Knowledge, attitude and practice of contraceptive methods among women with an unplanned pregnancy

Abstract

Objectives

The study aimed to investigate the knowledge, attitude and practice (KAP) of contraceptive methods among women with an unplanned pregnancy, aiming to improve their reproductive health and increase their understanding of contraceptive methods.

Design

This is a cross-sectional study.

Setting

The study was conducted at the Maternity and Child Healthcare Hospital of Hubei between 20 November 2022 and 20 January 2023.

Participants

Women with an unplanned pregnancy were included.

Primary and secondary outcome measures

The questionnaire was in the Chinese language and included demographic data, KAP assessments. Multivariate linear regression was performed to explore the factors associated with knowledge or practice scores.

Results

During the study period, 510 participants with valid questionnaires were included. The KAP scores were 7.30±2.91, 32.61±3.13 and 28.58±3.59, respectively. Place of residence (urban vs non-urban; B=0.66, 95% CI 0.02 to 1.29, p=0.043) and educational level (master’s degree or above vs post secondary or below; B=1.07, 95% CI 0.17 to 1.96, p=0.020) were positively associated with knowledge. Knowledge (B=0.25, 95% CI 0.17 to 0.32, p<0.001) and attitude (B=0.26, 95% CI 0.19 to 0.32, p<0.001) were positively associated with practice.

Conclusions

This study indicates a low level of KAP regarding contraceptive methods among women facing unplanned pregnancies. Place of residence and educational level were positively associated with knowledge scores. These findings may help improve future sex education policies and programmes.

Correspondence to Dr Dongmei Yao; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Robust methodology: the study’s cross-sectional design, ethical approval and informed consent enhance the reliability of findings.

• Comprehensive questionnaire: carefully crafted and pretested, the questionnaire ensures a thorough assessment, though potential biases may arise from self-reported data.

• Sampling method consideration: while the convenience sampling method was used, it introduces selection bias, limiting generalisability.

• The results may not fully represent women from other regions of the country.

• There may be a bias towards social desirability in the responses to our survey.

Introduction

In recent decades, China has witnessed a prevalent trend of increased sexual activity and premarital cohabitation,¹ resulting in a corresponding surge in unplanned premarital pregnancies.^{2 3} This unprecedented rise has also been linked to difficult access to contraceptives, lack of knowledge on their effective use and low perception of the risk of pregnancy. Further significant challenges in the sexual and reproductive health of Chinese youth also determine unplanned pregnancies. Widespread deficiencies in comprehensive sexuality education contribute to low sexual and reproductive health and rights (SRHR) knowledge, while inadequate access to youth-friendly reproductive health services results in low contraceptive uptake and limited options, particularly for unmarried youth. The fear of judgement and discrimination hinders access to safe abortion services, with reliance on unreliable private clinics.⁴

Despite these changing dynamics, societal norms in China continue to disapprove of childbirth outside of wedlock.⁵ Consequently, a considerable number of premarital pregnancies are addressed through induced abortions.^{6 7} In China, various national policy documents, including the National Program for Women’s Development (2011–2020), Healthy China 2030 and China’s Middle- and Long-Term Youth Development Plan (2016–2025), have prioritised the SRHR of young individuals, with a specific emphasis on preventing unprotected sex and unintended pregnancies. Nevertheless, the current state of young people’s SRHR in China is a cause for concern.⁴

Pregnancy termination, even when performed safely, can inflict physical and psychological distress on women. A nationwide survey in 2019, encompassing 11 076 unmarried Chinese women aged 15–24, reported that the self-reported prevalence of induced abortion was 3.9%, while that of repeated induced abortion was 0.8%.⁸ Other studies also highlight the association between risky sexual behaviour, unplanned pregnancies and repeated abortions among young, unmarried Chinese women.^{9 10} Limited access to reproductive health resources is exacerbated by the slow progression of sexual education in China.^{8 11} The 2009 Survey of Youth Access to Reproductive Health in China underscored that over 50% of young women expressed a desire to learn about reproductive health, including contraceptive methods, safe abortion and treatments for sexually transmitted infections.¹² Thus, improving sexual education programmes and policies in China is urgently needed. A better understanding of the current knowledge, attitudes and practices (KAP) among women with unplanned pregnancies could be of value in increasing the effectiveness of such educational initiatives.

