Views regarding the use of contraception amongst young people in the UK: A systematic review and thematic synthesis

Factors influencing contraception choice and use globally: a synthesis of systematic reviews

BACKGROUND

Unintended pregnancy has a huge adverse impact on maternal, child and family health and wealth. There is an unmet need for contraception globally, with an estimated 40% of pregnancies unintended worldwide.

METHODS

We systematically searched PubMed and specialist databases for systematic reviews addressing contraceptive choice, uptake or use, published in English between 2000 and 2019. Two reviewers independently selected and appraised reports and synthesised quantitative and qualitative review findings. We mapped emergent themes to a social determinants of health framework to develop our understanding of the complexities of contraceptive choice and use.

FINDINGS

We found 24 systematic reviews of mostly moderate or high quality. Factors affecting contraception use are remarkably similar among women in very different cultures and settings globally. Use of contraception is influenced by the perceived likelihood and appeal of pregnancy, and relationship status. It is influenced by women's knowledge, beliefs, and perceptions of side effects and health risks. Male partners have a strong influence, as do peers' views and experiences, and families' expectations. Lack of education and poverty is linked with low contraception use, and social and cultural norms influence contraception and expectations of family size and timing. Contraception use also depends upon their availability, the accessibility, confidentiality and costs of health services, and attitudes, behaviour and skills of health practitioners.

INTERPRETATION

Contraception has remarkably far-reaching benefits and is highly cost-effective. However, women worldwide lack sufficient knowledge, capability and opportunity to make reproductive choices, and health care systems often fail to provide access and informed choice.

Qualitative findings about stigma as a barrier to contraception use: the case of Emergency Hormonal Contraception in Britain and implications for future contraceptive interventions

BACKGROUND

Emergency Hormonal Contraception (EHC) has been underused in Britain and internationally since its introduction. 'Stigmatisation' has been identified as one of the barriers to EHC. However, few, if any publications have focussed on the significance of this factor in the British context, the social meanings for women of seeking EHC and the implications for future contraceptive provision and innovation.

METHOD

In-depth qualitative material from 27 women across two British studies was analysed. The first, in which 11 young women were interviewed in-depth regarding EHC specifically, was supplemented by material from a multi-stage narrative study of 15 women concerning their life history experiences of using contraception more broadly.

RESULTS

Stigmatisation of EHC use is a key barrier and derives from associations with irresponsible behaviour. This irresponsibility exists on a continuum with some behaviours and some women more ir/responsible than others. In addition, despite not being an abortifacient, EHC may be closely aligned with abortion meaning users can be perceived as 'bad women' in a similar way to abortion seekers. This stigma can deter participants seeking EHC when they may need it.

CONCLUSION

Stigma is a powerful barrier to EHC use due to the social significance of responsibility and expectations pertaining to the behaviour of 'good women.' Understandings about stigmatisation in the case of EHC should be translated to other aspects of contraceptive service delivery and future innovations, to ensure effective provision of methods and safeguard their uptake.

Changes in the prevalence and profile of users of contraception in Britain 2000-2010: evidence from two National Surveys of Sexual Attitudes and Lifestyles

AIM

To describe prevalence and trends in contraceptive method use in Britain through a comparison of the second and third National Surveys of Sexual Attitudes and Lifestyles (Natsal-2 and Natsal-3).

METHODS

Cross-sectional probability sample surveys. General population sample of women aged 16-44 years, resident in Britain, with ever-experience of vaginal sex and, for analysis by sociodemographic characteristics, vaginal sex in the last year. Main outcome measure was current contraceptive method use ('usual these days'), categorised by effectiveness.

RESULTS

Prevalence of current contraceptive use among women who had ever had vaginal sex declined between Natsal-2 and Natsal-3, 83.5% (95% CI 82.4 to 84.5) and 76.4% (95% CI 75.0 to 77.7), respectively. The condom and oral contraceptive pill remain the most commonly used methods. One in five women reported use of a most effective method. While no difference was found between surveys in use of most effective methods, a decline in sterilisation use was compensated by an increase in long-acting reversible contraceptive (LARC) use. Increased LARC use was particularly evident among under-25s compared with women aged 40-44 years (OR 11.35, 95% CI 3.23 to 39.87) and a decline was observed among those with two or more children relative to those with none (OR 0.21, 95% CI 0.13 to 0.35).

CONCLUSIONS

Strategies to improve access to LARC methods have been particularly successful in increasing uptake among young people in the first decade of the 21st century. Whether this trajectory is maintained given changing sociodemographic characteristics and more recent financial cuts to sexual health service provision will warrant investigation.

