Hum. Reprod. Advance Access originally published online on February 12, 2007
Human Reproduction 2007 22(5):1320-1326; doi:10.1093/humrep/dem012
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Contraceptive attitudes and contraceptive failure among women requesting induced abortion in Denmark
1 Department of International Health, Institute of Public Health 2 Department of Anthropology, University of Copenhagen, Copenhagen K, Denmark 3 Department of Sociology, Aalborg University, Aalborg, Denmark 4 Department of Obstetrics and Gynaecology, Hillerod Hospital, Hillerod, Denmark 5 Department of Obstetrics and Gynaecology, Næstved Hospital, Naestved, Denmark 6 Department of Obstetrics and Gynaecology, Sonderborg Hospital, Sonderborg, Denmark 7 Department of Obstetrics and Gynaecology, MAS University Hospital, Malmo, Sweden 8 Department of Obstetrics and Gynaecology, Odense University Hospital, Odense M, Denmark
9 To whom correspondence should be addressed at: Department of International Health, Institute of Public Health, University of Copenhagen, DK 1014 Copenhagen K, Denmark. Tel: +45 353 27472; Fax: +45 353 27383; E-mail: v.rasch{at}pubhealth.ku.dk
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Abstract |
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BACKGROUND: To elucidate how contraceptive attitudes among Danish-born and immigrant women influence the request of induced abortion.
METHODS: A case–control study, the case group comprising 1095 Danish-born women and 233 immigrant women requesting abortion, in comparison with a control group of 1295 pregnant women intending to give birth. The analysis used hospital-based questionnaire interviews.
RESULTS: Lack of contraceptive knowledge and experience of contraceptive problems were associated with the choice of abortion. This association was most pronounced among immigrant women, where women lacking knowledge had a 6-fold increased odds ratio (OR) and women having experienced problems a 5-fold increased OR for requesting abortion. Further, in this group of women, a partner's negative attitude towards contraception was associated with an 8-fold increased OR for requesting abortion. Contraceptive failure was prevalent; 21% of the women who did not plan to become pregnant but intended to give birth had experienced contraceptive failure. The same applied, respectively, for 45% of the Danish-born women and 36% of immigrant women, who requested abortion. Women who had experienced contraceptive failure were significantly more likely to request abortion.
CONCLUSIONS: Immigrant women seem to have more difficulties in using contraception than Danish-born women. To address this problem, there is a need for culturally sensitive information campaigns targeting this heterogonous group of women.
Key words: contraception/Denmark/immigrant/induced abortion
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Introduction |
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Over the past three decades, Denmark has experienced a decline in the abortion rate, reaching its lowest level since the act on induced abortion on request came into force in 1973. This decline has been from 23.7 per 1000 women aged 15–49 in 1975 to 12.2 per 1000 in 2005 (National Board of Health, 1997
, 2006). It is highly likely that the decline in the abortion rate reflects an increased access to modern contraception. Like the other Nordic countries, Denmark has a rather liberal and pragmatic view on sexual education and information, reproductive rights and availability of safe and reliable contraception (David et al., 1990; Wielandt and Knudsen, 1997; Knudsen et al., 2003). These conditions are important factors in a development which has provided the population in Denmark with extended possibilities of exercising an effective birth control. In the event of contraceptive failure or an unwanted pregnancy, in general, it is possible to have an induced abortion in Denmark. According to the act on pregnancy termination, all women in Denmark aged 18 or above are legally entitled to induced abortion on request. This intervention, which is free of charge, must be performed in a public hospital and before the end of the 12th gestational week (Act No. 350, 1973).
Widespread access to modern contraceptives and safe, legal abortion has helped Danish women to decide when and whether to have children. However, there is some concern of a widening reproductive health gap between Danish-born women and women who have recently established themselves in Denmark. This assumption is supported by statistical data showing that some groups of immigrant women are more likely to undergo abortion than Danish-born women, although the difference varies with the country of origin and the women's age (Rasch et al., 2005). Increased abortion rates among immigrant women are not restricted only to Denmark; several other European countries have reported higher levels of abortion rates among immigrants: In 2002, a Norwegian study found that women with foreign background in Oslo were over-represented among women requesting abortion, and similar findings were reported from a Swedish study in 2004 (Eskild et al., 2002; Helstrom et al., 2003). In addition, a Swiss study from the 1990s found that the rate of abortion for non-western women was twice that for Swiss women (Addor et al., 2003). The reason behind the comparatively higher abortion rate among immigrant women is unclear. Evidence, however, points in the direction of immigrant status being associated with low education, weak social network, poverty, unemployment and being outside common pathways to healthcare; this may influence the decision to have an abortion (Helstrom et al., 2003; Rasch et al., 2006).
