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Assessment of reproductive knowledge in an inner-city clinic
0277-9536.‘8?‘191657-06503.00 0 Copyright 0 1982 Per@amon Press Ltd
Ser. Sci. Mrd Vol. 16. pp. 1657 to 1662. 1982 Printed in Great Britain. All rights reserved
ASSESSMENT OF REPRODUCTIVE KNOWLEDGE IN AN INNER-CITY CLINIC SHIRLEY
2Department
M.
JOHNSON’ and LOUDELL F. SNOW’
‘Department of Anthropology,
of Family Medicine and Michigan State University, MI 48824. U.S.A.
East Lansing,
Abstract-A
number of studies have shown that misinformation and lack of information about the menstrual cycle contributes to unwanted fertility, particularly among black women. A short, self-administered questionnaire was developed and tested in an inner-city, prenatal clinic serving a primarily low-income undereducated, black clientele. Data were gathered concerning numbers of pregnancies and abortions, knowledge of the menstrual cycle, past contraceptive use, including dissatisfaction and discontinuance, and planned future use of contraception. Results showed that the majority of women had had at least one unwanted pregnancy. Their knowledge base about female reproductive function and their poor use of contraception contributed to these unwanted pregnancies. It is concluded that a few key questions can help identify the woman with special informational needs, enabling the health professional to gear educational efforts to the individual patient
INTRODUCTION Many social, psychological and economic factorssingly and in combination-are responsible for the occurrence of unwanted pregnancies. Recent studies suggest that misinformation and lack of information about the menstrual cycle also contribute to unwanted fertility, as do incorrect use of and dissatisfaction with contraceptives [l-3]. These findings are particularly striking among black women. In 1973 black women were reported to be Fore likely than white women to select and use effective contraception, but were also more likely to discontinue use without substituting another method[4]. More recent data has revealed. however, the black women were turning away from the more effective methods in favor of traditional ones [5]. This is an area of real concern. It is essential that the menstrual cycle and the times of greatest fertility and infertility be understood if pregnancy is to be avoided during periods of non-use of contraception, or if traditional methods are used sporadically. However, Presser has pointed out that black women are less likely than white women to have correct information on the function of menstruation and its connection with fertility. She reports that for black women discussion with physicians about contraception is nor associated with knowledge about time of maximum risk for pregnancy, that blacks attending clinics to obtain contraceptives overwhelmingly adopt since the. effectiveness of’ this the pill. and that “. method is not.dependent upon knowledge of time of risk. such information may not be communicated or attended to in the clinic” [l]. Such findings indicate that it is particularly important for health professionals to know of the beliefs and
This project was supported in part by BRSG Grant RR-0566-09 awarded by the Biomedical Research Support Grant Programs. Division of Research Resources. National Institutes of Health to the Michigan State Universit) College of Human Medicine.
knowledge deficits concerning the reproductive cycle among their clientele, enabling educational efforts to be geared to the needs of individual women. Such information can be gathered in the clinical setting: in 1975 the authors carried out a pilot study among the low-income mixed ethnic clientele of a Lansing. MI, prenatal clinic. Information was collected on attitudes, beliefs and knowledge the women had about reproductive life using a questionnaire administered during a 2-h interview. Results demonstrated that. irrespective of other factors, most of the women in this medical setting did not have the knowledge needed to allow them to prevent pregnancies when they so wished [6-93. An interview schedule of such length is impractical for clinical use, so a short, se/$ administered form of the questionnaire was developed with the results presented here. METHODS The new questionnaire contained 38 multiplechoice questions designed to provide a profile of a woman’s knowledge of the reproductive cycle, including her own reproductive and contraceptive history. Choices of answers included the most prevalent misinformation held by respondents in the pilot study as well as the correct information. It was tested during the month of August, 1978, at a hospital clinic offering. gynecological and obstetrical services in the inner-city of Detroit, Michigan. At that time there was an annual enrollment of more than 2200 women in the prenatal clinic, the majority of whom were at risk for their current pregnancy when social and medical factors were evaluated. Medical risks include age of mother, parity, birth interval, history of miscarriage or neonatal death, and other medical conditions complicating pregnancies. Social risks include low income, single marital status. race. and the mother’s education if less than high school [ 10. 111. The questionnaire was used as part of an educational program for the clinic. Its purpose was explained to patients. who were given the option of 1657
SHIRLEY M. JOHNSON and
1655 Table
I. Demographic
data.
Characteristic Ethnrc
0 ”
loo
300
Black .-lye < 15 15-19 20-24 25-29 3S34 35-39 40+ ‘Maritul‘
Discussion will include findings drawn from the data concerning (a) numbers of pregnancies and abortions. (b) knowledge of the menstrual cycle. (c) information about the causes of venereal disease. (d) reported use of contraception in the past. including dissatisfaction and discontinuance. and (e) planned future use of contraception. We will consider how these data may help explain some of the unwanted fertility reported by many of the women in the sample.