An interactive website for informed contraception choice: randomised evaluation of Contraception Choices

OBJECTIVE

Improving use of effective contraception to prevent unintended pregnancy is a global priority, but misperceptions and concerns about contraception are common. Our objective was to evaluate an interactive website to aid informed choice of contraception.

METHODS

The Contraception Choices website is an interactive digital intervention which offers tailored advice to aid contraception decision-making (www.contraceptionchoices.org). In a parallel single-blind trial, we randomised 927 women aged 15-30 years from six clinic settings to access the intervention website (n = 464) or to a waiting-list control group (n = 463). The study was initially a feasibility trial, evolving into an evaluation of efficacy, with two primary outcomes at six months: long-acting reversible contraception (LARC) use, and satisfaction with contraceptive method. Secondary outcomes included self-reported pregnancy and sexually transmitted infection diagnoses. Free-text comments on the 3 and 6 month outcome surveys were analysed thematically.

FINDINGS

There was no significant difference between intervention and control groups in the proportion of women using LARC [30.4% intervention versus 31.0% control; adjusted odds ratio 0.87 (95% confidence interval 0.60 to 1.28)]; satisfaction with contraceptive method [82.6% versus 82.1%; adjusted ordinal odds ratio 0.93 (95% CI 0.69 to 1.25)]; self-reported pregnancy [3.3% versus 4.1%; adjusted odds ratio 0.90 (95% CI 0.45 to 1.79)] nor sexually transmitted infection [5.3% versus 4.7%; adjusted odds ratio 0.72 (95% CI 0.55 to 2.36)]. Highly positive free-text comments from intervention participants indicated that the website facilitates contraception choice and can help women feel better prepared before consultation with healthcare providers.

INTERPRETATION

The Contraception Choices website was popular for its design, trustworthy information and decision aids but it was not associated with significant differences in use of LARC or satisfaction with contraceptive method. An interactive website can aid contraception choice, but interventions that address factors beyond women's control, such as access to services, and partner, family or community influences are needed to complement this approach.

RESEARCH IN CONTEXT

Preventing unintended pregnancy through effective use of contraception is essential for women's health, but choosing between different contraceptive methods can be challenging, and the opportunity for adequate discussion during routine consultations is often constrained.

EVIDENCE BEFORE THIS STUDY

We conducted two systematic literature reviews: 1) Factors influencing contraception choice, uptake and use: a meta-synthesis of systematic reviews; and 2) Effectiveness of interactive digital interventions (IDI) for contraception choice, uptake and use. For the first review we searched PubMed, CDSR, Epistemonikos, DoPHER, DARE, NHS Economic Evaluation Database, Campbell Library, NIHR Health Technology Assessment, and Health Evidence Canada databases for systematic reviews which addressed contraceptive choice, uptake or use, from 2000 to 2017. PROSPERO registration number: CRD42017081521 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81521. We synthesised the findings of 18 systematic reviews of mostly moderate or high quality. They highlighted the importance of women's knowledge, beliefs, perceptions of side effects and health risks, as well as relationship status, social network, economic and healthcare factors on contraception choice and use. For the second review, we searched 23 electronic databases, trials registers and reference lists for randomised controlled trials of IDI for contraception, including CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, ASSIA and PsycINFO, from start date to June 2017. PROSPERO registration number: CRD42017081636. We found only five randomised trials of IDI, all from the USA. Risk of bias prevented synthesis of results. www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81636.

ADDED VALUE OF THIS STUDY

Women's common concerns about contraception - fear of hormones, weight gain, cancer, infertility, mood changes, breaks from contraception and changes in bleeding patterns - underpinned development of a new interactive website (www.contraceptionchoices.org). Contraception Choices addresses women's concerns through succinct text; Q and A format (Frequently Asked Questions, Did you Know?; videos of women and health professionals); an effectiveness infographic, and an interactive decision aid (What's right for me?).In an online randomised trial with 927 women attending clinics, we found no association of the Contraception Choices intervention with the primary outcomes - satisfaction with contraceptive method and uptake of long-acting reversible methods at 6 months. Nor did we find an association with secondary adverse outcomes - sexually transmitted infections or pregnancy. Comments from women indicated that the website can meet young women's need for information on the benefits and drawbacks of contraception, help them to make informed decisions, and feel better prepared before healthcare consultations. Contraception Choices is now available on the NHS website: www.nhs.uk/conditions/contraception/which-method-suits-me.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

Interactive digital interventions (websites) can aid contraception choice, but other intervention research is needed to address wider influences on unintended pregnancy, including partner views, friends, family, the media, wider society and experiences with healthcare professionals. Future research could examine the impact of the website in different settings, e.g. schools or different countries. We hypothesise that use of the website during contraceptive consultations might improve the efficiency or quality of consultation, for both patients and healthcare providers. Appropriate methodology and time-scale for evaluating digital health interventions remains a key question.

