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Does ambivalence about becoming pregnant explain social class differentials in use of contraception?

Richard Layte, Hannah McGee, Kay Rundle, Collette Leigh
DOI: http://dx.doi.org/10.1093/eurpub/ckl263 477-482 First published online: 21 December 2006

Abstract

Background: Manual social class background has consistently been associated with markers of poorer sexual health. This study of adults examines contraceptive use across social classes and the role of ambiguity towards pregnancy in non-use. Method: A nationally representative sample of Irish men and women aged 18–45 years were surveyed (n = 3317). Use of contraception in the last year and at the last occasion of vaginal sexual intercourse was queried. Reasons for non-use were examined. Results: The consistency of contraceptive use in the last year was higher among women than men with lower use in unskilled manual social classes for both sexes. ‘Not having planned for sex’ was the most commonly cited reason for non-use (47% of men and 40% of women). ‘Not caring if pregnancy occurred’ was cited by 11% of women and 12% of men, while ‘took a chance’ was cited by 8% of both men and women. Results showed semi and unskilled manual women more likely to report that sex was unplanned or that they ‘took a chance’. Among men, all other classes were more likely to report each of the ambivalence statements than the professional and managerial class. Conclusions: The study provides evidence of social class differentials in use of contraception among adults, and shows that these may be due, in part, to higher levels of ambivalence about pregnancy among working class women. The article adds to the socio-demographic literature on class differentials in unwanted pregnancy and extends research on adolescents to cover patterns for adult women and men.

  • contraception
  • fatalism
  • pregnancy ambivalence
  • social class

Introduction

There is now a large body of research that examines the relationship between education, social class, early sexual initiation and use of contraception in Europe and the US.1 It is now well established that manual working class background and low levels of parental education are associated with an earlier age of first sexual intercourse.2–4 Research has shown that social background is also associated with a lower likelihood of using contraception at first and subsequent vaginal intercourse.3,5 The importance attached to sexual behaviour among young people is understandable, given the high rates of births to young women in some countries (notably the UK and the US) and the negative impact that early childbirth has on young women.6

Research on the relationship between education or social class and contraceptive use among the adult population is far less developed, but no less important. Childbirth can have serious consequences for the psychological well-being and life chances of women and their families if their economic, social or familial circumstances are challenging. Research has shown, for example, that the risks of poverty and deprivation increase substantially on the birth of any child but particularly a third or subsequent child among those who are already disadvantaged in terms of education or social class position.7 It is important to assess whether the class differentials found in research on adolescents are also found among adults, and that is the primary aim of this study. This article also provides insight into the processes that lead to class differentials in the use of contraception.

Research8 has examined women's use of and understanding of terms such as ‘planned’ or ‘unplanned’ pregnancy. This suggests that the term planned is only applicable if four main conditions are met: the woman has an intention to become pregnant; she has deliberately stopped using contraception; there is agreement between the partners and the couple are at the ‘right’ stage in their lives.8 Other research has identified wide-ranging definitions and understandings of the terms ‘intending’, ‘planning’ and ‘wanting’ among pregnant women.9–11 This ambiguity around pregnancy intentions may be one reason why some men and women may outwardly state that they do not wish to have a child and yet not take the contraceptive steps necessary to ensure that a pregnancy does not occur. Research has also identified a number of other reasons why contraception is not used including forgetting to use, having consumed alcohol and a lack of available contraception.12,13

The question remains, however, as to why differences in levels of ambiguity would emerge between social class groups. None of the literature just listed has examined this issue. It is perfectly possible that social class groups will differ in the proportion wishing to conceive and thus not using contraception. From a rationalistic perspective, children may present a higher economic and career ‘cost’ to women in higher occupational positions, and this alone could mean that these women are more likely to ensure contraception is used. However, it may also be that having a child or additional children is more attractive (or at least less punitive) to working class women because motherhood offers a more attractive role for these women than low waged unskilled paid work. We hypothesized that even among those women who state that they do not wish to become pregnant, ambiguity of intention means that a proportion will nonetheless not ensure that contraception is used and that this proportion will be higher among those in unskilled manual social class positions for whom occupational possibilities are limited due to low education and levels of skill. Research has shown, for instance,14 that working class women tend to have more children than they would ideally like, whereas middle class women tend to have fewer. It is less easy to see why opportunity costs would be a factor in the decisions of working class men who would not experience pregnancy and who are unlikely to leave the workforce.

