The Complexity of Multiple Contraceptive Method Use and the Anxiety That Informs It: Implications for Theory and Practice

Prevalence and Content of Multiple Method Use

Clinical practice recommendations in the U.S. state that women can best protect themselves from unintended pregnancy by using one effective method consistently and correctly (Centers for Disease Control and Prevention, 2013). Evidence from nationally representative surveys shows that most American women adhere to this advice (Jones, Mosher, & Daniels, 2012); national surveys of women in many other developed countries have yielded similar findings (Sato & Iwasawa, 2006; Spinelli, Talamanca, Lauria, & European Study Group on Infertility and Subfecundity, 2000; Toulemon & Leridon, 1998). However, other evidence suggests that, for some women, actual contraceptive practices may be more complex than indicated by these analyses, in that they may include more use of concurrent methods and less-effective¹ methods (Brown et al., 2011; Frost, Singh, & Finer, 2007b; Gray, Chowdhury, Caldwell, & Al-Sabir, 1999; Horner et al., 2009; Jones, Lindberg, & Higgins, 2014; Parr & Siedlecky, 2007; Spinelli et al., 2000; Whittaker, Merkh, Henry-Moss, & Hock-Long, 2010). Understanding women’s true contraceptive practices is crucial, both for research that aims to describe contraceptive use in a population, and for clinical practice designed to reduce individual women’s risk of exposure to unintended pregnancy. The present study expands this understanding by qualitatively exploring the contraceptive behaviors of women from demographic groups most at risk of having an unintended pregnancy. Our detailed examination of our respondents’ contraceptive practices over a one-year timeframe revealed much more frequent and complex use of multiple methods than indicated by any previous work.

The picture of U.S. women’s contraceptive use evoked by the country’s preeminent survey of fertility behaviors, the National Survey of Family Growth (NSFG), found just 9 % of currently contracepting women reported using two or more methods in a given month, and small proportions of contracepting women using less-effective methods such as condoms (14 %), withdrawal (6 %), and Fertility Awareness-based Methods (FABMs, 2 %) within their method mix (Jones et al., 2012). Analyses in France, Denmark, Germany, Spain, and Japan yield comparable results (Sato & Iwasawa, 2006; Spinelli et al., 2000; Toulemon & Leridon, 1998). However, other evidence suggests that a higher proportion of women use multiple methods in their efforts to avoid unintended pregnancy. A few surveys of developed countries (U.S., Australia, Italy, and Poland) have found rates of multiple method use ranging from 23 to 44 % (Frost et al., 2007b; Parr & Siedlecky, 2007; Spinelli et al., 2000). A recent, nationally representative US study, specifically designed to capture multiple method use, found about one-third of women reporting multiple method use within the last 30 days (Jones et al., 2014).

A possible explanation for the discrepancy in these reported rates of multiple method use may be the underreporting of the use of less-effective methods. Jones et al. (2014) found approximately one-third of women reporting any withdrawal use and any condom use within the last month, findings they attributed to a questionnaire design that placed withdrawal at the top of the list of coital method choices. It is also possible that the use of FABMs may be underrepresented, due to them being used in tandem with other methods (Jaccard, 2009). In fact, closer examination of the women using multiple methods in some national surveys reveals that women who use less-effective methods are likely to be using them in combination with another method (Jones et al., 2014; Parr & Siedlecky, 2007; Sato & Iwasawa, 2006; Toulemon & Leridon, 1998).

Mechanics and Motivations of Multiple Method Use

The literature above reported the existence of combination method use without shedding much light on exactly how or why women engage in this behavior. There are several documented ways, and reasons why, women may combine contraceptive methods or use more than one contraceptive method within the short timeframe typically examined (usually the past 30 days). One of the most commonly discussed forms is dual use, defined as concurrent use of a hormonal method to prevent pregnancy and condoms to prevent sexually transmitted infections (STIs) (Berer, 2006; Eisenberg, Allsworth, Zhao, & Peipert, 2012; Higgins & Cooper, 2012; Tyler et al., 2014; Woodsong & Koo, 1999). Method switching, i.e., the sequential use of multiple methods, for reasons such as experiencing side effects, changes in sexual frequency, ambivalence about preventing pregnancy, changing relationship dynamics, or a desire for a higher level of protection has also been extensively examined (Frost et al., 2007b; Grady, Billy, & Klepinger, 2002; Rosenberg & Waugh, 1998; Vaughan, Trussell, Kost, Singh, & Jones, 2008; Wellings et al., 2015).

