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An exploratory study to identify preconception contraceptive patterns of abortion patients Watts, Judith Mary E. 1974

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AN EXPLORATORY STUDY TO IDENTIFY PRECONCEPTION CONTRACEPTIVE PATTERNS OF ABORTION PATIENTS by JUDITH MARY E . WATTS B.Sc.N., S t a t e U n i v e r s i t y o f Iowa, 1965 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n t h e Department o f N u r s i n g We a c c e p t t h i s t h e s i s as co n f o r m i n g t o t h e requi**©^ s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA June, 1974 I n p r e s e n t i n g t h i s t h e s i s I n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may b e g r a n t e d by t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f / „ <\,-y->-<.*;.,} The U n i v e r s i t y o f B r i t i s h C o l u m b i a V a n c o u v e r 8 , C a n a d a ABSTRACT AN EXPLORATORY STUDY TO IDENTIFY PRECONCEPTION CONTRACEPTIVE PATTERNS OF ABORTION PATIENTS J u d i t h Mary E. Watts The purpose o f t h i s s t u d y was t o add t o t h e under-s t a n d i n g o f problems w i t h c o n t r a c e p t i v e u t i l i z a t i o n by d e s c r i b i n g c o n t r a c e p t i v e p r a c t i c e s , a t t i t u d e s , and know-ledge o f a b o r t i o n p a t i e n t s . Women h a v i n g a b o r t i o n s were s e l e c t e d as s u b j e c t s because o f t h e i r apparent c o n t r a c e p -t i o n d i f f i c u l t i e s . The study was c o n s i d e r e d o f v a l u e t o nurses who a r e i n a good p o s i t i o n t o p r o v i d e c o n t r a c e p t i o n s e r v i c e s t o p e o p l e . T h i r t y s u b j e c t s were randomly s e l e c t e d from p a t i e n t s h a v i n g D S C / a s p i r a t i o n a b o r t i o n s as i n - p a t i e n t s i n a l a r g e urban B r i t i s h Columbia h o s p i t a l . Data were g a t h e r e d u s i n g a s e m i - s t r u c t u r e d q u e s t i o n n a i r e i n a s i n g l e i n t e r v i e w h e l d t h e e v e n i n g b e f o r e t h e a b o r t i o n . A l a r g e amount o f d a t a were g a t h e r e d on c o n t r a -c e p t i v e u t i l i z a t i o n o f which t h e f o l l o w i n g items a re o f p a r t i c u l a r i n t e r e s t . 1) The women h a v i n g a b o r t i o n s t o d e a l w i t h unwanted p r e g n a n c i e s were a w i d e l y v a r i e d group i n terms o f age, m a r i t a l s t a t u s , e d u c a t i o n , and o c c u p a t i o n . The l a r g e s t number were i n t h e i r 2 0's and many (o v e r h a l f ) had s t a b l e r e l a t i o n s w i t h t h e i r s e x u a l p a r t n e r s . 2 ) A l m o s t a l l s u b j e c t s h a d u s e d c o n t r a c e p t i v e s a t some t i m e a n d many ( o v e r h a l f ) u s e d t h e m a t t h e t i m e o f c o n c e p t i o n o f t h e p r e g n a n c y b e i n g a b o r t e d . F i v e o f t h e s u b j e c t s e x p e r i e n c e d c o n t r a c e p t i v e f a i l u r e w i t h I U D ' s . 3 ) Many s u b j e c t s i n d i c a t e d a m b i v a l e n c e a b o u t t h e u s e o f a n d r e s p o n s i b i l i t y f o r c o n t r a c e p t i o n . T h e y f r e q u e n t l y w i s h e d t o s h a r e r e s p o n s i b i l i t y f o r c h o o s i n g c o n t r a c e p t i v e s w i t h t h e i r p a r t n e r s b u t o f t e n d i d n o t do s o . 4 ) M o s t s u b j e c t s w e r e n o t w e l l i n f o r m e d a b o u t c o n t r a -c e p t i o n . T h e i r s o u r c e s o f c o n t r a c e p t i o n i n f o r m a t i o n w e r e v a r i e d a n d t h e i r p a r e n t s t e n d e d t o b e i n c o n s i s t e n t a s s o u r c e s . 5 ) C o m p a r i n g u s e r s a n d n o n - u s e r s o f c o n t r a c e p t i v e s a t t h e t i m e o f c o n c e p t i o n , u s e r s t e n d e d t o be o l d e r , h a v e m o r e s t a b l e r e l a t i o n s w i t h t h e i r s e x u a l p a r t n e r s , be m o r e r e g u l a r a n d e f f e c t i v e c o n t r a c e p t i v e u s e r s , a n d n o t h a v e d e p e n d e d o n p a r e n t s a s s o u r c e s o f c o n t r a c e p t i o n i n f o r m a t i o n . N o n - u s e r s t e n d e d t o be y o u n g e r , h a v e l e s s s t a b l e r e l a t i o n -s h i p s w i t h t h e i r s e x u a l p a r t n e r , b e l e s s r e g u l a r a n d e f f e c t i v e c o n t r a c e p t i v e u s e r s , a n d h a v e d e p e n d e d o n p a r e n t s f o r c o n t r a c e p t i o n i n f o r m a t i o n . Some o f t h e i m p l i c a t i o n s d r a w n f r o m t h e d a t a a r e a s f o l l o w s . Women h a v i n g c o n t r a c e p t i v e u t i l i z a t i o n p r o b l e m s eome f r o m many s e t t i n g s a n d b a c k g r o u n d s . T h e r e f o r e , e f f o r t s t o i m p r o v e c o n t r a c e p t i v e u t i l i z a t i o n m u s t be v a r i e d a n d f l e x i b l e t o r e a c h a l l p e o p l e w i t h c o n t r a c e p t i o n n e e d s . E f f e c t i v e c o n t r a c e p t i v e u t i l i z a t i o n a p p e a r s t o be i n f l u e n c e d b y f e e l i n g s a b o u t i n d e p e n d e n c e a n d r e s p o n s i b i l i t y , a n d o f c o m f o r t w i t h o n e ' s s e x u a l i t y . C o n s e q u e n t l y , c o n t r a c e p t i o n s e r v i c e s n e e d t o i n c l u d e o p p o r t u n i t i e s t o d e a l w i t h t h e s e b r o a d e r i s s u e s . C o n t r a c e p t i o n k n o w l e d g e i s o f t e n l i m i t e d a n d e f f e c t i v e s o u r c e s o f i n f o r m a t i o n a r e n o t f o u n d c o n s i s -t e n t l y i n o u r s o c i e t y . P r o f e s s i o n a l e f f o r t s n e e d t o b e m a d e t o e n s u r e g o o d c o n t r a c e p t i o n e d u c a t i o n t h a t c a n s u p p l e m e n t w h a t i s l e a r n e d f r o m p a r e n t s . A r e a s r e c o m m e n d e d f o r f u t u r e s t u d y i n c l u d e m o r e t h o r o u g h i n v e s t i g a t i o n s o f c o n t r a c e p t i o n a t t i t u d e s a n d k n o w l e d g e , a n d t h e i r e f f e c t s o n p r a c t i c e . A l s o , c o m p a r -i s o n s t u d i e s o f c o n t r a c e p t i v e u t i l i z a t i o n o f o t h e r g r o u p s o f w o m e n a r e n e e d e d , a s a r e e x p e r i m e n t a l s t u d i e s t o t e s t t h e e f f e c t i v e n e s s o f c o n t r a c e p t i o n e d u c a t i o n a n d s e r v i c e s . T h e s i s C h a i r m a n i v TABLE OF CONTENTS Page LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i Chapter I INTRODUCTION 1 A. DEFINITION OF THE PROBLEM 1 1. Problem Statement 1 2. Elements of the Problem 1 B. SIGNIFICANCE OF THE PROBLEM TO NURSING 7 I I REVIEW OF THE LITERATURE 10 A. CONTRACEPTIVE UTILIZATION 10 1. Research L i t e r a t u r e 10 2. Opinion L i t e r a t u r e 18" B. CONTRACEPTIVE METHODS 20 C. DEMOGRAPHIC CHARACTERISTICS OF ABORTION PATIENTS 23 I I I DESIGN 26 A. RESEARCH QUESTION 26 B. DEFINITIONS 26 C. ASSUMPTIONS 27 D. LIMITATIONS 28" E. RESEARCH PLAN 28" 1. Approach 2$ 2. S e t t i n g 29 3 . P o p u l a t i o n 29 4 . Sample 29 5. Tool 30 V Chapter Page F. DEVELOPMENT OF THE TOOL 30 G. ANALYSIS OF THE DATA 33 IV RESULTS AND ANALYSIS 34 A. SAMPLING 34 B. DEMOGRAPHIC DATA 34 C. DATA IN RELATION TO THE OBJECTIVES 36 D. COMPARISON OF CONTRACEPTIVE USERS AND NON-USERS AT CONCEPTION 47 V DISCUSSION AND IMPLICATIONS 51 A. DISCUSSION 51 1 . Demographic C h a r a c t e r i s t i c s 51 2. Contraception P r a c t i c e 52 3 . Contraception A t t i t u d e s 55 4 . Contraception Knowledge 57 5. Subjects' Explanations 60 6 . Contraceptive Users and Non-Users 61 7. Study Design 62 B. IMPLICATIONS 64 1 . General 64 2. Contraception P r a c t i c e 65 3 . Contraception A t t i t u d e s 66 4 . Contraception Knowledge 67 5. Future Studies 67 BIBLIOGRAPHY 69 APPENDICES 71 A. QUESTIONNAIRE AND INTRODUCTORY MATERIAL 71 v i Chapter Page B. TABLE I : DEMOGRAPHIC DATA 91 C. TABLE I I : SCORES FOR EACH QUESTION ON KNOWLEDGE OF CONTRACEPTION 93 v i i LIST OF TABLES Table Page I Appendix B: Demographic Data 9 1 I I Appendix C: Scores f o r Each Question on Knowledge of Contraception 93 v i i i ACKNOWLEDGEMENTS I w i s h t o e x p r e s s my a p p r e c i a t i o n f o r t h e a s s i s t a n c e g i v e n b y t h e many p e o p l e who h e l p e d me w i t h t h i s w o r k . I n p a r t i c u l a r , I am g r a t e f u l f o r t h e c o - o p e r a t i o n o f t h e women who p r o v i d e d t h e d a t a f o r t h e s t u d y a t a t i m e w h i c h was d i f -f i c u l t a n d p a i n f u l f o r t h e m . The i n t e r e s t a n d e n c o u r a g e m e n t o f my c o m m i t t e e m e m b e r s , B a r b a r a H e r r i c k a n d H e l e n E l f e r t , a l l o w e d me t o c a r r y o u t t h e s t u d y w i t h a u s e f u l m i x o f f r e e d o m a n d g u i d a n c e . The s u p e r v i s o r a n d s t a f f n u r s e s o f t h e h o s p i t a l u n i t w h e r e t h e s u b j e c t s w e r e i n t e r v i e w e d w e r e h e l p f u l a n d s u p p o r t -i v e . W i t h o u t t h e i r a c c e p t a n c e t h i s s t u d y c o u l d n o t h a v e b e e n d o n e . F i n a l l y , I w i s h t o t h a n k D r . A . S . M a c p h e r s o n , M c M a s t e r U n i v e r s i t y M e d i c a l C e n t r e f o r h i s i n t e r e s t a n d a s s i s t a n c e w i t h t h e s t a t i s t i c a l a n a l y s i s : t h e c o m p u t e r a n d I c a n now c o m m u n i c a t e . ' M i s s E l a i n e R e i n h a r d t h a s w o r k e d w e l l w i t h t h e t y p i n g o f t h i s s t u d y a n d p a t i e n t l y w i t h t h e a n x i e t i e s o f t h e r e s e a r c h e r f o r w h i c h s h e h a s my t h a n k s . / Chapter I INTRODUCTION A. D e f i n i t i o n of the Problem 1) Problem Statement The purpose of t h i s e x p l o r a t o r y study i s t o describe the patterns of contraceptive u t i l i z a t i o n , as i d e n t i f i e d by knowledge, a t t i t u d e s and preconception use of c o n t r a c e p t i v e s , of a b o r t i o n p a t i e n t s i n a l a r g e , urban B r i t i s h Columbia h o s p i t a l . The study has grown out of concern w i t h the con-s i d e r a b l e number of abort i o n s being requested and performed i n centres i n Canada today. I d e n t i f i c a t i o n of these u t i l i z -a t i o n p atterns may i n d i c a t e s p e c i f i c problems w i t h e f f e c t i v e c o n t r a c e p t i o n . Knowledge of such problems could be used t o improve advice and education concerning contraception. 2) Elements i n the Problem a) A b o r t i o n a v a i l a b i l i t y . In the past few years, many cou n t r i e s have l i b e r a l i z e d t h e i r a b o r t i o n laws. Japan and the eastern European c o u n t r i e s were the f i r s t t o ex-perience extensive use of l e g a l abortions s t a r t i n g between the years 1949 t o I960, followed by Sweden and Great B r i t a i n i n 1965 and 1967 r e s p e c t i v e l y . Between 1967 and 1970, eleven s t a t e s i n the U.S.A. l i b e r a l i z e d t h e i r a b o r t i o n laws t o 2 v a r y i n g degrees. ^" I n Canada, the C r i m i n a l Code was amended i n 1969 so t h a t a b o r t i o n , w h i l e s t i l l coming under c r i m i n a l j u r i s d i c t i o n , may be made a v a i l a b l e i n any p u b l i c general h o s p i t a l f o l l o w -i n g approval of i n d i v i d u a l requests by a m a j o r i t y of the members of a committee of p h y s i c i a n s . This committee must be appointed by the h o s p i t a l board f o r the purpose of con-s i d e r i n g questions r e l a t e d t o t e r m i n a t i o n of pregnancy. The Code d i r e c t s t h a t the committee may approve a b o r t i o n i n any case where the c o n t i n u a t i o n of a woman's pregnancy, "would 2 or would be l i k e l y to endanger her l i f e or h e a l t h " . With t h i s l i m i t e d and f l e x i b l e d i r e c t i v e f o r a b o r t i o n approval, very l i b e r a l i n t e r p r e t a t i o n by i n d i v i d u a l h o s p i t a l s i s p o s s i b l e . I f a v a i l a b i l i t y of a b o r t i o n i n Canada i s considered, i t i s important to r e a l i z e that the r e v i s e d Code does not r e q u i r e a l l p u b l i c general h o s p i t a l s t o e s t a b l i s h a committee to deal w i t h a b o r t i o n s . However, i n the Province of B r i t i s h Columbia, s e v e r a l h o s p i t a l s have done so and may be assumed to be l i b e r a l w i t h t h e i r approval as i n d i c a t e d by the f o l l o w -i n g s t a t i s t i c s . I n 1970, there were 3.5 a b o r t i o n s performed per 100 l i v e b i r t h s i n B.C. and i n 1971 there were 19.1 a b o r t i o n s per 100 l i v e b i r t h s . For 1972, the B r i t i s h 1 D a n i e l Callahan, A b o r t i o n : Law, Choice and M o r a l i t y (London: C o l l i e r - M a c m i l l a n L t d . , 1970}, pp. 141 - 255. 2 R e v i s e d Sta t u t e s of Canada 1970» V o l . I I (Ottawa: Queen's P r i n t e r f o r Canada, 1970), pp. 1627 - 1629. 3 Columbia H o s p i t a l Insurance S e r v i c e p r e d i c t e d 25 a b o r t i o n s 3 per 100 l i v e b i r t h s . Those c o u n t r i e s which f i r s t made l e g a l a b o r t i o n s r e a d i l y a v a i l a b l e tended t o do so p r i m a r i l y f o r married women w i t h c h i l d r e n . However, more r e c e n t l y the general trend has allowed a b o r t i o n f o r s i n g l e n u l l i p a r o u s women a l s o . ^ The Canadian C r i m i n a l Code makes no d i f f e r e n t i a t i o n of m a r i t a l or parous s t a t u s f o r a b o r t i o n approval. As a b o r t i o n laws are eased f o r a l l c o u n t r i e s , one of the most c o n s i s t a n t concerns i n the a f f e c t e d c o u n t r i e s has been the p o s s i b l e tendency f o r abortions t o be used f o r 5 c o n t r a c e p t i o n . Contraception and a b o r t i o n have the same f i n a l g o a l : the prevention of c h i l d r e n being born. However, r e s o r t i n g t o a b o r t i o n as a contraceptive i s ofte n considered by h e a l t h personnel t o be " . . . n e i t h e r safe nor simple, and ...the long-term complications alone condemn i t s use as a contraceptive method."^ b) Contraception u t i l i z a t i o n . Contraceptives are l e g a l l y a v a i l a b l e t o a l l people i n Canada who are of the age of consent or considered t o be emancipated adolescents. ^Contraceptive P r a c t i c e s , V o l . I of Babies by Choice  Not by Chance (Vancouver, B.C.: United Community Se r v i c e s of the Greater Vancouver Area, December 1972) . p. 6 . ^ C a l l a h a n , op. c i t . , pp. 292-293. 5 ^Henry P. David, "Abortion i n P s y c h o l o g i c a l Per-s p e c t i v e , " American Journal of Orthopsychiatry, 4 2 : 65 , January 1 9 7 ^ "Contraception or A b o r t i o n , " Nursing Times, 6 9 : 250, February 24, 1972. 4 However, there are s i t u a t i o n s which i n h i b i t c o n t r a c e p t i o n u t i l i z a t i o n . For i n s t a n c e , teenagers and unmarried people i n our Western s o c i e t y are now ofte n s e x u a l l y a c t i v e and, though many of these people f i n d resource personnel who are w i l l i n g t o advise about and p r e s c r i b e c o n t r a c e p t i v e s , some do not. 7 Not a l l those who do use modern methods use them w e l l . Some people, e s p e c i a l l y the young and unmarried, are i n -h i b i t e d by p a r e n t a l and s o c i a l c o n s t r a i n t s from seeking and usin g c o n t r a c e p t i v e s e f f e c t i v e l y . Contraceptive a v a i l a b i l i t y i n Canada i s a l s o a f -fe c t e d by geography and l i m i t e d access t o appropriate r e -sources. The most e f f e c t i v e contraceptive methods ( p i l l s , I.U.D.^) re q u i r e a doctor's p r e s c r i p t i o n but not a l l p a r t s of the country have a doctor's s e r v i c e s a v a i l a b l e . Further, where doctors are a v a i l a b l e , not a l l are w i l l i n g t o provide f o r c o n t r a c e p t i v e s f o r reasons of s p e c i a l t y l i m i t a t i o n s or personal b e l i e f s . " ^ Although c o n t r a c e p t i v e methods are a v a i l a b l e t o both men and women, the most e f f e c t i v e ones are f o r female 'Callahan, op. c i t . , p. 293. M i c h e l l e Landsburg, "Our Shocking F a i l u r e i n B i r t h C o n t r o l , " C h a t e l a i n e , November 1972, p. 5&. 7 M i c h a e l B. Bracken, et a l , "Contraceptive P r a c t i c e Among New York Ab o r t i o n P a t i e n t s , " American J o u r n a l of  O b s t e t r i c s and Gynecology, 114: 969* December 1, 1972. 1 0 L a n d s b e r g , op. c i t . , p. 106. 