However, other explanations for class differentials in behaviour have been put forward that focus on class differences in self-efficacy and levels of fatalism. The concept of self-efficacy is now well established in the health psychology literature.15 It is typically defined as an overall sense of control taking account of both personal resources and perceived barriers.15,16 Modern social class theory17 has focused on employment relations and, specifically, the autonomy and control enjoyed by different occupations, as a defining characteristic of different social class positions. In the Erikson and Goldthorpe (EG) class schema,18 and subsequent schemas derived from this, the level of autonomy and the higher level of recompense received by an individual are the main differences between the ‘salariat’ or professional and managerial positions and those employed in manual working class positions on ‘labour’ contracts. Research by Melvin Kohn19,20 has long established that differences in the lived experience of being working class and particularly decreased personal autonomy, leads to lower levels of self-efficacy, and this factor has been consistently shown to be an important factor in determining a range of health related outcomes.21

It may be then that the higher levels of ambiguity in relation to pregnancy displayed by working class men and women is in fact the result of higher levels of fatalism about the future rather than a rational response to economic costs and benefits. From this perspective, lack of planning and increased risk taking are a consequence of a type of ‘voluntary irrationality’22 where individuals exercise restricted rationality because of learnt differences in self-efficacy.

Measuring pregnancy intentions and level of ambiguity around these intentions is problematic. The data used here were derived from a social survey that questioned respondents about their use of contraception and their reasons for non-use. Individuals may not fully recognize their own ambiguity and may give other rationalizations for their non-use of contraception. After examining the class patterning of contraceptive use among adults, this study focuses on whether explanations signalling ambivalence towards pregnancy were also present among adults by analysing the reasons given by respondents for not using contraception and whether these provide evidence of class difference. If working class and particularly unskilled manual working class individuals are more ambivalent about conceiving, we should see a higher proportion of these groups reporting reasons that are congruent with a hypothesis of ambivalence.

Methods

Irish Contraception and Crisis Pregnancy study (ICCP) was carried out in 2003 with the aim of providing nationally representative data on current attitudes, knowledge and experience of contraception, crisis pregnancy and related services among those aged 18–45 years in the Republic of Ireland. Telephone interviewing was selected as the preferred method of data collection as this has proved effective for gathering information on sensitive subjects both in Ireland and further afield.23,24 The sample for the survey was based on a single interview within private, non-institutional households, and drawn using a two-stage process. In the first stage, a sample frame of telephone number ‘stems’ representing local dialling codes was stratified at district electoral register level (DED) and a random selection drawn. In the second stage, the ‘hundreds bank’ method was then used whereby local telephone numbers are generated and the last two digits varied to create a set of numbers between zero and one hundred. Such random digit dialling allows contact with ex-directory and new numbers not yet listed in telephone directories.

Overall, 32 150 unique landline telephone numbers were called yielding 3317 full interviews (1356 men and 1961 women) with an overall response rate of 63.8%. This is a very satisfactory response rate given the sensitive nature of the subject matter and similar in level to that achieved in the British NATSAL surveys (1990 and 2000), which investigated sexual knowledge, attitudes and behaviours.25 The response rate was achieved using multiple strategies to facilitate participation including a ‘conversion call’ procedure for initial refusals. Twenty one percent of first time refusals opted to participate on a second invitation. While the increasing penetration of mobile phones raises the concern that samples drawn using landlines alone may be unrepresentative, a large study (the Survey of Income and Living Conditions (SILC) carried out face-to-face in the same year among 14 000 respondents) showed that 92% of the Irish adult population lived in a household with a landline. In tandem, the sample profile was found to be highly representative of the national population when compared with Census data. In addition, statistical weighting (using a minimum distance algorithm) was used to adjust for sample error.

