A Bother or a Benefit? How Contraceptive Users Balance the Trade-Offs Between Preferred Menstrual Bleeding Patterns and Preferred Contraceptive Methods in India, South Africa, and the United States

Figures & data

Figure 1. The construction of analytical samples for each country (see Materials and Methods for additional details). Of survey initiators, 32% (India), 46% (SA), and 54% (US) met the inclusion criteria. Eligible respondents were those currently using one of the specified HBC methods or using a non-HBC method. Of the eligible HBC users, those responding, “I would use hormonal birth control” were classified as H-receptive users, and of the eligible non-HBC users, those responding, “I don’t want to use any method of hormonal birth control” were classified as H-averse users.

Table 1. Sociodemographic characteristics of US H-receptive and H-averse respondents.

United States	H-receptive (1,820)	H-averse (1,871)
Age (mean ± SD; median years)	25.3 ± 5.7; 24	28.9 ± 6.0; 29
Education (high school or more)	99% (1,811)	99% (1,860)
Never married	69% (1,257)	46% (860)
No children	89% (1,624)	73% (1,361)
Want more children	50% (915)	50% (941)
Do not want more children	24% (436)	24% (455)
White	79% (1,443)	74% (1,390)
Hispanic	15% (269)	18% (339)
Black	9% (159)	10% (182)

Table 2. Sociodemographic characteristics of India H-receptive and H-averse respondents.

India	H-receptive (20)	H-averse (308)
Age (mean ± SD; median years)	25.7 ± 5.8; 24	26.9 ± 5.2; 26
Education (high school or more)	100% (20)	100% (308)
Never married	65% (13)	47% (144)
No children	75% (15)	81% (248)
Want more children	35% (7)	53% (163)
Do not want more children	45% (9)	22% (69)
Scheduled Caste (SC)^a	5% (1)	4% (13)
Other Backward Class (OBC)^a	20% (4)	13% (39)
Other ethnic group^a	75% (15)	83% (256)

^a This terminology is an integral feature of India’s socioeconomic hierarchy; historically, SC and OBC were substantially more disadvantaged than other castes (Sahgal et al., 2021).

Table 3. Sociodemographic characteristics of SA H-receptive and H-averse respondents.

South Africa	H-receptive (103)	H-averse (133)
Age (mean ± SD; median years)	23.8 ± 5.5; 22	27.7 ± 6.0; 27
Education (high school or more)	100% (80)	98% (130)
Never married	84% (87)	61% (81)
No children	93% (96)	82% (109)
Want more children	61% (63)	55% (73)
Do not want more children	17% (17)	25% (33)
White	66% (68)	58% (77)
Black African	20% (21)	25% (33)
Other (Colored, Indian, other)	14% (14)	17% (23)

Table 4. India.

	H-receptive		H-averse
	N	%	N	%	Total N
	20	6	308	94	328
A: “I don’t want to change my natural menstrual cycle.”
					Total	p
Agree	12	4.3	270	96	282	.0026
Disagree	5	18	23	82	28
Neutral	3	17	15	83	18
Did not answer	0		0		0
B: “I wish I could take a break from having my period.”
					Total	p
Agree	12	8	132	92	144	NS
Disagree	7	6	111	94	118
Neutral	1	2	64	98	65
Did not answer	0		1		1
C: “The only thing my period is good for is to let me know if I’m pregnant.”
					Total	p
Agree	12	10	110	90	122	.03
Disagree	6	4	157	96	163
Neutral	2	5	41	95	43
Did not answer	0		0		0
D: “My period is an important part of my gender identity.”
					Total	p
Agree	7	4	151	96	158	NS
Disagree	8	9	86	91	94
Neutral	5	7	71	93	76
Did not answer	0		0		0
E: “I feel empowered by my periods.”
					Total	p
Agree	10	6	161	94	171	NS
Disagree	5	10	46	90	51
Neutral	5	5	101	95	106
Did not answer	0		0		0
F: “I need to have periods to be in good health.”
					Total	p
Agree	17	6	255	94	272	NS
Disagree	2	7	27	93	29
Neutral	1	4	26	96	27
Did not answer	0		0		0
G: “My period helps me keep in touch with my body.”
					Total	p
Agree	15	7	194	93	209	NS
Disagree	3	7	42	93	45
Neutral	2	3	72	97	74
Did not answer	0		0		0
H: “My period represents fertility and potential motherhood.”
					Total	p
Agree	13	5	232	95	245	NS
Disagree	3	10	27	90	30
Neutral	4	8	49	92	53
Did not answer	0		0		0
J: “I need to have periods because they cleanse my body.”
					Total	p
Agree	8	4	174	96	182	NS
Disagree	8	10	72	90	80
Neutral	4	6	62	94	66
Did not answer	0		0		0
K: “It is difficult to manage my period bleeding.”
					Total	p
Agree	4	7	52	93	56	NS
Disagree	11	5	208	95	219
Neutral	5	10	44	90	49
Did not answer	0		3		3
L: “It is difficult to manage my period-related symptoms (for example, cramps).”
					Total	p
Agree	16	8	184	92	200	NS
Disagree	4	4	89	96	93
Neutral	0	0	31	100	31
Did not answer	0		4		4
M: “My life is worse when I am on my period.”
					Total	p
Agree	8	7	109	93	117	NS
Disagree	8	6	123	94	131
Neutral	4	5	76	95	80
Did not answer	0		0		0
N: “How often would you like to have your period?”
					Total	p
Regular periods	11	4	234	96	245	.037
Regular periods but being able to skip them sometimes	4	10	35	90	39
Not having periods except when I want to become pregnant	2	8	23	92	25
Never having a period	3	16	16	84	19
Did not answer	0		0		0

