Use of complementary and alternative medicine among women in New York City: a pilot study.

OBJECTIVE: This study documents the use of complementary and alternative medicine (CAM), among White, African American, and Hispanic/Latina women living in New York City. A pilot to a national survey of CAM use among American women, this study explores women's use of categories of CAM and various CAM practitioners, racial and ethnic differences in CAM use, and women's perceptions regarding the effectiveness of CAM. DESIGN AND LOCATION: Data were collected from women residing in New York City using random digit dialing/computer-assisted telephone interviewing (CATI). The sample of 300 had equal numbers of women (n = 100) who self-identified as White, Hispanic/Latina, and African American, equally stratified by age (below and above age 40). SUBJECTS: Eligibility requirements included self-identification as Anglo/white, African American, or Hispanic/Latina and between ages 18 and 80. MEASURES: Three distinct categories of CAM were explored: (1) medicinal teas, homeopathic remedies, herbs, vitamins; (2) yoga, meditation, spiritual practices; and (3) manual therapies including chiropractic, massage, acupressure. Health concerns of interest were those frequently described in prior focus groups, and included reproductive health issues (e.g., pregnancy, menstruation, menopause) as well as other common women's health problems (e.g., heart disease, high blood pressure, headaches). RESULTS: More than half the sample has used a CAM treatment or remedy, and 40% have visited a CAM practitioner. Among users, half have used only one of the CAM categories, approximately one third have used two, and 16% used all three. The category of CAM used most often was medicinal tea/herbs/vitamins; the practitioners visited most frequently were chiropractors (18%) and nutritionists (17%). Racial and ethnic differences in CAM use were minimal, and approximately one third of all treatments used were rated "very effective" by users. CONCLUSIONS: Substantial utilization of CAM remedies and treatments for a variety of women's health concerns is observed. Further inquiry with larger samples of women is recommended.

Potential barriers to the removal of Norplant among family planning clinic patients.

OBJECTIVES: This study examined the prevalence and effects of potential barriers to removal of levonorgestrel implants (Norplant) among low-income women. METHODS: A sample of 687 women who received Norplant at hospital-based family planning clinics were interviewed before Norplant insertion and 6 months after Norplant insertion (or at Norplant removal if removal occurred earlier). Those who continued to use Norplant were reinterviewed at 2 years or at removal. RESULTS: In a multivariate analysis, only 1 of the 4 potential barriers--cost--significantly impeded Norplant discontinuation. CONCLUSIONS: Family planning clinics need to make clear that they follow a policy of Norplant removal on demand, regardless of the patient's ability to pay.

Condom use among women choosing long-term hormonal contraception.

CONTEXT: Women who rely on long-term hormonal contraception may neglect to use condoms, and thus increase their risk of contracting sexually transmitted diseases, including AIDS. METHODS: Data from a prospective, multisite study were collected to examine the probability of condom use among 1,073 new users of either the contraceptive implant or injectable; users were interviewed when they accepted their method and again six months to one year later. Multivariate logistic regression analyses identified factors that significantly predicted the likelihood of dual method use. RESULTS: Condom use dropped markedly among women who adopted long-term hormonal contraception. The proportion who always used condoms in the previous three months fell from 21% at the time of adoption to 11% at follow-up. Among women with one sexual partner, this decrease was from 20% to 10%; however, among those with more than one partner, use increased from 25% to 31%. The factors significantly predicting dual method use included previous condom use (odds ratio of 2.5), receipt of AIDS-specific counseling (odds ratio of 1.6), the perception of being at some risk of AIDS at baseline (odds ratio of 1.4) and having had more than one sexual partner over the study period (odds ratio of 5.4). In addition, injectable users, teenagers and black women were more likely than other women to use condoms with their hormonal method. CONCLUSIONS: Although condom use among all women declined markedly once they initiated long-term hormonal contraception, frequency of condom use varied by subgroup and was associated with several factors. Most importantly, women with more than one sexual partner and those who received a message during counseling on the need to continue using condoms were more likely than others to use condoms in conjunction with the implant or injectable.

