Misconceptions About Missed Conceptions

Unintended Pregnancy in Young Women

More than 1 million unwanted pregnancies occur annually in the United States among women below the age of 25, with the highest incidence in 18 to 24 year olds (CDC, 2009). Despite a downward trend for many years, unintended pregnancy among adolescents and young adult women remains a significant public health problem in the United States (Martin et al., 2009). In 2005, 2.4 million pregnancies occurred in females below 25 years of age—approximately 50% were unintended (CDC, 2009). That same year, 1.21 million abortions were performed in the United States—one half were performed on women less than 25 years of age (Alan Guttmacher Institute [AGI], 2006). Along with the increased number of abortions, negative outcomes associated with these pregnancies include depression and decreased quality of life (AGI, 2006). Exacerbating this dilemma, recent data indicates a reversal of the downward trend; pregnancy rates have increased across all age groups less than 25 years old (Martin et al., 2009).

ECP

ECP, which is also known as “the morning after pill,” has few side effects (ACOG, 2005; World Health Organization [WHO], 1998) and is well tolerated in young women (Harper, Rocca, Darney, von Hertzen, & Raine, 2004; Sambol et al., 2006), and its availability does not result in increased negative sexual behaviors (Adamji & Swartout, 2010). Although some postovulatory mechanisms were thought to be present with ECP use (Trussell, Ellertson, Stewart, Raymond, & Sochet, 2004), more recent data indicate that it acts only through an inhibiting effect on follicular development, thereby delaying ovulation (Gemzell-Danielson, 2010). While not intended as a primary method of contraception, ECP has the potential to significantly reduce the number of unintended pregnancies when more reliable forms of birth control are absent (Society for Adolescent Medicine [SAM], 2004). Earlier predictions of a reduction of nearly 80% (Trussel, Rodriguez, & Ellertson, 1998) have proven overly optimistic; (Raymond, Trussel, & Pollis, 2007); it can, however, reduce pregnancy risk for individual women (Cheng, Gulmezoqlu, Piaggio, Ezcurra, & Van Look, 2008). As advanced planning is not required, it is well suited to the developmental needs of most adolescents and many young adults who have not yet developed the formal operational thought processes required to envision potential consequences of actions (Gordon, 1990; Steinberg, 2004) and are therefore more likely to engage in unprotected sexual activity (Hensley, Lappin, Wells, Barone, & Dalton, 2010). The only contraindication to ECP is pregnancy; however, since it has no detrimental effect on existing pregnancies, clinical evaluation or testing is not required before ECP is provided (ACOG, 2005).

However, even given these benefits, there continues to be low ECP use among young women. It has been posited that health care provider attitudes (Beckman, Harvey, Sherman, & Petitti, 2001) and lack of access (Camp, Harper, & Raine, 2003) are responsible for infrequency of use in this population. However, several studies have refuted these hypotheses; even with advanced provision, ECP use remains low (Gold, Sucato, Conrad, & Hillard, 2004; Polis et al., 2010). Rocca and colleagues (2007) assessed the acceptability of ECP in young women and nearly all the participants reported favorable attitudes toward it. Yet, only 50% of this same group, who had ECP on hand and reported having unprotected sex, chose to use it (Raine et al., 2005). The reasons for this discrepancy between attitudes and actual use are not well defined.

Relationship Dynamics

Two recent studies conducted in the United Kingdom (Free et al., 2002; Free & Ogden, 2005) suggest there are other contextual factors influencing young women’s views on ECP. One of these factors is the role that male partners play in decisions related to its use (Free & Ogden, 2005). Relationships by definition are predicated on interpersonal goals, expectations, and interactions that influence each partner’s subsequent behaviors (Reis, Collins, & Berscheid, 2000). While there is a growing focus on the couple dyad as the unit of analysis in reproductive health research (Cubbins et al., 2007), most of these studies are limited to adult married dyads (Becker, 1996). The few studies that did examine relationship factors and the use of other forms of contraception in young couples found that while contraception was often a difficult topic to discuss (Coleman & Ingham, 1999), the length and quality of the relationship (Manning, Longmore, & Giordano, 2000) and comfort and openness in sexual communication (Widman, Welsh, McNulty, & Little, 2006) were predictive of successful contraception. How couple dynamics influence decision making related to ECP use in young adults is unknown. Therefore, the interaction within the couple dyad was the primary focus of analysis for this study. Grounded theory was chosen as the methodology as its goal is to construct abstract theoretical explanations from social processes (Glaser & Strauss, 1967).

