Predictors of long-acting reversible contraception use among unmarried young adults

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Predictors of long-acting reversible contraception use among unmarried young adults Angela R. Dempsey, MD; Caroline C. Billingsley, MD; Ashlyn H. Savage, MD; Jeffrey E. Korte, PhD OBJECTIVE: The objective of the study was to improve the understand-

ing of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy. STUDY DESIGN: We performed a secondary data analysis of a national

survey conducted by Guttmacher Institute of unmarried women and men aged 18-29 years. LARC is defined as an intrauterine device (IUD) or implant. Predictors of LARC use and IUD knowledge among those at risk for unintended pregnancy (n ⫽ 1222) were assessed using ␹2 analysis and logistic regression models. RESULTS: LARC use was associated with older age, high IUD knowl-

edge, and earlier onset of sexual activity. Respondents with high IUD knowledge were 6 times more likely to be current LARC users (odds ra-

tio [OR], 6.3; 95% confidence interval [CI], 1.4 –28.8). Sociodemographic variables did not predict use. Respondents with lower education (OR, 1.76; 95% CI, 1.0 –3.0), an external locus of control (OR, 1.6; 95% CI, 1.1–2.3), male sex (OR, 2.8; 95% CI, 1.9 – 4.1), and foreign language had less knowledge of IUD. CONCLUSION: Increasing knowledge of IUD among certain groups may

improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy. Key words: contraceptive implant, intrauterine device, knowledge of long-acting reversible contraception, long-acting reversible contraception use

Cite this article as: Dempsey AR, Billingsley CC, Savage AH, et al. Predictors of long-acting reversible contraception use among unmarried young adults. Am J Obstet Gynecol 2012;206:526.e1-5.

R

educing the proportion of unintended pregnancies, which currently account for nearly half of all pregnancies in the United States, has been prioritized as a national public health goal.1,2 Increasing the use of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, is a recognized strategy

From the Department of Obstetrics and Gynecology (Drs Dempsey, Billingsley, and Savage) and the Division of Biostatistics and Epidemiology, Department of Medicine (Dr Korte), Medical University of South Carolina, Charleston, SC. Received Oct. 26, 2011; revised Feb. 2, 2012; accepted Feb. 21, 2012. A.H.S. is on the speaker’s bureau for Merck. The remaining authors report no conflict of interest. Presented as an oral abstract at the 74th annual meeting of the South Atlantic Association of Obstetricians and Gynecologists, Naples, FL, Jan. 15-18, 2012. Reprints: Angela R. Dempsey, MD, Department of Obstetrics and Gynecology, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 634, Charleston, SC 29425. [email protected]. 0002-9378/$36.00 © 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2012.02.014

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for reducing unintended pregnancy.3,4 Requiring no user compliance once inserted, LARC methods essentially eliminate the inconsistent and incorrect use that plagues other contraceptive methods.5 These methods are the most efficacious and cost-effective reversible forms of contraception, resulting in fewer pregnancies during the first year of use than any other reversible method.6,7 Despite these positive attributes, LARC methods are utilized by relatively few women, with approximately 5% of women reporting ever-use of an intrauterine device or contraceptive implant.8,9 A barrier to improved use may be lack of knowledge of LARC methods. As many as two thirds of adolescent and young adult women report that they had never heard of these methods.10,11 Lack of provider knowledge and misinformation in the media may also negatively impact use.12,13 Contraceptive decision making is likely influenced by a complex array of sociodemographic, behavioral, attitudinal, and knowledge factors as well as the influence of the social network, partner characteristics, and recommendations from health care providers.5,14-19 Partner influence and relationship dynamics are also emerging as influential factors in contraceptive deci-

American Journal of Obstetrics & Gynecology JUNE 2012

sion making, although less research has addressed the characteristics of men whose partners use LARC.20,21 Increasing the proportion of at risk women who use LARC will require better understanding of use patterns and development of targeted interventions. We used data collected through a nationally representative survey to further explore factors associated with LARC use among a population at risk for unintended pregnancy.

