Being on the Safe Side: A Qualitative Study of Condom Use Motivations According to Contraceptive Type among Adolescents in Atlanta,Georgia

Study ObjectiveQuantitative data suggest that adolescent users of long-acting reversible contraception (LARC), compared with short-acting methods (pill, patch, ring, depot medroxyprogesterone acetate [DMPA]), might be less likely to use condoms. We qualitatively describe and explain adolescent contraceptive users’ motivations for condom use, including variation according to contraceptive type.DesignIndividual, in-depth qualitative interviews, analyzed thematically.SettingParticipants were recruited from public family planning clinics and an adolescent medicine clinic, as well as university and other community settings in Atlanta, Georgia.ParticipantsSexually active contraceptive users aged 17-19 years old (n = 30), including LARC (n = 10), DMPA (n = 10), and oral contraceptive (n = 10) users.ResultsOf the 30 participants, most (n = 25; 83%) used condoms with their more effective contraceptive method, although 11 of 25 used them inconsistently (44%). Oral contraceptive users were particularly motivated to use condoms for pregnancy prevention, because of concerns about contraceptive method efficacy and a desire to be on “the safe side.” In contrast, LARC users were primarily motivated by sexually transmitted infection (STI) prevention. DMPA users’ motivations were more mixed. Across contraceptive type, factors influencing condom use motivations included sexual health education, personal awareness and/or experience, and perceived consequences and risk.ConclusionBecause all participants were using an effective contraceptive method, it is notable that pregnancy prevention was a prominent motivator for using condoms, although LARC users reported STI prevention to be a more important motivation. Parental and school-based sexual health education that clearly addresses STI prevention in addition to pregnancy prevention has the potential to influence condom use motivations and behavior.     

STD prevention and unplanned pregnancies in Great Britain

The HIV/AIDS epidemic necessitated promotion of condoms. By the late 1980s condom use had surpassed use of all other contraceptive methods, including oral contraceptives, in the UK. The change from use of a medical contraceptive method to use of a readily available nonmedical method occurred at the same time family practitioners surpassed community family planning centers as contraceptive providers. During the 1980s the rate of women attending family planning clinics fell (15% to 10%, 1980-1990) and condom use among the women who did attend these clinics increased (10% to about 16%). At the same time the number of unwanted pregnancies in England and Wales, as reflected in the legal abortion rate (10% to 13%), rose, especially after the mid-1980s. Two studies indicate that unwanted pregnancies are most common in the youngest women using condoms. After young women with an unwanted pregnancy due to condom failure undergo abortion, they tend not to use condoms. The condom promotion campaign in the UK asserted that the condom was an acceptable contraceptive method as well as a means to protect against sexually transmitted diseases, including HIV infection, which led many women to discontinue the more effective contraceptives and to use only condoms. The campaign should have emphasized condom use along with simultaneous use of an effective contraceptive, such as the birth control pill. This combination (Double Dutch method) is acceptable in other countries, for example, in Holland. Increased use of the Double Dutch method should reduce unwanted pregnancies.     

Dual protection against sexually transmitted infections and pregnancy in South Africa

Promotion of simultaneous protection against sexually transmitted infections (STIs) and unintended pregnancy, referred to as dual protection, represents an important public health intervention. We investigated its prevalence and correlates in South Africa. A cross-sectional survey of 929 sexually active women, aged 15-49 years, was conducted in 89 public primary health care clinics, with dual method use and use of condom alone at last sexual intercourse as outcomes. At last intercourse, 12% of women were protected from both STIs and pregnancy. In multivariate analysis, higher education, being unmarried, and multiple sex partnership in the past year were predictors of dual method use, while younger age, higher education and awareness of the dual function of condoms were predictors of condom use alone. Dual protection is low in this population. The predominance of hormonal contraceptive use in South Africa means that increasing barrier method use among hormonal contraceptive users is an important strategy for increasing dual protection.     

Acceptability of Norplant at a well-woman clinic in Turkey.