Social Class

Social class was measured by combining information reported by respondents on their own occupation and that of the ‘primary earner’ in the household. Information on occupation was used to construct the Irish Central Statistics Office's measure of social class that differentiates between: higher professionals and managers; lower professionals and managers; other non-manual; skilled manual; semi-skilled manual; and unskilled manual. In analyses, the higher and lower professionals and managers were combined into one social class group as were the unskilled and semi-skilled groups. The social class position of the respondent and the ‘primary earner’ in the household were computed individually and a ‘dominance’ procedure (i.e. the highest social class assuming order stated earlier) used to establish the household social class position.

Contraception

The ICCP questionnaire asked respondents who stated that they had ever had vaginal sex about use of contraception both in the last year and at the last occasion of vaginal sexual intercourse. Contraception in the last year was assessed by asking respondents which, if any contraception had been used in the last year with one option being ‘none’. A second question then assessed the consistency of contraceptive use with outcome categories: always, mostly, sometimes, rarely and never. For descriptive analyses, the categories of mostly, sometimes and rarely were combined into a single ‘inconsistent’ category (producing three categories ‘never’, ‘inconsistent’ and ‘always’), but five categories were retained within multivariate analyses. A third question on contraceptive use at the most recent occasion of vaginal sex was also used.

Reasons for Non-use of Contraception

After each of the sections on use of contraception in the last year and last occasion of vaginal sex, those respondents who either did not use, or had inconsistent use in the last year, were given 11 precoded reasons why they may not have used contraception:

  1. Against my beliefs/religion to use contraception

  2. Don't like contraception/methods unsatisfactory

  3. Partner doesn't like/won't use contraception

  4. Not my responsibility

  5. I/partner forgets to take the contraceptive pill

  6. Difficult to discuss contraception with my partner

  7. Drinking alcohol/taking drugs

  8. Didn't/don't care if pregnancy happens

  9. Sex was not planned or was unexpected

  10. Can't get contraception services

  11. I/we took a chance

Respondents could select multiple reasons as to why they did not use contraception if they wished. It would be possible to analyse the class distributions of all these rationalizations, but as we are seeking to test a hypothesis about ambivalence, it is more efficient to select only those that could be regarded as providing evidence of ‘ambivalence’ towards conception. Three stand out:

  • Didn't/don't care if pregnancy happens

  • Sex was not planned or was unexpected

  • I/we took a chance.

We would accept that the second of these rationalizations provides less clear-cut evidence of ambivalence, but it could be argued that going ahead with sex in the absence of contraception because of lack of planning shows a certain disregard for possible conception. Given this, we retain this rationalization in the analyses to come.

Age and Relationship Status

Although those respondents who are infertile, trying to become pregnant or already pregnant are excluded from the analysis, it is still likely that use of protection is still strongly related to age and relationship status, and these may confound the social class relationship. To guard against these two variables representing age group (18–25, 26–35, 36–45) and relationship status (married, cohabiting, steady relationship, casual relationship and not in a relationship) are entered into the analyses.

Analyses

Ordered logistic regression was used to assess the consistency of contraceptive use in the last year. Ordered logistic regression estimates the influence of a set of covariates on the probability of being at a given or higher point on an ordinal variable. Logistic regression analysis was used to assess the effects of social class on use of contraception in the last year and at last event controlling for the respondent's age and marital status. Logistic regression was also used to estimate the independent effect of social class on the probability of volunteering specific reasons for non-use or inconsistent use of contraception.

Results

Social Class and Contraceptive Use in the Last Year

In all analyses, individuals who reported that they were pregnant, trying to become pregnant or not at risk of pregnancy (either through infertility or menopause) were deleted from the analysis. The consistency of contraceptive use in the last year was found to be higher among women than men (table 1) with 87% of women always using contraception in the last year compared with 76% of men. This difference between the sexes was largely related to the higher proportion of men reporting inconsistent use. Semi and unskilled manual groups were less likely than other social classes to always use contraception. Specifically, whereas 76% of professional and managerial men ‘always’ used contraception, this was true of 70% of the semi-skilled and unskilled men. Among women the difference between the classes was greater with 91% of professional and managerial women using contraception compared with 81% of the semi-skilled and unskilled women.

