Factors associated with lack of effective contraception among obese women in the United States Lisa S. Callegari, Karin M. Nelson, David E. Arterburn, Sarah W. Prager, Melissa A. Schiff, Eleanor Bimla Schwarz PII: DOI: Reference:
S0010-7824(14)00248-0 doi: 10.1016/j.contraception.2014.05.005 CON 8339
To appear in:
Contraception
Received date: Revised date: Accepted date:
10 March 2014 29 April 2014 1 May 2014
Please cite this article as: Callegari Lisa S., Nelson Karin M., Arterburn David E., Prager Sarah W., Schiff Melissa A., Schwarz Eleanor Bimla, Factors associated with lack of effective contraception among obese women in the United States, Contraception (2014), doi: 10.1016/j.contraception.2014.05.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Factors associated with lack of effective contraception among obese women in the United States
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Lisa S Callegari, MD, MPH1,2,3, Karin M Nelson, MD, MSHS3,4, David E. Arterburn, MD, MPH4,5, Sarah W Prager, MD, MAS1,6, Melissa A Schiff, MD, MPH1,2, Eleanor Bimla Schwarz, MD, MS7,8,9 ___________________________ 1 Department of Obstetrics & Gynecology, University of Washington, Seattle WA 2 Department of Epidemiology, University of Washington, Seattle WA 3 Health Services Research and Development (HSR&D), Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 4 Department of Medicine, University of Washington, Seattle WA 5 Group Health Research Institute, Seattle WA 6 Department of Health Services, University of Washington, Seattle WA 7 Department of Medicine, University of Pittsburgh, Pittsburgh, PA 8 Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 9 Department of Obstetrics & Gynecology, University of Pittsburgh, Pittsburgh, PA The authors report no conflicts of interest.
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L.S.C was supported in part by Project #T76 MC00011 from the Maternal and Child Health Bureau (Title V, Social Security Act) and by a VA Health Services Research and Development Postdoctoral Fellowship (TPM 61-041).
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The findings and conclusions in this report are those of the authors and do not represent the views of the Department of Veterans Affairs or the United States Government.
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An abstract describing this work was presented at the North American Forum on Family Planning, October 6-7, 2013, Seattle, WA.
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Corresponding author: Lisa S. Callegari, University of Washington, VA HSR&D Puget Sound 1100 Olive Way, Suite 1400 Seattle, WA 98101, Phone: (206) 277-3129, Fax: (206) 768-5343, Email: [email protected] Key words: Contraception; contraceptive counseling; obesity; unintended pregnancy. Running title: Obesity and lack of effective contraception Abstract: 252 words Total manuscript: words 2762
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ACCEPTED MANUSCRIPT Abstract Objective: To identify factors associated with contraceptive nonuse and use of less effective
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methods among obese women in the US.
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Study Design: We analyzed data from sexually active obese women (body mass index >30 kg/m2) age 20-44 using the 2006-2010 National Survey of Family Growth. We conducted
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multinomial logistic regression to assess associations between current contraceptive use and
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demographic, reproductive, and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal, fertility awareness), and barrier method users
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(condoms) to prescription method users (pill, patch, ring, injection, implant, intrauterine device). Results: Of 1,345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8%
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barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4%
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of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to
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have previously discontinued a contraceptive method due to dissatisfaction (adjusted RR[aRR]
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1.93, 95%CI 1.09-3.44) and nonusers were more likely to perceive difficulty becoming pregnant (aRR 3.86, 95%CI 2.04-7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR 0.16, 95%CI 0.10-0.27; behavioral methods: aRR 0.13, 95%CI 0.06-0.25, barrier methods: aRR 0.15, 95%CI 0.09-0.25), than prescription method users. Conclusions: Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider.
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ACCEPTED MANUSCRIPT Implications Efforts are needed to increase contraceptive counseling for obese women, who face
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increased risks of morbidity from unintended pregnancy.
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Introduction
Obesity currently affects one third of women of childbearing age [1]. Obese women
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experience unintended pregnancy at similar to slightly higher rates than non-obese women in the
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US [2, 3] where half of all births are unintended [4]. Obese women, however, are more likely to experience significant morbidity from pregnancy [5], making the overlap of the obesity and
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unintended pregnancy epidemics an increasingly important public health issue [6, 7]. Preliminary data suggest contraceptive use patterns in obese women differ from non-
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obese women, with varying effects on unintended pregnancy risk. Several studies report that
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obese women are more likely to use highly effective methods such as intrauterine devices (IUDs) and sterilization than normal weight women [7-9]. In contrast, obese women may be more likely
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to be noncompliant with oral contraceptives than non-obese women [10]. Obese women may
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also be at increased risk of contraceptive nonuse [11], although recent studies have not confirmed this association [7, 12]. Women at highest risk of unintended pregnancy include contraceptive nonusers and users of contraceptive methods with the highest failure rates [13, 14]. Reported failure rates for prescription methods range from 6-9% for the pill, patch, ring, and injection to 30 kg/m2) [19]. NSFG data on BMI is self-reported (current weight in kilograms divided by height in meters squared). Women under age 20 were not included because BMI data was not collected from adolescents in the 2006-2010 NSFG. We excluded respondents who reported no prior sexual intercourse with a man, prior sterilization or hysterectomy, a sterilized or infertile male partner, current desire for pregnancy, and no sex in the past 3 months [20], or who were missing information about contraceptive use. The study was exempted from review by the Human Subjects Division at the University of Washington.