Past research in China has often linked unplanned pregnancies primarily to contraceptive misuse,⁶ overlooking the multifaceted factors contributing to such occurrences. In this cross-sectional study, we used a KAP survey¹³ as a structured quantitative method to analyse to what extent women with unplanned pregnancies are familiar with contraception and what are their attitudes towards contraception. The objective of this research was to comprehensively examine the association between demographic characteristics and unplanned pregnancies, aiming to contribute valuable insights that could enhance the efficacy of sexual education programmes.

Methods

Patient and public involvement

None.

Study design and participants

This cross-sectional study was conducted at the Maternity and Child Healthcare Hospital of Hubei between 20 November 2022 and 20 January 2023. For subject recruitment, the convenience sampling method was used. Participant recruitment involved patients experiencing unplanned pregnancies in both the ward and outpatient department. The inclusion criterion comprised outpatients and inpatients experiencing unplanned pregnancies. Exclusion criteria encompassed women who (1) declined participation in the study and (2) were unable to complete the questionnaire, including those with insufficient writing skills or individuals dealing with mental illness. Some women with unexpected pregnancies, stemming from multiple pregnancies, were categorised as high-risk cases necessitating hospitalisation for surgery. Others with ectopic pregnancies required hospitalisation. These patients were admitted to the hospital for the necessary care.

Questionnaire

Questionnaire Star (Changsha Ranxing Information Technology Co.), a professional online software platform, was employed for crafting and generating questionnaire links in alignment with prevalidated forms.^{14 15} The designed questionnaires were subsequently modified according to the opinions of two senior experts. Additionally, 46 patients were analysed in a pretest, with Cronbach’s α=0.78. The final questionnaire was in Chinese and included four aspects, that is, demographic data (subject age, age at first intercourse, number of unplanned pregnancies, religion, education level, place of residence, income, marital status, prior induced abortion, use of contraceptive methods, and reasons for unplanned pregnancy), as well as KAP assessments. Participation was voluntary, with only willing patients completing the questionnaire, resulting in a 100% response rate.

The knowledge dimension included a total of 13 questions. The answer ‘yes’ to the question number 3 was scored with 1 point, while ‘no’ implicated 0 point; for the other questions, correct answers counted as 1 point, while wrong or unclear responses were counted as 0 point. The score range was 0–13 points. The attitude dimension comprised 9 questions evaluated on the 5-point Likert scale: from very positive (5 points) to very negative (1 point); the score range was 9–45 points. The practice dimension included 8 questions evaluated on a 4-point Likert scale: from always (4 points) to never (1 point); the score range was 8–32 points.

Questionnaire Star distributed the online questionnaires, and the data were collected via WeChat and QQ groups. We obtained the consent of the research subjects before sending the questionnaire, and only those who agreed proceeded with the subsequent survey. To ensure the quality and completeness of the answers, each IP address could be used for submission only once, and all items were compulsorily submitted. Subsequently, an Excel spreadsheet was exported from the Questionnaire Star platform. All questionnaires were checked for completeness, consistency and validity by members of the research team.

Statistical analysis

The SAS software (V.14.0; SAS Institute) was used for statistical analysis. Continuous data with normal distribution were expressed as mean±SD and compared by Student’s t-test or analysis of variance. Data not conforming to normal distribution were expressed as median (range) and compared using Wilcoxon-Mann-Whitney test or Kruskal-Wallis test. Categorical data were expressed as n (%) and compared using the χ² test. We used pathway analysis to evaluate the association between KAP scores. Variables that showed significant differences in the univariate analysis were included in the multivariate linear regression to explore the factors associated with knowledge or practice scores. Two-sided p <0.05 were considered statistically significant.

