Women’s Contraceptive Method Choice in the United States: The Role of the Health Care System, the Importance of Contraceptive Attributes, and Exploring the Potential for a Decision Support Intervention in the Clinical Setting

In spite of an expanding menu of contraceptive options, women in the United States (US) continue to experience high rates of unintended pregnancy, with 50% of all pregnancies being unintended. Unintended pregnancy has been associated with a number of adverse health outcomes for mothers and their children and results in significant financial cost to society. While the root causes of unintended pregnancy are likely complex and multi-factorial, the direct cause of an unintended pregnancy is sexual activity coupled with contraceptive misuse, failure or nonuse altogether. Although most women who do not wish to become pregnant have at some point used contraception, nonuse and inconsistent use of contraception in any given year is common. Thus, at its most proximal level, reducing unintended pregnancy requires increasing and improving contraceptive use among women and couples that want to avoid pregnancy. This research focuses on contraceptive method choice as a critical decision because the method used by a woman has implications for how well she is able to prevent an unintended pregnancy. Further, dissatisfaction with the contraceptive methods women use is high, highlighting the importance of assisting women with choosing methods that meet their needs. Contraceptive method choice is a highly individualized decision made in the context of a woman’s life circumstances. This decision can be complex and involves a number of considerations that can affect a woman’s ability to successfully use the method. Given that the most commonly used and most effective methods require a prescription and/or an interaction with a health care provider in the US, factors related to the health care system influence the methods women choose. There is a need to develop patient-centered interventions that can assist women in choosing a contraceptive method that best meets their individual needs. This dissertation presents the findings of three interrelated studies related to women’s contraceptive method choice. The first paper presents the findings of a critical literature review of the role of the US health care system in impacting women’s contraceptive method choice. In this study, I identified a comprehensive set of factors related to the health care system, such as the provision of specific services by providers, that are associated with contraceptive method choice. The second paper examined a component of the contraceptive choice decision-making process by assessing the importance women assign to several contraceptive attributes when choosing a method. This quantitative analysis tested hypotheses to determine if the importance women assigned to various contraceptive attributes aligned with the methods they chose. Finally, in the third paper, I explored patient perceptions of a contraceptive decision support tool that can be used in clinical settings to help women choose contraceptive methods. Specifically, this qualitative study used semi-structured interviews to describe patients’ perception of the value and utility of the tool in order to understand the mechanisms through which these tools have an impact on contraceptive method choice