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ACCEPTED MANUSCRIPT We defined current contraceptive use as the most effective method respondents used in the month of interview, based on published contraceptive failure rates [13]. We identified self-
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reported demographic, reproductive, and health services factors that were potentially related to
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contraceptive use based on a literature review [8, 11, 12, 21, 22]. We categorized age by fiveyear intervals and used the age group 25-29 as the referent category. Race/ethnicity was
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categorized as non-Hispanic white, non-Hispanic black, Hispanic, and other. Socioeconomic
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indicators included education (high school or less, some college, college degree or higher), income (250% of federal poverty level) and insurance status (uninsured or
separated, widowed, never married).
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not). Relationship status was categorized as married, cohabitating, or single (divorced,
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Reproductive characteristics considered included parity (none, >1), prior history of
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abortion (no, yes), frequency of intercourse in past 4 weeks (0, 1-3, >4 times) and number of male partners in the past 3 months (1, >2). Additional factors included perception of fertility
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(“As far as you know, would you, yourself, have any difficulty getting pregnant or carrying
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another baby?”), future pregnancy intention (“Looking to the future, do you, yourself, want to have a baby at some time in the future?”) and having discontinued a method in the past due to dissatisfaction (“What method or methods did you stop because you were not satisfied?”). Health services indicators included reporting discussing contraception with a clinician, which was defined as having received contraceptive counseling or having had a visit related to contraception in the past year, and having had a Pap smear in the past year. We considered a Pap smear in the past year to be a surrogate measure for access to preventive health services, as annual Pap smears were relatively common practice in the US between 2006-2010 (although are not recommended by current guidelines).
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ACCEPTED MANUSCRIPT We calculated the percentages of obese women in our sample using each type of contraceptive. We then compared demographic, reproductive and health services factors by
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contraceptive method used in the month of the interview (no method, behavioral method, barrier
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method, prescription method) using χ2 tests. Lastly, we constructed a multinomial logistic regression model to identify factors associated with using no method, behavioral methods, and
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barrier methods, compared to the referent category of using a prescription method, accounting
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for correlated effects. First, we included all of the factors in our descriptive analyses in the initial multinomial model, given that all were identified a priori as potential factors associated
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with contraceptive use [8, 11, 12, 20-23]. We then excluded variables that were not significantly associated with any of the outcome categories at the p30 kg/m2). Obese women who had never had sex with a male partner (n=132), reported sterilization or hysterectomy (n=885), or had a sterile or infertile partner (n=149) were excluded from the analysis. Women who were actively trying to get pregnant (n=163) or had not had sex in the past 3 months (n=490) were excluded, as were women without information on current contraceptive use (n=12 missing or “other”). Thus, a total of 1,345 sexually active obese women at risk of unintended pregnancy were included in this analysis.
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ACCEPTED MANUSCRIPT Just over one-fifth (21.5%) of our sample reported no contraceptive use in the month of the interview (Table 1). Nonprescription methods reported as the most effective method used in
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the month of the interview included withdrawal (8.5%), fertility awareness (1.8%), and male
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condoms (20.6%). Prescription methods reported as the most effective method used included birth control pills (29.1%), intrauterine devices (8.7%), injections (5.7%), vaginal ring (2.5%),
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contraceptive implant (1.0%), and contraceptive patch (4 times per month. Nonusers were almost 4 times more likely to perceive difficulty getting pregnant in the future. Compared to prescription method users, behavioral method users
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were more likely to be age 40-44 and to have discontinued a contraceptive method in the past
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due to dissatisfaction and barrier method methods users were more likely to be in the youngest and oldest age groups. Compared to prescription method users, nonusers, behavioral method
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users and barrier method users were all less likely to report discussing contraception with a
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healthcare provider in the past year (nonusers: aRR 0.16, 95%CI 0.10-0.27; behavioral method users: aRR 0.13, 95%CI 0.06-0.25, barrier methods users: aRR 0.15, 95%CI 0.09-0.25) and less
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likely to report having a Pap smear in the past year (nonusers: aRR 0.40, 95%CI 0.24-0.69; behavioral method users: aRR 0.50, 95%CI 0.26-0.95, barrier method users: aRR 0.45, 95%CI
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0.24-0.82).
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Discussion
In this nationally representative sample of sexually active obese women, we found that
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over half reported contraceptive nonuse or reliance on nonprescription methods with high failure
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rates. Obese women who had discussed contraception with a provider in the past year were significantly less likely to rely on either a nonprescription method or no form of contraception. However, the majority of obese women reported no recent discussion of contraception with a provider. Factors associated with lack of effective contraception differed between nonusers, behavioral method users and barrier method users, suggesting that contraceptive counseling messages should be tailored for each of these groups. However, overall, factors associated with contraceptive use among obese women did not differ substantially from what has been reported in the general population.
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ACCEPTED MANUSCRIPT While the role of the clinician in contraceptive decision-making has been controversial [24], a growing body of literature in the general population suggests that provider counseling is
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influential in women’s perceptions and decisions [25-28]. Research demonstrates that obese
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women receive less preventive counseling about topics such as smoking and injury prevention [29] and are less likely to receive preventive services such as Pap smears [30, 31]. The increased
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complexity of contraceptive decision-making for obese women, who often have comorbid
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medical conditions, may reduce the quality of contraceptive counseling they receive [6]. We found a strong correlation between having discussed contraception and effective contraceptive
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use among obese women, however, suggesting that provider counseling may influence decisions to select effective methods among obese women as well. Because our data are cross-sectional,
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however, we can only detect association and not infer causality; women who were motivated to
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obtain prescription contraception may also have been more likely to recall contraceptive discussions. Prospective studies are needed to further explore the quality of provider counseling
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and the impact of provider counseling on contraceptive decision-making among obese women.