OBJECTIVE: To make an assessment of the acceptability and cost of subdermal implants, a new method in Turkey, in a free-choice environment. METHODS: The records of women attending a university well-woman clinic in Istanbul, Turkey, were analyzed retrospectively. Among other contraceptives registered in the country, the women were offered subdermal contraceptive implants (Norplant) during counselling sessions. The women who chose implants were invited to attend for follow-up three times during the first 12 months and were advised to return annually thereafter. An estimation of cost was performed for Norplant, using the government price of the implant and the wage rates of public-sector staff. An estimation of cost was also performed for oral contraceptives. RESULTS: Among the 5650 women who applied to the Clinic for contraception between 1 January 1995 and 31 December 1998, 274 women decided to use implants, giving an initial acceptance rate of 5.1%. Continuation rates were 91.8%, 71.6% and 42.5% at 12 months, 24 months and 36 months, respectively. There were no pregnancies within the study period. The only demographic characteristic that was positively related to the acceptability of Norplant was younger age. The cost of contraception with Norplant was found to be lower than that for oral contraceptives. CONCLUSION: The high initial acceptance and continuation rates, combined with its high efficacy, make Norplant a valuable tool for Turkey's National Family Planning Program. Contraception with Norplant is also a cost-effective method, at least for the public sector.     

Comparison of continuation rates for hormonal contraception among adolescents.

BACKGROUND: Inadequate contraception is common among sexually active female adolescents, resulting in a high incidence of unwanted pregnancy. The authors were interested in comparing continuation rates for the different forms of hormonal contraception in this age group. METHODS: A retrospective chart review. The setting was an urban clinic in a large Midwestern city. Participants were 64% black, 34% white, and the average age was 15.5 years (+/- 1.6 SD), with implant users significantly older than oral contraceptive pill (OCP) users (P < .05). Interventions were self-selection to depo-medroxyprogesterone acetate (Depo-Provera; DMPA), levonorgestrel implants (Norplant), or oral contraceptive pills (OCPs). Previous pregnancy was significantly more prevalent in implant and DMPA users than in OCP users (P < .001). Over 4 years of follow-up, continuation rates were significantly higher for implant users than for the other hormonal groups (P < .001). At 1 year, continuation rates were as follows: 82% implants, 45% DMPA, and 12% OCPs. Combining these rates with those of the subsample who switched without interruption to another hormonal method, "continued protection" rates were much higher after 1 year: 96% implants, 83% DMPA, and 49% OCPs. Calculations of contraceptive "restarts," i.e., hormonal method use in those who discontinued and then restarted after a gap of time, also increased to the prevalence of contraceptive protection. CONCLUSION: Continuation rates for levonorgestrel implants were significantly higher than those for DMPA and OCPs, the latter group having the lowest continuation rates. Factoring in switches and restarts to other hormonal methods further boosted the prevalence rates of contraceptive use in the adolescent population.     

Preventing Repeat Teen Pregnancy: Postpartum Depot Medroxyprogesterone Acetate,Oral Contraceptive Pills,or the Patch?

STUDY OBJECTIVE: To prospectively evaluate the repeat teen pregnancy rates, within one year of delivery, among adolescents who choose the contraceptive patch (Ortho Evra) versus oral contraceptive pills (OCP) versus Depot Medroxyprogesterone Acetate (Depo Provera, DMPA) for postpartum contraception. DESIGN: Observational, prospective cohort study. Comparison groups are postpartum teens, who self-select the contraceptive patch (n = 55) versus DMPA (n = 142) versus OCPs (n = 55) immediately postpartum. SETTING: Medical University of South Carolina, a tertiary medical center. PARTICIPANTS: Postpartum teens, 11-19 years old; 72% were African American, and 96% qualified for Medicaid insurance. INTERVENTIONS: A structured telephone interview was performed every 3 months. MAIN OUTCOME MEASURES: The primary outcome measure was a repeat pregnancy within 12 months of the index delivery. Secondary outcome variables were contraceptive continuation rates, reasons for discontinuation, side effects and condom usage. RESULTS: At 1-year follow-up, repeat pregnancy rates were 14.2%, 29.7%, and 31.8% among DMPA, OCP, and patch users respectively (P = 0.02). DMPA users were significantly more likely to be using any form of hormonal contraception 1 year postpartum than patch or OCP users. Condom use was similarly low among all cohorts. CONCLUSION: Adolescents who choose DMPA for postpartum contraception are significantly less likely to become pregnant within 1 year of delivery, as compared to teens who choose OCPs or the patch.     

