One size doesn't fit all. Why we need to continue to develop new contraceptive methods.
The reasons why women at risk for pregnancy aren’t using contraception are likely as complex as women’s lives. Through my own practice, I have seen many unintended pregnancies (not surprising given that 45% of all pregnancies in the US are unintended). Research provides some insight into why women may experience unintended pregnancies – and the answers may surprise you!
Nearly all women in the United States have used contraception at some point in their lives. However, the average American woman who wants two children must effectively use contraception for 30 years in order to avoid an unintended pregnancy. That’s a lot of opportunity for error. The reality is that most birth control methods work remarkably well when used perfectly – but how many of us are perfect? But even more importantly, 60% of unintended pregnancies happen when women aren’t using contraception at all.
In an article called, Nonuse of contraception among women at risk of unintended pregnancy in the United States, the study authors evaluated factors associated with nonuse of contraception by US women at risk of becoming pregnant through analysis of a large, nationally representative database. Here’s a small sample of what they found:
Among study participants not using birth control who had an unintended pregnancy:
41% said they did not think they could get pregnant
24% of women did not expect to have sex
20% said they didn’t really mind if they got pregnant
12% said their male partner did not want her to use birth control, or he did not want to use birth control
10% were worried about side effects of birth control
Leaving aside the 41% that said they did not think they could get pregnant (which I delve into further below) and the 20% who said they didn't really mind if they got pregnant (also known as "pregnancy ambivalence" the topic of a future post), the remaining reasons for non-use could be addressed with better contraceptive methods.
did not expect to have sex => options that are immediately effective and that can be obtained easily. These options would likely be "on-demand" methods (like condoms) and better woman-controlled and user-friendly on-demand methods are desperately needed
male partner objection => more woman controlled options that are discrete and/or don't require a male partner's approval/participation (though reproductive coercion is a real issue which I will also discuss in a future post)
side effects => these are usually related to hormonal contraception highlighting the need for more non-hormonal options or an improvement in side effects of existing hormonal options. Unfortunately, the only non-hormonal options currently available include the Copper IUD (which requires insertion by a trained provider) or barrier methods such as condoms which can be difficult to negotiate or use (see point above)
Why did almost half of the women with unintended pregnancy think they could not get pregnant? In my clinical experience, women often have a lot of myths regarding their menstrual cycle and misunderstanding of their fertility. (For more information - go to my Health Class Redux post: Your Period). Sometimes a woman who has had unprotected sex for some period of time without getting pregnant thinks that must mean she is infertile. This is likely reinforced by sex ed programs (particularly abstinence-only based programs) which emphasize that pregnancy can result from the first act of unprotected intercourse. This, of course, is true but the vast majority of women will not become pregnant following a single act of intercourse. And once a woman has had multiple acts of unprotected intercourse without getting pregnant, it might be difficult for her to see the point of starting a contraceptive method - especially if she has concerns regarding side effects. However, the truth is that 85% of women who are sexually active with a male partner but don't use contraception will get pregnant within a year. So we have work to do to educate ourselves about our fertility while also advocating for the development of improved contraception options.
To read about some interesting efforts to develop contraceptive methods of the future, check this blog post from my recent trip to Kenya working with The Bill and Melinda Gates Foundation or the work of one of my sponsors Evofem Biosciences which is currently conducting a Phase 3 trial of a new contraceptive vaginal gel.