CONTRACEPTION

CONDOM USE AND BREAKAGE AMONG WOMEN IN A MUNICIPAL HOSPITAL FAMILY PLANNING CLINIC

ALEXA E. ALBERT, B.A. Brown University summer Intern: Emmy university summer Programin Family Planning andHuman Sexuality Atlanta, GA ROBERT A. HATCHER, M.D., M.P.H. Professor of Gynecology and Obstetrics Dimctor, Grady Memorial Hospital Family Planning Clinic Emory University School of Medicine Atlanta, GA WILLIAM GRAVES, Ph.D. Associate Professor of Gynecology and Obstetrics Associate Professor of Sociology Director,GmdyMemorialHospitalSocialReseamh Emory University School of Medicine Atlanta, GA

For those who choose to be sexually active, condoms are the best available means of protection against sexually transmitted diseases including the human immunodeficiency virus (HIV), which causes acquired immunodcficiency syndrome (AIDS). Condoms are also an effective method for preventing pregnancy. Unfortunately, condoms are not 100% effective at preventing pregnancy or the spread of infection, in part because condoms do break. In crder to gain insight into condom breakage, a questionnaire was administered to women attending a municipal hospital family planning clinic. Thirty-six percent of the 106 subjects had experienced at least one condom breakage. Condom breakage occurred in using condoms, with a lifetime breakage rate approximately1outof1OOactsofintemcmme of 10 per 1000 condom uses and a past year breakage rate of 8 per 1000 condom uses. Breakage rates did not differ substantially by age. Five percent of the women’s unplanned pmgnancies were attributed to broken condoms. The results of this study corroborate previously mported rates. Factors associated with these women’s most recent breakage experiences included: vaginal intercourse, minimal foreplay, and breakage prior to ejaculation. Controlled studies will be needed to determine how the condom can be used to reduce the likelihood of breakage. Submitted for publication August 20, 1990 Accepted for publication January 4, 1991

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As a method of contraception, condoms have an expected failure rate of 2%; that is, out of 100 acts of intercourse among couples who initiate use of a condom (not necessarily for the fmt time) and who use it perfectly (both consistently and correctly), two sre expected to result in an accidental pregnancy during the first year if condom use is not stopped for any other reason.’ However, in a recent review of literature, Trussell et al. found 12% of typical couples experience an accidental pregnancy.1*2 The most common cause of failure is non-use, or failure by the couple to use the condom. User misuse, including putting the condom on too late (after penile-vaginal contact has been made) or using the same condom more than once, accounts for additional failums.~3~4~s Momover. condoms sometimes break. For sexually active individuals, use of latex condoms is currently the best protection against AIDS and other sexually transmitted diseases (STDs). Unfortunately, condoms may fail to prevent disease for the same reasons they fail to prevent pregnancy -non-use, misuse, or breakage. With the advent of AIDS and apparent increasing prevalence of other STDs, it has become increasingly important for the public health community to consider means of improving the effectiveness of condoms. Since very little is known about condom breakage (Table I), this investigation was undertaken (1) to determine how frequently condoms break during use among women in a municipal hospital family planning clinic, and (2) to identify factors associated with breakage. The clinic under study is unique for its massive condom distribution program “Condom Sense,” which provides up to 160 free condoms per person per clinic visit, and provided a total of 673,000 condoms in 1989.

This study was conducted from July 12-26,1989, in the family planning clinic of Grady Memorial Hospital, a large municipal hospital serving inner-city women in Atlanta, GA. Subjects were interviewed in private counseling rooms during initial intake to the clinic by a female counselor who had been trained to administer the study questionnaim. All female patients seen by this counselor (one of four in the clinic) were asked to participate. Subjects were informed that the clinic was conducting a voluntary study on condoms, and that they could stop the interview at any time. None of the invited women refused to participate or quit prior to completion. The condom questionnaire was orally administered at the conclusion of the general intake procedure, which consisted of gathering a personal, health, and sexual history prior to the clinician’s examination. Administration of the questionnaire took approximately 13-15 minutes. Interviews were completed with 113 women, but seven (6%) were excluded from analysis because they had never used a condom. Therefore, the final sample size for this analysis was 106. Condom use was defined as the reported use of a condom during sexual activity by the subject and her partner. Condom breakage was defined as the report& incidents of a condom breaking or tearing during sexual activity. Analysis consisted of demrmining the condom breakage rates over the subject’s lifetime and the last 12 months. To calculate breakage rates, total condom breaks were divided by total condom use for each period of time. Better subject recall of condom use and breakage was expected for the last 12 months, a relatively recent time peri& in contrast to the more lengthy lifetime period.