In 1999, the Ministry of Health in Denmark launched a ‘Plan of Action to Reduce the Number of Induced Abortions’. This plan of action focused on improved prevention of both induced abortions and unintended pregnancies, stressing the need for new knowledge on: (i) the reasons for choosing induced abortion, (ii) the quality of the physicians' information and counselling to women who experience unwanted pregnancies and (iii) identification of vulnerable groups of women. Further, the National Board of Health stated that the main aim of a continuing preventive action was to maintain the low abortion rate and to concentrate on the preventive action in relation to women who are especially at risk of having an induced abortion. The present study was part of the earlier mentioned Plan of Action and aims to elucidate how contraceptive knowledge and attitudes among Danish-born and immigrant women influence them in their choice of abortion.
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Materials and methods |
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Study population
Data were collected among women who requested induced abortion before the completion of the 12th week of gestation and among antenatal care attendees, during the period September 2002 through April 2003, in eight different hospitals dispersed in seven different counties in Denmark.
Women requesting induced abortion were invited to participate in the study when they came to the hospital for the initial examination before the abortion. In total, 1862 women were invited to participate and 1384 women agreed to participate, thus giving a response rate of 74.3%.
Women attending antenatal care were invited to participate in the study when they came for routine ultrasound scanning during the 12th–20th week of gestation. In total, 1675 pregnant women were invited to participate in the survey and 1306 (77.9%) agreed to participate.
Methods
The analysis presented here is part of a larger study which is based on a triangle of methods: register-based quantitative analyses covering the period 1981–2001, hospital-based questionnaire interviews with 2690 women and in-depth qualitative interviews with 40 selected women (Rasch et al., 2005). The present paper is based on the questionnaire interviews.
A case–control design was utilized: the case group comprising women who requested abortion before the end of the 12th gestational week and the control group comprising pregnant women who came for antenatal care during the 12th–20th gestational weeks. Data were obtained by a self-administered questionnaire focusing on socio-economic characteristics, contraceptive knowledge, experience and attitudes and ethnic background. When the woman did not understand Danish, and was accompanied by an interpreter at the hospital, the interview took place with the assistance of the accompanying interpreter. In addition, the questionnaire was translated into English and the patient information was translated into Arabic, Farsi, Urdu, Serbo-Croatian, Somali, Turkish and English. The patient information included information about the purpose of the survey and an offer to be interviewed by telephone in the woman's own language. If the woman agreed to such a telephone interview, she was asked to give her phone number and was later interviewed by an interpreter. It was stressed that participating in the survey was voluntary, and that the women could withdraw from the study at any time. Permission to carry out the survey was granted by the regional ethical committee in the counties where the data were gathered.
The women's ethnic background was determined on the basis of the information they had provided in the questionnaire about their and their parents' country of birth. Women born in Denmark by Danish parents were categorized as being Danish-born, women born in Denmark of parents born outside Denmark were categorized as descendants and women born outside Denmark were categorized as immigrants. In accordance with these categories, 1294 women who had chosen to undergo abortion had a Danish background, 15 were descendants and 242 were immigrants. Descendants were analysed together with women of Danish origin and all women of ‘other origin’ were considered together. The 1306 women who came for antenatal care were considered together as a reference group, regardless of ethnic origin.
Among the 1384 women applying for abortion, 56 questionnaires were incomplete (33 were missing information about ethnic background and 23 were missing information about contraceptive practice). These questionnaires were excluded, giving a study population of 1328 women who were applying for induced abortion. Among the 1306 antenatal care attendees, 11 questionnaires were incomplete and therefore excluded from the analyses, giving a study population of 1295 women who were attending antenatal care.
Statistical analyses
Data were recorded using the software Epi Info version 6.04 for Epidemiology and Disease surveillance from the Centres for Disease Control and Prevention, Atlanta, USA. Statistical analyses were carried out by the Statistical Package for the Social Sciences (SPSS for windows, version 12.0). Stratified analyses based on the women's ethnic backgrounds were performed and a case–control design was utilized in which Danish-born and immigrant women requesting abortion comprised the case group, with a control group of women intending to give birth. Contraceptive knowledge, partner's attitude towards contraception, previous use of contraception, pregnancy planning and contraceptive failure were included as explanatory variables. The associations are presented as odds ratio (OR) with 95% confidence intervals (CI).
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Results |
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To assess the representativeness of the study population, the women's background characteristics (age, parity and marital situation) were compared against the national figures (Table I). The age distribution among the women who underwent abortion is largely consistent with the national statistics, although the women in this study tend to be slightly younger. Regarding the women's marital situation and parity, there also seems to be a large consistency.
