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Use of ‘dual protection’ and other combinations of contraceptive methods in Australia

Use of ‘dual protection’ and other combinations of contraceptive methods in Australia T his paper examines current contraceptive practices in Australia, paying particular attention to use of condoms with other methods. Although contraceptive practices involving two or more methods have been found to be fairly widespread overseas, more so among the young, studies into contraceptive use in Australia have all concentrated on the main method used. Following its introduction in 1961, the oral contraceptive pill (OCP) was rapidly adopted by Australian women, while the use of other methods, including condoms, declined. The rise in the incidence of HIV/AIDS in Australia after the first cases were reported in 1982 focused attention on the public health implications of contraceptive use, particularly the importance of condom use. Condom use increased. Rising rates of notification of chlamydia and gonorrhoea since the late 1990s have led to a renewed emphasis on condoms. The correct and consistent use of condoms is the only contraceptive method that protects against sexually transmitted infections (STIs) and HIV/AIDS for both men and women. Since the 1980s, pamphlets and teaching on STIs have emphasised the idea of ‘safe sex’, which means that at any time of risk condoms should be used. The Commonwealth Department of Health, HIV/AIDS and family planning organisations have issued authoritative advice on the use of condoms to protect both men and women from the risk of STIs. Restrictions on the advertising and display of condoms have been relaxed and condom vending machines have facilitated easier access. However, since the condom alone is less effective as a contraceptive than hormonal methods and intra uterine devices (IUDs), the twin goals of preventing the spread of STIs and preventing unwanted pregnancy through the simultaneous use of both the pill and the condom (so‐called ‘dual protection’) has been advocated. Dual protection is particularly beneficial for younger adults who are at a greater risk of contracting STIs and of unwanted pregnancy. Methods The data used are from Wave 5 of the Household Income and Labour Dynamics in Australia (HILDA) survey. HILDA is a large‐scale, nationwide, longitudinal survey of the household population funded by the Commonwealth Government's Department of Family, Community Services and Indigenous Affairs. A multi‐stage, cluster sample design was used. Waves have been conducted annually, with Wave 5 in 2005. The section on fertility and family planning forms part of an international survey program co‐ordinated by the United Nations. Of the 3,231 women aged 18‐44 on their last birthday who were interviewed for Wave 5, 31% were excluded from the question on contraceptive use because they were currently pregnant or infertile or they or their partner had been sterilised. Univariate and multivariate analyses of the variation in the proportions were undertaken using the seven most prevalent contraceptive practices between age groups, marital status, parity, education level, whether studying for a bachelor's or higher degree, place of residence, birthplace, and Aboriginal or Torres Strait Islander descent (ATSI). However, due to space limitations only the univariate differences are tabulated. The text highlights only the differences that are significant ( p <0.1) in the multivariate analyses. The distribution of the sample between categories of the explanatory variables is shown in the final column of Table 2 . 