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TABLE I. Summary of studier of condom brankagc Totaltimes

Richlers,etal., 1988 ’

Total Ceo&mbfc&s aYl&lm percahdanuscs 1: 125 1:200

34

unkmwn 1468

117

Comments

Naimbiprostitutes BN inooefemaleand ratefa twomaietuothels 4 months Sydney,Awtralia

1

: 17

Homosexualmen

1

: 13

Homosexualmen Bm fakfa 6 months

1:

ConwmaReporrs. 3300 1989 *

total -vaginal -anal

HatckrbHughcs, 1988 9

457

46,657

443

1

Halcha&Hughes

160

1428

32

1:45

(1989 - uopublishcd)

. .

Chw%zww s ofsample

140

: 165 1 : 105

1

: 105

Bnalrage Reproductive healfhemployees, lw for universitystudents lifetime &wanenaaending a U.S. municipal hospital family planningclinic, 1987-1988* Womenattending Brralrage a U.S. municipal r8t for 12 months

* The condom breaks-to-userratio among 282 reproductiveemployees. working in family plmming. rcpdwtive hedtk and gynecology d obtetriu. awaged 1 : 161 (%44 condoma broke of the total 39, 383 wending the public family planning clinic, the condom breaks-to-uses condmnld). Amongthe89women ratio averaged 1: 16 - a breakage ratio 10 timea bigha than 6~ rqwdwtive employees’ (146 condomc? broke ofthetod2.4CMccdomswcd). The86lmivarityrtudsntlhd~brerlo_to_urslr~oof1:92(53condorm between populathms. reproddve he&h brokeofthc~~4,870).Thc~~rnoterthrtrhcyediff~ empbyem with a mean age 37 and clinic p&ah with a mean age of 23, may aaccount for the different condoms use tot& (139 vs. 27 per person, respectively).

. . DemopraDhrc Table II summa&s demographic characmistics for the 106 female subjects, including age, years of education completed, and marital status. All but six of the subjects were black, and all women had engaged in sexual intermum.

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Age (yrs)

Mean 23.4; Range 1441 (S.D.5.6)

Education (yrs)

Mean 12.3; Range 8-17 (SD. 1.7)

Marital status lnevcxmarried llnaaied

75% 12% 5% 7%

:z

m Condom breakage, both lifetime and in the last 12 months, was analyzed by age (Tables III, IV). No substantial differences appeared, and any variation is most likely a result of the small sample size and not rqresentative of any actual age differences. Lifetime breakage me: Of the 106 women who had ever used a condom, 38 (36%) at least one condom breakage. Cut of the 11,877 condoms used, 116 broke -- a breakage rate of 10 per 1000 condom uses (Table III). Of the 106 women, 21 (20%) had experienced at least two breakages. had experienced

TABLE III Age and condom breakage in lifetime amoog women attending a municipal hospital family planning clinic Grady Memorial Hospital; Atlanta, Georgia; July, 1989 Number

Total times Totalcoodom in lifetime

condombloaks per con&m uses in lifetime

CuldombreaLage rateper condomuses

14-19

26

1387

14

1:99

10

20-24

43

4447

26

1 : 171

6

25-29

17

1807

24

1 : 75

13

30+

20

4236

52

1 : 82

12

Total

106

11877

116

1: 102

10

Post year breakage rate: Fifteen (14%) of the 106 women experienced a condom breakage in the last 12 months. Cut of the 2,484 condoms used in the last 12 months, 20 broke -- a breakage rate of 8 per 1000 condom uses (Table IV). Six (6%) women had experienced at least two incidents of breakage in this per&L

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CONTRACEPTION TABLE

IV.

municipal

Age and condom breakage in last 12 months among women attending a hoepita family planning clinic Grady Memorial Hospital; Attanta, Georgta; July, 1989

Numbcx Total times

Totalaxhm

coodombnalrs

ch&nnbI&ege raheper1000 c0llQmu.W

women usedin last 12 mos

lest 12 mos

uses in last 12 mos

14-19

26

631

4

1 : 159

6

20-24

43

831

4

I:208

5

25-29

17

340

I

1:49

21

30+

20

676

5

1 : 135

7

Total

106

2484

24l

1: 124

8

Data for the number of lifetime condom breaks were analyzed by the number of different partners the women had had flable V). Women who had had only one partner had a lower breakage rate than women with at least two partners. There was no substantial difference, however, between women with two or more than two partners. TABLE V. Lifetime sexual partners and condom breakage among women attending a municipal hospital family planning clinic Grady Memorial Hospital; Atlanta, Georgia; July, 1989 Numbof lifelime pelmcrs

