Factors associated with choosing highly effective reversible (HER) contraception or less-effective contraception at the time of abortion: A prospective qualitative study
Awarded 2013
Complex Family Planning Fellowship Research
Meredith Warden, MD, MPH
University of California, San Francisco

Women presenting for abortion are at high risk of subsequent unintended pregnancies. Little is known about contraceptive use in the post-abortion setting, but some data suggest that contraceptive discontinuation and repeat pregnancy is high. Women choosing highly effective reversible (HER) contraception at the time of abortion are more likely to experience subsequent unintended pregnancies and have high rates of continuation and satisfaction.

Despite the body of evidence suggesting that choosing HER contraception at the time of abortion is effective at preventing unintended pregnancy and subsequent abortion, and highly satisfactory to women, there is little known about contraceptive decision-making at the time of abortion. Specifically, there are little data on why some women presenting for abortion choose HER contraception, and why some choose less-effective methods of contraception (LEM).

This study explored factors associated with choosing HER contraception and LEM at the time of abortion. Our primary objective was to qualitatively describe the decision-making associated with contraceptive method choice at the time of abortion. We conducted individualized semi-structured interviews exploring the decision-making process of women choosing HER contraception or LEM at the time of abortion. We also interviewed women at three months after their abortion to further elucidate factors affecting contraceptive decision making, use and satisfaction in the post-abortion period.

We found that women choosing LEM felt that the ritualized act of using LEM methods on a daily, monthly, weekly or with each sex act basis helped them to demonstrate their responsibility to preventing pregnancy. They also felt that because of the abortion experience, they would be more likely to use the method, and “be responsible”. In contrast, HERC choosers recognized that they either haven’t been able to use a LEM method consistently in the past, or that they wouldn’t be able to maintain the adherence required by the LEM method. HERC users wanted something more immune to human error. Anther theme involved an inconsistency among LEM choosers, who talked about wanting to have more personal control over their method, specifically expressing that they wanted to be able to start and stop the method when they wanted to. But they also seemed to feel that they actually have very little control over whether or not they get pregnant. We also found that all participants in the study felt that birth control was inherently risky, but that HERC choosers were more likely to be willing to accept that risk. Another theme was the idea of “starter birth control”, where all participants believed that HERC methods are inappropriate for young or first-time birth control users, and that LEM methods should be exhausted first before trying a HERC method. Finally, we found that overall, participants have very little understanding of the difference in efficacy among methods.

This study contributes to the very limited literature exploring the contraceptive decision-making of women seeking abortions, and clearly demonstrates that the way in which HERC and LEM choosers think about birth control is very different. And importantly, very different from how providers think about birth control. These themes may be useful in counseling women seeking abortion to help them choose the method most congruent with their values and goals. Future research is needed to assess whether counseling interventions that address these themes might affect contraceptive satisfaction, continuation and unintended pregnancy.