2 More widely used combinations of methods by background characteristics for at‐risk a women aged 18‐44. Per cent using combination of methods Pill only Condom only Pill and condom Implant only Injection only IUD only Condom and withdrawal n b Age (years) 18‐24 26.1 10.5 20.9 1.9 2.2 0.1 1.5 737 25‐29 35.1 11.5 12.1 5.8 2.5 1.9 1.9 368 30‐34 28.3 17.5 6.7 3.1 1.9 1.2 1.7 417 35‐39 22.5 17.3 3.3 4.7 2.5 4.4 1.4 365 40‐44 26.1 15.8 1.8 1.5 1.5 3.9 0.9 334 Marital status Never married c 21.0 9.0 17.3 2.0 2.9 0.2 1.1 843 Married 29.6 22.3 5.6 2.6 1.6 3.3 2.1 764 Cohabiting 38.0 11.7 10.7 6.1 1.7 1.7 1.5 461 Formerly married d 19.6 5.2 4.6 3.3 2.0 4.6 0.7 153 Children ever born 0 27.7 11.4 16.2 2.5 1.6 0.4 1.0 1,217 1 26.5 15.5 5.7 2.5 2.2 1.9 1.6 319 2 29.9 18.2 4.3 5.2 3.8 4.7 2.9 446 3 23.9 14.5 5.7 4.4 1.9 3.8 1.9 162 4 or more 19.7 19.7 1.3 2.6 1.3 5.3 0.0 77 Highest level of education Bachelors or above 27.6 16.1 9.9 3.4 1.1 1.9 1.8 629 Year 12 but not bachelors 29.1 13.4 13.9 3.7 1.8 1.5 1.3 794 Below Year 12 25.5 12.6 9.1 2.5 3.3 2.3 1.5 798 Studying for bachelors or above Yes 21.6 13.1 21.2 2.1 1.4 0.7 2.5 285 No 28.3 14.0 9.5 3.3 2.2 2.1 1.4 1,936 Place of residence Major city 26.3 15.1 11.1 2.6 1.7 1.7 1.7 1,512 Regional 29.9 11.5 10.9 4.2 3.0 2.3 0.9 670 Remote 26.3 7.9 7.7 7.9 2.6 5.3 5.3 39 Birthplace Australia 29.1 12.9 12.2 3.2 2.4 1.7 1.5 1,810 MES e 21.6 13.8 8.6 4.3 0.0 5.2 1.7 118 Europe f 23.7 23.7 1.7 3.4 1.7 3.4 1.7 59 Asia g 14.2 22.3 4.1 2.0 0.7 1.4 1.4 150 Other 25.0 14.3 8.3 3.6 1.2 1.2 1.2 84 ATSI h ATSI h 22.5 7.0 7.0 1.4 5.6 1.4 1.4 71 Not ATSI 27.6 14.1 11.1 3.2 2.0 1.9 1.5 2,150 All 27.4 13.9 11.0 3.2 2.1 1.9 1.5 2,221 Notes: (a) Does not exclude women who are not sexually active and women who are currently trying to get pregnant. (b) Nine women currently using contraception did not respond to the question on method use. (c) Never married and not currently cohabiting. (d) Separated or divorced or widowed and not currently cohabiting. (e) Main English‐speaking countries i.e. UK, Ireland, New Zealand, Canada, and USA. (f) Excludes the UK and Ireland. (g) Excludes the Middle East. (h) Aboriginal and Torres Strait Islander. Results Two‐thirds of respondents (66.3%; 95% CI 64.3‐68.2) were currently using a method of contraception (excluding sterilisation) and 85.3% (95% CI 83.8‐86.7) had ever done so. While the use of a single method was the most common, 15.4% of respondents (95% CI 13.9‐16.9) (23.2% of current users 95% CI 21.0‐25.3) reported using two or more methods. The numbers of women using the pill or condoms far exceeded those using other methods. Use of more than one method tended to be much higher among users of the sex‐related methods (condom, withdrawal, rhythm, diaphragm, foams/jellies/creams/suppositories, and emergency contraception) than among users of the ‘medical’ methods (pill, implant, injection, IUD) (see Table 1 ). More than one‐quarter of pill users (28%) were using condoms as well. The condom was also the method that was most frequently combined with all the other main methods. Women who combined the use of condoms with either withdrawal or the rhythm method outnumbered those using either of these methods alone. 1 Use of contraceptive methods by at‐risk a women aged 18‐44 and use of multiple methods. Method % using % of method (95% CI) (n=2,221) b % of method users also using another method (95% CI) % of method users also using a condom (95% CI) Pill 38.8 29.5 28.4 (36.8‐40.9) (26.4‐32.5) (25.4‐31.4) Condom 28.3 50.9 NA (26.4‐30.1) (47.0‐54.8) Implants 3.7 14.6 13.4 (2.9‐4.5) (6.9‐22.3) (6.0‐20.8) Withdrawal 3.2 67.6 46.5 (2.5, 3.9) (56.6, 78.6) (34.8, 58.2) Injections 2.8 24.2 21.0 (2.1‐3.5) (13.4‐34.9) (10.8‐31.2) Rhythm 2.3 69.6 45.1 (safe period) c (1.7‐2.9) (55.8‐81.5) (31.3‐58.9) IUD 2.0 4.6 2.3 (1.4‐2.6) (0.0‐10.8) (0‐6.7) Other d 1.3 65.5 44.8 (0.8‐1.8) (47.9‐83.1) (26.4‐58.9) Any method 66.3 23.2 NA (64.3‐68.2) (21.0‐25.3) Not using 33.7 NA NA (31.9‐35.9) Notes: (a) Does not exclude women who are not sexually active and women who are trying to get pregnant. (b) Nine women currently using contraception did not respond to the question on method use. Multiple responses allowed. (c) Includes Persona. (d) Includes emergency, diaphragm/cervical cap, foam/cream/jelly/suppository and ‘other’. The use of the pill alone was the most widely used contraceptive practice across all subgroups except for the Asia‐born and Europe‐born (see Table 2 ). It was significantly associated with age, marital status, studying and birthplace. The use of the pill only peaked in the 25‐29 age group and was significantly less common among women who were not in unions, students, and migrants. The use of the condom as a single method was significantly higher among women who were in a union and among residents of the major cities. The number of women who combined use of the pill and a condom was only