Results

Demographic characteristics

A total of 512 questionnaires were collected; of them, 2 were excluded due to inconsistency and 510 questionnaires were finally processed. The basic demographic characteristics of the respondents are shown in table 1. Subjects were aged 18–40 years old; almost half of them (49.80 %) were 30–39 years old, followed by those between 23 and 29 years old (29.80%), 18–22 years old (14.22%), and ≥40 years old (6.27%). The age at first intercourse was 21–25 in most cases (44.90%), followed by ≤20 age group (39.61%), and ≥26 age group (15.49%). When asked about the number of unplanned pregnancies, half of the respondents (50.00%) experienced one episode, while 29.02%, 10.78% and 10.20% reported 2, 3 or ≥3, respectively. Religion inquiry showed that a small portion of women were Islamic, Christian or Buddhist (1.57%, 4.90% and 10.00%, respectively), while the majority belonged to other creeds (83.53%). Most respondents lived in urban areas (78.04%) and had a college degree (61.37%). Other educational backgrounds were Master’s degree or above (12.35%) and postsecondary education or below (26.27%). The income level ranged (in yuan/year) from<10 000 (42.94%), 10 000–20 000 (16.86%), 20 000–30 000 (10.78%) and >30 000 (29.42%). Most subjects were married (64.09%), and slightly more than half had undergone an induced abortion (51.96%). As shown in online supplemental figure 1, commonly used contraceptive methods were condoms (66.27%), safe period contraception (21.57%), emergency pills (9.80%), short-acting oral protection (cycle contraceptives) (5.49%) and intrauterine devices (4.71%), while the rest practised coitus interruptus (28.24%). Among the reasons for unplanned pregnancy, the main reason was not taking any birth control measures (42.45%), followed by safe period contraception (17.45%), ineffective use of condoms (16.86%), coitus interruptus (15.49%), missing to take short-acting oral contraceptives (6.47%) and ineffective intrauterine devices (1.37%).

Table 1

Baseline data and knowledge, attitudes and practices scores of respondents

Variables	N (%)	Knowledge score		Attitude score		Practice score
		Mean±SD	P value	Mean±SD	P value	Mean±SD	P value
Total	510	7.30±2.91		32.61±3.14		28.58±3.59
Age (years)			0.488		0.447		0.694
18–22	72 (14.12)	7.64±2.80		32.63±2.67		28.96±3.43
23–29	152 (29.80)	7.07±2.92		32.36±3.08		28.65±3.61
30–39	254 (49.80)	7.30±2.97		32.69±3.31		28.44±3.69
≥40	32 (6.27)	7.59±2.66		33.06±3.00		28.56±3.09
Age at first intercourse (years)			0.382		0.699		0.257
≤20	202 (39.61)	7.53±2.72		32.63±2.97		28.80±3.40
21–25	229 (44.90)	7.24±3.00		32.66±3.13		28.52±3.59
≥26	79 (15.49)	6.87±3.10		32.38±3.56		28.24±4.03
Number of unplanned pregnancies			0.710		0.082		0.391
1	255 (50.00)	7.18±2.90		32.58±3.13		28.43±3.66
2	148 (29.02)	7.41±3.02		32.78±3.23		28.59±3.54
3	55 (10.78)	7.29±2.85		31.84±3.14		28.49±3.57
>3 times	52 (10.20)	7.58±2.77		33.10±2.78		29.40±3.35
Religion			0.088		0.949		0.034
Islamic	8 (1.57)	5.88±4.29		32.00±3.38		26.88±2.53
Christian	25 (4.90)	6.08±3.11		32.32±2.61		26.96±3.54
Buddhist	51 (10.00)	6.82±3.06		32.73±3.16		28.29±4.22
Others	426 (83.53)	7.45±2.83		32.62±3.17		28.75±3.50
Place of residence			0.007		0.436		0.510
Urban	398 (78.04)	7.49±2.82		32.69±3.13		28.61±3.55
Non-urban	112 (21.96)	6.60±3.14		32.32±3.14		28.48±3.74
Educational			0.022		0.688		0.637
Post secondary or below	134 (26.27)	6.69±3.21		32.40±3.06		28.55±3.80
College/university	313 (61.37)	7.42±2.84		32.73±3.19		28.67±3.62
Master’s degree or above	63 (12.35)	8.00±2.36		32.46±3.03		28.24±2.91
Income (CNY)			0.152		0.393		0.512
<10 000	219 (42.94)	7.44±2.75		32.58±3.11		28.62±3.70
10 000–2000	86 (16.86)	7.62±2.87		32.81±3.44		28.84±3.30
20 000–30 000	55 (10.78)	6.36±3.35		32.02±2.93		27.89±3.76
>30 000	150 (29.41)	7.25±2.96		32.75±3.07		28.64±3.52
Marital status			0.431		0.910		0.744
Unmarried	179 (35.10)	7.22±2.80		32.58±2.99		28.66±3.58
Married	331 (64.90)	7.34±2.98		32.63±3.21		28.54±3.60
Prior induced abortion			0.233		0.956		0.327
Yes	265 (51.96)	7.42±2.92		32.56±3.23		28.74±3.56
No	245 (48.04)	7.16±2.90		32.66±3.04		28.41±3.61

