Young women's accounts of factors influencing their use and non-use of emergency contraception: in-depth interview study
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7377.1393 (Published 14 December 2002) Cite this as: BMJ 2002;325:1393
- Caroline Free (caroline.free{at}kcl.ac.uk), NHS R&D national primary care training fellow⇑a,
- Raymond M Lee, professor of social research methodsb,
- Jane Ogden, reader in health psychologya
- a Department of General Practice and Primary Care, Guy's, King's College, and St Thomas's School of Medicine, London SE11 6SP
- b Department of Social and Political Science, Royal Holloway University of London, Egham, Surrey TW20 0EX
- Correspondence to: C Free
- Accepted 24 September 2002
Abstract
Objectives: To explore young women's accounts of their use and non-use of emergency contraception.
Design: Qualitative study using in-depth interviews.
Participants: 30 women aged 16-25; participants from socially deprived inner city areas were specifically included.
Setting: Community, service, and educational settings in England.
Results: Young women's accounts of their non-use of emergency contraception principally concerned evaluations of the risk conferred by different contraceptive behaviours, their evaluations of themselves in needing emergency contraception, and personal difficulties in asking for emergency contraception.
Conclusions: The attitudes and concerns of young women, especially those from disadvantaged backgrounds, may make them less able or willing than others to take advantage of recent increases in access to emergency contraception. Interventions that aim to increase the use of emergency contraception need to address the factors that influence young women's non-use of emergency contraception.
What is already known on this topic
What is already known on this topic Limited knowledge of, or poor access to, emergency contraception, and concerns about side effects and moral issues may reduce the use of emergency contraception in women at risk
Young people can be embarrassed about using contraception services
Interventions to increase knowledge of and access to emergency contraception have had limited success among teenagers
What this study adds
What this study adds Perceptions of low vulnerability to pregnancy, negative self evaluations about the need for such contraception, and concerns about what others think deter young women from using emergency contraception
These women find it difficult to ask for emergency contraception
The attitudes and concerns of young women, especially those from deprived inner city areas, may render them least willing and able to obtain emergency contraception
Introduction
Increasing the use of emergency contraception is one means of reducing unwanted and teenage pregnancies.1 Limited knowledge of emergency contraception among women has been identified, and campaigns have aimed to improve this.2–4 Access to emergency contraception has been increased by providing it in advance or by increasing the range of providers. 5 6 Emergency contraception costs £24.00 ($38.10, €37.81) and can now be obtained over the counter by those aged 16 and over. Among teenagers in inner city areas, however, there has been low use of free emergency contraception provided by local pharmacies.7 Concerns about side effects may explain low usage.8 In a telephone survey of women aged 16-44, moral or religious reasons were given for non-usage. Some women had not used emergency contraception because they thought or hoped they would not get pregnant.9 The attitudes of general practitioners and pharmacists may also deter women from seeking emergency contraception.10 Although these factors are relevant to the use of emergency contraception, the area of investigation has been predefined by the researchers.
We used qualitative methods to allow women to define the issues relevant to their own use or non-use of emergency contraception. The views of non-users and women living in socially deprived areas may be different from those of users and women living in more affluent areas. We are unaware of any published qualitative work outside university settings of women's accounts of their use and non-use of emergency contraception.11 We conducted in-depth interviews of young women to elicit accounts of the factors influencing their use and non-use of emergency contraception after problems with contraception. We also explored young women's experiences of seeking emergency contraception.
Methods
CF interviewed women aged 16-25, recruited from general practices, hostels for homeless people, youth groups, schools, and family planning clinics in the London area. We purposefully sampled young women and specifically included those living in deprived inner city areas with high pregnancy rates among teenagers.
We obtained ethical approval for our study from St Thomas's Hospital ethics committee. CF obtained informed consent from the women for the interviews. They were informed about the purpose of the study, and they were told that they could stop the interview at any point without giving a reason, that quotes would be used anonymously, and that if they did not wish to answer a question the interviewer would move on to another area. Each interview lasted about an hour. The women were interviewed in a private room either where they were recruited or at home, according to their preference. In three cases the women wanted to be interviewed with friends. Participants were asked about their use or non-use of contraception and emergency contraception. They were asked about their experiences in seeking emergency contraception.