5 11 use. Consequently, problems of contraception o f t e n become a concern f o r women. This s i t u a t i o n cannot help but be i n -t e n s i f i e d by the f a c t t h a t i t i s the woman who becomes preg-nant and must deal w i t h the de s i r e d or undesired consequences reg a r d l e s s of her partner's i n t e r e s t (or l a c k of) i n support- -i n g her. Indeed, i t i s considered a common expectation among both many men and women tha t the woman can and should p r o t e c t h e r s e l f . E f f e c t i v e u t i l i z a t i o n of c o n t r a c e p t i v e s , as w i t h any t o o l , r e q u i r e s that the user be knowledgeable of the method of use, reason f o r use, and f u n c t i o n s of the c o n t r a -c e p t i v e . Thus, o p p o r t u n i t i e s f o r l e a r n i n g about con t r a c e p t i o n and c o n t r a c e p t i v e s are necessary before c o n t r a c e p t i v e s may be used w e l l . However, i n Canada today education concerning these matters has no co n s i s t a n t p a t t e r n or o r g a n i z a t i o n . A person may l e a r n about s e x u a l i t y and con t r a c e p t i o n from f a m i l y or f r i e n d s , i n sch o o l , from doctors, nurses, community workers or not at a l l . The completeness and accuracy of what 12 i s learned may vary from a l l t o nothing. Opportunities f o r any l e a r n i n g must i n v o l v e more than p r o v i s i o n of content. M o t i v a t i o n and a t t i t u d e s of both i n s t r u c t o r and l e a r n e r may g r e a t l y i n f l u e n c e the l e a r n e r ' s c a p a c i t y t o l e a r n . This i s a major concern i n any area of education but p a r t i c u l a r l y w i t h a subject as emotionally charged as co n t r a c e p t i o n . Thus, a person's comfort w i t h h i s sexual r o l e i n the context of h i s s o c i e t y w i l l i n f l u e n c e I b i d . , p. 107. " ^ I b i d . , pp. 58" & 106. 6 both acceptance of contraception knowledge and h i s a b i l i t y t o use t h a t knowledge."*"^ , 1 4 , 1 5 The choice of contraceptives may a l s o be i n f l u e n c e d by a person's m o t i v a t i o n and a t t i t u d e s . Whether a person can accept and comfortably use contraceptive methods which are d i r e c t l y or i n d i r e c t l y r e l a t e d t o i n t e r c o u r s e may r e l a t e t o that person's comfort w i t h h i s s e x u a l i t y , f e e l i n g s about the purpose of i n t e r c o u r s e , and the Tightness of sexual d e s i r e . ^ F i n a l l y , there i s the element of p o t e n t i a l f a i l u r e s t a t i s t i c a l l y p o s s i b l e w i t h a l l c o n t r a c e p t i v e s . These f a i l u r e p o s s i b i l i t i e s are a f u n c t i o n of the t e c h n i c a l imperfections of the methods, and as such, are not r e l a t e d t o problems of u t i l -i z a t i o n nor amenable t o avoidance by improved use. S p e c i f i c r a t e s of f a i l u r e f o r the d i f f e r e n t methods of contraception are hard t o d e f i n e , having been c a l c u l a t e d by various people, using various research methods, and p r o v i d i n g various r a t i n g s . How-ever, the d i f f i c u l t y of ob t a i n i n g accurate r a t i n g s does not do 17 away w i t h the r e a l i t y of contraceptive f a i l u r e . "^L.P.O. Tunnadine, Contraception and Sexual L i f e (London: Tavistock P u b l i c a t i o n s , 1970) , p. 13 . "^Nancy G a r r e t t , "Choosing Contraceptives According t o Need," The Canadian Nurse, 68: 4 0 - 4 1 , September, 1972. -^John P e e l and Malcolm P o t t s , Textbook of  Contraceptive P r a c t i c e (Cambridge: Cambridge U n i v e r s i t y P r e s s , 1969) , p. 42" Tunnadine, op. c i t . , pp. 37 - 4 1 . 17 P e e l , op. c i t . , pp. 41 - 4$ . 7 B. S i g n i f i c a n c e of the Problem t o Nursing The Canadian Nurses' A s s o c i a t i o n has s t a t e d i t s b e l i e f t h a t , "Family planning, and i t s a s s o c i a t e d and support-in g s e r v i c e s , are b a s i c t o i n d i v i d u a l and f a m i l y h e a l t h 1$ care." As such, f a m i l y planning and contraception must be a concern f o r nursi n g . The concepts of primary prevention and of c r i s i s theory can give d i r e c t i o n t o nurses f o r t h e i r involvement w i t h people needing contraceptives and co n t r a -ceptive education. Speaking on the p r i n c i p l e s of preventive p s y c h i a t r y , Caplan s t a t e s t h a t primary prev e n t i o n , " . . . i n v o l v e s lowering the r a t e of new cases of mental d i s o r d e r i n a population over a c e r t a i n p e r i o d by counteracting harmful circumstances before 19 they have a chance t o produce i l l n e s s . " U t i l i z i n g t h i s con-cept one may consider that primary prevention i n v o l v e s lower-ing the number of abortions by preventing unwanted conceptions, thus a v o i d i n g the chance of unwanted pregnancies. Prevention of conception w i t h s e x u a l l y a c t i v e people r e q u i r e s e f f e c t i v e u t i l i z a t i o n of c o n t r a c e p t i v e s . An unwanted pregnancy and subsequent a b o r t i o n i s a p e r i o d of p o t e n t i a l c r i s i s f o r a person. The p a t i e n t ' s increased s u s c e p t i b i l i t y f o r involvement as i d e n t i f i e d i n c r i s i s theory i n d i c a t e s t h a t contraceptive need assessment "Canadian Nurses' A s s o c i a t i o n P o s i t i o n on Family Planning and Related Health Care," The Canadian Nurse, 68: 11, August 1972. 19 7 G e r a l d Caplan, P r i n c i p l e s of Prevention P s y c h i a t r y (New York: Basic Books Inc., 196X77""P* 26. 3 and education may be p a r t i c u l a r l y e f f e c t i v e at t h i s time of 20 c r i s i s . For e f f e c t i v e c r i s i s r e s o l u t i o n , f u t u r e planning w i t h a b o r t i o n p a t i e n t s must i n v o l v e such need assessment and teaching w h i l e the p a t i e n t i s going through the c r i s i s pro-cess. The C.N.A. has elaborated i t s p o s i t i o n t o s t a t e t h a t , "Nurses must be prepared w i t h s k i l l s based on know-ledge of the complex r e l a t i o n s h i p s and psychodynamics i n v o l v e d i n s e x u a l i t y , human reproduction, and c o n t r a c e p t i o n t o permit them t o provide the needed s e r v i c e and education i n f a m i l y 21 planning and r e l a t e d h e a l t h care." With such p r e p a r a t i o n , nurses w i l l be able t o c a r r y out primary prevention and c r i s i s i n t e r v e n t i o n w i t h p a t i e n t s having c o n t r a c e p t i v e s e r -v i c e and education needs. Present p r o f e s s i o n a l o p p o r t u n i t i e s f o r c o n t r a -ception teaching may be found i n h o s p i t a l s , p r i v a t e medical s e r v i c e s , o b s t e t r i c and g y n e c o l o g i c a l c l i n i c s , f a m i l y planning c l i n i c s and a s s o c i a t i o n s , and community h e a l t h and welfare agencies. Nurses f u n c t i o n p o t e n t i a l l y i n a l l of these areas and as such have ready access t o people w i t h c o n t r a c e p t i o n needs. Another convincing aspect t o the argument f o r nurses as c o n t r a c e p t i o n a d v i s o r s and teachers i s f i n a n c i a l . S o c i e t a l h e a l t h needs i n c l u d e e f f e c t i v e c o n t r a c e p t i o n ed-u c a t i o n and s o c i e t y d e s i r e s t h i s s e r v i c e at as low a cost as 2 0 I b i d . , p. 48. 21 "Canadian Nurses' A s s o c i a t i o n P o s i t i o n , " op. c i t . , p .11. 9 p o s s i b l e . Nurses may perform t h i s task f o r l e s s expense than would doc t o r s , who could then confine t h e i r work to c o n s u l t a t i o n and p a t i e n t contact necessary to deal w i t h com-ple x s i t u a t i o n s . As appropriate teachers of c o n t r a c e p t i o n , nurses need to understand the problems of contraceptive p r a c t i c e , knowledge, and a t t i t u d e s experienced by i n d i v i d u a l s i f contraception teaching i s t o f a c i l i t a t e e f f e c t i v e u t i l i z a t i o n . As i d e n t i f i e d h i g h - r i s k contraceptive u s e r s , a b o r t i o n p a t i e n t s are appropriate subjects f o r a nursing study to define c o n t r a -ception problems. 10 Chapter I I REVIEW OF THE LITERATURE A. Contraceptive U t i l i z a t i o n I n the preceding d i s c u s s i o n concerning c o n t r a c e p t i o n , three aspects of contraceptive u t i l i z a t i o n have been de-l i n e a t e d : c o n t r a c e p t i o n p r a c t i c e , knowledge, and a t t i t u d e s . The s e l e c t i o n of these three areas as target, concerns i n t h i s study f o l l o w s the trend i n the l i t e r a t u r e . 1) Research L i t e r a t u r e The f i r s t question asked i n most research on c o n t r a -ception p r a c t i c e i s whether o r not contraception had been used by the subjects some time i n t h e i r l i v e s or at the time of conception i f they were pregnant. A d d i t i o n a l questions have considered many v a r i a b l e s as they r e l a t e to who had or had not used co n t r a c e p t i o n . In 1972, Bracken et a l reported on a study done i n a p r i v a t e h o s p i t a l i n New York C i t y w i t h 1033 a b o r t i o n p a t i e n t s . A s e l f - a d m i n i s t e r e d questionnaire was presented to a l l p a t i e n t s whose abo r t i o n requests were accepted during the study p e r i o d . 1 They found t h a t l+5»5f° of the sample had used some form of contraception w i t h i n the previous 12 months. The method which had been most commonly used was the p i l l but w i t h a l l methods used, t e c h n i c a l l y i n e f f e c t i v e methods Michael B. Bracken, et a l , "Contraceptive P r a c t i c e Among New York Abortion P a t i e n t s , " American Journal of  O b s t e t r i c s & Gynecology, 114: 963, December 1, 1972. 11 were r e l i e d on h e a v i l y . T e c h n i c a l l y e f f e c t i v e methods were 2 i d e n t i f i e d as the p i l l , IUD and diaphragm. Most of the contraception users had used more than one method, and when methods were changed i t was to l e s s e f f e c t i v e ones i n 90$ 3 of the cases. Concerning other v a r i a b l e s , they found t h a t e f f e c t i v e c ontraception increased w i t h age i n c r e a s e . Married women tended t o p r a c t i c e more e f f e c t i v e c ontraception as d i d women who had had previous pregnancies. An increase of i n t e r c o u r s e frequency r e l a t e d t o increased use of the p i l l whereas sub-j e c t s who had i n t e r c o u r s e i n f r e q u e n t l y tended to use the withdrawal and rhythm methods. Changes i n r e l a t i o n s h i p s w i t h partners were f r e q u e n t l y reported to precede changes i n method which, as noted above, tended t o be a move to l e s s e f f e c t i v e methods. 4 Grauer reported on a study done between A p r i l 1971 and March 1972 w i t h 150 a b o r t i o n p a t i e n t s i n a community h o s p i t a l i n Montreal. Data were c o l l e c t e d i n i n t e r v i e w s conducted by the author. The sampling method was not c l e a r l y defined i n the r e p o r t . Grauer found t h a t 59$ of the subjects reported u s i n g some form of contraception at the time of conception, a s i t u a t i o n which he defined as cont r a c e p t i o n 2 I b i d . , p. 969. 3 I b i d . , p. 975. 4 I b i d . , p. 975. 5 H. Grauer, "A Study of Contraception as Related to Unwanted Pregnancy," Canadian Medical A s s o c i a t i o n J o u r n a l , 107: 739, October 21, 1972. 12 f a i l u r e . Of t h i s 59$, 14$ had r e l i e d completely on t h e i r partner to use c o n t r a c e p t i o n . ^ He noted t h a t 47$ of the subjects under 25 years of age had used co n t r a c e p t i v e s at conception but tha t 67$ of those over 25 years had p r a c t i c e d c o n t r a c e p t i o n , thus agree-i n g w i t h Bracken et a l that contraception p r a c t i c e increased w i t h age. Married subjects had used contraception more o f t e n than s i n g l e but no c o r r e l a t i o n w i t h c o n t r a c e p t i o n p r a c t i c e was evident f o r data on e d u c a t i o n a l , s o c i a l , or r e l i g i o u s 7 background. Grauer a l s o n o t i c e d t h a t w i t h those subjects who sought a b o r t i o n at 11 weeks g e s t a t i o n o r l a t e r , only 34$ had used c o n t r a c e p t i v e s . However, w i t h those who sought a b o r t i o n e a r l i e r , 66$ had been users. A complex study to explore sexual knowledge, a t t i t u d e s , and c o n t r a c e p t i v e p r a c t i c e s of g i r l s seen at a Teen C l i n i c operated by Planned Parenthood i n C a l i f o r n i a was done be-o tween November 1969 and J u l y 1970 by Goldsmith et a l . Three groups of subjects were compared: multiparous women r e c e i v i n g contraception advice, women seeking a b o r t i o n , and women con-t i n u i n g out-of-wedlock pregnancies to term. These three groups were considered comparable i n age and socioeconomic s t a t u s . 1 ^ 6 I b i d . , p. 740. 7 I b i d . , p. 740. 8 I b i d . , p. 741. Q Sadja Goldsmith, et a l , "Teenagers, Sex & Contra-c e p t i o n , " Family Planning P e r s p e c t i v e s , 4: 32, January, 1972. 1 0 I b i d . , pp. 32 - 33. 13 The three groups reported having used c o n t r a c e p t i v e s at some time i n the- f o l l o w i n g numbers: advice seekers - &7$ a b o r t i o n seekers - 76$ maternity p a t i e n t s - 62$ They reported having used c o n t r a c e p t i v e s s i n c e t h e i r l a s t menstraul p e r i o d as f o l l o w s : advice seekers - 59$ a b o r t i o n seekers - 39$ 12 maternity p a t i e n t s - 34$ S p e c i f i c to the ab o r t i o n group, l e s s t e c h n i c a l l y e f f e c t i v e methods of contraception were used at a higher r a t e than e f f e c t i v e methods, both since the l a s t menstraul p e r i o d and at any previous time. E f f e c t i v e methods are de-f i n e d i n t h i s study as the p i l l , IUD, and diaphragm, i n 13 agreement w i t h Bracken et a l . Several other s t u d i e s have reported data u s e f u l t o an understanding of contraception p r a c t i c e . An unpublished study by Weiner & Davis done i n Vancouver i n 1969 revealed t h a t only 39$ of t h e i r small sample of unmarried, pregnant g i r l s r e c e i v i n g p r e n a t a l care at the Women's C l i n i c of a l a r g e general h o s p i t a l had p r a c t i c e d contraception at some 1 : L I b i d . , p. 37. 1 2 I b i d . , p. 37. 1 3 I b i d . , p. 37. 14 time. In a study by H i l l completed i n October 1971 w i t h 1,642 a b o r t i o n p a t i e n t s i n Kansas, i n t e r v i e w data were analysed t o show that 20 .1$ of the subjects had used c o n t r a -ceptives at the time of conception, a number somewhat l e s s than t h a t reported i n the Bracken and Grauer s t u d i e s . No d i f f e r e n c e was noted i n contraception p r a c t i c e between who were or had been married, but s i n g l e g i r l s used con t r a -ceptives s i g n i f i c a n t l y l e s s often than d i d married ones. 15 A l s o , contraception use increased w i t h age. D a i l y and Nicholas compared use of contraceptives by women t e r m i n a t i n g pregnancy e i t h e r by b i r t h or a b o r t i o n . They found t h a t of the a b o r t i o n p a t i e n t s , 59$ had used con-t r a c e p t i o n i n the past two years and of the post partum p a t i e n t s , only 45$ had used contraception w i t h i n the same time, In both groups, p a t i e n t s between 15 and 19 years of age used contraceptives much l e s s o f t e n than d i d p a t i e n t s between 25 and 29 y e a r s . 1 6 Oppel et a l compared contraception use between e a r l y ^Enid Weiner & J u d i t h Davis, " P r o v i s i o n a l Study of a Group of Unmarried Mothers i n the C i t y of Vancouver: Some S o c i a l C h a r a c t e r i s t i c s , Knowledge of A t t i t u d e s Towards & P r a c t i c e of Contraception." (unpublished paper, U n i v e r s i t y of B r i t i s h Columbia, 1969), pp. 5 - 6 . 15 ^James G. H i l l , " B i r t h C o n t r o l Usage Among Abortion P a t i e n t s , " Kansas Medical S o c i e t y J o u r n a l , 73: 296-97, June 1972. 16 Edwin F. D a i l y & Nick N i c h o l a s , "Use of Conception C o n t r o l Methods Before Pregnancies Terminating i n B i r t h or a Requested Abortion i n New York C i t y M u n i c i p a l H o s p i t a l s , " American Journal of P u b l i c Health, 6 2 : 1544-1545, November, 1972. 