Needs assessment for sexual health services development in a small European Union member state

Introduction

Awareness of sexual health in Malta – a small European Union member state started to gain momentum in the new millennium. Taboos and norms about sexuality pose strong barriers for the provision of information, and reproductive health services. A major contributor is the strong influence of the Roman Catholic Church, which holds fast to its prohibitions of sexual behaviours, albeit counterbalanced by the liberal standpoint adopted by the State in recent years.

Methods

Survey data were collected from 269 students aged 16–21 (response rate 89.7%) in a state post-secondary school. The sample was selected through convenience sampling within the school grounds.

Results

Women were more knowledgeable in relation to available services and risks when compared to men. No geographical differences were found. School was the most common source for information, while health professionals, namely general practitioners were considered trusted resources for their needs. Confidentiality was deemed to be the most requested and crucial feature of sexual health services.

Conclusions

Three important multisectoral needs emerged, namely adequate dissemination system of sexual health information, scientifically based sexual health education for professionals in contact with young people, and well-designed and accessible sexual health services. Implications for management include updating health sexual education and promotion strategies, as well as designing better services. Young people should be able to make informed choices regarding their sexual health, in line with contemporary needs.

Context Matters: Revisiting the First Step of the 'Sequence of Prevention' of Sports Injuries

It is possible to prevent sports injuries. Unfortunately, the demonstrated efficacy and effectiveness of injury prevention approaches are not translated into lasting real-world effects. Contemporary views in sports medicine and injury prevention suggest that sports injuries are ‘complex’ phenomena. If the problem we aim to prevent is complex, then the first step in the ‘sequence of prevention’ that defines the ‘injury problem’ already needs to have considered this. The purpose of this paper is to revisit the first step of the ‘sequence of prevention’, and to explore new perspectives that acknowledge the complexity of the sports injury problem. First, this paper provides a retrospective of the ‘sequence of prevention’, acknowledging contemporary views on sports injuries and their prevention. Thereafter, from the perspective of the socioecological model, we demonstrate the need for taking into account the complex nature of sports injuries in the first step. Finally, we propose an alternative approach to explore and understand injury context through qualitative research methods. A better understanding of the injury problem in context will guide more context-sensitive studies, thus providing a new perspective for sports injury prevention research.

Use of non-medical contraceptive methods: a survey of women in western Sweden

OBJECTIVES

To describe women's self-reported use of non-medical contraceptive methods (including barrier methods, fertility awareness-based methods and withdrawal), explore reasons for and satisfaction with choice of contraceptive methods and examine women's fertility awareness.

METHODS

A cross-sectional survey was conducted among women consulting at primary healthcare clinics not using medical contraceptives.

RESULTS

Most of the 648 participants (67%) reported using a mix of condom use, withdrawal and a calendar method, while 23% used only condoms. Eleven percent reported using the Billings ovulation method, diaphragm/cap or fertility monitor and found these methods highly satisfactory. A majority of the women who primarily used condoms also reported being satisfied. Most women actively chose non-medical contraception because it was perceived as without adverse effects, uncomplicated and effective. Fertility awareness was generally poor.

CONCLUSION

Frequent use of withdrawal and a calendar method, as well as poor fertility awareness, suggests a need for improved counselling at contraceptive clinics on fertility awareness and more effective non-medical contraceptive methods to assist women in making an informed contraceptive choice.

Risk and teenage parenthood: an early sexual health intervention

Purpose

The purpose of this paper is to outline the development of a resource designed to support practitioners, who are not sexual health specialists, but who work with young people who may be at risk of teenage pregnancy or parenthood. Its aim was to enable practitioners to carry out an assessment using a screening tool, and to use educational interventions designed to reduce risk-taking behaviour or refer to a sexual health specialist. A research project to examine the perceptions of practitioners who had used the resource is reported.

Design/methodology/approach

The resource was based on a local needs assessment and developed by a multi-agency working group. The research utilised an online questionnaire and telephone interviews with practitioners.

Findings

Practitioners reported using the screening tool with young people with an average age of 13.1 years. They thought the educational interventions provided knowledge and helped with communication, self-awareness, reflection, confidence, attitudes and values clarification.

Research limitations/implications

The project was based in one county in England. A sample of 17 per cent of the practitioners responded to the questionnaire, and they might be biased towards those who had engaged most, or most positively, with the resource. Three practitioners undertook interviews. The views and behaviours of young people are yet to be evaluated.