.V = 200
Number
2.0
4 62 71 42 14 6
31.0 35.5 21.0 7.0 3.0 0.5
RESULTS Pregnancy
sratus
Married Divorced Widowed
Living with someone Never married No answer Education i 8th Grade
85OOGf7000 $800~-910.ooo 511,00~515,000 P 16,0Wf20.000 820.000+ No answer
48 11 3 19 118
24.0 5.5 1.5 9.5 59.0 0.5
6 58 72 55 6 0 3
3.0 29.0 36.0 21.5 3.0 0.0 1.5
89 31 14 14 7 1 44
44.5 15.5 7.0 7.0 3.5 0.5 22.0
Table
0
pregnancies Number of living children per woman ,I ?otal number of living children *U Number t-Y Number
I
2. Pregnancy
75 37.5
45 22.5
0
75
90
49 24.5
36 18
16 8.0
49
72
48
90 49 0
experiences.
Number of pregnancies 2 3 4 5
0 0
40 20.0 120
of pregnancies per woman = 2.4. of living children per woman = I.1
20 10.0
14 7.0
80
70
6 3.0 24
experiences
The 200 women in the sample had been pregnant a total of 478 times for an average of 2.4 pregnancies (Table 2). The number of pregnancies per woman ranged from one to nine: 60”” of the women had had one or two pregnancies. They had 212 living children. or 1.1 per woman. The difference between the total number of pregnancies and the total number of living children can be accounted for by the fact that about 687; of the women were currently pregnant. 21”,, had had at least one abortion, and 15”” had experienced a miscarriage or a stillbirth. These pregnancy statistics are evidence of already high fertility. particularly in view of the relatively young age of t,he sampleP90”,, less than 30 years of age and 33”~~still in their teens. The implications of these data for the future childbearing of these Detroit women is therefore of concern. Only the future will show what the total fertility experience will be for the women in this study; it seems likely, however, that attempts by them to control their fertility will depend upon more than availability and selection of effective contraceptive methods. Sixty per cent of the women in the sample reported that they had become pregnant at least once when they did not want to be. Of these, 58”; were not using contraception at the time or thought they were ‘safe’, almost 25”C, said they had either used a method incorrectly or the method failed, and more than 25”” did not know why they became pregnant or said it ‘just happened’. Data will be presented in succeeding sections which suggest why some women were not using contraceptive methods. why they had failed in
not completing it if they so wished. A total of 261 questionnaires were distributed, of these, 24 were returned incomplete and were discarded. The questionnaire was completed by 237 women, of whom 210 were self-identified as black. The following report concerns the 200 black women who reported one or more pregnancies. A third of these respondents were teenagers, 59p/, had never been married, 32”,/, had not completed high school, and the majority were poor (see Table 1 for a demographic profile).
Number of times women pregnant “_I ?otal number of
LOUDELL F. Ssow
2 I.0 10
IV = 200 respondents
and living children 6 7 8
3 1.5
0 0
2 I.0
9
10
Total
I 0.5
0 0
200
9
0
378 Pregnancies*
I00”o
IX
0
16
0 0
0 0
0 0
I 0.5
0 0
200 women
0
0
0
9
0
2 12children+
I 00”(,
Assessment Table
of reproductive
knowledge
3. Lack of understanding
in an inner-city
of the menstrual
clinic
1659
cycle. N = 200
Number of respondents
y0 of total sample
III 61
55.5 33.5
become pregnant Do not know ‘safe time’ for intercourse
127
63.5
without pregnancy Do not know if women can become pregnant before return of menses after giving birth Do not know if women can become pregnant while breastfeeding infants Do riot know if pregnancy can occur during menopausal years Avoid intercourse during menstruation
158
79.0
40
20.0
120
60.0
74 162
37.0 81.0
Do not know reason for menstruation Do not know source of mentrual blood Do not know
when it is possible
their attempts to use contraception, fertility may have seemed inexplicable
to
and why their to them.
Lack qf understanding of the menstrual cycle The women in our present sample, just as those in the pilot study, had little understanding of the function of menstruation (Table 3). More than half were unable to correctly answer the question, “Why do women menstruate?” Many felt that the process serves to cleanse the body of impurities, or to rid it of excess blood. They were also uninformed about the time of ovulation. The question was asked in two ways: “When is it possible to become pregnant?“, and “Is there a ‘safe time’ to have intercourse without becoming pregnant?” Of those responding, 63.574 were unable to correctly answer the first question and
Table 4. Contraceptive
Method Oral contraceptives Sometimes forgot: IUD Failed to check string: Diaphragm Not used with gels: Not used each intercourse: Not left in at least 8 h: Condom Not used each intercourse: Not on penis before penetration: Spermicides Not used each intercourse: Not left in at least 8 h: Rhythm Withdrawal Breastfeeding Douche Other
Methods Number
usedt 9,
1351163 27.1163 11’163
42:163
401163
151163 18:163 51163 24.‘163 2!163
*37 Women (18.5”,) had never used contraception. +.Y Number of methods usedxontraceptor = 2.0. CCriteria of incorrect use.
