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Breaking the Contraceptive Barrier: Techniques for Effective Contraceptive Consultations

(Published September 2008)

Personal Factors That Influence Contraceptive Use

Personal attitudes affecting behavior

Many factors converge to shape a woman’s attitudes about the use of and the need for contraception. One factor is ambivalence about pregnancy. In a recent study, 62 percent of women considered it very important to avoid pregnancy, 20 percent considered it only somewhat important, and 18 percent said avoiding pregnancy was of little or no importance. Women who are ambivalent about avoiding pregnancy are less likely to use contraception and more likely to have gaps in contraceptive use that put them at risk for unintended pregnancy.1 Health care providers should discuss pregnancy risks and contraceptive options with women who are not motivated to prevent pregnancy and emphasize the value of planning for a healthy pregnancy before it occurs.2

Low perception of risk for pregnancy is another critical factor in influencing attitudes about contraception. An analysis of data from the 2000–2002 Pregnancy Risk Assessment Monitoring System (PRAMS) revealed that 42 percent of women who had an unintended pregnancy ending in birth believed that they could not become pregnant at the time of intercourse or that they, or their partners, were sterile.3

“Lack of thought or preparation” or “perceived low risk for pregnancy” was the reason cited for unintended pregnancy in more than half of a PRAMS subgroup of 1,429 women. Women who responded that the reason was “lack of thought or preparation” stated they “just were not thinking,” were “careless,” or ran out of their method but still had sex. Of particular note are the women who stated that the reason for having unprotected intercourse was a perceived low risk for pregnancy. This group included women who:

  • Had infertility problems
  • Were breastfeeding or had had a recent miscarriage
  • Stated that a health care provider had told them they were unable to get pregnant
  • Felt that a condition, such as endometriosis or diabetes, put them at low risk for becoming pregnant
  • Thought their partner was sterile
  • Thought they were too old or too young to get pregnant

These findings highlight areas where health care providers can help to ensure that women are receiving clear messages about their risk for pregnancy.

Historical, cultural, and religious beliefs

"Clinicians who develop a heightened sensitivity towards their patient’s cultural orientation can enhance the opportunity for a successful outcome and ensure that the care delivered is congruent with that patient’s values and beliefs."
- Elizabeth Roberts1,2

Another factor that influences a woman’s contraceptive use is her level of satisfaction with her chosen method. Many women are dissatisfied with their contraceptive options. In a recent study, 38 percent of women chose their current method primarily because they did not like any other method. Nearly 40 percent of women were not satisfied with their current method for reasons such as reduced sexual pleasure, anticipated side effects, and worry about effectiveness. The women who were not completely satisfied with their method tended to have gaps in use and to use methods incorrectly or inconsistently, putting them at increased risk for unintended pregnancy.2

An awareness of historical, cultural, and religious beliefs helps health care providers give factual information that addresses a woman’s beliefs and concerns. Some of the beliefs you may encounter include:5-7

  • Women must bear children to please their husbands
  • Only promiscuous women use contraceptives
  • Contraception is a means to control the African-American population
  • All sexual acts must be open to procreation

Social norms around contraception, pregnancy, and childbearing will likely vary within your patient population. Beliefs about the age at which woman should begin having children, acceptability of unplanned pregnancy, and lack of partner support for contraceptive use are just a few of the issues you may encounter. Awareness of and sensitivity to these attitudes will positively impact your ability to effectively counsel patients.

Consider the personal beliefs that are at play in Margarite’s case study.

Margarite. Margarite is a newly married 22-year-old bank teller who enjoys her job and is thinking about taking courses at the local community college to advance her career. You ask her what she is using as a contraceptive method. She replies that she is using nothing. You ask if she is trying to get pregnant. She tells you that she really does not want to get pregnant, but that her husband does not approve of using contraceptives.

Many potential beliefs could be at work here with Margarite and her husband. Cultural attitudes could influence her husband to believe that it is his wife’s duty to bear children or that only promiscuous women use contraceptives. Religious beliefs could be the root of her husband’s not wanting Margarite to use contraception. He could lack knowledge or have misinformation about contraceptives. Maybe he is afraid that contraceptives will harm Margarite or cause her to become infertile.