Originality/value

Within a climate of limited resources, the findings suggest that the project is providing an acceptable proportionate universalist, early sexual health intervention for young people.

Using Computer Simulations for Investigating a Sex Education Intervention: An Exploratory Study

Background

Sexually transmitted infections (STIs) are ongoing concerns. The best method for preventing the transmission of these infections is the correct and consistent use of condoms. Few studies have explored the use of games in interventions for increasing condom use by challenging the false sense of security associated with judging the presence of an STI based on attractiveness.

Objectives

The primary purpose of this study was to explore the potential use of computer simulation as a serious game for sex education. Specific aims were to (1) study the influence of a newly designed serious game on self-rated confidence for assessing STI risk and (2) examine whether this varied by gender, age, and scores on sexuality-related personality trait measures.

Methods

This paper undertook a Web-based questionnaire study employing between and within subject analyses. A Web-based platform hosted in the United Kingdom was used to deliver male and female stimuli (facial photographs) and collect data. A convenience sample group of 66 participants (64%, 42/66) male, mean age 22.5 years) completed the Term on the Tides, a computer simulation developed for this study. Participants also completed questionnaires on demographics, sexual preferences, sexual risk evaluations, the Sexual Sensation Seeking Scale (SSS), and the Sexual Inhibition Subscale 2 (SIS2) of the Sexual Inhibition/Sexual Excitation Scales-Short Form (SIS/SES - SF).

Results

The overall confidence of participants to evaluate sexual risks reduced after playing the game (P<.005). Age and personality trait measures did not predict the change in confidence of evaluating risk. Women demonstrated larger shifts in confidence than did men (P=.03).

Conclusions

This study extends the literature by investigating the potential of computer simulations as a serious game for sex education. Engaging in the Term on the Tides game had an impact on participants’ confidence in evaluating sexual risks.

Attitudes towards motherhood and fertility awareness among 20-40-year-old female healthcare professionals

OBJECTIVE

To explore attitudes towards family formation and fertility awareness among Danish female healthcare professionals.

METHODS

We collected cross-sectional baseline data from a prospective cohort study of 863 women, ranging in age from 20 to 40 years, working at a hospital in Denmark. Information about participants' intentions and attitudes towards family formation and fertility knowledge was gathered by means of a questionnaire.

RESULTS

Only 2% of the respondents did not want children. Most women believed that motherhood is important, and hoped to have two to three children. About half of the respondents intended to have their last child after the age of 35 years. The most important prerequisites for family formation included: living in a stable relationship, having completed one's studies, a sound financial situation, a job that can be kept when having children, access to public child day care, and the possibility of travelling. As many as 50% of women underrated the impact of a woman's age on fertility, and overestimated the success rates of assisted reproductive technology (ART) treatments.

CONCLUSIONS

Many female healthcare professionals contemplated giving birth after the age of 35 years. Knowledge of fertility and ART success rates is needed to make well-informed decisions about when to have children.

Perceptions of teen motherhood in Australian adolescent females: life-line or lifederailment

PURPOSE

The findings presented in this paper describe the beliefs and attitudes of three different groups of adolescent females about teen motherhood. These were elicited from a larger analysis that explored and theorized contraceptive pathways in a sample of young Australian women.

METHODS

A purposive sample of females aged 14 to 19 years was recruited from three distinct populations in the city of Perth, Western Australia: (1) never-pregnant; (2) pregnant-terminated; and (3) pregnant-continued. Grounded theory principles were used to analyze data generated from 69 semi-structured interviews conducted over a 21 month period (2006-2008).

RESULTS

Two categories that described teenagers' attitudes to pregnancy and motherhood were elicited from the analysis. These explained the level of priority that teenagers placed on using contraception and postponing the transition to parenthood. The category labeled 'life derailment' represented how those who had never had a pregnancy or had terminated a pregnancy constructed teen motherhood as potentially restricting their personal, career and social transition to adulthood. The alternative category, 'life-line', reflected how those who continued with their pregnancy perceived teen motherhood as a positive and transformative experience that fostered personal growth.

CONCLUSIONS

The findings from this study contribute further insight into the complex nature of adolescent contraceptive use and pregnancy risk. The analysis has strengthened evidence of the critical role of self-perceptions of pregnancy and childbearing on teenagers' fertility outcomes. It has also emphasized the broader life circumstances that shape these attitudes, intentions and related behavior. Strategies directed toward academic support and vocational skill development may broaden teenage girls' perceived future options and achievement capacity, thus influencing key reproductive health outcomes.