79% were unable to answer the second. Their lack of knowledge of time of pregnancy risk is of concern because of their poor contraceptive histories. Many of the women who reported use of medical methods of contraception had histories of incorrect and/or discontinued use of these methods, as will be seen. There was a strong behavioral taboo against intercourse during menstruation, reported by 817” of the total sample and 91% of teenagers in the sample. This negative attitude may have affected the possible selection.of the intrauterine device as a method of birth control. Since it is the practice in many clinics to insert this device during a woman’s menstrual period, we asked the question, “Some physicians prefer to insert the IUD while a woman is having her menstrual period-would you be willing to have it done at that time?” Many (72”,/,)‘of those otherwise willing
methods
Incorrect Number
ever used, N = 163*
use :b
82.8 881135
65.2
8,‘27
29.6
S/l 1 3/l 1 3111
45.5 27.3 27.3
16.6
Stopped/dissatisfied/ problem Number yb 1031135
16.3
28/l 35
13127
48.1
l/27
6.7
Ii1
25.8 19142
45.2
3 :42
7.1
14140 10140
35.0 25.0
24.5
9.2 11.0 3.1 14.7 1.2
Pregnant using method Number Y0 20.7 3.7
I
9.1
13!42
31.0
4142
9.5
13,J40
32.5
9 140
22.5
5115 508 l/5 3;‘24
33.3 27.8 20.0 12.5
12,‘15 6,‘18
80.0 33.3
5/24
20.8
SHIRLEY M. JOHNSON and LOUDELL F. SNW.
I660
to consider the intrauterine device answered that they were unsure about or would not use it in such a case. There was a lack of knowledge about other aspects of the menstrual cycle among the women studied. A fifth of them did not know if, after the birth of a baby, a woman could become pregnant again before the return of her normal menses. Sixty per cent were not sure if a woman could become pregnant while breastfeeding an infant. More than a third were unsure if a woman could become pregnant during the menopausal years. It is probably safe to say that ignorance about the menstrual cycle will contribute to more unwanted pregnancies for them. Lack of knowledge in other areas of reproductiae health The women also lacked correct information in two other areas important to reproductive health-the causes of venereal disease and the reason for and importance of the routine pap smear. Venereal disease is a significant health problem in Detroit: in 1979, the city ranked first in the state for reported cases of gonorrhea, with 44% of all cases coming from there [12]. In this group of Detroit women, 22% reported that they had been told or believed that they had had a venereal disease at least once. When questioned as to the cause of such a problem, 83% correctly answered “Intercourse with infected person”. There were multiple answers possible, however, and a number of respondents checked other answers as well: “From toilet seats”, 16.5%; “Too many sex partners”, 26%; and “Dirty personal habits”, 20.57:*. They were also concerned about vaginal cleanliness, which is not surprising considering their beliefs about venereal disease and their negative feelings about menstruation. One third reported a habit of douching one or more times per week; douching with such frequency has been associated with pelvic inflammatory disease in at least one study [13]. They were also confused about the purpose of the pap smear. Although 63% of patients in the sample selected “Test for cancer” as an answer to the question. “What is a pap’s test? (pap smear)“, many chose other answers as well: “Test for pregnancy”, 10%; “Test for venereal disease”, 19.5%; “Test for infection”, 263:. A few women (4”/,) simply marked, “Don’t know”. Since the reason for having a pap smear was not entirely clear to many of these women, it is understandable that one-quarter of them were unsure of the necessity of continuing to have pap smears done after the menopause. Past contraceptive
*These selections were included since they were frequent to the same question
FUTURE
CONTRACEPTIVE
USE
The women’were asked whether they planned to use any contraceptive methods in the future. and the majority (88%) responded that they planned to begin or to continue the use of some method (Table 5). One-fifth of them planned sterilization for themselves (2OY/,)or for their mates (19;); the remainder elected to use some reversible method of birth control. Surprisingly, there was little correlation between patients’ dissatisfaction with their previous use of a contraceptive method and their willingness to try it again. For example, 60% (55/92) of women who had used oral contraceptives in the past stated that they intended to use them again, although of these women. 647; (33155) had stopped their use at least once because of dissatisfaction, and 18”; (10/55) had become pregnant while using them. Their history of previous misuse of contraception, linked with the lack of correct information about periods of greatest fertility, suggest that these women will have difficulty in controlling their fertility in the future. regardless of the method(s) chosen, medical or traditional. DISCUSSION
use
Incorrect use of contraception no doubt led to unplanned pregnancies for some of our respondents. We asked if they had ever used any of the following methods of contraception: oral contraceptives, intrauterine device. diaphragm, condom, spermicide, rhythm, withdrawal, breastfeeding, douching, tubal ligation. or vasectomy (in the questionnaire commonly used terms such as IUD, foam and rubbers were included). If they had used any method they were then asked if they had ever stopped using it because they had a problem with it, or were dissatis-
responses
fied. They were also asked if they had become pregnant while using any of the above methods. Eightytwo per cent of the women had a history of contraceptive use (Table 4). An average of two methods had been tried per woman. but this does not adequately reflect the experience of many who had tried and discontinued use of literally every reversible method of contraception. In many instances the selection of method was made without the support of their sexual partner. Forty per cent of the women indicated that they and their partners did not agree about the use of contraception; 14O; did not discuss contraception with their partners at all. Inconsistent use of contraceptives and unsatisfactory experiences with them were evident with most of the methods tried. Due to their widespread use, we feel there is particular significance in our findings regarding oral contraceptives: of those who reported using them, 65”, reported incorrect use (our assessment), 767; had discontinued use because they were dissatisfied with them, and nearly ?I”, had become pregnant while taking them (see Table 4). Effective contraception includes much more than mere selection-the method must be used correctly and consistently.
in the pilot study.