M ATERIALS AND M ETHODS We performed a secondary analysis using data collected through a national survey of fertility and contraceptive knowledge commissioned by the National Campaign to Prevent Teen and Unplanned Pregnancy and conducted by the Guttmacher Institute.10 This survey gathered detailed information from a nationally representative probability-based sample of 1800 unmarried women and men aged 18-29 years. The methods have been previously described.10 Briefly, the sampling method included random digit dialing of land lines and cell phones as well as targeted sampling of land lines. African Americans and Hispanics were oversampled and constituted 21% and 22% of the final study pop-

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TABLE 1

Baseline respondent characteristics among those at risk of unintended pregnancy by current LARC usea

Characteristic

Total population (n ⴝ 1222)

Current LARC users (n ⴝ 56)

Current LARC nonusers (n ⴝ 1156)

Sex, %

P valueb .14

.....................................................................................................................................................................................................................................

Male

54

41

54

Female

46

59

46

..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Age, %

.003

.....................................................................................................................................................................................................................................

18-19 y

26

3

27

20-24 y

40

52

39

25-29 y

35

45

34

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Race, %

.3

.....................................................................................................................................................................................................................................

Non-Hispanic white

59

64

59

Non-Hispanic black

16

13

16

Hispanic

18

22

18

6

1

6

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................

Asian

..............................................................................................................................................................................................................................................

Insurance, %

.47

.....................................................................................................................................................................................................................................

Medicaid only

15

25

14

.....................................................................................................................................................................................................................................

Medicaid and private

9

9

9

51

49

51

2

2

2

23

16

24

.....................................................................................................................................................................................................................................

Private only

.....................................................................................................................................................................................................................................

Other Insurance

.....................................................................................................................................................................................................................................

Uninsured

..............................................................................................................................................................................................................................................

Education, %

.2

.....................................................................................................................................................................................................................................

Less than high school

17

9

17

High school graduate/GED

30

41

30

Greater than high school

53

50

53

English as primary language, %

84

91

84

.25

Have children, %

25

46

24

.03

Prior unplanned pregnancy, %

27

49

26

.002

Age at first intercourse younger than 17 y, %

54

73

53

.04

External locus of control, %

60

65

35

.55

Stated very/somewhat important to avoid pregnancy, %

88

94

88

.2

High IUD knowledge, %

64

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

91

63

.005

..............................................................................................................................................................................................................................................

GED, graduate equivalency degree; IUD, intrauterine device; LARC, long-acting reversible contraception. a

All data are presented as column percent. No frequencies are reported given the weighted nature of the data; b P values are based on ␹2 test for comparison of categorical variables between current users and nonusers of LARC.

Dempsey. Predictors of LARC use among young adults. Am J Obstet Gynecol 2012.

ulation, respectively. The primary research team weighted the data prior to public release. Permission was obtained to use the data for our analysis. Approval from the Institutional Review Board of the Medical

University of South Carolina was obtained prior to the analysis. To obtain a sample deemed at risk of unintended pregnancy, we excluded respondents who had not had sex within

the last year (22%), who reported previous sterilization (4%), and who reported that they were pregnant or trying to become pregnant (5%). Current contraceptive use was not used to define risk status. Our primary outcome was the current use of LARC, defined as use reported within the last month. Male respondents were asked whether a partner had used an intrauterine device or implant when having sex with them during the past month. If they responded yes, they were considered current users of LARC in our analysis. Knowledge of intrauterine contraception was treated as a secondary outcome. Six intrauterine device (IUD) knowledge questions with true/false answers were asked of both male and female respondents. These questions assessed IUD knowledge in the following areas: legality of IUD use in the United States, safety of concomitant use of IUDs and tampons, whether IUD insertion requires a surgical operation, safety of IUD use in nulliparous women, the ability of an IUD to move around in a woman’s body, and the ability of a male partner to feel the IUD during intercourse. The number of correct answers to these questions was summed to create a knowledge score ranging 0 –7. Using the mean number of correct answers as a cut point, a dichotomous variable was created with low IUD knowledge defined as 2 or fewer correct answers and high IUD knowledge defined as 3 or more correct answers. IUD knowledge is analyzed as both an ordinal and dichotomous variable. The following variables were considered as potential predictors of current LARC use: sex, age, race/ethnicity, insurance status, foreign-born status, primary language, religious affiliation, education level, prior sexual education, age at first intercourse, locus of control, gravidity, parity, experience of prior unplanned pregnancy, self-rated importance of avoiding pregnancy, prior use of any birth control, and knowledge of intrauterine contraception. Locus of control is a general construct referring to the extent to which individuals believe that they can control events that happen to them. For our analysis, we