Symbolic Interactionism

The theoretical and methodological perspective of couple relationship that provides the framework of this study is based on symbolic interactionism (Blumer, 1969). Symbolic interactionism is a psychosocial theory, with roots in the philosophy of pragmatism, which proposes that society is a symbolic world that is constituted through shared meanings among individuals in relationships (Denzin, 1992). These meanings, including that of self and others, are derived by an interpretive process through social interaction and provide the basis for human behavior (Blumer). Symbolic interactionism is especially salient to couple/family studies as it emphasizes these relationships as providing the primary social interactions in which individuals develop a sense of meaning to the world around them (LaRosa & Reitzes, 1993).

The epistemological assumptions of symbolic interactionism provide the underpinnings of grounded theory and the lens through which analyses are undertaken as an action/interaction orientation (Clarke, 2005). With this foundation in both pragmatism and symbolic interactionism, Clarke (2003) maintains that grounded theory may be viewed as a “theory/methods package” (p. 559). Through the processes of grounded theorizing, salient categories consistent with contemporary grounded theory principles (Clarke, 2005) were constructed to characterize the meanings of ECP use in young couples.

Recruitment and Participants

Approval was obtained from the University of California, San Francisco Committee on Human Research prior to any study procedures. Couples were recruited through public notices and snowball sampling (Fain, 2004). Inclusion criteria were women aged 18 through 25 years, English speaking (as their partners), and currently in a sexual relationship with a partner willing to participate in the study. Due to possible age disparities between partners, men up to 30 years old were acceptable, but to avoid confusion regarding the differing age parameters young men were not directly recruited. The young women made the first contact with the researcher via telephone or email. Prior use of ECP was not required, but all participants were screened to insure they possessed basic knowledge of ECP (that it is a postcoital contraceptive) and were willing to discuss it with their partners. For those meeting the inclusion criteria, a mutually convenient place and time were chosen for the young women and their partners to meet with the interviewer. The settings included various public venues (secluded areas of libraries, college campuses, and parks where confidentiality could be maintained) and couples’ homes. Each member of the dyads was given US$25.00 per interview as compensation for their time.

Twenty-two sexually active couples (N = 44), with both partners between the ages of 18 and 25 years, were interviewed. None of the couples were married (marital status was not an inclusion criteria). Racial and ethnic self-identification included 4 African Americans, 3 Asians, 3 Hispanics, and 34 Whites. One woman (Asia) and two men (Brazil and India) had immigrated to the United States within the past 5 years; the remainder had spent their formative years in the United States. The majority of participants (n = 37) had at least 1 year of college, and 10 of those had attained baccalaureate degrees. The remainder (n = 7) had completed high school. Couples had been sexually involved from 6 months to 4 years.

One half of the couples (n = 11) had used ECP at least once, the majority (n = 10) in their present relationships; of these, 2 had used ECP twice, 1 three times, and 1 four times. Another woman and her partner had both used ECP in previous relationships only. Only one couple in this group was using a hormonal method of birth control (OCPs) prior to ECP use; the remaining couples’ previous contraceptive behavior consisted of condom use, withdrawal, no method at all, or some combination of the three. Four subsequently initiated hormonal contraception. The remainder of the couples (n = 11) had no personal experience with ECP. The majority (n = 9) of this group were using some form of hormonal contraception. All of the women in the study were aware of ECP prior to first contact as were the majority of men; one was informed by his partner immediately prior to the first interview.

At the first meeting, any further questions were answered and written consent and demographic information were obtained. The design of the study included three consecutive interviews. The first interview was conducted individually with the female partner of the couple dyad with the interview lasting about 30 to 45 min. The second interview was conducted individually with male partner of the couple dyad with the interview lasting about 30 to 45 min. A conjoint interview was then conducted with the couple dyad approximately 1 week later, taking 45 min to 1 hr to complete. The exceptions to this process occurred with one couple in which the partner was initially unavailable requiring the postponement of two interviews, and one couple who failed to return for the joint interview. The interview guide included questions regarding contraception use in general, knowledge and attitudes about ECP, how they were first made aware of ECP, and contraceptive decision making within the couples’ relationship.