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The vast majority of women who intended to give birth and the Danish-born women requesting abortion felt that they had sufficient knowledge about contraception, whereas immigrant women were less likely to state the same (Table II). Lack of contraceptive knowledge among immigrant women was associated with an increased OR for requesting abortion. Perceived side effects and having experienced problems in relation to contraceptive use were also found to be more strongly associated with the choice of abortion among immigrant women in comparison with Danish-born women. Hence, immigrant women, who believed that contraception was associated with side effects, had a 2-fold increased OR for requesting abortion, whereas immigrant women who had experienced problems in relation to contraceptive use had a 5-fold increased OR for requesting abortion. Further, in the group of immigrant women, a partner's negative attitude towards contraception was found to be associated with an 8-fold increased OR for requesting abortion.
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Women who had experienced contraceptive problems in the past had a higher OR of requesting abortion (Table III). Furthermore, women who previously had experienced contraceptive side effects were found to have a greater OR for requesting abortion. Focusing on oral contraceptives, Danish-born and immigrant women, who stated they had stopped using this method due to experienced side effects, had an increased OR of 3.67 and 10.2, respectively, for requesting abortion. A similar picture was found in relation to intrauterine device (IUD) use, where discontinuation due to side effects was found to be associated with an increased OR of 2.20 among Danish-born women and 2.29 among immigrant women for requesting abortion. Lastly, among women who had been using the condom in the past, an increased OR of 3.19–3.49 for requesting abortion was found between those who had stopped using the method because they found it inconvenient to use. Further, women who had stopped using the condom because of their partner's attitude had an increased OR of 5.55–8.25 for requesting abortion.
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In the group of women requesting abortion, 94% of Danish-born women and 92% of immigrant women stated that their pregnancy was unplanned (Table IV). Among these women, 45% and 36%, respectively, stated they had become pregnant in spite of contraceptive use (Table V). In contrast, in the group of women intending to give birth, only 18% stated that the pregnancy was unplanned and 21% of these women had experienced contraceptive failure. Danish-born and immigrant women, who had experienced method failure in relation to condom use, had an increased OR of 5.02 and 3.87, respectively, for choosing abortion. Failure of oral contraception was found to be associated with an increased OR of 2.03 for requesting abortion among Danish-born women, whereas the association was insignificant among immigrant women.
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Emergency contraception had not been commonly used among women who had not planned on becoming pregnant. Among women choosing abortion, only 11% stated that they had used emergency contraception in relation to the intercourse during which they had most likely conceived (Table VI). Danish-born and immigrant women did not differ from one another. The corresponding figure among women intending to give birth was 2.5%. In the comparative analysis, women who stated that they had used emergency contraception unsuccessfully were five times more likely to choose abortion in comparison with women who had not used any emergency contraception. No difference was found according to ethnic background.
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Discussion |
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The present study relied on a hospital-based approach since it provided the option of attaining personal contact with the women and was helpful when recruiting women who were not able to read and speak Danish. To ensure best possible representativeness of the study population, data were collected in seven different counties. The age, marital situation and parity of the women participating in the study were compared with nationwide register data of women seeking abortion and women giving birth (Rasch et al., 2005
). No pronounced discrepancy was found, indicating that the study population may be considered a representative sub-sample of women living in Denmark choosing to either undergo abortion or to go through with a pregnancy.
Sexual and reproductive health education is part of the Danish school curriculum and it is a general assumption that young people living in Demark are well aware of basic physiology and how to avoid unwanted pregnancies as well as sexually transmitted infections (David et al., 1990; Wielandt and Knudsen, 1997; Wielandt et al., 2002; Knudsen et al., 2003). The findings from the present study also indicate that the level of contraceptive knowledge in general is high in Denmark. The vast majority of women intending to give birth and Danish-born women requesting abortion claimed to have received sufficient information about contraception. A similar high contraceptive awareness among women applying for abortion has been reported in other Danish studies as well as in Nordic studies (Kristiansen et al., 1991; Ingelhammar et al., 1994; Savonius et al., 1995; Rasch, 2002). A worrisome finding, however, was that immigrant women far more often felt that they were insufficiently informed about contraception and this insufficient knowledge was associated with an increased OR for requesting induced abortion. It may be assumed that women, who feel they lack information about contraception in comparison with women who feel they are well informed, may experience more difficulties in accessing contraception as well as using the methods correctly. The study in this respect indicates that immigrant women comprise a particularly vulnerable group, who are at increased risk of experiencing unwanted pregnancy. This is also reflected in the qualitative part of the full study which showed that immigrant women, in contrast to Danish-born women, often were lacking basic knowledge about reproductive physiology and contraceptive use (Rasch et al., 2005). Effective family planning implies that the women have an actual choice between different contraceptive methods. This again requires that the women have knowledge about different contraceptive methods, how they function and where to access them. Although this is the situation for most women living in Denmark, the present study indicates that there are some women who are less well informed about contraception and thus at risk of experiencing an induced abortion.