Knowledge

In terms of the knowledge dimension, the only demographical features that showed significant differences among respondents were ‘place of residence’ and ‘education’ (both <0.05; table 1). In particular, living in urban areas and having higher educational backgrounds resulted in upper knowledge scores. The respondents’ answers to the pertinent survey are shown in table 2. The question with the highest correct rate was ‘Are you familiar with the function of the male condom?’ (91.60%), and the question with the lowest correct rate was ‘After ejaculation, how long do sperm cells live on average?’ (24.90%). When asked about the side effects of oral contraceptives (online supplemental figure 2), respondents were familiar with weight gain (51.18%), increased risk of thrombosis (25.72%), hepatorenal dysfunction (47.77%), irregular vaginal bleeding (54.90%) and hyperpigmentation (24.93%).

Table 2

Respondents’ knowledge of contraception

Knowledge	N (%)
	Correct	Wrong/unclear
1. After ejaculation, how long do sperm cells live on average?	127 (24.90)	383 (75.10)
2. Have you ever used a condom for contraception?	423 (82.94)	87 (17.06)
3. Are you familiar with the function of the male condom?	371 (91.60)	34 (8.40)
4. If a woman forgets to take the contraceptive pill for 3 days, can she get pregnant?	344 (67.45)	166 (32.55)
5. Is the intra-uterine contraceptive device only suitable for females who have given birth?	139 (27.25)	371 (72.75)
6. Do you think oral contraceptives have side effects?	381 (74.71)	129 (25.29)
8. Do you know what the ‘safe period’ contraception is?	321 (62.94)	189 (37.06)
9. Is the safe period an effective contraceptive method?	325 (63.73)	185 (36.27)
10. Is emergency contraception a regular contraceptive method?	267 (52.35)	243 (47.65)
11. If using emergency contraception 72 hours after intercourse, the contraceptive efficiency will be decreased.	323 (63.33)	187 (36.67)
12. During intercourse, if a female does not have an orgasm, she will not get pregnant.	375 (73.53)	135 (26.47)
13. Is vaginal douching after intercourse an effective female contraceptive?	326 (63.92)	184 (36.08)

Attitude

Most subjects (78.83%) had a non-negative attitude towards premarital sex, and nearly half of the respondents (46.47%) considered that the male partner should be the one using contraceptives (online supplemental figure 3).