Data Analysis

Consistent with the principles of grounded theory (Glaser & Strauss, 1967), analysis began simultaneously with data collection. All analytical processes were performed by the first author under the supervision or review of three senior researchers all experienced in qualitative research and grounded theory. Interviews were audiotaped and transcribed verbatim. The data were initially analyzed using strategies of open coding and memoing (Charmaz, 2006). Axial and comparative coding were then performed, along with ongoing memoing, to identify themes and their relationships. As axial codes emerged, additional couples were recruited to allow for theoretical sampling (Strauss & Corbin, 1998) and focused coding (Charmaz, 2006) and also to augment authenticity (Beck, 2009). Revisions were made to the original interview guide to pursue the emerging findings as they occurred throughout the data-collection/analysis period. Interviews were conducted from November 2008 to August 2009. In-depth field notes of participants’ behaviors, obtained through participant observation, were also taken to provide for credibility (Beck, 2009), and the data were incorporated into the analysis to augment the findings.

Consistent with contemporary grounded theory methods (Clarke, 2005), the data were then reassembled to construct abstract schemas to begin to explain the knowledge, attitudes, and experiences of young couples with ECP. Saturation—when no new categories emerge (Strauss & Corbin, 1998) was reached after interviewing 18 couples, but an additional 5 were recruited to insure comprehensive analysis and coverage of the data, as well as theoretical verification. All data and tapes were secured in a locked cabinet during the course of the study; at the conclusion, identifying indicators were deleted from the transcripts and the tapes were destroyed. A total of 63 interviews were analyzed. Several core concepts emerged around couple dynamics in decision making and the meanings of ECP use. This article focuses on the latter—the meanings ECP use held for these couples.

Making Moral Decisions

Some participants suggested that ECP is akin to abortion and therefore felt that its use should be restricted. At the extreme end of the continuum, one young woman professed that the use of ECP was morally wrong under any circumstances:

This particular woman was the only participant who professed such an immutable stance against ECP use. This solitary view may be an indication of a self-selection process among the participants—those with more conservative views may have been unwilling to participate because they felt that their views were less socially acceptable.

While no other participant took such an inflexible moral outlook regarding ECP, some expressed extremely value-laden views. One young woman felt that the morality of ECP use was based on the timing of its use. She had also conceptualized a moral continuum of methods of contraception, and where she positioned ECP in this range was based on the chronology of its action in relation to the process of conception. What she saw as the ambiguity of this interaction strongly influenced her decision making regarding the use of ECP.

Another female participant perhaps best explained why this conceptual blurring between ECP and abortion occurred for some young couples—it is at least partially rooted in the question of when does life begin.

Several other participants spoke of similarities between the action of ECP and abortion, which they found acceptable; therefore, it did not pose a moral dilemma. The majority of couples, though, were also free of moral conflicts with ECP use regardless of their views on abortion, as they saw no similarities between the two as evidenced by the interchange of one couple.

One young woman articulated this view very succinctly:

Judging the Level of Personal Responsibility Related to ECP Use

Couples views on ECP use with regard to responsible behavior also forged a continuum. A minority felt that the antecedent behavior—unprotected consensual sex, was a serious lapse in judgment regardless of the circumstances. Many other couples took a much more forgiving stance and expressed the opposing view—“mistakes happen.” Those that claimed the middle ground did so by basing their views on contextual issues. One young woman supported the availability of ECP politically but initially did not see it as an option for herself.

Notably though, her view softened somewhat when she returned for the couple interview, having had discussed it with her partner.

We both know is an option (ECP) if that ever did happen . . . I’ve been thinking about it more, for example, because I just switched my birth control methods, and I’m having to go back to take a pill every day . . .

One young man, however, was unyielding in his views

Another young man, while not as vehement in his speech, definitely viewed ECP use, especially repeated use, the result of irresponsible behavior.

Another female concurred,

Most of those who believed the need for ECP resulted from irresponsible behavior had not used it themselves. However, one young man whose partner had recently taken ECP needed to justify their use of it—it was not irresponsible since it occurred in the context of a “true emergency.”

