Areas of Focus
Factors that Influence Contraception, Sexuality and Pregnancy
Postpartum contraception and repeat pregnancy
Contraceptive Acceptability
Pregnancy & Substance abuse
Contraceptive Devices
Reproductive Health Care for Low-income Latina and
African American Women
Systematic Reviews
Approximately 10.3 million women between 15 and 44 years of age in the United States (US) rely on tubal sterilization for contraception, making it the most widely used method of contraception other than oral contraceptives (OCs). Nearly half of all tubal sterilizations in the US are performed postpartum. In general, research on sterilization has focused on rates and predictors of sterilization use and health outcomes after the procedure. Only a handful of investigators have considered those women who request postpartum sterilization but do not undergo the procedure i.e., unfulfilled postpartum sterilization request. From a clinical and public health standpoint, it is important to study unfulfilled postpartum sterilization requests. Women with an unfulfilled postpartum sterilization request will rely on a reversible method of contraception, or obtain sterilization at a later time (interval sterilization), or use no contraceptive method. It is well-documented that contraception can be particularly problematic during the postpartum period (9-12 months) placing some women (low-income women, non-breastfeeding women and adolescents in particular) at risk of early repeat pregnancy. Early repeat pregnancy carries health risks, since birth intervals of less than 18 months are associated with an increased risk of adverse birth outcomes including: low birth weight, preterm births, small for gestational age fetuses, and neonatal and infant mortality. Similarly, women who have medical illnesses or contraindications to pregnancy may be referred for postpartum sterilization yet experience an unfulfilled request. Thus, there are potential personal and public health consequences of unfulfilled postpartum sterilization request. Dr. Gilliam in the Section of Family Planning has conducted studies to advance knowledge on the phenomenon of an unfulfilled postpartum sterilization request and to determine whether this population is vulnerable to early repeat pregnancy and warrants attention by providers. She has studied the incidence of an unfulfilled sterilization request, barriers to sterilization fulfillment and the postpartum course of women at one university hospital through a retrospective chart review and pilot longitudinal study with three cohorts of women: those who never desired a postpartum sterilization, those who desired the postpartum sterilization but did not obtain it, and those who desired the postpartum sterilization and did obtain it. Ultimately, we hope our studies will improve reproductive care for women who request a postpartum sterilization by identifying suggestions for reducing barriers to sterilization and risk of repeat pregnancy in the postpartum period. The following are some highlights of these studies:
- Over a two-year period (2002-2004) 46% (n=327) of women who requested postpartum sterilization did not obtain the procedure prior to discharge.
- Predictors of unfulfilled requests included young age, African American race, request for sterilization early in pregnancy (perhaps reflecting provider recommendation rather than patient choice), and/or having a vaginal versus cesarean delivery
- Not having a valid signed Medicaid consent form prevented 38% of women from obtaining their desired postpartum sterilization. Other barriers to unfulfilled requests were related to health (maternal or infant delivery outcome), the institution/hospital-system (no available operating room, scheduling problems) and personal factors (fear of the procedure, change of mind, desire to delay procedure).
- Unfulfilled sterilizations may also lead to unwanted future pregnancies. Dr. Gilliam et al. found that 18% of women with unfulfilled postpartum sterilizations became pregnant within a year due to contraceptive non-use and discontinuation and/or difficulty obtaining an interval sterilization.
- Gilliam M, Davis SD, Berlin A, Zite NB. A qualitative study of barriers to postpartum sterilization and women's attitudes toward unfulfilled sterilization requests. Contraception 2008; 77: 44-49.
- Zite N, Wuellner S, Gilliam M. Barriers to obtaining a desired postpartum tubal sterilization. Contraception 73 (2006) 404– 407.