15 a b o r t i o n p a t i e n t s having a d i l a t a t i o n and curretage procedure (D & C) wit h l a t e a b o r t i o n p a t i e n t s having a s a l i n e i n d u c t i o n . He reported t h a t the e a r l y a b o r t i o n p a t i e n t s used c o n t r a -c e p t i v e s more f r e q u e n t l y and more e f f e c t i v e l y thus agreeing 17 w i t h Grauer's f i n d i n g s w i t h t h i s v a r i a b l e . L i t e r a t u r e of research i n v o l v i n g contraception a t t i t -udes and knowledge i s much more l i m i t e d than t h a t j u s t review-ed on contraception p r a c t i c e . Behavioural d e f i n i t i o n s and measurements of contraception a t t i t u d e s have not been developed to any extend and t e s t s of knowledge tend to be i n c o n c l u s i v e and incompletely reported. The Goldsmith study w i t h three groups of C a l i f o r n i a teenagers sought data on a t t i t u d e s towards c o n t r a c e p t i o n , pregnancy, i n t e r c o u r s e and masturbation i n an attempt de-1$ signed to assess a t t i t u d e s towards s e x u a l i t y . The authors noted t h a t the group who were seeking advice on contraception and who had i n d i c a t e d g r e a t e r use of con t r a c e p t i v e s had more comfortable f e e l i n g s about s e x u a l i t y than d i d the two pregnant groups planning a b o r t i o n or d e l i v e r y . They concluded that "an a t t i t u d e accepting one's own s e x u a l i t y i s a more important c o r r e l a t e w i t h contraceptive use than such other f a c t o r s as exposure t o sex education, knowledge of sex and cont r a c e p t i o n 19 or r e l i g i o u s background." Some of the s p e c i f i c data showed 17 Wallace Oppel, et a l , "Contraceptive Antecedents t o E a r l y & Late Therapeutic Abortions," American Journal of  P u b l i c Health, 62: 826, June, 1972. 1$ Goldsmith, op. c i t . , pp. 34-35. 1 9 I b i d . , pp. 36-37. 16 that the contraceptive-seekers found i n t e r c o u r s e more enjoy-able and t h a t they took i n i t i a t i v e to seek out e f f e c t i v e c o n t r a c e p t i v e s while the pregnant subjects sought help only 20 a f t e r becoming pregnant. Both Grauer and Oppel reported d i f f e r e n c e s i n c o n t r a -ceptive use between p a t i e n t s seeking abortions e a r l i e r or l a t e r i n t h e i r pregnancies. Grauer suggested that the e a r l y a b o r t i o n seekers, who used co n t r a c e p t i v e s more o f t e n i n d i c a t e d a more r e a l i s t i c a t t i t u d e toward the p o s s i b i l i t y of conception 21 and r e c o g n i t i o n of pregnancy. Contraception knowledge was a l s o considered by Goldsmith et a l . They found that scores obtained by the contra-ception advice-seeking group on knowledge about b i r t h c o n t r o l and general sexual m a t e r i a l , while somewhat higher than the scores of the two pregnant groups, were not s t a t i s t i c a l l y 22 s i g n i f i c a n t . The general s t a t e of knowledge found i n . a l l three groups had l i m i t a t i o n s . For example, h a l f of the g i r l s who had used the rhythm method d i d not know tha t t h e i r f e r t i l e 23 time probably occured mid c y c l e . Oppel et a l , who found t h a t e a r l y abortees used con t r a c e p t i v e s more o f t e n than l a t e abortees, noted t h a t there was no d i f f e r e n c e between the contraception knowledge scores of each g r o u p . 2 4 Kane et a l , i n a study done i n North C a r o l i n a 2 0 I b i d . , pp. 37-38. 2 1 G r a u e r , op. c i t . , p. 740. 22 23 Goldsmith, op. c i t . , p. 3 3 . I b i d . , p. 37. 24, Oppel, op. c i t . , p. 287. 17 i n 196S-69 w i t h p a t i e n t s d e l i v e r e d of babies, a l s o found that the contraception knowledge of contraceptive users d i d not 25 vary s i g n i f i c a n t l y . ^ The adequacy of knowledge of the sub-j e c t s i n these s t u d i e s was not i d e n t i f i e d . Weiner and Davis reported that only 27.3$ of t h e i r unwed, pregnant subjects i n d i c a t e d accurate knowledge of contraception i n general and no one had more than minimal knowledge of s p e c i f i c c ontraceptive methods. They a l s o con-s i d e r e d the sources of knowledge and found t h a t only 27.3$ of the subjects learned about sex from t h e i r parents and only 26 5.5$ learned about b i r t h c o n t r o l from parents. H i l l noted th a t none of the a b o r t i o n p a t i e n t s he s t u d i e d r e c e i v e d inform-27 a t i o n about contraception i n s c h o o l . To summarize b r i e f l y the l i t e r a t u r e reviewed t o t h i s p o i n t , research has i n d i c a t e d t h a t contraception i s p r a c t i c e d by many women who f i n d themselves pregnant and seek abor t i o n s or d e l i v e r y . I n e f f e c t i v e contraception and l a c k of c o n t r a -ception may be r e l a t e d t o such v a r i a b l e s as age, m a r i t a l s t a t u s , choice of c o n t r a c e p t i v e , stage of pregnancy when seek-in g help, and previous pregnancy. Research concerning a t t i t -udes, though not w e l l defined or developed, has suggested th a t comfort w i t h the r e a l i t y of one's s e x u a l i t y may a f f e c t ^ F r a n c i s J . Kane, et a l , " M o t i v a t i o n a l Factors A f f e c t -i n g Contraceptive Use," American Journal of O b s t e t r i c s &  Gynecology, 110: 1052, August 15 , 1971. 2 f\ Weiner, op. c i t . , p. 5 . 2 7 H i l l , op. c i t . , p. 301. the a b i l i t y t o use c o n t r a c e p t i o n knowledge and p r a c t i c e c o n t r a c e p t i o n e f f e c t i v e l y . Research on c o n t r a c e p t i o n know-ledge appears i n c o n c l u s i v e but has i n d i c a t e d t h a t knowledge tends t o be l e s s than adequate i n most s u b j e c t s . 2) Opinion L i t e r a t u r e With the d e f i c i t of r e s e a r c h on c o n t r a c e p t i o n a t t i t -udes and knowledge, l i t e r a t u r e w i t h d i s c u s s i o n and o p i n i o n s on these areas has been c o n s i d e r e d . In h i s textbook on c o n t r a c e p t i v e u t i l i z a t i o n , P e e l concluded t h a t e f f e c t i v e use of c o n t r a c e p t i v e s probably de-pends p a r t i c u l a r l y on s o c i a l and p s y c h o l o g i c a l v a r i a b l e s a s s o c i a t e d w i t h t h e i r a c c e p t a b i l i t y . He i n c l u d e d such v a r i -a b l e s as an i n d i v i d u a l ' s m o t i v a t i o n f o r i n t e r c o u r s e and 28 c o n t r a c e p t i o n . Bracken et a l , i n t h e i r comments on t h e i r study of c o n t r a c e p t i o n p r a c t i c e among a b o r t i o n p a t i e n t s , s t a t e d , "We need t o c l a r i f y some o f the i n t e r v e n i n g processes which op-era t e a t the p s y c h o s o c i a l and i n t r a p s y c h i c l e v e l and which d e s c r i b e i n g r e a t e r d e t a i l t he woman who i s a t r i s k o f an un-2 9 wanted pregnancy and, t h e r e f o r e , an a b o r t i o n . " They were p a r t i c u l a r l y i n t e r e s t e d i n the i n t e r p e r s o n a l r e l a t i o n s h i p s which are conducive t o poor c o n t r a c e p t i o n p r a c t i c e . Sandberg, drawing on c l i n i c a l experience w i t h a b o r t i o n 2 g J o h n P e e l & Malcolm P o t t s , Textbook of C o n t r a c e p t i v e P r a c t i c e (Cambridge: Cambridge U n i v e r s i t y P r e s s , 1969), p. 42. ^ B r a c k e n , op. c i t . , p. 976. 19 p a t i e n t s s t a t e d , " I t i s apparent that contraceptive e f f e c t i v e -ness i s not simply a matter of technology but i s a l s o a matter of the i n f l u e n c e s of p s y c h o l o g i c a l , s o c i o l o g i c , and many other f a c t o r s . " He defined 14 p o s s i b l e categories of i n t r a p s y c h i c and i n t e r a c t i o n a l reasons why presumably undesired pregnancies have been allowed t o occur through i n e f f e c t i v e c o n t r a c e p t i o n . - ^ In a paper concerned w i t h choice of c o n t r a c e p t i v e s , Garrett wrote that problems of acceptance of s e x u a l i t y frequent-l y l e a d t o c o n f l i c t and ambivalence concerning contraception p r a c t i c e . She discussed the need t o a s c e r t a i n a person's f e e l i n g s about s e x u a l i t y when a d v i s i n g on co n t r a c e p t i o n , and described some p o s s i b l e problem s i t u a t i o n s as f o l l o w s . C o n f l i c t a r i s i n g from d i v i d e d a l l e g i a n c e t o the new and o l d m o r a l i t i e s can create g u i l t l e a d i n g t o s e l f punishment behaviour potent-i a t i n g uncomfortable s i d e e f f e c t s of c o n t r a c e p t i v e s . C o n f l i c t about having c h i l d r e n could cause d i f f i c u l t y making d e c i s i o n s about and c a r r y i n g through contraception p r a c t i c e . C o n f l i c t about s e x u a l i t y could i n h i b i t a b i l i t y t o use contrac e p t i v e s 31 a s s o c i a t e d w i t h i n t e r c o u r s e . Tunnadine described work i n a f a m i l y planning c l i n i c i n London, s t r e s s i n g the need t o study a t t i t u d e s i n order t o understand a c c e p t a b i l i t y and mo t i v a t i o n of contraceptive 30 Eugene C. Sandberg & R. I . Jacobs, "Psychology of the Misuse & R e j e c t i o n of Contraception, "American Journal of  O b s t e t r i c s & Gynecology," 110: 223, May 15, 1971. 31 Nancy G a r r e t t , "Choosing Contraceptives According t o Need," The Canadian Nurse, 63: 40-41, September, 1972. 20 32 use. She enlarged on the e f f e c t s of c o n f l i c t such as G a r r e t t discussed and went on t o note t h a t the p a t i e n t whose only-problem was ignorance was r a r e . She summarized the l i n k be-tween a t t i t u d e s and knowledge when s t a t i n g , " f a c t u a l t e a c h i n g . . can only be accepted and taken i n by i n d i v i d u a l p a t i e n t s 33 according t o t h e i r own emotional c a p a c i t y . " While doing h i s study w i t h a b o r t i o n p a t i e n t s , H i l l gathered anecdotal i n f o r m a t i o n which i n d i c a t e d t o him a l s o t h a t many p a t i e n t s had strong ambivalent f e e l i n g s about t h e i r sex-u a l behaviour. Such p a t i e n t s had ofte n been unable t o seek contraceptive advice because of d i f f i c u l t y a d m i t t i n g t o plans f o r i n t e r c o u r s e . He noted t h a t most p a t i e n t s regarded faVOUr-S^ I a b l y the opportunity t o discuss t h e i r s e x u a l i t y . ^ B. Contraceptive Methods Techniques and devices which are g e n e r a l l y considered t o have some contraceptive value are the f o l l o w i n g : o r a l c ontraceptive p i l l s , i n t r a u t e r i n e devices (IUD), diaphragms, spermacides, condoms, the rhythm method, and c o i t u s i n t e r -'s c ruptus (withdrawal). 1 Douches are not considered of cont r a -c e p t i v e value, and i n f a c t , may a s s i s t sperm t o move i n t o the c e r v i c a l o r i f i c e . 3 2L.P.O. Tunnadine, Contraception & Sexual L i f e (London: Tavistock P u b l i c a t i o n s , 1970), p. X I I I . 3 3 I b i d . , p. 37. 3 4 H i l l , op. c i t . , pp. 298-301. 3^Donna Cherniak & A l l a n Feingold (eds.), B i r t h C o n t r o l  Handbook (Montreal: A r t s & Science Undergraduate S o c i e t y of M c G i l l U n i v e r s i t y , 1970), pp. 33-34. 21 L i t e r a t u r e concerning e f f e c t i v e n e s s of v a r i o u s c o n t r a -ceptives i s d i f f i c u l t t o assess due t o many v a r i a t i o n s of study techniques and f r e q u e n t l y c o n f l i c t i n g c o n c l u s i o n s . The pamphlet commonly c a l l e d the M c G i l l Handbook noted the need t o d i s t i n g u i s h between " t h e o r e t i c a l f a i l u r e r a t e " , defined as "the e f f e c t i v e n e s s of a method i f i t i s used a b s o l u t e l y con-s i s t a n t l y and according t o i n s t r u c t i o n s , " and the " c l i n i c a l f a i l u r e r a t e " , defined as "the e f f e c t i v e n e s s of a method used under average c o n d i t i o n s by average people." This c l i n i c a l f a i l u r e r a t e acknowledges the i n f l u e n c e of v a r i a b l e s which a r i s e from the human component of contraceptive u t i l i z a t i o n . An example used i n the Handbook i s t h a t though both p i l l s and condoms may have a t h e o r e t i c a l f a i l u r e r a t e of near . 0 $ , the c l i n i c a l f a i l u r e r a t e i s higher f o r condoms than p i l l s because use of condoms provides many more o p p o r t u n i t i e s f o r i n d i v i d u a l 37 f a i l u r e than do p i l l s . Kleinman made the same type of d i s t i n c t i o n u s i n g the label's of " t h e o r e t i c a l e f f e c t i v e n e s s " and " u s e - e f f e c t i v e n s s s " . In c o n s i d e r i n g methods f o r c a l c u l a t i n g u s e - e f f e c t i v e n e s s , Kleinman described the P e a r l formula, developed i n the 1 9 3 0 's. This t r a d i t i o n a l l y used formula c a l c u l a t e s i n percent the number of times conception occurs during a year's p e r i o d of exposure, assuming that o v u l a t i o n occurs 13 times a year, and t h a t r e g u l a r heterosexual contacts occur. He noted t h a t t h i s formula does not consider such p e r t i n e n t v a r i a b l e s as c o n t i n u -i t y of use, d u r a t i o n of use, and i n f l u e n c e of s i d e e f f e c t s . 3 6 I b i d . , p. 34 . 3 7 I b i d . , p. 3 4 . . 22 However, u n i v e r s a l l y accepted measures of these v a r i a b l e s have not been developed. Using the P e a r l formula, the M c G i l l Handbook l i s t e d the c l i n i c a l f a i l u r e r a t e s of contraceptive methods as f o l l o w s p i l l (combination type) - .05$ I.U.D. - 1.5 - 8$ condom 10 - 15$ diaphragm & spermacide - 10 - 20$ spermacide - 15 - 25$ rhythm - 15 - 30$ withdrawal - 20 - 30$ 3 9 C o n s i d e r a t i o n of a b o r t i o n as another contraceptive method was discussed by P e e l . He argued t h a t "acceptance of p r i n c i p l e s of contraception must a l s o e n t a i l an acceptance of a b o r t i o n as f i n a l defence against unwanted pregnancy." He went on t o note that a b o r t i o n i s the l e a s t d e s i r a b l e form of b i r t h c o n t r o l . 4 ^ Many human-use problems l e a d i n g t o i n d i v i d u a l f a i l u r e of c ontraceptive methods appear t o be r e l a t e d t o the type of contact inherent i n the method. I t i s i n t e r e s t i n g t o note t h a t , i n the P e a r l formula r a t i n g s the c l i n i c a l f a i l u r e r a t e s are lowest f o r those methods ( p i l l & IUD) having the l e a s t 3 gR.L. Kleinman (ed.), Medical Handbook, (London: I n t e r n a t i o n a l Planned Parenthood Federation, 1968), p. 88-90. 3 9 C h e r n i a k , op. c i t . , p. 34. 4 0 P e e l , op. c i t . , p. 243. 23 d i r e c t contact w i t h i n t e r c o u r s e . G a r r e t t , Tunnadine, and the M c G i l l Handbook have described and discussed many such prob-Z1 / 2 / 3 lems and approaches f o r d e a l i n g w i t h the problems. C. Demographic C h a r a c t e r i s t i c s of Abortion P a t i e n t s In order t o have some bas i c understanding of the c h a r a c t e r i s t i c s of the population of women seeking a b o r t i o n s , demographic data from two s t u d i e s w i l l be noted. Grauer stu d i e d 150 a b o r t i o n p a t i e n t s i n Montreal and reported the f o l l o w i n g data. The study was done between A p r i l 1971 and March 1972. age group: under 15 15-20 21-25 2 6 - 3 0 31-35 36-40 over 40 1$ 12$ m a r i t a l s t a t u s : s i n g l e 40$ 2 6 $ 15$ 25$ 17$ married 52$ divorced 4$ separated 3 $ employment outside home  at time of conception:; yes no 42$ 53$ education l e v e l : c o l l e g e c o l l e g e elementary High school t r a i n i n g incomplete complete 11$ 49$ 26$ G a r r e t t , op. c i t . , pp. 40-41* Tunnadine, op. c i t . , pp. 3 3 - 4 0 . Cherniak, op. c i t . , pp. 14-34. 24 number of weeks pregnant when t o the doctor: weeks 4 5 6 7 8 9 10 4$ 5 .3$ 24$ 8.7$ 20$ 4.7$ 11 12 13 14 15 16 12$ 18 .67$ 4 4 4$ 8$ 2$ 4 .7$ .67$ 1.3$ Claman et a l s t u d i e d a b o r t i o n p a t i e n t s i n Vancouver between 1965 and J u l y 1970. During t h i s p e r i o d 500 abort i o n s were performed i n the study i n s t i t u t i o n , 179 (36$) of which were done between 1965 - 196.9 and the r e s t o c c u r r i n g i n 1970 f o l l o w i n g the amendment of the C r i m i n a l Code. Un f o r t u n a t e l y , the report does not separate the data from before and a f t e r the change i n law so th a t any d i f f e r e n c e s i n the p a t i e n t s of the two periods cannot be considered. age groups: under 15 15-19 20-24 25-29 30-34 35-40 over 40 1$ 17$ 20$ 21$ 18$ 15$ 8$ m a r i t a l s t a t u s : s i n g l e married divorced' separated widowed 38$ 48$ s o c i a l s t a t u s : p r o f e s s i o n a l 17$ u n s k i l l e d 11$ 5$ 7$ s k i l l e d labour 26$ student 17$ 2$ business 21$ welfar e 7$ Grauer, op. c i t . , p.. 740. 