https://orcid.org/0000-0002-1522-6462
Abstract
Objective
To estimate the prevalence of contraceptive method use among women, assess concerns about hormonal contraception (HC) and copper intrauterine device (Cu-IUD) and determine characteristics associated with concerns of HC and Cu-IUD.
Method
Cross-sectional study. Swedish speaking women (n = 212) aged 16–50 attending midwives at four outpatient clinics in two of Sweden’s larger cities answered a waiting room questionnaire. Content analysis was used to categorise open-ended questions with free text answers.
Results
Long-acting reversible contraceptives (LARC) was used by 30.4%, short acting reversible contraceptives (SARC) by 28.0%, and 16.4% did not use any contraception during most recent intercourse. Four out of ten (41.2%) had concerns about using HC and 52.3% about using Cu-IUD. The most common reason for having concerns regarding HC was unspecified side effects, fear of hormones and adverse mood symptoms; regarding Cu-IUD, concerns related to increased bleeding and menstrual pain. Among those expressing concerns, experience of induced abortion was twice as common. Women who did not have concerns about HC were using combined oral contraception (COC) to a higher extent.
Conclusion
Concerns about using HC and Cu-IUD are common. This needs to be considered during contraceptive counselling.
避孕方法的使用和态度：女性对激素避孕和带铜宫内节育器的担忧 摘要
目的：估计各避孕方法在女性中的流行程度, 评估对激素避孕（hormonal contraception, HC）和铜宫内节育器（hormonal contraception, Cu-IUD）的担忧, 并确定与担心使用HC和Cu-IUD相关的因素。
方法：横断面研究。在瑞典两个较大城市的四家门诊, 接受助产士治疗的16-50岁讲瑞典语的女性（n=212）回答了一份候诊室问卷。内容分析用于对带有自由文本答案的开放式问题进行分类。
结果：30.4%的人使用长效可逆避孕药（long-acting reversible contraceptives, LARC）, 28.0%的人使用短效可逆避孕药（short acting reversible contraceptives, SARC）, 16.4%的人在最近一次性交中未使用任何避孕措施。十分之四（41.2%）的人担心使用HC, 52.3%的人担心使用Cu-IUD。担心使用HC的最常见的原因是未明确的副作用、对激素的恐惧和不良情绪症状；担心使用Cu-IUD的原因是出血增多和痛经。在表达担忧的人中, 流产的经历高达两倍。不担心使用HC的女性在更大程度上使用复方口服避孕药（combined oral contraception, COC）。
结论：担心使用HC和Cu-IUD, 是常见的问题, 需要在避孕咨询期间对其加以考虑。
Introduction
Unintended pregnancies are a global health problem [Citation1]. In the United States, more than half of women who report an unintended pregnancy are not using any form of birth control [Citation2]. In Sweden, contraceptives are subsidised and contraceptive counselling is free of charge to all women aged 25 or younger. Nevertheless, between 15 and 20% of women have unmet needs for contraception with regard to their reproductive intentions [Citation3,Citation4]. A recently published Swedish study among women attending contraceptive counselling, found that 13% did not use any contraceptive methods during their most recent intercourse [Citation4]. Long-acting reversible contraception (LARC), that is recommended in the national guidelines due to its high effectiveness [Citation5], was used by 23% of the women, and short-acting reversible contraception (SARC) by two thirds (65%) [Citation4].
Women’s attitudes towards family planning and use of contraception depend on a number of factors such as the life situation, age, access to contraceptive counselling, social policy, religion, education and costs [Citation6]. Other important influences on contraceptive uptake are interactions within social networks, communities as well as media channels [Citation7,Citation8]. Hormonal contraceptives (HC) are among the most commonly prescribed pharmaceuticals in the world [Citation9] and copper intrauterine devices (Cu-IUDs) the most commonly used IUDs [Citation10].
In Sweden, ‘fear of hormones’ significantly increased between 2013–2017, as a reason for not using HC [Citation3], and in 2009 around one third of all women in a student health clinic had concerns about using hormonal contraceptives [Citation11]. In another Swedish study from 2016, women reported adverse mood symptoms as the main reason for cessation of combined oral contraceptives (COC) [Citation12]. International research on self-reported contraceptive compliance and preferences showed that around half of the women were reluctant to any additional/foreign oestrogen in the body [Citation13]. Other studies have reported negative perceptions about COC among women, mainly related to fear of infertility, thrombosis and weight gain [Citation14,Citation15].