It is often fear of or experienced side effects which make women decide against using effective contraception (Rasmussen, 1983; Sidenius et al., 1983; Bertelsen, 1994; Ingelhammar et al., 1994). As previously documented, the women, in particular, found oral contraceptives and IUDs to be associated with side effects and considered intake of hormones on a daily basis harmful (Rasch et al., 2005). In addition, especially immigrant women express concern about oral contraceptives being associated with an increased risk of cancer (Rasch et al., 2005). The fear of side effects, together with insufficient knowledge about the different contraceptive methods' course of action, may result in ambivalent feelings towards modern contraception and lead to method change (Sidenius et al., 1983; Larsson, et al., 2002; Rasch et al., 2005). The use of contraceptives for many women is a compromise, a trade-off, where they have to choose the ‘least evil’ method. To find the best possible method, they may change between different contraceptive methods (Rasch et al., 2005). While changing contraceptive methods, the women are less protected against pregnancy, compared with when they use a method continuously and are therefore at increased risk of induced abortion (Sidenius et al., 1983; Larsson et al., 2002). Contraceptive discontinuation due to side effects may also be the explanation behind the surprising finding that women who had previously been using IUDs had a significantly increased OR for requesting induced abortion. Abortion seeking women, who have been using IUDs, often complain about associated backache and increased bleeding. They find these side effects intolerable and therefore decide against using the IUD (Rasch et al., 2005). If they discontinue using the IUD without switching to another highly effective contraceptive method, they will be at an elevated risk of unplanned pregnancy and subsequently induced abortion (Rasch et al., 2005).
Unplanned pregnancies occurred among both women seeking abortion and women intending to give birth. Especially among women applying for induced abortion, there had been attempts to avoid these unplanned pregnancies by contraceptive use, and the high rate of contraceptive failures reported by women requesting abortion, reflects that many women who have induced abortions had actively tried to avoid an unwanted pregnancy. This finding is in accordance with other studies which has documented that many women requesting induced abortion claim to have used contraception during the intercourse in which they most likely became pregnant (Ingelhammar et al., 1994; Sorensen et al., 1994; Savonius et al., 1995; Kero et al., 2001; Rasch, 2002). However ‘reversible contraceptive methods are not always used perfectly, some degree of failure—sometimes to a substantial degree—occurs with all reversible methods’ (Trussell et al., 1990). Occurrence of oral contraceptive failure was, in the present study, reported by 34% of the women who had experienced contraceptive failures. Two-thirds of these women, however, mentioned that there had been isolated omissions of taking the pill due to forgetfulness. The qualitative part of the full study revealed that many women experiencing abortion found it difficult to remember to take the pill every day (Rasch et al., 2005). Inconsistent use in relation to oral contraceptives is well known. Rosenberg et al. (1998) reported that 47% of oral contraceptive users missed one or more pills per cycle and 22% missed two or more (Rosenberg et al., 1998). Regarding the use of condoms, 55% of the women with unplanned pregnancy who had experienced contraceptive failure stated that they had used the condom. This result partly reflects the popularity of the method; however, it is most likely that it also reflects that failure in relation to condom use is common, either because of inconsistent or incorrect use or because of condom breakage and slippage.
Correct use of emergency contraception among women who either experience contraceptive failure or have unprotected intercourse without intending to become pregnant may reduce the need for induced abortion. Two previous studies, investigating the use of emergency contraception in Denmark, only in 1994 and 2000, have shown that 4.2% and 6.6% of women requesting abortion had used emergency contraception in trying to prevent the current pregnancy (Sorensen et al., 2000; Perslev et al., 2002). The corresponding figure in the present study was 11.6%. This increasing number may reflect an increasing access to emergency contraception, since it became available over the counter in 2001. A similar trend of increased use of emergency contraception, when it became available at pharmacies without prescription, has been reported in a recent Swedish study (Larsson et al., 2004).
In conclusion, this study has shown that it seems to be much more difficult for immigrant women than Danish-born women to protect themselves against unwanted pregnancies. In this context, it has to be acknowledged that an abortion is not an isolated event in a woman's life. It is often a last resort for a woman who is faced with an unplanned pregnancy which she feels, for various reasons, she is not able to manage. Accordingly, doing more to help immigrant women avoid unintended pregnancies would help them make a more informed choice about contraceptive use and thereby reduce their risk of experiencing an induced abortion. To address the problem of induced abortion, it is of paramount importance that immigrant women are reached by culturally sensitive information campaigns which address the specific situation of this very heterogonous group of women.
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The study was supported by the Danish National Board of Health. V.R., L.B.K. and T.G. designed the study. V. R. performed the analyses, and led the writing. J.T.C., M.E., J.J.P.C. and J.B.S. assisted in designing the study and supervised the implementation of the study. All authors contributed to the interpretation of the findings and reviewed drafts of the paper.
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Submitted on October 4, 2006; resubmitted on December 13, 2006; accepted on December 27, 2006.
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