Determinants of Contraceptive Choice: Factors Affecting Contraceptive Nonuse among Urban ...

123 Pages·2013·2.4 MB·English

Determinants of Contraceptive Choice: Factors Affecting Contraceptive
Nonuse among Urban Women Utilizing Title X Services

A thesis submitted to the
Graduate School
of the University of Cincinnati
in partial fulfillment of the
requirements for the degree of

Master of Public Health

in the Department of Environmental Health
of the College of Medicine

by
Aalap Bommaraju

B.S. University of Cincinnati
December 2010
A.T.S. University of Cincinnati
March 2012

Committee Chair: William A. Mase, Dr.P.H., M.P.H., M.A.
Abstract
Background: Disparities in unintended pregnancy are partially due to ineffective contraceptive
method choice among vulnerable populations. Improved understanding of the ecological,
individual, and health system related determinants of contraceptive choice can provide guidance
for how to reduce ineffective contraceptive method choice among women at high risk for
unintended pregnancy.
Objectives: Secondary data analysis is performed on visit data from women utilizing Title X
Family Planning services at the Cincinnati Health Department’s Reproductive Health &
Wellness Program (RHWP) to determine the significance of predisposing factors (age, African-
American race, education), enabling factors (income, health insurance status, socio-behavioral
risks), need factors (having had a recent birth, number of living children) on choosing an
ineffective contraceptive method. Mediation analysis is performed to determine if health system
factors mediated the effect of these explanatory variables.
Methods: Using data from 1,119 RHWP clients who were not seeking pregnancy, multinomial
logistic regression is used to compare pill, patch, and ring users, depot medroxyprogesterone
acetate (DMPA) users, and long-acting reversible contraception (LARC) users with a reference
group of ineffective method users. Multinomial logistic regression is first performed with all
independent variables except health system mediation. Then, it is performed with inclusion of
health system mediation. Multiple linear regression analysis is performed to determine
significant relationships between independent factors and health system mediation. Mediation
analysis is performed for any independent variable that is significantly correlated with both
contraceptive method choice and health system mediation for the purpose of determining if any
witnessed mediation effect is statistically significant.
Results: The model including health system mediation is found to account for more variance in
the data than the model excluding health system mediation (Nagelkerke R-squared = 0.195 and
0.158, respectively). Through both models, and in all three comparisons, higher age is found to
reduce the odds of choosing a more effective method with only minor mediation effects. Having
more children results in higher odds of both DMPA and LARC uptake in both models and is
unmediated by the health system. Being of African-American race results in lower odds of
LARC use in both models – a finding that is also not mediated by the health system. Health
system mediation effects are found in the LARC and DMPA comparisons and not in the pills,
patch, or ring comparison. In the DMPA comparison, inclusion of health system mediation
eliminates income and insurance status as significant explanatory variables. In the LARC
comparison, inclusion of health system mediation eliminates the explanatory significance of
having a recent birth.
Conclusions: Analysis of the role of health system mediation suggests that health system level
factors play a large role in explaining contraceptive choice among contraceptive methods that
require increased health care utilization. The impact of health system mediation on the
significance of other predisposing, enabling, and need variables implies that health care access,
utilization, and quality are important factors that should be included in future models for
understanding contraceptive choice.

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Acknowledgements
I would like to thank Dr. Jennifer Mooney for dedicating extraordinary amounts of time
and energy towards the completion of this work. Thanks for pushing me to try a little bit harder,
put myself out there, and make it work. That was an important step for me to take. Your patience
with my last minute freak-outs-for-no-reason has been an incredible blessing. Here’s to hoping
that at least some small bit of your inimitable perseverance has rubbed off on me.
I would also like to thank Dr. Bill Mase for being so helpful and flexible throughout my
time in UC’s MPH program. Your encouragement for me to take on a thesis despite being
enrolled in an extended internship was so important in the early days. I’m grateful for all the
opportunities you’ve offered me.
Finally, I’d like to thank…
My partner Liz, for showing me how to be a feminist.
My mother, Suguna, for loving me in spite of all those mistakes.
My father, Rama, for reminding me what it means to work hard at something.
My brother, Kalki, for always having the best advice.
And Arthur Trese, for being an inspiration to us all.