The direction of the discussion between Margarite and her health care provider could differ dramatically, depending on the health care provider’s assumptions about underlying beliefs. Assuming that her husband has a cultural or religious belief that Margarite does not share, a health care provider might present her with a discrete contraceptive method, such as an injectable or an intrauterine device (IUD), or provide her with emergency contraception. However, if her husband disapproves because he lacks knowledge about contraceptives or has concerns for his wife’s health, it could be advantageous to involve him in a discussion to educate him about the safety and reversibility of contraception before she chooses a method.

This case illustrates the importance of an accurate exchange of information between patients and health care providers. Biases from both parties can influence the course of the interaction and the ultimate outcome.

Teenage attitudes

Teens are an important group in which attitudes—those held by the teen as well as those held by the health care provider—play a large role in contraceptive success.

The latest National Survey of Family Growth (NSFG) data reports that about 47 percent of female teens (4.6 million) and about 46 percent of male teens (4.7 million) had engaged in sexual intercourse at least once.9 When initiating their first sexual intercourse, many teens will not have consulted with a health professional about contraception.10 Many of these teens will either not use a contraceptive at all or will use a contraceptive ineffectively. In addition, among males ages 15 to 19, between 10 percent and 14 percent have had oral sex but not vaginal intercourse. Approximately 11 percent of females ages 15 to 17 have had oral sex but not intercourse.11 Although they largely avoid the risks of unintended pregnancy with oral sex, many teens are exposing themselves to sexually transmitted infections (STIs) such as human papillomavirus (HPV), chlamydia, trichomoniasis, and herpes simplex.12

Adults often believe that teens view themselves as invulnerable and that teens are incapable of rationally weighing risks and benefits. Research by Valerie Reyna, a professor at Cornell University, and Frank Farley, a professor at Temple University, may contradict these strongly held assumptions about teens. In 2006, Reyna and Farley published research suggesting that teens do rationally weigh benefits and risk. However, they often go ahead with the risk because they see the benefits as outweighing the risks.13

Table 1: Common Teen Attitudes10,15
Partner issues “I didn’t know him well enough to ask him to use a condom” or “I would have used contraceptives if the guy weren’t so opposed to it.”
Media influences

“Sex just happens, and in the movies they never stop to put on a condom.”

Ambivalence about their actions “I really didn’t think it was right for me to be having sex, so I never thought about contraception until it was too late.”
Fear and misconceptions “I didn’t talk to my doctor about contraception because I didn’t want to have a pelvic exam” or “My friends say that birth control pills aren’t safe.”
Confidentiality concerns “If I talk to the doctor, she’ll have to tell my mom and dad, and they’d kill me.”
Health care access challenges “I didn’t know where to go,” “I didn’t have any way to get to the clinic,” or “I couldn’t get an after-school appointment.”
Health care delivery challenges “I never had a doctor ever tell me anything about any type of birth control, never even asked me if I was having sex;” or “They wait until you’re already knocked up to throw it at you. Get on birth control, get on birth control, get on birth control.”
Personal attitudes “I wanted to become pregnant.”

Neuroscientists who study the development of the teenage brain have found that the brain undergoes major remodeling during adolescence. Brain scans have shown that during certain tasks, teens tend to have much more diffuse activity in the frontal regions of the brain—those regions involved in planning and executing actions—than adults. Bea Luna, a neuroscientist at the University of Pittsburgh Medical Center, notes, “The adolescent brain is acting like an adult brain doing something much more difficult. An adolescent can look so much like an adult, but cognitively, they are not really there yet.” B.J. Casey, from the Weill Medical College of Cornell University, notes, “A reward center in overdrive coupled with planning regions not yet fully functional could make an adolescent an entirely different creature to an adult when it comes to seeking pleasure.”15

Reyna and Farley use the example of Russian roulette to illustrate how teens and adults think differently. Would you play Russian roulette for a million dollars? A teen will try to logically weigh the benefit of having a million dollars—a fortune that lasts a lifetime—against a 1 in 6 risk of dying and may decide that the benefit is worth the risk. An adult would likely reach a different conclusion. Reyna and Farley explain that as people gain more life experiences, they become more intuitive and base decisions on “gist,” the overall sense of what makes the best course of action. Gist helps adults see the forest through the trees, get to the bottom line more quickly, and reduce risky behavior. “Gist-based thinking” bypasses the details of weighing the number of bullets against the amount of money and leads the adult to the conclusion that no amount of money is worth putting a gun to your head.13

Likewise, teens may conclude that the benefits of having sex outweigh the risk of getting pregnant or even the risks of seeking out and using contraception. As shown in Table 1, there are numerous attitudes and issues that health care providers need to be aware of and work with when talking to teens about contraception.