Note. Green: N and % for all persons in Indian sample agreeing with prompt. Blue: N and % for all persons in Indian sample disagreeing with prompt. Orange: The majority response to the prompt. p Values indicate significance for chi-square test of association between agree/other and H-receptive/H-averse.

Table 5. South Africa.

	H-receptive		H-averse
	N	%	N	%	Total N
	103	44	133	56	236
A: “I don’t want to change my natural menstrual cycle.”
					Total	p
Agree	42	28	107	72	149	.00001
Disagree	38	72	15	28	53
Neutral	23	68	11	32	34
Did not answer	0		0		0
B: “I wish I could take a break from having my period.”
					Total	p
Agree	65	48	71	52	136	NS
Disagree	25	41	36	59	61
Neutral	13	33	26	67	39
Did not answer	0		0		0
C: “The only thing my period is good for is to let me if know I’m pregnant.”
					Total	p
Agree	37	45	45	55	82	NS
Disagree	50	41	73	59	123
Neutral	16	52	15	48	31
Did not answer	0		0		0
D: “My period is an important part of my gender identity.”
					Total	p
Agree	37	42	51	58	88	NS
Disagree	42	48	46	52	88
Neutral	24	40	36	60	60
Did not answer	0		0		0
E: “I feel empowered by my periods.”
		HR			Total	p
Agree	33	38	53	62	86	NS
Disagree	38	49	39	51	77
Neutral	32	44	41	56	73
Did not answer	0		0		0
F: “I need to have periods to be in good health.”
					Total	p
Agree	54	40	81	60	135	NS
Disagree	24	47	27	53	51
Neutral	25	50	25	50	50
Did not answer	0		0		0
G: “My period helps me keep in touch with my body.”
		HR			Total	p
Agree	46	34	90	66	136	.003
Disagree	30	58	22	42	52
Neutral	27	56	21	44	48
Did not answer	0		0		0
H: “My period represents fertility and potential motherhood.”
					Total	p
Agree	62	42	85	58	147	NS
Disagree	24	51	23	49	47
Neutral	17	40	25	60	42
Did not answer	0		0		0
J: “I need to have periods because they cleanse my body.”
					Total	p
Agree	33	36	59	64	92	NS
Disagree	45	49	47	51	92
Neutral	25	48	27	52	52
Did not answer	0		0		0
K: “It is difficult to manage my period bleeding.”
					Total	p
Agree	29	49	30	51	59	NS
Disagree	59	41	84	59	143
Neutral	12	43	16	57	28
Did not answer	3		3		6
L: “It is difficult to manage my period-related symptoms (cramps, mood changes).”
					Total	p
Agree	62	44	79	56	141	NS
Disagree	32	47	36	53	68
Neutral	6	29	15	71	21
Did not answer	3	50	3	50	6
M: “My life is worse when I am on my period.”
					Total	p
Agree	47	48	50	52	97	NS
Disagree	31	36	54	64	85
Neutral	25	46	29	54	54
Did not answer	0		0		0
N: “How often would you like to have your period?”
					Total	p
Regular periods	47	36	82	64	129	.014
Regular periods but being able to skip them sometimes	22	50	22	50	44
Not having periods except when I want to become pregnant	18	56	14	44	32
Never having a period	16	52	15	48	31
Did not answer	0		0		0

Note. Green: N and % for all persons in SA sample agreeing with prompt. Blue: N and % for all persons in SA sample disagreeing with prompt. Orange: The majority response of either agreed or disagreed with prompt. p Values indicate significance for chi-square test of association between agree/disagree and H-receptive/H-averse.

