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Patterns of contraceptive use and pregnancy among young hispanic women on the Texas–Mexico border
J O U R N A L OF A D O L E S C E N T H E A L T H 1993;14:373-379
ORIGINAL ARTICLE
Patterns of Contraceptive Use and Pregnancy Among Young Hispanic Women on the Texas-Mexico Border A. Y V O N N E R U S S E L L , M . D . I P h . D . I M A R T H A S. W I L L I A M S r P h . D . / P A T R I C I A A. F A R R / M . A . I M . S . W . I A. J A M E S S C H W A B ! P h . D . I A N D SUE P L A T T S M I E R r M . A .
Our objective was to identify significant family planning and health access problems of young Hispanic women on the Texas-Mexico border. Samples of 300 young Hispanic women living in each of the twin cities of El Paso and Juarez were interviewed regarding their knowledge, attitudes, and experiences with respect to birth control, pregnancy, maternal and child health, and health-care services. Knowledge and attitudes of the women about birth control technology were assessed along with their beliefs regarding the use of such technology. Results showed that contraceptive knowledge and usage patterns for young Hispanic women in Juarez and El Paso were significantly different. They relied on different types of birth control methods and also differed with respect to confidence in these methods and related medical services. Both groups reflected positive attitudes toward both child bearing and use of birth control although Juarez women were significantly more favorable toward child bearing. Both groups overwhelmingly favored female doctors. The young women studied have accepted the need for birth control, prefer fewer children, and have some degree of confidence in medical services. Their knowledge and use of reliable versus unreliable birth control devices appear to be major areas requiring culturally sensitive intervention.
From the Department of Pediatrics, School of Medicine, The University of Texas Medical Branch at Galveston, (A.Y.R.). and School of Social Work, The University of Texas at Austin (M.S.W., P.A.F., A.J.S., S.P.), Texas. Address reprint requests to: A. Yvonne Russell, M.D., Ph.D., Department of Pediatrics, School of Medicine, Office of Student Affairs, Ashbel Smith Building 1.208, The University of Texas Medical Branch at Galveston, Galveston, TX 77555-1307. Manuscript accepted December 28, 1992.
KEY WORDS:
Contraception Teenage pregnancy Mexican-American adolescents Hispanic women's health Maternal and child health Cross-cultural health care Border health care An increasing number of women at risk for unwanted pregnancy live on the border of the United States and Mexico, and many of them, as teenagers, lack contraceptive knowledge. The adverse health risks to these young mothers, and the likelihood of poor developmental outcomes for their children, is documented in the growing body of literature on health risks (1). The extent and nature of such health risks, the pattern of utilization of available family planning services, and perceived barriers to service usage which can mitigate risk (2) are the subject of this study. Unique health problems, high fertility rates, high school-dropout rates, lack of education, and lack of employment opportunities (3-5) combine to create a pattern of social and economic stresses for youth in both countries. Population shifts, economic downturns, and social and political changes along the border have blurred public versus private responsibilities and national lines of jurisdiction and have also impeded progress toward the adequate organization of data, conceptualization of problems, and development of action strategies needed to address health and related problems (6,7).
© Society for Adolescent Medicine, 1993 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
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This study was designed to understand better the extent of contraceptive practices adopted by young Hispanic women on both sides of the border, and addresses the approach that public health institutions must take in providing cross-cultural health care for sexually active youth.
Cross-Cultural Aspects of Hispanic Adolescent Pregnancy The populations along the border have been described as growing rapidly (8-10), and this growth is expected to continue. Migration, in part, explains the population growth. It is the lure of jobs in the maquiladoras (twin plants) that continues to attract people from the rural interior of Mexico to the border region and especially to the twin cities (11-13). The majority of jobs in the maquilas are held by women of reproductive age (14) often living in substandard conditions (15). Cultural factors, psychosocial profiles, and degree of acculturation must be taken into account when trying to understand Hispanic teenage contraceptive use and childbearing decision making (1618). A decrease in the mortality rate and a continued high birth rate characterizes the border populations of the area (19-21). Even though the birth rate in other age groups has declined, the rate of births to adolescents has increased (22-25).
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the most common reason given by adolescent women for a range of educational difficulties (4447). Children born to teenage parents appear more likely than children born to older parents to suffer behaviorally, socially, intellectually, and physically (48-54). Given the critical nature of the health and other social problems facing young women (and young men) who reside in the twin cities, it is important to monitor their attitudes about contraception, pregnancy, and child care. Educational interventions to promote maternal and child health must be culturally sensitive to client lifestyles and preferences. Extent of knowledge and use of contraceptive methods by this population must necessarily be explored, and educational programs and health services structured accordingly.
Methods In order to explore the contraceptive attitudes and practices of young Hispanic border women, the researchers felt that it was important to conduct personal interviews in a non-threatening, supportive manner in the neighborhoods where the women resided. Therefore, in the Spring of 1988, 300 women in E1 Paso and 300 women in Juarez were randomly selected and interviewed utilizing a questionnaire designed by the research team.