25 previous induced abortions:-no yes l e g a l i l l e g a l 89$ 10$ 5$ 5$ 4 5 ^ A . David Claman, et a l , "Impact on H o s p i t a l P r a c t i c e "of L i b e r a l i z i n g Abortions & Female S t e r i l i z a t i o n s , "Canadian Medical A s s o c i a t i o n J o u r n a l , 105: 3&\ J u l y 10, 1971 26 Chapter I I I DESIGN A. Research Question Hypotheses were not formulated and t e s t e d f o r t h i s study. Research r e l a t e d t o the problem has not yet c o n s i s t a n t -l y i d e n t i f i e d and defined v a r i a b l e s of contraceptive u t i l i z -a t i o n . The researcher t h e r e f o r e attempted t o answer the f o l l o w i n g question. What are the c o n t r a c e p t i o n p r a c t i c e s , a t t i t u d e s , and knowledge of a group of a b o r t i o n p a t i e n t s ? B. D e f i n i t i o n s 1) Abortion P a t i e n t - a woman admitted t o an a c c r e d i t e d or approved h o s p i t a l t o undergo t e r m i n a t i o n of pregnancy as approved according t o s e c t i o n 237 of the C r i m i n a l Code of Canada. 2) Contraceptive U t i l i z a t i o n - behaviour by a s e x u a l l y a c t i v e couple which i s s p e c i f i c t o prevention of conception and which may be i d e n t i f i e d i n terms of p r a c t i c e , a t t i t u d e s , and knowledge. 3) Contraception P r a c t i c e - any a c t i o n s by an a b o r t i o n p a t i e n t and/or her p a r t n e r designed t o prevent conception as reported by the p a t i e n t . 4) Contraception A t t i t u d e s - d i s p o s i t i o n t o regard co n t r a c e p t i o n p r a c t i c e and 27 knowledge i n a p o s i t i v e or negative way as reported and i n d i c a t e d by an a b o r t i o n p a t i e n t . 5) Contraception Knowledge - i n f o r m a t i o n concerning the process of conception and the methods and f u n c t i o n s of contraceptive techniques as reported by an a b o r t i o n p a t i e n t . 6) Preconception - t h a t p e r i o d of time a f t e r puberty and preceding the conception of the preg-nancy f o r which the p a t i e n t i s seeking a b o r t i o n . 7) Unwanted Pregnancy - a pregnancy which was unplanned and/or undesired at the time of conception. 3) E f f e c t i v e Contraception - contraceptive u t i l i z a t i o n which i s not f o l l o w e d by pregnancy. 9 ) I n e f f e c t i v e Contraception - c o n t r a c e p t i v e u t i l i z a t i o n which i s f o l l o w e d by pregnancy. 10) Contraception F a i l u r e - i n e f f e c t i v e c o n t r a c e p t i o n which occurs when cont r a c e p t i o n p r a c t i c e s have been c a r r i e d out according t o pre-s c r i b e d methodology and which i s followed by pregnancy. C. Assumptions The f o l l o w i n g assumptions are b a s i c t o the p u r s u i t of t h i s study. 1) Contraception p r a c t i c e s , a t t i t u d e s , and knowledge which the a b o r t i o n p a t i e n t r e p o r t s or i n d i c a t e s describe 28 contraceptive u t i l i z a t i o n . 2) A b o r t i o n p a t i e n t s seek a b o r t i o n i n order t o terminate pregnancies which are unwanted. 3) Unwanted pregnancies may occur w i t h i n e f f e c t i v e c o n t raceptive u t i l i z a t i o n . 4) Subjects are able and w i l l i n g t o r e c a l l i n f o r m a t i o n and answer questions a c c u r a t e l y . D. L i m i t a t i o n s The f o l l o w i n g l i m i t a t i o n s are inherent i n t h i s study. 1) The e f f e c t s of s t r e s s on the a b o r t i o n p a t i e n t s ' accuracy of r e c a l l and r e p l y are not c o n t r o l l e d . 2) The p o p u l a t i o n i s l i m i t e d t o : - E n g l i s h speaking a b o r t i o n p a t i e n t s - i n e f f e c t i v e c o n traceptive u t i l i z e r s who become pregnant and who seek l e g a l a b o r t i o n s t o deal w i t h unwanted pregnancies. 3) V a l i d i t y of the research t o o l i s l i m i t e d t o face and content v a l i d i t y and so has no e m p i r i c a l b a s i s . Consequently r e s u l t s of the study cannot be g e n e r a l i z e d and provide only i n d i c a t i o n s of trends w i t h i n the study p o p u l a t i o n . E. Research Plan 1) Approach The study was e x p l o r a t o r y . The data were gathered by the researcher i n i n t e r v i e w s w i t h a b o r t i o n p a t i e n t s u s i n g a questionnaire t o s t r u c t u r e the i n t e r v i e w . 29 2) S e t t i n g The data were gathered from a b o r t i o n p a t i e n t s on an i n - p a t i e n t u n i t i n an urban general h o s p i t a l . The i n t e r v i e w s were conducted the evening before the day of surgery, a f t e r the p a t i e n t s were admitted. 3) Pop u l a t i o n The study p o p u l a t i o n i n c l u d e d a l l women admitted t o the i n - p a t i e n t u n i t of an urban B r i t i s h Columbia h o s p i t a l f o r an^abortion by the D & C / a s p i r a t i o n methods over a continuous 22 day p e r i o d . These p a t i e n t s were under the s e r v i c e s of e i t h e r s t a f f or p r i v a t e p h y s i c i a n s . 1+) Sample The study sample was made up of 30 p a t i e n t s s e l e c t e d from the p o p u l a t i o n . On each day of the study p e r i o d t h a t a b o r t i o n p a t i e n t s were admitted t o the. study u n i t , 2 p a t i e n t s were randomly s e l e c t e d t o be inte r v i e w e d . The s e l e c t e d p a t i e n t s had the study explained, the method described, and were assured t h a t p a r t i c i p a t i o n was vo l u n t a r y and withdrawal from the i n t e r v i e w p o s s i b l e at any time. A l l p a r t i c i p a t i n g p a t i e n t s signed a form consenting t o be interviewed f o r the study. A plan was made t o check the demographic data of the sample w i t h t h a t of the study p o p u l a t i o n and of the l a r g e r p o p u l a t i o n of a b o r t i o n p a t i e n t s having had D & C / a s p i r a t i o n abortions during the preceding year i n the study h o s p i t a l . This was t o be done i n order t o check the representativeness of the sample t o these two pop u l a t i o n s . However, demographic data on the a b o r t i o n p a t i e n t population had not been c o l l e c t e d by the h o s p i t a l i n a manner u s e f u l t o the study and p a t i e n t records over the d e s i r e d p e r i o d were not a v a i l a b l e t o the researcher. 5) The Tool - a d e s c r i p t i o n . The data c o l l e c t i o n instrument was a questionnaire developed s p e c i f i c a l l y f o r the study. The questions were administered v e r b a l l y and recorded on paper by the researcher during a p r i v a t e i n t e r v i e w w i t h each s u b j e c t . The recording of the answers was s t r u c t u r e d according t o a p a t t e r n o f a n t i c i p a t e d responses developed f o r each question but w i t h room f o r unexpected responses. The questionnaire had 5 s e c t i o n s . There were 7 questions concerning demographic i n f o r m a t i o n , 16 questions concerning contraception p r a c t i c e , 14 questions concerning contraception a t t i t u d e s , 15 questions concerning c o n t r a -ception knowledge, and one question concerning the subject's explanation of the occurance of the pregnancy. The t o t a l was 53 questions. F. Development of the Tool There were three major concerns i n the research question: contraception p r a c t i c e s , contraception a t t i t u d e s , and contraception knowledge. In the questionnaire develop-ment process, 14 areas of inf o r m a t i o n p e r t i n e n t t o the three major concerns were i d e n t i f i e d and defined as o b j e c t i v e s . These o b j e c t i v e s were t o l e a r n from each a b o r t i o n p a t i e n t : 31 - concerning p r a c t i c e : 1) what con t r a c e p t i v e s had been used i n the past. 2) w i t h what consistancy had co n t r a c e p t i v e s been used. 3) how were con t r a c e p t i v e methods chosen. 4) what had been the subject's need f o r c o n t r a -c e p t i o n . 5) what plans d i d the subject have f o r f a i l e d c o n t r a -c e p t i o n . - concerning a t t i t u d e s : 6) what f e e l i n g s the subject had about co n c e i v i n g . 7) what f e e l i n g s the subject had about u s i n g c o n t r a c e p t i v e s . 3) what f e e l i n g s the subject had about co n t r a c e p t i v e s and sexual r o l e . 9) what f e e l i n g s the subject had about a b o r t i o n . - concerning knowledge: 10) what the subject knows about c o n t r a c e p t i o n . 11) what the subject knows about conception. 12) what the subject had known about a b o r t i o n pre-conception. 13) the source of the sub j e c t s i n f o r m a t i o n concern-i n g c o n t r a c e p t i o n . - concerning the subject's e x p l a n a t i o n : 14) the subject's own understanding of why t h i s preg-nancy occured. The s e l e c t i o n of these 14 o b j e c t i v e s was made from 32 reviewing the l i t e r a t u r e and from the researcher's own ex-perience. In the l i t e r a t u r e on contraceptive u t i l i z a t i o n each study or d i s c u s s i o n considered only a few questions. The researcher attempted t o i d e n t i f y a l l of those questions which suggested s o l u t i o n s t o the research question and t o combine them i n t o a sequence of o b j e c t i v e s . The researcher a l s o considered her own work w i t h a b o r t i o n p a t i e n t s and w i t h nurses who cared f o r the p a t i e n t s , l o o k i n g at any experiences which provided i n s i g h t i n t o the p a t i e n t s ' c o ntraceptive u t i l i z a t i o n . This background was used t o confirm or adjust the o b j e c t i v e s as i d e n t i f i e d from the l i t e r a t u r e . Once the o b j e c t i v e s of the questionnaire were s e l e c t e d , questions were developed to gather s p e c i f i c i n f o r m a t i o n t o meet the o b j e c t i v e s . P r e l i m i n a r y t e s t i n g of the questions was done i n the s e t t i n g t o be used f o r the study. I n i t i a l t e s t i n g evaluated the c l a r i t y of the questions, and the questions' usefulness i n p r o v i d i n g d e s i r e d i n f o r m a t i o n . The p a t i e n t s ' r e c e p t i o n t o the i n d i v i d u a l questions and t o the i n t e r v i e w process were a l s o assessed. When the format of the questionnaire was f i n a l i z e d , i t was t e s t e d along w i t h the f o r m a l i z e d i n t r o d u c t i o n f o r t i m i n g and p a t i e n t acceptance. The questionnaire was r e -viewed during i t s development and i n i t s f i n a l form by r e -source personnel but was not subjected t o e m p i r i c a l v a l i d i t y t e s t i n g . The questionnaire and i n t r o d u c t o r y m a t e r i a l are i n Appendix A. 33 G. A n a l y s i s of the Data A n a l y s i s of the data was done i n three p a r t s . Frequency d i s t r i b u t i o n s were compiled f o r the pre-l i m i n a r y demographic data. Frequency d i s t r i b u t i o n s were compiled f o r each of the 53 questions and considered i n r e l a t i o n to each of the 14 o b j e c t i v e s . Groupings of the subjects according to any v a r i a b l e s i n d i c a t i n g s i g n i f i c a n t d i f f e r e n c e s were considered f o r c o r r e l a t i o n a n a l y s i s . The chi-square contingency procedure and the F i s h e r exact p r o b a b i l i t y t e s t were used t o t e s t f o r s i g n i f i c a n c e . 34 Chapter IV RESULTS AND ANALYSIS A. Sampling A t o t a l of 33 a b o r t i o n p a t i e n t s were randomly s e l e c t e d from a population of 77 and asked t o p a r t i c i p a t e i n the study. Two p a t i e n t s refused consent. One of these was a h o s p i t a l employee who f e l t uneasy about involvement i n any a c t i v i t y not necessary f o r the a b o r t i o n and the other s t a t e d she was under p s y c h i a t r i c care and too anxious t o be i n v o l v e d . A t h i r d subject consented but became i l l during the i n t e r v i e w which was disc o n t i n u e d . The t o t a l number of respondents was 30 and the response r a t e was 9 0 . 9 $ . B. Demographic Data The data discussed i n t h i s s e c t i o n are ta b u l a t e d i n Appendix B, Table I . 1) Age The age range of the sample was 16-37 years. The mean age was 22.5 years and the mode was 21 years. Condensing the ages i n t o f o u r groupings, the d i s t r i b u t i o n was as f o l l o w s : ages: 1 6 - 1 9 - 7 20 - 23 - 13 2 4 - 2 7 - 7 2 8 - 3 7 - 3 2) M a r i t a l Status The m a r i t a l s t a t u s of the s u b j e c t s , i n c l u d i n g whether or not they l i v e d w i t h t h e i r sexual partner was as f o l l o w s : w i t h partner - 17 - married - 9 common law - 8 35 without partner - 13 - s i n g l e - 9 separated - 3 divorced - 1 Of the s i n g l e g i r l s l i v i n g without t h e i r p a r t n e r s , 4 l i v e d w i t h t h e i r parents and 5 l i v e d on t h e i r own. 3) Number of C h i l d r e n The subjects without c h i l d r e n numbered 20 and those w i t h c h i l d r e n were 10. Of these 10 , 4 had one c h i l d , 4 had 2 c h i l d r e n , one had 4 c h i l d r e n , and one had 5 c h i l d r e n . 4) Occupation The occupation d i s t r i b u t i o n was as f o l l o w s : housewife —• 8 student - 8 employed - 14 - p r o f e s s i o n a l - 1 b u s i n e s s / c l e r i c a l - 7 s k i l l e d labour - 3 u n s k i l l e d labour - 3 5) Education L e v e l Completed The d i s t r i b u t i o n of sc h o o l i n g l e v e l s was as f o l l o w s : grade school incomplete high school incomplete high school completed 6) Number of Weeks Pregnant When t o Doctor The number of weeks the subjects were pregnant when they sought medical a s s i s t a n c e ranged from 3 t o 17 weeks, mean was 6 .8 weeks. - 9 - completed grade 9 - 1 completed grades 10 & 11 - 8 - 18 - no f u r t h e r - 11 post H.S. - 7 36 Although a b o r t i o n by D & C / a s p i r a t i o n i s g e n e r a l l y considered l e s s safe a f t e r the t w e l f t h week, 3 subjects were between 13 and 17 weeks pregnant when f i r s t t o the doctor. The other 27 were pregnant as f o l l o w s : weeks 3 -- 4 - 10 5 -- 6 - 7 7 -- 8 - 6 9 -- 12 - 4 7) Number of Previous Abortions There were 3 subjects who had had a previous a b o r t i o n , one each. This was a f i r s t experience f o r the other 27. C. Data i n R e l a t i o n t o the Objectives 1) What contraceptives have been used? There were 27 subjects out of the 30 who had used contraceptives at some time, and 3 who had never used them. S p e c i f i c methods had been used at some time by the f o l l o w i n g numbers: contraceptive p i l l s - 23 withdrawal - 10 rhythm - 10 spermacide - 9 IUD - 7 condom - 6 diaphragm - 1 Concerning the number of d i f f e r e n t methods used by each subject at some time, # had used one method, 9 had used 2 methods, 5 had used 3 methods, 3 had used 4 methods, and one each had used 6 and 7 methods. At the time of conception of the pregnancy being aborted, 17 subjects reported having used some method of contr a c e p t i o n and 13 reported not having been users. 37 Of the 17 users, 7 were using the more e f f e c t i v e methods of p i l l and IUD, while 10 were using methods of l i m i t e d e f f e c t -iveness as f o l l o w s : l i m i t e d e f f e c t i v e n e s s - 10 - spermacide - 5 condom - 1 withdrawal - 2 rhythm - 2 e f f e c t i v e - 7 - p i l l - 2 IUD - 3 IUD and spermacide - 2 2) With what consistancy had contraceptives been used? Concerning contraceptive use e r r o r s i n the past year, the 27 subjects who had used contraceptives at some time r e -ported as f o l l o w s : e r r o r s known - 16 e r r o r s not known - 11 Concerning contraceptive e r r o r s at the time of con-c e p t i o n , the 17 users reported as f o l l o w s : e r r o r s known - 5 ~ contraceptives used - p i l l s spermacide withdrawal rhythm e r r o r s not known - 12 - contraceptives used - IUD spermacide withdrawal rhythm condom Three questions s p e c i f i c t o p i l l use were asked. There were 23 subjects who had at some time used contraceptive p i l l s and who had stopped them. The reasons given f o r stopping the p i l l s were problems w i t h side e f f e c t s - 11, concern f o r h e a l t h - 7, t o take a break from continuous use - 3, no money t o buy them - 1, and c o n t r a -c e p t i o n not needed at the time - 1. 