PIP: Concerns have been raised that women who use long-term hormonal contraceptive methods to prevent pregnancy will fail to protect themselves from sexually transmitted diseases (STDs), including AIDS, through concomitant condom use. This possibility was investigated in a prospective (1993-94), multi-site US (Pittsburgh, Pennsylvania; Dallas, Texas; and New York, New York) study of 1073 new users of either contraceptive implants or Depo-Provera. The mean age of study participants was 23 years; 63% were Hispanic, 24% Black, and 13% White. Overall, the proportion of women who always used condoms in the previous 3 months dropped from 21% at the time of method initiation to 11% at follow-up 6-12 months after enrollment. However, use increased from 25% to 31% among women with more than 1 sexual partner. Significant predictors of dual method use included previous condom use (odds ratio (OR), 2.5); receipt of AIDS-specific counseling (OR, 1.6); the perception, at baseline, of being at some risk of AIDS (OR, 1.4); and more than 1 sexual partner during the study period (OR, 5.4). In addition, injectable users, teenagers, and Black women were more likely than other women to use condoms with their hormonal method. These findings have important implications for family planning programs, especially the need for counseling on the continued importance of condom use for STD prevention when pregnancy is prevented by non-barrier methods.

Depressive symptoms and Depo-Provera.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptives. Women choosing Depo-Provera (n = 495) were evaluated before starting these contraceptives and were reinterviewed 1 year later. Women who continued the method had lower depressive symptom scores at baseline than did the women who discontinued the method or who were lost to follow-up. Among the continuing Depo-Provera users, the depressive symptom scores improved slightly at 1 year (7.4 vs 6.7). Those subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores at follow-up.

PIP: The product labeling for Depo-Provera cites depression as an infrequent side effect. Previous research on this topic has documented self-reported depression or mood changes in 1-5% of Depo-Provera users. These studies were limited, however, by a lack of measurement of baseline depression. In the present study, 495 new acceptors of Depo-Provera enrolled in a broader prospective cohort study conducted at three US hospitals (Texas, Pennsylvania, New York) were interviewed at enrollment and again after 12 months of use. Included in both the initial and follow-up questionnaires were six questions on depressive symptoms in the past month taken from the Mental Health Inventory. At 12 months, 172 women were still using Depo-Provera, 221 had discontinued the method, and 102 were lost to follow-up. Women who were still using Depo-Provera at 12 months had lower depressive symptom scores at baseline than women who discontinued use or were lost to follow-up. Between baseline and the 12-month follow-up, the mean depression score dropped from 7.4 to 6.7 among continuing users and remained steady at 8.0 among discontinuers. The mean depression score in the quintile of women with the highest depression scores at baseline also decreased after 12 months of use, from 15.4 to 9.5. These results suggest that Depo-Provera use is not likely to exacerbate symptoms in women with pre-existing depression.

Depressive symptoms and Norplant contraceptive implants.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptive implants. Women choosing Norplant implants (n = 910) were evaluated before starting this contraceptive and were reinterviewed at 6 months and 2 years. Women who continued the method had lower depressive symptom scores before initiating Norplant implants than did the women who discontinued the method or who were lost to follow up. Among the continuing Norplant implant users, the mean scores were similar before starting Norplant and at 6 months (7.9 vs 7.7). The strongest overall predictor of the depressive symptom score was relationship satisfaction. At 24 months, the subgroup of continuing users with decreased relationship satisfaction had an increase in depressive symptom score, but those with stable or improved relationships had stable depressive symptom scores. The subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores during follow-up. These results are reassuring for women who are concerned that Norplant use may adversely affect their mood.

