Abstract
The unintended pregnancy rate in the United States remains high, and there are large race and education differences in unintended pregnancy and fertility. These differences make it important to study race and education differences in contraceptive behavior. Using nationally representative data from the 2002 National Survey of Family Growth, this study examines the effects of race and education on the likelihood that women have ever used particular types of hormonal contraception and have ever discontinued hormonal contraception because of dissatisfaction. The results show that blacks and Latinas were more likely to have used injectable contraceptives (“the shot”) and less likely to have used oral contraceptives (“the pill”) than were white women. Women with less education were more likely than college-educated women to have used the shot but there were no significant education differences in use of the pill. Among women who had ever used hormonal birth control, those with less than a college degree were more likely than college-educated women to discontinue the birth control because of dissatisfaction. However, net of education, this study found no significant racial/ethnic differences in discontinuation. The most commonly stated reason for discontinuation because of dissatisfaction was side effects.
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Notes
The unintended pregnancy rate for black women also has important implications for race differences in having more children than intended; Morgan and Rackin (2010) found that race differences between black and white women in the likelihood of overachieving fertility intentions (versus achieving intentions) were largely eliminated after accounting for experiencing births from pregnancies that the women themselves retrospectively called unwanted or mistimed.
They defined non-method-related reasons as the desire to become pregnant or lack of exposure to pregnancy; they defined all other incidences of discontinuation as method-related. The authors used a contraceptive calendar in conjunction with a sexual activity calendar to determine why women stopped use. (The survey did not ask about reasons for discontinuation.) Using these calendars, the authors infer when women stopped use for method-related and non-method-related reasons. See Vaughan et al. (2008:2) for more detail.
In a similar vein, Thorburn and Bogart (2005) found that in a random sample of 324 black women, only half agreed that “the government tells the truth about the safety and side effects of new birth control methods” (p. 478). See also Crocker et al. (1999) for a discussion of similar results for black and white college students.
The Institute of Medicine (2004) used the definition of health literacy presented by the National Library of Medicine (Selden et al. 2000). The authors define health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Selden et al. 2000:vi).
The health literacy scale used included four categories: Below Basic, Basic, Intermediate, and Proficient. Although those in the Below Basic category demonstrate “no more than the most simple and concrete literacy skills,” those at the next level (Basic) demonstrate the “skills necessary to perform simple and everyday literacy activities” (Kutner et al. 2006:5). See Kutner et al. (2006) for more discussion.
Previous analyses (not shown) included women of “other” races as a separate category and reached similar conclusions to those herein.
Of those women included in the sample, types of hormonal contraception include the pill, the patch, Depo-Provera (the shot), Lunelle, and Norplant. Emergency contraception is not included as a form of hormonal contraception.
Analyses were also performed with “other methods” as a third dependent variable. These methods included the patch, Norplant, and Lunelle; the injectable Lunelle was included with “other methods” because of the very small number of women who used this method. Because of space constraints and the heterogeneity of this variable, these findings are not discussed. However, the results are available upon request.
Because the analysis sample includes only women who had ever used hormonal methods, the dependent variable indicates which of these women had ever stopped hormonal birth control because of dissatisfaction.
In published reports on education data from the NSFG, The National Center for Health Statistics (NCHS) restricts its analytical sample to women ages 22–44. Because some women may be poised to earn a bachelor’s degree at age 22 but still be in college, the current study restricts the sample to women ages 23–44 in an effort to further minimize the number of women who may report not having a bachelor’s degree solely because they were not yet old enough to complete their education at the time of the interview.
This may be especially true for women who were younger than 18, for example, who would be included in the “less than high school” category simply because they were not old enough to be high school graduates rather than because they dropped out of high school.
Black and white respondents are those who selected black or white, respectively, as their race and indicated that they were not of Hispanic origin.
To determine whether women with a bachelor’s degree differed from those with more than a bachelor’s degree, analyses were performed with separate dummy variables for each respective group (results not shown). The analyses revealed no significant differences between women with a bachelor’s degree and those with more than a bachelor’s degree on any of the outcomes.
Analyses were performed with family income at the survey date, expressed in a series of dummy variables, included in the models, but including these controls had little effect on the coefficients for race or education.
χ 2 tests were used as a measure of association for all bivariate results presented.
The bivariate analysis presents data on current use of sterilization rather than “ever-use” (with the sample restricted to nonpostpartum women at risk of unintended pregnancy) because it may better reflect current satisfaction with available methods (or desire for a method with a lower risk of failure). The results for “ever use” of sterilization are qualitatively similar.
Multinomial logistic regression models were also used for a categorical dependent variable constructed with these data. A three-category dependent variable was constructed with the following categories: (1) did not stop because of dissatisfaction, (2) stopped because of dissatisfaction with side effects, and (3) stopped for other reasons. The results are not discussed because of the small percentages in the categories for all reasons other than side effects and the resultant heterogeneity introduced by creating a residual “Other reasons” category, but the results are available upon request.
The “side effects” category in Table 4 combines the categories “Did not like changes to menstrual cycle” and “Had side effects” from Table 3 because “changes to menstrual cycle” can be thought of as a side effect to using hormonal birth control. “Worried might have side effects” is not included because a woman worrying that she might have side effects at some point may not be equivalent to experiencing side effects (or believing that she is).
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Acknowledgments
I am grateful to Paula England, Michael Rosenfeld, C. Matthew Snipp, and anonymous reviewers for their very helpful comments. I also thank the Migration, Ethnicity, Race and Nation Workshop of Stanford University. An earlier version of this article was presented at Bringing the Body Back In: Towards a Corporeal Social Science, University of Arizona, April, 2009 and at the annual meetings of the American Sociological Association, San Francisco, August, 2009.
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Littlejohn, K.E. Hormonal Contraceptive Use and Discontinuation Because of Dissatisfaction: Differences by Race and Education. Demography 49, 1433–1452 (2012). https://doi.org/10.1007/s13524-012-0127-7
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DOI: https://doi.org/10.1007/s13524-012-0127-7