The two hundred black women in the study reported here were found to poorly understand the menstrual cycle and the time during which they were at greater risk of becoming pregnant; 794; did not know ‘safe time’. Eighty-one per cent of the women further reported that they avoided intercourse during menstruation, perhaps unknowngly restricting their sexual activity to the time during the cycle when risks for pregnancy are higher. Though the majority had used various methods of contraception in the past. they reported both incorrect use of and dissatisfaction and discontinuance with both medical and traditional contraceptive methods. These facts, coupled with their poor understanding of fertility cycles almost guaran-
Assessment
of reproductive
knowledge
in an inner-city
clinic
1661
teed that they would fail in preventing pregnancies. Sixty per cent of the women, in fact, stated that they had become pregnant at least one time when they did not want to be. Their future plans at controlling unwanted childbearing unfortunately seem equally problematic. Eighty-eight per cent of these women stated that they planned to use contraceptive methods in the future, but despite their good intentions, because of gaps in the reproductive knowledge and their erratic histories of contraceptive use, we believe that the potential for failure to effectively utilize their chosen contraceptive will be high. This will probably be true both for those again attempting to use a method which they had had some experience, and for the women who had not used their chosen method before-medical or traditional. Based on their previous experiences one can only expect that the pattern of problems with contraception exhibited in the past-sporadic, inconsistent, or around’ among multiple incorrect use, ‘shopping methods. discontent with and discontinuation of various methods-will again surface, and will again produce unwanted or mistimed pregnancies. Their contraceptive knowledge, attitudes, and practices are not conducive to effective fertility control. Most of them did not learn effective birth control early and their attempts at contraception have not been successful. For many of them, planning a family is not a viable option. SUMMARY
The sample of this clinic population was composed of black women who were primarily poor, undereducated. single, and at the beginning of their childbearing years. Many were at high risk for pregnancy because of medical and social factors. They were victims of misinformation and a lack of information about the basic reproductive facts essential to control fertility. Many had had unwanted pregnancies and many will have unwanted pregnancies in the future. In such a setting it is imperative that health professionals take the time to assess the reproductive knowledge base of their clients-by short questionnaire or direct questioningin order to individualize patient education. REFERENCES
1. Presser H. B. Guessing and misinformation about pregnancy risk among urban mothers. Fam. Plann. Persprct. 9, 111-115. 1977. for contraceptive fail2. Blame M. D. ‘Mismanagement’ ure. Fam. Plum. Prrspect. 8, 72-76. 1976. between beliefs about the 3. Scott C. The relationship menstrual cycle and choice of fertility regulating method within five ethnic groups. Int. J. Gynec. Ohstet. 13, 105-190. 1975. 4. Vaughan B.. Trussel .I.. Menken J. and Jones E. F. Contraceptive failure among married women in the United States. 1970-1973. Fam. P/am. Persprct. 9, 251-258. 1977. K. Contraceptive use in the United States. 5. Ford 1973-1976. Fam. Plann. Perspect. 10, 264-269. 1978. S. M.‘and Mayhew H. E. The 6. Snow L. F.. Johnson behavioral implications of some old wives’ tales. Ohstet. G~xrc. 51. 727-732. 1978. S. ht.. Snow L. F. and Mayhew H. E. Limited 7. Johnson
I662
SHIRLEY M. JOHNSON and LOCDELL F. SNOW
patient knowledge as a reproductive risk factor. J. Fatn. Prac. 6. 855-862. 1978: S. M. and Snow L. F. The profile of some 8. Johnson unplanned pregnancies. In The Anthro&og.r of He&h (Edited by Bauwens E. E.), p. 46. C.V. Mosby. St Louis. 1978. 9. Snow L. F. and Johnson S. M. Modern day menstrual folklore: some clinical implications. JAMA 237, 27362139, 1917. 10. Dott A. B. and Fort A. T. Medical and social factors
affecting early teenage pregnancy. .-lt~. J. Ohstrf. Cy,~rc. 125. 532-536. 1976. 11 Perkin G. W. Assessment of reproductive risk In nonpregnant women. Ant. J. Ohsrer. 101. 709-717. 1968. 12 PlaiN Brorw Wrapper. Venereal Disease in .tfic/licqtrn 1979. Venereal Disease Division. Michigan Department of Public Health. Lansmg. MI. 1979. 13 Newman H. H. and DeCherney A. Douching and pelvic inflammatory disease. ,Yrrr E/U/I. J. .Mrd. 295. 789. 1976.