slightly less than the number who used condoms only. In contrast to the use of the pill as a single method, there was a steep reduction in the combined use of pill and condom above age 25. As for the pill only, the combined use of pill and condom was significantly less among migrants than among the Australia‐born, with the Asia‐born and Europe‐born having particularly low levels of use. Students were significantly more likely to use the combination of pill and condom than non‐students. The use of implants alone was significantly higher in the more fertile ages, among unmarried co‐habitors, at parities two and three, and in regional or remote areas. There was significant variation in the use of injections alone by marital status and parity. In contrast to its lower use as a single method, the combined use of the condom and withdrawal was significantly higher in remote areas. It was also significantly greater among students than non‐students. Discussion This study shows that use of the condom with other contraceptive methods is widespread in Australia. Earlier studies of contraceptive use that concentrated on the main methods may thus have under‐reported condom use. A consistent data collection practice that allows the use of multiple methods to be identified is needed for trends in contraceptive use to be assessed. Unlike the wave of HILDA used in this study, in future surveys questions on contraceptive use should seek to identify whether non‐contraceptors are trying to get pregnant or are not at risk due to sexual inactivity. The greater use of the pill and the condom among the young and among students would reflect their being more likely to have changing sexual partners, and the associated greater need to protect against both STIs and unwanted pregnancy. Age‐specific fertility rates for women aged under 25 have continued to decline, in contrast to a small rise in total fertility since 2001. The adoption of a combined use of pill and condom by a substantial number of women in this age range would have contributed to their declining fertility and also to a reported reduction in induced abortion. However, rising rates of chlamydia and gonorrhoea indicate there is still a need for more widespread use of condoms, either as a single method or combined with other methods. High rates of STIs and lower levels of condom use, either alone or in combination, may also be an indication of a greater need for education and access among ATSI. The reported use of injections is low. Research in other countries has suggested that use of this method may be under‐reported because some women use it clandestinely; it is undetectable by partners and others who disapprove of contraceptive use. The newer hormonal IUDs and implants have only become available in the past 10 years. A declining level of IUD use has been reported previously. An apparent small reversal of this trend, shown by this study, may be related to the introduction in 2000 of the new levonorgesterol intrauterine system, which lasts for five years, and its inclusion in the Pharmaceutical Benefits Scheme (PBS) since 2003. The new hormonal implant, which lasts for three years, is also on the PBS. These methods control heavy bleeding. This study shows implants and IUDs are more widely used in regional and remote areas where access to services and supplies is more difficult. The particularly low level of use of condoms as a single method and the greater combined use of condom and withdrawal in these areas may also reflect such supply problems. Family Planning NSW has found that women in remote areas are often prepared to travel long distances to the nearest rural health facility to obtain the longer‐acting methods (Family Planning NSW personal communication). Conclusion Clearly it is no longer sufficient to examine contraceptive practices purely from a fertility viewpoint; it is also necessary to consider the use of condoms as protection against STIs. Education, cultural factors arising from ethnic background, and the nature of sexual and family relationships are important factors in determining contraceptive choices. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Use of ‘dual protection’ and other combinations of contraceptive methods in Australia