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Not surprisingly, the majority of women in our study who were using prescription contraception had discussed contraception with a provider in the past year, given that interactions with providers are needed to obtain these methods. However, only 20.4% of nonprescription method users had discussed contraception with a provider in the past year, representing a substantial gap in services for these women. The low proportion of women who had discussed contraception with a provider even among those who had received a pap in the past year (28.5%) suggests that many providers are failing to routinely offer contraception counseling. This gap in services is not limited to obese women, as one study found that only 52% of sexually active women in all BMI categories in NSFG reported contraceptive counseling or family planning
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ACCEPTED MANUSCRIPT services in the past year [32]. However, contraceptive counseling is critical for obese women given their greater risk of morbidity from unintended pregnancy.
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Factors associated with lack of effective contraception among obese women did not differ
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substantially from what has been reported in studies in women in the general population [14, 2022, 33, 34]. Consistent with published studies [21, 22, 33, 34], we found that contraceptive
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nonuse and use of behavioral and barrier methods were 2 to 3 times more common among
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women 40 years of age and older. While fertility is known to decrease with age, older obese women who become pregnant are more likely to experience morbidity related to complications
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such as gestational diabetes and hypertensive disorders of pregnancy [11]. Patient or provider concerns about safety of prescription methods in older obese women for whom estrogen may be
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contraindicated may contribute to reduced use of prescription contraception, although we could
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not assess this in our analyses. Efforts to increase awareness of the safety of progesterone-only methods and intrauterine devices for older obese women may be warranted.
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Our multinomial analysis highlights factors that differed in importance between obese
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nonusers, behavioral and barrier method users, suggesting that counseling messages be tailored differently to these groups. Obese behavioral method users, most of whom used withdrawal, were 2-fold more likely to have been dissatisfied with a prior method of contraception compared to prescription method users, consistent with previous research in the general population which found withdrawal users were often dissatisfied with hormonal methods or condoms and rarely discussed withdrawal with providers [35]. Obese barrier method users were more likely to be age 20-24 compared to prescription method users. While condoms are recommended to reduce sexually transmitted infection (STI) risk, reliance on barrier methods alone substantially increases unintended pregnancy risk [13]. Young obese women therefore need counseling about
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ACCEPTED MANUSCRIPT the importance of dual method use. Lastly, obese contraceptive nonusers in our sample were more likely to perceive difficulty getting pregnant, consistent with prior studies in the general
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population [20-22]. While obese women may have decreased fertility compared to non-obese
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women [36], they still experience significant rates of unintended pregnancy [2] and counseling should therefore address these obese women’s perceptions of their fertility.
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Studies in the general population have linked lower socioeconomic status to lack of
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effective contraception [21, 22, 34]. In our sample of obese women, however, we found that socioeconomic indicators including education, income and insurance status were not
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significantly associated with lack of effective contraception or prescription contraception use in adjusted analyses. Receipt of a pap smear in the past year, our proxy measure of access to care,
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was highly correlated to prescription method use in the adjusted analyses. This suggests that
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poor access to services may be a more important predictor of lack of effective contraception and that programs which increase access to family planning for low income women, such as Title X,
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play an important role in meeting the contraceptive needs of obese women.
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Strengths of our study include our large population-based sample and low percentage of missing data. We limited our analyses to obese women to enable us to explore factors associated with nonuse and less effective method use in depth, given previous reports of differences in contraceptive choices compared to non-obese women and obese women’s elevated risk of complications from unintended pregnancy. Use of multinomial modeling allowed us to contrast risk factors between nonusers, behavioral method users and barrier method users and to disentangle correlated effects. Several additional limitations of our study also deserve mention. First, BMI data in NSFG are calculated from self-reported weight and height, which could result in under-ascertainment of obesity. However, the percentage of obesity in the NSFG is similar to
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ACCEPTED MANUSCRIPT validated national estimates [1], suggesting that underreporting of BMI is not a significant concern. Second, residual confounding may be present as we could only adjust for factors
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measured by the NSFG and could not adjust for factors that may have influenced contraceptive
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decisions such as medical comorbidities.
In conclusion, factors associated with lack of effective contraception among obese
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women did not differ substantially from what has been reported in the general population. Our
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results suggest, however, that obese women have unmet needs for contraceptive counseling and service provision, which is of particular concern given their greater risk of pregnancy
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complications. Expanding targeted counseling and service provision may decrease nonuse and
Acknowledgements/Footnotes
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reliance on less effective methods with high failure rates among obese women.