We tape recorded and fully transcribed the interviews. All the authors discussed each stage of the analysis. We examined the transcripts to identify themes. We analysed the relation between the themes to produce a coding framework. CF coded each interview according to the framework and examined each section of the coded transcripts to identify how it confirmed or contradicted the emerging analysis. We explored the role of the broader social context of contraceptive behaviour in the differing accounts of emergency contraception use. CF conducted the interviews until saturation, when no new themes emerged.
Results
CF interviewed 41 women. Of these, 11 were virgins. We report here on the findings from the 30 women who were sexually active. The table gives their personal details.
Eight of the women were either pregnant or had children; of these, seven had become pregnant while a teenager. All but three of the women had experienced a problem with contraception at a time when they did not want to be pregnant. Seventeen of the women had used emergency contraception at least once. Nine of these women also reported episodes when they had not used emergency contraception after problems with other forms of contraception.
Emergency contraception was used when no contraception had been used or when women were uncertain if a condom had been used properly or had split or come off. Only one woman reported using emergency contraception after a problem with the contraceptive pill.
The data we collected were complex and varied, reflecting contradictory influences on the women's decisions about contraception. We present the key themes identified.
Safety and vulnerability
Those women who described the strongest desire to avoid pregnancy used contraception and, if necessary, emergency contraception. Such women tended to have strong aspirations for education, careers, travel, or lifestyle rather than motherhood. Typically they reported that a pregnancy would be a “complete disaster” and contraception use that was anything less than “obsessional” left them feeling highly vulnerable to pregnancy. A few women reported “extra safe” contraceptive behaviour, making use of both contraceptive pills and condoms or getting emergency contraception even though only one contraceptive pill had been late. This behaviour was reported in the context of either early sexual experience combined with the expectation of being in education for many more years or in the context of having experienced an unplanned pregnancy (box 1).
Issues of safety and vulnerability
Being extra safe
I was on the pill as well but we decided to use a condom… I think it was just an extra just to be extra safe. (Interviewee 3, aged 20, university student, describing her first sexual experience)
And it's better to have two safety barriers than none at all and get pregnant and have a child. (Interviewee 10, aged 17, planned to go on to university, describing her only relationship, started within the past 6 months)
Relaxing contraception use over time
You know I was I'm surprised how sensible I was cos really it scared me, it scared me the thought of having sex and not being protected but as I say after I'd been on the pill for a while (I thought) I'm not going to get pregnant so sod the rest it won't happen to me, it always happens to the other person. Maybe after the first year it started happening oh yeah I'll be alright I've been on it a year I haven't been caught out yet … I think its down to naivety because obviously if I had sat down and thought about it I would have known it wasn't safe but being on the pill so long I had that sort of faith it all I know you can get pregnant but the possibility was very slight. (Interviewee 15, aged 24)
Personal invulnerability
And I thought oh no I'll never I won't get pregnant I just thought oh nothing will happen to me I really I just didn't think at all that I'd get pregnant. (Interviewee 16, aged 25, talking about her experiences as a teenager)
You are aware that they can happen but they can't happen to you. (Interviewee 28, aged 23, talking about her experiences as a teenager)
I just didn't think I'd fall pregnant like. (Interviewee 27, aged 19)
Vulnerability to pregnancy
Interviewee: Yes I went up and got that cos I was a bit uneasy so erm.
Interviewer: Did you take it?
Interviewee: Yes I took that but this time I thought I am not going to get pregnant there is no way I'm going to get pregnant but I did. (Interviewee 22, aged 18)
We didn't use a condom and then the next morning woke up in an absolute panic. (Interviewee 11, aged 20)
Interviewer: Was there any time when you haven't used contraception?
Interviewee: Yes yeah (laughs) there has… We did that once and then the next day I was paranoid and went down with my friend and they gave me emergency contraception. (Interviewee 17, aged 19)
Personal characteristics of women interviewed
Many women reported a lower sense of vulnerability to pregnancy. Those with the lowest sense of vulnerability thought that the risk of pregnancy was small when they missed or did not use contraception. Evaluations of the risk of pregnancy conferred by different contraceptive behaviours were based on advice and experience. In particular the women cited their own or friends' experience in becoming or not becoming pregnant when contraception was missed or not used. Some experienced users of contraception said that over time they had come to believe that they were less at risk of pregnancy and consequently their use of contraception had relaxed.