38 When asked what contraceptives were used a f t e r the p i l l s were stopped, the subjects reported as f o l l o w s : no contraceptive - # l i m i t e d - e f f e c t i v e method - 10 e f f e c t i v e method - 5 3) How were contraceptive methods chosen? When asked i f they spoke w i t h t h e i r partners about co n t r a c e p t i o n , the subjects reported t h a t 20 d i d and 10 d i d not ( i n c l u d i n g the 3 who never used c o n t r a c e p t i v e s ) . Concerning who made the d e c i s i o n on what contraceptive t o use, the 27 sometime-users reported as f o l l o w s : subject and partner decided - 10 subject decided alone - 17 Therefore, of the 20 subjects who t a l k e d w i t h t h e i r partners about c o n t r a c e p t i o n , only 10 shared the d e c i s i o n . When asked about t h e i r reasons f o r s e l e c t i n g t h e i r c o n t r a c e p t i v e s , the subjects s t a t e d w i t h decreasing frequency; ease and convenience of use, r e l i a b i l i t y , doctor's recommend-a t i o n , and obtainable without a doctor's p r e s c r i p t i o n . 4) What had been the su b j e c t s ' need f o r contraception? Concerning t h e i r need f o r co n t r a c e p t i o n , the subjects reported i n t e r c o u r s e frequency as f o l l o w s : 2-3 times per week - 1$ about once per week - 6 i r r e g u l a r and infrequent - 6 Around the time of conception, 23 reported no change i n t h e i r frequency patterns of i n t e r c o u r s e w h i l e 6 reported decreased frequency and one reported increased frequency. When asked i f they or t h e i r partner had any c o n d i t i o n 3 9 which they thought may i n t e r f e r e w i t h conception, 2 7 reported none known. One subject s t a t e d she had a t u b a l abnormality, one had thought her partner was i n f e r t i l e because he was usi n g s t r e e t drugs, and one had b e l i e v e d she could not become preg-nant f o r u n s p e c i f i e d reasons. 5) What plans had the subject considered f o r f a i l e d  contraception? When asked i f they had thought about the p o s s i b i l i t y of becoming pregnant i n the past year, 2 2 subjects reported they had and 8 reported they had not. When asked i f they had spoken w i t h t h e i r partners about the p o s s i b i l i t y of pregnancy, 1 9 s t a t e d they had and 1 1 s t a t e d they had not. Concerning plans regarding the p o s s i b i l i t y of preg-nancy, 1 7 had had no thoughts or pl a n s , 5 had vaguely consider-ed the p o s s i b i l i t y of a b o r t i o n , and 8 had had s p e c i f i c plans - 6 expected t o have an a b o r t i o n i f necessary and 2 expected t o keep the baby. Comparing the above data, though more subjects thought and t a l k e d about the p o s s i b i l i t y of pregnancy than d i d not, fewer subjects made any plans t o deal w i t h t h i s p o s s i b i l i t y . This p a t t e r n c o i n c i d e s w i t h contraceptive choosing patterns i n which more subjects t a l k e d w i t h t h e i r partners about con-t r a c e p t i o n but fewer shared the choice. 6 ) What had been the s u b j e c t s ' f e e l i n g s about the  p o s s i b i l i t y of conceiving? In an attempt t o deal w i t h t h i s o b j e c t i v e , the sub-j e c t s were asked i f they had worried about the p o s s i b i l i t y of 40 conceiving during the past year. They reported as f o l l o w s : very worried - 6 some worry - 9 had not worried - 1 5 When asked i f they wanted t o have a baby sometime i n the f u t u r e , 22 reported they d i d , 4 reported perhaps, and 4 reported they d i d not. Concerning f e e l i n g s of s a t i s f a c t i o n about knowing of t h e i r a b i l i t y t o conceive, 16 were pleased t o know, 11 were i n d i f f e r e n t , and 3 were unhappy. The reasons given f o r making the d e c i s i o n t o terminate the pregnancy were, i n decreasing frequency: not at a good or convenient time t o have a c h i l d , not married, unable t o support a c h i l d , having a c h i l d would be too demanding on them-s e l v e s , and no more c h i l d r e n wanted. 7) What f e e l i n g s the subject had about u s i n g contraceptives? When asked t h e i r f eelings'about using c o n t r a c e p t i v e s , the subjects reported as f o l l o w s : happy t o use - 15 i n d i f f e r e n t / n o thoughts - 5 d i s l i k e u sing - 10 Concerning t h e i r comfort t a l k i n g about and arranging f o r c o n t r a c e p t i o n , the subjects reported t h a t 19 were comfort-able and 11 were uncomfortable. When asked about t h e i r f e e l i n g s concerning responsib-i l i t y f o r co n t r a c e p t i o n , 19 f e l t t h a t r e s p o n s i b i l i t y should be shared by t h e i r p a r t n e r s , 10 f e l t they should take the r e -s p o n s i b i l i t y , and one had no op i n i o n . Comparing these f e e l i n g s about r e s p o n s i b i l i t y w i t h the chosing of c o n t r a c e p t i v e s , i t i s i n d i c a t e d t h a t though U many f e l t r e s p o n s i b i l i t y should be shared (19), fewer a c t u a l l y d i d share i t (10). 8) What f e e l i n g s the subject had about contraception and  sexual r o l e . Concerning these f e e l i n g s , subjects were asked how t h e i r enjoyment of i n t e r c o u r s e was a f f e c t e d by the contraceptive most r e c e n t l y used. The repor t s were as f o l l o w s : no e f f e c t -12, increased r e l a x a t i o n w i t h c o n t r a c e p t i v e - 8, decreased r e l a x a t i o n w i t h contraceptive - 6, no answer - l+. When asked about t h e i r u s u a l enjoyment of i n t e r c o u r s e , the subjects r e -sponded as f o l l o w s : very enjoyable - 20, u s u a l l y enjoyable - 6, sometimes enjoyable - 3, seldom enjoyable - 1. When asked about t h e i r comfort t a l k i n g about sexual matters, 21 st a t e d they were comfortable, one was i n d i f f e r e n t , and 8 were uncomfortable. These data f o l l o w the p a t t e r n of the s u b j e c t s ' comfort d e a l i n g w i t h c o n t r a c e p t i o n . Concerning the importance of sexual r e l a t i o n s t o the su b j e c t s , the most frequent response was tha t i t was part of a clos e r e l a t i o n s h i p . Other responses were: pleasure f o r t h e i r partner and pleasure f o r themselves. 9) What f e e l i n g s the subject had about abortion? When asked about t h e i r f e e l i n g s on the importance of ab o r t i o n i n r e l a t i o n t o con t r a c e p t i o n , 28 subjects f e l t i t was a necessary procedure. Of these, 19 viewed a b o r t i o n as a necessary t o o l t o deal w i t h i n e v i t a b l e f a i l e d c o ntraception w h i l e 9 saw a b o r t i o n i n a more negative l i g h t as a form of b i r t h c o n t r o l , the present need of which was unfortunate. Two 42 subjects f e l t t hat a b o r t i o n should not be necessary as a contraceptive method. Concerning t h e i r comfort about having t h i s a b o r t i o n , the responses were as f o l l o w s : comfortable - 10 accept but do not l i k e - 14 uncomfortable and do not l i k e - 6 The subjects were asked i f they p r e f e r r e d t o be awake or asleep during the a b o r t i o n procedure. There were 24 pre-f e r r i n g t o be asleep and 6 w i t h no preference. 10) What d i d the subject know about contraception? The subjects were asked t o l i s t the contra c e p t i v e s they knew up t o f o u r : 23 subjects l i s t e d 4 c o n t r a c e p t i v e methods, 2 l i s t e d 3 methods, 2 l i s t e d 2 methods, 1 l i s t e d 1 method, and 2 were unable t o l i s t any method. Concerning t h e i r knowledge of the l i s t e d methods, the subjects were asked f o r i n f o r m a t i o n r e l a t i n g t o : - how the methods functioned t o prevent conception - how the methods were used - what problems were inherent t o the methods - how e f f e c t i v e were the methods There was a p o s s i b l e t o t a l score of 8" f o r each subject's knowledge of each contraceptive she i d e n t i f i e d i n each of the 4 question areas. The scores i n d i c a t e d a p a t t e r n of cont r a c e p t i o n know-' ledge s i m i l a r i n a l l 4 question areas. This p a t t e r n f o l l o w e d an S curve w i t h higher numbers of subjects s c o r i n g i n both the very low range and the medium-high range. Scores 0 1 2 3 4 5 6 7 8 T o t a l no. of responses - 15 5 4 10 14 26 17 17 12 The scores f o r each of the 4 question areas are tabul-ated i n Appendix C, Table I I . 11) What d i d the subject know about conception Concerning knowledge of conception, the sub j e c t s were asked about female and male anatomy and f u n c t i o n . The scores i n d i c a t e d b e t t e r knowledge of the female than the male, and were as f o l l o w s : Scores 0 1 2 knowledge r e : female 3 9 18 knowledge r e : male 6 15 9 Knowledge of the female f e r t i l i t y p e r i o d appeared t o be poor according t o the scores on a question about c a l c u l a t i n g t h a t p e r i o d . The scores were as f o l l o w s : Scores 0 1 2 number of responses 16 6 8 The t o t a l scores f o r the above questions on knowledge of conception were as f o l l o w s : Scores 0 1 2 t o t a l number of 25 30 35 responses 44 12) What d i d the subject know about a b o r t i o n , preconception. Concerning the s u b j e c t s ' knowledge, preconception, about the l e g a l a v a i l a b i l i t y of a b o r t i o n s , the answers were as f o l l o w s : a v a i l a b l e l e g a l l y - 23 i l l e g a l only - 3 d i d not know - 4 Concerning the ease of a v a i l a b i l i t y , the s u b j e c t s ' knowledge was as f o l l o w s : $ understood abortions were a v a i l a b l e on request, 10 thought they were "perhaps" a v a i l a b l e , 7 b e l i e v e d they were d i f f i c u l t t o o b t a i n , and 5 had had no ideas about a v a i l a b i l i t y . Regarding knowledge of a b o r t i o n techniques, 12 subjects reported no knowledge, 9 reported some knowledge by s t a t i n g "D & C" but were unable t o describe t h i s procedure, and 9 described the scraping or s u c t i o n i n g aspect of the D & C/ a s p i r a t i o n techniques. No subjects noted an i n d u c t i o n and d e l i v e r y technique. Concerning knowledge of p o s s i b l e problems w i t h a b o r t -i o n s , 5 subjects noted some s p e c i f i c problems, 16 i d e n t i f i e d some g e n e r a l , vague problem areas, and 9 d i d not know of any-t h i n g . 13) What were the sources of the s u b j e c t s ' i n f o r m a t i o n r e - garding c o n t r a c e p t i o n . When asked t o l i s t a l l of the sources of t h e i r i n -formation on sexual r e l a t i o n s and pregnancy, the subjects noted the f o l l o w i n g i n decreasing frequency: f r i e n d s school programmes mothers 45 reading m a t e r i a l s partners s i b l i n g s doctors f a t h e r s The s i n g l e best sources of in f o r m a t i o n were reported as f o l l o w s : partner - 8 reading m a t e r i a l - 8 f r i e n d s - 5 mother - 3 school programme - 3 d i d not know - 3 Sources of in f o r m a t i o n about contraception were l i s t e d i n decreasing frequency as f o l l o w s : doctor reading m a t e r i a l f r i e n d s mother school programme f a m i l y planning c l i n i c pharmacist s i b l i n g s partner s o c i a l worker The s i n g l e best sources of in f o r m a t i o n about contraceptives were as f o l l o w s : reading m a t e r i a l - 10 doctor - 9 mother - 2 s o c i a l worker - "1 school programme - 1 f a m i l y planning c l i n i c - 1 pharmacist - 1 d i d not know - 5 Data were requested s p e c i f i c a l l y about parents as sources of i n f o r m a t i o n about c o n t r a c e p t i o n . The responses concerning speaking w i t h parents about sexual r e l a t i o n s and pregnancy were as f o l l o w s : spoke w i t h parents - 14 d i d not speak w i t h parents - 16 The responses concerning speaking w i t h parents about c o n t r a -ceptives were as f o l l o w s : spoke w i t h parents - 6 d i d not speak w i t h parents - 24 When asked about t h e i r comfort t a l k i n g w i t h parents about sex-u a l matters, the subjects reported as f o l l o w s : comfortable - 6 uncomfortable - 13 l i t t l e or no t a l k - 11 14) What was the s u b j e c t s ' own explanations f o r the occurrence  of t h i s pregnancy. This question was not s t r u c t u r e d i n any way. The s u b j e c t s ' unaided responses were recorded and were then con-s i d e r e d f o r s i m i l a r c h a r a c t e r i s t i c s . In many responses, more than one c h a r a c t e r i s t i c was noted. This coding was done by the researcher alone w i t h no outside v a l i d a t i o n . The response c h a r a c t e r i s t i c s were as f o l l o w s : a v o i d a n c e / u n r e a l i s t i c - 21 ( d i d not consider the p o s s i b i l i t y of c o n t r a -ception f a i l u r e , the need f o r more inform-a t i o n , or the poss-i b i l i t y of pregnancy) ignorance of the e f f e c t i v e n e s s - 13 of the method used contraception f a i l u r e - 10 magical t h i n k i n g - " w i l l - 6 not happen t o me" c a r e l e s s c o ntraceptive use - 5 passiveness about the a b i l i t y t o i n f l u e n c e the p o s s i b i l i t y of pregnancy - 4 l a c k of concern - had a l t e r n a t i v e s planned - 2 47 D.. Comparison of Contraceptive Users & Non-users at  Conception. As planned i n the study design f o r the a n a l y s i s of the data, groupings i n the data were considered f o r c o r r e l a t i o n a n a l y s i s . The one grouping of i n t e r e s t which was explored concerned the use of. contraceptives at the time of conception of the pregnancy being terminated by a b o r t i o n . There were 17 subjects who reported having used con-t r a c e p t i v e s at the time of conception and 13 who d i d not use them. The r e s t of the data were coded and analysed according t o these two groups. S i g n i f i c a n t d i f f e r e n c e s and i n t e r e s t i n g tendencies between the two groups were noted w i t h s e v e r a l items. i f i c a n c e (when two frequencies were below 5) were used t o check c o r r e l a t i o n a l s i g n i f i c a n c e . F ollowing i s an o u t l i n e of the d i f f e r e n c e s noted between the two groups: 1) Demographic Chi-square contingency and F i s h e r ' s t e s t s f o r s i g n -a) Age. Users were more often over 21 years than were non-users. ^ 21 > 21 14 5 5.5268 U NU 2 6 df = 1 N 27 /. s i g n i f i c a n t at <.02 l e v e l b) M a r i t a l s t a t u s . Users tended t o be more oft e n l e g a l l y married than d i d non-users. 48 Users a l s o tended t o be more o f t e n l i v i n g w i t h t h e i r partners (married or common law) than d i d non-users. °) Occupation. Users tended more oft e n t o be students than d i d non-users who were more o f t e n housewives or working. d) Education l e v e l completed. Users tended more oft e n to have continued s t u d i e s a f t e r grade 12 than d i d non-users. e) Number of weeks pregnant when t o doctor. Users tended to go t o a doctor e a r l i e r i n t h e i r pregnancy than d i d non-users. P r a c t i c e a) Contraceptives ever used. Users had t r i e d out a grea t e r number of co n t r a -ceptive methods than had non-users. b) Contraceptive use a f t e r stopping contraceptive p i l l s . Users had used some other method a f t e r stopping p i l l s more oft e n than had non-users who stopped p i l l s . U NU nothing used something used F i s h e r t e s t of s i g -n i f i c a n c e : 0 14 8 1 P < .005 c°c s i g n i f i c a n t at <.005 l e v e l Users more oft e n used e f f e c t i v e contra ceptive methods a f t e r stopping p i l l s than d i d non-users. e f f e c t i v e contrac. l i m i t e d e f f e c t -i v e contrac. X 2 = 4.1071 df = 1 U NU 5 0 N = 23 9 9 .". s i g n i f i c a n t at <.05 l e v e l 49 c) Contraceptive e r r o r s . Users tended t o be more aware of contraceptive e r r o r s made i n the l a s t year than d i d non-users. d) Choosing contraceptive methods. Users tended t o t a l k more o f t e n about con-t r a c e p t i o n w i t h t h e i r partners than d i d non-users. Users shared decision-making about contraceptive choice w i t h t h e i r p a r t -ners more oft e n than d i d non-users. Chosen Both 9  by s e l f chose Hc = 4.9787 df = 1 U 8 9 NU 9 1 . ' . s i g n i f i c a n t at <.05 l e v e l N = 27 e) The p a t i e n t s ' need f o r contraception . Users had i n -ter c o u r s e more r e g u l a r l y and f r e q u e n t l y than d i d non-users. 