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Reprint requests: Lisa S. Callegari, University of Washington, VA HSR&D Puget Sound 1100
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[email protected]
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Olive Way, Suite 1400 Seattle, WA 98101, Phone: (206) 277-3129, Fax: (206) 768-5343, Email:
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[20] Jones J, Mosher W, Daniels K. Current Contraceptive Use in the United States, 20062010, and Changes in Patterns of Use Since 1995. 2012. [21] Wu J, Meldrum S, Dozier A, Stanwood N, Fiscella K. Contraceptive nonuse among US women at risk for unplanned pregnancy. Contraception. 2008;78:284-9. [22] Frost JJ, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007;39:90-9. [23] Kavanaugh ML, Jerman J, Hubacher D, Kost K, Finer LB. Characteristics of women in the United States who use long-acting reversible contraceptive methods. Obstet Gynecol. 2011;117:1349-57. [24] Kirby D. The impact of programs to increase contraceptive use among adult women: a review of experimental and quasi-experimental studies. Perspect Sex Reprod Health. 2008;40:34-41. [25] Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception. 2003;67:11532. [26] Lee JK, Parisi SM, Akers AY, Borrero S, Schwarz EB. The impact of contraceptive counseling in primary care on contraceptive use. J Gen Intern Med. 2011;26:731-6. [27] Harper CC, Brown BA, Foster-Rosales A, Raine TR. Hormonal contraceptive method choice among young, low-income women: how important is the provider? Patient Educ Couns. 2010;81:349-54. [28] Callegari LS, Parisi SM, Schwarz EB. Perceptions of intrauterine contraception among women seeking primary care. Contraception. 2013;88:269-74. [29] Hernandez-Boussard T, Ahmed SM, Morton JM. Obesity disparities in preventive care: findings from the National Ambulatory Medical Care Survey, 2005-2007. Obesity (Silver Spring). 2012;20:1639-44. [30] Littman AJ, Koepsell TD, Forsberg CW, Boyko EJ, Yancy WS, Jr. Preventive care in relation to obesity: an analysis of a large, national survey. Am J Prev Med. 2011;41:465-72. [31] Ludman EJ, Ichikawa LE, Simon GE, et al. Breast and cervical cancer screening specific effects of depression and obesity. Am J Prev Med. 2010;38:303-10. [32] Borrero S, Schwarz EB, Creinin M, Ibrahim S. The impact of race and ethnicity on receipt of family planning services in the United States. J Womens Health (Larchmt). 2009;18:91-6. [33] Upson K, Reed SD, Prager SW, Schiff MA. Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy. Contraception. 2010;81:427-34. [34] Foster DG, Bley J, Mikanda J, et al. Contraceptive use and risk of unintended pregnancy in California. Contraception. 2004;70:31-9. [35] Whittaker PG, Merkh RD, Henry-Moss D, Hock-Long L. Withdrawal attitudes and experiences: a qualitative perspective among young urban adults. Perspect Sex Reprod Health. 2010;42:102-9. [36] Gesink Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Hum Reprod. 2007;22:414-20.
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21.5 % 31.1 8.5 1.8 20.6 0.2 47.4 29.1 0.4 2.5 5.7 8.7 1.0 100%
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No method Nonprescription methods Withdrawal Fertility awareness methods Condoms Other barrier Prescription methods Pill Patch Ring Injectable contraception Intrauterine device Contraceptive implant Total Percentages are weighted to account for NSFG’s sampling design.
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Table 1. Contraceptive use among obese respondents at risk for unintended pregnancy, National Survey of Family Growth (NSFG) 2006-2010, N=1,345.
ACCEPTED MANUSCRIPT Table 2. Characteristics by contraceptive use among obese respondents, National Survey of Family Growth (NSFG) 2006-2010, N=1,345. No method
Behavioral method % (N=135)
Barrier method % (N=315)
Prescription method % (N=604)
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% (N=291) Demographic Age*** 20-24 15.4 14.0 20.6 20.6 25-29 23.6 23.2 24.6 33.1 30-34 12.7 26.1 21.7 21.4 35-39 30.2 20.1 13.2 18.6 40-44 18.2 16.5 19.9 6.4 Race* Non-Hispanic white 53.3 54.3 50.1 58.9 Non-Hispanic black 27.3 12.9 17.4 14.0 Hispanic 11.4 21.9 20.2 20.6 Other 8.0 10.9 12.4 6.5 Education High school or less 52.6 46.7 44.2 41.1 Some college 21.0 22.7 24.0 27.0 College degree/higher 26.4 30.6 31.8 31.8 Marital status*** Single 48.4 16.7 31.1 30.3 Cohabitating 6.1 17.5 12.4 20.1 Married 45.5 65.8 56.6 49.6 Uninsured 15.6 15.7 12.5 13.5 Income (% of federal poverty level) 0-99% 23.6 19.3 19.8 25.4 100-249% 44.4 35.7 35.9 33.5 >250% 32.0 45.0 44.4 41.1 Foreign born* 6.3 20.4 16.5 13.5 Reproductive Parity 0 24.5 30.5 31.0 35.7 1+ 75.6 69.5 69.0 64.3 Prior history of abortion 16.8 23.0 14.9 15.4 Number of male sexual partners in past 12 months 1 86.5 93.4 87.4 89.3 2+ 13.6 6.6 12.7 10.7 Frequency of sex over the past month*** 0 30.0 1.8 1.0 8.3 1-3 33.3 31.0 39.8 32.5 4+ 36.7 67.2 59.2 59.2 Perceives difficulty having pregnancies in the future** 27.4 10.8 15.0 11.9 Intends to have more pregnancies in future 42.2 57.0 50.6 54.3 Discontinued a contraceptive method in past due to dissatisfaction 45.7 60.7 50.4 46.3 Health services Discussed contraception with a provider in past 22.2 17.3 20.2 66.8 12 months*** Pap smear in past 12 months*** 63.9 61.7 61.5 87.1 *p
S0010-7824(14)00248-0 doi: 10.1016/j.contraception.2014.05.005 CON 8339
To appear in:
Contraception
Received date: Revised date: Accepted date:
10 March 2014 29 April 2014 1 May 2014
Please cite this article as: Callegari Lisa S., Nelson Karin M., Arterburn David E., Prager Sarah W., Schiff Melissa A., Schwarz Eleanor Bimla, Factors associated with lack of effective contraception among obese women in the United States, Contraception (2014), doi: 10.1016/j.contraception.2014.05.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Factors associated with lack of effective contraception among obese women in the United States
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Lisa S Callegari, MD, MPH1,2,3, Karin M Nelson, MD, MSHS3,4, David E. Arterburn, MD, MPH4,5, Sarah W Prager, MD, MAS1,6, Melissa A Schiff, MD, MPH1,2, Eleanor Bimla Schwarz, MD, MS7,8,9 ___________________________ 1 Department of Obstetrics & Gynecology, University of Washington, Seattle WA 2 Department of Epidemiology, University of Washington, Seattle WA 3 Health Services Research and Development (HSR&D), Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 4 Department of Medicine, University of Washington, Seattle WA 5 Group Health Research Institute, Seattle WA 6 Department of Health Services, University of Washington, Seattle WA 7 Department of Medicine, University of Pittsburgh, Pittsburgh, PA 8 Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 9 Department of Obstetrics & Gynecology, University of Pittsburgh, Pittsburgh, PA The authors report no conflicts of interest.