Table 6. United States.

	H-receptive		H-averse
	N	%	N	%	Total N
	1,820	49	1,871	51	3,691
A: “I don’t want to change my natural menstrual cycle.”
					Total	p
Agree	397	23	1,305	77	1,702	<.0001
Disagree	1,008	78	284	22	1,292
Neutral	412	59	282	41	694
Did not answer	3	100	0	0	3
B: “I wish I could take a break from having my period.”
					Total	p
Agree	1,381	58	992	42	2,373	<.0001
Disagree	190	29	473	71	663
Neutral	246	38	406	62	652
Did not answer	3	100	0	0	3
C: “The only thing my period is good for is to let me know if I’m pregnant.”
					Total	p
Agree	964	63	576	37	1,540	<.0001
Disagree	620	38	1,031	62	1,651
Neutral	233	47	262	53	495
Did not answer	3	60	2	40	5
D: “My period is an important part of my gender identity.”
					Total	p
Agree	309	37	532	63	841	<.0001
Disagree	1,065	60	714	40	1,779
Neutral	443	41	625	59	1,068
Did not answer	3	100	0	0	3
E: “I feel empowered by my periods.”
					Total	p
Agree	258	31	581	69	839	<.0001
Disagree	1,074	60	710	40	1,784
Neutral	485	46	580	54	1,065
Did not answer	3	100	0	0	3
F: “I need to have periods to be in good health.”
					Total	p
Agree	547	35	1,007	65	1,554	<.0001
Disagree	878	67	439	33	1,317
Neutral	392	48	425	52	817
Did not answer	3	100	0	0	3
G: “My period helps me keep in touch with my body.”
					Total	p
Agree	704	37	1,186	63	1,890	<.0001
Disagree	710	67	348	33	1,058
Neutral	403	54	337	46	740
Did not answer	3	100	0	0	3
H: “My period represents fertility and potential motherhood.”
					Total	p
Agree	754	39	1,172	61	1,926	<.0001
Disagree	654	66	340	34	994
Neutral	409	53	359	47	768
Did not answer	3	100	0	0	3
J: “I need to have periods because they cleanse my body.”
					Total	p
Agree	446	37	752	63	1,198	<.0001
Disagree	1,038	62	634	38	1,672
Neutral	333	41	485	59	818
Did not answer	3	100	0	0	3
K: “It is difficult to manage my period bleeding.”
					Total	p
Agree	372	43	503	57	875	<.0001
Disagree	1,169	51	1,124	49	2,293
Neutral	185	44	232	56	417
Did not answer	94	0	12	0	106
L: “It is difficult to manage my period-related symptoms.”
					Total	p
Agree	1,006	48	1,092	52	2,098	NS
Disagree	577	49	607	51	1,184
Neutral	143	47	159	53	302
Did not answer	94	0	13	0	107
M: “My life is worse when I am on my period.”
					Total	p
Agree	1,094	58	801	42	1,895	<.0001
Disagree	367	37	620	63	987
Neutral	356	44	449	56	805
Did not answer	3	0	1	0	4
N: “How often would you like to have your period?”
					Total	p
Regular periods	513	31	1,132	69	1,645	<.00001
Regular periods but being able to skip them sometimes	453	61	284	39	737
Not having periods except when I want to become pregnant	457	70	195	30	652
Never having a period	394	60	259	40	653
Did not answer	3		1		4

Note. Green: N and % for all persons in US sample agreeing with prompt. Blue: N and % for all persons in US sample disagreeing with prompt. Orange: The majority response of either agreed or disagreed with prompt. p Values indicate significance for chi-square test of association between agree/disagree and H-receptive/H-averse.

Table 7. Responses to the question, “Why did you choose the method you relied on most?” (select all that apply).