Number of Women

Total times usedin

Tocalcondan LYraksin lifetime

culldomm PeroonQm uses in lifetime

Chhiealcage ratepa

lifetime

Cond0mUSC.S

1

17

709

4

1 : 177

6

2

14

468

5

1:94

11

3-5

50

6114

61

1: loo

10

6-10

18

1471

20

1 : 14

14

ll+

I

3115

26

1: 120

8

TcYrAL

106

11.g17

116

1: 102

10

Of the unplanned pregnancies reported by women who had used a condom, 5% were attributed to condom breakage (Table VI). Women aged 14- 19 experienced a pregnancy attributed to condom breakage 7.4 times more than women ages 30+, 3.4 times more than women 25-29, and 2.0 times more than women 20-24. One pregnancy occurred approximately every 19 times a condom broke.

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CONTRACEPTION TABLE VL

women

Age and unplanned pregnancies and their attributed causes * among a municipal hospital family planning clinic Grady Memorial Hospital; Atlanta, Georgia; July, 1989

attending

Number Total Numba w urqjenredpngnsncies PaconQmw women pregnancies Attributedtoa~ CbMOlllBti

Numba Amiito condolnrvli~

Nllillbet ww

NUliIbfX

usingMetI&

uso

14-19

26

21

2

1:7

1

1

17

20-24

43

54

2

1: 13

5

12

36

25-29

17

14

1

1:24

2

1

10

3c+

20

35

1

1 : 52

0

4

31

Total

106

124

6

1 : 19

8

18

94

Regnmc~conldbe~~omore~are-weep. 1. To celcolate Pm8nancie~ per Condom Bruklge, each age group’s total numba of unplanned pre8naocies lmibutedtor~kukwadividedintDi~~tllmrmbcroflifstimccadombr~(weTlbleIII). 2. Condom Mimtse refer to tlte pmgtuncie~ readtin from uwr frihtn; for example, rlipps8e or fGhre to hold thcrimofthecondomuponwi~~wlloffhsflrcidpnirfromthav~ 3. Using Anok Method includw the pr~~~mcisr which occwmd despite UICof. con~uxptive other than condoms. Mcth& reporkd includcdz Mii-pills (2/M). foam, (l/M), IUD (l/18). Paihtra to double- up for mimed Pill& * wer-failure were allo inchad (6/M). 4. Uaittg No Method inclodu those pmguocias rqorted to ocau lRcr subjects ran out of Pills (2&i) or stopped consirtent till-taking (3194). l

Of the 38 women who had experienced condom breakage, 39% reporkd learning to use a condom in a health class, 30% from a partner, and 24% from a health professional. These pexcentages did not differ from those of the total group of condom users, or all 106 women (Table VII). TABLE VII. Age and primary Bource of condom use information among women in a municipal hospital family planning clinic Grady Memorial Hospital; Atlanta, Georgia; July, 1989 NUtttbU OfWOllXil

%OFW~MJ&EA~MBY:

Parmex

14-19

26

31

20-24

43

28

25-29

17

30+ Total

Friends

HealthClass

Dr/Nutse

Books

58

8

4

28

23

5

65

18

6

20

25

35

35

106

34

35

19

12

5

Trial&Error

Otkx

5 12 5

3

4

1

Data from all 106 condom users were analyzed by age in order to assess the pattern of condom use. In the last 12 months, 29 women, nearly one in four, experienced at least one condom slippage (when the penis is removed from the vagina and the condom has slipped off). Women experienced 84 slippages, or one slippage for every 30 acts of

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CONTRACEPTION

intercourse using a condom. Six (21%) of these 29 women also experienced condom bmakage in this period. Of the unplanned pregnancies mported by women who had used a condom, two (2%) wem attributed to condom slippage. Fifteen (14%) of the 106 women had used two condoms together (one on top of another) at least once. Use of two condoms together occuned four times mom uently in women who had experienced breakage than in those who had not; twelvem89b (8 ) of these women had experienced at least one condom breakage, and eight (53%) had experienced at least two breakages. These 12 women had experienced 41 lifetime breaks, 35% of the total condom bmaks mported by all the subjects.