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L.S.C was supported in part by Project #T76 MC00011 from the Maternal and Child Health Bureau (Title V, Social Security Act) and by a VA Health Services Research and Development Postdoctoral Fellowship (TPM 61-041).
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The findings and conclusions in this report are those of the authors and do not represent the views of the Department of Veterans Affairs or the United States Government.
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An abstract describing this work was presented at the North American Forum on Family Planning, October 6-7, 2013, Seattle, WA.
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Corresponding author: Lisa S. Callegari, University of Washington, VA HSR&D Puget Sound 1100 Olive Way, Suite 1400 Seattle, WA 98101, Phone: (206) 277-3129, Fax: (206) 768-5343, Email: [email protected] Key words: Contraception; contraceptive counseling; obesity; unintended pregnancy. Running title: Obesity and lack of effective contraception Abstract: 252 words Total manuscript: words 2762
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ACCEPTED MANUSCRIPT Abstract Objective: To identify factors associated with contraceptive nonuse and use of less effective
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methods among obese women in the US.
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Study Design: We analyzed data from sexually active obese women (body mass index >30 kg/m2) age 20-44 using the 2006-2010 National Survey of Family Growth. We conducted
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multinomial logistic regression to assess associations between current contraceptive use and
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demographic, reproductive, and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal, fertility awareness), and barrier method users
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(condoms) to prescription method users (pill, patch, ring, injection, implant, intrauterine device). Results: Of 1,345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8%
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barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4%
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of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to
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have previously discontinued a contraceptive method due to dissatisfaction (adjusted RR[aRR]
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1.93, 95%CI 1.09-3.44) and nonusers were more likely to perceive difficulty becoming pregnant (aRR 3.86, 95%CI 2.04-7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR 0.16, 95%CI 0.10-0.27; behavioral methods: aRR 0.13, 95%CI 0.06-0.25, barrier methods: aRR 0.15, 95%CI 0.09-0.25), than prescription method users. Conclusions: Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider.
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ACCEPTED MANUSCRIPT Implications Efforts are needed to increase contraceptive counseling for obese women, who face
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increased risks of morbidity from unintended pregnancy.
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Introduction
Obesity currently affects one third of women of childbearing age [1]. Obese women
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experience unintended pregnancy at similar to slightly higher rates than non-obese women in the
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US [2, 3] where half of all births are unintended [4]. Obese women, however, are more likely to experience significant morbidity from pregnancy [5], making the overlap of the obesity and
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unintended pregnancy epidemics an increasingly important public health issue [6, 7]. Preliminary data suggest contraceptive use patterns in obese women differ from non-
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obese women, with varying effects on unintended pregnancy risk. Several studies report that
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obese women are more likely to use highly effective methods such as intrauterine devices (IUDs) and sterilization than normal weight women [7-9]. In contrast, obese women may be more likely
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to be noncompliant with oral contraceptives than non-obese women [10]. Obese women may
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also be at increased risk of contraceptive nonuse [11], although recent studies have not confirmed this association [7, 12]. Women at highest risk of unintended pregnancy include contraceptive nonusers and users of contraceptive methods with the highest failure rates [13, 14]. Reported failure rates for prescription methods range from 6-9% for the pill, patch, ring, and injection to 30 kg/m2) [19]. NSFG data on BMI is self-reported (current weight in kilograms divided by height in meters squared). Women under age 20 were not included because BMI data was not collected from adolescents in the 2006-2010 NSFG. We excluded respondents who reported no prior sexual intercourse with a man, prior sterilization or hysterectomy, a sterilized or infertile male partner, current desire for pregnancy, and no sex in the past 3 months [20], or who were missing information about contraceptive use. The study was exempted from review by the Human Subjects Division at the University of Washington.
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ACCEPTED MANUSCRIPT We defined current contraceptive use as the most effective method respondents used in the month of interview, based on published contraceptive failure rates [13]. We identified self-
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reported demographic, reproductive, and health services factors that were potentially related to
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contraceptive use based on a literature review [8, 11, 12, 21, 22]. We categorized age by fiveyear intervals and used the age group 25-29 as the referent category. Race/ethnicity was
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categorized as non-Hispanic white, non-Hispanic black, Hispanic, and other. Socioeconomic
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indicators included education (high school or less, some college, college degree or higher), income (250% of federal poverty level) and insurance status (uninsured or
separated, widowed, never married).
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not). Relationship status was categorized as married, cohabitating, or single (divorced,
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Reproductive characteristics considered included parity (none, >1), prior history of
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abortion (no, yes), frequency of intercourse in past 4 weeks (0, 1-3, >4 times) and number of male partners in the past 3 months (1, >2). Additional factors included perception of fertility
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(“As far as you know, would you, yourself, have any difficulty getting pregnant or carrying
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another baby?”), future pregnancy intention (“Looking to the future, do you, yourself, want to have a baby at some time in the future?”) and having discontinued a method in the past due to dissatisfaction (“What method or methods did you stop because you were not satisfied?”). Health services indicators included reporting discussing contraception with a clinician, which was defined as having received contraceptive counseling or having had a visit related to contraception in the past year, and having had a Pap smear in the past year. We considered a Pap smear in the past year to be a surrogate measure for access to preventive health services, as annual Pap smears were relatively common practice in the US between 2006-2010 (although are not recommended by current guidelines).
