Partner influence on early discontinuation of the Pill in a predominantly hispanic population.

CONTEXT: Although studies have examined U.S. pill users' patterns of discontinuation, little is known about pill discontinuation, and the effects of partner influence, among Hispanics.

METHODS: Follow-up data on pill use were collected from 213 predominantly Hispanic women who requested the pill in an urban family planning clinic in 2000. Logistic regression analyses were conducted to assess the association between a range of factors, including partner and relationship variables, and the odds that women discontinued use before starting their second pack of pills.

RESULTS: The overall rate of early discontinuation was 23%. Women who reported that their partner was unaware of their planned pill use had significantly elevated odds of discontinuing use (odds ratio, 3.4). Other variables that were independently associated with increased odds of early pill discontinuation were not taking the first pill during the clinic visit (3.0), feeling happy about the prospect of a pregnancy in the next six months (2.4) and intending to use the pill for one year or less (2.3). Age, which was assessed as a continuous variable, was negatively associated with the odds of early discontinuation (0.9).

CONCLUSIONS: Male partners' awareness of planned pill use may be a marker for the level of communication and commitment in the relationship. Women may choose to disclose their planned pill use to supportive partners, and this may be beneficial to the relationship and the couple's contraceptive use. However, clinicians should take women's circumstances and needs into account before counseling them to tell a partner that they intend to use the pill.

Perspectives on Sexual and Reproductive Health, 2003, 35(6):256-260

**********

Approximately half of U.S. women aged 15-24 who currently practice contraception use the pill, (1) and more than 80% of all women aged 15-44 have ever used the pill. (2) Many women who initiate pill use discontinue within one year. In one study, for example, more than half of women who discontinued pill use in the first six months did so within two months of starting, and the discontinuation rate was highest in the first month of use. (3) Estimated discontinuation rates range from 30% to 60% at one year, (4) and 20% of unintended pregnancies that occur each year in the United States may be attributable to pill discontinuation. (5)

Several studies have found that a male partner's influence is associated with contraceptive use among both white and black women and among adolescents. (6) Twenty percent of women reported in a national survey that their partner had a lot of influence on their decision to adopt the pill. (7) Many variables may be proxies for a partner's influence in contraceptive decision-making, including his education, the duration and stability of the relationship, the level of intimacy in the relationship, the extent of the partner's support, his feelings about pill use and the age difference between partners. For example, extensive research on the influence of the age difference between partners, especially among adolescents, suggests that the prevalence of contraceptive use in general is lower when the man is five or more years older than the woman. (8) Other research indicates that women in longer relationships are more likely than those in shorter relationships to stay on the pill. (9) Moreover, women are more likely to choose the pill and to use it consistently when they report that they are in a stable, intimate relationship and that their partner is happy with the method than otherwise. (10) These measures of partner influence may indicate that a mutual commitment to the relationship is associated with a woman's decision to use and remain on the pill.

Relatively little is known, however, about how partners influence contraceptive use and about overall patterns of use among the rapidly growing population of Hispanics, who now make up 12% of the U.S. population. (11) Data from the 1995 National Survey of Family Growth indicate that the proportion of pregnancies that are unintended is the same among Hispanics and non-Hispanics (490%); however, because Hispanics have more pregnancies than non-Hispanics, they have a far higher rate of unintended pregnancies (69 vs. 42 unintended pregnancies per 1,000 women aged 15-44). (12) Moreover, 25% of Hispanic women aged 15-44 use the pill for contraceptive purposes. (13)

The purpose of this exploratory study is to evaluate the male partner's influence on early pill discontinuation in a predominantly Hispanic urban clinic population. We hypothesize that among Hispanic women, a partner's influence on the decision to use the pill is mediated by the level of commitment in the relationship. The variables under study include those identified in previous studies and others that reflect this hypothesis. The study aims to identify the variables that are associated with early pill discontinuation among Hispanic women so clients and provider can better understand the barriers to effective pill use in this population.

METHODS

Clients at a New York City family planning clinic who were first-time pill users or repeat users initiating a new segment were eligible for the prospective study. (Ongoing users who were renewing a pill prescription were ineligible.) Fewer than 10% of eligible women refused to participate; 250 women enrolled between April and September 2000.