Contraceptive Use
Questionnaire
A number of studies verify different contraception usage rates for Anglos versus Hispanics (7,20,26), with Anglos generally having the lower rates. Hispanics seem to desire more contraceptive information (15,27,28) even though the culture imposes impediments to seeking help outside the family (29) and consistent use of contraception is limited (30). Teens are reported to account for one-half of all outof-wedlock births (31), many for the second time (32). Teenagers are likely to have inadequate contraceptive information (33), especially Hispanics (34,35).
The instrument developed for the study included simple questions that could be utilized in an interview of less than 1 hr. The questions on the final version of the instrument included the following study variables: family structure, lifestyle, healthpreserving habits, attitudes toward health services (formal and informal), demographics, attitudes toward self and mental status, and use of health devices and/or services. Items and scales from other research instruments were incorporated (55-58). Comparable English and Spanish versions of the final questionnaire were developed so that interviewees could request their language of preference (copies of the English and Spanish versions of the questionnaire are available from the authors on request). Pilot testing of the instrument and interviewing procedures occurred over several months prior to the training of interviewers, all of whom were young Hispanic social work students attending The University of Texas at Austin El Paso or Universidad Autonoma de Ciudad Juarez. E1 Paso inter-
Greater Risk to Teen Mothers and Children In one study conducted in Nuevo Laredo 37.9% of all infants who died had teenage mothers (36). Pregnancy-induced hypertension or toxemia rates are reported higher in teenage pregnancies (37,38), with Hispanics teens especially vulnerable to these and related diseases (39-43). Pregnancy appears to be
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viewers were bilinqual and all were reimbursed for their time. All Juarez interviews were conducted in Spanish.
Sample In order to select a random (cluster) sample of 300 Hispanic women in Juarez and 300 Hispanic women in E1 Paso who resided in dispersed neighborhoods throughout each of the two cities, a demographer with knowledge of and previous sampling experience in the two cities was employed. His detailed sampling plan (a complete description of the sampling plan is available from the authors upon request), was implemented by the 22 trained college student interviewers over a 2-month period. In households selected, interviews were requested with females between the ages of 14 and 21 years, and individuals of appropriate age in any given household were selected at random. The interviewers recorded the location in the neighborhood where each interviewee lived, and the final sample was monitored in terms of conformity with the original sampling plan. The women interviewed were considered typical of the young Hispanic w o m e n residing in the E1 Paso-Juarez twin cities because of the careful efforts made to identify and interview a random sample of subjects.
Results The responses of the women concerning contraceptive knowledge, attitudes toward pregnancy, and utilization of health services are summarized below.
Description of the Sample All 300 respondents in the Juarez sample completed the Spanish version of the questionnaire, whereas 278 respondents in El Paso completed the English version and 22 completed the Spanish version. The Juarez and El Paso samples were compared in terms of demographics (all tests of significance were set at p = 0.05). The average ages were 16.58 (El Paso) and 17.24 (Juarez) years (t = 3.1857; p = 0.002). Most were Catholic (El Paso, 80.0%; Juarez, 86.3%), although religious preference was significantly different for the two groups (X2 = 11.895; p = 0.008). The E1 Paso respondents primarily identified themselves as "Mexican-Americans" (83.3%), whereas the Juarez respondents identified themselves primarily as "Mexicanas" (96.6%). All were Hispanics and most were never married (El Paso "'never mar-
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fled," 88.0%; Juarez, 78.7%; x 2 = 9.408; p = 0.002). Most were also not employed at the time of the survey (El Paso, 79.7%; Juarez, 64.8%; x 2 = 16.24; p = 0.00006), and, of the 231 not employed in E1 Paso and 145 not employed in Juarez, 75.3% and 62.8%, respectively, reported that the main reason that they were not employed was because they were students. The majority of both groups had minimal personal annual incomes; less than $5,000 (82.8%) in E1 Paso and less than 100,000 pesos (83.5%) in Juarez. The majority had family incomes of less than $15,000 in E1 Paso and less than 200,000 pesos in Juarez. The sample in E1 Paso more often identified themselves to be in the "upper middle class" or "upper class" (44.9% compared to 26.8% in Juarez; x 2 = 26.519; p = 0.001). The majority in each sample, however, identified themselves as "lower class" or "lower middle class." Most of the respondents had resided in their present dwellings "during the last 2 years" and frequency of moving during the last 2 years did not differ for the two groups; however, the El Paso sample had lived at their present addresses a longer period of time. Furthermore, the E1 Paso sample lived in households with fewer members (El Paso mean = 4.92 versus Juarez mean = 5.56). The two groups did not differ significantly in response to the question, "Have you ever been pregnant?" (×2 = 3.084; p = 0.079) and 11.7% of the E1 Paso sample and 16.7% of the Juarez sample had been pregnant at some time. At the time of the interviews, 3.7% of the E1 Paso sample and 6.0% of the Juarez sample were pregnant, the majority for the first time. In addition, 30 (10%) of the E1 Paso sample and 47 (16%) of the Juarez sample had children of their own living with them. Furthermore, 33 of the E1 Paso sample and 42 of the Juarez sample reported losing one or more children before the sixth month after birth. In summary, the E1 Paso sample was slightly younger, were more identified with a higher social class, were living in less crowded houses, had lived a longer time at their present addresses, and were more likely to be students. In both groups, most were Catholic, had not been pregnant, and were students.