Where is the condom? Contraceptive practice in a rural district of South Africa

Interviews were conducted with 848 African women aged 15-49 years in a rural area of South Africa to determine the extent to which condoms are used, reasons for contraceptive method choice and unmet contraceptive need. Injectable contraceptives were being used by 22.1% of respondents, who considered them to be convenient, safe, effective, and/or a method that could be used secretly. The decision to use this method was often made on the recommendation of a health worker. Eleven women said they were using the male condom, seven of whom were using it because it provides protection against pregnancy and sexually transmitted infections. Many (70.3%) women were not using any form of contraception. Counselling about contraceptive options should take into account the need for dual protection, and strategies for increasing condom use should be promoted.     

Double Dutch: looking at the usage of combined pill plus condom in girls under 25.

OBJECTIVE: To establish what proportion of young girls who were prescribed the contraceptive pill at Manchester family planning clinics have first remembered, and second followed, advice also to use the condom for protection from sexually transmitted infection. METHOD: An anonymous self-administered questionnaire was issued to all females up to the age of 25 years, who were already using the pill and who attended one of 20 different clinic locations. Questions included duration of present relationship, frequency of condom use and reasons for use or non-use. RESULTS: The age of respondents ranged from 13 to 25 years, with one-third in the group of 17-19-year-olds. Out of 104 responses, condoms were used most of the time by 29 girls, occasionally by 42 and never by 33. Only 15 of the 104 knew the phrase 'double Dutch'. Dual use most of the time primarily for sexually transmitted disease protection was reported by 23 girls. Previous treatment for sexually transmitted disease was reported by 14 girls, of whom half never used condoms and only three now used condoms most of the time. In the group of girls using condoms occasionally, 70% were using condoms primarily to cover missed pills, antibiotics, etc. Extrapolating from the number of condoms used in the past month and the fact that 80% of girls obtained their condoms from the clinic, the extra cost to the family planning budget is over 14,000 Pounds (over 22,500 Ecu) per year. CONCLUSION: Our result that 22% of young pill users regularly used condoms to protect from sexually transmitted diseases indicates that the message is understood, but the term 'double Dutch' is not.     

Adolescents' contraceptive use and pregnancy history: is there a pattern?

OBJECTIVE: To examine the association between pregnancy experience and adolescents' contraceptive use. METHODS: We conducted a retrospective study of 920 sexually active adolescents not desiring pregnancy. Adjusted multivariable logistic regression analyses were used to assess the explanatory value of previous birth and abortion as well as first pregnancy at presentation on contraceptive practice. RESULTS: Twenty-seven percent of the adolescents had been pregnant. Regardless of pregnancy history, 52% of adolescents used noneffective contraception (ie, condoms inconsistently or no method). Adolescents with previous abortion were three times (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.6, 7.3) more likely than never-pregnant adolescents to use hormonal contraception. However, although more likely to use contraceptive injections or implants, adolescent mothers were not more likely than never-pregnant adolescents to use oral contraceptives. Adolescents with prior abortion or birth were less than half (ORs 0.3 and 0.4, 95% CIs 0.2, 0.5 and 0.2, 0.6, respectively) as likely as never-pregnant adolescents to use condoms consistently. CONCLUSION: Previous pregnancy is associated with increased likelihood to use hormonal methods; however, a significant proportion of adolescents use noneffective methods and, thus, are at risk for repeat teenage pregnancies.     

Safety and efficacy of levonorgestrel implant, intrauterine device, and sterilization

OBJECTIVE: To evaluate safety and efficacy of levonorgestrel-releasing contraceptive implants (Norplant; Leiras Oy, Turku, Finland) in developing countries. METHODS: We used controlled cohort methodology. Women attending family planning clinics in eight developing countries selecting Norplant were enrolled, together with women of similar age choosing intrauterine devices (IUDs) or surgical sterilization. Participants were interviewed and examined at semi-annual visits and followed-up for 5 years regardless of change of contraceptive methods. Incidence rate ratios of health events were estimated for initial and current method use. RESULTS: Altogether, 7977 women initiated Norplant, 6625 IUD, and 1419 sterilization. The overall follow-up rate was 94.6% and 78,323 woman-years of observation were accumulated. Pregnancy rates for Norplant, copper IUDs, and sterilization each averaged less than 1 per 100 woman-years. With two exceptions, no significant excess risk of serious morbidity was detected for Norplant users compared with controls. The incidence of gallbladder disease was higher in women who initiated Norplant use than in controls (rate ratio 1.52, 95% confidence interval [CI] 1.02, 2.27), as was the incidence of hypertension and borderline hypertension in current implant users (rate ratio 1.81; CI 1.12, 2.92). Other new findings were increased risks of respiratory diseases and decreased risks of inflammatory disease of the genital tract in Norplant users compared with IUD users and sterilized women. CONCLUSION: The study confirms the safety with respect to serious disease and the high contraceptive efficacy of Norplant, copper IUDs, and sterilization.     