Baseline interviews were conducted at the end of the visit in the language that the woman preferred (English or Spanish). Follow-up telephone interviews were conducted six weeks later; 91% of the women enrolled were successfully contacted. The 23 women who were lost to follow-up did not differ significantly from those who completed the study with respect to age, past pill use, language or partner characteristics. Once we excluded 14 women who discontinued use because they became pregnant or desired a pregnancy, the final sample for analysis consisted of 213 women.

In follow-up interviews, women were asked about each day of pill use from the start through day 29. The study outcome was not having started a second pack of pills-i.e., discontinuing oral contraceptive use before pill number 29. The interviews also elicited women's reasons for discontinuing use. (Most discontinuation occurs within two months of initiating use; (14) because our study population typically has poor follow-up, we used an even shorter follow-up period in the hopes of limiting the rate of loss to follow-up.) Some women took their first pill at the clinic, while others were instructed to take the first pill later, a decision that was determined clinically by the provider and the client. Data regarding when and where the first pill was taken are presented elsewhere. (15)

The baseline interviews solicited information on demographic and social characteristics, reproductive and oral contraceptive history, fertility desires and sexual behavior, degree of acculturation and measures of influence of the male partner. The partner's influence was assessed through questions about the partner's age and fertility intention, the duration of the relationship and whether the woman thought it would last, whether the couple were cohabiting, whether the partner was aware that the woman planned to start pill use that day, how certain she was about wanting to use the pill, how strongly her partner approved of pill use and how satisfied the woman was with her partner. Responses to the last three items were scaled, but we dichotomized them for ease of analysis.

Variables that were significantly associated with discontinuation in a univariate analysis were entered into a multivariate analysis. We used logistic regression to determine which variables were independently associated with discontinuation of the pill. We performed survival analysis to identify when in the 29 days of pill use discontinuation was most likely to occur. All data were analyzed with SPSS 8.0 software. We also assessed how the partner and relationship variables were correlated by examining the chi-square statistic.

RESULTS

On average, the women were 22.4 years old (standard deviation, 5.7); they ranged in age from 13 to 46, and 42% were younger than 21 (Table 1, page 258). The vast majority (88%) were Hispanic, and 81% of these women were Dominican (not shown). Slightly more than half of women were unemployed, and a similar proportion had completed at least 12 years of school (or a GED). A minority spoke only English at home (21%) or with friends (38%). Sixty-one percent of the sample had used the pill, 70% had been pregnant and 47% had given birth.

Of the 204 women who said they had a partner, 37% lived with him, 73% said that he knew of their planned pill use and 64% were very satisfied with him. Thirty-six percent of women with a partner said that he was five or more years older than they were, and 27% reported that he wanted them to become pregnant within the next six months.

More than half of women were very certain they wanted to use the pill and intended to do so for more than one year; however, close to half said they would be happy if they became pregnant within the next six months. Twenty-seven percent of clients took their first pill in the clinic. A majority had intercourse at least once a week (64%) and had had only one partner in the past year (74%).

Overall, 48 women-23%-discontinued the pill before starting the second pack. Women stopped the pill within 29 days for user-related reasons (e.g., they forgot to take pills or were confused about how to take them) or because of side effects or the fear of side effects.

Seven women who accepted the method in the clinic nonetheless never initiated use at home. There was no association between not taking any pill and the partner's awareness of the woman's original intentions to use the pill. The rates of discontinuation during the first week of use were similar between women whose partner knew of their planned pill use and those whose partner did not; however, a higher proportion of women whose partner did not know discontinued use by day 29. Moreover, women whose partner was unaware of their intended pill use discontinued at a steady rate throughout the 29 days, whereas those who informed their partner mostly discontinued within the first 14 days or at day 29. Reported discontinuation tended to occur at the end of a week of use (i.e., at days seven, 14, 21, and 28 or 29), but we do not know whether women actually discontinued on these exact days or tended to report discontinuation that way.