A small number of studies have also documented the practice of substituting one method for another. In the Jones et al. (2014) study, of women who reported using either condoms or withdrawal during the month, 62 % reported switching between the two methods. Although that study did not explore the reasons why women substituted one method for another, other work has found that relationship characteristics have an effect on method choice; women with multiple partners may use condoms with certain partners and not others because of differing perceptions of the risk of STIs (Lansky, Thomas, & Earp, 1998; Lescano et al., 2006; Macaluso, Demand, Artz, & Hook, 2000).

Women’s and couples’ motivation to maintain some level of protection from pregnancy even when not using their primary² method has also been shown to motivate method substitution. Whittaker et al.’s (2010) qualitative study of withdrawal use among young adult family planning clients revealed that respondents commonly substituted withdrawal for condoms when they did not have condoms on hand, when they were intoxicated, because of partner objections or when men desired more sexual pleasure. These findings are also present in other qualitative work examining the use of less-effective methods among specific populations or demographic subgroups (Gray et al., 1999; Horner et al., 2009). Method substitution in the form of “backing up” inconsistent pill use with other methods (Gold, 1999; Oakley, Potter, de Leon-Wong, & Visness, 1997; Weisman, Plictha, Nathanson, Ensminger, & Robinson, 1991; Williams-Deane & Potter, 1992) or using Emergency Contraception (EC) when a coital method was not used, was misused or failed has also been described (Abuabara et al., 2004; Keogh, 2005; Sanfilippo & Downing, 2008; Trussell, Raymond, & Cleland, 2014).

Another documented form of combination multiple method use, using methods concurrently at the same act of sex, also appears to be motivated in part by a desire to increase one’s level of protection from pregnancy. The Jones et al. (2014) study found that among respondents who reported using multiple methods within the same month, significant proportions reported using those methods during the same act of intercourse. Again, qualitative work on this topic provides some insight about motivations; a study in rural Bangladesh found that concurrent use of methods was driven by distrust of the efficacy of methods, a desire to increase the effectiveness of coital methods by combining them with use of “safe periods” or FABMs, a preference for ejaculation outside of the body and, among male respondents, uncertainty that their female partners were taking contraceptive pills properly (Gray et al., 1999). All of these reasons were echoed by Whittaker et al.’s (2010) respondents with respect to withdrawal. The combination use of withdrawal and/or condoms to boost the efficacy of FABMs during perceived fertile periods has been documented in other developing countries (Arevalo, Jennings, Nikula, & Sinai, 2004; Sinai & Jennings, 2014) and in at least one qualitative U.S. study of African American and Latina FABM users—even though official descriptions of FABMs only recommend periodic abstinence during the fertile days of the cycle (Jennings & Burke, 2011; Guzman, Caal, Peterson, Ramos, & Hickman, 2013).

The Need for a Greater Understanding of Multiple Method Use

The existing research on the use of multiple contraceptive methods in combination is somewhat inconsistent, and work on this topic within the U.S. is limited. Varying rates of multiple method use have been found, with the bulk of the evidence showing that the practice is, at most, occurring among about a third of all women using contraception (Frost et al., 2007b; Jones et al., 2014; Mosher & Jones, 2010; Parr & Siedlecky, 2007; Sato & Iwasawa, 2006; Spinelli et al., 2000; Toulemon & Leridon, 1998). Such use is generally found to be concentrated among users of less-effective methods, although lower levels of combining less- and highly effective methods were also identified in these studies (Frost et al., 2007b; Gray et al., 1999; Jones et al., 2014; Parr & Siedlecky, 2007; Sato & Iwasawa, 2006; Spinelli et al., 2000; Toulemon & Leridon, 1998; Whittaker et al., 2010). There is some evidence that, in the U.S., both multiple method use and use of less-effective methods are higher among members of disadvantaged subgroups: young people and racial and ethnic minorities (Brown et al., 2011; Frost & Darroch, 2008; Guzman et al., 2013; Mosher & Jones, 2010; Sznitman et al., 2009). Reflecting this, in-depth research on combination and less-effective method use has either has been carried out among specific subgroups (rather than examining all women), or has focused on use of specific methods, rather than looking at a woman’s full range of contraceptive methods (Arevalo et al., 2004; Brown et al., 2011; Gray et al., 1999; Guzman et al., 2013; Horner et al., 2009; Sinai & Jennings, 2014; Sznitman et al., 2009; Whittaker et al., 2010). These limitations make it difficult to identify the full scope of combination multiple method use, while the variety shown in the existing literature on the prevalence, content, mechanics, and motivations of such use indicate that it is a fruitful area for further inquiry. The current study was designed to thoroughly explore women’s efforts to protect themselves from pregnancy by qualitatively examining contraceptive use over 1 year.