PIP: Although depression is cited in the Norplant contraceptive implant product labeling as a rare side effect, previous evaluations of this association have not included baseline measurement of mood. To assess this association more systematically, the present study followed a cohort of 910 new Norplant acceptors recruited from three urban hospitals in the US (Texas, Pennsylvania, New York) for 24 months. Included in both the initial and follow-up questionnaires were six questions drawn from the Mental Health Inventory on depressive symptoms in the past month. At the end of the study period, 293 women were still using Norplant, 295 had discontinued use, and 138 were lost to follow-up. Women who continued with Norplant for 2 years had significantly lower depression scores at baseline than women who discontinued use or were lost to follow-up. Among continuing Norplant users, mean depressive symptom scores were similar before starting Norplant and after 6 months of use (7.9 and 7.7, respectively). The strongest overall predictor of the depression score was relationship satisfaction. At 24 months, the subgroup of continuing users with decreased relationship satisfaction had an increase in depression score, while those with no change or improved relationships had stable scores. The mean depression score of the quintile of women most depressed at enrollment improved during the study period from 15.4 to 11.0, dispelling concerns that Norplant exacerbates pre-existing depression. Only 4.4% of discontinuers cited mood changes as a reason for terminating Norplant use and there were no cases of psychiatric hospitalization. These findings suggest that concern about possible mood changes is not a reason to withhold Norplant.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women.

OBJECTIVES: This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy. METHODS: A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later. RESULTS: The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%. CONCLUSIONS: DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.

Determinants of early implant discontinuation among low-income women.

The determinants of contraceptive implant discontinuation within six months of insertion were examined among 786 low-income women attending family planning clinics in three U.S. cities. The six-month cumulative life-table discontinuation rate was 7.6%. Menstrual side effects were the most common reasons given for early implant removal, although women who discontinued use were no more likely than those who continued with the method to report menstrual irregularities. Women who opted for early removal were more likely than those who continued with the method to experience headaches, hair loss, weight gain and arm infection. Logistic regression analysis indicates that dissatisfaction with prior contraceptive methods, a partner who wants a child within the next two years, perceived pressure from health care providers to choose the implant, exposure to negative media coverage and the number of implant side effects significantly predict early implant discontinuation. Women's social and demographic characteristics, Medicaid status and motivation to avoid an unplanned pregnancy were not significantly related to early removal.

PIP: This study examines early contraceptive implant discontinuation among low-income clinic patients in Dallas, New York, and Pittsburgh and the impact of negative media coverage of Norplant in the press. Interviews were conducted among 786 women during 1993-94 at baseline, prior to insertion, and 6 months later. The explanatory logistic model included sociodemographic characteristics of users, motivation to avoid unintended pregnancy, satisfaction with previous contraceptive methods, and negative media coverage of a method of birth control. The sample population included only 55% who had completed high school, 22% who were currently employed, and 94% with at least one prior pregnancy. 70% had had at least one unintended pregnancy. 29% had experienced two or more unintended pregnancies. 8% had had no live births. 60% of the women were adolescents at the time of their first birth. The cumulative life table 6-month discontinuation rate was 7.6% (58 women out of 786). The removal rate was 1.02 during month 2, 1.55 during month 3, and almost 1.50 during months 4-6. 28% had the implant removed due to menstrual side effects, 19% complained of headaches, and 10% had some arm discomfort. 9% experienced weight changes and early removal. 7% discontinued use due to mood changes, and 5% stated hair loss, chest pains, or negative media reports as the reasons. About 75% of discontinuers and continuers reported side effects due to less regular menstrual periods. Discontinuers were more likely than continuers to report headaches, hair loss, weight gain, and the perception of long-term health problems. Discontinuers were more likely to report arm infection. Among the 33% exposed to intense negative media coverage, only 15% discontinued use. Findings suggest that counselors should explore the fertility desires of a woman and her spouse and refrain from promoting a specific method.

Beliefs about Norplant implants among low income urban women.