1-3X/ i r r e g u l a r / i n - 2 week frequent X = 4.8869 df = 1 U 16 1 NU 8 5 . / . s i g n i f i c a n t at <.05 l e v e l N = 30 Users had more con s i s t a n t patterns of in t e r c o u r s e frequency around the time of conception than d i d non-users. l e s s 2 no change frequent X = 9.3110 df = 1 U 16 0 NU 7 6 / . s i g n i f i c a n t at< . 0 1 l e v e l N = 29 f ) Ideas about d e a l i n g w i t h pregnancy i f i t occurred. Users tended t o have s p e c i f i c a l l y thought of the p o s s i b i l i t y of ab o r t -io n more o f t e n i f pregnancy occurred than d i d non-users. 50 A t t i t u d e a ) Feelings about us i n g c o n t r a c e p t i v e s . Users tended t o f e e l happier about usi n g contraceptives than d i d non-users. Users f e l t t hat r e s p o n s i b i l i t y f o r using contraception should be shared w i t h t h e i r partners more oft e n than d i d non-users. U NU s e l f respon. 3 7 shared respon. 14 5 X " = 5.1543 df = 1 / . s i g n i f i c a n t at < .05 l e v e l N = 29 Knowledge a) T o t a l scores on knowledge of c o n t r a c e p t i v e s . Users tended t o have more high scores f o r contraceptive knowledge than d i d non-users, who had more low scores. b) Scores on knowledge of male anatomy and sexual f u n c t i o n . Users tended t o have more high scores f o r knowledge of the male than d i d non-users, who had more lower scores. c) Sources of inf o r m a t i o n on con t r a c e p t i o n . Users tended t o t a l k l e s s o f t e n w i t h parents about sex and pregnancy than d i d non-users. Chapter V 51 DISCUSSION AND IMPLICATIONS A. D i s c u s s i o n 1) Demographic C h a r a c t e r i s t i c s The most s t r i k i n g observation t o be made from the p r e l i m i n a r y data i s t h a t there appear t o be few cha r a c t e r -i s t i c s common or unique t o most of the 30 s u b j e c t s . The most common s i t u a t i o n was that 27 of the 30 had never had an i n -duced a b o r t i o n before. Drawing from those c h a r a c t e r i s t i c s f i t t i n g at l e a s t two-thirds (20 +) of the s u b j e c t s , one has a composite p i c t u r e of an a b o r t i o n p a t i e n t between 20-26 years of age (or under 24 y e a r s ) , w i t h no c h i l d r e n , having completed some l e v e l of high s c h o o l , who sought medical a s s i s t a n c e by the 7th week of pregnancy, and who never had an a b o r t i o n before. Looking at those c h a r a c t e r i s t i c s which f i t between one-half and two—thirds (15-20) of the s u b j e c t s , one adds t o the composite p i c t u r e a m a r i t a l s t a t u s of e i t h e r l e g a l l y -s i n g l e ( l i v i n g s i n g l y and common law) or l i v i n g - w i t h - p a r t -ner (married and common la w ) , and an education l e v e l of high school or higher completed. The occupation item showed the most common charact-e r i s t i c as employed but t h i s group i s j u s t under one-half (14) of the s u b j e c t s . These demographic data do not d i f f e r g r e a t l y from those of e i t h e r the Grauer or Claman s t u d i e s , though they are 5 2 probably a l i t t l e c l o s e r t o daman's group from the same u r -ban centre. The present study's subjects tended t o be a 1 2 l i t t l e younger and l e s s o f t e n l e g a l l y married. ' 2) Contraception P r a c t i c e a) Contraceptives Used. Most subjects had used some form of contraception sometime i n the past. The p i l l was the most frequent i n d i v i d u a l method used at some time but more of the subjects (over one-half) had used methods of l i m i t e d e f f e c t i v e n e s s . Just over h a l f of the subjects (17) reported u s i n g a contraceptive at the time of conception. This number i s s i m i l a r t o Grauer's f i n d i n g s t h a t 57$ of h i s subjects had used 3 c o n t r a c e p t i v e s at the time of conception. The most common i n d i v i d u a l method used by the group of 17 was a spermacide. Over h a l f of the group used methods of l i m i t e d e f f e c t i v e n e s s . b) Consistancy of Contraceptive Use. Almost two-t h i r d s of those who had ever used contraceptives were aware of making e r r o r s i n t h e i r use at some time. Of the 17 subjects who used contraceptives at the time of conception, only 5 knew of an e r r o r made i n the use. H. Grauer, "A Study of Contraception as Related t o Unwanted Pregnancy," Canadian Medical A s s o c i a t i o n J o u r n a l , 107: 740, October 21, 1972. 2 A. David Claman, et a l , "Impact on H o s p i t a l P r a c t i c e of L i b e r a l i z i n g Abortions & Female S t e r i l i z a t i o n s , " Canadian  Medical A s s o c i a t i o n J o u r n a l , 105: 38, J u l y 10, 1971. Grauer, op. c i t . , p. 740. 53 However, combining those who knew they had used no c o n t r a -ceptive w i t h those who i d e n t i f i e d t h e i r c o n t r a c e p t i v e e r r o r at conception, i t i s evident t h a t w e l l over h a l f (18) of the subjects could i d e n t i f y the contraceptive use problem i n v o l v e d i n t h e i r pregnancy. Of the 12 who could not i d e n t i f y t h e i r c o n traceptive e r r o r at conception, 5 reported having an IUD (3 used the IUD alone and 2 combined i t w i t h a spermacide). Since the subject has l i t t l e t o do w i t h the u s e - e f f e c t i v e n e s s of the IUD, these instances may be considered c o n t r a c e p t i o n f a i l u r e . Few of the subjects i n d i c a t e d knowledge of how t o check f o r the pre-sence of the IUD. I t could be questioned how o f t e n t h i s technique i s taught t o IUD users. Data s p e c i f i c t o p i l l use i n d i c a t e d t h a t over two-t h i r d s (23) of the subjects had used co n t r a c e p t i v e p i l l s at some time and had stopped them most oft e n because of s i d e e f f e c t problems. Only 5 of these 23 subjects switched t o another e f f e c t i v e c o n t r a c e p t i v e , an IUD. Thus, over two-t h i r d s of the " p i l l - s t o p p e r s " moved t o l e s s e f f e c t i v e c o n t r a -c e p t i o n . This number i s s i m i l a r though somewhat l e s s than the 90$ who switched from the p i l l t o l e s s e f f e c t i v e methods i n Bracken's s t u d y . 4 c) Contraceptive Choice. Although two-thirds of the subjects reported t a l k i n g w i t h t h e i r partners about c o n t r a -^"Michael B. Bracken, et a l , "Contraceptive P r a c t i c e Among New York A b o r t i o n P a t i e n t s , " American Journal of  O b s t e t r i c s & Gynecology, 114: 975, December 1, 1972. 54 c e p t i o n , over h a l f a l s o s t a t e d they chose t h e i r c o n t r a c e p t i v e themselves. Thus contraceptive choice was, i n r e a l i t y , a r e s p o n s i b i l i t y of the woman. The c h a r a c t e r i s t i c s most d e s i r a b l e i n a c o n t r a c e p t i v e method were given as ease and convenience of use, and r e -l i a b i l i t y . d) Need f o r Contraception. Over two-thirds of the sub-j e c t s reported having i n t e r c o u r s e r e g u l a r l y and f a i r l y f r e q -u e n t l y , and thus were needing r e g u l a r c o n t r a c e p t i o n . This number a l s o noted no change i n i n t e r c o u r s e frequency nor know-ledge of a c o n d i t i o n i n h i b i t i n g conception i n themselves or t h e i r partners at the time of conception. e) C o n s i d e r a t i o n of F a i l u r e of Conception. During the past year, over two-thirds of the subjects thought about the p o s s i b i l i t y of becoming pregnant, and a few l e s s t a l k e d about t h i s w i t h t h e i r p a r t n e r s . However, over h a l f (17) had not thought through t o what they would do i f they d i d become preg-nant. Of the 13 who d i d have some ideas about how they would deal w i t h a pregnancy, most considered the p o s s i b i l i t y of having an a b o r t i o n . f ) Summary of P r a c t i c e Data. The composite p i c t u r e pre-sented by over h a l f of the subjects concerning contraceptive use i s as f o l l o w s : an a b o r t i o n p a t i e n t who had used contraceptives but ones of l i m i t e d e f f e c t i v e n e s s , who was aware of the c o n t r a c e p t i v e problem l e a d i n g t o her pregnancy, and who had used p i l l s at 55 some time, stopped, and then switched t o l e s s e f f e c t i v e methods. She a l s o tended t o t a l k w i t h her partner about con t r a c e p t i o n but then chose the method h e r s e l f , l o o k i n g f o r ones t h a t were easy t o use and r e l i a b l e . She re q u i r e d contraception r e g u l a r l y , and though she thought and t a l k e d about the p o s s i b i l i t y of pregnancy she seldom considered what she might do i f pregnancy occurred. 3) Contraception A t t i t u d e s a) Feelings about the P o s s i b i l i t y of Conceiving. The occurrence of pregnancy appeared t o have some p o s i t i v e aspects f o r many of the s u b j e c t s . Almost a l l (26) reported they would l i k e t o consider having a c h i l d sometime i n the futu r e and h a l f were pleased t o be aware of t h e i r f e r t i l i t y . Although more thought about the p o s s i b i l i t y of be-coming pregnant, h a l f of the subjects a c t i v e l y worried about i t w h i l e h a l f s t a t e d they had not worr i e d . The reasons f o r t h i s v a r i a t i o n i n concern were not explored. The most common reasons given f o r d e c i d i n g t o terminate the pregnancy r e l a t e d d i r e c t l y t o the su b j e c t s ' s i t u a t i o n : inconvenient t i m i n g t o have a c h i l d and not being married. b) F e e l i n g s about Using Contraceptives. Almost two-t h i r d s (19) of the subjects f e l t t h a t the r e s p o n s i b i l i t y f o r contr a c e p t i o n should be shared by h e r s e l f and her pa r t n e r . However, over one-half reported making con t r a c e p t i o n choices by themselves, a s i t u a t i o n which could have caused these sub-j e c t s t o resent having the r e s p o n s i b i l i t y . 56 This discrepency may a l s o r e l a t e t o the data t h a t only one-half of the subjects reported being happy about using con-t r a c e p t i v e s while o n e - t h i r d s t a t e d they s p e c i f i c a l l y d i s l i k e d u s ing them. Adding t o the apparent i n c o n s i s t a n c y i n f e e l i n g s about usi n g c o n t r a c e p t i o n , two-thirds of the subjects reported being comfortable t a l k i n g about contra c e p t i v e s w h i l e only o n e - t h i r d were not. c) Feelings about Contraception and Sexual Role. Most subjects (26) reported they u s u a l l y enjoyed having i n t e r c o u r s e . Despite some negative f e e l i n g s about us i n g c o n t r a c e p t i v e s as reported above, two - t h i r d s of the subjects s t a t e d t h e i r en-joyment of i n t e r c o u r s e was unaff e c t e d or increased when using c o n t r a c e p t i v e s . A l s o , over two-thirds of the subjects r e -ported f e e l i n g comfortable t a l k i n g about sexual matters, a s i m i l a r but l a r g e r number than those who were comfortable t a l k i n g about contraception. d) Feelings about Abor t i o n . Most of the subjects viewed a v a i l a b i l i t y of a b o r t i o n as necessary t o deal w i t h f a i l e d c ontraception and b i r t h c o n t r o l . However, although over tw o - t h i r d s of the subjects reported they r a t i o n a l l y accepted the idea of having an a b o r t i o n f o r themselves, two-t h i r d s a l s o noted t h e i r unhappiness about having i t . e) Summary of A t t i t u d e Data. A composite p i c t u r e of the more frequent a t t i t u d e s of the subjects i s as f o l l o w s : an a b o r t i o n p a t i e n t who wants t o have a baby someday, but 57 decided against keeping t h i s pregnancy because the t i m i n g was inconvenient or she was not married. Her f e e l i n g s were am-b i v a l e n t about the p o s s i b i l i t y of pregnancy and about having to take r e s p o n s i b i l i t y f o r c o n t r a c e p t i o n . She was a l s o am-b i v a l e n t about us i n g contraceptives though her enjoyment of i n t e r c o u r s e was not u s u a l l y a f f e c t e d by t h e i r use. The tendency t o ambivalence concerning some aspects of contraceptive u t i l i z a t i o n r e f l e c t s the ideas about d i f f -i c u l t i e s a r i s i n g from s e x u a l i t y problems as discussed by 5 6 7 s e v e r a l of the authors reported i n the l i t e r a t u r e . I t i s suggested t h a t a person who i s uncomfortable w i t h t h e i r s e x u a l i t y and who d i s l i k e s or resents u s i n g c o n t r a c e p t i v e s , may not use them w e l l . 4) Contraception Knowledge a) Knowledge of Contraceptives. Although over two-t h i r d s of the subjects were able t o l i s t at l e a s t 4 methods of c o n t r a c e p t i o n , contraceptive knowledge scores i n d i c a t e d t h a t few had complete knowledge of these methods. The l a r g e s t group of sub j e c t s (14) scored between 50$ - 75$ c o r r e c t know-ledge. Just under one-fourth of the subjects scored between 75$ - 100$, but another quarter scored between 0 - 50$. These ''L.P.O. Tunnadine, Contraception & Sexual L i f e (London: Tavistock P u b l i c a t i o n s , 1970) , pp. 37-41 . 6Nancy G a r r e t t , "Choosing Contraceptives According t o Need," The Canadian Nurse, 6 8 : 4 0 , September, 1972. 7James G. H i l l , " B i r t h C o n t r o l Usage Among Abortion P a t i e n t s , " Kansas Medical S o c i e t y J o u r n a l , 73: p. 29$, June, 1972. 58 data c o i n c i d e w i t h the Weiner and Davis study i n which very incomplete knowledge of s p e c i f i c c o n traceptive methods was i n d i c a t e d by the s u b j e c t s . Of the four s p e c i f i c questions concerning knowledge of contraceptive f u n c t i o n , use, problems, and e f f e c t i v e n e s s , the answer scores were g e n e r a l l y higher f o r the p r a c t i c a l knowledge of use and e f f e c t i v e n e s s , and lower f o r the depth understanding of f u n c t i o n and problems. b) Knowledge of Conception. T o t a l scores f o r know-ledge of conception followed a p a t t e r n s i m i l a r t o that of contraceptive knowledge. Complete knowledge was r a r e . The l a r g e s t group of subjects had scores between 50 - 75$ c o r r e c t knowledge w i t h s u b s t a n t i a l groups i n the ranges of 0 - 50$ and 75 - 100$. On the i n d i v i d u a l questions, the subjects i n d i c a t e d b e t t e r knowledge of female than of male anatomy and f u n c t i o n . A l s o , over two-thirds i n d i c a t e d incomplete or no understanding of how t o estimate the average female f e r t i l i t y p e r i o d . This f i n d i n g i s s i m i l a r t o Goldsmith's who reported that subjects using the rhythm method oft e n d i d not know when t h e i r f e r t i l i t y 9 p e r i o d probably occurred. c) Knowledge of Ab o r t i o n . G e n e r a l l y , knowledge con-Enid Weiner & J u d i t h Davis, " P r o v i s i o n a l Study of a Group of Unmarried Mothers i n the C i t y of Vancouver: Some S o c i a l C h a r a c t e r i s t i c s , Knowledge of A t t i t u d e s Towards & P r a c t i c e of Contraception," (unpublished paper, U n i v e r s i t y of B r i t i s h Columbia, 1969). P-5. ^Sadja Goldsmith, et a l , "Teenagers, Sex & Contra-c e p t i o n , " Family Planning P e r s p e c t i v e s , 4: 37, January, 1972. 