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Publisher
Wiley
Copyright
Copyright © 2007 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1753-6405.2007.00145.x
pmid
18081579
Publisher site
See Article on Publisher Site

Abstract

T his paper examines current contraceptive practices in Australia, paying particular attention to use of condoms with other methods. Although contraceptive practices involving two or more methods have been found to be fairly widespread overseas, more so among the young, studies into contraceptive use in Australia have all concentrated on the main method used. Following its introduction in 1961, the oral contraceptive pill (OCP) was rapidly adopted by Australian women, while the use of other methods, including condoms, declined. The rise in the incidence of HIV/AIDS in Australia after the first cases were reported in 1982 focused attention on the public health implications of contraceptive use, particularly the importance of condom use. Condom use increased. Rising rates of notification of chlamydia and gonorrhoea since the late 1990s have led to a renewed emphasis on condoms. The correct and consistent use of condoms is the only contraceptive method that protects against sexually transmitted infections (STIs) and HIV/AIDS for both men and women. Since the 1980s, pamphlets and teaching on STIs have emphasised the idea of ‘safe sex’, which means that at any time of risk condoms should be used. The Commonwealth Department of Health, HIV/AIDS and family planning organisations have issued authoritative advice on the use of condoms to protect both men and women from the risk of STIs. Restrictions on the advertising and display of condoms have been relaxed and condom vending machines have facilitated easier access. However, since the condom alone is less effective as a contraceptive than hormonal methods and intra uterine devices (IUDs), the twin goals of preventing the spread of STIs and preventing unwanted pregnancy through the simultaneous use of both the pill and the condom (so‐called ‘dual protection’) has been advocated. Dual protection is particularly beneficial for younger adults who are at a greater risk of contracting STIs and of unwanted pregnancy. Methods The data used are from Wave 5 of the Household Income and Labour Dynamics in Australia (HILDA) survey. HILDA is a large‐scale, nationwide, longitudinal survey of the household population funded by the Commonwealth Government's Department of Family, Community Services and Indigenous Affairs. A multi‐stage, cluster sample design was used. Waves have been conducted annually, with Wave 5 in 2005. The section on fertility and family planning forms part of an international survey program co‐ordinated by the United Nations. Of the 3,231 women aged 18‐44 on their last birthday who were interviewed for Wave 5, 31% were excluded from the question on contraceptive use because they were currently pregnant or infertile or they or their partner had been sterilised. Univariate and multivariate analyses of the variation in the proportions were undertaken using the seven most prevalent contraceptive practices between age groups, marital status, parity, education level, whether studying for a bachelor's or higher degree, place of residence, birthplace, and Aboriginal or Torres Strait Islander descent (ATSI). However, due to space limitations only the univariate differences are tabulated. The text highlights only the differences that are significant ( p <0.1) in the multivariate analyses. The distribution of the sample between categories of the explanatory variables is shown in the final column of Table 2 . 