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ACCEPTED MANUSCRIPT We calculated the percentages of obese women in our sample using each type of contraceptive. We then compared demographic, reproductive and health services factors by
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contraceptive method used in the month of the interview (no method, behavioral method, barrier
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method, prescription method) using χ2 tests. Lastly, we constructed a multinomial logistic regression model to identify factors associated with using no method, behavioral methods, and
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barrier methods, compared to the referent category of using a prescription method, accounting
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for correlated effects. First, we included all of the factors in our descriptive analyses in the initial multinomial model, given that all were identified a priori as potential factors associated
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with contraceptive use [8, 11, 12, 20-23]. We then excluded variables that were not significantly associated with any of the outcome categories at the p30 kg/m2). Obese women who had never had sex with a male partner (n=132), reported sterilization or hysterectomy (n=885), or had a sterile or infertile partner (n=149) were excluded from the analysis. Women who were actively trying to get pregnant (n=163) or had not had sex in the past 3 months (n=490) were excluded, as were women without information on current contraceptive use (n=12 missing or “other”). Thus, a total of 1,345 sexually active obese women at risk of unintended pregnancy were included in this analysis.
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ACCEPTED MANUSCRIPT Just over one-fifth (21.5%) of our sample reported no contraceptive use in the month of the interview (Table 1). Nonprescription methods reported as the most effective method used in
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the month of the interview included withdrawal (8.5%), fertility awareness (1.8%), and male
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condoms (20.6%). Prescription methods reported as the most effective method used included birth control pills (29.1%), intrauterine devices (8.7%), injections (5.7%), vaginal ring (2.5%),
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contraceptive implant (1.0%), and contraceptive patch (4 times per month. Nonusers were almost 4 times more likely to perceive difficulty getting pregnant in the future. Compared to prescription method users, behavioral method users
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were more likely to be age 40-44 and to have discontinued a contraceptive method in the past
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due to dissatisfaction and barrier method methods users were more likely to be in the youngest and oldest age groups. Compared to prescription method users, nonusers, behavioral method
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users and barrier method users were all less likely to report discussing contraception with a
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healthcare provider in the past year (nonusers: aRR 0.16, 95%CI 0.10-0.27; behavioral method users: aRR 0.13, 95%CI 0.06-0.25, barrier methods users: aRR 0.15, 95%CI 0.09-0.25) and less
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likely to report having a Pap smear in the past year (nonusers: aRR 0.40, 95%CI 0.24-0.69; behavioral method users: aRR 0.50, 95%CI 0.26-0.95, barrier method users: aRR 0.45, 95%CI
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0.24-0.82).
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Discussion
In this nationally representative sample of sexually active obese women, we found that
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over half reported contraceptive nonuse or reliance on nonprescription methods with high failure
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rates. Obese women who had discussed contraception with a provider in the past year were significantly less likely to rely on either a nonprescription method or no form of contraception. However, the majority of obese women reported no recent discussion of contraception with a provider. Factors associated with lack of effective contraception differed between nonusers, behavioral method users and barrier method users, suggesting that contraceptive counseling messages should be tailored for each of these groups. However, overall, factors associated with contraceptive use among obese women did not differ substantially from what has been reported in the general population.
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ACCEPTED MANUSCRIPT While the role of the clinician in contraceptive decision-making has been controversial [24], a growing body of literature in the general population suggests that provider counseling is
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influential in women’s perceptions and decisions [25-28]. Research demonstrates that obese
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women receive less preventive counseling about topics such as smoking and injury prevention [29] and are less likely to receive preventive services such as Pap smears [30, 31]. The increased
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complexity of contraceptive decision-making for obese women, who often have comorbid
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medical conditions, may reduce the quality of contraceptive counseling they receive [6]. We found a strong correlation between having discussed contraception and effective contraceptive
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use among obese women, however, suggesting that provider counseling may influence decisions to select effective methods among obese women as well. Because our data are cross-sectional,
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however, we can only detect association and not infer causality; women who were motivated to
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obtain prescription contraception may also have been more likely to recall contraceptive discussions. Prospective studies are needed to further explore the quality of provider counseling
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and the impact of provider counseling on contraceptive decision-making among obese women.
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Not surprisingly, the majority of women in our study who were using prescription contraception had discussed contraception with a provider in the past year, given that interactions with providers are needed to obtain these methods. However, only 20.4% of nonprescription method users had discussed contraception with a provider in the past year, representing a substantial gap in services for these women. The low proportion of women who had discussed contraception with a provider even among those who had received a pap in the past year (28.5%) suggests that many providers are failing to routinely offer contraception counseling. This gap in services is not limited to obese women, as one study found that only 52% of sexually active women in all BMI categories in NSFG reported contraceptive counseling or family planning
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ACCEPTED MANUSCRIPT services in the past year [32]. However, contraceptive counseling is critical for obese women given their greater risk of morbidity from unintended pregnancy.
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Factors associated with lack of effective contraception among obese women did not differ
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substantially from what has been reported in studies in women in the general population [14, 2022, 33, 34]. Consistent with published studies [21, 22, 33, 34], we found that contraceptive
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nonuse and use of behavioral and barrier methods were 2 to 3 times more common among
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women 40 years of age and older. While fertility is known to decrease with age, older obese women who become pregnant are more likely to experience morbidity related to complications
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such as gestational diabetes and hypertensive disorders of pregnancy [11]. Patient or provider concerns about safety of prescription methods in older obese women for whom estrogen may be
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contraindicated may contribute to reduced use of prescription contraception, although we could
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not assess this in our analyses. Efforts to increase awareness of the safety of progesterone-only methods and intrauterine devices for older obese women may be warranted.