Long-acting hormonal contraception: assessing impact on bone density, weight, and mood.

The decline in unintended pregnancies and abortions in the United States has been attributed largely to increased use of two highly effective, hormonal contraceptive methods, depot medroxyprogesterone acetate injection (DMPA) and levonorgestrel implants (Norplant). Despite the efficacy and increasing acceptability of these long-term methods, some clinicians and women are reluctant to use them because of concerns regarding reduction in bone density with DMPA, and depressive symptoms and body weight issues with both injectables and implants. Recent multicenter experience showed no increase in depressive symptoms after 1 year's DMPA use and 2 years' Norplant use, even among users with the highest mean depressive symptom scores pre-therapy. Observational studies indicate that, as with other hormonal contraceptives and hormone replacement, DMPA does not cause significant weight gain, even during long-term use. Multicenter experience with the new soft-tubing Norplant product found an average annual pregnancy rate of <1% and a cumulative 5-year pregnancy rate of 4.2% in women weighing 70 kg or more--substantially lower than failure rates cited in the product labeling. Trends in bone density seen with DMPA appear similar to those during lactation. Subgroups of long-term DMPA users may experience a decrease in spinal bone density that appears to be reversible following discontinuation. A once-a-month injectable contraceptive combining 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate (Cyclo-Provera, Cyclofem or Lunelle), a 2-rod levonorgestrel system, and a single-rod 3-ketodesogestrel implant system may become available in the United States. Large-scale trials have established the safety, efficacy, and acceptability of Cyclo-Provera. In contrast to DMPA, users of Cyclo-Provera experience predictable, regular monthly bleeding, fewer discontinue due to bleeding-related problems. Fertility returns rapidly following discontinuation. A U.S. multicenter study is currently nearing completion.     

Increased sexual risk taking behavior among Swedish female university students: repeated cross-sectional surveys

BACKGROUND: The aim of this study was to perform a repeated cross-sectional study of female university students' sexual and contraceptive behavior, as well as experiences of pornography and sexual harassment and compare the findings with those from earlier studies. METHODS: Waiting-room questionnaires to female university students (n = 315) visiting a Student Health Centre in Sweden. Similar investigations had been performed earlier, which enabled comparisons. RESULTS: Almost all women (98%) had experienced intercourse and giving oral sex (94%). Condoms were most often used at first intercourse (72%) and combined oral contraceptives at latest intercourse (67%). The ever use of emergency contraceptive pills had increased from 22% to 52% over five years and there was a tendency towards more risk-taking behavior with more sexual partners (mean 5.4 in 1999 and mean 7.4 in 2004), more experience of first-date intercourse without a condom (37-45%), and more self-reported sexually transmitted infections (14-21%). The proportion of women who had undergone an abortion remained stable (6%) and fewer women reported ever being sexually harassed in 2004 compared to 1999. CONCLUSIONS: In conclusion, contraceptive use remained stable over time, but there was a trend towards more risky sexual behavior with more sexual partners, more unprotected first-date intercourse, and more self-reported sexually transmitted infections. Induced abortions, however, had not increased, but the use of emergency contraceptive pills had more than doubled in the five years between 1999 and 2004.     