Knowledge Of and Use of Contraception Technology Table 1 provides a summary of the responses of the women to the question "have you heard about" contraceptive methods or devices. Most in both groups had heard of "the pill," although the E1 Paso group
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Table 1. Knowledge About and Use of Contraception a Contraception knowledge Have you heard about? Contraceptive Method The pill IUDs Condoms Contraceptive injection Vaginal methods Sterility or tubal ligation Vasectomy Billing's method Rhythm Withdrawal Traditional methods Other methods
E1 Paso Juarez % yes % yes
Contraception use Are you now using?
Contraception use Have you used sometime?
X2
p
El Paso Juarez % yes % yes
98.0 49.8 93.7 34.1 79.7
91.3 55.4 74.7 79.8 67.8
13.349 1.853 40.296 126.787 10.900
0.001 0.173 0.001 0.001 0.001
17.7 0.7 19.3 5.0 6.9
16.7 12.7 10.2 8.1 3.4
63.3 69.0 5.3 36.4 65.3 33.4 9.2
89.9 73.2 19.2 73.6 44.5 37.8 11.8
58.992 1.255 26.718 82.697 25.911 1.221 1.011
0.001 0.263 0.001 0.001 0.001 0.269 0.315
0.0 0.0 0.0 11.3 22.8 14.4 22.2
0.5 0.0 2.3 18.1 10.1 2.3 0.0
x2
p
E1 Paso % yes
Juarez % yes
0.093 17.108 6.620 0.964 2.435
0.760 0.001 0.010 0.326 0.119
12.0 0.0 6.6 2.3 0.0
16.3 21.2 10.0 6.8 1.9
1.181 0.277 -
2.350 0.125 6.998 0.008 8.766 0.003 -
0.0 0.0 0.0 3.4 5.4 2.5 8.3
1.7 0.0 6.3 26.4 14.0 3.6 0.0
17.875 0.001 -
x2
p
IUD, intrauterine device. Note: No ~2 or p value indicates that numbers were too small for statistical tests. aSample sizes were n = 300 for E1 Paso and n = 300 for Juarez for each question.
claimed m o r e k n o w l e d g e . Significantly more of the El Paso w o m e n h a d h e a r d of c o n d o m s , vaginal m e t h o d s , a n d withdrawal; significantly m o r e of the Juarez w o m e n h a d h e a r d of injections, sterility or tubal ligation, vasectomy, Billing's m e t h o d , a n d the r h y t h m m e t h o d . Table I s h o w s the p r o p o r t i o n s w h o h a d used each m e t h o d at some time a n d s h o w s the p r o p o r t i o n s using each m e t h o d at the time of the interviews. M a n y in both g r o u p s h a d used, or were using, unreliable m e t h o d s (rhythm, withdrawal, traditional methods), a n d there were significant variations a m o n g the E1 Paso a n d Juarez samples in the p r o p o r t i o n s using each of the methods. Use of a combination of m e t h o d s was not explored. O n l y 2.3% in E1 Paso a n d 0.3% in Juarez reported never h a v i n g u s e d birth control m e t h o d s of a n y sort.
Attitudes About Birth Control, Pregnancy, an'd Health Services Table 2 c o m p a r e s some of the attitudes a b o u t birth control, p r e g n a n c y , a n d health services. These w o m e n expressed the opinion that more information o n birth control is n e e d e d (especially in Juarez), that family p l a n n i n g is also the responsibility of the man, that couples should have fewer children, a n d that birth control m e t h o d s offered b y clinics are somew h a t effective. M a n y e n d o r s e d the opinion that "birth control m e t h o d s are bad for o n e ' s health" (especially in Juarez). The w o m e n in Juarez also app e a r e d to be m o r e positive a b o u t p r e g n a n c y a n d
childbearing in general. Both g r o u p s believed that " m e n think it is okay for [the w o m e n ] to use birth control m e t h o d s , " but m a n y of the w o m e n also felt that " m e n should be part of the decision" (especially in Juarez). The w o m e n in E1 Paso r e p o r t e d that they "visited the doctor m o r e often d u r i n g the last year for reasons other than c h e c k - u p s " (El Paso m e a n n u m b e r of visits was 1.88 versus Juarez m e a n of 1.25, t = 2.8084, p = 0.005) a n d a large majority of b o t h g r o u p s of w o m e n preferred to visit female doctors (see Table 3).