At the univariate level, two background and fertility-related variables were associated with significantly reduced odds of discontinuation (Table 2, page 259)-having at least 12 years of schooling (odds ratio, 0.4) and having intercourse at least once a week (0.5). On the other hand, six variables were associated with significantly increased odds of discontinuation-being younger than 21 (not shown), not taking the first pill in the clinic, not having used it before, being less certain about wanting to use the pill, intending to use it for a year or less, and feeling happy about the prospect of a pregnancy within the next six months (2.0-2.6).

Only one of the variables related to the partner or relationship was significantly associated with discontinuation: Women whose partners were unaware of their plan to initiate pill use had elevated odds of discontinuing use prematurely (3.5). When we limited the analysis to women younger than 18 (not shown), there was a marginally significant association between having a partner who was at least five years older and stopping the pill in the first month of use (odds ratio, 2.1; 95% confidence interval, 0.5-9.0).

Once we controlled for all the variables that were significantly associated with pill discontinuation at the univariate level, five variables remained significant (Table 2). In the multivariate logistic regression model, older age was significantly related to lowered odds of stopping pill use before starting the second pack (odds ratio, 0.9).* The odds of early discontinuation were significantly elevated if women did not take the first pill at the clinic (3.0), intended to use the pill for a year or less (2.3), were happy with the idea of a pregnancy (2.4) or said that their partner did not know of their planned pill use (3.4).

Many of the partner and relationship variables were interrelated (not shown). The partner's approval of pill use, in particular, was associated with his awareness that the woman planned to initiate use, his desire for a pregnancy within six months and the woman's satisfaction with him. For example, partner's awareness of planned pill use was significantly associated with discontinuation among women whose partner desired a pregnancy within six months (odds ratio, 4.4; 95% confidence interval, 1.9-10.1) but not among those whose partner did not desire a pregnancy (odds ratio, 1.9; 95% confidence interval, 0.6-6.1). A partner's awareness of planned pill use was highly correlated with the duration of the relationship, the age difference between partners and whether they were cohabiting. Finally, a woman's happiness about a potential pregnancy was associated with her partner's desire for one in the next six months, but not with her certainty about pill use. Her attitude toward a possible pregnancy was also not related to how long she intended to take the pill.

DISCUSSION

In this exploratory study of partner influence in a mostly Hispanic (Dominican) population, women whose partners were unaware of their plans to initiate pill use had elevated odds of discontinuing prematurely. A male partner's knowledge of planned pill use may reflect that the woman explicitly told him or that he had an implicit understanding of it. Both of these possibilities require a degree of communication within the relationship. Communication in a relationship affects contraceptive use in general and may be a marker for a serious and committed relationship. (16) Partners who are in a committed relationship may find it easier to communicate about contraceptive use, which may lead to higher continuation rates.

Conversely, the lack of commitment in a relationship may be associated with poor contraceptive use. For example, women who are in a short-term relationship or who are at east five years younger than their partner are more likely than others to use no method. (17) Although in our study the duration of the relationship, the age difference between partners and other relationship commitment variables were not independently associated with discontinuation, they were highly correlated with the partner's being aware of planned pill use. Unfortunately, this study was far too small to dis-entangle the separate effects of highly correlated variables.

The association between the partner's knowing about planned pill use and discontinuation may also suggest that the woman's decision to tell her partner depends on her perception of his supportiveness. (A study conducted among Indonesian women found that discontinuation of a method was less associated with partner agreement over the method than with whether the woman had received the method she wanted. (18) In our study, a partner's knowing about planned pill use and his approving of it were highly correlated, and women might have been more likely to tell their partner if they thought that he would approve.

Poor motivation to practice contraception was also independently associated with pill discontinuation: Although all women in our study requested and received pills from the clinic, nearly half were ambivalent about avoiding pregnancy (i.e., they reported being happy about the prospect of a pregnancy in the next six months). Since a woman's intention to use the pill for one year or less was significantly associated with her odds of discontinuation, planned duration of use may serve as another measure of contraceptive motivation.