This study documents the counseling experiences and beliefs about Norplant implants that are held by an ethnically diverse sample of low income clinic patients in the United States. Virtually all implant acceptors, but only about half of those choosing other contraceptives, receive information about the Norplant system during clinic-based counseling. Exposure to group counseling and to a film regarding Norplant implants are associated with high levels of knowledge among acceptors. Several important patterns emerge in comparing the beliefs of patients choosing the Norplant system with those of patients choosing other methods of birth control. Substantial proportions of the latter group adhere to several inaccurate beliefs about the method, associating its use with: long-term health problems, problems for future babies, future fertility problems, infection, and high cost. These outcomes in particular, as well as several others described, should be systematically addressed and reviewed in contraceptive counseling.

Beliefs about Depo-Provera among three groups of contraceptors.

This article examines the beliefs about Depo-Provera held by three groups of contraceptors utilizing urban family planning clinics in the United States (n = 836). Patients choosing Depo-Provera, oral contraceptives, and Norplant were asked about their beliefs regarding Depo-Provera in the following four domains: effectiveness in preventing pregnancy, convenience, side-effects, and risk to health; and also for their perceptions regarding the physical discomfort and cost associated with the method. Findings reveal that patients choosing the pill and Norplant give Depo-Provera significantly lower ratings for both convenience and effectiveness than do Depo-Provera acceptors. Given the documented effectiveness of Depo-Provera, this is a potential cause for concern. Moreover, Norplant and pill choosers are most likely to hold inaccurate beliefs regarding both the cost of Depo-Provera, and certain side-effects associated with its use. Although more than half of all patients believe the Depo-Provera would cause menstrual changes and weight gain, it is noteworthy that the proportions are not higher, given their known association with the method. Knowledge about the likelihood of these side-effects is essential, particularly for those choosing Depo-Provera. Implications for physicians, counselors, and other family planning professionals are discussed.

Subsequent childbearing among teenage mothers: the determinants of a closely spaced second birth.

Data from the National Longitudinal Survey of Youth reveal that approximately one-quarter of teenage mothers have a second child within 24 months of their first birth. The prevalence of closely spaced second births is greatest (31%) among young women whose first birth occurred prior to age 17. Teenage mothers' characteristics before the first birth (such as race or ethnicity and parents' level of education) and at the time of the first birth (such as years of schooling completed and whether their first birth was wanted) influence whether they have a rapid second birth. For example, those with more educated parents are less likely than others to have had a closely spaced second birth. In addition, young mothers who obtain additional schooling in the period after their first birth are less likely to have a closely spaced second birth, while those who marry are more likely to have a rapid second birth.

Placing an infant for adoption: the experiences of young birthmothers.

This article describes the experiences of 215 young birthmothers who placed their infants for adoption through 30 maternity residences and agencies in 13 states. The prebirth services they received, their immediate postbirth experiences, and several characteristics of their adoption arrangements are described. A bivariate analysis revealed that several service-procedural variables are related to social-psychological outcomes for the birthmothers at six months after the birth. Policy implications are presented.

The determinants of young women's pregnancy-resolution choices.

PIP: A longitudinal study of young women's pregnancy resolution decision making provided evidence of the important role of significant others; also observed was a positive association between prior adoption socialization experiences and the choice of adoption. Conceptual approaches to decision making considered in the analysis included opportunity structures, socialization, social networks, and expectancy value theory. Subjects included 527 unmarried women 21 years of age or younger who were recruited from US maternity residences and prenatal clinics. Mean age was 17 years; 73% of subjects were White. On a descriptive level, the adoption choice was more frequent among White women (55%), and those with above-average educational aspirations (51%). When the subject's mother was in favor of placement, 75% chose adoption and only 18% kept the child; when the boyfriend wanted adoption, these statistics were 82% and 34%, respectively. If the subject or a close relative had been adopted, 59% chose adoption and 39% kept the child. Next, logistic regression was used to develop a multivariate analysis of pregnancy resolution decisions. The most significant (p 0.001) determinants of pregnancy choice were mother wants placement of child, close relative wants placement, and the expectancy that the quality of the mother and child's life would be adversely influenced by keeping the child. Significant at the 0.01 level were not having a boyfriend or having a boyfriend who wants placement. Only 1 demographic variable--women in an age-appropriate grade--was significantly associated with adoption. Since adoption is selected by less than 3% of US women, this outcome was overrepresented in this sample by the inclusion of maternity homes as a recruitment site.^ieng

Adoption versus parenting among young pregnant women.