Ser. Sci. Mrd Vol. 16. pp. 1657 to 1662. 1982 Printed in Great Britain. All rights reserved
ASSESSMENT OF REPRODUCTIVE KNOWLEDGE IN AN INNER-CITY CLINIC SHIRLEY
2Department
M.
JOHNSON’ and LOUDELL F. SNOW’
‘Department of Anthropology,
of Family Medicine and Michigan State University, MI 48824. U.S.A.
East Lansing,
Abstract-A
number of studies have shown that misinformation and lack of information about the menstrual cycle contributes to unwanted fertility, particularly among black women. A short, self-administered questionnaire was developed and tested in an inner-city, prenatal clinic serving a primarily low-income undereducated, black clientele. Data were gathered concerning numbers of pregnancies and abortions, knowledge of the menstrual cycle, past contraceptive use, including dissatisfaction and discontinuance, and planned future use of contraception. Results showed that the majority of women had had at least one unwanted pregnancy. Their knowledge base about female reproductive function and their poor use of contraception contributed to these unwanted pregnancies. It is concluded that a few key questions can help identify the woman with special informational needs, enabling the health professional to gear educational efforts to the individual patient
INTRODUCTION Many social, psychological and economic factorssingly and in combination-are responsible for the occurrence of unwanted pregnancies. Recent studies suggest that misinformation and lack of information about the menstrual cycle also contribute to unwanted fertility, as do incorrect use of and dissatisfaction with contraceptives [l-3]. These findings are particularly striking among black women. In 1973 black women were reported to be Fore likely than white women to select and use effective contraception, but were also more likely to discontinue use without substituting another method[4]. More recent data has revealed. however, the black women were turning away from the more effective methods in favor of traditional ones [5]. This is an area of real concern. It is essential that the menstrual cycle and the times of greatest fertility and infertility be understood if pregnancy is to be avoided during periods of non-use of contraception, or if traditional methods are used sporadically. However, Presser has pointed out that black women are less likely than white women to have correct information on the function of menstruation and its connection with fertility. She reports that for black women discussion with physicians about contraception is nor associated with knowledge about time of maximum risk for pregnancy, that blacks attending clinics to obtain contraceptives overwhelmingly adopt since the. effectiveness of’ this the pill. and that “. method is not.dependent upon knowledge of time of risk. such information may not be communicated or attended to in the clinic” [l]. Such findings indicate that it is particularly important for health professionals to know of the beliefs and
This project was supported in part by BRSG Grant RR-0566-09 awarded by the Biomedical Research Support Grant Programs. Division of Research Resources. National Institutes of Health to the Michigan State Universit) College of Human Medicine.
knowledge deficits concerning the reproductive cycle among their clientele, enabling educational efforts to be geared to the needs of individual women. Such information can be gathered in the clinical setting: in 1975 the authors carried out a pilot study among the low-income mixed ethnic clientele of a Lansing. MI, prenatal clinic. Information was collected on attitudes, beliefs and knowledge the women had about reproductive life using a questionnaire administered during a 2-h interview. Results demonstrated that. irrespective of other factors, most of the women in this medical setting did not have the knowledge needed to allow them to prevent pregnancies when they so wished [6-93. An interview schedule of such length is impractical for clinical use, so a short, se/$ administered form of the questionnaire was developed with the results presented here. METHODS The new questionnaire contained 38 multiplechoice questions designed to provide a profile of a woman’s knowledge of the reproductive cycle, including her own reproductive and contraceptive history. Choices of answers included the most prevalent misinformation held by respondents in the pilot study as well as the correct information. It was tested during the month of August, 1978, at a hospital clinic offering. gynecological and obstetrical services in the inner-city of Detroit, Michigan. At that time there was an annual enrollment of more than 2200 women in the prenatal clinic, the majority of whom were at risk for their current pregnancy when social and medical factors were evaluated. Medical risks include age of mother, parity, birth interval, history of miscarriage or neonatal death, and other medical conditions complicating pregnancies. Social risks include low income, single marital status. race. and the mother’s education if less than high school [ 10. 111. The questionnaire was used as part of an educational program for the clinic. Its purpose was explained to patients. who were given the option of 1657
SHIRLEY M. JOHNSON and
1655 Table
I. Demographic
data.
Characteristic Ethnrc
0 ”
loo
300
Black .-lye < 15 15-19 20-24 25-29 3S34 35-39 40+ ‘Maritul‘
Discussion will include findings drawn from the data concerning (a) numbers of pregnancies and abortions. (b) knowledge of the menstrual cycle. (c) information about the causes of venereal disease. (d) reported use of contraception in the past. including dissatisfaction and discontinuance. and (e) planned future use of contraception. We will consider how these data may help explain some of the unwanted fertility reported by many of the women in the sample.