- Zite N, Wuellner S, Gilliam M. Failure to Obtain Desired Postpartum Sterilization: Risk and Predictors. Obstet Gynecol. 2005; 105(4):794-79
Factors that Influence Contraception, Sexuality and Pregnancy
Understanding factors that influence contraception, sexuality, and pregnancy among different populations is important for targeting reproductive care programs and services. Faculty and Fellows in the Section of Family Planning Research Program are interested in studying practices, patterns and predictors of contraceptive and sexual behaviors, particularly among adolescents and young adults at risk for unintended pregnancies. We are studying these behaviors using multiple methods, including surveys, focus groups, interviews, and analyses of large, national datasets. In particular, researchers study predictors of timing of sexual initiation and use, non-use, and acceptability of effective short and long-acting methods (e.g., NuvaRing, the intrauterine device) or less effective methods (e.g., coitus interruptus). In addition, we explore knowledge, attitudes, and practices regarding contraception and pregnancy among groups such as Latina adolescents and young adults, college students and women living in underserved areas from the inner city neighborhoods of Chicago to rural communities in Ghana, Africa. Our studies employ multi-system and resilience frameworks such as the ecological model which consider the context in which the sexual or contraceptive behavior occurs. As such, our studies examine the role of personal, cultural, familial, peer, partner, biological, and health care related factors in contraceptive and sexual behaviors or decision-making. Here are some findings from available publications:
Publication |
Main Findings |
Gilliam M, Berlin A, Kozloski M, Hernandez M, Grundy M. Interpersonal and personal factors influencing sexual debut among Mexican-American young women in the US. Journal of Adolescent Health 2007; 41(5):495-503. |
Main findings: Strong family expectations regarding educational attainment, parental messages objecting to premarital sex, resistance to the influence of peers and partners, and a greater sense of personal control over behaviors are positively associated with delay of sexual initiation among Latinas. Greater sense of personal control over these behaviors was the strongest predictor of timing of sexual initiation, suggesting that their own beliefs regarding sexual activity matter more than the influences of peers, partners, and/or their family. Implications: Provides a model that can be used to better understand Latina sexual decision making. Inform future programs for Latinas, as they suggest that increasing girls’ feelings of personal control over decisions regarding sexual debut and helping Latino parents to communicate strong messages about educational achievement, pregnancy, and sexuality may lead to positive health behaviors. |
Gilliam M, Hernandez M. Factors influencing the acceptability of coitus interruptus among Latina teens and young adults. Women and Health 2007; 45(3):65-83 |
Main findings: . Women willing to use withdrawal: were more likely to believe it to be an effective method of contraception, to be married, and to communicate with their partners about sex; had less knowledge of contraception, and; were less likely to have used oral contraceptives. Demonstrates belief in efficacy of withdrawal, lack of knowledge of hormonal contraception and inexperience with hormonal contraception may be key factors related to willingness to use withdrawal among Latinas. withdrawal may be a central method for many Latinas. Implications: Providing effective contraceptive care to Latinas requires a better understanding of current contraceptive practices and barriers to successful contraceptive use. |
Gilliam M, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus group approach. Contraception 2004; 69: 413-418. |
Main findings: Perceptions of side effects as well as personal experience with side effects as reasons for not using or discontinuing the use of contraception. Demonstrated incorrect knowledge about contraception, and tended to value anecdotal information over information from health professionals. Reliance on less-effective methods of contraception. Concern about side effects, fear of health consequences and misinformation barriers to effective contraceptive use in young, low-income Latinas. Implications: Providers caring for this population should address potential concerns about side effects of contraception as well as assess patients’ understanding in light of cultural and language barriers. |
Gilliam M. The role of parents and partners in the pregnancy behaviors of Latina teens. Hispanic Journal of Behavioral Sciences 2007; 29: 50-67. |