Discussion The y o u n g w o m e n interviewed in this s t u d y rep o r t e d a n e e d for m o r e information a b o u t birth control a n d a readiness to accept family p l a n n i n g m e t h o d s offered b y physicians a n d clinics, a l t h o u g h they expressed some concern a b o u t the effects of these practices on their health a n d the reliability of the devices. Of greatest c o n c e r n is their a p p a r e n t reliance on less reliable m e t h o d s a n d their u n e v e n k n o w l e d g e a b o u t contraceptive options. The findings suggest that these y o u n g w o m e n have accepted the n e e d for birth control, prefer fewer children, a n d for the m o s t part, have confidence in medical services. Especially in Juarez, the w o m e n believe that birth control frequently d o e s n ' t w o r k (and that is probably the case, given some of the options they have c h o s e n to use), a l t h o u g h t h e y do believe that services offered b y physicians a n d clinics are rela-
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Table
CONTRACEPTWE USE AND PREGNANCY: HISPANIC WOMEN
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2. A t t i t u d e s T o w a r d C o n t r a c e p t i o n a n d P r e g n a n c y
Statement Using birth control causes the woman to forget her duties as a mother. It is very satisfying to have a baby. More information on birth control and family planning is needed. Pregnancy is a woman's happiest time. Family planning is also the responsibility of the man. Birth control devices offered by public health clinics usually don't work well. The decision to use something to prevent having babies should be the w o m a n ' s decision. Even the worst health clinic gives better care than the best midwife. Actually, couples should have only a few children. A medical exam is required monthly during pregnancy. The doctors in public health clinics make every effort to understand and help their patients. Birth control and family planning methods are basically directed at women. A woman has more confidence in a clinic which has birth control methods available. Pregnancies make a woman "wear out" sooner. Public health clinics make women use birth control even if they don't want it. A good diet is important in order for a woman to have a healthy baby. It is necessary to consult a doctor during the first month of pregnancy. The birth control methods offered by clinics are very effective. Birth control methods are bad for one's health. Finding out that one is pregnant brings a woman a lot of happiness. The government should do something so men would use birth control methods too. Birth control frequently doesn't work. Your husband/partner thinks it is okay for you to use birth control w h e n you want to.
El Paso Mean Rating' n = 300
Juarez Mean Rating' n = 300
3.70 2.57 1.93 2.80 1.65 3.32
3.75 1.89 1.71 2.39 1.55 2.99
- 0.5599 9.0819 3.1288 5.2917 1.6468 4.7857
0.576 0.001 0.002 0.001 0.100 0.001
2.93 2.98 2.70 1.96
3,95 2.21 1.65 1.76
- 10.5548 9.7638 13.6991 3.0903
0.001 0.001 0.001 0.002
2.16 2.69
2.22 3.20
0.8630 -5.3720
0.389 0.001
2.68 3.03
1.99 2.87
9.7961 1.7864
0.001 0.075
3.62 1.68 1.82 2.62 3.10 2.67
3.35 1.49 1.87 2.08 2.98 2.12
3.2448 3.3993 0.6923 8.2255 1.4396 7.6021
0.001 0.001 0.489 0.001 0.151 0.001
2.22 3.10
1.91 2.63
3.7422 6.0187
0.001 0.001
2.58
2.42
1.8168
0.070
t
-
-
p
~Scale: 1 = Very much agree, 2 = Agree, 3 = Undecided, 4 = Disagree, 5 = Very much disagree.
tively effective (especially in E1 Paso). They preferred to go to female doctors for care related to maternal and child health and birth control. Finally, the w o m e n (especially in Juarez) expressed positive feelings about childbearing. It is therefore important to present birth control as a way to plan for the "op-
Table
3. P r e f e r r e d S o u r c e of H e a l t h C a r e Services
F r o m w h o m d o y o u p r e f e r to receive m a t e r n a l a n d c h i l d h e a l t h or f a m i l y p l a n n i n g services? Source
El Paso % n = 300
Juarez % n = 300
Male doctor Female doctor Other person No preference No response
5.6 64.3 1.7 24.0 4.3
9.0 56.0 5.0 26.7 3.3
Percentages are rounded and may not total 100%. X2 = 9.8170, p < 0.044; expected frequencies for "female doctor" appear to be producing most of the effect.
timum" time for such experiences (when children can best be cared for) rather than to present birth control as a way to avoid an "unpleasant" state, an interventive strategy which could be counterproductive given the cultural norms of the women in this target population. Male responsibility for birth control was also perceived as important by these women, yet use of condoms was not as widespread as "withdrawal" as a birth control strategy. This suggests that education of male partners should be a high priority for this age group. The need for more female physicians is suggested. Most of these women preferred female doctors and should be more willing to visit and follow through with the health-care advice of individuals they prefer. Perhaps male-female teams of doctors serving young male and female couples would be a delivery strategy that many would find acceptable. This study also underscores the importance of devising culturally relevant education, research, and
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service programs geared toward adolescents who vary greatly in knowledge, attitudes, and behavior depending on the geography, social context, cultural norms, and family systems within which they grow to adulthood. The Texas-Mexico border represents an especially diverse and rich setting for such program initiatives. This research was supported by grants from the March of Dimes Birth Defects Foundation, Grant No. 11-171, and the Hogg Foundation for Mental Health. In collaboration with colleagues at The Universidad Autonoma de Cuidad Juarez, Juarez, Mexico.