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SAAOG Papers defined the external locus of control as a response of “somewhat or strongly agree” to the following statement: “It does not matter whether you use birth control or not; when it is your time to get pregnant, it will happen.” Descriptive analyses were conducted to describe the distribution of these variables among the population at risk for unintended pregnancy. Because the survey used weighted sampling methods, all results are reported as weighted proportions, not frequencies. Current LARC users were compared with nonusers through a bivariate analysis using a RaoScott ␹2 test. Significance was set at P ⬍ .05. All variables with P ⬍ .1 in bivariate analysis were considered for inclusion in a multivariable logistic regression model with current LARC use as a dichotomous outcome. The final model was constructed using stepwise subtraction of variables with retention of variables that remained significant with P ⬍ .05. A separate logistic regression model was constructed in the same fashion using our dichotomous IUD knowledge variable as the outcome. Results are reported as odds ratios (ORs) with 95% confidence intervals (CIs). All statistical analyses were conducted using SAS 9.2 (SAS Institute, Cary, NC), taking into account the weighted nature of the data.

R ESULTS Among those at risk for unintended pregnancy (n ⫽ 1222), only 4% of participants were currently using a LARC device (IUD 52; implant 4). Baseline characteristics of respondents in our sample are outlined in Table 1. Males represented 54% of the total respondents in our sample and 41% of those who reported use of LARC within the last month. The population was predominantly white (59%), English speaking (84%), and had insurance (77%). The majority of the respondents had at least a high school education (83%). Most reported that avoiding pregnancy was important (very important, 77%; somewhat important, 11%). Approximately half experienced sexual debut at age 16 years or younger. Approximately one526.e3

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TABLE 2

Unadjusted and adjusted odds ratios of current LARC use Variable

Unadjusted OR (95% CI)

P value

Adjusted OR (95% CI)a

P valueb

Race/ethnicity

.....................................................................................................................................................................................................................................

White non-Hispanic

Referent

Referent

Black non-Hispanic

0.7 (0.3–1.8)

.5

0.6 (0.2–1.5)

.3

Hispanic

1.1 (0.4–2.6)

.8

1.4 (0.5–3.7)

.5

Asian/other

0.1 (0.03–0.5)

.003

0.1 (0.03–0.4)

.002

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Age

.....................................................................................................................................................................................................................................

18–19

0.1 (0.02–0.4)

.0009

0.1 (0.01–0.2)

.0001

20–24

1.002 (0.5–2.1)

25–29

Referent

.99

Referent

.6

Age at sexual debut

0.9 (0.8–0.98)

.02

0.8 (0.7–0.9)

.0007

Have children

2.7 (1.3–5.6)

.01

—

—

Prior unplanned pregnancy

2.8 (1.3–5.8)

.01

—

—

.....................................................................................................................................................................................................................................

0.8 (0.4–1.8)

..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. c .............................................................................................................................................................................................................................................. d .............................................................................................................................................................................................................................................. d .............................................................................................................................................................................................................................................. e

Total IUD knowledge

.....................................................................................................................................................................................................................................

Low

Referent

High

5.8 (1.5–23.0)

Referent

.....................................................................................................................................................................................................................................

.01

6.2 (1.4–28.5)

.02

..............................................................................................................................................................................................................................................