Main findings : Open communication with parents is rare, particularly their fathers. Mothers play role in preventing early pregnancy by supporting education over early child-bearing and condemning early sexual activity outside the confines of marriage. Reinforce messages using “scare tactics. Difficulty negotiating condoms. Implications: Research and prevention programs should recognize the social context in which pregnancy prevention and susceptibility occur. |
Gilliam M, Holmquist S, Berlin A. Factors associated with willingness to use the contraceptive vaginal ring. Contraception 2007; 76(1):30-34 . |
Main Findings: Willingness to use the contraceptive vaginal ring is associated with willingness to use the patch, being employed at least 20 hours/wk, acceptability of a monthly contraceptive method and self-insertion, acceptability of feeling the ring during intercourse, and concern over hormonal side effects Implications: Counseling should focus on addressing women’s’ concerns about self-administration and side effects. |
Gilliam M, Warden M, Tapia B. Young Latinas recall primary versus secondary pregnancy: A focus group approach. Journal of Pediatric & Adolescent Gynecology 2004; 17:279-287. |
Main findings: Lack of information and family beliefs prohibitingbirth control and sexual activity contributes to high rates of non use of contraceptives and/or reliance of inconsistent use of less effective methods (condoms, withdrawal). Following pregnancy, participants had greater access to Implications: Different approaches are needed for prevention of the first pregnancy compared to subsequent ones among Latino adolescents and young adults. |
Postpartum contraception and repeat pregnancy
Little is known about the appropriate contraceptive methods to recommend to postpartum women and how women use contraception in the postpartum period. Yet, the postpartum period is a vulnerable time often characterized by chaos and transition. Indeed, studies show that women are often concerned about their ability to use contraception during this period, yet are particularly motivated to avoid repeat pregnancies after recently delivering a child. The inability to use effective contraception in the postpartum period raises the risk of poorly timed or rapid repeat pregnancies which have an increased risk of negative maternal and fetal outcomes. Thus, providing effective, high quality prenatal and postpartum contraceptive counseling can reduce unintended pregnancies, decrease maternal and fetal morbidity and mortality, and can prevent abortions. Similarly, counseling during the prenatal and postpartum period offers the opportunity to reach women who may not normally have access to health care services. The Section conducts studies on postpartum contraception and repeat pregnancy among such vulnerable populations as adolescent mothers of color and women with an unfulfilled sterilization ( women who were unable to have their planned postpartum sterilization procedure) . The Section is also conducting a study on the safety and efficacy of immediate postplacental insertion of the intrauterine device (IUD), i.e. IUD insertion at the time of delivery. Summaries of these studies and any available findings from publications are detailed below:
- The reasons behind lack of contraceptive use among Latinas is complex. As young Latinas are at increased risk of rapid repeat pregnancy, a qualitative study was conducted to understand factors that influence use or non use of contraception among Latina adolescents. This study found that Latina adolescents are motivated to use contraception after pregnancy. During the postpartum period, they have greater access and are more accepting of contraceptive methods. Still, persistent concerns about hormonal side effects and continued desire to use withdrawal increased their risk of repeat pregnancy.
- In a review of medical records at one university setting, we found that approximately half of all women who request postpartum sterilization will not undergo the procedure prior to hospital discharge . 2 Subsequently, using prospective data, we studied the public health and personal consequences of unfulfilled sterilizations. The study found that 18% of women with unfulfilled postpartum sterilizations became pregnant within a year due to contraceptive non-use and discontinuation and difficulty obtaining an interval sterilization. Reasons for unfulfilled sterilization requests included last minute misgivings, maternal medical complications, lack of a valid Medicaid consent form, fear of the procedure, and provider influence. Sense of autonomy regarding sterilization decision-making and ability to obtain interval sterilization or initiate and successfully use reversible contraception influenced subsequent attitudes regarding an unfulfilled request.