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Our multinomial analysis highlights factors that differed in importance between obese
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nonusers, behavioral and barrier method users, suggesting that counseling messages be tailored differently to these groups. Obese behavioral method users, most of whom used withdrawal, were 2-fold more likely to have been dissatisfied with a prior method of contraception compared to prescription method users, consistent with previous research in the general population which found withdrawal users were often dissatisfied with hormonal methods or condoms and rarely discussed withdrawal with providers [35]. Obese barrier method users were more likely to be age 20-24 compared to prescription method users. While condoms are recommended to reduce sexually transmitted infection (STI) risk, reliance on barrier methods alone substantially increases unintended pregnancy risk [13]. Young obese women therefore need counseling about
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ACCEPTED MANUSCRIPT the importance of dual method use. Lastly, obese contraceptive nonusers in our sample were more likely to perceive difficulty getting pregnant, consistent with prior studies in the general
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population [20-22]. While obese women may have decreased fertility compared to non-obese
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women [36], they still experience significant rates of unintended pregnancy [2] and counseling should therefore address these obese women’s perceptions of their fertility.
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Studies in the general population have linked lower socioeconomic status to lack of
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effective contraception [21, 22, 34]. In our sample of obese women, however, we found that socioeconomic indicators including education, income and insurance status were not
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significantly associated with lack of effective contraception or prescription contraception use in adjusted analyses. Receipt of a pap smear in the past year, our proxy measure of access to care,
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was highly correlated to prescription method use in the adjusted analyses. This suggests that
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poor access to services may be a more important predictor of lack of effective contraception and that programs which increase access to family planning for low income women, such as Title X,
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play an important role in meeting the contraceptive needs of obese women.
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Strengths of our study include our large population-based sample and low percentage of missing data. We limited our analyses to obese women to enable us to explore factors associated with nonuse and less effective method use in depth, given previous reports of differences in contraceptive choices compared to non-obese women and obese women’s elevated risk of complications from unintended pregnancy. Use of multinomial modeling allowed us to contrast risk factors between nonusers, behavioral method users and barrier method users and to disentangle correlated effects. Several additional limitations of our study also deserve mention. First, BMI data in NSFG are calculated from self-reported weight and height, which could result in under-ascertainment of obesity. However, the percentage of obesity in the NSFG is similar to
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ACCEPTED MANUSCRIPT validated national estimates [1], suggesting that underreporting of BMI is not a significant concern. Second, residual confounding may be present as we could only adjust for factors
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measured by the NSFG and could not adjust for factors that may have influenced contraceptive
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decisions such as medical comorbidities.
In conclusion, factors associated with lack of effective contraception among obese
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women did not differ substantially from what has been reported in the general population. Our
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results suggest, however, that obese women have unmet needs for contraceptive counseling and service provision, which is of particular concern given their greater risk of pregnancy
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complications. Expanding targeted counseling and service provision may decrease nonuse and
Acknowledgements/Footnotes
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reliance on less effective methods with high failure rates among obese women.
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Reprint requests: Lisa S. Callegari, University of Washington, VA HSR&D Puget Sound 1100
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[email protected]
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Olive Way, Suite 1400 Seattle, WA 98101, Phone: (206) 277-3129, Fax: (206) 768-5343, Email:
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[1] Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jama. 2012;307:491-7. [2] Kaneshiro B, Edelman A, Carlson N, Nichols M, Jensen J. The relationship between body mass index and unintended pregnancy: results from the 2002 National Survey of Family Growth. Contraception. 2008;77:234-8. [3] Brunner Huber LR, Hogue CJ. The association between body weight, unintended pregnancy resulting in a livebirth, and contraception at the time of conception. Matern Child Health J. 2005;9:413-20. [4] Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84:478-85. [5] Robinson HE, O'Connell CM, Joseph KS, McLeod NL. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol. 2005;106:1357-64. [6] Grimes DA, Shields WC. Family planning for obese women: challenges and opportunities. Contraception. 2005;72:1-4. [7] Kaneshiro B. Contraceptive use and sexual behavior in obese women. Semin Reprod Med. 2012;30:459-64. [8] Schraudenbach A, McFall S. Contraceptive use and contraception type in women by body mass index category. Womens Health Issues. 2009;19:381-9. [9] Scott-Ram R, Chor J, Bhogireddy V, Keith L, Patel A. Contraceptive choices of overweight and obese women in a publically funded hospital: possible clinical implications. Contraception. 2012. [10] Westhoff CL, Torgal AT, Mayeda ER, Shimoni N, Stanczyk FZ, Pike MC. Predictors of noncompliance in an oral contraceptive clinical trial. Contraception. 2011. [11] Chuang CH, Chase GA, Bensyl DM, Weisman CS. Contraceptive use by diabetic and obese women. Womens Health Issues. 2005;15:167-73. [12] Vahratian A, Barber JS, Lawrence JM, Kim C. Family-planning practices among women with diabetes and overweight and obese women in the 2002 National Survey For Family Growth. Diabetes Care. 2009;32:1026-31. [13] Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397-404. [14] Dude A, Neustadt A, Martins S, Gilliam M. Use of withdrawal and unintended pregnancy among females 15-24 years of age. Obstet Gynecol. 2013;122:595-600. [15] Lopez LM, Grimes DA, Chen M, et al. Hormonal contraceptives for contraception in overweight or obese women. Cochrane Database Syst Rev. 2013;4:CD008452. [16] McNicholas C, Zhao Q, Secura G, Allsworth JE, Madden T, Peipert JF. Contraceptive failures in overweight and obese combined hormonal contraceptive users. Obstet Gynecol. 2013;121:585-92. [17] Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84:363-7. [18] Groves RM, Mosher WD, Lepkowski JM, Kirgis NG. Planning and development of the continuous National Survey of Family Growth. Vital Health Stat 1. 2009:1-64. [19] Obesity: preventing and managing the global epidemic. World Health Organization Technical Report Series 894. 2000:1-252.