CI, confidence interval; IUD, intrauterine device; LARC, long-acting reversible contraception; OR, odds ratio. a

n ⫽ 1203 for the adjusted model, which is smaller than the entire sample size, n ⫽ 1222, because of missing responses for age at first intercourse; b OR, 95% CIs, and P values were generated through univariate and multivariate logistic regression modeling; c In the model, age at sexual debut was treated as a continuous variable, with the OR representing the probability of current LARC use for each additional year older at the time of sexual debut; d These variables were no longer significant in the adjusted analysis; e IUD knowledge was defined as low if 2 or fewer of 6 questions were answered correctly and high if 3 or more of 6 were answered correctly.

Dempsey. Predictors of LARC use among young adults. Am J Obstet Gynecol 2012.

quarter of patients had given birth or fathered a child and a quarter had experienced an unintended pregnancy. More than half of the respondents were classified as having an external locus of control. In the univariate analysis (Table 2), current LARC use was less likely among 18-19 year olds when compared with 25-29 year olds (OR, 0.1; 95% CI, 0.02– 0.4) and was less likely among those who classified their race as Asian or other (OR, 0.1; 95% CI, 0.03– 0.5). For each year older a respondent was at the time of sexual debut, they were 10% less likely to be a current LARC user (OR, 0.9; 95% CI, 0.8 – 0.98). Those who had given birth or fathered a child were 2.7 times more likely to report current LARC use (95% CI, 1.3–5.6). Prior unplanned pregnancy was also associated with current LARC use (OR, 2.8; 95% CI, 1.3–5.8). Those with a high knowledge of intrauterine contracep-

American Journal of Obstetrics & Gynecology JUNE 2012

tion, defined as answering 3 or more of 6 knowledge questions correctly, were 5.8 times more likely to be current LARC users when compared with those who answered fewer than 3 questions correctly (95% CI, 1.5–23). Current LARC use was not associated with sex, insurance status, educational attainment, primary language, locus of control, or self-rated importance of avoiding pregnancy (Table 1). In the multivariate analysis, age, race/ ethnicity, age at sexual debut, and IUD knowledge remained associated with current LARC use (Table 2). The strongest predictor of current LARC use in the adjusted model was high IUD knowledge. When adjusting for age, race/ethnicity, and age at sexual debut, those with high IUD knowledge were 6.2 times more likely to be current LARC users than those with low knowledge (95% CI, 1.4 –28.5). We repeated the multivariable model treating the IUD knowledge score as an ordinal variable (data not

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TABLE 3

Unadjusted and adjusted odds ratios of low IUD knowledge Variable

Unadjusted OR (95% CI)

P value

Adjusted OR (95% CI)a

P valueb

Sex

.....................................................................................................................................................................................................................................

Female

Referent

Male

2.9 (2.0–4.2)

Referent

.....................................................................................................................................................................................................................................

⬍ .0001

2.8 (1.9–4.1)

⬍ .0001

.............................................................................................................................................................................................................................................. c

Race/ethnicity

—

.....................................................................................................................................................................................................................................

White non-Hispanic

Referent

Black non-Hispanic

1.6 (1.04–2.6)

.03

Hispanic

2.8 (1.9–4.3)

⬍ .0001

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................

1.5 (0.8–2.8)

.2

Insured

Asian/other

0.4 (0.3–0.6)

⬍ .0001

—

Foreign born

3.6 (2.3–5.7)

⬍ .0001

—

Non-English speaking

4.2 (2.8–6.4)

⬍ .0001

3.5 (2.2–5.5)

.............................................................................................................................................................................................................................................. c .............................................................................................................................................................................................................................................. c .............................................................................................................................................................................................................................................. d

⬍ .0001

..............................................................................................................................................................................................................................................

Education

.....................................................................................................................................................................................................................................

More than high school/GED

Referent 2.0 (1.4 –2.9)

.0005

2.3 (1.4–3.7)

.0005

Referent 1.8 (1.2–2.7)

.007

1.8 (1.04–3.0)

.03

.....................................................................................................................................................................................................................................

