Researchers studied more than 1,000 women, ages 18 and 19 years, over several years, asking them weekly questions about their contraceptive use, sex, and pregnancy. They found that women who experience material hardship use contraceptives less consistently.1,2
“A lot of studies ask you retrospectively if, in the past year, you used contraceptives consistently, and people would say they use it consistently every time,” says Elly Field, MA, PhD candidate in sociology, National Science Foundation graduate research fellow, and predoctoral trainee at the Population Studies Center at the University of Michigan. “But being overall consistent is different from being consistent every time.”
The weekly questions capture women’s answers closer to the time of their reported behavior. The data came from the Relationship Dynamics and Social Life Study.
“I was interested in women’s health and experience with inequality and poverty, and I used a set of questions that asked if they were economically disadvantaged,” Field says.
The questions included:
- Have you experienced food insecurity?
- Was your electricity cut off?
- Were any utilities cut off?
Measuring the young women’s income was challenging. “They have varying levels of reliance and support on their families,” Field explains. “An income measure might not indicate the same level of hardship.”
Some young women with low incomes have their basic needs met by their families. Others are suffering from material hardship. “Income is important, and it’s also important to get at hardship, as well,” Field says. “We can miss people who don’t meet an income threshold but are experiencing the inability to meet their needs.”
For instance, young women with relatively higher income levels might experience medical costs that force them to choose between paying rent and paying for their medical needs. Variations in income and hardship are common for this population of young women transitioning into adulthood, she notes.
Field also studied the women’s answers about contraceptive consistency and how this related to their income and material hardship answers. Questions included:
- Are you using contraceptives at all?
- Which methods are you using?
- Are you using this method every time?
- Are there gaps in your use?
The answer was that hardship made it more challenging for women to use contraceptives consistently. “I didn’t look at the pregnancy rates in this paper because it’s a smaller group,” Field explains. “There were not quite enough pregnancies in that time period.”
Field focused on women who had unprotected sex even when they said they did not want children. “I restrict analyses to women who don’t want to become pregnant and would like to avoid pregnancy,” she says. “These were divided between those who experienced material hardship and those who did not have material hardship.”
Material hardship includes lack of insurance, homelessness, and unmet needs. Young women experiencing material hardship might have to pawn their belongings or donate plasma to make ends meet.
While some poor families can meet their needs through social assistance programs that provide food and housing essentials, other people with similar incomes find that their demands exceed their resources. “I find that women experiencing multiple hardships are much less likely to use any contraception over the period of the study,” Field says. “They’re unlikely to use contraceptive methods because they don’t have insurance, and they’re also less likely to use condoms and other coital-specific methods like spermicides or diaphragms.”
Women experiencing material hardship also are more likely to switch from more effective methods to less effective methods. They also go through periods without using any contraceptive methods at all, she adds.
Investigators studied different factors to explain the connection between material hardship and contraceptive use. One factor is access. “We asked women, ‘Do you believe you can afford contraception, and is it easy to access?’” she explains. “Access does explain why women experiencing hardship are less likely to use contraception, and why women who do not have insurance are less likely to use contraception.”
In much of contraception literature, it is assumed that birth control is reasonably priced and widely available. “But that’s not really always true,” Field notes. “It should be a priority to enhance access through programs like Title X clinics.”
But reproductive health clinicians should keep in mind that access still is a barrier in the United States. “Even if condoms can be purchased anywhere, that’s not enough for women who are experiencing the acute effects of poverty,” Field says. “This study is before the expansion of the ACA [Affordable Care Act], but it’s not a failsafe even with the ACA.”
Field suggests that family planning providers and reproductive health clinicians help women improve access through these changes:
- Recognize how material hardship, poverty, and lack of insurance can affect women’s health and how economic insecurity is a risk factor;
- Keep in mind that women who carry the burden of worrying about contraception also carry the burden of worrying about money, family members, and other factors that can affect their ability to process information and make wise decisions;
- Consider what a person needs to obtain the form of birth control the provider recommends.
“It’s easy to write a prescription and say, ‘Pick it up every month.’ But if she has an unreliable work schedule or child care responsibilities, it can be a real burden, hard to remember, and hard to get to the store to pick it up,” Field says. “Someone might not have a car or be able to pay for gas this month, and these barriers can add up. Not having enough money to make ends meet and support yourself can impact health and other domains in your life, and that’s not understood as well as it should be. It’s a really important part of poverty, and it’s one that has cascading effects on your life.”
- Field E. Material hardship and contraceptive use during the transition to adulthood. Demography 2020;57:2057-2084.
- Barber J, Kusunoki Y, Gatny H, et al. Participation in an intensive longitudinal study with weekly web surveys over 2.5 years. J Med Internet Res 2016;18:e105.