2 More widely used combinations of methods by background characteristics for at‐risk a women aged 18‐44. Per cent using combination of methods Pill only Condom only Pill and condom Implant only Injection only IUD only Condom and withdrawal n b Age (years) 18‐24 26.1 10.5 20.9 1.9 2.2 0.1 1.5 737 25‐29 35.1 11.5 12.1 5.8 2.5 1.9 1.9 368 30‐34 28.3 17.5 6.7 3.1 1.9 1.2 1.7 417 35‐39 22.5 17.3 3.3 4.7 2.5 4.4 1.4 365 40‐44 26.1 15.8 1.8 1.5 1.5 3.9 0.9 334 Marital status Never married c 21.0 9.0 17.3 2.0 2.9 0.2 1.1 843 Married 29.6 22.3 5.6 2.6 1.6 3.3 2.1 764 Cohabiting 38.0 11.7 10.7 6.1 1.7 1.7 1.5 461 Formerly married d 19.6 5.2 4.6 3.3 2.0 4.6 0.7 153 Children ever born 0 27.7 11.4 16.2 2.5 1.6 0.4 1.0 1,217 1 26.5 15.5 5.7 2.5 2.2 1.9 1.6 319 2 29.9 18.2 4.3 5.2 3.8 4.7 2.9 446 3 23.9 14.5 5.7 4.4 1.9 3.8 1.9 162 4 or more 19.7 19.7 1.3 2.6 1.3 5.3 0.0 77 Highest level of education Bachelors or above 27.6 16.1 9.9 3.4 1.1 1.9 1.8 629 Year 12 but not bachelors 29.1 13.4 13.9 3.7 1.8 1.5 1.3 794 Below Year 12 25.5 12.6 9.1 2.5 3.3 2.3 1.5 798 Studying for bachelors or above Yes 21.6 13.1 21.2 2.1 1.4 0.7 2.5 285 No 28.3 14.0 9.5 3.3 2.2 2.1 1.4 1,936 Place of residence Major city 26.3 15.1 11.1 2.6 1.7 1.7 1.7 1,512 Regional 29.9 11.5 10.9 4.2 3.0 2.3 0.9 670 Remote 26.3 7.9 7.7 7.9 2.6 5.3 5.3 39 Birthplace Australia 29.1 12.9 12.2 3.2 2.4 1.7 1.5 1,810 MES e 21.6 13.8 8.6 4.3 0.0 5.2 1.7 118 Europe f 23.7 23.7 1.7 3.4 1.7 3.4 1.7 59 Asia g 14.2 22.3 4.1 2.0 0.7 1.4 1.4 150 Other 25.0 14.3 8.3 3.6 1.2 1.2 1.2 84 ATSI h ATSI h 22.5 7.0 7.0 1.4 5.6 1.4 1.4 71 Not ATSI 27.6 14.1 11.1 3.2 2.0 1.9 1.5 2,150 All 27.4 13.9 11.0 3.2 2.1 1.9 1.5 2,221 Notes: (a) Does not exclude women who are not sexually active and women who are currently trying to get pregnant. (b) Nine women currently using contraception did not respond to the question on method use. (c) Never married and not currently cohabiting. (d) Separated or divorced or widowed and not currently cohabiting. (e) Main English‐speaking countries i.e. UK, Ireland, New Zealand, Canada, and USA. (f) Excludes the UK and Ireland. (g) Excludes the Middle East. (h) Aboriginal and Torres Strait Islander. Results Two‐thirds of respondents (66.3%; 95% CI 64.3‐68.2) were currently using a method of contraception (excluding sterilisation) and 85.3% (95% CI 83.8‐86.7) had ever done so. While the use of a single method was the most common, 15.4% of respondents (95% CI 13.9‐16.9) (23.2% of current users 95% CI 21.0‐25.3) reported using two or more methods. The numbers of women using the pill or condoms far exceeded those using other methods. Use of more than one method tended to be much higher among users of the sex‐related methods (condom, withdrawal, rhythm, diaphragm, foams/jellies/creams/suppositories, and emergency contraception) than among users of the ‘medical’ methods (pill, implant, injection, IUD) (see Table 1 ). More than one‐quarter of pill users (28%) were using condoms as well. The condom was also the method that was most frequently combined with all the other main methods. Women who combined the use of condoms with either withdrawal or the rhythm method outnumbered those using either of these methods alone. 1 Use of contraceptive methods by at‐risk a women aged 18‐44 and use of multiple methods. Method % using % of method (95% CI) (n=2,221) b % of method users also using another method (95% CI) % of method users also using a condom (95% CI) Pill 38.8 29.5 28.4 (36.8‐40.9) (26.4‐32.5) (25.4‐31.4) Condom 28.3 50.9 NA (26.4‐30.1) (47.0‐54.8) Implants 3.7 14.6 13.4 (2.9‐4.5) (6.9‐22.3) (6.0‐20.8) Withdrawal 3.2 67.6 46.5 (2.5, 3.9) (56.6, 78.6) (34.8, 58.2) Injections 2.8 24.2 21.0 (2.1‐3.5) (13.4‐34.9) (10.8‐31.2) Rhythm 2.3 69.6 45.1 (safe period) c (1.7‐2.9) (55.8‐81.5) (31.3‐58.9) IUD 2.0 4.6 2.3 (1.4‐2.6) (0.0‐10.8) (0‐6.7) Other d 1.3 65.5 44.8 (0.8‐1.8) (47.9‐83.1) (26.4‐58.9) Any method 66.3 23.2 NA (64.3‐68.2) (21.0‐25.3) Not using 33.7 NA NA (31.9‐35.9) Notes: (a) Does not exclude women who are not sexually active and women who are trying to get pregnant. (b) Nine women currently using contraception did not respond to the question on method use. Multiple responses allowed. (c) Includes Persona. (d) Includes emergency, diaphragm/cervical cap, foam/cream/jelly/suppository and ‘other’. The use of the pill alone was the most widely used contraceptive practice across all subgroups except for the Asia‐born and Europe‐born (see Table 2 ). It was significantly associated with age, marital status, studying and birthplace. The use of the pill only peaked in the 25‐29 age group and was significantly less common among women who were not in unions, students, and migrants. The use of the condom as a single method was significantly higher among women who were in a union and among residents of the major cities. The number of women who combined use of the pill