High school/GED

.....................................................................................................................................................................................................................................

Less than high school

.............................................................................................................................................................................................................................................. c

No prior sexual education

1.7 (1.1–2.5)

.014

—

External locus of control

1.8 (1.3–2.5)

.001

1.6 (1.1–2.3)

..............................................................................................................................................................................................................................................

.01

..............................................................................................................................................................................................................................................

CI, confidence interval; GED, general equivalence diploma; IUD, intrauterine device; OR, odds ratio. a

n ⫽ 1214, which is smaller than the total sample size, n ⫽ 1222, because of missing responses; b ORs, 95% CIs, and P values were generated through univariate and multivariate logistic regression modeling; c These variables were no longer significant in the adjusted model; d Non-English speaking are those respondents who reported speaking a language other than English at home.

Dempsey. Predictors of LARC use among young adults. Am J Obstet Gynecol 2012.

shown). For each additional question that a respondent answered correctly, they were 30% more likely to be a current LARC user (OR, 1.3; 95% CI, 1.1–1.5). Unadjusted and adjusted ORs for low IUD knowledge are outlined in Table 3. In adjusted analyses, race/ethnicity, insurance status, foreign-born status, and prior sexual education were no longer significant predictors when controlling for the other variables in the model. Males remained 2.8 times more likely to have low IUD knowledge (95% CI, 1.9 – 4.1). Those with high school education or less were approximately 80% more likely to have low IUD knowledge (less than high school, OR, 1.8; 95% CI, 1.04 – 3.0; high school, OR, 1.8; 95% CI, 1.2– 2.7). Those whose primary language at home was not English were 3.5 times more likely to have low IUD knowledge (95% CI, 2.2–5.5). Respondents with an external locus of control were 60% more

likely to have low IUD knowledge compared with those with an internal locus of control (OR, 1.6; 95% CI, 1.1–2.3).

C OMMENT The majority of young men and women at risk for unintended pregnancy are not using LARC. Only 4% of respondents in our sample were currently using an IUD or implant, which is similar to the reported national prevalence.9 Eighteen to 19 year olds and those who identified themselves as Asian/other race were less likely to be current LARC users, whereas those with a high IUD knowledge and early onset of sexual activity were more likely to be current users. The variable most strongly associated with current LARC use was high IUD knowledge. Furthermore, we observed a graded association between these factors: specifically, for each additional

question answered correctly, respondents were more likely to be current LARC users. However, because our analysis was cross-sectional, we cannot conclude whether knowledge leads to LARC use or LARC use leads to increased knowledge. In our analysis, those with the lowest IUD knowledge were males, respondents whose primary language at home was not English, those with lower educational attainment, and those with an external locus of control. These groups may represent targets for interventions to increase knowledge of LARC. It may not be surprising that males were more likely to have low IUD knowledge because they are not the primary users of the contraceptive method. However, research indicates that partners play a role in contraceptive decision making.20,21 Traditional avenues of contraceptive education may not reach males. Further exploration of the role that male partners may play in adoption and continuation of LARC methods is warranted, as is the consideration of targeted interventions to improve LARC knowledge among males. Those whose primary language is one other than English and those with lower levels of educational attainment are groups that appear to have LARC knowledge deficits in our study. This finding highlights the importance of considering health literacy and cultural competence in provider counseling and patient education materials. To our knowledge, external locus of control has not previously been identified as a predictor of low IUD knowledge. We speculate that individuals with an external locus of control may be less likely to actively seek out information about LARC. Additionally, they may be more likely to underestimate their individual ability to prevent unintended pregnancy by using a highly effective birth control method. One possible limitation of our analysis was that our definition of external locus of control is based on only 1 question (“It does not matter whether you use birth control or not; when it is your time to get pregnant, it will happen”). However, we found the same results using a more gen-