Reyna developed a gist-based approach to risk prevention that helps adolescents develop gist and make better decisions. To help resist spontaneous, unprotected sex, girls practice ways to say “no” and not worry about losing their boyfriends. A 15-year-old who had already had one unintended pregnancy had this to say when asked if the intervention made her feel more in control of her life: “Yes, because in talking about all the different ways to say ‘no,’ I’ve actually used them, which makes me feel much more comfortable. And I feel confident. I don’t feel stupid saying ‘no.’ And even if people think I’m stupid, that’s their problem.”13

Research by Reyna and colleagues has shown that even brief exposure to positive or negative experiences contributes to developing “good” or “bad” gist. Practicing realistic examples of potentially risky situations helps adolescents automatically access the gist of the situation and avoid risky behaviors.15 Reyna also suggests that teens can develop positive and negative gists through visual depictions, films, novels, serial dramas, and other emotionally evocative media.13 It is important to note that this approach differs from some traditional approaches that emphasize reflection, deliberation, and details at the time of the decision. Reyna’s research has shown that risk taking increases when adolescents engage in such traditional “rational” weighing of costs and benefits.16

Brianna. Brianna is 14 years old. You see her today because she sprained her ankle at cheerleading practice. During your discussion, you ask her about sexual activity, and she tells you that she has a boyfriend and they are getting “pretty serious.” You ask her about contraceptive methods. She tells you that her friend wears “some kind of sticker-like thing” on her back so she won’t get pregnant, and she wonders how that works.

First, answer Brianna’s question about the “sticker” by explaining that her friend is most likely using a contraceptive patch. Briefly explain how it works and tell her it is very effective. Ask her if she wants a prescription for a contraceptive to get started on now and give her a prescription for emergency contraception. Health care providers may also want to talk to Brianna about HPV immunization as well as the risks of sexually transmitted infections and the use of condoms. Suggest that she discuss contraceptive methods with her boyfriend, if he’s open to that. You may even suggest that she and her boyfriend come to the office or clinic for a confidential discussion of contraceptive methods with a staff member.

Strategies for breaking barriers of personal beliefs4,10,15
  • Begin counseling before the onset of sexual activity.
  • Emphasize the value of planning for a healthy pregnancy before it occurs.
  • Use active listening—allow patients to speak without being interrupted so that they can state their concerns.
  • Consult the Cultural Competence Health Practitioner Assessment (CCHPA), developed by the National Center for Cultural Competence, which helps clinicians deliver culturally sensitive services (http://www11.georgetown. edu/research/gucchd/nccc).
  • Provide accurate information about the risks of pregnancy, STIs, and contraceptives to every teen, regardless of the reason for the visit. Initiate the conversation. Teens often feel embarrassed and uncomfortable initiating a discussion about sex or contraception.
  • Assure teens that the office or clinic provides confidential care for birth control and that they are welcome to come in when they think they may get sexually involved.
  • Assure teens that they do not need a pelvic examination to receive contraceptives.
  • Address barriers to availability of information and services. Provide attractive take-home materials that have an appropriate reading level. Also provide a welcoming office or clinic environment with after-school and after-work appointments, when possible.
  • Have non-judgmental support staff trained in effective counseling.
  • Discuss cost and explain how to fill prescriptions; many younger patients have never filled a prescription themselves.
  • Be familiar with the policies and laws of your state regarding consent for sensitive services.
  • Don’t be afraid to be “prescriptive”. If the patient asks for your advice, give her a recommendation.


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  2. Guttmacher Institute. Improving contraceptive use in the United States. In Brief. 2008 Series, No.1 April 2008.
  3. Nettleman MD, Chung H, Brewer J, Ayoola A, Reed PL. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception. 2007;75:361-6.
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