.V = 200
Number
2.0
4 62 71 42 14 6
31.0 35.5 21.0 7.0 3.0 0.5
RESULTS Pregnancy
sratus
Married Divorced Widowed
Living with someone Never married No answer Education i 8th Grade
85OOGf7000 $800~-910.ooo 511,00~515,000 P 16,0Wf20.000 820.000+ No answer
48 11 3 19 118
24.0 5.5 1.5 9.5 59.0 0.5
6 58 72 55 6 0 3
3.0 29.0 36.0 21.5 3.0 0.0 1.5
89 31 14 14 7 1 44
44.5 15.5 7.0 7.0 3.5 0.5 22.0
Table
0
pregnancies Number of living children per woman ,I ?otal number of living children *U Number t-Y Number
I
2. Pregnancy
75 37.5
45 22.5
0
75
90
49 24.5
36 18
16 8.0
49
72
48
90 49 0
experiences.
Number of pregnancies 2 3 4 5
0 0
40 20.0 120
of pregnancies per woman = 2.4. of living children per woman = I.1
20 10.0
14 7.0
80
70
6 3.0 24
experiences
The 200 women in the sample had been pregnant a total of 478 times for an average of 2.4 pregnancies (Table 2). The number of pregnancies per woman ranged from one to nine: 60”” of the women had had one or two pregnancies. They had 212 living children. or 1.1 per woman. The difference between the total number of pregnancies and the total number of living children can be accounted for by the fact that about 687; of the women were currently pregnant. 21”,, had had at least one abortion, and 15”” had experienced a miscarriage or a stillbirth. These pregnancy statistics are evidence of already high fertility. particularly in view of the relatively young age of t,he sampleP90”,, less than 30 years of age and 33”~~still in their teens. The implications of these data for the future childbearing of these Detroit women is therefore of concern. Only the future will show what the total fertility experience will be for the women in this study; it seems likely, however, that attempts by them to control their fertility will depend upon more than availability and selection of effective contraceptive methods. Sixty per cent of the women in the sample reported that they had become pregnant at least once when they did not want to be. Of these, 58”; were not using contraception at the time or thought they were ‘safe’, almost 25”C, said they had either used a method incorrectly or the method failed, and more than 25”” did not know why they became pregnant or said it ‘just happened’. Data will be presented in succeeding sections which suggest why some women were not using contraceptive methods. why they had failed in
not completing it if they so wished. A total of 261 questionnaires were distributed, of these, 24 were returned incomplete and were discarded. The questionnaire was completed by 237 women, of whom 210 were self-identified as black. The following report concerns the 200 black women who reported one or more pregnancies. A third of these respondents were teenagers, 59p/, had never been married, 32”,/, had not completed high school, and the majority were poor (see Table 1 for a demographic profile).
Number of times women pregnant “_I ?otal number of
LOUDELL F. Ssow
2 I.0 10
IV = 200 respondents
and living children 6 7 8
3 1.5
0 0
2 I.0
9
10
Total
I 0.5
0 0
200
9
0
378 Pregnancies*
I00”o
IX
0
16
0 0
0 0
0 0
I 0.5
0 0
200 women
0
0
0
9
0
2 12children+
I 00”(,
Assessment Table
of reproductive
knowledge
3. Lack of understanding
in an inner-city
of the menstrual
clinic
1659
cycle. N = 200
Number of respondents
y0 of total sample
III 61
55.5 33.5
become pregnant Do not know ‘safe time’ for intercourse
127
63.5
without pregnancy Do not know if women can become pregnant before return of menses after giving birth Do not know if women can become pregnant while breastfeeding infants Do riot know if pregnancy can occur during menopausal years Avoid intercourse during menstruation
158
79.0
40
20.0
120
60.0
74 162
37.0 81.0
Do not know reason for menstruation Do not know source of mentrual blood Do not know
when it is possible
their attempts to use contraception, fertility may have seemed inexplicable
to
and why their to them.
Lack qf understanding of the menstrual cycle The women in our present sample, just as those in the pilot study, had little understanding of the function of menstruation (Table 3). More than half were unable to correctly answer the question, “Why do women menstruate?” Many felt that the process serves to cleanse the body of impurities, or to rid it of excess blood. They were also uninformed about the time of ovulation. The question was asked in two ways: “When is it possible to become pregnant?“, and “Is there a ‘safe time’ to have intercourse without becoming pregnant?” Of those responding, 63.574 were unable to correctly answer the first question and
Table 4. Contraceptive
Method Oral contraceptives Sometimes forgot: IUD Failed to check string: Diaphragm Not used with gels: Not used each intercourse: Not left in at least 8 h: Condom Not used each intercourse: Not on penis before penetration: Spermicides Not used each intercourse: Not left in at least 8 h: Rhythm Withdrawal Breastfeeding Douche Other
Methods Number
usedt 9,
1351163 27.1163 11’163
42:163
401163
151163 18:163 51163 24.‘163 2!163
*37 Women (18.5”,) had never used contraception. +.Y Number of methods usedxontraceptor = 2.0. CCriteria of incorrect use.