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48. Roosa M, Fitzgerald H, Carson N. Teenage and older mothers and their infants: A descriptive comparison. Adolescence 1982;17:1-17. 49. McCarthy J, Menken J. Marriage, remarriage, marital disruption, and age at first birth. Fam Plann Perspect 1979;11:2130. 50. Fielding J. Adolescent pregnancy revisited. N Engl J Med 1978;299:893-6. 51. Bolton F. The pregnant adolescent. Beverly Hills, CA: Sage, 1980:1-246. 52. Thomburg H. Teenage pregnancies: Have they reached epidemic proportions? Phoenix: Arizona Governor's Council on Children, Youth, and Families, 1979. 53. Furstenberg F Jr. Unplanned parenthood: The social consequences of teenage child-bearing. New York, The Free Press, 1976:1-293. 54. Menken J. The health and social consequences of teenage childbearing. Fam Plann Perspect 1972;4:45-53. 55. Majri F, Moor B, E1-ArousyO. Effect of two prophylaxis programs on the knowledge and behavior of 13 to 15 year old school children. Schweiz Monatsschr Zahnmed 1984:695-706. 56. Moos R, Moos B. Family Environment Scale. Palo Alto, CA: Consulting Psychologists Press, 1974. 57. Guerrero Sanguino A, Chavez Azuela J, Gonzalez Hernandez R, et al. Hazards of pregnancy in the adolescent patient. Ginecol Obstet Mex 1975;37:119-28. 58. Ramirez D. Analysis of the patterns of use of community mental health services by Mexican Americans. San Antonio, TX: Intercultural Development Research Association, 1982:1144. 59. Texas Medicine: Public Health. Health risks of adolescent sexual activity are focus of TMA report. Tex Med 1991;87: 60-1.
ORIGINAL ARTICLE
Patterns of Contraceptive Use and Pregnancy Among Young Hispanic Women on the Texas-Mexico Border A. Y V O N N E R U S S E L L , M . D . I P h . D . I M A R T H A S. W I L L I A M S r P h . D . / P A T R I C I A A. F A R R / M . A . I M . S . W . I A. J A M E S S C H W A B ! P h . D . I A N D SUE P L A T T S M I E R r M . A .
Our objective was to identify significant family planning and health access problems of young Hispanic women on the Texas-Mexico border. Samples of 300 young Hispanic women living in each of the twin cities of El Paso and Juarez were interviewed regarding their knowledge, attitudes, and experiences with respect to birth control, pregnancy, maternal and child health, and health-care services. Knowledge and attitudes of the women about birth control technology were assessed along with their beliefs regarding the use of such technology. Results showed that contraceptive knowledge and usage patterns for young Hispanic women in Juarez and El Paso were significantly different. They relied on different types of birth control methods and also differed with respect to confidence in these methods and related medical services. Both groups reflected positive attitudes toward both child bearing and use of birth control although Juarez women were significantly more favorable toward child bearing. Both groups overwhelmingly favored female doctors. The young women studied have accepted the need for birth control, prefer fewer children, and have some degree of confidence in medical services. Their knowledge and use of reliable versus unreliable birth control devices appear to be major areas requiring culturally sensitive intervention.
From the Department of Pediatrics, School of Medicine, The University of Texas Medical Branch at Galveston, (A.Y.R.). and School of Social Work, The University of Texas at Austin (M.S.W., P.A.F., A.J.S., S.P.), Texas. Address reprint requests to: A. Yvonne Russell, M.D., Ph.D., Department of Pediatrics, School of Medicine, Office of Student Affairs, Ashbel Smith Building 1.208, The University of Texas Medical Branch at Galveston, Galveston, TX 77555-1307. Manuscript accepted December 28, 1992.
KEY WORDS:
Contraception Teenage pregnancy Mexican-American adolescents Hispanic women's health Maternal and child health Cross-cultural health care Border health care An increasing number of women at risk for unwanted pregnancy live on the border of the United States and Mexico, and many of them, as teenagers, lack contraceptive knowledge. The adverse health risks to these young mothers, and the likelihood of poor developmental outcomes for their children, is documented in the growing body of literature on health risks (1). The extent and nature of such health risks, the pattern of utilization of available family planning services, and perceived barriers to service usage which can mitigate risk (2) are the subject of this study. Unique health problems, high fertility rates, high school-dropout rates, lack of education, and lack of employment opportunities (3-5) combine to create a pattern of social and economic stresses for youth in both countries. Population shifts, economic downturns, and social and political changes along the border have blurred public versus private responsibilities and national lines of jurisdiction and have also impeded progress toward the adequate organization of data, conceptualization of problems, and development of action strategies needed to address health and related problems (6,7).
© Society for Adolescent Medicine, 1993 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
373 1054-139X/93/$6.00
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This study was designed to understand better the extent of contraceptive practices adopted by young Hispanic women on both sides of the border, and addresses the approach that public health institutions must take in providing cross-cultural health care for sexually active youth.
Cross-Cultural Aspects of Hispanic Adolescent Pregnancy The populations along the border have been described as growing rapidly (8-10), and this growth is expected to continue. Migration, in part, explains the population growth. It is the lure of jobs in the maquiladoras (twin plants) that continues to attract people from the rural interior of Mexico to the border region and especially to the twin cities (11-13). The majority of jobs in the maquilas are held by women of reproductive age (14) often living in substandard conditions (15). Cultural factors, psychosocial profiles, and degree of acculturation must be taken into account when trying to understand Hispanic teenage contraceptive use and childbearing decision making (1618). A decrease in the mortality rate and a continued high birth rate characterizes the border populations of the area (19-21). Even though the birth rate in other age groups has declined, the rate of births to adolescents has increased (22-25).
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the most common reason given by adolescent women for a range of educational difficulties (4447). Children born to teenage parents appear more likely than children born to older parents to suffer behaviorally, socially, intellectually, and physically (48-54). Given the critical nature of the health and other social problems facing young women (and young men) who reside in the twin cities, it is important to monitor their attitudes about contraception, pregnancy, and child care. Educational interventions to promote maternal and child health must be culturally sensitive to client lifestyles and preferences. Extent of knowledge and use of contraceptive methods by this population must necessarily be explored, and educational programs and health services structured accordingly.