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[20] Jones J, Mosher W, Daniels K. Current Contraceptive Use in the United States, 20062010, and Changes in Patterns of Use Since 1995. 2012. [21] Wu J, Meldrum S, Dozier A, Stanwood N, Fiscella K. Contraceptive nonuse among US women at risk for unplanned pregnancy. Contraception. 2008;78:284-9. [22] Frost JJ, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007;39:90-9. [23] Kavanaugh ML, Jerman J, Hubacher D, Kost K, Finer LB. Characteristics of women in the United States who use long-acting reversible contraceptive methods. Obstet Gynecol. 2011;117:1349-57. [24] Kirby D. The impact of programs to increase contraceptive use among adult women: a review of experimental and quasi-experimental studies. Perspect Sex Reprod Health. 2008;40:34-41. [25] Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception. 2003;67:11532. [26] Lee JK, Parisi SM, Akers AY, Borrero S, Schwarz EB. The impact of contraceptive counseling in primary care on contraceptive use. J Gen Intern Med. 2011;26:731-6. [27] Harper CC, Brown BA, Foster-Rosales A, Raine TR. Hormonal contraceptive method choice among young, low-income women: how important is the provider? Patient Educ Couns. 2010;81:349-54. [28] Callegari LS, Parisi SM, Schwarz EB. Perceptions of intrauterine contraception among women seeking primary care. Contraception. 2013;88:269-74. [29] Hernandez-Boussard T, Ahmed SM, Morton JM. Obesity disparities in preventive care: findings from the National Ambulatory Medical Care Survey, 2005-2007. Obesity (Silver Spring). 2012;20:1639-44. [30] Littman AJ, Koepsell TD, Forsberg CW, Boyko EJ, Yancy WS, Jr. Preventive care in relation to obesity: an analysis of a large, national survey. Am J Prev Med. 2011;41:465-72. [31] Ludman EJ, Ichikawa LE, Simon GE, et al. Breast and cervical cancer screening specific effects of depression and obesity. Am J Prev Med. 2010;38:303-10. [32] Borrero S, Schwarz EB, Creinin M, Ibrahim S. The impact of race and ethnicity on receipt of family planning services in the United States. J Womens Health (Larchmt). 2009;18:91-6. [33] Upson K, Reed SD, Prager SW, Schiff MA. Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy. Contraception. 2010;81:427-34. [34] Foster DG, Bley J, Mikanda J, et al. Contraceptive use and risk of unintended pregnancy in California. Contraception. 2004;70:31-9. [35] Whittaker PG, Merkh RD, Henry-Moss D, Hock-Long L. Withdrawal attitudes and experiences: a qualitative perspective among young urban adults. Perspect Sex Reprod Health. 2010;42:102-9. [36] Gesink Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Hum Reprod. 2007;22:414-20.
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21.5 % 31.1 8.5 1.8 20.6 0.2 47.4 29.1 0.4 2.5 5.7 8.7 1.0 100%
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No method Nonprescription methods Withdrawal Fertility awareness methods Condoms Other barrier Prescription methods Pill Patch Ring Injectable contraception Intrauterine device Contraceptive implant Total Percentages are weighted to account for NSFG’s sampling design.
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Table 1. Contraceptive use among obese respondents at risk for unintended pregnancy, National Survey of Family Growth (NSFG) 2006-2010, N=1,345.
ACCEPTED MANUSCRIPT Table 2. Characteristics by contraceptive use among obese respondents, National Survey of Family Growth (NSFG) 2006-2010, N=1,345. No method
Behavioral method % (N=135)
Barrier method % (N=315)
Prescription method % (N=604)
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% (N=291) Demographic Age*** 20-24 15.4 14.0 20.6 20.6 25-29 23.6 23.2 24.6 33.1 30-34 12.7 26.1 21.7 21.4 35-39 30.2 20.1 13.2 18.6 40-44 18.2 16.5 19.9 6.4 Race* Non-Hispanic white 53.3 54.3 50.1 58.9 Non-Hispanic black 27.3 12.9 17.4 14.0 Hispanic 11.4 21.9 20.2 20.6 Other 8.0 10.9 12.4 6.5 Education High school or less 52.6 46.7 44.2 41.1 Some college 21.0 22.7 24.0 27.0 College degree/higher 26.4 30.6 31.8 31.8 Marital status*** Single 48.4 16.7 31.1 30.3 Cohabitating 6.1 17.5 12.4 20.1 Married 45.5 65.8 56.6 49.6 Uninsured 15.6 15.7 12.5 13.5 Income (% of federal poverty level) 0-99% 23.6 19.3 19.8 25.4 100-249% 44.4 35.7 35.9 33.5 >250% 32.0 45.0 44.4 41.1 Foreign born* 6.3 20.4 16.5 13.5 Reproductive Parity 0 24.5 30.5 31.0 35.7 1+ 75.6 69.5 69.0 64.3 Prior history of abortion 16.8 23.0 14.9 15.4 Number of male sexual partners in past 12 months 1 86.5 93.4 87.4 89.3 2+ 13.6 6.6 12.7 10.7 Frequency of sex over the past month*** 0 30.0 1.8 1.0 8.3 1-3 33.3 31.0 39.8 32.5 4+ 36.7 67.2 59.2 59.2 Perceives difficulty having pregnancies in the future** 27.4 10.8 15.0 11.9 Intends to have more pregnancies in future 42.2 57.0 50.6 54.3 Discontinued a contraceptive method in past due to dissatisfaction 45.7 60.7 50.4 46.3 Health services Discussed contraception with a provider in past 22.2 17.3 20.2 66.8 12 months*** Pap smear in past 12 months*** 63.9 61.7 61.5 87.1 *p