View this table:
Table 1

The association between consistency of contraceptive use in the last year and social class by sex (for those having vaginal sex in the last year)

NeverInconsistentAlwaysn (unweighted)
Men
    Professional and managerial1.622.675.8383
    Other non-manual1.717.480.9152
    Skilled Manual0.223.776.1205
    Semi and unskilled manual3.826.070.2158
    All1.722.875.5898
Women
    Professional and managerial1.27.591.3565
    Other non-manual4.710.484.9266
    Skilled manual1.97.990.2197
    Semi and unskilled manual2.616.381.1262
    All2.610.487.11290

However, an ordered logistic model using five categories from always to never (table 2) shows that controlling for age and marital status, none of the class categories was significantly different from the professional and managerial category among men. Among women on the other hand, semi and unskilled manual women were 50% less likely to have consistently used contraception than women in the professional and managerial class.

View this table:
Table 2

Ordered logistic regression analysis of the consistency of contraceptive use in the last year

ORP95% CI
Men (n = 898)
Aged 18–251.00
Aged 26–351.110.6040.75–1.63
Aged 36–451.540.0980.92–2.56
Married1.00
Cohabiting1.090.7940.56–2.15
Steady relationship0.820.4850.47–1.43
Casual relationship0.450.0070.25–0.80
Not in a relationship0.34<0.0010.21–0.54
Professional and managerial1.00
Other non-manual1.400.1850.85–2.31
Skilled manual1.220.3430.81–1.82
Semi and unskilled manual0.800.2880.53–1.21
Women (n = 1290)
Aged 18–251.00
Aged 26–351.940.0041.23–3.05
Aged 36–452.90<0.0011.63–5.16
Married1.00
Cohabiting3.150.0071.38–7.20
Steady relationship1.250.4490.70–2.24
Casual relationship0.750.4250.38–1.51
Not in a relationship1.040.8790.60–1.82
Professional and Managerial1.00
Other non-manual0.660.0790.42–1.05
Skilled manual0.720.2820.39–1.31
Semi and unskilled manual0.500.0020.32–0.77

Social Class and Contraceptive Use at Last Occasion of Vaginal Intercourse

Analyses of the association between social class position and non-use of contraception at the last occasion of vaginal sex show that a smaller proportion of women than men were likely to report non-use of contraception on an event specific basis with 17% of men reporting non-use at the last event compared with 12% of women. Among men, the contrast was largely between the manual and non-manual classes with the professional and managerial class least likely (13%) to report non-use of contraception. Among women, 11% of professional and managerial women reported not using contraception at the last event compared with 12% of skilled manual women and 16% of semi and unskilled social class women.

Although logistic regression (table 3) shows all other classes to be more likely to report non-use of contraception when compared with the professional and managerial class, only the parameter for the skilled manual was statistically significant among men. Among women there was a significantly higher likelihood of non-use of protection among semi and unskilled women. These women were almost twice as likely as those in the professional and managerial social class to not use contraception at the last event.

View this table:
Table 3

Multiple logistic regression analysis of the probability of non-use of contraception at last vaginal intercourse (of those at risk of pregnancy and not wishing to conceive)

ORP95% CI
Men (n = 1019)
Aged 18–251.00
Aged 26–350.820.5540.42–1.59
Aged 36–450.960.9050.48–1.92
Married1.00
Cohabiting0.750.5080.33–1.75
Steady relationship0.240.0010.11–0.53
Casual relationship1.080.8620.44–2.63
Not in a relationship0.930.8120.50–1.73
Professional and managerial1.00
Other non-manual1.240.4430.71–2.16
Skilled manual1.810.0331.05–3.14
Women (n = 1849)
Aged 18–251.00
Aged 26–352.360.1160.81–6.90
Aged 36–453.270.0421.04–10.24
Married1.00
Cohabiting0.670.3470.29–1.55
Steady relationship0.110.0010.03–0.41
Casual relationship1.030.9710.24–4.41
Not in a relationship1.070.850.52–2.21
Other non-manual0.670.3470.29–1.55
Professional and managerial1.00
Other non-manual1.110.7640.57–2.16
Skilled manual1.000.9950.58–1.74
Semi and unskilled manual1.910.0261.08–3.37