59 cerning a b o r t i o n s was l i m i t e d . Although over two-thirds of the subjects knew that a b o r t i o n s could be performed l e g a l l y , most d i d not know how r e a d i l y a v a i l a b l e they were. Over h a l f had only vague knowledge of the a b o r t i o n procedure and the same number knew l i t t l e or nothing about problems r e l a t e d t o a b o r t i o n s . d) Sources of the Contraception Knowledge. The sub-j e c t s l i s t e d a v a r i e t y of sources f o r i n f o r m a t i o n but no one source appeared t o be p a r t i c u l a r l y u s e f u l . Just over h a l f (16) of the subjects l i s t e d t h e i r partners or reading m a t e r i a l s as t h e i r best source of i n f o r m a t i o n on sexual r e l a t i o n s and pregnancy. Almost three-quarters (19) l i s t e d reading m a t e r i a l s or t h e i r doctors as t h e i r best source of i n f o r m a t i o n on con-t r a c e p t i o n . I t was i n t e r e s t i n g t o note t h a t many subjects suggested schools could be the most appropriate and u s e f u l source of such i n f o r m a t i o n . Parents d i d not show as u s e f u l or comfortable sources of sexual or contraception i n f o r m a t i o n . Over h a l f of the s u b j e c t s reported they d i d not t a l k w i t h t h e i r parents about sexual r e l a t i o n s and over three-quarters d i d not t a l k w i t h parents about co n t r a c e p t i o n . e) Summary of Knowledge Data. A composite p i c t u r e of the s u b j e c t s ' contraception knowledge l e v e l i s as f o l l o w s : an a b o r t i o n p a t i e n t who was aware of s e v e r a l methods of contraception but whose knowledge of these methods was i n -complete and s u p e r f i c i a l . Her knowledge about conception was a l s o incomplete, being b e t t e r about the female r o l e than the 60 male though very poor concerning an understanding of the f e -male f e r t i l i t y p e r i o d . About a b o r t i o n s , her knowledge was a l s o l i m i t e d concerning a v a i l a b i l i t y , the a b o r t i o n techniques, and a s s o c i a t e d problems. She learned about sexual r e l a t i o n s and pregnancy most-l y from her partner and reading m a t e r i a l s , and about c o n t r a -c e p t i o n mostly from reading m a t e r i a l s and her doctor. Her parents were a poor source of i n f o r m a t i o n and she was un-comfortable t a l k i n g w i t h them about sexual matters. I t was noted i n the l i t e r a t u r e review t h a t i n f o r m a t i o n concerning adequacy of contraception knowledge was i n c o n c l u s i v e but d i d suggest t h a t such knowledge was o f t e n l i m i t e d . This study supports the suggestion t h a t knowledge i s o f t e n i n -complete. 5) Subjects' Explanations The l a r g e s t number of subjects p r o v i d i n g a common ex-p l a n a t i o n f o r the occurrence of t h e i r pregnancies i n d i c a t e d t h a t they u n r e a l i s t i c a l l y avoided c o n s i d e r a t i o n of the pos-s i b i l i t y of pregnancy a r i s i n g from t h e i r sexual r e l a t i o n s . This suggests t h a t a major problem w i t h contraceptive u t i l i z -a t i o n i s i n the area of d e a l i n g d i r e c t l y w i t h the r e a l i t y of s e x u a l i t y and i m p l i c a t i o n s of sexual contacts. Two other notable problem areas were contraception f a i l u r e and ignorance concerning contraceptive methods. These two explanations by the subjects have some support from the data. Five of the subjects s p e c i f i c a l l y reported c o n t r a -ception f a i l u r e w i t h IUD's and the l e v e l of contraception 61 knowledge was l i m i t e d f o r most s u b j e c t s . 6) Comparison of Contraceptive Users & Non-Users The v a r i a b l e s showing s t a t i s t i c a l l y s i g n i f i c a n t d i f -ferences between the users and non-users of contraceptives at the time of conception provide the f o l l o w i n g p i c t u r e s of the two groups. The u s e r s , numbering 17 out of 30, were o l d e r , had more r e g u l a r and g r e a t e r need f o r c o n t r a c e p t i o n , showed a p a t t e r n of more e f f e c t i v e contraceptive choice, and wished t o and d i d share r e s p o n s i b i l i t y f o r contraception w i t h t h e i r p a r t n e r s . I t i s notable that 5 of these 17 subjects were usi n g IUD's and so could be c l a s s e d as examples of c o n t r a -ception f a i l u r e . t The non-users, numbering 13 out of 30, were younger, had more i r r e g u l a r and infrequent need f o r c o n t r a c e p t i o n , showed a p a t t e r n of i n e f f e c t i v e c o n traceptive choice, and d i d not wish t o and d i d not share r e s p o n s i b i l i t y f o r c o n t r a c eption. The v a r i a b l e s showing notable d i f f e r e n c e s but not at s i g n i f i c a n t l e v e l s between contraceptive users and non-users add as f o l l o w s t o the p i c t u r e s of the two groups. The users tended t o be e i t h e r l e g a l l y married or l i v i n g w i t h t h e i r p a r t n e r s , and t o be more h i g h l y educated and o f t e n s t i l l s tudents. They tended t o seek medical a s s i s t a n c e e a r l y i n t h e i r pregnancies. They o f t e n had t r i e d s e v e r a l c o n t r a -ceptive methods, were happy using c o n t r a c e p t i v e s , and were aware of contraceptive e r r o r s . They had considered a b o r t i o n i f e r r o r occured. Their knowledge of contraceptives and of 6 2 male sexual f u n c t i o n tended t o be f a i r l y good and t h e i r parents were not u s u a l l y good sources of contraception i n f o r m a t i o n . The non-users tended t o be not l e g a l l y married and l i v i n g alone. They were u s u a l l y housewives or working and l e s s w e l l educated acedemically. They tended t o go t o the doctor l a t e r i n t h e i r pregnancies. G e n e r a l l y , they had t r i e d fewer c o n t r a c e p t i v e s , d i d not l i k e u sing them, were not aware of contraception e r r o r s , and seldom had s p e c i f i c thoughts about what they would do i f e r r o r occurred. T h e i r knowledge of contraceptives and of male sexual f u n c t i o n tended t o be poor and t h e i r parents were u s u a l l y considered t h e i r main source of contraception i n f o r m a t i o n . These two groups of subjects having the same need f o r ab o r t i o n d i f f e r considerably i n many c h a r a c t e r i s t i c s . This suggests t h a t contraception problems may be complex and v a r i e d i n t h e i r development. 7) The Study Design a) The Approach. The use of only one i n t e r v i e w e r t o gather data had advantages of convenience and l a c k of i n t e r -personal v a r i a t i o n s i n i n t e r v i e w technique. However, i t d i d not provide a check f o r biases i n the s i n g l e i n t e r v i e w e r ' s approach nor f o r s h i f t s i n that approach as the i n t e r v i e w process became more r o u t i n e t o the i n t e r v i e w e r . The use of a questionnaire t o s t r u c t u r e the i n t e r v i e w provided consistancy i n the data c o l l e c t e d and i n coding those data. A non-structured i n t e r v i e w might have l e a d t o a broader range of data but consistancy would have been l i m i t e d and 63 a n a l y s i s d i f f i c u l t . C o n sideration of an even more s t r u c t u r e d approach, such as a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e , might have been use-f u l . This approach would have, while l i m i t i n g the range of i n f o r m a t i o n gathered, provided even more consista n c y , f a c i l i t -ated t e s t i n g f o r v a l i d i t y and r e l i a b i l i t y , and provided a more p r i v a t e format f o r the subjects t o answer questions w i t h which they might have f e l t uncomfortable. b) S e t t i n g . I n i t i a l contact w i t h the subjects had t o be made on an open ward where a l l the p a t i e n t s were having a b o r t i o n procedures. The l a c k of p r i v a c y w h i l e e x p l a i n i n g the study procedure appeared t o l e a d t o the researcher's discom-f o r t more than the p a t i e n t s ' . The i n t e r v i e w i t s e l f took place i n a quiet conference room k i n d l y provided by the ward s t a f f . The subjects were g e n e r a l l y most co-operative and r e c e p t i v e . They f r e q u e n t l y s t a t e d they were pleased t o have something to do during the l o n g , quiet evening before the a b o r t i o n next morning. Their continued co-operation may have been f a c i l i t a t e d by the i n -t e r v i e w e r o f f e r i n g t o answer any questions and e x p l a i n pro-cedures a f t e r the questionnaire was completed. c) Population and Sample. The sampling procedure was c a r r i e d out without d i f f i c u l t y and as planned. The r e -sponse r a t e of 90.9$ i s s u f f i c i e n t t o have confidence i n the d a t a . 1 0 David J . Fox, Fundamentals of Research i n Nursing (New York: Appleton - Century - C r o f t s , 1970), p. 177. 64 d) The Tool. Approximately three quarters of an hour was necessary t o administer the questionnaire by i n t e r v i e w . Most of the questions e l i c i t e d answers r e a d i l y but some of the l i s t s of p o s s i b l e answers d i d not f i t w e l l w i t h the data r e -ceived. This r e q u i r e d t h a t answers be w r i t t e n i n during the i n t e r v i e w and that coding be adjusted t o accommodate the un-a n t i c i p a t e d answers. P r e l i m i n a r y t e s t i n g w i t h more subjects could have prevented t h i s s i t u a t i o n . The items on contraception p r a c t i c e sought and gener-a l l y e l i c i t e d s t r a i g h t - f o r w a r d data which provided some c l e a r answers t o the p r a c t i c e part of the research question. Design of items on contraception a t t i t u d e s was d i f -f i c u l t due t o the l a c k of examples from the l i t e r a t u r e and t o the d i f f i c u l t y of i d e n t i f y i n g s u b j e c t i v e f e e l i n g s t a t e s be-h a v i o u r a l l y . The data r e l a t e d t o the a t t i t u d e part of the research question thus i n d i c a t e d p o s s i b l e trends but no c l e a r answers.. The items on contraception knowledge u s u a l l y were f a i r l y complex r e q u i r i n g v e r b a l r e c a l l answers. A l a r g e r number of w e l l developed, s i n g l e question, m u l t i p l e choice items could have f a c i l i t a t e d c l e a r e r t e s t i n g of more s p e c i f i c u n i t s of knowledge. Coding of answers would a l s o have been e a s i e r and probably more c o n s i s t a n t . These data, t h e r e f o r e , i n d i c a t e d some answers t o the knowledge part of the research question but d i d not c l e a r l y i d e n t i f y problem areas. B. I m p l i c a t i o n s 1) General 65 The r e s u l t s of t h i s study suggest t h a t a b o r t i o n p a t i e n t s are a v a r i e d group i n r e l a t i o n t o age, m a r i t a l s t a t u s , occupation, and education l e v e l . Thus, any attempt t o reduce the need f o r a b o r t i o n s through contraceptive u t i l i z a t i o n should not be l i m i t e d as t o approach, t o whom i t may be d i r -ected, nor by whom i t may be c a r r i e d out. 2) Contraception P r a c t i c e Contraceptives are widely needed and used. They t h e r e -f o r e need t o be r e a d i l y a v a i l a b l e i n a manner which ensures t h e i r e f f e c t i v e use. The a v a i l a b i l i t y of contraceptives was not considered i n t h i s study but needs t o be described i n fu t u r e research i f a t o t a l understanding of contraceptive u t i l i z a t i o n i s t o be gained. The comfort and i n t e l l i g e n t s k i l l necessary f o r e f f e c t i v e c ontraception w i l l depend on the user's a t t i t u d e s and knowledge. S p e c i f i c i m p l i c a t i o n s from t h i s study's data on these f a c t o r s w i l l f o l l o w . Technical problems w i t h contraceptives cause many d i f f i c u l t i e s . Few methods are h i g h l y e f f e c t i v e even given c o r r e c t use and a l l methods have p o t e n t i a l f o r human e r r o r i n use. Users t h e r e f o r e need t o be w e l l and comfortably informed as t o e f f e c t i v e n e s s , use, f u n c t i o n , and problems i n order t o make contraceptive choices s u i t a b l e t o i n d i v i d u a l needs. Given t h i s f a i l u r e p o t e n t i a l of p r e s e n t l y a v a i l a b l e c o n t r a c e p t i v e s , promotion of the development of s a f e r , more e f f e c t i v e , and convenient contraceptives i s of importance. Also necessary i s a r e a l i s t i c c o n s i d e r a t i o n of the r o l e and sa f e t y of a b o r t i o n as a back-up f o r i n e v i t a b l e f a i l u r e s i n contr a c e p t i o n . 66 The apparent l i m i t e d sharing of contraception d e c i s i o n -making and d i s c u s s i o n of p o t e n t i a l problems of pregnancy by s e x u a l l y a c t i v e couples i s notable. Further study i s i n -d i c a t e d as t o the i m p l i c a t i o n s of these s i t u a t i o n s f o r both contraceptive u t i l i z a t i o n and the much broader area of com-munication between p a r t n e r s . 3) Contraception A t t i t u d e s Although more and b e t t e r s t u d i e s are needed f o r a c l e a r e r understanding of the e f f e c t s of a t t i t u d e s on co n t r a -ceptive use, the c o n f l i c t s and ambivalence that were ap-parent i n t h i s study's subjects suggests problems i n t h i s area. Concerns about when t o have d e s i r e d c h i l d r e n and about sharing of contraception r e s p o n s i b i l i t i e s i n d i c a t e the necess-i t y of t r u s t and openness between s e x u a l l y a c t i v e couples. C o n f l i c t s about using contraceptives w h i l e acknowledging the enjoyment and importance of sexual r e l a t i o n s i n d i c a t e the need f o r acceptance of personal s e x u a l i t y . Approaches t o these problems could be made through programmes on human s e x u a l i t y and communication designed t o d e s e n s i t i z e and inform people concerning t h e i r s e x u a l i t y . Such programmes may be b e n e f i c i a l f i r s t f o r p r o f e s s i o n a l people such as'nurses, doctors, s o c i a l workers, and teachers who are seen and used as resources f o r d e a l i n g w i t h s e x u a l i t y problems and education. These programmes would a l s o be bene-f i c i a l f o r parents as they help t h e i r c h i l d r e n deal w i t h t h e i r developing s e x u a l i t y . Other p o s s i b l e means t o i n f l u e n c e healthy c o n t r a -c e p t i o n a t t i t u d e s i n c l u d e : w e l l developed school programmes 67 on f a m i l y l i f e and sex education, i d e n t i f i c a t i o n and t r e a t -ment of s e x u a l i t y problems by f a m i l y p h y s i c i a n s and other primary care workers, and thorough assessment and education f o r people requesting c o n t r a c e p t i v e s . 4) Contraception Knowledge Two important issues may be drawn from the data on contraception knowledge. F i r s t , knowledge of the subjects concerning contraception was often incomplete. Second, parents appeared t o have been poor sources of i n f o r m a t i o n and no con-s i s t a n t and e f f e c t i v e resource replaced them. This suggests the need f o r s p e c i f i c and formal pro-grammes t o provide contraception education. Such programmes can probably be most economically provided i n s c h o o l s , though e f f o r t s t o reach a d u l t s , i n c l u d i n g e s p e c i a l l y parents, would be u s e f u l and important. The development of programmes w i t h i n the context of s e x u a l i t y education, f a m i l y l i f e education, and communications education would provide a healthy and r e a l i s t i c framework f o r contraception education. 5) Future Studies Further research would be u s e f u l i n most areas covered by t h i s study i n order t o check and f o l l o w up on the r e s u l t s reported here. R e l i a b i l i t y and v a l i d i t y t e s t i n g would be necessary i f the t o o l developed f o r t h i s study were t o be used again. Studies i n g r e a t e r depth f o r each aspect of the r e -search question could provide b e t t e r understanding of c o n t r a -ception p r a c t i c e s and the i n f l u e n c e of a t t i t u d e s and know-68 ledge. Comparative s t u d i e s w i t h non-abortion subjects of c h i l d - b e a r i n g age are necessary t o i d e n t i f y any unique char-a c t e r i s t i c s of the a b o r t i o n p a t i e n t s . Experimental s t u d i e s may now be i n d i c a t e d t o t e s t out approaches t o deal w i t h some of the problems of contraceptive u t i l i z a t i o n . F i n a l l y , i t i s evident from the l i t e r a t u r e and general observations that a t t i t u d e s and p r a c t i c e s concerning s e x u a l i t y are s h i f t i n g and changing i n our s o c i e t y . No one d e s c r i p t i o n of contraceptive u t i l i z a t i o n nor any s i n g l e preventive or treatment method i s going t o i d e n t i f y or solve a l l problems. Constant re-assessment and planning i s necessary i f good contraceptive h e a l t h care i s t o be a v a i l a b l e . 