A NATIONAL SURVEY EVALUATING FACTORS INFLUENCING AMERICANS’ WILLINGNESS TO USE AND UPTAKE OF EMERGENCY CONTRACEPTIVE PILLS

Abstract

In the United States, a paradox exists around the issue of contraception; there are more highly effective contraceptive methods available than ever before, including emergency contraception, yet unintended pregnancies have increased in the last 2 decades. Currently, 1 in 2 pregnancies in the United States are unplanned. These disparities are not equitably distributed among women of reproductive age and people who can become pregnant; the burden disproportionately falls upon those with limited access to healthcare, people of color, gender and sexual minorities, those with lower socioeconomic status, and people living in the South. Recognizing the multiple factors driving decisions made about contraception, evaluation of the underutilization and other potential barriers to emergency contraceptive pills (ECP) can be in part addressed by the completion of a national survey. Most of the existing survey data for the United States provide insight into the perceptions of pharmacists, healthcare providers in emergency rooms, and college-aged women. A survey capturing the needs and experiences of a wider range of Americans has not yet been developed—most notably the need for a survey that is inclusive of an expansive understanding of gender identity and sexual orientation to evaluate what, if any, differences exist in how members of these groups view and choose to use ECPs. A web survey was completed in March 2022. Two groups of participants were recruited simultaneously: a group of cisgender, heterosexual women (n = 351), and a group of cisgender sexual minority women and gender minorities assigned female at birth (n = 408), for a total of 759 participants. Comparisons between cisgender heterosexual participants and cisgender sexual minority participants were completed using chi-squared tests and t tests to determine if there were differences in willingness to use and uptake of ECPs by sexual orientation. Latent class analysis (LCA) was completed to identify subgroups among the respondents. The latent class model was then used to determine if membership in the three latent classes predicted willingness to use ECPs and the number of times ECPs were used. Differences between classes on these two outcomes of interest were compared using chi-squared tests. Among each group, approximately 1 in 3 respondents had used ECPs at least once. Cisgender sexual minority participants had a higher willingness to use ECPs when compared to cisgender heterosexual participants (F[2, 708] = 16.33, p < .001). Cisgender sexual minority participants who used ECPs previously also were found to be less willing to reuse ECPs again when compared to their cisgender, heterosexual counterparts (χ2 [2] = 5.14, p = .023), with the most common reason of not wanting to use ECPs again due to participants indicating they would desire to be pregnant. The LCA final model had three classes: high reproductive coercion/low stigma (Class 1), low reproductive coercion/low stigma (Class 2), and low reproductive coercion/high stigma (Class 3). When regressed on the number of times ECPs were used, the three-class model was found to be statistically significant for the overall model (χ2 = 28.95, p < .001). Class 3 (low reproductive coercion, high stigma) was significantly different from Class 1 and Class 2 when comparing the mean number of times ECPs had been used, with members of Class 3 averaging using ECPs 1.56 times versus Class 1 and Class 2 both averaging .56 times use (p < .001). The high levels in which sexual minority women were willing to use ECPs but were less likely to reuse them again should be explored more in depth to understand underlying factors in decision making around contraceptive uptake and pregnancy intentions. The desire to become pregnant is the most common reason given for why sexual minority women would not use ECPs, highlighting the need for healthcare providers to have regular conversations with their patients about sexual behavior, contraceptive use, and pregnancy intentions. Individuals experiencing higher levels of stigma toward their use of ECPs have a higher prevalence of use. Although the direction of this association is yet to be determined, further investigation of this phenomenon can inform practice and policy to understand the impact of stigma and promote reproductive justice.