Reasons for Not Using Contraception

Respondents who reported that they had not always used contraception in the last year or who had not used it on the last occasion of vaginal sex were asked why they had not used contraception. The results of these analyses revealed that not having planned for sex was the most commonly cited reason for non-use. This was cited by 47% of men and 40% of women, followed by having consumed alcohol (24% of men, 12% of women) and not caring if pregnancy occurred (11% of women, 12% of men). Eight percent of both men and women cited ‘taking a chance’ as a reason for not using contraception. Although there were significant age differences across these responses, there were no significant social class differences. The three responses taken to test the hypothesis that working class groups would exhibit higher levels of ambivalence were considered in more detail and results are shown in Table 4.

View this table:
Table 4

Probability of reporting different reasons for not using contraception by sex (% and odds ratio controlling for age and relationship status)

%ORP95% CIn
‘Don't care if pregnancy happens’
Men (n = 248)
    Professional and managerial11.01.0098
    Other non-manual12.01.290.7440.27–6.1036
    Skilled manual18.52.940.0331.09–7.8964
    Semi and unskilled manual9.11.180.7960.33–4.1750
Women (n = 207)
    Professional and managerial18.71.0089
    Other non-manual4.00.280.0930.07–1.2437
    Skilled manual19.20.900.860.29–2.8134
    Semi and unskilled manual4.40.240.0710.05–1.1347
‘Sex was unplanned’
Men (n = 248)
    Professional and managerial39.51.0098
    Other non-manual50.81.540.4190.54–4.4336
    Skilled manual46.91.140.7730.45–2.8864
    Semi and unskilled manual49.11.250.6140.53–2.9550
Women (n = 207)
    Professional and managerial27.41.0089
    Other non-manual42.11.260.6840.41–3.8737
    Skilled manual22.71.010.980.33–3.1734
    Semi and unskilled manual53.82.310.1150.81–6.5547
‘We took a chance’
Men (n = 248)
    Professional and managerial6.31.0098
    Other non-manual16.52.950.1430.69–12.6336
    Skilled manual7.21.170.8220.30–4.6264
    Semi and unskilled manual1.10.170.1160.02–1.5750
Women (n = 207)
    Professional and managerial4.81.0089
    Other non-manual2.81.080.9330.16–7.2637
    Skilled manual13.22.690.2340.52–13.8834
    Semi and unskilled manual15.65.840.0530.98–34.8247

Men in the skilled manual class were significantly more likely to report ‘not caring’ if a pregnancy happened than men in the professional and managerial class. No clear patterns emerged for women for this response.

Professional and managerial men and women were less likely than other classes to report that sex was unplanned as the reason for non-use of contraception. For example, whereas 49% of semi and unskilled manual men gave no prior planning as a reason, this was true of 40% of professional and managerial men. Among women, the difference between the semi and unskilled and professional classes was larger (54 vs 27%). None of these differences was statistically significant.

No clear pattern of responses for whether the partners ‘took a chance’ emerged for men, whereas for women, the manual working class groups were more likely to give this reason compared with non-manual groups. Here the adjusted parameter for semi and unskilled women compared with professional and managerial women was significant at the 6% level.

Discussion

Results from this large random sample of the adult population aged 18–45 years in Ireland show support for the hypothesis that contraceptive use was lower among unskilled manual working class groups. Among women not intending to become pregnant, those in semi and unskilled manual working class groups were significantly less likely to have used contraception on the last occasion of sex and over the last year when compared with professional and managerial women. Among men, there were no significant class differences in the consistency of use in the last year, but men in the skilled manual class were significantly less likely to have used contraception at the last event when compared with professional and managerial men. For women at least, these patterns are very similar to those found among adolescents where social class is an important predictor of use of contraception at first and subsequent sexual intercourse.