Although usage pattern, method satisfaction and its associations with method compliance has been well explored in previous research [Citation16–18], less attention has been paid to women’s concerns towards HC, Cu-IUDs and potential characteristics associated with these concerns among women.
Ultimately, a better understanding of these matters is needed in order to perform a patient-centred care, promote women’s reproductive autonomy and adequately address unmet family planning needs.
Objectives
The objectives were to:
Estimate the prevalence of contraceptive method use among women
Assess concerns about HC and Cu-IUDs
Determine characteristics associated with concerns about HC and Cu-IUDs.
Method
Ethical considerations
An application was sent to the Swedish Ethical Review Authority (dnr 2019-04587), who assessed that there was no need for an ethical permission since the study did not process any personal data, and as data could not be traced to any individual. A cover letter was attached to the questionnaire, which informed that participation was voluntary and could be terminated at any time. A completed and submitted questionnaire was considered as written consent.
Study design and setting
We conducted this cross-sectional descriptive questionnaire study at four out-patient clinics in two of Sweden’s larger cities. Two of the clinics were public and two were privately owned. They were all located in city centre areas. Compared to the general population in Sweden, people in larger cities have a higher level of education, but similar levels of employment and background of immigration [Citation19]. In Sweden, contraceptive counselling is free of charge and contraceptives are subsidised for women below age 25. Registered nurse-midwives are licenced to prescribe contraceptives, test against sexually transmitted infections (STIs), take pap smears and perform counselling prior to early pregnancy termination. Approximately 80% of contraceptive counselling in Sweden is performed by midwives [Citation12].
Data were collected during ten weeks between January and March 2020.
The questionnaire was a modified version of earlier surveys conducted in previous studies [Citation11,Citation20,Citation21], comprising 55 questions covering: demography, HPV vaccination, STIs, contraceptive use, sexual habits, abortion, emergency contraception, pornography consumption and fertility awareness. The survey consisted of both multiple choice and open-ended questions. A reliability test was performed with test-retest on 31 nursing students in November 2019 for validation.
For this specific study, 14 questions divided into six categories were analysed;
Socio-demographic characteristics (6 questions): age, occupation, sexual orientation, parity, country of birth and relationship status.
Tobacco habits (2 questions): smoking and use of oral tobacco.
Contraceptive use (2 questions): methods used during the most recent intercourse and emergency contraceptive usage.
Experience of STIs (1 question): yes or no.
Experience of abortion (1 question): yes or no.
Concerns regarding contraceptives (2 open-ended questions): HC and Cu-IUD.
Swedish-speaking women aged 16–50 meeting with a midwife for either contraceptive counselling, STI-testing, abortion or pap smear test at one of the four outpatient-clinics were asked to participate. Pregnant women seeking maternal care were not approached. The midwives or receptionist working at the clinic were responsible for identifying, approaching and informing individuals meeting the inclusion criteria. They were also supposed to document how many women that had been approached, in order to be able to calculate the response rate. Participants that agreed to take part were instructed to place the questionnaire in an envelope, seal it, and thereafter put it in a sealed box in the waiting room. The participants completed the questionnaire, either before or after the appointment.
Neither the clinics nor the participants were offered any compensation for their participation.
Data analyses
Group comparisons were performed using Fisher’s exact test and Pearson’s chi square test. A two sided p < 0.05 was considered statistically significant. All statistical analyses were performed in SPSS statistics, version 26 (IBM Corp., Armonk, NY, USA). All the answers to the open-ended questions were analysed with manifest content analysis, resulting in different categories and presented in the text with illustrating quotes.
Results
Participants
In total, 212 women filled in the questionnaire. Due to incomplete data collection, exact response rate could not be calculated, but one clinic presented that out of 57 women approached, 54 agreed to participate. This generated an estimated response rate of 94.7%. At the second clinic, 35 women out of 39 agreed participation, and at the third clinic, the corresponding number was 32 women out of 60 asked, generating a response rate of 89.7% and 53.3%, respectively. No data regarding response rates could be obtained from the fourth clinic.
The internal dropout regarding the quantitative questions varied between 0–6.6% and increased throughout the questionnaire. The background characteristics are presented in . The mean age of women was 29.4 years, most were born in Sweden, had a stable relationship, and one out of four had children.
Table 1. Background characteristics of study population n = 212.
Use of contraception
shows that 16.4% did not use any contraceptive method during the most recent intercourse and that COC was the most commonly used method. LARC was used by 30.4% and SARC by 28.0%.