Several limitations of this study should be mentioned. The information on the partner's desires, attitudes and awareness of planned pill use was obtained from the woman and not from the partner himself, so some of it might have been inaccurate; our data thus report the woman's perception of her partner's knowledge about and attitude toward pill use. Further, the woman's perception of her partner's knowledge was assessed in the baseline interview only;, women who reported that their partner did not know of their planned pill use may have informed him about it later. Another limitation is the sample's small size; a larger sample would allow the associations between partner influence and pill discontinuation to be more precisely characterized. Finally, grouping all Hispanic women together obscures the ethnic, racial and cultural diversity among Hispanics; our findings may not apply to all subgroups.

The dynamic between a woman and her partner that influences the decision to continue pill use is highly complex. The partner's awareness of the decision to initiate use likely reflects aspects of the relationship that are associated with discontinuation, such as levels of communication and commitment in the relationship. Communication about contraceptive use likely benefits the couple in many ways, but women who do not disclose their planned pill use may make that choice because they consider their partner un-supportive or fear adverse consequences. It is therefore important for clinicians to take into account individual women's circumstances and needs before counseling them to inform their partner of their intention to use this method. Studies that incorporate longer follow-up periods are needed among different Hispanic populations to help elucidate the interplay of partner support and communication and its effect on pill discontinuation.

TABLE 1. Percentage distribution of clinic clients initiating pill use,
by selected characteristics, New York City, April-September 2000

Characteristic                                                     %
                                                                (N=213)

BACKGROUND

Age
< 21                                                              42.3
[greater than or equal to] 21                                     57.7

Ethnicity
Hispanic                                                          88.3
Other                                                             11.7

Currently employed
Yes                                                               46.0
No                                                                54.0

Education
< 12 yrs.                                                         43.7
[greater than or equal to] 12 yrs. ([dagger])                     56.3

Language at home
English only                                                      20.7
English and Spanish                                               34.3
Spanish/other language only                                       45.0

Language with friends
English only                                                      37.6
English and Spanish                                               31.4
Spanish/other language only                                       31.0

Time spent in country of origin in past two yrs.
None                                                              56.3
[less than or equal to] 3 mos.                                    29.1
> 3 mos.                                                          14.6

CONTRACEPTIVE/REPRODUCTIVE

Ever used the pill
Yes                                                               61.0
No                                                                39.0

Duration of previous use
None                                                              39.0
[less than or equal to] 12 mos.                                   33.3
> 12 mos.                                                         27.7

Ever been pregnant
Yes                                                               70.4
No                                                                29.6

Age at first pregnancy
Never pregnant                                                    29.6
< 18                                                              25.3
[greater than or equal to] 18                                     45.1

Ever had a live birth
Yes                                                               46.5
No                                                                53.5

Ever had an abortion
Yes                                                               60.6
No                                                                39.4

PARTNER/RELATIONSHIP

Length of time with partner ([double dagger])
< 12 mos.                                                         30.9
[greater than or equal to] 12 mos.                                69.1

Lives with partner ([double dagger])
Yes                                                               37.3
No                                                                62.7

Age difference between partners ([double dagger])
<5 yrs. ([section])                                               63.7
[greater than or equal to] 5 yrs.                                 36.3

Partner knows of planned pill use ([double dagger])
Yes                                                               72.5
No                                                                27.5

Extent of partner approval of pill use ([double dagger])
Strongly approves                                                 52.0
Approves somewhat/disapproves                                     48.0

Partner wants pregnancy in next six mos. ([double dagger])
No/doesn't know                                                   73.5
Yes                                                               26.5

Satisfaction with partner ([double dagger])
Very satisfied                                                    64.2
Somewhat satisfied/unsatisfied                                    35.8

How long woman thinks relationship will last ([double
dagger])
Forever                                                           37.3
< forever                                                         62.7

FERTILITY MOTIVATIONS/BEHAVIOR

Certainty of pill use
Very certain                                                      56.8
Somewhat certain/uncertain                                        43.2

Intended duration of pill use ([dagger][dagger])
> 1yr.                                                            55.5
[less than or equal to]  1 yr.                                    44.5

Reaction to prospect of pregnancy in next six mos.
Unhappy                                                           54.9
Happy                                                             45.1

