Abstract
Background: There are relatively few unwanted pregnancies in the Netherlands, as evidenced by low abortion and teenage pregnancy rates. However, even in the Netherlands, one in eight pregnancies end in an induced abortion. Many unwanted pregnancies could have been prevented by better use of reliable contraceptive methods. In this thesis,
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contraceptive behaviour is studied with an emphasis on where the use of contraception goes wrong and the demographic profile of the women who have difficulty to use contraception effectively. In addition, in some of these studies, possible relations with socio-cognitive factors are explored. In a literature review, behavioural problems, their correlates and existing intervention are mapped. Most interventions have very limited effects on behaviour and unwanted pregnancy. The empirical studies aim to increase insight in target populations, behavioural endpoints, and changeable determinants for more effective behaviour change interventions. Methods: One study was based on abortion registration data. All other studies used panel-based internet surveys. Three studies made use of two instances of the nationally representative Sexual Health in the Netherlands Survey. Results: In a study on contraceptive method choice, current method was mostly consistent with what women found important with regard to contraceptive use. In a second study, users of oral contraceptive pills (OCPs) were asked about whether they missed pills. One in five OCP users had missed more than one pill of the same pack during the previous months. Missing OCPs was related to attitudes and self-efficacy with regard to the use of ‘the pill’. Differences between Dutch/Western and non-Western migrant women were mediated by differences in these socio-cognitive factors. In a third study, frequency of skipping the pill-free period among OCP users proved to be very common. Our fourth study investigated whether better knowledge about emergency contraceptive pills (ECPs) was related to intention to use these pills. If women knew that ECPs were available without doctor’s prescription, they were more likely to intend to use them. However, better knowledge of their suboptimal efficacy was related to less intention. In a final study, women from Caribbean descent (Surinam and Netherlands Antilles) are relatively likely to have a first, and even more likely to have a repeat abortion. However, women who had a repeat abortion were more likely to have used any contraception prior to their unwanted pregnancy Discussion: Improving adherence to OCP regimens and promoting extended regimens of OCPs seem to be the most promising behavioural goals, based on these studies. Improved contraceptive method choice and increased ECP use may be less likely to be effective. Improving attitudes and self-efficacy with regard to OCP adherence seems particularly useful. Continuation of a chosen contraceptive method and ending contraceptive non-use have not been studied for this thesis and may be other important targets. Women who undergo an abortion are an important target group, because of the high proportion of repeat procedures. The studies were cross-sectional, retrospective and based on self-report. The representativeness of the samples may be limited. Nevertheless, these studies may help to develop more evidence-based interventions.
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