The second hypothesis of the article was that this differential in contraceptive use could be explained through the greater levels of ambivalence towards pregnancy on the part of working class individuals with fewer attractive occupational possibilities. The results here were more mixed, with no clear class pattern emerging among women for the response that ‘they didn't care’ if conception happened. On the other hand, professional and managerial women were less likely to report that sex was unplanned or that they ‘took a chance’ compared with semi and unskilled manual women. However, only the last of these approached statistical significance. Among men, all other classes were more likely to report each of the ambivalence statements than the professional and managerial class, but this difference was only significant for the skilled manual group for ‘not caring’ about the outcome. These results lend partial support to the hypothesis. Despite the large overall sample in this study, the groups not using contraception or citing reasons other than ambivalence for non-use, meant that there were relatively small sample sizes in social class groups. This is likely to be a common challenge across similar studies.

It could be suggested that the ‘ambivalent’ rationalisations put forward by respondents for non-use may actually reflect higher levels of alcohol use. This could be true for instance if alcohol use is higher among working class groups. In fact, data do not show higher alcohol use among working class groups in Ireland.26 Analysis of responses to the ICCP survey also show that only a small proportion of individuals who give responses taken to indicate ‘ambivalence’ also give alcohol consumption as a reason for not using contraception. This would suggest that alcohol use was not a mediating factor.

These results are consistent with the hypothesis that the differential in use of contraception across social class groups reflects the difference in occupational possibilities for women with better levels of education and a higher social class position. Children will be far more costly in terms of forgone earnings for these women than for working class women whose occupational possibilities are smaller. Similarly, more educated, higher social class women are also more likely to identify more strongly with their occupational career than their domestic role than are working class women. If this argument is correct, it is hard to explain the pattern of lower contraceptive use of working class men since they will not, given the standard gender roles, tend to see care giving as their primary identity. However, it may be that men may generally see the provision of contraception as the woman's responsibility and thus go along with the lower use of contraception of their partners (who given the prevailing patterns of homogomy will tend to have a similar educational and occupational profile as themselves).

On the other hand, these results are also consistent with a hypothesis based on differences in levels of self-efficacy among social class groups. According to this hypothesis, the greater ambivalence of working class groups towards conception is actually the result of their higher level of fatalism towards the future rather than a rational calculation of the opportunity costs of pregnancy. In this explanation, the higher levels of non-use of protection among working class groups is the result of low levels of perceived self-efficacy derived from their experience of low levels of resources and lack of autonomy/powerlessness. This explanation has the advantage that it applies equally to men and women, whereas the explanation based on opportunity costs is far stronger among women. Unfortunately we cannot decide among these two hypotheses with the data from the ICCP survey since both will exhibit themselves in a similar fashion, i.e. a lower usage of contraception and less planning, risk taking and ambivalence. However, it may be possible to decide between these explanations if data were available on levels of self-efficacy as well as contraceptive behaviour for the same individuals.

In sum, this article provides some evidence of social class differentials in individual adults’ explanations for non-use of contraception to avoid pregnancy. It adds to the socio-demographic literature on class differentials in ‘unplanned’ pregnancy and extends on teenage research to cover patterns for adult women and men.

Key points

  • Women are more likely than men to report using contraception at most recent intercourse and higher consistency over the last year.

  • Unskilled manual social class groups are less likely to use contraception than professional and managerial groups.

  • Not planning for sex, having consumed alcohol and not caring if conception occurred are the most common reasons given for the non-use of contraception.

  • Semi and unskilled manual working class women are more likely to report that sex was unplanned or that they ‘took a chance’ in not using contraception.

  • Skilled manual men are more likely to state that they did not care about the outcome when not using contraception.

Acknowledgements

The data used in this article were collected as part of a project funded by the Crisis Pregnancy Agency, Dublin, Republic of Ireland.

Conflict of Interest: None declared.

References

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