Primary Contraceptive Method use and Sexually Transmitted Infections in a Nationally Representative Sample of Young Women

Study objectiveRates of sexually transmitted infections (STIs) in the United States have increased for the sixth consecutive year. Young people ages 15-24 account for over half of all new infections despite comprising only a quarter of the sexually active population. A potential explanation for this is the increased use of long-acting reversible contraceptives, (LARCs) which could result in lower condom use and/or increased sexual risk-taking due to higher pregnancy prevention efficacy.DesignThis paper uses the National Survey of Family Growth to examine the relationship between primary contraceptive method use among young women ages 15-24 and STI treatment in the past year, as well as the extent to which this association is mediated by relationship status and frequency of condom use.ResultsFindings did not show differences in STI treatment in the past year by primary contraceptive method, indicating that LARC use among young women does not equate to increased STI risk. Findings did show that young women who had been in casual-only relationships or a mix of relationship types in the past year were more likely to have been treated for an STI than young women in serious or dating-only relationships, regardless of the primary method used. Additionally, young women who used condoms “some” of the time were more likely to have been treated for an STI compared with women who used condoms “all” or “most” of the time. This association was mediated by relationship status (P = .05).ConclusionFindings suggest that efforts to address the growing STI burden should be directed at providing comprehensive, gender-equitable sexual health education that enables young people to engage in healthy relationships and consistent condom use.     

Bacterial flora of the cervix in women using different methods of contraception

Bacteriologic culture samples were taken from the cervix in three groups of 10 healthy, sexually active women using barrier contraception, oral contraceptives, or a levonorgestrel-releasing intrauterine contraceptive device. Culture samples for Candida albicans and Trichomonas vaginalis were taken, a cytologic vaginal smear was obtained, and an amine sniff test was performed; these were in addition to a routine gynecologic examination. Multiple bacteria were isolated from the cervix in women using oral contraceptives or an intrauterine contraceptive device, whereas lactobacilli alone dominated the flora of women using barrier contraception. Significantly more anaerobic bacteria were isolated from the cervix in oral contraceptive and intrauterine contraceptive device users when compared with the barrier method users. Symptoms and findings evident of anaerobic vaginosis were associated with the occurrence of anaerobic bacteria in the cervix of three patients using the intrauterine contraceptive device. The results showed that the cervical bacterial flora in sexually active healthy women is rich in anaerobes that can be regarded as a normal finding in women using oral contraceptives or intrauterine contraceptive devices. Barrier contraception with a condom prevents this anaerobic shift and maintains a lactobacilli-dominated flora in the cervix.     

Update on pregnancy, condom use, and prevalence of selected sexually transmitted diseases in adolescents.

Adolescent pregnancy and its consequences continue as major sources of morbidity in the United States. A teenager who becomes a parent is at a significant disadvantage in becoming a contributing adult, both psychosocially and economically. The physician who cares for adolescents has the responsibility of helping parenting teens to find needed support so that they will be able to overcome this significant hurdle. Attention from public agencies has focused on increasing condom use as one approach to adolescent pregnancy prevention. The major advantage of using condoms is that they also prevent transmission of sexually transmitted diseases. Of note is that level of knowledge about condoms is not related to their use, and engaging in high-risk behaviors is related to a decreased likelihood of condom use. With rates of condom use estimated at less than 50%, rates of sexually transmitted disease remain high, as reported in recent surveys.     

Barrier contraceptives

The efficacy and use of barrier contraceptives are discussed in the context of the current need to prescribe 2 methods simultaneously to women who are at risk for both pregnancy and sexually transmitted diseases (STDs). Latex condoms prevent passage of bacteria, chlamydia, and viruses, even the small viruses herpes and HIV. Laboratory tests suggest that use of spermicidal lubricants will kill HIV in the event of condom breakage. With the emergence of HIV, condom use has increased among U.S. homosexual men, resulting in a plateau in HIV infections in that group, but use has not risen among teens, iv drug users or their partners. A female condom, consisting of 2 polyurethane rings in a polyurethane sheath, meant to protect women from STDs more effectively, is being studied. It is now recognized that there is some risk of urinary tract infections (UTI) and a slight risk of toxic shock syndrome associated with use of diaphragms. UTIs may be due to obstructive urethropathy, especially if the diaphragm is too large, or to vaginal colonization with E. coli, resulting from constant exposure to the detergent activity of spermicide. It is recommended that neither diaphragms, sponges nor cervical caps be used during menses to reduce risk of toxic shock syndrome, although the most common spermicide, nonoxynol-9, is reported to kill the causative organism, Staph. aureus. Nonoxynol-9 is bactericidal and virucidal, effective against gonococci, chlamydia and HIV. The FDA has approved octoxynol-9 and menfegol for use in over-the-counter spermicides, but turned down 3 other surfactants and 2 mercurials.     