His statement clearly implied that ECP use, at least for him and his partner, is acceptable only under prescribed circumstances. Though she took a more lenient stance, this notion of conditional approval was also expressed by a young woman who felt that the use of ECP was neither responsible nor irresponsible in itself, but rather dependent on the situation.

Most participants were also much less judgmental of ECP use by either themselves or others; this was true of both those that had previously used it and those who had not.

Another young man, who never experienced the need for ECP in any of his relationships, also held no negative views toward those who might use it. “Yeah. I was gonna say I have absolutely no kind of—there’s no like stigma attached to the use of EC—for me, it’s not.” Another concern that a small number of couples had about repeated use of ECP in a monogamous relationship was the low efficacy rate—yet many had concerns about safety.

Judging the Safety of ECP

Couples’ views about the safety of ECP also patterned a continuum, but the range of responses was concentrated toward the extreme of toxicity. The most favorable views on safety were mainly neutral, with a minority of participants reporting they had not heard anything negative about ECP. Several couples indicated that they believed ECP was harmful to a woman’s body, especially with repeated use. This was true of both couples who had used ECP in the past—often having obtained it from a health care professional—and those who had not used it. Some viewed it as an extremely potent or “super birth control pill.”

One young woman relayed the information she had received about the safety of ECP this way:

A minority of participants harbored few or no fears about the safety of ECP.

Judging the Efficacy of ECP

Despite the pervasive negative assumptions about the safety of ECP, the range of views on efficacy favored a positive direction—the majority of participants firmly believed ECP would produce the desired results. Their reasons though were varied. Some based it on information obtained from a health care provider or provided on the package insert. More often though, it was word of mouth and/or their own experience that guided their judgment. The following young woman’s statement is typical of the majority of participants.

A young man concurred,

While very few participants questioned the efficacy of ECP, remarkably, the one young man who was most skeptical was a member of the dyad that had used ECP more than any other couple in the study—four times and had not experienced a pregnancy. Apparently, contextual factors and word of mouth weighed more heavily than his own experience in forming his view.

Limitations

One of the limitations of this study—a result of the self-selection process of participants, was the lack of diversity among the couples. Most were well educated, all were heterosexual, and none experienced a pregnancy despite ECP use. Despite, or perhaps as a result of this limitation, this study is consistent with the goals of contemporary constructivist grounded theory—pursuing angles of vision that elucidate situated complexities rather that generalities (Clarke, 2005). In contemporary performance of grounded theory analysis, it is a goal to acknowledge differences and complexities among perspectives about a given phenomenon, and therefore products of analysis aim to portray the range of variation rather than distilling data into a central tendency. Another limitation is that the study makes no claims to a substantive theory. Yet the findings move beyond description into the realm of explanation, which is also consistent with contemporary constructivist-grounded theory (Clarke, 2005).

Clinical Implications

Due to the pervasive misconceptions and lack of knowledge regarding ECP that emerged, nurses who provide care to adolescents, young adults, and families need to focus more on education and exploring ways to dispel these misconceptions. The most basic intervention would be to routinely incorporate discussions about contraception, including ECP, into primary care visits. Also, clinicians who work with this population need to be cognizant that though many young people are aware of ECP, they are harboring erroneous information about it that is acting as a barrier to use. Nurses should become acquainted with the prevailing myths and address these misconceptions routinely in their practice. They should not only ascertain awareness of ECP but also explore the meanings and nuances it holds for the individual. It is only with accurate information that young couples will be able to make sound decisions.

Clinicians also need to expand their focus with reproductive health teaching to include young men and begin to explore the salience of partner influence. All participants in this study were surveyed about the circumstance in which they first learned of ECP, yet among the young men, only one reported being informed by a health care provider. Ideally, this teaching should occur in the context of routine care. Also, families should be offered ongoing education regarding reproductive health. Parental communication has been shown to increase positive sexual decision making and contraception use in young people (Commendador, 2010), yet none of the participants in the study reported being informed about ECP from a parent. We need to expand our teaching to encourage parents of young people of both genders to discuss safe sex and birth control with them, including ECP, thereby preventing misconceptions and myths. This expanded approach to reproductive health would allow young people to have the necessary knowledge when entering into a sexual relationship and thus facilitate the ultimate goal—preventing unwanted pregnancies among adolescents and young adults.