Methods In order to explore the contraceptive attitudes and practices of young Hispanic border women, the researchers felt that it was important to conduct personal interviews in a non-threatening, supportive manner in the neighborhoods where the women resided. Therefore, in the Spring of 1988, 300 women in E1 Paso and 300 women in Juarez were randomly selected and interviewed utilizing a questionnaire designed by the research team.
Contraceptive Use
Questionnaire
A number of studies verify different contraception usage rates for Anglos versus Hispanics (7,20,26), with Anglos generally having the lower rates. Hispanics seem to desire more contraceptive information (15,27,28) even though the culture imposes impediments to seeking help outside the family (29) and consistent use of contraception is limited (30). Teens are reported to account for one-half of all outof-wedlock births (31), many for the second time (32). Teenagers are likely to have inadequate contraceptive information (33), especially Hispanics (34,35).
The instrument developed for the study included simple questions that could be utilized in an interview of less than 1 hr. The questions on the final version of the instrument included the following study variables: family structure, lifestyle, healthpreserving habits, attitudes toward health services (formal and informal), demographics, attitudes toward self and mental status, and use of health devices and/or services. Items and scales from other research instruments were incorporated (55-58). Comparable English and Spanish versions of the final questionnaire were developed so that interviewees could request their language of preference (copies of the English and Spanish versions of the questionnaire are available from the authors on request). Pilot testing of the instrument and interviewing procedures occurred over several months prior to the training of interviewers, all of whom were young Hispanic social work students attending The University of Texas at Austin El Paso or Universidad Autonoma de Ciudad Juarez. E1 Paso inter-
Greater Risk to Teen Mothers and Children In one study conducted in Nuevo Laredo 37.9% of all infants who died had teenage mothers (36). Pregnancy-induced hypertension or toxemia rates are reported higher in teenage pregnancies (37,38), with Hispanics teens especially vulnerable to these and related diseases (39-43). Pregnancy appears to be
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viewers were bilinqual and all were reimbursed for their time. All Juarez interviews were conducted in Spanish.
Sample In order to select a random (cluster) sample of 300 Hispanic women in Juarez and 300 Hispanic women in E1 Paso who resided in dispersed neighborhoods throughout each of the two cities, a demographer with knowledge of and previous sampling experience in the two cities was employed. His detailed sampling plan (a complete description of the sampling plan is available from the authors upon request), was implemented by the 22 trained college student interviewers over a 2-month period. In households selected, interviews were requested with females between the ages of 14 and 21 years, and individuals of appropriate age in any given household were selected at random. The interviewers recorded the location in the neighborhood where each interviewee lived, and the final sample was monitored in terms of conformity with the original sampling plan. The women interviewed were considered typical of the young Hispanic w o m e n residing in the E1 Paso-Juarez twin cities because of the careful efforts made to identify and interview a random sample of subjects.
Results The responses of the women concerning contraceptive knowledge, attitudes toward pregnancy, and utilization of health services are summarized below.
Description of the Sample All 300 respondents in the Juarez sample completed the Spanish version of the questionnaire, whereas 278 respondents in El Paso completed the English version and 22 completed the Spanish version. The Juarez and El Paso samples were compared in terms of demographics (all tests of significance were set at p = 0.05). The average ages were 16.58 (El Paso) and 17.24 (Juarez) years (t = 3.1857; p = 0.002). Most were Catholic (El Paso, 80.0%; Juarez, 86.3%), although religious preference was significantly different for the two groups (X2 = 11.895; p = 0.008). The E1 Paso respondents primarily identified themselves as "Mexican-Americans" (83.3%), whereas the Juarez respondents identified themselves primarily as "Mexicanas" (96.6%). All were Hispanics and most were never married (El Paso "'never mar-
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fled," 88.0%; Juarez, 78.7%; x 2 = 9.408; p = 0.002). Most were also not employed at the time of the survey (El Paso, 79.7%; Juarez, 64.8%; x 2 = 16.24; p = 0.00006), and, of the 231 not employed in E1 Paso and 145 not employed in Juarez, 75.3% and 62.8%, respectively, reported that the main reason that they were not employed was because they were students. The majority of both groups had minimal personal annual incomes; less than $5,000 (82.8%) in E1 Paso and less than 100,000 pesos (83.5%) in Juarez. The majority had family incomes of less than $15,000 in E1 Paso and less than 200,000 pesos in Juarez. The sample in E1 Paso more often identified themselves to be in the "upper middle class" or "upper class" (44.9% compared to 26.8% in Juarez; x 2 = 26.519; p = 0.001). The majority in each sample, however, identified themselves as "lower class" or "lower middle class." Most of the respondents had resided in their present dwellings "during the last 2 years" and frequency of moving during the last 2 years did not differ for the two groups; however, the El Paso sample had lived at their present addresses a longer period of time. Furthermore, the E1 Paso sample lived in households with fewer members (El Paso mean = 4.92 versus Juarez mean = 5.56). The two groups did not differ significantly in response to the question, "Have you ever been pregnant?" (×2 = 3.084; p = 0.079) and 11.7% of the E1 Paso sample and 16.7% of the Juarez sample had been pregnant at some time. At the time of the interviews, 3.7% of the E1 Paso sample and 6.0% of the Juarez sample were pregnant, the majority for the first time. In addition, 30 (10%) of the E1 Paso sample and 47 (16%) of the Juarez sample had children of their own living with them. Furthermore, 33 of the E1 Paso sample and 42 of the Juarez sample reported losing one or more children before the sixth month after birth. In summary, the E1 Paso sample was slightly younger, were more identified with a higher social class, were living in less crowded houses, had lived a longer time at their present addresses, and were more likely to be students. In both groups, most were Catholic, had not been pregnant, and were students.