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SAAOG Papers eral question (“In life, things just seem to happen to me”). This finding is notable because it would be feasible to include such a question on a clinic intake form to target these individuals for interventions to increase LARC knowledge. Another interesting finding in this analysis is that respondents were more likely to use LARC the earlier their sexual debut. One possible explanation for this is the possibility of provider bias about risk of unintended pregnancy based on sexual behavior. Prior research has documented that providers vary their contraceptive recommendations based on patient demographic and historical characteristics.22,23 Providers play an important role in an individual’s contraceptive decision making,18,19 and judgments that limit counseling, recommendations, or method provision may result in decreased prevalence of LARC use at a population level. Limitations of our analysis include the small absolute number of respondents who were current users of LARC and the inability to discern causal associations from cross-sectional data. Furthermore, we could analyze only variables captured in this survey and could not further explore interesting associations related to locus of control and knowledge. In summary, IUD knowledge is strongly associated with current LARC use among young adult men and women at risk for unintended pregnancy. Target groups for interventions to increase knowledge of LARC include males, patients who speak a language other than English at home, those with lower educational attainment, and those with an external locus of control. Such interven-

526.e5

www.AJOG.org tions may increase LARC use and in turn f decrease unintended pregnancy. REFERENCES 1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90-6. 2. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Available at: www. healthypeople.gov/2020/topicsobjectives2020. Accessed Sept. 16, 2011. 3. Committee on Gynecologic Practice. Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114:1434-8. 4. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008;78:197-200. 5. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health 2008;40:94-104. 6. Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89-96. 7. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception 2009;79: 5-14. 8. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of US women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005:1160. 9. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 23 2010:144. 10. Kaye K, Suellentrop K, Sloup C. The fog zone: how misperceptions, magical thinking, and ambivalence put young adults at risk for unplanned pregnancy. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2009. 11. Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception 2008;78:211-7. 12. Madden T, Allsworth JE, Hladky KJ, Secura GM, Peipert JF. Intrauterine contraception in

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Saint Louis: a survey of obstetrician and gynecologists’ knowledge and attitudes. Contraception 2010;81:112-6. 13. Weiss E, Moore K. An assessment of the quality of information available on the internet about the IUD and the potential impact on contraceptive choices. Contraception 2003;68: 359-64. 14. Dehlendorf C, Diedrich J, Drey E, Postone A, Steinauer J. Preferences for decision-making about contraception and general health care among reproductive age women at an abortion clinic. Patient Educ Couns 2010;81:343-8. 15. Yee L, Simon M. The role of the social network in contraceptive decision-making among young, African American and Latina women. J Adolesc Health 2010;47:374-80. 16. Yee L, Simon M. Urban minority women’s perceptions of and preferences for postpartum contraceptive counseling. J Midwifery Womens Health 2011;56:54-60. 17. Whitaker AK, Dude AM, Neustadt A, Gilliam ML. Correlates of use of long-acting reversible methods of contraception among adolescent and young adult women. Contraception 2010; 81:299-303. 18. Kottke M, Goedken P, Gidvani M, Cwiak C. Factors associated with choosing a long acting reversible contraceptive method amongst postpartum women in an urban teaching hospital. Contraception 2010;82:197-8. 19. Selitsky L, MacIsaac L, Freedman P. What factors influence women’s contraception decisions? Contraception 2010;82:195-6. 20. Billy JO, Grady WR, Sill ME. Sexual risktaking among adult dating couples in the United States. Perspect Sex Reprod Health 2009;41: 74-83. 21. Grady WR, Klepinger DH, Billy JO, Cubbins LA. The role of relationship power in couple decisions about contraception in the US. J Biosoc Sci 2010;42:307-23. 22. Dehlendorf C, Ruskin R, Darney P, Vittinghoff E, Grumbach K, Steinauer J. The effect of patient gynecologic history on clinician contraceptive counseling. Contraception 2010;82: 281-5. 23. Dehlendorf C, Ruskin R, Grumbach K, et al. Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ ethnicity and socioeconomic status. American J Obstet Gynecol 2010;203:319.e1-8.