79% were unable to answer the second. Their lack of knowledge of time of pregnancy risk is of concern because of their poor contraceptive histories. Many of the women who reported use of medical methods of contraception had histories of incorrect and/or discontinued use of these methods, as will be seen. There was a strong behavioral taboo against intercourse during menstruation, reported by 817” of the total sample and 91% of teenagers in the sample. This negative attitude may have affected the possible selection.of the intrauterine device as a method of birth control. Since it is the practice in many clinics to insert this device during a woman’s menstrual period, we asked the question, “Some physicians prefer to insert the IUD while a woman is having her menstrual period-would you be willing to have it done at that time?” Many (72”,/,)‘of those otherwise willing
methods
Incorrect Number
ever used, N = 163*
use :b
82.8 881135
65.2
8,‘27
29.6
S/l 1 3/l 1 3111
45.5 27.3 27.3
16.6
Stopped/dissatisfied/ problem Number yb 1031135
16.3
28/l 35
13127
48.1
l/27
6.7
Ii1
25.8 19142
45.2
3 :42
7.1
14140 10140
35.0 25.0
24.5
9.2 11.0 3.1 14.7 1.2
Pregnant using method Number Y0 20.7 3.7
I
9.1
13!42
31.0
4142
9.5
13,J40
32.5
9 140
22.5
5115 508 l/5 3;‘24
33.3 27.8 20.0 12.5
12,‘15 6,‘18
80.0 33.3
5/24
20.8
SHIRLEY M. JOHNSON and LOUDELL F. SNW.
I660
to consider the intrauterine device answered that they were unsure about or would not use it in such a case. There was a lack of knowledge about other aspects of the menstrual cycle among the women studied. A fifth of them did not know if, after the birth of a baby, a woman could become pregnant again before the return of her normal menses. Sixty per cent were not sure if a woman could become pregnant while breastfeeding an infant. More than a third were unsure if a woman could become pregnant during the menopausal years. It is probably safe to say that ignorance about the menstrual cycle will contribute to more unwanted pregnancies for them. Lack of knowledge in other areas of reproductiae health The women also lacked correct information in two other areas important to reproductive health-the causes of venereal disease and the reason for and importance of the routine pap smear. Venereal disease is a significant health problem in Detroit: in 1979, the city ranked first in the state for reported cases of gonorrhea, with 44% of all cases coming from there [12]. In this group of Detroit women, 22% reported that they had been told or believed that they had had a venereal disease at least once. When questioned as to the cause of such a problem, 83% correctly answered “Intercourse with infected person”. There were multiple answers possible, however, and a number of respondents checked other answers as well: “From toilet seats”, 16.5%; “Too many sex partners”, 26%; and “Dirty personal habits”, 20.57:*. They were also concerned about vaginal cleanliness, which is not surprising considering their beliefs about venereal disease and their negative feelings about menstruation. One third reported a habit of douching one or more times per week; douching with such frequency has been associated with pelvic inflammatory disease in at least one study [13]. They were also confused about the purpose of the pap smear. Although 63% of patients in the sample selected “Test for cancer” as an answer to the question. “What is a pap’s test? (pap smear)“, many chose other answers as well: “Test for pregnancy”, 10%; “Test for venereal disease”, 19.5%; “Test for infection”, 263:. A few women (4”/,) simply marked, “Don’t know”. Since the reason for having a pap smear was not entirely clear to many of these women, it is understandable that one-quarter of them were unsure of the necessity of continuing to have pap smears done after the menopause. Past contraceptive
*These selections were included since they were frequent to the same question
FUTURE
CONTRACEPTIVE
USE
The women’were asked whether they planned to use any contraceptive methods in the future. and the majority (88%) responded that they planned to begin or to continue the use of some method (Table 5). One-fifth of them planned sterilization for themselves (2OY/,)or for their mates (19;); the remainder elected to use some reversible method of birth control. Surprisingly, there was little correlation between patients’ dissatisfaction with their previous use of a contraceptive method and their willingness to try it again. For example, 60% (55/92) of women who had used oral contraceptives in the past stated that they intended to use them again, although of these women. 647; (33155) had stopped their use at least once because of dissatisfaction, and 18”; (10/55) had become pregnant while using them. Their history of previous misuse of contraception, linked with the lack of correct information about periods of greatest fertility, suggest that these women will have difficulty in controlling their fertility in the future. regardless of the method(s) chosen, medical or traditional. DISCUSSION
use
Incorrect use of contraception no doubt led to unplanned pregnancies for some of our respondents. We asked if they had ever used any of the following methods of contraception: oral contraceptives, intrauterine device. diaphragm, condom, spermicide, rhythm, withdrawal, breastfeeding, douching, tubal ligation. or vasectomy (in the questionnaire commonly used terms such as IUD, foam and rubbers were included). If they had used any method they were then asked if they had ever stopped using it because they had a problem with it, or were dissatis-
responses
fied. They were also asked if they had become pregnant while using any of the above methods. Eightytwo per cent of the women had a history of contraceptive use (Table 4). An average of two methods had been tried per woman. but this does not adequately reflect the experience of many who had tried and discontinued use of literally every reversible method of contraception. In many instances the selection of method was made without the support of their sexual partner. Forty per cent of the women indicated that they and their partners did not agree about the use of contraception; 14O; did not discuss contraception with their partners at all. Inconsistent use of contraceptives and unsatisfactory experiences with them were evident with most of the methods tried. Due to their widespread use, we feel there is particular significance in our findings regarding oral contraceptives: of those who reported using them, 65”, reported incorrect use (our assessment), 767; had discontinued use because they were dissatisfied with them, and nearly ?I”, had become pregnant while taking them (see Table 4). Effective contraception includes much more than mere selection-the method must be used correctly and consistently.
in the pilot study.
