she does not do what he desires with the pregnancy. Reproductive control was present in violent as well as non-violent relationships. By assessing for male reproductive control among women seeking reproductive health services, including antenatal care, health care providers may be able to provide education, care, and counseling to help women protect their reproductive health and physical safety.

Timing of steps and reasons for delays in obtaining abortions in the United States.

OBJECTIVE: We studied the steps in the process of obtaining abortions and women's reported delays in order to help understand difficulties in accessing abortion services. METHODS: In 2004, a structured survey was completed by 1209 abortion patients at 11 large providers, and in-depth interviews were conducted with 38 women at four sites. RESULTS: The median time from the last menstrual period to suspecting pregnancy was 33 days; the median time from suspecting pregnancy to confirming the pregnancy was 4 days; the median time from confirming the pregnancy to deciding to have an abortion was 0 day; the median time from deciding to have an abortion to first attempting to obtain abortion services was 2 days; and the median time from first attempting to obtain abortion services to obtaining the abortion was 7 days. Minors took a week longer to suspect pregnancy than adults did. Fifty-eight percent of women reported that they would have liked to have had the abortion earlier. The most common reasons for delay were that it took a long time to make arrangements (59%), to decide (39%) and to find out about the pregnancy (36%). Poor women were about twice as likely to be delayed by difficulties in making arrangements. CONCLUSIONS: Financial limitations and lack of knowledge about pregnancy may make it more difficult for some women to obtain early abortion.

Reasons U.S. women have abortions: quantitative and qualitative perspectives.

CONTEXT: Understanding women's reasons for having abortions can inform public debate and policy regarding abortion and unwanted pregnancy. Demographic changes over the last two decades highlight the need for a reassessment of why women decide to have abortions. METHODS: In 2004, a structured survey was completed by 1,209 abortion patients at 11 large providers, and in-depth interviews were conducted with 38 women at four sites. Bivariate analyses examined differences in the reasons for abortion across subgroups, and multivariate logistic regression models assessed associations between respondent characteristics and reported reasons. RESULTS: The reasons most frequently cited were that having a child would interfere with a woman's education, work or ability to care for dependents (74%); that she could not afford a baby now (73%); and that she did not want to be a single mother or was having relationship problems (48%). Nearly four in 10 women said they had completed their childbearing, and almost one-third were not ready to have a child. Fewer than 1% said their parents' or partners' desire for them to have an abortion was the most important reason. Younger women often reported that they were unprepared for the transition to motherhood, while older women regularly cited their responsibility to dependents. CONCLUSIONS: The decision to have an abortion is typically motivated by multiple, diverse and interrelated reasons. The themes of responsibility to others and resource limitations, such as financial constraints and lack of partner support, recurred throughout the study.

The availability and use of publicly funded family planning clinics: U.S. trends, 1994-2001.

CONTEXT: It is important to monitor trends among publicly funded family planning clinics to determine where clinics are successfully meeting the contraceptive service needs of low-income women and where more effort is needed. METHODS: Service data for all U.S. agencies and clinics providing subsidized family planning services were collected for 2001 and compared with similar data collected for 1997 and 1994. Trends reflecting clinic structure and capacity were analyzed at the national and state levels. Client numbers were compared with numbers of women needing publicly funded contraceptive services to create a measure of met need for states and groups of states, according to Medicaid family planning waiver status. RESULTS: In 2001, some 7,683 publicly funded family planning clinics provided contraceptive services to 6.7 million women-representing an 8% rise in clinics and a 2% increase in clients since 1994. Change varied by type of provider and clinic location. Health departments and Planned Parenthood affiliates served more clients at fewer sites; community health centers served fewer clients at more sites. One-third of states experienced growth in clinic capacity, with 5-65% increases in met need. In another third of states, met need declined by 5% or more. States with income-based Medicaid family planning waivers served 24% more clients, with met need increasing from 40% to 50%. CONCLUSIONS: Among states, there has been tremendous variation in the ability of publicly funded family planning clinics to serve women. Implementation of income-based Medicaid family planning waivers in some states was associated with clinics' serving greater numbers of women. Further efforts are needed to ensure access to family planning services for low-income women in every state.