Took first pill in clinic
Yes                                                               26.8
No                                                                73.2

Wants more children ([dagger][dagger])
Yes                                                               85.2
No                                                                14.8

Frequency of intercourse
< once weekly                                                     35.7
[greater than or equal to] once weekly                            64.3

No. of sex partners in last yr. ([double dagger double
dagger])
1                                                                 73.6
[greater than or equal to] 2                                      26.4

Knows of peers who use the pill
Yes                                                               68.5
No                                                                31.5

Peers are happy using the pill ([subsection])
Yes                                                               79.0
No                                                                21.0

Total                                                            100.0

([dagger]) Includes those with a GED. ([double dagger]) Excludes nine
women who reported no partner. ([section]) Includes couples in which
the woman was older than the man. ([dagger][dagger]) Excludes four
women who did not answer the question or reported "don't know."
([double dagger double dagger]) Excludes one woman had no partner in
last  year. ([subsection]) Excludes 67 women who knew no pill users or
reported "don't know."

Table 2. Unadjusted and adjusted odds ratios (and 95%
confidence intervals) from logistic regression analyses
assessing the association between selected variables and
pill discontinuation before the second pack

Variable               Unadjusted             Adjusted

Age                    na                     0.91 (0.83-0.98) *

Education
< 12 yrs.              1.00                   1.00
[greater than or       0.37 (0.19-0.72) **    ns
  equal to] 12
  yrs. ([dagger])

Frequency of
intercourse
< once weekly          1.00                   1.00
[greater than or       0.46 (0.24-0.88) *     ns
  equal to] once
  weekly

Took first pill
in clinic
Yes                    1.00                   1.00
No                     2.55 (1.07-6.06) **    3.03 (1.19-7.68) *

Ever used the pill
Yes                    1.00                   1.00
No                     2.01 (1.05-3.84) *     ns

Certainty of
pill use
Very certain           1.00                   1.00
Somewhat certain/      1.98 (1.03-3.79) *     ns
  uncertain

intended duration
of pill use
> 1 yr.                1.00                   1.00
[less than or equal    2.31 (1.20-4.47) **    2.28 (1.10-4.71) *
  to] 1 yr.

Reaction to prospect
of pregnancy in next
six mos.
Unhappy                1.00                   1.00
Happy                  2.50 (1.29-4.85) **    2.36 (1.14-4.88) *

Partner knows of
planned pill use
Yes                    1.00                   1.00
No                     3.52 (1.75-7.06) ***   3.43 (1.66-7.09) ***

* p [less than or equal to] .05 ** p [less than or equal to] .01.
*** .p [less than or equal to] .001. ([dagger]) Includes those with a
GED. Notes: All variables that were significant at p<.05 in the
unadjusted analyses are included as controls in the multivariate
analysis. na=not applicable because age was measured as a categorical
variable  in the unadjusted analysis. ns=not significant.

Acknowledgments

The authors thank Cynthia Harper and Paul Newcheck for their valuable feedback on earlier drafts. Financial support was provided by grant 39239 from the National Institute of Child Health and Human Development and by the William and Flora Hewlett Foundation.

* Age was measured as a categorical variable in the univariate analysis. In the multivariate analysis, we modeled age as both a categorical and a continuous variable; results of the two multivariate analyses were almost identical, but the model achieved a better fit with the continuous variable.

REFERENCES

(1.) Abma JC et al., Fertility, family planning and women's health: new data from the 1995 National Survey of Family Growth, Vital and Health Statistics, 1997, Series 23, No. 19.

(2.) Ortho Pharmaceutical, Report on the 1992 Ortho Annual Birth Control Survey, Raritan, NJ: Ortho Pharmaceutical, 1993.

(3.) Rosenberg MJ and Waugh MS, Oral contraceptive discontinuation: a prospective evaluation of frequency and reasons, American Journal of Obstetrics and Gynecology, 1998, 179(3, pt. 1):577-582.