In the total 11,877 acts of intercourse analyzed in this study, the man exclusively put the condom on 64% of the time, whereas both partners participated in putting on the condom 33% of the time. The primary factors motivating condom use were fear of pregnancy, fear of STDs and fear of AIDS (Table VIII). This held true across all age groups. Because of the small sample size, the motivations of women who had experienced breakage were not analyxed. TABLE VIII. Age and factors motivating condom nse among women attending a municipal hospital family planning clinic* Grady Memorial Hospital; Atlanta, Georgia; July, 1989 4w Ors)

Numba d women

q Easyto use

Easyto buy

Fearof AIDS

Feaof 8TDs

Fesrof PregnsncY

Pamler

U~Of

olher

““““c

14-19

26

19

8

23

39

85

8

15

15

#)-a

43

14

I

54

14

93

7

33

I

25-29

17

18

6

59

59

82

6

24

6

30+

m

m

15

50

40

80

5

15

10

Total

106

17

9

46

57

87

I

24

9

* W-mrepaminsdom9t~ofthef~~whichmotivusdmeiroondomwe.thus~~niUmt total 100. All the fxctorx. put and pcsen& xffecting theit de&ion to use wdotnx were 6ought. “Other” idttdec Back-up method when begimting the pill (5/106); ptotection against trxtumitting 8TD to her partner (YlO6); DL’S xttggestion dming infection (l/106); to keq sex “clcxtb” not messy (l/106); m&od used during her first 8exud expuience (l/106).

y ln order to determine factors associated with breakage, women were asked to mcall “the last time a condom broke.” Data for 37 of the 38 womtn who had ever experienced a breakage were obtained. The results were analyzed by age but no substantial differences appeared. Therefore, we collapsed across age for the following results.

Ninety-seven percent of the 37 condom breakages occurred during vaginal sex, and one condom broke while being put onto the penis. In 73% of the cases, intercourse had not been “‘unusuallyrough or vigorous,” while sex “definitely” had been so in 19% of the incidents of breakage.

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Eighty-one percent of the 37 condoms which broke were pm-lubricated, and only three women added extra lubricant: two with Vaseline, an oil-based lubricant, and one with water-soluble K-Y Jelly. Five of the broken condoms were not lubricated at all. Space was left in the tip of the condom (to catch the ejaculate) in the majority of the cases; 78% of the condoms had reservoir tips, and 8% of the couples deliberately left space. Nineteen percent of the women could not remember if space had been left Forty-six percent of the 37 breakages occurred in women whose vaginas were “well lubricated or wet” before the penis entered the vagina, while 38% of the vaginas were not well lubricated. Five women (14%) did not remember the degree of lubrication. In 65% of the instances of breakage, foreplay had lasted O-5 minutes, and in 22% of the breaks, foreplay ranged from 6-15 minutes. Foreplay was defined as ‘kissing, touching, massaging, fondling, etc., before the penis entered the vagina.” Foreplay extended beyond 16 minutes for only four women. Of the women with drier vaginas, 7 1% had engaged in foreplay for O-5 minutes1 Forty-two percent of the women who experienced minimal foreplay, had drier vaginas. Breakage was known to occur prior to ejaculation in 51% of the 37 cases, and was noted after ejaculation in 38% of the breaks. Sixty-four percent of the women with drier vaginas experienced breakages pm-ejaculation. Nineteen percent of the 37 breaks were discovered by women before the male ejaculated, while 76% of the breaks were discov& post-ejaculation.

Any retrospective study runs the risk of unreliable recall. However, the two calculated breakage rates, lifetime and the last 12 months, corroborate each other, suggesting reliable subject recall. These rates are further supported by the comparable breakage rates determined in previous studies (Table I). The population most resembling ours is Hatcher and Hughes’ (1988) women attending family planning clinics with an identical lifetime breakage rate of 10 per 1000 condom uses. Similarly, our calculated pregnancy attributed to condom breakage corresponds to theirs, 1:19 and 1:16, respectively. Contrary to what one might expect, younger women did not have higher breakage rates; in this study, teens had lower breakage rates than women ages 25 and older for both time intervals, lifetime and past year (Tables III, IV). For whatever reasons condoms break, it appears that teens are not more likely or at greater risk for breakage than older women. Adolescents are often considered less careful, less responsible and less educated about contraceptive use, and as a result, one might speculate that teens would demonstrate more condom breakage experiences. This was not the case in the present study, impressing upon us the necessity to inform all condom users - not just the young users- that breakage occurs in approximately 1 out of 100 acts of intercourse using condoms. Because this study was retrospective rather than controlled, we cannot determine factors which am definitively associated with condom breakage; we can, however, make note of the recalled circumstances surmunding the breakages. In foreplay, positively facilitate decreased