Knowledge Of and Use of Contraception Technology Table 1 provides a summary of the responses of the women to the question "have you heard about" contraceptive methods or devices. Most in both groups had heard of "the pill," although the E1 Paso group
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Table 1. Knowledge About and Use of Contraception a Contraception knowledge Have you heard about? Contraceptive Method The pill IUDs Condoms Contraceptive injection Vaginal methods Sterility or tubal ligation Vasectomy Billing's method Rhythm Withdrawal Traditional methods Other methods
E1 Paso Juarez % yes % yes
Contraception use Are you now using?
Contraception use Have you used sometime?
X2
p
El Paso Juarez % yes % yes
98.0 49.8 93.7 34.1 79.7
91.3 55.4 74.7 79.8 67.8
13.349 1.853 40.296 126.787 10.900
0.001 0.173 0.001 0.001 0.001
17.7 0.7 19.3 5.0 6.9
16.7 12.7 10.2 8.1 3.4
63.3 69.0 5.3 36.4 65.3 33.4 9.2
89.9 73.2 19.2 73.6 44.5 37.8 11.8
58.992 1.255 26.718 82.697 25.911 1.221 1.011
0.001 0.263 0.001 0.001 0.001 0.269 0.315
0.0 0.0 0.0 11.3 22.8 14.4 22.2
0.5 0.0 2.3 18.1 10.1 2.3 0.0
x2
p
E1 Paso % yes
Juarez % yes
0.093 17.108 6.620 0.964 2.435
0.760 0.001 0.010 0.326 0.119
12.0 0.0 6.6 2.3 0.0
16.3 21.2 10.0 6.8 1.9
1.181 0.277 -
2.350 0.125 6.998 0.008 8.766 0.003 -
0.0 0.0 0.0 3.4 5.4 2.5 8.3
1.7 0.0 6.3 26.4 14.0 3.6 0.0
17.875 0.001 -
x2
p
IUD, intrauterine device. Note: No ~2 or p value indicates that numbers were too small for statistical tests. aSample sizes were n = 300 for E1 Paso and n = 300 for Juarez for each question.
claimed m o r e k n o w l e d g e . Significantly more of the El Paso w o m e n h a d h e a r d of c o n d o m s , vaginal m e t h o d s , a n d withdrawal; significantly m o r e of the Juarez w o m e n h a d h e a r d of injections, sterility or tubal ligation, vasectomy, Billing's m e t h o d , a n d the r h y t h m m e t h o d . Table I s h o w s the p r o p o r t i o n s w h o h a d used each m e t h o d at some time a n d s h o w s the p r o p o r t i o n s using each m e t h o d at the time of the interviews. M a n y in both g r o u p s h a d used, or were using, unreliable m e t h o d s (rhythm, withdrawal, traditional methods), a n d there were significant variations a m o n g the E1 Paso a n d Juarez samples in the p r o p o r t i o n s using each of the methods. Use of a combination of m e t h o d s was not explored. O n l y 2.3% in E1 Paso a n d 0.3% in Juarez reported never h a v i n g u s e d birth control m e t h o d s of a n y sort.
Attitudes About Birth Control, Pregnancy, an'd Health Services Table 2 c o m p a r e s some of the attitudes a b o u t birth control, p r e g n a n c y , a n d health services. These w o m e n expressed the opinion that more information o n birth control is n e e d e d (especially in Juarez), that family p l a n n i n g is also the responsibility of the man, that couples should have fewer children, a n d that birth control m e t h o d s offered b y clinics are somew h a t effective. M a n y e n d o r s e d the opinion that "birth control m e t h o d s are bad for o n e ' s health" (especially in Juarez). The w o m e n in Juarez also app e a r e d to be m o r e positive a b o u t p r e g n a n c y a n d
childbearing in general. Both g r o u p s believed that " m e n think it is okay for [the w o m e n ] to use birth control m e t h o d s , " but m a n y of the w o m e n also felt that " m e n should be part of the decision" (especially in Juarez). The w o m e n in E1 Paso r e p o r t e d that they "visited the doctor m o r e often d u r i n g the last year for reasons other than c h e c k - u p s " (El Paso m e a n n u m b e r of visits was 1.88 versus Juarez m e a n of 1.25, t = 2.8084, p = 0.005) a n d a large majority of b o t h g r o u p s of w o m e n preferred to visit female doctors (see Table 3).