Several women reported a sense of personal invulnerability—pregnancy happened to other people and not to them—either currently or in the past. This was different to not believing that the behaviour was risky. Women who reported that their behaviour wasn't particularly risky or had a sense of personal invulnerability did not use emergency contraception. In contrast, users of emergency contraception were highly concerned that they would get pregnant (see box 1).
Negative evaluations of emergency contraception use and users
The use of contraception and the ability to use services were predominantly reported as illustrations both of the responsible way the women were behaving and of their maturity. Initial embarrassment in using general contraception services was reported by some of the younger women. In contrast, needing emergency contraception was linked to negative evaluations for many of the women (box 2). It was seen as a personal failing, and the women felt ashamed. The younger women reported being concerned about what other people might think if they asked for emergency contraception, especially for a second time. A combination of these factors was why emergency contraception had not been used (see box 2). Women who linked emergency contraception to “undesirable behaviour” wanted to dissociate themselves from any negative connotations about themselves or their relationship if they sought emergency contraception. A few women dissociated themselves from emergency contraception entirely, reporting that they were not the kind of person who would ever need it (see box 2).
Negative evaluations of emergency contraception use and users
Feeling guilty or ashamed
I think I'm a lot more mature now and I don't see it as such a failing on my part (if I needed to get emergency contraception). (Interviewee 2, aged 23)
I thought it was a really bad thing to say I need a morning after pill. (Interviewee 5, aged 16)
The thing is you do something bad and you come you come here and you discuss and you think to yourself well he or she might think “well why didn't she use it why didn't she use it instead of coming here” or something and it just feels embarrassed sometimes, embarrassed, so I think that's one reason why you don't want to bother coming because you are going to feel ashamed or something. (Interviewee 19, aged 18)
Concerns about what others may think
Interviewee: And to say to the doctor can I have the morning after pill it's embarrassing.
Interviewer: What's embarrassing about it?
Interviewee: Cos I'm still young erm and they might think you're a little slag or something so but but they are all right the doctors … you feel you're still young you shouldn't be having sex and coming for the morning after cos you might be pregnant. Twenty that's all right cos it doesn't matter everyone knows if you're twenty you must be having sex not when you're fifteen. (Interviewee 25, aged 16)
It was just the whole thing of going there and actually admitting to being you know frivolous, not frivolous but irresponsible. (Interviewee 16, aged 25, talking about why she didn't use emergency contraception as a teenager)
Dissociating oneself from negative evaluations
I wanted to tell them I've been going out with him for along time and it wasn't just a flippant thing and I did use contraception and they don't really want to know about that well I feel I need to justify it to them. (Interviewee 2, aged 23)
Nobody wants anyone to think oh yeah she's not you know she's not stable you want people to think you was you know mature for your age and you know what's going on … I don't want people thinking oh yeah she doesn't know anything sort of like … (you want them to think) that you're a young women and you've taken precautions and had a condom split. (Interviewee 31, aged 16)
Interviewee: Have you ever used the morning after pill, emergency contraception?
Interviewee: Erm I think … so I you know I wouldn't I would never allow that as an option to go wild you know. (Interviewee 13, aged 24)
Getting emergency contraception is an overwhelming task
It's sometime that err you don't really want to know you don't really want to know you just want to block it off. If you come in (to the clinic) it's going to be even more worrying cos you are going to be thinking even more by the time you get off the bus get to the clinic but if you just pretend that it didn't happen then you don't worry that much. (Interviewee 19, aged 18)
It's like when you do a mistake and you know you are doing the wrong thing and I was thinking oh I'll just sort it out later on when it does happen to me but I doubt it will ever happen to me so I'm not going to think about it now. (Interviewee 17, aged 18)
In contrast some women reported use of emergency contraception in the absence of negative evaluations of either themselves or other users. Such women were older or had gone on to university.
Getting emergency contraception is an overwhelming task
Some women put the risk of pregnancy to the back of their mind. This was reported in the context of a combination of three factors: high levels of anxiety in thinking about the risk of pregnancy, a strong sense of shame about what had happened and the need for emergency contraception, and high levels of concern about what others might think of their sexual behaviour. It was easier for these women not to think about the risk of pregnancy, which might not occur, than to endure the stigmatisation over the need for emergency contraception and unplanned pregnancy (see box 2). Women describing this strategy for dealing with risk were teenagers either living in the most deprived areas or homeless. It may be that these women had the least personal resources in being able to cope with and respond to the risk that had occurred.