174

the majority of cases (65%), breakage occurred when there had been minimal defined as foreplay for five minutes or less. Foreplay is generally related to female arousal or vaginal lubrication, a physiologic mechanism that helps to penile thrusting. lo When sufficient lubrication fails to occur, there is often vaginal capacity and increased friction. I1 This vaginal friction against a latex

FEBRUARY 1991 VOL. 43 NO. 2

CONTRACEPTION condom could cause a tear or break. Since many of the condoms were reported as breaking pre-ejaculation, it appears that breakage is associated less with the action of ejaculation (i.e., the impact of ejaculation or the condom’s volume capacity), and more with the vaginal environment. Similarly, in a condom breakage study with prostitutes, all the bteaks occurred pm-ejaculation.’ Although not mentioned in that study, the amount of foreplay time in cases of prostitution or paid sex is generally minimal, and one could speculate that vaginaI lubrication may also be minimal. In the present study, 38% of the women qorted having had dry vaginas at the time of their last breakage which may be an under-mporting; many women may be uncomfortable with their bodies and/or have limited knowledge about how their bodies function, and were thus, not aware when, and if, they were well lubricated. A good indication might be to ask women if sex were painful eqecially at the time of penile insertion. Controlled studies are needed to determine ways in which the condom can be used to help decrease the likelihood of breakage. We would like to suggest, however, some guidelines and behavior modifications for condom users which might help reduce the chance of breakage; spend time engaging in foreplay, which will help to lubricate the female’s vagina as well as to expand the pleasurable potentials of sexual intimacy. Add extra lubricant if necessary; use of condoms designed specifically for anal sex, having an additional lubricant, have been found to result in fewer breaks or tears than vaginal condoms developed for conuaception.’ Do not use oil-based lubricants which can weaken the condom, an often advised guideline. 2i2 Do not use the same condom more than once. Use spermicidal condoms and/or an additional contraceptive method which can help to prevent both pregnancy and infection. Check the condom for tears or breaks just prior to ejaculation; if the condom is torn, the couple can either replace the condom or sexually please one another by a means other than penile-vaginal contact. One of the intrinsic benefits of using the condom is the ability to verity whether or not the condom is indeed still intact and will be effective. Some women in this study mported using two condoms together after having had breakages using one condom Of the seven women in our study who had never used a condom, two (29%) reported fear of the condom breaking as a factor related to their choice not to use condoms. Yet, &spite breakage experiences and/or the perceived risk of breakage, 99 of the 113 women interviewed left the clinic with a total of 6,620 condoms, or an average of 67 condoms per person, suggesting that condoms were still very valued and used. Given our breakage rates, what do s conclude? Is breakage a legitimate fear, warranting the sacrifice of the condom’s prophylactic benefits? While breakage and the factors associated with breakage will need further examination, we believe that the risks which can result from not using a condom are far greater than the risk of breakage.

We gratefully acknowledge the assistance of Maxine Keel, Catherine Sanderson, Elixabeth Adams. Jada Bussey, Sherry Simmons, Dr. Herbert Peterson, Dr. Thomas Lowe, Yvonne Green, and the staff and patients of the Grady Memorial Hospital Family Planning Clinic.

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Trussell J, Hatcher RA, Cates W Jr., Stewart FH, Kost K. Contraceptive failure in the United States: An update. Studies in Family Planning 1990, 21(l): 51-4.

2.

Hatcher RA, Stewart F, Trusell J, Kowal D, Guest F, Stewart GK, Gates W. $n&aceptive Technology 1990-1992. New York, NY: Irvmgton Pubhshers, Inc.,

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Tmdall B, Donovan B, Cooper DA, unpublished, c.f. Richters J et al., 1988.

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van Griensven GJ, de Vmome EM, Tielmsn RA, Coutinho RA. Failure rate of condoms during anogenital intercourse in homosexual men. Genitourin Med 1988; 64(5): 344-6.

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Can you rely on condoms.

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Fgmher RA, Hughes MS. The truth about condoms. - .

Consumer Reports. March 1989: 135141.

10. Barbach, LG. For Yourself: The fulfiient

SIECUS Report 1988; 17(2):

of female sexuality. Garden City, NY:

Anchor Press, 1976. 11. Freeman, MG. The problem of female dyspareunia. 5(2): 25-33.

G 0 Dept Bull, EUSM 1983;

12. White N, Taylor R, Lysxkowski A, Tullett J. Morris C. Dangers of lubricants used with condoms [letter]. Nature 1988; 335(6185): 19.

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