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Table of Contents
Abstract ........................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iv
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................ ix
Chapter 1 – Introduction ................................................................................................................. 1
Chapter 2 – Review of Related Literature ...................................................................................... 4
Section 1 – Unintended Pregnancy ............................................................................................. 4
Defining Unintended Pregnancy ............................................................................................. 4
Consequences of Unintended Pregnancy ................................................................................ 6
Rates and Disparities of Unintended Pregnancy ................................................................... 14
Causes of Unintended Pregnancy ......................................................................................... 15
Section 2 – Contraception ......................................................................................................... 16
Contraceptive Efficacy.......................................................................................................... 17
Types of Contraception ......................................................................................................... 18
Benefits of Effective Contraceptive Use............................................................................... 27
Section 3 – Understanding Contraceptive Decision-Making .................................................... 28
Individual-Focused Theories and Models ............................................................................. 29
Critiques of Individual-Focused Theories and Models ......................................................... 32
Exploring Contraceptive Choice through the Study of Health Care Access ........................ 34
Components of the General Framework to Study Vulnerable Populations .......................... 37
Section 4 – Conclusion ............................................................................................................. 42
Chapter 3 – Methodology ............................................................................................................. 44
Section 1 – The Cincinnati Health Department Reproductive Health and Wellness Program
(RHWP) .................................................................................................................................... 44
Section 2 – Data Collection & Participants .............................................................................. 46
Section 3 – Measures ................................................................................................................ 47
Ecological-Level Predisposing Factors................................................................................. 47
Ecological-Level Enabling Factors ....................................................................................... 49
Ecological-Level Need Factors ............................................................................................. 50
Individual-Level Predisposing Factors ................................................................................. 51
Individual-Level Enabling Factors ....................................................................................... 53
Individual-Level Need Factors ............................................................................................. 55
Health Care System Mediation ............................................................................................. 56
Contraceptive Method Choice .............................................................................................. 58
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Section 4 – Statement of Hypotheses........................................................................................ 59
Section 5 – Analytic Strategy ................................................................................................... 61
Chapter 4 – Results ....................................................................................................................... 66
Section 1 – Excluded Cases ...................................................................................................... 66
Section 2 – Description of the Study Population ...................................................................... 67
Section 3 – Pill, Patch, or Ring vs. Ineffective Contraceptive Method .................................... 68
Bivariate Analysis ................................................................................................................. 69
Multivariate Analysis ............................................................................................................ 70
Section 4 – DMPA vs. Ineffective Contraceptive Method ....................................................... 72
Bivariate Analysis ................................................................................................................. 72
Multivariate Analysis ............................................................................................................ 74
Section 5 – Long-Acting Reversible Contraception vs. Ineffective Contraceptive Method .... 78
Bivariate Analysis ................................................................................................................. 78
Multivariate Analysis ............................................................................................................ 79
Chapter 5 – Discussion ................................................................................................................. 83
Section 1 – Study Population .................................................................................................... 83
Section 2 – Models for Predicting Contraceptive Choice ......................................................... 84
Section 3 – Predisposing Factors .............................................................................................. 84
Age ........................................................................................................................................ 84
Race/Ethnicity ....................................................................................................................... 86
Education .............................................................................................................................. 87
Section 4 – Enabling Factors .................................................................................................... 88
Income................................................................................................................................... 88
Insurance Status .................................................................................................................... 89
Socio-Behavioral Risk .......................................................................................................... 89
Section 5 – Need Factors .......................................................................................................... 90
Having a Birth within the Last 18 Months............................................................................ 90
Number of Living Children .................................................................................................. 90
Section 6 – Implications for Theory and Practice ..................................................................... 91
SES and Contraceptive Choice ............................................................................................. 91
Culture and Contraceptive Choice ........................................................................................ 92
Health Care Access, Utilization, & Quality and Contraceptive Choice ............................... 92
Section 7 – Limitations ............................................................................................................. 94
Data Limitations.................................................................................................................... 94
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Response Bias ....................................................................................................................... 94
Health System Mediator Score ............................................................................................. 95
Section 8 – Directions for Future Research .............................................................................. 95
Chapter 6 – Conclusion ................................................................................................................. 97
Bibliography ................................................................................................................................. 99
Appendix A – University of Cincinnati IRB Approval Letter .................................................... 111
Appendix B – Cincinnati Health Department IRB Approval Letter ........................................... 113

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List of Tables

Table 1 Comparison of STI Incidence between Cincinnati, Hamilton County, Ohio, 51
and the United States

Table 2 Distribution of Predisposing Factors, Enabling Factors, Need Factors, Health 68
System Mediation Factors, and Contraceptive Method Choice among RHWP
Clients (n=1119)

Table 3 Differences across Predisposing, Enabling, and Need Factors between Clients 69
Choosing Ineffective Contraceptive Methods and Clients Choosing Pills,
Patches, or Rings

Table 4 Independent Correlates of Choosing Pills, Patches, or Rings over Choosing an 71
Ineffective Contraceptive Method

Table 5 Differences across Predisposing, Enabling, and Need Factors between Clients 73
Choosing Ineffective Contraceptive Methods and Clients Choosing DMPA

Table 6 Independent Correlates of Choosing DMPA over Choosing an Ineffective 75
Contraceptive Method with Multinomial Logistic and Multiple Linear
Regressions Testing for Health System Mediation

Table 7 Differences across Predisposing, Enabling, and Need Factors between Clients 79
Choosing Ineffective Contraceptive Methods and Clients Choosing Long-
Acting Reversible Contraception

Table 8 Independent Correlates of Choosing Long-Acting Reversible Contraception 80
over Choosing an Ineffective Contraceptive Method with Multinomial
Logistic and Multiple Linear Regressions Testing for Health System
Mediation

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List of Figures

Figure 1 Theoretical Framework for Studying Contraceptive Choice in Vulnerable 36
Populations

Figure 2 Analytic Framework for Studying Contraceptive Choice among Urban 61
Women Utilizing Title X Services

Figure 3 Steps Involved with Analyzing the Effect of Health System Mediation on 65
Individual-Level Determinants of Contraceptive Choice

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