The two hundred black women in the study reported here were found to poorly understand the menstrual cycle and the time during which they were at greater risk of becoming pregnant; 794; did not know ‘safe time’. Eighty-one per cent of the women further reported that they avoided intercourse during menstruation, perhaps unknowngly restricting their sexual activity to the time during the cycle when risks for pregnancy are higher. Though the majority had used various methods of contraception in the past. they reported both incorrect use of and dissatisfaction and discontinuance with both medical and traditional contraceptive methods. These facts, coupled with their poor understanding of fertility cycles almost guaran-
Assessment
of reproductive
knowledge
in an inner-city
clinic
1661
teed that they would fail in preventing pregnancies. Sixty per cent of the women, in fact, stated that they had become pregnant at least one time when they did not want to be. Their future plans at controlling unwanted childbearing unfortunately seem equally problematic. Eighty-eight per cent of these women stated that they planned to use contraceptive methods in the future, but despite their good intentions, because of gaps in the reproductive knowledge and their erratic histories of contraceptive use, we believe that the potential for failure to effectively utilize their chosen contraceptive will be high. This will probably be true both for those again attempting to use a method which they had had some experience, and for the women who had not used their chosen method before-medical or traditional. Based on their previous experiences one can only expect that the pattern of problems with contraception exhibited in the past-sporadic, inconsistent, or around’ among multiple incorrect use, ‘shopping methods. discontent with and discontinuation of various methods-will again surface, and will again produce unwanted or mistimed pregnancies. Their contraceptive knowledge, attitudes, and practices are not conducive to effective fertility control. Most of them did not learn effective birth control early and their attempts at contraception have not been successful. For many of them, planning a family is not a viable option. SUMMARY
The sample of this clinic population was composed of black women who were primarily poor, undereducated. single, and at the beginning of their childbearing years. Many were at high risk for pregnancy because of medical and social factors. They were victims of misinformation and a lack of information about the basic reproductive facts essential to control fertility. Many had had unwanted pregnancies and many will have unwanted pregnancies in the future. In such a setting it is imperative that health professionals take the time to assess the reproductive knowledge base of their clients-by short questionnaire or direct questioningin order to individualize patient education. REFERENCES
1. Presser H. B. Guessing and misinformation about pregnancy risk among urban mothers. Fam. Plann. Persprct. 9, 111-115. 1977. for contraceptive fail2. Blame M. D. ‘Mismanagement’ ure. Fam. Plum. Prrspect. 8, 72-76. 1976. between beliefs about the 3. Scott C. The relationship menstrual cycle and choice of fertility regulating method within five ethnic groups. Int. J. Gynec. Ohstet. 13, 105-190. 1975. 4. Vaughan B.. Trussel .I.. Menken J. and Jones E. F. Contraceptive failure among married women in the United States. 1970-1973. Fam. P/am. Persprct. 9, 251-258. 1977. K. Contraceptive use in the United States. 5. Ford 1973-1976. Fam. Plann. Perspect. 10, 264-269. 1978. S. M.‘and Mayhew H. E. The 6. Snow L. F.. Johnson behavioral implications of some old wives’ tales. Ohstet. G~xrc. 51. 727-732. 1978. S. ht.. Snow L. F. and Mayhew H. E. Limited 7. Johnson
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SHIRLEY M. JOHNSON and LOCDELL F. SNOW
patient knowledge as a reproductive risk factor. J. Fatn. Prac. 6. 855-862. 1978: S. M. and Snow L. F. The profile of some 8. Johnson unplanned pregnancies. In The Anthro&og.r of He&h (Edited by Bauwens E. E.), p. 46. C.V. Mosby. St Louis. 1978. 9. Snow L. F. and Johnson S. M. Modern day menstrual folklore: some clinical implications. JAMA 237, 27362139, 1917. 10. Dott A. B. and Fort A. T. Medical and social factors
affecting early teenage pregnancy. .-lt~. J. Ohstrf. Cy,~rc. 125. 532-536. 1976. 11 Perkin G. W. Assessment of reproductive risk In nonpregnant women. Ant. J. Ohsrer. 101. 709-717. 1968. 12 PlaiN Brorw Wrapper. Venereal Disease in .tfic/licqtrn 1979. Venereal Disease Division. Michigan Department of Public Health. Lansmg. MI. 1979. 13 Newman H. H. and DeCherney A. Douching and pelvic inflammatory disease. ,Yrrr E/U/I. J. .Mrd. 295. 789. 1976.