Table 2. Contraception method use during most recent intercourse n = 207.
Concerns regarding hormonal contraception
shows that 41.2% had concerns about using HC, and the reasons for being concerned were grouped into 14 categories based upon responses to the open-ended questions. Unspecified side effects were the most commonly mentioned reason for concern, followed by ‘fear of hormones’. Almost half (41.3%) of all women reported concerns for emotional side effects, including mood changes (22.5%) or depressed mood (18.8%).
Table 3. Are you concerned about using hormonal contraception? N = 199.
The women described both their experiences and perceptions towards using HC. Some examples of responses to the question ‘Do you have concerns about using hormonal contraceptives? If yes, why?’ are presented below:
‘I’ve tried, but I don’t feel well using them’. ‘It doesn’t feel good to add more hormones’. ‘Depression and mental illness’ and ‘I’m scared of changed mood or blood clots’.
A comparison of the group that had concerns about HC-use with the group that did not () showed a significant difference (p = 0.002) in history of induced abortion, which was twice as common among women with concerns.
Table 4. Reproductive health and background characteristics among women having or not having concerns.
shows differences in contraceptive use during most recent intercourse. The use of SARC was significantly higher (p = 0.001) among women with no concerns (36.8%), where more than twice as many used SARC compared to the group of women expressing concerns (15.9%).
Table 5. Use of contraception method during most recent intercourse among women having or not having concerns.
Table 6. Are you concerned about using a copper intrauterine device? N = 199 .
Out of the women who had concerns regarding using HC, 73.2% (n = 60) also had concerns about using Cu-IUD.
Concern regarding Cu-IUD
More than half of the women, (52.3%) were concerned about using the Cu-IUD, and 77.0% of the reasons for concern related to increased bleeding and menstrual pain ().
Following are some examples of quotes for the question, ‘Do you have concerns about using a copper intrauterine device, and if so why?
‘Bleeding and cramps’. ‘I’m mostly worried about the insertion’. ‘My sister had a bad experience’. ‘I’ve heard that it gives you sleep disturbances and mood changes because of magnesium deficiency’. ‘I don’t know how it works…’
Discussion
Findings and interpretation
In this sample, as many as one fourth of women reported no use or use of ineffective methods (coitus interruptus) at the most recent intercourse. Reasons for no use, or ineffective contraceptive use, were not studied in this material. However, since the women in our study came for contraceptive counselling, we believe that few refrained contraception due to wishes to conceive. Hence, our results correspond well with previous research showing high divergence between contraceptive use and reproductive intentions; 23% of parous and 10% of nulliparous in Skogdal et al’s study (2018) did not use contraceptives although they did not intend to have children [Citation4].
Another interesting finding was the high number of women expressing concerns towards contraceptive methods; four out of ten had unspecific concerns about side effects regarding HC, and half had concerns about using the Cu-IUD. Regarding HC, our findings may indicate that women of today worry more than women did a decade ago, when three out of ten women stated that they had concerns about using HC [Citation11]. This is also supported by a recently published national survey where ‘fear of hormones’ significantly increased over time as a reason for not using HC [Citation3].
Past observations have shown how media and social networks have a direct influence on women’s contraception decisions [Citation22]. Over the years, HC has attracted attention from the media, and nowadays increasingly by social media. Perhaps part of an explanation could be found in the rapidly changing media climate, where access to other women’s and social influencers testimonials concerning contraceptive use has widely increased. In Sweden, social influencers often recommend natural family planning such as fertility based methods over HC, and digital fertility applications are positively advertised as hormonal free alternatives that enhances reproductive autonomy among users [Citation23].
After unspecified side effects, adverse mood symptoms was the most commonly mentioned reason for concerns about HC, which is being supported by previous research [Citation24,Citation25]. Adverse mood symptoms as a main reason for cessation have become more prevalent over time, possibly due to increased stress and anxiety in society in general [Citation12]. Another explanation could be that acceptance of side effects including adverse mood symptoms has decreased, and that higher awareness has led to increasing concerns and a lowered threshold for cessation. In 2016, a Danish register-based study showed an association between HC and treatment with antidepressants and diagnosis of depression among adolescents [Citation26], which caught a lot of media attention. Despite being disputed, this might still have affected women’s perceptions [Citation27].
Interestingly, pregnancy termination was twice as common and COC was used to a lesser extent among women expressing concerns towards HC. This is important to consider in counselling as it could potentially affect women’s reproductive health, in terms of decreased contraceptive use and increased risk of unplanned pregnancy.