Participants

We conducted 52 semi-structured face-to-face in-depth interviews (IDIs) with unmarried, lower- and middle-³ income women between the ages of 18 and 30 who had been sexually active with a man within the past year. The sample was selected to reflect the demographic groups that have been shown to have difficulty using contraception consistently and correctly, and who experience the highest rates of unintended pregnancy and abortion in the U.S. (Finer & Zolna, 2014; Frost & Darroch, 2008; Frost, Singh, & Finer, 2007a; Jones, Finer, & Singh, 2010; Mosher & Jones, 2010). We selected approximately equal numbers of African American, Latina and white women, as their contraceptive use patterns differ (Frost et al., 2007a; Frost & Darroch, 2008; Mosher & Jones, 2010). Additionally, we included women whose self-identified primary language was Spanish, in order to have representation in the sample from the largest immigrant group in the U.S. (Migration Policy Institute, 2014).

We recruited women in a large Northeastern city and a smaller Midwestern city through a professional recruiting company and Craigslist (www.craigslist.org), a popular classified advertisement website. In both locations, the recruiting company identified potential respondents from their database who met the screening criteria. Respondents from Craigslist were screened for eligibility via phone and email. Interviews took place during November 2013 in private offices in the cities where respondents were recruited.

The interviewers (LF, NB, and HW) were trained in the informed consent process, the administration of the interview guide, and interviewing techniques. Verbal and written consent was provided by all participants. All participants received $100 cash as compensation. During the informed consent process, respondents were told that they could stop the interview at any time and could decline to answer any interview question, and that they would still receive full compensation if they chose to do either; no respondent ended the interview early or declined to answer an interview question. Interviews lasted between 45 and 120 min. At the conclusion of the interview, participants filled out a short questionnaire on their socio-demographic characteristics. Study protocols were approved by the Guttmacher Institute’s Institutional Review Board.

Measure

The interview guide focused on women’s contraceptive use to prevent pregnancy over the last 12 months. This timeframe was chosen in order to explore a longer period than most quantitative analyses and therefore potentially capture method switching (Jones et al., 2014; Mosher & Jones, 2010; Sato & Iwasawa, 2006; Toulemon & Leridon, 1998), but also to limit the possible recall biases and inability to recount details that may appear in work that asks respondents to report on lifetime contraceptive use (Horner et al., 2009; Reed, England, Littlejohn, Conroy Bass, & Caudillo, 2014; Whittaker et al., 2010). The guide was pretested with eight respondents who met all of the eligibility criteria, and changes were subsequently made to improve question clarity. In order to help respondents think about all contraceptive options, they were shown cards with labeled pictures representing all known methods and behaviors that can be used to prevent pregnancy: sterilization, an IUD, an implant, an injection, oral contraceptive pills, a patch, the ring, EC, male and female condoms, a cervical cap, a diaphragm, a sponge, spermicides, withdrawal, calendar or FABMs, and abstinence (defined as the avoidance of penile–vaginal intercourse to avoid the risk of pregnancy and hereafter referred to as “temporary celibacy” to differentiate it from the periodic abstinence that may be a part of some women’s practices of FABMs). Participants were asked to separate out any methods they had ever used for any reason, and then to separate those used in the past 12 months. If women did not initially include withdrawal, FABMs, or EC, they were prompted about whether they had used these methods, using colloquial terms. We then asked a series of questions about how women used those methods in the previous year, which enabled us to assess consistency and correctness of use, reasons for use other than pregnancy prevention and respondents’ perceptions of method efficacy. Methods used with different partners and women’s perceptions of their partners’ attitudes toward contraception were also explored. When more than one method was used over the course of the year, we probed about if and how the methods were used in conjunction with each other. Instances as well as periods of nonuse were also scrutinized.

Data Analysis

All of the IDIs were digitally recorded and transcribed verbatim. Identifying information was stripped during the cleaning phase. Interviews conducted in Spanish were professionally translated and the translations were checked for accuracy by the interviewer.

We followed Agar’s qualitative strategy of reading each woman’s interview in its entirety to understand each respondent’s comprehensive narrative (Agar, 1980). Respondents’ narratives of their full contraceptive practices unfolded across the entire interview; we summarized this information for each respondent in a standardized format for this analysis (Huberman & Miles, 1998). The use of quotes in this analysis is therefore spare relative to other qualitative work, and we rely more heavily on the summaries described above in order to illustrate the phenomena described in this paper. Respondents are identified using pseudonyms.