and a condom was only slightly less than the number who used condoms only. In contrast to the use of the pill as a single method, there was a steep reduction in the combined use of pill and condom above age 25. As for the pill only, the combined use of pill and condom was significantly less among migrants than among the Australia‐born, with the Asia‐born and Europe‐born having particularly low levels of use. Students were significantly more likely to use the combination of pill and condom than non‐students. The use of implants alone was significantly higher in the more fertile ages, among unmarried co‐habitors, at parities two and three, and in regional or remote areas. There was significant variation in the use of injections alone by marital status and parity. In contrast to its lower use as a single method, the combined use of the condom and withdrawal was significantly higher in remote areas. It was also significantly greater among students than non‐students. Discussion This study shows that use of the condom with other contraceptive methods is widespread in Australia. Earlier studies of contraceptive use that concentrated on the main methods may thus have under‐reported condom use. A consistent data collection practice that allows the use of multiple methods to be identified is needed for trends in contraceptive use to be assessed. Unlike the wave of HILDA used in this study, in future surveys questions on contraceptive use should seek to identify whether non‐contraceptors are trying to get pregnant or are not at risk due to sexual inactivity. The greater use of the pill and the condom among the young and among students would reflect their being more likely to have changing sexual partners, and the associated greater need to protect against both STIs and unwanted pregnancy. Age‐specific fertility rates for women aged under 25 have continued to decline, in contrast to a small rise in total fertility since 2001. The adoption of a combined use of pill and condom by a substantial number of women in this age range would have contributed to their declining fertility and also to a reported reduction in induced abortion. However, rising rates of chlamydia and gonorrhoea indicate there is still a need for more widespread use of condoms, either as a single method or combined with other methods. High rates of STIs and lower levels of condom use, either alone or in combination, may also be an indication of a greater need for education and access among ATSI. The reported use of injections is low. Research in other countries has suggested that use of this method may be under‐reported because some women use it clandestinely; it is undetectable by partners and others who disapprove of contraceptive use. The newer hormonal IUDs and implants have only become available in the past 10 years. A declining level of IUD use has been reported previously. An apparent small reversal of this trend, shown by this study, may be related to the introduction in 2000 of the new levonorgesterol intrauterine system, which lasts for five years, and its inclusion in the Pharmaceutical Benefits Scheme (PBS) since 2003. The new hormonal implant, which lasts for three years, is also on the PBS. These methods control heavy bleeding. This study shows implants and IUDs are more widely used in regional and remote areas where access to services and supplies is more difficult. The particularly low level of use of condoms as a single method and the greater combined use of condom and withdrawal in these areas may also reflect such supply problems. Family Planning NSW has found that women in remote areas are often prepared to travel long distances to the nearest rural health facility to obtain the longer‐acting methods (Family Planning NSW personal communication). Conclusion Clearly it is no longer sufficient to examine contraceptive practices purely from a fertility viewpoint; it is also necessary to consider the use of condoms as protection against STIs. Education, cultural factors arising from ethnic background, and the nature of sexual and family relationships are important factors in determining contraceptive choices.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Dec 1, 2007

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