Among the women having concerns about using HC, more than two-thirds also had concerns about using Cu-IUD. Although the methods have different mechanisms of action and different side effects, some women seem to be concerned with both methods. Whether this is because of lack of knowledge or a general scepticism is difficult to say, but it highlights a challenge in contraceptive counselling.
Increased bleeding, menstrual pain and fear of insertion were the most common concerns about the Cu-IUD. These are also the most common side effects that indeed do occur when using or inserting a Cu-IUD, in contrast to the more unspecific reported concerns regarding HC.
In order to meet women’s concerns regarding HC and Cu-IUDs, it is important to discuss the potential of effective counselling [Citation28]. Patient centred approaches have previously shown to be efficient in patient consultations and may be suitable in contraceptive counselling as well [Citation29,Citation30]. The woman should be given the opportunity to express her own experiences, thoughts, concerns and wishes in the very beginning of the consultation. In general practice consultations, this is often referred to as ‘the patient’s agenda’ [Citation31,Citation32]. This will increase the chances of shared and informed decision-making, ultimately affecting compliance, where both health care provider and patient contribute to a common strategy tailored to fit the individual [Citation33–35].
Strengths and limitations
Part of the novelty of this study is the patient/user-centred perspective with focus on women’s concerns regarding HC and Cu-IUDs. Attitudes among users are important prerequisites for compliance and continuously needs to be monitored in order for prescribers to be updated and able to adequately meet women’s concerns during contraceptive counselling. Our findings may contribute to increased knowledge in these matters.
A strength of the study was that the questionnaire had been used in other studies [Citation11,Citation20,Citation21]. In addition, the internal drop out was low; only up to 6.6% of the answers on the quantitative questions were missing.
One limitation was the small sample size. We collected data at the beginning of the Covid-19 pandemic when fewer women attended the clinics. The clinic-based design also presents a risk for selection bias, as it only includes women seeking care. The clinics were located in areas with higher socioeconomic standards, which is reflected in the study population. The level of employment was higher [Citation36], the daily smoking was lower [Citation37], as was the proportion of women born outside of Sweden, when compared to the Swedish population in general [Citation38], which limits the study's generalisability.
Regarding contraceptive use, many aspects influence the use or non-use of contraception and individuals may occasionally deviate from the ordinary contraceptive method for a variety of reasons [Citation39]. Consequently, contraceptive use during most recent intercourse does not have to reflect the woman’s usual choice of method. Nevertheless, in sexual behaviour research, it is an often-used indicator for contraceptive use.
As the question ‘are you concerned about using contraceptive pills or other hormonal contraceptives?’ is broad and may encompass both possible experiences and general perceptions, this should be taken into consideration when interpreting the results. It is not known whether the concerns given was in ‘fear of’ or ‘actual experience of’. Closed options could have given a more precise response, but since it was of importance to enable comparison with earlier studies by using the same questionnaire, the question remained in its original form.
Implications and further research
HC and Cu-IUD are commonly used methods globally. It is possible that we are facing a shift, where acceptance of side effects is decreasing; therefore, health care professionals need to anticipate this in order to prevent decreasing sexual and reproductive health.
To further assess the possible trend of increasing concerns, longitudinal studies regarding this matter would potentially give greater insight. As this was a small explorative study, we were only able to perform descriptive analyses, and we encourage future, larger studies to further explore the associations studied.
Qualitative research regarding the reasons behind concerns is also needed to raise awareness on attitudes towards contraception and contraceptive counselling. Although this study could not find any distinct differences in socio-demographic characteristics regarding concerns for HC and/or Cu-IUD, this should be evaluated again with a more well adapted method.
Conclusion
In this population, LARC use was as common as SARC and one fourth reported no- or ineffective contraceptive use. A significant number of women were concerned about using HC and Cu-IUD, which needs to be considered in contraceptive counselling. Among women expressing concerns about HC, experience of induced abortion was twice as common which could indicate an unmet need for effective contraception.
| Abbreviations | ||
| HC | = | Hormonal contraception |
| CHC | = | Combined hormonal contraception |
| COC | = | Combined oral contraception |
| POP | = | Progestin only pill |
| SARC | = | Short-acting reversible contraception |
| LARC | = | Long-acting reversible contraception |
| IUD | = | Intrauterine device |
| Cu-IUD | = | Copper intrauterine device |
| LNG-IUS | = | Levonorgestrel-releasing intrauterine system |
Disclosure statement
No potential conflict of interest was reported by the author(s).
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