69 BIBLIOGRAPHY Books, Pamphlets and Reports Callahan, D a n i e l . A b o r t i o n : Law, Choice and M o r a l i t y . London: C o l l i e r - Macmillan L t d . , 1970. Caplan, Gerald. P r i n c i p l e s of Preventive P s y c h i a t r y . New York: Basic Books Inc., 1964. Cherniak, Donna, and A l l a n Feingold (eds.). B i r t h C o n t r o l Hand-book. Montreal: A r t s and Science Undergraduate S o c i e t y of M c G i l l U n i v e r s i t y , 1970. Contraceptive P r a c t i c e s . V o l . I of Babies by Choice Not by  Chance. Vancouver, B. C : United Community Se r v i c e s of the Greater Vancouver Area, December, 1972. Fox, David J . Fundamentals of Research i n Nursing. New York: Appleton - Century - C r o f t s , 1970. Kleinman, R. L. (ed.). Medical Handbook. London: I n t e r -n a t i o n a l Planned Parenthood Federation, 1968. 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"Contraceptive Antecedents t o E a r l y and Late: Therapeutic A b o r t i o n s , " American Journal of  P u b l i c Health, 62: 824 -827 , June , " 1 9 7 2 . Sandberg, Eugene C. and R. I . Jacobs. "Psychology of the Misuse and R e j e c t i o n of Contraception," American Journa l 'of O b s t e t r i c s and Gynecology, 110: 227-242, May 1 5 , 1971. Appendix A QUESTIONNAIRE AND INTRODUCTORY MATERIAL An E x p l o r a t o r y Study To I d e n t i f y Preconception Contraceptive Patterns of Abortion P a t i e n t s Age C i v i l S t a t u s : s i n g l e - parents on own common law married separated divorced Number of c h i l d r e n Occupation Education completed 72 Number of weeks pregnant when to doctor Number of previous abortions 7 3 l ) What contraceptives have been used - by whom 1. Here i s a l i s t of con- withdrawal rhythm IUD p i l l TL vasectomy nothing t r a c e p t i v e s commonly condom used. What methods have diaphragm spermacide douche you or your (partner) used i n the past year to prevent pregnancy? 2. Were you u s i n g any of these methods around the time you became pregnant? Which none ones? 74 2) With what consistancy contraceptives have been used N/A i f never used 1. Most people at some time miss u s i n g t h e i r c o n t r a - , ce p t i v e s . Can you des-c r i b e any s l i p s you have made i n the past year w i t h your d i f f e r e n t contraceptives? forgot p i l l s o c c a s i o n a l l y IUD e x p e l l e d - not checked used i r r e g u l a r l y by s e l f used i r r e g u l a r l y by partner out of s u p p l i e s - no s u b s t i t u t e wanted baby no s l i p s , e r r o r s 2. Can you e x p l a i n what method happened w i t h your con- e r r o r t r a c e p t i o n when you became pregnant? s p e c i f i c r e : p i l l . 3. Many people use the p i l l f o r c o n traception at some time and then stop. Have you done t h i s ? yes-no — s p e c i f i c r e : sometime p i l l user. 4. Could you t e l l me why you stopped using the p i l l when you did? concerned r e : s a f e t y of p i l l s i d e e f f e c t s to take a break from con-stant use to have a baby What contraceptive d i d use r i g h t a f t e r you stopped t a k i n g the p i l l 76 3) How were contraceptive methods chosen - by whom, why N/A i f none used 1. I am i n t e r e s t e d i n knowing a l i t t l e about how you come t o choose your con-t r a c e p t i v e s . Do you and your (partner) t a l k about usi n g contraception? 2. When a contraceptive method was chosen, who made the d e c i s i o n on what to use? yes no o c c a s i o n a l l y s e l f p a r t n e r both 3. What were the reasons f o r l i k i n g the contrac e p t i v e s you chose t o use? easy, convenient r e l i a b l e safe f o r h e a l t h accept, f o r r e l i g i o n doctor recommended pa r t n e r recommended used by male only method known no connection w i t h i n t e r c o u r s e 77 4) What has been the p a t i e n t ' s need f o r contraception 1. The k i n d of contraceptive t h a t i s most s u i t a b l e f o r a person may-depend on how much she needs i t . Can you t e l l me approximately how r e g u l a r l y you have had i n t e r c o u r s e during the past year? n e a r l y every day 2-3 times a week about once a week 2-3 times a month very o c c a s i o n a l l y 2. Can you remember any changes i n your usual p a t t e r n of i n t e r c o u r s e around the time you became pregnant? no l e s s frequent more frequent more r e g u l a r more i r r e g u l a r 3. Do you or your (partner) have any c o n d i t i o n t h a t may decrease your chance of becoming pregnant? no TL ovarian abnormality u t e r i n e abnormality vasectomy 78 5) What plans the p a t i e n t had f o r f a i l e d c o ntraception 1. Whenever you had i n t e r c o u r s e during the past year, d i d you ~ t h i n k very o f t e n about the p o s s i b i l i t y of becoming pregnant? never o c c a s i o n a l l y o f t e n 2. Did you t a l k about the p o s s i b i l i t y of becoming pregnant w i t h your partner? 3. What ideas d i d you have of what you would do i f you became pregnant? yes no o c c a s i o n a l l y no ideas keep baby adopt out baby go away f o r a while have an a b o r t i o n f o r sure have an a b o r t i o n per-haps 79 6) What f e e l i n g s the p a t i e n t has had about conceiving 1. Do you want t o have a baby sometime i n the future? yes no perhaps don't know 2. In the past year, how much d i d you worry about becoming pregnant when you had i n t e r c o u r s e ? 3. Could you t e l l me why you decided not t o continue t h i s pregnancy? very worried a l l the time worried sometimes d i d not worry do not want any c h i l d r e n do not want more c h i l d r e n too close t o l a s t pregnancy not a convenient time not married unable t o support c h i l d f a m i l y pressure pressure from partner medical problem too demanding on s e l f 4 . I s there any s a t i s f a c t i o n f o r you t o know that you are able t o become pregnant? pleased t o know i n d i f f e r e n t unhappy 8 0 7) What f e e l i n g s the p a t i e n t has about us i n g c o n t r a c e p t i v e s 1. R e f e r r i n g t o co n t r a c e p t i v e s again, who do you f e e l should take r e s p o n s i b i l i t y f o r u s i n g c o n t r a c e p t i v e s i n your r e l a t i o n -ship? s e l f p a r t n e r both 2. In general, do you have any f e e l i n g s of l i k e or d i s l i k e about the idea of us i n g con-t r a c e p t i v e s ? no thoughts happy t o use do not l i k e t o use i n d i f f e r e n t r e : use 3. How comfortable do you f e e l about t a l k i n g of and arranging f o r contraceptives? very comfortable i n d i f f e r e n t uncomfortable 8) What f e e l i n g s the p a t i e n t has about contraception and sexual r o l e 81 1. How i s your enjoyment of sexual r e l a t i o n s a f f e c t e d by using your most r e c e n t l y used contraceptive? 2. Do you g e n e r a l l y get enjoyment out of your sexual r e l a t i o n s ? 3. How would you d e s c r i b e the b a s i c importance of sexual r e l a t i o n s f o r you? 4. How comfortable i s i t f o r you to t a l k about sexual t h i n g s ? no e f f e c t more rela x e d w i t h more relaxed without no ideas very enjoyable u s u a l l y enjoyable sometimes enjoyable seldom enjoyable never enjoyable expression of l o v e , f e e l i n g pleasure f o r s e l f pleasure f o r partner to have c h i l d r e n part of marriage comfortable uncomfortable i n d i f f e r e n t 82 9 ) What f e e l i n g s the p a t i e n t has about a b o r t i o n 1. There has been a l o t necessary as a contraceptive u n f o r t u n a t e l y necessary f o r f a i l e d c ontraception should not be necessary of t h i n k i n g l a t e l y about the connection between ~ contraception and a b o r t i o n . How necessary or important do you f e e l a b o r t i o n i s as r e l a t e d t o con-t r a c e p t i o n ? 2. Could you t e l l me a comfortable about having l i t t l e about how you do not l i k e , uncomfortable do not l i k e , but accept i n d i f f e r e n t are f e e l i n g about having t h i s abortion? 3. Do you mind whether want t o be asleep would l i k e to be awake do not care you are awake or asleep during t h i s surgery? $3 10) What the p a t i e n t knows about contraception People sometimes do not know a l o t about contraceptives and i t seems important f o r nurses t o f i n d out what women know so we can answer questions b e t t e r . I have some questions about how d i f f e r e n t methods work, and I would be pleased t o answer any questions you have a f t e r we f i n i s h t h i s . 1. Looking at the l i s t of contraceptive methods, which of these methods have you used or heard of before? consider up t o 4 methods w i t h which the p a t i e n t i s f a m i l i a r . 2. Would you t e l l me anything you know about how works t o prevent pregnancy? 3. Would you t e l l me what you have heard about how i s used? 4. What s o r t of problems do you know about u s i n g problems th a t may make i t l e s s popular t o use? 5. How would you r a t e f o r preventing pregnancy? - very e f f e c t i v e - e f f e c t i v e most of time - sometimes e f f e c t i v e - questionable - no e f f e c t method f u n c t i o n how t o use problems e f f e c t i v e n e s s 1. 2. 3. 4. 1. 2. 3. 4. 85 11) What the p a t i e n t knows about conception I have diagrams of male and female reproductive" anatomy which show something of what i t i s l i k e i n s i d e a woman and a man. 1. With the female diagram, would you t e l l me the names of the d i f f e r e n t p a r t s and what they have t o do w i t h producing a baby? co r r e c t i n c o m p l e t e / i n c o r r e c t don't know 2. A l s o , w i t h the male diagram, could you t e l l me the names of the p a r t s and what they have to do w i t h producing a baby? 3. I f a woman has a r e g u l a r 28 day menstrual c y c l e , how many days a f t e r the f i r s t day of her peri o d i s pregnancy most l i k e l y ? c o r r e c t i n c o m p l e t e / i n c o r r e c t don't know s h o r t l y b e f o r e / a f t e r p e r i o d middle time between periods 12-16 days (2 weeks) a f t e r 8-11 days a f t e r 17-20 days don't know 8 6 12) What the p a t i e n t knew about a b o r t i o n , preconception 1. Before you became pregnant d i d you know whether abort i o n s were l e g a l or i l l e g a l ? l e g a l i l l e g a l d i d not know 2. Could you t e l l me what you knew about how a v a i l a b l e a b o r t i o n s were, before you became pregnant? easy t o arrange a v a i l a b l e f o r h e a l t h only a v a i l a b l e f o r economics a v a i l a b l e on request perhaps a v a i l a b l e nothing known 3. Before you became pregnant, what d i d you hear about how aborti o n s were done? 4. Before you became pregnant, can you describe anything you heard of about p o s s i b l e problems w i t h having an abortion? D & C s a l i n e i n d u c t i o n scraped out s u c t i o n , vacuum nothing known few problems no problems w i t h l e g a l a b o r t i o n s dangerous i f i l l e g a l b l e e d i n g p a i n i n f e c t i o n decreased f e r t i l i t y problems c a r r y i n g f u t u r e pregnancy more problems i f a b o r t i o n l a t e nothing known $7 13) The source of the p a t i e n t ' s i n f o r m a t i o n concerning  contraception 1 . What were a l l the places or people where you learned about sexual r e -l a t i o n s and pregnancy? where d i d you l e a r n the most? mother f a t h e r s i b l i n g s f r i e n d s p artner nurse SW doctor school c l a s s f.p. c l i n i c magazines books nowhere 2. What were a l l the places or people where you learned about contraceptives? — where d i d you l e a r n the most? mother f a t h e r s i b l i n g s f r i e n d s p artner nurse SW doctor school c l a s s f.p. c l i n i c magazines books nowhere 3. When you were w i t h your parents: d i d you t a l k about sex and pregnancy w i t h them? yes no d i d you t a l k about con t r a c e p t i v e s w i t h them? yes no how comfortable were you and your parents t a l k i n g about sexual t h i n g s ? 88 14) What i s the p a t i e n t ' s own explanation f o r the occurance  of t h i s pregnancy 1. This i s the l a s t question t h a t I have. To sum up, what do you see was the main, general reason you became pregnant now? 89 Explanation t o P a t i e n t s My name i s Judy Watts and I am a R e g i s t e r e d Nurse working toward a Master's degree a t . U n i v e r s i t y of B r i t i s h Columbia. I am doing a study w i t h p a t i e n t s coming t o t h i s h o s p i t a l f o r a b o r t i o n s . I hope t o l e a r n about t h e i r prob-lems and concerns w i t h using contraceptives so t h a t , i n f u t u r e , nurses can help women t o understand more about e f f e c t i v e c o n t r a c e p t i o n. I would be pleased i f you would help me w i t h t h i s study by d i s c u s s i n g and answering some questions. You are f r e e t o decide whether t o p a r t i c i p a t e , and t o withdraw at any time i n our d i s c u s s i o n i f you wish. Very b r i e f l y , I would l i k e t o t a l k t o you of some of the t h i n g s you know about c o n t r a c e p t i o n , of what contraceptive methods you may have thought of or used, and of your f e e l i n g s about co n t r a c e p t i o n . This d i s c u s s i o n should take about three quarters of an hour t h i s evening. Each person I w i l l be speaking t o has been s e l e c t e d randomly, by chance, from a l l the p a t i e n t s admitted today. No name or any other form of i d e n t i f i c a t i o n w i l l appear w i t h the i n f o r m a t i o n gathered, so that everything you say w i l l be completely c o n f i d e n t i a l and anonymous. The nursing a d m i n i s t r a t i o n of the h o s p i t a l has given me permission t o approach you. I f you are w i l l i n g t o t a l k w i t h me, I w i l l need your signed consent. Consent Form I , , have been requested t o p a r t i c i p a t e i n the study e n t i t l e d "An E x p l o r a t o r y Study t o I d e n t i f y Preconception Contraceptive Patterns of Abortion P a t i e n t s . " I understand t h a t t o p a r t i c i p a t e , I w i l l be interviewed by Judy Watts, R.N., and t h a t the i n t e r v i e w w i l l take about three quarters of an hour. I understand t h a t questions w i l l be asked about what I know of con t r a c e p t i o n , what contrac e p t i v e s I have used, and my f e e l i n g s about con t r a c e p t i o n . I understand t h a t my name w i l l not appear on any of the m a t e r i a l s and th a t the i n f o r m a t i o n gathered w i l l be c o n f i d e n t i a l . I f u r t h e r understand t h a t I am f r e e t o withdraw from the i n t e r v i e w at any time. I hereby give my consent t o p a r t i c i p a t e i n t h i s study. Signed: Date: APPENDIX B TABLE I DEMOGRAPHIC DATA N = 30 Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Age 16 X 17 X X X 18 X 19 X X 20 X 21 X X X X X 22 X X X 23 X X X X 24 X 25 X X X 26 X X X 28 X 30 X 37 X M a r i t a l Married- X X X X X X X X X Status Common-law X X X X X X X X S i n g l e X X X X X X X X X Separated X X X Divorced X w i t h partner X X X X X X X X X X X X X X X X X without partner X X X X X X X X X X X X X C h i l d r e n 0 X X X X X X X X X X X X X X X X X X X X 1 X X X X 2 X X X X 4 X 5 X N = 30 Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Occupation student HW working w o r k i n g - p r o f e s s i o n a l b u s i n e s s / c l e r i c a l s k i l l e d labour u n s k i l l e d labour XXX X XXX X XXX XXX XXX XXX XXX X X X X X X X X X X X X X X X X X X X X X Education grades < 8 L e v e l 9 10 11 12 >12 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Previous 0 Abortions 1 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Weeks Pregnant 3 when t o Doctor 4 5 6 7 8 9 10 13 14 17 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X vO 93 APPENDIX C TABLE I I SCORES FOR EACH QUESTION ON KNOWLEDGE OF CONTRACEPTION |l) knowledge of c o n t r a -ceptive f u n c t i o n scores 0 1 2 3 4 5 6 7 8 Numbers 0 1 2 3 4 5 6 7 8 9 x X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 2) knowledge of co n t r a -ceptive use technique 0 1 2 3 4 5 6 7 8 x x X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 3) knowledge of problems w i t h contraceptive 0 1 2 3 4 5 6 7 8 x X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 4) knowledge of e f f e c t i v e -ness of contraceptive 0 1 2 3 4 5 6 7 8 x X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 94 APPENDIX C TABLE I I SCORES FOR EACH QUESTION ON KNOWLEDGE OF CONTRACEPTION Numbers 0 1 2 3 4 5 6 7 8 9 T o t a l knowledge scores 0 - 4 X X X X X 5 - 8 X X 9 - 12 X X 13 - 16 X X X X 17 - 20 X X X X X X X X X 21 - 24 X X X X X X X 25 - 28 X X X X X X 29 - 32 X X X 

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