- Adolescent mothers of color are at particularly high risk of unintended, rapid repeat pregnancies. In the Postpartum Adolescent Birth Control Study (PABC), we are investigating factors that affect repeat pregnancy among first- time minority youth mothers in the postpartum period. This study looks at how contraceptive behaviors, support systems, partner and family relationships and communication, daily life behaviors, self-esteem and/or depression, and biological factors such as physical changes and degree of physical activity during the postpartum period increase risk of or protect against a repeat pregnancy. Findings from this study are expected to be published next year
- The IUD is an excellent method of contraception and is appealing for use in the post-partum period. Yet, the current standard of care is to wait to insert the IUD until the post-partum check-up or even later. Unfortunately, many women do not return for this visit and therefore do not get the IUD inserted. Immediate postplacental IUD insertion, i.e. insertion of the IUD within 10 minutes of delivery of the placenta, has the potential to address this problem and to increase IUD use in the post-partum period. In the “Post-Cesarean Section IUD (PIXIE) study, we study differences in IUD use, bleeding, quality of life, pregnancy, expulsion and discontinuation rates among women randomly assigned to postplacental IUD insertion versus insertion 4-8 weeks later. This will be the first randomized controlled trial comparing immediate postplacental IUD insertion vs. interval insertion following cesarean delivery. Findings from this study are expected to be published next year.
- Gilliam M, Warden M, Tapia B. Latinas recall primary versus secondary pregnancy: A focus group approach. Journal of Pediatric & Adolescent Gynecology 2004; 17:279-287.
- Gilliam M , Davis S, Berlin A, Zite N. Qualitative Study of Barriers to Postpartum Sterilization and Women’s Attitudes toward Unfulfilled Sterilization Requests. Accepted Contraception August 2007.
- Zite N, Gilliam M. Failure to obtain desired postpartum sterilization: Risks and predictors Obstet Gynecol 2005; 105(4):794-799.
Reproductive Health Care for Low-income Latina and African American Women
Unplanned and unintended pregnancy is of particular concern in adolescents and teenage pregnancy has well documented ramifications. For the adolescent herself, there is a lower chance of completing high school or college and of marrying and staying married. They are also more likely to live in poverty compared to their peers who do not bear children. African American and Latino adolescents typically become sexually active at earlier ages, yet are less likely to use contraception at first intercourse. Subsequently, they are twice as likely as non-Latina white adolescents to experience an unintended pregnancy during adolescence. African American and Latino youth are also at disproportionate risk for sexually transmitted infections (STIs) and HIV. Yet there is a lack of formative research to inform the development of adequate reproductive health education and pregnancy prevention aimed at meeting the unique reproductive health needs of these youth. Our research examines the influence of individual level factors such as age, attitudes, belief and knowledge of contraceptive methods, as well as social, ethnic and cultural factors, on sexual and contraceptive attitudes, behaviors, and decision-making. Summaries of our studies and any available findings from publications are detailed below:
- A series of focus groups with young Latinas: a complex web of social, cultural, gender and language barriers prevent these women from seeking contraception and reproductive health care. Many women stated they were unable to communicate with partners, parents or school officials about sex, sexuality and contraception and that all of these subjects were considered taboo. Yet, they also felt social and even family pressure to become sexually attractive but were inadequately prepared for these experiences. Many women felt they held a very low social position in their families and in society in general and that that having children was a way to get out of their households and to "grow up". Most stated they were not expected to get an education, but wanted their own daughters to be educated and to have a life different than their own. They also felt violence and violence against women was too accepted in their neighborhoods and households. Many talked about wanting to communicate with their partners so that they would not experience the violence that their mothers or older sisters had faced. Women related this powerlessness as another reason that family planning was so difficult. Yet, if felt that if they refused to have sex or become pregnant they would lose their man.
- To better understand factors influencing the delay of sexual intercourse among Latina adolescents, we conducted a survey of 271 Mexican American women aged 17 to 25 years. We found that personal, family and peer/partner related factors influence the sexual decision-making of these young women. Strong family expectations regarding educational attainment and negative parental messages towards sexuality, resistance to the influence of peers and partners, greater sense of personal control over behaviors, preference to speak Spanish, and small age difference between the young woman and her first sexual partner were all positively associated with delay of sexual initiation. Among these, greater sense of personal control over behaviors is the strongest factor influencing delay of sexual initiation.