Practice

Most assessed practices (online supplemental figure 4) revealed frequent risky behaviour. For instance, affirmative (‘always’ + ‘sometimes’ combined) replies were collected in low percentages for the following practices: ‘I would use contraceptive methods if there is no pregnancy plan’ (11.17%), ‘I would use emergency contraception if I have unprotected sex’ (30.98%), ‘Children are a gift from God, so I prefer not using contraceptive methods’ (33.14%), ‘In order to prevent unplanned pregnancy, I prefer using contraceptive methods’ (13.13%). Moreover, nearly half of the replies were affirmative (‘always’ + ‘sometimes’ combined) to ‘I usually do not use contraceptive methods during the safe period’ (47.05%), ‘I would like to receive education on contraceptive knowledge’ (46.86%) and ‘I would recommend contraceptive methods to a friend if needed’ (45.89%), evidencing poor level again in the practice dimension.

Path analysis and multivariate linear regression

Knowledge had a direct impact on attitude (β=0.34, 95% CI 0.249 to 0.401, p<0.001) and practice (β=0.34, 95% CI 0.262 to 0.432, p<0.001). Attitude had a direct influence on practice (β=0.13, 95% CI 0.071 to 0.225, p=0.002) (figure 1).

Figure 1. Pathway analysis.

Place of residence (urban vs non-urban; B=0.66, 95% CI 0.02 to 1.29, p=0.043) and educational level (master’s degree or above vs post secondary or below; B=1.07, 95% CI 0.17 to 1.96, p=0.020) were positively associated with knowledge scores. The knowledge scores (B=0.25, 95% CI 0.17 to 0.32, p<0.001) and attitude scores (B=0.26, 95% CI 0.19 to 0.32, p<0.001) were positively associated with the practice scores (table 3).

Table 3

Multiple linear regression

	B (95% CI)	P value
Knowledge
Place of residence
Non-urban	Ref.
Urban	0.66 (0.02 to 1.29)	0.043
Education
Post secondary or below	Ref.
College/university	0.56 (−0.05 to 1.17)	0.070
Master’s degree or above	1.07 (0.17 to 1.96)	0.020
Practice
Knowledge score	0.25 (0.17 to 0.32)	<0.001
Attitude score	0.26 (0.19 to 0.32)	<0.001

Discussion

The findings of this study indicate a low level of KAP regarding contraceptive methods among women experiencing unplanned pregnancies. Positive associations were observed between place of residence and educational level with knowledge scores. Furthermore, both knowledge scores and attitude scores demonstrated positive correlations with practice scores. The path analysis conducted in our study revealed a significant and positive influence of knowledge on attitude and practice, respectively. Similar results were found in the path analysis from attitude to practice. These findings may help improve future sex education policies and programmes.

With rising numbers of unplanned pregnancies and abortions in China,¹⁶ it becomes increasingly important to investigate the extent to which women understand contraceptives and how they use them. By elucidating how women experience contraception, our findings may contribute to improving sex education policies and programmes.

Our study revealed that women with higher educational backgrounds and those residing in urban areas exhibited elevated contraceptive knowledge scores in comparison to their counterparts with lower education levels or residing in non-urban settings. This discrepancy may be attributed to the improved access to health literacy associated with prolonged attendance at educational institutions, as well as the greater availability and diversity of schools, public education programmes and medical services in urban regions compared with rural areas.¹⁷ Very recently, three comparable cross-sectional surveys that studied the prevalence of abortion and related factors in women across China during 2016, 2017 and 2021 were analysed.¹⁸ Consistent with the present findings, they concluded that better educational backgrounds are associated with better contraceptive knowledge and practice, including fewer unintended pregnancies and consequent abortions.^{19 20} Kang et al¹⁸ also found a positive connection between higher income and contraceptive knowledge and practice, which was not significant in the present study. However, this discrepancy may be due to the smaller sample size and the fact that we specifically focused on women with ongoing unplanned pregnancies who resided in a specific region.

