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ORIGINAL RESEARCH |
From the 1Department of Obstetrics and Gynecology, Women & Infants Hospital, Brown Medical School, Providence, Rhode Island; and 2Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: We analyzed baseline data of 424 nonpregnant women between the ages of 14 and 25 years enrolled in a randomized trial to prevent sexually transmitted diseases and unplanned pregnancy (Project PROTECT). Women at high risk for sexually transmitted diseases or unplanned pregnancy were included. Participants completed a demographic, substance use, and reproductive health questionnaire. We compared women with and without a history of unplanned pregnancy using bivariate analysis and log binomial regression.
RESULTS: The prevalence of past unplanned pregnancy in this sample was 43%. Women reporting an unplanned pregnancy were older, and had less education, and were more likely to be nonwhite race or ethnicity. History of an unplanned pregnancy was not associated with usage of a contraceptive method (relative risk 1.01, 95% confidence interval 0.87–1.16) in bivariate analysis or when potential confounders were accounted for in the analysis (adjusted relative risk 1.10, 95% confidence interval 0.95–1.28).
CONCLUSION: Several factors were associated with both unplanned pregnancy and overall contraceptive method use in this population. However, a past unplanned pregnancy was not associated with overall contraceptive method usage. Future studies are necessary to investigate the complex relationship between unplanned pregnancy and contraceptive method use.
LEVEL OF EVIDENCE: II-2
What is not clear from these data is the role that an unplanned pregnancy plays in contraceptive decision-making. Health events that provide motivation for individuals to make better health decisions have been labeled "teachable moments" by health educators. McBride et al4 proposed that increased emotion, increased perception of risk and positive outcomes, and redefined self-concept or social role should optimally surround an event for it to be a "teachable moment" affecting behavior change. Experiencing an unplanned pregnancy could involve these elements for some individuals.
The objective of this analysis was to evaluate the relationship between past experience of an unplanned pregnancy and current overall contraceptive method usage. To investigate this research question, we performed a cross-sectional analysis of baseline factors in a sample of 14–25-year-old women at high risk for sexually transmitted diseases and unplanned pregnancy. Our hypothesis was that women with a past unplanned pregnancy would be more likely to use any contraceptive method compared with women without a past unplanned pregnancy.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Women eligible for Project PROTECT included English-speaking women between the ages of 14 and 35 years who were competent to give informed consent. Parental consent and minor assent were obtained for all participants aged younger than 18 years. Women were recruited from Memorial Hospital and Women and Infants Hospital in Providence, Rhode Island and Planned Parenthood of Rhode Island. Locations of recruitment at Women and Infants Hospital were the Women's Triage Unit, Women's Primary Care Center, and private physicians' offices. Participants were also recruited using newspaper advertisements, from schools, and other referral mechanisms. Women were screened for this study and enrolled between October 25, 1999, and October 7, 2003. Women were included if they were sexually active with a male in the past 12 months and expressed the desire to avoid a pregnancy for 24 months after randomization. Women consistently using dual methods of contraception were excluded.
For this cross-sectional analysis, data for participants aged 25 years or younger were included. All women aged 25 years and younger meeting the above inclusion criteria were eligible for Project PROTECT. Women between 26 and 35 years old were eligible if they had a risk factor for STD or unplanned pregnancy (eg, previous unplanned pregnancy, multiple sexual partners, etc.). Because entry criteria for the trial differed based on age, we chose to limit our analysis to women aged younger than 25 years. In this age group, there were 815 potential participants. Four hundred thirty-four consented and were randomly assigned for the study. Data were analyzed for a total of 424 participants (Fig. 1).
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At the time of the initial visit, a baseline questionnaire was completed, with each participant answering questions about her sexual history, substance abuse, experiences of violence and abuse, and levels of stress. Participants were asked questions regarding demographic characteristics (eg, age, race, ethnicity, etc.), insurance coverage, current contraceptive use, plans for future contraceptive use, stage of change for condom and hormonal contraceptive use, STD history, history of unplanned pregnancy, and number of sexual partners. Questionnaires were administered both in written form and as part of the computer-based intervention. It typically took participants 30–40 minutes to complete the questionnaire.