Three groups of young pregnant women living in maternity residences--those who intended to place their babies for adoption, those who considered adoption but planned to parent and those who never considered adoption--were compared regarding their socioeconomic characteristics, attitudes toward adoption and the personal influences on their decisions. Of the 430 young women, those who intended to place their babies for adoption tended to be at one extreme on most profile variables, those who had considered placing were in an intermediate position, and those who never considered placing their babies were at the other extreme. Placers were both the most advantaged socioeconomically and held the most positive attitudes toward adoption, while young women who never considered adoption were the least advantaged and held the least favorable attitudes. Placers consistently reported that their choice to place their babies rather than parent would increase the likelihood of outcomes such as continuing with school, having enough money to live comfortably and benefiting the baby's emotional development, while those young women who did not consider adoption tended to feel that these outcomes would be more likely if they parented, or that the likelihood of the outcomes would not be affected by their choice. Young women who intended to place their babies were encouraged in that direction by their mothers, fathers and boyfriends, while the two groups of women who chose parenting were encouraged to do so by those in their social networks.

Barriers to prenatal care among low-income women in New York City.

Postpartum in-hospital interviews with 496 low-income women in New York City revealed that attitudinal and motivational barriers as well as financial obstacles are significant impediments to timely initiation of prenatal care. The two most common reasons cited by these women in explaining why they had obtained prenatal care late or not at all were motivational items: "feeling depressed and not up to going for care" and "needing time and energy to deal with other problems." In logistic regression analyses, receipt of late or no prenatal care was significantly associated with the latter motivational barrier, along with the cost of care, having no health insurance, being Hispanic, being a substance abuser and holding negative attitudes toward the use of prenatal care.

PIP: Interviewers questioned 496 low-income black and Hispanic women postpartum in New York City on attitudinal, motivational and financial barriers to prenatal care. Women who had little or no prenatal care were oversampled, so this study is not representative of the New York City population. Oversampling also fixes the distribution of the dependent variable which can bias the regression coefficients unless logistic regression is used. In this study, 54% of the women had received timely prenatal care, while 46% received late or no care. A questionnaire was used with both open-ended and closed questions to determine which barriers to prenatal care were most important. Age was a categorical variable for the descriptive analysis, and a continuous variable for the regression analyses. Health insurance was used as a series of dummy variables. The timely care group ranked depression, lack of energy, travel distance, and transportation problems among the top barriers to prenatal care. The late or no care group ranked lack of energy, depression, cost of care, travel distance, transportation problems, and lack of child care among the top barriers. Those who were most likely to receive timely care were those women with health insurance. Those women with regular doctors were also more likely to receive good prenatal care. Logistic regression according to 2 models showed that late or no prenatal care could be predicted. Lack of health insurance is a major predictor of timely prenatal care. Substance abuse also played an important role in the timeliness of prenatal care. Recommendations are made to reform maternity service financing, and to alleviate substance abuse among pregnant women.

Contraceptive use. A comparison between ever- and never-pregnant adolescents.

There is controversy about how the experience of a teenage pregnancy affects the contraceptive behavior of adolescent women. Data from 425 sexually active, unmarried teenage women who had access to contraception were used to address this issue. Chi-square tests suggest that ever-pregnant teens are significantly less likely to have used contraception at last intercourse than never-pregnant teens. This finding persists when comparing never-pregnant teens to subgroups of ever-pregnant adolescents whose contraceptive behavior was expected to have been affected positively by their pregnancy. Logistic regression results show a significant pregnancy-history effect after controlling for other important predictors of teenage contraceptive behavior. Additional analysis suggests that the negative effect of pregnancy history may occur because ever-pregnant teens hold more positive attitudes about pregnancy than their never-pregnant peers.