WHO/CONRAD technical consultation on nonoxynol-9, World Health Organization,Geneva, 9-10 October 2001: summary report

This report summarises the evidence presented to a technical consultation on the safety of N-9 and its effectiveness for protection against pregnancy, sexually transmitted infections and HIV, organized by the World Health Organization Department of Reproductive Health and Research with CONRAD in October 2001. Key conclusions from the meeting include: 1. Although Nonoxynol-9 has been shown to increase the risk of HIV infection when used frequently by women at high risk of infection, it remains a contraceptive option for women at low risk. 2. Nonoxynol-9 offers no protection against sexually transmitted infections such as gonorrhoea or chlamydia. 3. There is no evidence that condoms lubricated with nonoxynol-9 are any more effective in preventing pregnancy or infection than condoms lubricated with silicone, and such condoms should no longer be promoted. However, it is better to use a nonoxynol-9 lubricated condom than no condom at all. 4. Nonoxynol-9 should not be used rectally.     

Characteristics of adolescent women who stop using contraception after use at first sexual intercourse

STUDY OBJECTIVE: Identify correlates of contraceptive discontinuation, which if modified, might make teenagers more, not less, effective contraceptors as they age. SETTING: Teen clinic. PARTICIPANTS: Teenagers who used contraception at first intercourse (N = 120). Some "never" used contraception during the 4 months immediately prior to the survey ("contraceptive stoppers"; n = 38). The others (n = 82) did so "always" or "most of the time" ("consistent contraceptive users"). INTERVENTIONS: Questionnaire responses were used to determine univariate and multivariate associations between contraceptive use group and five categories of factors: inability to plan for sex, belief that pregnancy is unlikely to occur, belief that contraceptives are unsafe, inability to negotiate contraceptive use, and lack of desire to remain non-pregnant. MAIN OUTCOME MEASURE: Odds of being a contraceptive stopper. RESULTS: In univariate analyses contraceptive stoppers scored significantly higher on scales that assessed inability to plan for sex, belief that pregnancy is unlikely, and lack of desire to remain non-pregnant. Contraceptive stoppers were also older and more likely to have been sexually active for at least 6 months. In multivariate analyses, those who were sexually active for at least 6 months (odds ratio [OR]: 2.9, confidence interval [95%CI]: 1.1-7.1), those who believed that pregnancy was unlikely (OR: 3.8; 95% CI: 1.7-8.6), and those who lacked the desire to remain non-pregnant (OR: 2.7; 95% CI: 1.4-5.1) were more likely to stop using contraception. CONCLUSIONS: Our findings suggest that teens who use contraception at coitarche stop doing so as they mature sexually because they begin to doubt the necessity and desirability of using contraceptives. Longitudinal studies are needed to determine if such doubts are preventable and if doing so encourages teens to continue to use contraception.     

Non-oral contraception

Non-oral contraception is increasingly being promoted by contraceptive experts as a more convenient and, in many cases, safer and more efficacious alternative to oral contraception. Injectables, implants and intrauterine methods offer the advantage of being long-acting and less user dependent, factors which may potentially improve contraceptive compliance. Combined contraceptive methods in non-oral delivery forms offer a choice for women who find it difficult to adhere to daily use. The barrier methods, particularly the male and female condoms, offer user-controlled but default-vulnerable protection against sexually transmitted infections.     

Factors influencing women's satisfaction with birth control methods.

OBJECTIVES: To study the extent to which variation in satisfaction with a birth control method is explained by variation in perceived physical and psychological effects. METHODS: A population survey among 1466 German women was carried out. Within the overall sample, 1303 women had ever used oral contraceptives, 996 had relied on condoms, 342 had ever used intrauterine devices (IUD), 428 had used natural family planning and 139 women were sterilized. For each method a woman had ever used, she answered questions about satisfaction with the method, concerns about getting pregnant or suffering health risks during use, ease of use, changes in sexual relationship, relationship with the partner and mood. Past and current users of oral contraceptives and IUDs and sterilized women additionally reported changes in menstrual bleeding. RESULTS: Variation in satisfaction was, for a large part, explained by variation in health concerns among oral contraceptive users, by variation in perceived changes in the quality of the sexual relationship among condom users, by perceived ease of use among IUD users and sterilized women, and by variation in pregnancy concern among natural family planning users. CONCLUSION: Counselling about these perceived experiences is most likely to result in greater satisfaction and therefore improved compliance.