Discussion The y o u n g w o m e n interviewed in this s t u d y rep o r t e d a n e e d for m o r e information a b o u t birth control a n d a readiness to accept family p l a n n i n g m e t h o d s offered b y physicians a n d clinics, a l t h o u g h they expressed some concern a b o u t the effects of these practices on their health a n d the reliability of the devices. Of greatest c o n c e r n is their a p p a r e n t reliance on less reliable m e t h o d s a n d their u n e v e n k n o w l e d g e a b o u t contraceptive options. The findings suggest that these y o u n g w o m e n have accepted the n e e d for birth control, prefer fewer children, a n d for the m o s t part, have confidence in medical services. Especially in Juarez, the w o m e n believe that birth control frequently d o e s n ' t w o r k (and that is probably the case, given some of the options they have c h o s e n to use), a l t h o u g h t h e y do believe that services offered b y physicians a n d clinics are rela-
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Table
CONTRACEPTWE USE AND PREGNANCY: HISPANIC WOMEN
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2. A t t i t u d e s T o w a r d C o n t r a c e p t i o n a n d P r e g n a n c y
Statement Using birth control causes the woman to forget her duties as a mother. It is very satisfying to have a baby. More information on birth control and family planning is needed. Pregnancy is a woman's happiest time. Family planning is also the responsibility of the man. Birth control devices offered by public health clinics usually don't work well. The decision to use something to prevent having babies should be the w o m a n ' s decision. Even the worst health clinic gives better care than the best midwife. Actually, couples should have only a few children. A medical exam is required monthly during pregnancy. The doctors in public health clinics make every effort to understand and help their patients. Birth control and family planning methods are basically directed at women. A woman has more confidence in a clinic which has birth control methods available. Pregnancies make a woman "wear out" sooner. Public health clinics make women use birth control even if they don't want it. A good diet is important in order for a woman to have a healthy baby. It is necessary to consult a doctor during the first month of pregnancy. The birth control methods offered by clinics are very effective. Birth control methods are bad for one's health. Finding out that one is pregnant brings a woman a lot of happiness. The government should do something so men would use birth control methods too. Birth control frequently doesn't work. Your husband/partner thinks it is okay for you to use birth control w h e n you want to.
El Paso Mean Rating' n = 300
Juarez Mean Rating' n = 300
3.70 2.57 1.93 2.80 1.65 3.32
3.75 1.89 1.71 2.39 1.55 2.99
- 0.5599 9.0819 3.1288 5.2917 1.6468 4.7857
0.576 0.001 0.002 0.001 0.100 0.001
2.93 2.98 2.70 1.96
3,95 2.21 1.65 1.76
- 10.5548 9.7638 13.6991 3.0903
0.001 0.001 0.001 0.002
2.16 2.69
2.22 3.20
0.8630 -5.3720
0.389 0.001
2.68 3.03
1.99 2.87
9.7961 1.7864
0.001 0.075
3.62 1.68 1.82 2.62 3.10 2.67
3.35 1.49 1.87 2.08 2.98 2.12
3.2448 3.3993 0.6923 8.2255 1.4396 7.6021
0.001 0.001 0.489 0.001 0.151 0.001
2.22 3.10
1.91 2.63
3.7422 6.0187
0.001 0.001
2.58
2.42
1.8168
0.070
t
-
-
p
~Scale: 1 = Very much agree, 2 = Agree, 3 = Undecided, 4 = Disagree, 5 = Very much disagree.
tively effective (especially in E1 Paso). They preferred to go to female doctors for care related to maternal and child health and birth control. Finally, the w o m e n (especially in Juarez) expressed positive feelings about childbearing. It is therefore important to present birth control as a way to plan for the "op-
Table
3. P r e f e r r e d S o u r c e of H e a l t h C a r e Services
F r o m w h o m d o y o u p r e f e r to receive m a t e r n a l a n d c h i l d h e a l t h or f a m i l y p l a n n i n g services? Source
El Paso % n = 300
Juarez % n = 300
Male doctor Female doctor Other person No preference No response
5.6 64.3 1.7 24.0 4.3
9.0 56.0 5.0 26.7 3.3
Percentages are rounded and may not total 100%. X2 = 9.8170, p < 0.044; expected frequencies for "female doctor" appear to be producing most of the effect.
timum" time for such experiences (when children can best be cared for) rather than to present birth control as a way to avoid an "unpleasant" state, an interventive strategy which could be counterproductive given the cultural norms of the women in this target population. Male responsibility for birth control was also perceived as important by these women, yet use of condoms was not as widespread as "withdrawal" as a birth control strategy. This suggests that education of male partners should be a high priority for this age group. The need for more female physicians is suggested. Most of these women preferred female doctors and should be more willing to visit and follow through with the health-care advice of individuals they prefer. Perhaps male-female teams of doctors serving young male and female couples would be a delivery strategy that many would find acceptable. This study also underscores the importance of devising culturally relevant education, research, and
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service programs geared toward adolescents who vary greatly in knowledge, attitudes, and behavior depending on the geography, social context, cultural norms, and family systems within which they grow to adulthood. The Texas-Mexico border represents an especially diverse and rich setting for such program initiatives. This research was supported by grants from the March of Dimes Birth Defects Foundation, Grant No. 11-171, and the Hogg Foundation for Mental Health. In collaboration with colleagues at The Universidad Autonoma de Cuidad Juarez, Juarez, Mexico.
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