		India				South Africa				United States
		HR (n = 20)		HA (n = 308)		HR (n = 103)		HA (n = 133)		HR (n = 1,820)		HA (n = 1,871)
% = (N selected/Total N for each HR or HA sample)		n	%	n	%	n	%	n	%	n	%	n	%
A	I don’t need a prescription to get it.	7	35	152	49	7	7	53	40	113	6	877	47
B	It makes my period more predictable (comes at the same time every month).	11	55	74	24	67	65	24	18	929	51	237	13
C	It decreases bleeding during my period.	4	20	11	4	52	50	6	5	1,069	59	45	2
D	It has health benefits (e.g., treats acne or menstrual migraines).	7	35	9	3	41	40	7	5	621	34	53	3
E	It is affordable.	7	35	149	48	25	24	29	22	1,221	67	383	20
F	It is easy to use.	15	75	223	72	55	53	66	50	1,234	68	1,072	57
G	It is not invasive (not implanted or inserted).	9	45	142	46	32	31	62	47	635	35	999	53
H	It doesn’t have side effects.	4	20	233	76	10	10	101	76	157	9	1,471	79
I	It doesn’t have hormones.	0		167	54	2	2	89	67	17	1	1,433	77
J	It prevents infections (STIs).	0		142	46	1	1	35	26	15	1	360	19
K	It lasts a long time.	4	20	27	9	24	23	2	2	751	41	97	5
L	A friend or family member recommended it.	2	10	16	5	23	22	1	1	420	23	97	5
M	My health care provider recommended it.	8	40	13	4	57	55	5	4	939	52	91	5
N	My partner likes/approves of it.	5	25	132	43	15	15	37	28	487	27	727	39
O	It is easy to buy/get.	8	40	174	56	28	27	52	39	499	27	704	38
P	I can stop using it whenever I want.	12	60	134	44	56	54	44	33	1,040	57	750	40
Q	I don’t have to remember to do something every day.	2	10	134	44	21	20	46	35	749	41	733	39
R	It doesn’t affect my ability to become pregnant when I want to.	4	20	160	52	19	18	62	47	542	30	833	45
S	It fits with my religious beliefs.	0		12	4	2	2	3	2	37	2	115	6
T	I am able to hide it/use it without others knowing.	3	15	59	19	15	15	5	4	419	23	188	10
U	I can use it with my health condition.	6	30	54	18	16	16	17	13	237	13	263	14
V	It was the only option available to me.	2	10	36	12	14	14	7	5	61	3	117	6
W	I don’t need to depend on my partner.	9	45	17	6	23	22	10	8	818	45	121	6
X	It is very effective at preventing pregnancy.	8	40	98	32	40	39	33	25	1,102	61	445	24

Note. The top options selected in each sample are bolded.

Figure 2. Intersections of the responses by US H-averse respondents (n = 1871) and US H-receptive respondents (n = 1817) to three prompts: A, “I don’t want to change my natural menstrual cycle”; B, “I wish I could take a break from having my period”; N, “How often would you like to have your period?”. Findings for prompt A depicted in headers at top, and for B and N in stacked bars (from left to right). (a) 70% (1305/1871) of H-averse respondents did not want to change their natural menstrual cycle; of these, 72% (946) wanted regular cycles (sum of green bars); of these, 30% (280/946, dark green bar) wanted to take a break from their cycle. The remaining 358 respondents who didn’t want to change their natural cycle (sum of yellow bars), wanted fewer periods; of these, 81% (291/358) wanted to take a break from their cycle (dark yellow bar). In total, 44% [(291+280)/1305] of H-averse respondents who did not want to change their natural menstrual cycle still wanted to take a break from their cycle. (b) 30% (566/1871) of H-averse users were not opposed to changing their cycles; of these, 67% (380/566) wanted fewer periods (sum of yellow bars); 74% (332+88 = 420, sum of dark yellow and dark green bars) wanted to take a break from their periods; 33% wanted regular periods (sum of green bars). (c) 22% (397/1817) of H-receptive users did not want to change their natural menstrual cycle; of these, 58% (230) wanted regular cycles (sum of green bars); 22% (87/397, dark green bar) wanted to take a break from their cycle. The remaining 167 respondents who didn’t want to change their natural cycle (sum of yellow bars) wanted fewer periods; of these, 82% (136/167) wanted to take a break from their cycle (dark yellow bar). In total, 56% [(136+87)/397] of H-receptive respondents who did not want to change their natural cycle still wanted to take a break from their cycle. (d) 78% (1420/1817) of H-receptive users were not opposed to changing their cycles; of these, 80% (1137/1420) wanted fewer periods (sum of yellow bars); 82% (1016+142 = 1158, sum of dark yellow and dark green bars) wanted to take a break from their periods); 20% wanted regular periods (sum of green bars).

Sahgal, N., Evans, J., Salazar, A. M., Starr, K. J., & Corichi, M. (2021). Religion in India: Tolerance and segregation (p. 233). Pew Research Center. https://www.pewresearch.org/religion/2021/06/29/attitudes-about-caste/

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