Cross-case analysis was conducted to identify themes and concepts, and to explore similarities and differences. We counted the number of contraceptive methods respondents had used and analyzed how they used these methods (Miles & Huberman, 1994). Additionally, we performed targeted coding on respondents’ method use and factors that informed their beliefs and decisions about that use (LeCompte & Schensul, 1999). Coding was performed by two members of the research team (LF and NB) after over 95 % inter-coder reliability had been established.

Backing Up Inconsistent Method Use

More than half of multiple method users in our sample (n = 26) described inconsistent use of a method backed up by the use of another method in order to maintain protection from pregnancy. Some of these respondents reported backing up their primary method, i.e., they occasionally substituted withdrawal for condoms, used another method to account for inconsistent pill use, and/or used EC when they had not used any other method at an act of intercourse.

However, our data reveal another level of backing up inconsistent method use: backing up a backup method with a tertiary method. Most often, the primary method was hormonal, the secondary method was condoms, and the tertiary was withdrawal. Sonya, a long-term pill user, reported that she often took her pills late or missed them up to 2 days in a row. As a result, she felt she needed to back up her pill use with another method, and preferred to use condoms for this purpose because she felt they would be most effective. However, Sonya’s condom use was inconsistent as well. Pressure from her partner, coupled with the fact that Sonya herself preferred withdrawal when she was intoxicated, led her to back up her condom use with withdrawal. Sonya reported that because her pill use was so erratic, she backed it up by using either condoms or withdrawal at most acts of sex over the past year, thereby implementing a three-layered system of substitution to achieve her desired level of protection from pregnancy.

EC was also named by many women as a tertiary backup when they were unable to enact their preferred substitution for their primary method, or when they when they were not confident about their secondary backup method. Audrey frequently either forgot to take her pills or took them late, and would use withdrawal to back up these missed pills. She did not try to use withdrawal at every act of intercourse though, and her partner was not always successful when they did intend to use it, so Audrey frequently took EC for additional protection. She reported taking EC six or seven times over the course of the year.

Similarly, when Rosemary missed her appointment for her injectable and was waiting until she could get another one, she used temporary celibacy as a backup, and withdrawal as a tertiary backup when she had sex. In one instance during that period, her boyfriend did not withdraw on time. Frightened (but not impregnated) by this event, Rosemary switched to an IUD.

When explaining their reasons for inconsistent use that led them to back up their methods, our respondents reported lack of access to their primary method (e.g., running out of condoms or leaving home without their pills), intoxication, and pressure from partners. They also explained the way that their own sexual pleasure informed their practice of substituting withdrawal for condoms. They described using withdrawal in place of condoms when irritation from condoms interfered with their pleasure during sex, or when they wished to experience the pleasure they associated with sexual acts that included withdrawal. Faye reported alternating between condoms and withdrawal at most acts of sex, depending on “how passionate we’re feeling and how sensitive we’re feeling.” She clarified that withdrawal was more pleasurable for both of them, but she considered condoms to be more effective at preventing pregnancy, and so felt compelled to try to use them sometimes. Most women who alternated between condoms and withdrawal to maintain pregnancy protection while increasing sexual pleasure reported withdrawal as the more pleasurable option of the two methods, but this was not universal.

Buttressing Method Use for More Perceived Protection From Pregnancy

Thirty women in our sample described a technique of using methods in combination, which we are naming “buttressing,” wherein one method is used with another in order to produce a perceived higher level of protection from pregnancy than from one method alone. As opposed to backing up, buttressing did not happen when women felt unprotected due to inconsistent use of a primary method. Rather, buttressing was the concurrent use of multiple contraceptive methods when women (or their partners) felt the need to layer on an additional method to bolster the effectiveness of a primary method.

Combining Mechanisms and Broad Method Mix

Lisa’s narrative helps illustrate how our respondents often utilized more than one mechanism of method combination. In the previous quote, Lisa states that she used condoms when she was fertile, with “no exceptions.” However, at another point in the interview, she described one instance in the past year of backing up her condom use with withdrawal when she felt her cycle indicated she should use a condom, but her partner did not have one. Therefore, Lisa (and 13 other respondents) was not just a “backer up” or a “buttresser,” but both.