- Techniques used by providers in neighborhood clinics may provide important insights for providing reproductive health care to low income, African American youth. We conducted focus groups with providers at two clinics serving a predominately low-income, African American clientele. We found that these providers used a number of tactics in order to address the reproductive health needs of African American youth. Clinic employees worked collectively to care for patients and to forge strong relationships with teens through the use of language, shared background experiences, honesty and spending extra time with youth, with all staff members, both professional and clerical, contributing to the provider-patient relationship. Providers sought unique opportunities for contraceptive counseling, even attempting to reach males outside of clinic.
- There is also limited knowledge about reasons for repeat pregnancies among teenagers and few interventions designed to prevent subsequent teen pregnancies have been successful. In our current Postpartum Adolescent Birth Control Study (PABC), we are investigating factors that affect repeat pregnancy among first- time minority youth mothers in the postpartum period and how contraceptive behaviors, support systems, partner and family relationships and communication, daily life behaviors, self-esteem and/or depression, and biological factors influence repeat pregnancy. Findings from this study are expected to be published late this year.
- Gilliam M , Knight S, McCarthy M. Importance and knowledge of oral contraceptives in antepartum, low income African Americans. Journal of Pediatric & Adolescent Gynecology 2003; 16:355-360.
- Gilliam M, Tapia B, Goldstein C. Increasing contraceptive use among sexually active Latinas: evaluation of a self-efficacy enhancing videotape. Hispanic Health Care International 2003; 2:63-72.
- Gilliam M, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus group approach. Contraception 2004; 69: 413-418.
- Gilliam M, Warden M, Tapia B. Latinas recall primary versus secondary pregnancy: A focus group approach. Journal of Pediatric & Adolescent Gynecology 2004; 17:279-287.
- Gilliam M. The role of parents and partners in the pregnancy behaviors of Latina teens. Hispanic Journal of Behavioral Sciences 2007; 29: 50-67.
- Gilliam M , Hernandez M. Providing Contraceptive Care to Low-Income, African American Teens: The Experience of Urban Community Health Centers. Journal of Community Health 2007;32(4):231-244.
- Gilliam M, Warden M, Tapia B. Latinas recall primary versus secondary pregnancy: A focus group approach. Journal of Pediatric & Adolescent Gynecology 2004; 17:279-287.
- Gilliam M , Berlin A, Kozloski M, Hernandez M, Grundy M. Interpersonal and personal factors influencing sexual debut among Mexican-American young women in the US. Journal of Adolescent Health 2007; 41(5):495-503.
- Four main patterns of EC use emerged. Participants reported using EC as a result of condom failures (i.e., breakage or slippage). A significant minority used EC in conjunction with a regular hormonal method to be certain they would not become pregnant (i.e., when initiating pill use or taking an antibiotic). Conversely, a number of women reported using EC after unprotected sex. Commonly, women had discontinued hormonal contraception at the end of a relationship or during periods of sexual inactivity and found themselves unprotected during a casual encounter or when sexual relations resumed. Finally, a significant number of women relied on EC in conjunction with intentional nonuse of contraception or when using withdrawal. Such women expressed concern with long-term hormonal contraception, disliked condoms, and/or experienced difficulty negotiating condom or withdrawal use with their partner.
- While the majority of women interviewed stated that they would use the method again in an appropriate situation and would recommend EC to a friend, many participants equated their need to use EC with irresponsible behavior (especially first or one time users).
- Many participants stated that when they first heard about EC they thought it was a good thing, but did not view it as something they would ever need to use. Consequently many participants were not sure exactly what EC was or how it worked at the time of initial use.
- Women with limited initial knowledge of EC appeared likely to have a more difficult time accessing and paying for EC (i.e., relied on accessing it from the emergency room because they did not know where else to get it or because they were uncertain of time frame for taking EC).
- Gilliam M. Emergency contraception: politics and science move forward. Obstetrics and Gynecology 2006; 108:1060-1061.