Kang et al¹⁸ described a majoritarian percentage of women (married and unmarried altogether) taking contraceptive measures, although the numbers differed in magnitude (89.04%; 57.65% in our study). Further nationwide research also found that most Chinese women use birth control.²¹ Nevertheless, in recent years, there has been a decrease in the prevalence of birth control among married women (from 89.1% in 2010 to 80.6% in 2018),¹⁹ and the use of long-acting contraceptives (from 80.0% in 2010 to 63.6% in 2018), in favour of less-effective short-acting ones, which increased from 9.1% in 2010 to 17.0% in 2018.²² On the other hand, a meta-analysis of the ways unmarried Chinese women used contraceptives from 1982 to 2017 showed that only 32.2% of them engaged in birth control, which seems relatively low in the context of increasing rates of premarital sex.³ Scarce use of contraceptives among unmarried women, in contrast to the higher percentages reported for the married, probably reflects their poor reproductive education and lack of access to pertinent counselling. Our results did not reveal significant differences in KAP scores between married and unmarried women, which could be due to differences in population sample size and location between studies. In light of the above, discontinuity and decline in the use of contraceptives may explain the considerable number of women with more than one unplanned pregnancy (50.00%) detected in our study. Furthermore, a percentage of 10.20% have had more than three unplanned pregnancies, which poses a serious attention-calling matter for public healthcare.

Noteworthy, less than half of the assessed women were disposed to learn about birth control (46.86%, considering the ‘always’ and ‘sometimes’ answers altogether). Previous research has also reported non-majoritarian percentages (31.85%) and showed that women who were willing to learn about birth control were more likely to have undergone induced abortions in the past and might long for education to prevent more unplanned pregnancies.¹⁸

The results also showed that most women relied on condoms as contraceptives (66.27%). Condoms have been the preferred method for the unmarried in the last decades (Wang et al, 2019),³ while the most frequently used contraceptives among married women were long-active ones, such as intrauterine devices.²³ Although more than half of the women in our study were married (64.90%), only 4.71% applied intrauterine devices, which could be due to local population characteristics and sample size. In addition, we found an important number of women relying on less effective birth control measures, such as coitus interruptus (28.24%), and safety-period contraception (21.57%), while some did not use contraceptive methods at all (10.00%), as discussed in a previous meta-analysis.³ These findings raised concerns about reproductive health in women of childbearing age, highlighting the need for more sex education programmes and policies for married and unmarried women in China.^{24 25}

With reference to religion and contraception, being a Buddhist or practising a religion other than Islam or the Christian faith was associated with higher contraceptive practice scores. In this regard, data from the Chinese General Social Survey²⁶ showed that religious beliefs had a more significant influence on the fertility preferences of Christians and Muslims (how many children women intend to have), which coincides with our findings of religion influencing practice in reproductive decisions and actions.

While this KAP study provides further insights into sexual and reproductive health among women with unplanned pregnancies in China, the present findings should be interpreted with caution due to some limitations. First, there are some discrepant findings compared with other publications, probably due to differences in sample size and location (local vs nationwide surveys) as this is a single-centre study. Thus, our results may not fully represent women from other regions of the country. Second, as premarital sex remains taboo in China, there may be a bias towards social desirability in the responses to our survey.

Conclusion

The study shed new light on the reality of contraception among unmarried Chinese women with unplanned pregnancies. Nevertheless, greater efforts towards better reproductive education for women of all ages and marital statuses are still needed to contain the high numbers of unplanned pregnancies and abortions across the country. Importantly, new and current educational programmes could be further improved by recognising demographic differences in contraceptive KAP.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s)

Ethics approval

This study obtained ethical approval from the Institutional Review Board of Maternity and Child Healthcare Hospital of Hubei (#2022 IEC 109). Participants gave informed consent to participate in the study before taking part.

Footnote

Contributors BS and JT carried out the studies, participated in collecting data and drafted the manuscript. BS and HZ performed the statistical analysis and participated in its design. BS and DY participated in the acquisition, analysis or interpretation of data and draft the manuscript. All authors read and approved the final manuscript. BS is the guarantor.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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