Strengths and Limitations

Our findings must be viewed in light of the fact that they rely on women’s self-reports and retrospective recall. However, in contrast to other qualitative studies that have attempted to examine detailed narratives of contraceptive use (Horner et al., 2009; Reed et al., 2014; Whittaker et al., 2010), the current study focused only on the past year, and procedures and questions were geared toward drawing out and clarifying every detail of women’s contraceptive behavior during the timeframe. Another limitation concerns the applicability of our findings to women in general. Small qualitative samples are not designed to produce generalizable findings, especially given that our sample was selected in order to elucidate the practices of women most at risk of unintended pregnancy (Finer & Zolna, 2014; Frost & Darroch, 2008; Frost et al., 2007a; Jones et al., 2010; Mosher & Jones, 2010). For these two reasons, it is possible that these results may overstate the prevalence of combination method use for the rest of the population. Additionally, our respondents may have over-reported their method use due to social desirability bias (Stuart & Grimes, 2009). We attempted to mitigate the influence of this effect through techniques such as using language that acknowledged and normalized method use that is perceived as “incorrect” (e.g., removing condoms during sex) and ineffective (probing on methods such as withdrawal and FABMs), as well as contraceptive nonuse.

Implications

When Gray et al. (1999) discuss the patterns of contraceptive use they saw in their data from Bangladesh, they conclude that it is the combination, rather than the individual methods “that is really the method being used” (p. 51). Our data show that this conclusion may be equally applicable to women in the U.S. at risk of unintended pregnancy, and therefore should be incorporated into contraceptive counseling practice. There are several ways that this could be achieved. Our respondents perceived that their concurrent combination method use, which often comprised less-effective methods, augmented their level of protection from pregnancy as compared to using only one of these methods. Counselors and other health professionals need to be aware of this belief so that they can uncover women’s combination method use and help users assess whether these behaviors are actually affording them the level of protection they are seeking. Contraceptive counseling can also take combination method use into account when advising women about switching methods. Previous work shows a connection between switching methods and exposure to unintended pregnancy (Frost et al., 2007b), and our data make clear that for many women this switching may not be from just one method to another, but may involve combinations of methods. Contraceptive counseling guidelines also advise that women who wish to switch methods should overlap methods to avoid a gap in coverage (Centers for Disease Control and Prevention, 2013); acknowledging concurrent method use may make this recommendation easier to follow.

Women using contraceptive methods care about efficacy, but that valuation does not always translate into use of one highly effective method. Current clinical practice tends to focus on a tiered approach highlighting the most-effective methods up front, particularly the IUD and implant (Gavin et al., 2014; Madden, Mullersman, Omvig, Secura, & Peipert, 2013; Trussell et al., 2013). It is clear why the public health model makes this recommendation; from a rationalist perspective, the insecurity prompted by inconsistent method use and ineffective methods that our respondents experienced could be ameliorated by switching to long-acting reversible contraceptives (which a few respondents in the sample did). Yet women who decline to use these highly effective methods may still benefit from counseling about ways to increase their level of protection from pregnancy by engaging in contraceptive practices using less-effective methods (Luker, 1999). Finally, because respondents who were using methods that are considered moderately to highly effective expressed doubt that they were adequately protected, counseling can acknowledge these beliefs while addressing women’s concerns.

These findings have implications for research on contraceptive use as well as counseling. Jones et al. discussed the reasons for underreporting of withdrawal, and their survey design innovation shows that reporting can be improved (Jones et al., 2014). Our results indicate that other less-effective methods such as condoms, FABMs, EC, spermicides, and even temporary celibacy may be similarly underreported; further research could test whether reporting of use of these methods could be increased if survey design changes. Our findings also indicate that research based on large-scale national survey reporting of contraceptive use that utilizes only the “most-effective method used” variables, while useful in understanding the risk of unintended pregnancy at the population level, can miss complex contraceptive behavior. Analyses that take concurrent multiple method use into account will better reflect women’s actual contraceptive practices. Our findings show that qualitative or mixed-methods approaches have great value in this endeavor. Finally, while our data revealed that women are often operating under assumptions about the efficacy and effects of methods that are not factual, it was beyond the scope to this study to fully examine the content and origin of those beliefs. This would be a rich area for subsequent exploration.

Examining how women use methods in combination provides insight into the effort they put into preventing pregnancy, as well as illuminating the beliefs and motivations that underlie that behavior. Taken together, our results (and the other work examining multiple method use that we build on) illustrate that women may not only be contraceptive “risk-takers” or cost-benefit analysts (Luker, 1977), fatalists (Woodsong, Shedlin, & Koo, 2004), and “magical-thinkers,” (Frohwirth et al., 2013), but are also extremely anxious about unintended pregnancy, and highly motivated by the desire to avoid that outcome. Contraceptive counseling (as well as the theory and research that inform it) that acknowledges women’s practices of and motivations for multiple method use that may result, might better resonate with women’s lived experiences.