The main exposure (unplanned pregnancy) and outcome (use of a contraceptive method) were determined by information obtained on this baseline questionnaire. The question used to determine history of an unplanned pregnancy was "Have you ever had an unplanned pregnancy," with the response options being "yes" or "no." The question used to determine use of a contraceptive method was "Are you now using no birth control method?" with the response options being "yes" and "no." This question was cross-referenced with questions asking about specific contraceptive method use (eg, "Are you now using male condoms?" and "Are you now using Depo-Provera?") to confirm that the main outcome question was answered reliably.
The data were analyzed using Statistical Analysis Software (SAS 8.2, SAS Institute, Cary, NC). Our first step was to describe the sample in terms of reproductive health history and demographic characteristics and assess the distribution of the exposure (unplanned pregnancy) in our study sample. Next, we described which contraceptive methods were used by the sample. Categorical variables were compared using a 
2 or Fisher exact test. We estimated the relative risk (RR) of using any contraceptive method for women with a history of unplanned pregnancy compared with women without a history of unplanned pregnancy. The complete case approach was used for the regression analyses, because the proportion of missing data was small (19 observations of 424). More specifically, relative risks were estimated using log binomial regression. This approach has been shown to be a better measure of association than the odds ratio when the prevalence of the outcome (in this case, overall contraceptive use) is greater than 10%.5 McNutt et al5 found that when logistic regression was used to get odds ratios as estimators of RR with a common outcome (prevalence > 10%), the RR was overestimated.
We performed a sample size and power calculation based on the following assumptions: prevalence of unplanned pregnancy approximately 40–50% in this high-risk population and 50% of women without a history of unplanned pregnancy would be using a method of contraception. Assuming an 
= 0.05 and ß = 0.20 (power = 80%), we would need 304 women to detect a 33% increase in contraceptive use in women with a history of unplanned pregnancy (RR = 1.33). Thus, with 424 women in our data set we had more than 80% power.
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RESULTS |
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This study population was racially and ethnically diverse. Forty-four percent of the population was white, non-Hispanic; 21% was African American, non-Hispanic; and 22% was Hispanic. History of unplanned pregnancy varied significantly by racial and ethnic category. In this population, 27% of white, non-Hispanic women, 52% of African-American, non-Hispanic women, and 60% of Hispanic women had experienced an unplanned pregnancy (P < .005).
Level of education was negatively associated with a history of unplanned pregnancy. Of women with less than a high school education, 52% had experienced a past unplanned pregnancy, compared with 22% of women with a 4-year post–high school education. As level of education increased, the probability of having a past unplanned pregnancy decreased (P = .01).
Other factors found to be associated with a past unplanned pregnancy were type of insurance coverage (P < .001), reporting a history of a STD (P < .001), and experiencing physical or emotional abuse in the past (P < .01). Factors that were not associated with a past unplanned pregnancy in this sample were the number of lifetime sexual partners and current cigarette smoking.
Table 2 shows the types of contraception that were being used by the study population. The table is stratified by women with and without a history of an unplanned pregnancy. Thirty-four percent of women in the study, regardless of whether they had a previous unplanned pregnancy, reported currently using no method of contraception. In this study population, no women reported use of the cervical cap, the female condom, the contraceptive sponge, or the diaphragm. When comparing women with and without a past unplanned pregnancy, a higher proportion of women with an unplanned pregnancy were using injectable methods of contraception (P < .001), and a higher proportion of women without an unplanned pregnancy were using only the birth control pill for contraception (P = .02).
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Table 3 presents the results of the final binomial logistic regression model. When the crude RR of using any method of contraception was calculated, we found that a history of an unplanned pregnancy had no effect (RR 1.01, 95% confidence interval [CI] 0.87–1.16). The full model controlled for all factors felt to be associated with unplanned pregnancy and contraceptive method use. These factors were age, race or ethnicity, level of education, insurance status, and behavioral factors. In this full model, unplanned pregnancy was not associated with usage of a contraceptive method. Also, insurance status, number of lifetime sexual partners, cigarette smoking, and a history abuse were not associated with method use. We found that African-American, non-Hispanic women were 16% less likely to use any method of contraception when compared with whites (RR 0.84, 95% CI 0.70–1.00). This relationship approached statistical significance. Additionally, women with less than a high school education were 20% less likely to be using a method of contraception when compared with women with a high school education (RR 0.80, 95% CI 0.64–1.00). This relationship, as well, approached statistical significance.