Knowledge, service barriers, side effects, and moral concerns
Limited knowledge and service barriers were each reported to have contributed to non-use of emergency contraception by two women. Side effects of emergency contraception were reported by more than half of the women. Concerns about the harmful effects of emergency contraception had contributed to a decision not to use emergency contraception in a few women. One woman who had used emergency contraception was concerned that it was similar to having an abortion (box 3).
Knowledge, side effects, service barriers, and moral concerns
Knowledge
I didn't know where I was supposed to go and if I was allowed to go to the doctors to get it, because I was young I was like 14. (Interviewee 9, aged 17)
Side effects
I didn't like to take it it made me feel sick it made me feel sick so but I'd rather take it than end up pregnant. (Interviewee 6, aged 22)
But it did make me feel really sick and headaches I was vomiting as well … weren't nice and I vowed never to take it again but I ended up taking it another two times after that I think it was. (Interviewee 30, aged 23)
A lot of my friends have said … and um “It will make you feel really rough sick” … just generally a horrible feeling and I've taken it once or twice and it hasn't had any effect on me whatsoever. (Interviewee 15, aged 24)
Service barriers
Interviewee: I went home and then I come here the same morning.
Interviewer: Did you?
Interviewee: Yeah I was here about three hours… waiting it's bad waiting in here… After that I didn't come down here to get nothing I just left it … cos I couldn't be bothered to wait and erm it made me feel ill as well so I didn't wanna come back and get that. (Interviewee 25, aged 16)
Interviewee: It's just a hassle and a worry.
Interviewer: So a hassle in terms of?
Interviewee: That you've gotta try and—depends what you were doing getting to the doctor and if they had an appointment fitting it around whatever I had to do, you know that couple of days.
Interviewer: And a worry?
Interviewee: It's just worrying then until you get your next period. (Interviewee 12, aged 24)
Moral concerns
I know it's sort of equivalent to having an early abortion really. If you actually had an egg it would. And I never thought about it then but thinking about it now I wouldn't take the morning after pill again I feel it's a bit… you know it's my responsibility to take precautions and my partner's responsibility to take precautions and it's not the baby's fault. So I think that's just wrong. (Interviewee 16, aged 25)
Experiences with healthcare professionals and services
The women reported both positive and negative experiences of interactions with healthcare professionals (box 4). Although some encounters were described in a matter of fact way, those that concerned asking for emergency contraception were inherently difficult for many prospective recipients. Interactions where the healthcare professional was matter of fact, friendly, and understanding were easiest. For some of the women a good relationship with a healthcare professional made it easier to get emergency contraception.
Experiences of healthcare professionals and services
Positive experiences
Interviewer: And how was getting the morning after pill?
Interviewee: It was fine, yeah I just rang up here and got an appointment. Basically if it wasn't the doctor it was the nurse and you know they just got the doctor to sign the form. (Interviewee 12, aged 24)
I've been coming here so the receptionists sort of they all know me, they know my family and everything so when I walked in I said I really really really need to see Dr X and er she (name) sort of looked at me and said OK she just gave me the card and let me sit down and … they're really good out there. (Interviewee 15, aged 24)
And then when I went there I was still nervous but when they actually spoke to me they made me feel relaxed so I was OK … and as I've got older there is nothing to be embarrassed about. (Interviewee 14, aged 21)
I mean if she was a different person I'd like feel embarrassed to come an get it. (Interviewee 29, aged 22)
And he was quite young and I thought oh dear I don't know if I really want to say this to a bloke which is quite unlike me but and erm he was really matter of fact and nice about it and he was really good. (Interviewee 2, aged 23)
Negative experiences
I did feel like she was really telling me off… and I think and I think that's what made me in some ways not wanna go back but … I mean she was making sense but she was … it was a bit of a sort of erm. It was a bit of a telling off way but it was also sort of concerned way like do you know the risks that you are taking and you know this isn't a form of contraception I just remember that so well this isn't a form of contraception you know. (Interviewee 16, aged 25)
Cos some some nurses I don't know. I've been to like nurses before like the one with my son, that was in Walthamstow. And they just made you really uneasy … they say well you now it's your fault, you should be taking more care and that they're not like believing you when you're saying the condom split, when I come here I feel easy. (Interviewee 30, aged 23)
The first time I got it was an absolutely horrendous experience, I think I was about erm twenty and erm I'd just started having sex with my first boyfriend… it's two days after my twentieth birthday, that when and erm erm I went to this clinic by myself and erm the lady who gave it to me was horrendous, I think, and made me feel like a, you know, a slapper basically. And erm it was just a really awful experience and I had a panic attack after taking the second lot of pills.