(4.) Ibid.; and Rosenberg MJ, Waugh MS and Long S, Unintended pregnancies and use, misuse and discontinuation of oral contraceptives, Journal of Reproductive Medicine, 1995, 40(5):355-360; and Hatcher RA et al., Contraceptive Technology, 17th ed., New York: Ardent Media, 1998.

(5). Rosenberg MJ, Waugh MS and Long S, 1995, op. cit. (see reference 4).

(6.) Darroch JE, Landry DJ and Oslak S, Age differences between sexual partners in the United States, Family Planning Perspectives, 1999, 31 (4): 160-167; Forste R and Morgan J, How relationships of U.S. men affect contraceptive use and efforts to prevent sexually transmitted diseases, Family Planning Perspectives, 1998, 30(2):56-62; Kaiser Family Foundation, The Kaiser Family Foundation National Survey on Public perceptions About Contraception, Menlo Park, CA: Kaiser Family Foundation, 1997; Forrest JD and Frost JJ, The family planning attitudes and experiences of low-income women, Family Planning Perspectives, 1996, 28(6):246-255 & 277; and Rosenberg MJ et al., Compliance and oral contraceptives: a review, Contraception, 1995, 52(3):137-141.

(7.) Kaiser Family Foundation, 1997, op. cit. (see reference 6).

(8.) Darroch JE, Landry DJ and Oslak S, 1999, op. cit. (see reference 6); Abma J, Driscoll A and Moore K, Young women's degree of control over first intercourse: an exploratory analysis, Family Planning Perspectives, 1998, 30(1): 12-18; and Manning WD, Longmore MA and Giordano PC, The relationship context of contraceptive use at first intercourse, Family Planning Perspectives, 2000, 32(3): 104-110.

(9.) Forrest JD and Frost JJ, 1996, op. cit. (see reference 6); and Weisman CS et al., Adolescent women's contraceptive decision making,Journal of Health and Social Behavior, 1991, 32(2):130-144.

(10.) Whitley BE, College student contraceptive use: a multivariate analysis,Journal of Sex Research, 1990, 27(2):305-313; and Oakley D et al., Oral contraceptive use and protective behavior after missed pills, Family Planning Perspectives, 1997, 29(6):277-279 & 287.

(11.) U.S. Census Bureau, Population by Race and Hispanic or Latino Origin for the United States: 1990 and 2000. Census 2000 Redistricting Data, Washington, DC: U.S. Census Bureau, 2001.

(12.) Henshaw SK, Unintended pregnancy in the United States, Family Planning Perspectives, 1998, 30(1):24-29 & 46.

(13.) Abma JC et al., 1997, op. cit. (see reference 1).

(14.) Rosenberg MJ and Waugh MS, 1998, op. cit. (see reference 3).

(15.) Westhoff C et al., Quick Start: novel oral contraceptive initiation method, Contraception, 2002, 66(3): 141-145.

(16.) Forrest JD and Frost JJ, 1996, op. cit. (see reference 6); Polit-O'Hara D and Kahn JR, Communication and contraceptive practices in adolescent couples, Adolescence, 1985, 20(77):33-43; and Burger JM and Inderbitzen HM, Predicting contraceptive behavior among college students: the role of communication, knowledge, sexual anxiety and self-esteem, Archives of Sexual Behavior, 1985, 14(4):343-350.

(17.) Forrest JD and Frost JJ, 1996, op. cit. (see reference 6); and Weisman CS et al., 1991, op. cit. (see reference 9).

(18.) Pariani S, Heer D and van Arsdol MD, Does choice make a difference to contraceptive use? evidence from East Java, Studies in Family Planning, 1991, 22(6):384-390.

Author contract: [e-mail]

Jennifer Kerns, formerly of the Department of Obstetrics and Gynecology, Columbia University, New York, is a medical student at the University of California, San Francisco, School of Medicine. Carolyn Westhoff is professor of obstetrics and gynecology, and Patricia Aikins Murphy is associate research scientist, both at the Department of Obstetrics and Gynecology, Columbia University. Chelsea Morroni, formerly of the Department of Obstetrics and Gynecology, Columbia University, is a medical student at the University of Cape Town, School of Public Health, Cape Town, South Africa.