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DISCUSSION |
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Orcutt et al6 investigated the effects of pregnancy experience on contraceptive practice in African-American and white women aged 13 to 19 years. In their retrospective review, they focused on change in contraceptive use based on unplanned pregnancy as an exposure. They found that 17% of women in the never-pregnant/no pregnancy scare group and 20% women in the never-pregnant/with a pregnancy scare group were using no method of contraception at their most recent intercourse. Of women in the ever-pregnant group, 29% were using no method of contraception at most recent intercourse. This difference was significant, and the authors concluded that experiencing an unplanned pregnancy or a pregnancy scare does not improve contraceptive use. They also concluded that ever-pregnant women were the poorest users of contraceptives.
Life events that have been shown to be motivators of behavior change have been labeled "teachable moments." To be a motivator for behavior change, a life event does not need to be a negative event or adverse event for a particular individual. Pregnancy and the postpartum period have been suggested as "teachable moments" for smoking cessation and increased physical activity.4,7,8 The behaviors that most studies have focused upon are smoking cessation,4 weight loss,9 alcohol use,10 or appropriate medication use.11,12
Unplanned pregnancy, the exposure in this study, can be divided into "mistimed pregnancy" (a pregnancy that occurred earlier than desired) and "unwanted pregnancy" (a pregnancy that occurred to women not desiring any more pregnancies). This distinction was not made in our study, because we feel that any unplanned pregnancy is a life event that could involve increased emotion, increased perception of risk and positive outcomes, and redefined self-concept or social role and thereby motivate behavior change.
We may not have seen an association between past unplanned pregnancy and current contraceptive use for several reasons. The first is that different individuals react differently to situations. What may be a "teachable moment" for one woman may not be experienced or thought about in the same way for another woman. Also, unplanned pregnancy often results from lack of contraceptive use or ineffective contraceptive use. Factors contributing to poor method use (eg, dislike of contraception, lack of health care access, fears of contraceptive use, denial of risk, poor sexual assertiveness skills) are often associated with both the exposure (unplanned pregnancy) and the outcome (current contraceptive use). Motivation provided by an unplanned pregnancy may have been overshadowed by those multiple factors influencing contraceptive use.
Our study investigated unplanned pregnancy, a major public health problem, as an exposure. The goal of this analysis was to examine unplanned pregnancy as a life event that could function as a motivator for contraceptive use. Our findings are the result of secondary analysis of baseline data from a randomized controlled trial. Individuals recruited into a randomized trial focusing on STDs and prevention of unplanned pregnancy may be different from the general population, and external validity or generalizability may be compromised. Additionally, this analysis studied only women aged 14–25 years, therefore the results are specific for this age group and cannot be generalized for all women.
As a secondary data analysis, we did not have all desirable data points of interest. For example, information such as the outcome of the pregnancy (abortion or live birth), number of unplanned pregnancies, and time elapsed since unplanned pregnancy were not part of the data set. Also, information on the exposure "unplanned pregnancy" was determined using only 1 question. Additional questions and information may have helped with validity of this measurement but were not available in the data set.
In this analysis, we found that the experience of an unplanned pregnancy was not associated with overall use of a contraceptive method. Although unplanned pregnancy meets the standards for what would be considered a "teachable moment," women who had experienced an unplanned pregnancy were not more likely to use any contraceptive method than women not having experienced an unplanned pregnancy. This suggests that the experience alone is not adequate as a motivator for contraceptive use. Future studies to investigate the complex relationship between unplanned pregnancy and contraceptive method use are necessary.
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Footnotes |
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Blue Ribbon Award at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, San Francisco, California, May 7–11, 2005.
Corresponding author: Kristen A. Matteson, MD, Division of Research, Women & Infants Hospital, 101 Dudley Street, Providence, RI 02806; e-mail: KMatteson{at}CareNE.org.
doi:10.1097/01.AOG.0000192170.16746.ea
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REFERENCES |
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  Unplanned Pregnancy Doesn't Influence Subsequent Use of Contraception Journal Watch (General), January 24, 2006; 2006(124): 4 - 4. [Full Text]
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