Ethnocultural issues in contraception

The choice of contraception may be influenced by a number of factors, including:

• Age, health, conditions such as diabetes or hypertension and current use of potentially interacting medications.

• Fertility.

• Smoking.

• Religion and culture.

• Number of partners, risks of infections, etc.

The ease of availability (with or without the intervention of a doctor), cost and the acceptability of the method to the couple all affect the method used.

Over the reproductive period in a woman's life the methods vary as they may need to be compatible with breast-feeding, needing to try for another baby soon, being too old for the combined pill, concurrent illnesses such as diabetes and the partner changing, which may lead to a different set of choices. Women may wrongly assume their age-related decline in fertility is sufficient contraception.¹

Age

Differing age at menarche

Different populations tend to have different physical and emotional maturity.² Age at menarche of European children is higher than those from the Caribbean or from the Indian subcontinent.

Risk takers

Younger people are more likely to have sex with multiple partners and engage in other risk-taking behaviour such as drugs and alcohol. These factors, with a less than rigorous approach to regular pill taking, may result in a higher rate of pregnancy.

Peer pressure, along with media exposure of sex, may put some young people under pressure to experiment with sex before they are ready or mature enough to do so:

• There is evidence of increasing use of contraception at first intercourse, but an underlying trend to earlier age at first intercourse (now plateauing) has been found to be associated with a rise in teenage pregnancy and sexually transmitted diseases.³

• There may also the feeling that everyone is 'doing it' (whereas most may just be 'talking' about it).

• Teenagers tend to be aware of preventing pregnancy but not as aware of sexually transmitted infections or the consequences to fertility.⁴

Studies of sexual activity and contraceptive use in five developed countries show different teenage pregnancy rates:^{5 6}

• The age of sexual debut varies little across countries, yet American teenagers are the most likely to have multiple partners.

• Adolescent childbearing is more common in the USA (22% of women reported having had a child before the age of 20) than in Great Britain (15%), Canada (11%), France (6%) and Sweden (4%).

• A greater proportion of women in the USA reported no contraceptive use at either first or recent intercourse (25% and 20%, respectively) than reported non-use in Great Britain (21% and 4%), France (11% and 12%), and Sweden (22% and 7%).

Emergency contraception - hormonal or coil insertion

Some groups find this an acceptable remedy to contraceptive failure - eg, slipped sheath or unprotected sex, when they would not accept termination.

• In some religious groups, such as the Roman Catholic church, this is seen as a form of termination, ie interfering with a fertilised ovum.

• In certain risk-taking teenage culture groups this may be seen as a form of contraception rather than an emergency intervention.

• One way of remedying this is by making sure that the long-term contraceptive needs of such persons are addressed.

• There is also need to inform culturally isolated women about the availability of such methods.

Culture

Despite the widespread availability of various contraceptive methods, the responsibility for arranging contraception is more often borne by women than men.⁷

• Although female sterilisation is more invasive than vasectomy, it is still the more common procedure.

• HIV has resulted in some change with more men using condoms.

Cultural attitudes to premarital sex

In certain cultures, premarital sex is considered a matter of shame and a loss of family honour. The consequences of premarital sex can be so severe in some cultures that it is essential to ensure that strict confidentiality in relation to these matters is maintained at all times.

Changing attitudes to divorce and remarriage

The intrauterine system is as effective a method of contraception as sterilisation, although it is easily removable.^{8 9} Marital splits and altered relationships may lead to renewed desire for offspring from the new unions, and reversal of sterilisation does not guarantee conception. Alternatives to sterilisation should be considered and patients counselled about the irreversible nature of sterilisation.

Cultural isolation

Some cultures disapprove of the education of women. This can result in women becoming isolated, particularly when they emigrate with their family to a different country with a different primary language.

A special need exists for their education about the availability of different choices of contraceptive methods so that they can be empowered to control their fertility according to their needs.

Religion

Religious beliefs can limit a patient's contraceptive choices. When 'artificial' contraception is forbidden, a few natural methods may be acceptable:

• Coitus interruptus (withdrawal before ejaculation) is a method practised by many, as it requires no special arrangements or planning. However, a great deal of self-control is required and it is not a particularly effective method (at best, 4% failure rate per annum):
  

  • Some men feel not ejaculating denies them the climax of intercourse. Ejaculation can take place just as long as it is not in the vagina or in the surrounding area.

• The mucothermic method:
  

  • This relies on abstinence from intercourse at the most fertile time (around ovulation) of the menstrual cycle.

  • Most of these methods are better suited to older couples where fertility is reduced.

  • This group of patients is less likely to use emergency contraception or seek termination.⁵

Orthodox religions

These include Judaism, Islam, Hinduism and Sikhism. Orthodox followers of all these religions tend to:

• Regard sex outside marriage as taboo.

• Forbid abortion and regard menses as unclean.

• Extend the taboos against sex before marriage to sex outside marriage, ie adultery.

• Forbid seeing any other man than the husband in intimate circumstances.

• Consider a male physician often as not acceptable, even with a chaperone.

The punishments for adultery or sex before marriage in certain countries/cultures can be death. These cultural taboos are followed more closely in some cultures than in others, even if they are of the same religion.

NB: medical indications can override many prohibitions.

Christianity

Contraception and abortion are forbidden in Catholicism. Mucothermic methods of contraception are acceptable.

Politics of contraception - control and freedom

One of the effects of contraceptive control has been to liberate the tie between sex and reproduction:

• This gives women the freedom to time their pregnancies to fit in with a more independent lifestyle.

• It also allows them freedom to follow other paths such as study and employment.

• It has liberated them from uncontrolled large families (they can still have them but now it's by choice).

One of the results of this has been to empower women within their societies.

Contraceptive control can have effects on political control. This means that controlling the availability of certain contraceptive choices can manipulate the population's behaviour - eg, some governments or religious organisations may give inducements for using, or not using, contraception.

Population migration

In recent years there has been an increase in movement between countries in Western Europe and asylum-seeking from further afield. This can lead to problems in communication:

• This may involve not only language, but style of communication.¹⁰

• Communication problems tend to result in a lower quality of care.¹¹

• Their expectations and the manner in which patients present their problems may all differ.

Problems may be experienced when cultures clash, particularly over issues such as attitudes to women and sexual morals.