Qualitative Research: Unlike quantitative research, which seeks to convert human phenomena into numeric or statistical data, the aim of qualitative research is to gain in-depth an understanding of the nuances of human behaviors, attitudes, and experience. Qualitative research methods are particularly useful in developing research hypotheses, conceptualizations, and working-theories about previously understudied phenomenon. In our own research, we often utilize qualitative methods, such as in-depth interviews and focus groups, to gather rich data on the contraceptive and family planning attitudes and behaviors of various populations of women, men, and youth. This approach allows us to gather insights into the myriad of personal, cultural, social, and systemic factors that may affect contraceptive use and outcomes and to explore more fully the meaning of various phenomenon from the perspective of the individual themselves. Below are summaries of some of the qualitative research projects we are currently working on or have conducted in the past:
- In our current longitudinal, Postpartum Adolescent Birth Control Study (PABC), we have conducted over 100 in-depth interviews with first-time teen moms in order to explore the utility of a biopsychosocial model in examining the ecological, biological, daily life and psychosocial factors that may influence the risk of repeat pregnancy among Latina and African American adolescents. Thus far, these interviews have provided great insight into the natural history of adolescent sexual and contraceptive behavior in the first postpartum year, among two major groups at especially high risk of having a second or higher order unintended birth while teenagers: low-income African American and Latina adolescent girls. Data gathered from these interviews will be used to inform the development of culturally and socially relevant educational and intervention programs aimed at reducing repeat pregnancy in these two populations of youth.
- In our study of Contraception and Family Planning in Minority Adolescent Men and Women we conducted a total of 33 focus groups with African American and Latino male and female teens, mothers, and fathers and community health care providers. Choosing f ocus groups as a mode of data collection for this study allowed us to gain insight into the contraceptive and reproductive health attitudes and behaviors of African American and Latino youth, to further our understanding of how other community members, such as peers, sexual partners, parents, and health care providers influence these attitudes and behaviors, and to generate hypotheses regarding the delivery of effective interventions and contraceptive care aimed at reducing rates of unintended pregnancy among African American and Latino teens.
- In a longitudinal study of Postpartum Sterilization, we followed a cohort of low-income, minority mothers prospectively for one year to assess the personal and public health consequences of not obtaining a desired postpartum sterilization. The qualitative data we collected from over 100 postpartum women, allowed us to better understand why some women request but do not obtain postpartum sterilization and what happens to women who do not obtain a requested procedure. We hope that this qualitative research will improve prenatal contraceptive counseling and postpartum contraceptive care for women at high risk for unintended pregnancies.
- In our study of Contraceptive Use in Young Latinas , we began by conducting seven focus groups to determine questions most relevant to the personal experience of young Latina women regarding their use of contraception and family planning. The young women who participated in our focus groups shed light on the salient factors that influenced their personal contraceptive attitudes and use. From this data we were able to develop a conceptual model of contraceptive decision-making among young Latina women, which was then used to develop quantitative survey instrument based on the relevant domains. The survey was pre-tested and then administered to 270 Latina between the ages of 17 and 25.
- In order to inform future educational initiatives and promotion of EC as a method of preventing unintended pregnancy and abortion, we performed a qualitative study tiled, Conceptualizing Emergency Contraception: An In-depth Interview study, looking at how personal characteristics, knowledge, attitudes and decision-making affect a woman’s choice to use EC. These interviews shed light on how and why women use EC and the influence of male partners, previous contraceptive use, and family planning attitudes on their decision to obtain and use EC.
- Gilliam M, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus group approach. Contraception 2004; 69: 413-418.
- Gilliam M, Warden M, Tapia B. Latinas recall primary versus secondary pregnancy: A focus group approach. Journal of Pediatric & Adolescent Gynecology 2004; 17:279-287.
- Gilliam M. The role of parents and partners in the pregnancy behaviors of Latina teens. Hispanic Journal of Behavioral Sciences 2007; 29: 50-67.
- Gilliam M, Hernandez M. Providing Contraceptive Care to Low-Income, African American Teens: The Experience of Urban Community Health Centers. Journal of Community Health 2007;32(4):231-244.
- Gilliam M, Davis S, Berlin A, Zite N. Qualitative Study of Barriers to Postpartum Sterilization and Women’s Attitudes toward Unfulfilled Sterilization Requests. Accepted Contraception August 2007.