Interviewer: Did you, right.
Interviewee: And you know very ashamed right at the beginning the first time you know. And erm this lady made me feel like you know I she just made me feel dirty which was horrible thing for her to do. (Interviewee 2, aged 23)
Consultations that focused largely on the risks that had been taken made the women feel told off and reluctant to reattend (box 4). Such women resorted to a different service or chose not to use emergency contraception. A few encounters were described in the most negative terms (box 4). A few women reported being angry about the way healthcare professionals had treated them.
Discussion
Young women's accounts of their non-use of emergency contraception mainly concerned evaluations of the risk conferred by different contraceptive behaviours, their evaluations of users of emergency contraception and of themselves in needing it, and personal difficulties in asking for emergency contraception. Limited knowledge, problems in gaining access to emergency contraception, and concerns about side effects also contributed to non-use of emergency contraception.
The importance of perceived vulnerability is pivotal to the adoption of behaviour that is protective to health.12 We identified links between a strong motivation to avoid pregnancy and the perception that the risk of pregnancy is high. These factors in turn were related to both consistent use of contraception and compensatory behaviour for using emergency contraception. Some women reported a lower sense of vulnerability to pregnancy. These women used contraception but acknowledged that they sometimes forgot to take their contraceptive pill or did not use contraceptives. Optimism about personal risk results from selective focus on safe behaviours.13 A similar process may be occurring with risks of pregnancy. Some of the women believed that they were invulnerable to pregnancy. Personal invulnerability and the tendency to perceive that others are at greater risk of disease than yourself have been well documented in a range of behaviours.13
In public discourse the risks associated with particular courses of action are often discussed in a way that renders their situational and contigent character invisible.14 In this way, environmental risks become “closed to decision.” This was the case in our study, because although the women knew about emergency contraception, their understandings of the risks of pregnancy after problems with contraception meant that the use of emergency contraception was not considered. Many of these women also felt ashamed about what had happened and about needing emergency contraception. They found it particularly difficult to ask for emergency contraception. Some healthcare professionals had shown good communication skills, but there were also some negative experiences. Those women who sought emergency contraception were inherently those who knew they had been at risk. Consultations that focused on the risks that had been taken deterred women from reattending for emergency contraception.
For some women the fear associated with a possible pregnancy and the shame and anxiety in asking for emergency contraception was overwhelming. Interventions that arouse further fear would not be effective for such women and might even be counterproductive. For these women educational interventions need to focus on increasing the resources for obtaining emergency contraception. In addition, interventions could focus on providing emergency contraception in a way that avoids young people having to ask for it or that improves their use of other forms of contraception.
Personal invulnerability to pregnancy or concerns about what other people think were predominantly reported by the younger women or those reporting their views as teenagers. The attitudes and concerns held by many younger women may render them less able than others to take advantage of recent increases in access to emergency contraception.
Those women who thought it easier to avoid emergency contraception rather than face their own anxiety, sense of guilt, and concern about what others might think were teenagers who either lived in disadvantaged areas or were homeless. The concerns and personal resources of such women may render them least willing and able to obtain emergency contraception. They will also be least able to afford over the counter emergency contraception.
In addition to increasing knowledge and access to emergency contraception, interventions to increase the use of emergency contraception in at risk populations should take into account factors influencing women's non-use of contraception and emergency contraception. Educational interventions should aim to promote the attitudes and personal skills needed to obtain emergency contraception.
Acknowledgments
We thank the staff in the hostels for homeless people, youth groups, schools, family planning clinics, and surgeries, the participants, and Connie Smith, codirector of Westside Contraceptive Services, for her comments on the paper.
Contributors: CF designed the study, carried out the field work, conducted the analysis, and wrote the paper; she will act as guarantor for the paper. RML and JO acted as advisers for the design and conduct of the research and the analysis. All authors made comments on the paper.
Footnotes
Funding Department of Health as part of the national primary care training fellowship.
Competing interests None declared.