rapid decline in Italian abortion rates since 1982 (D'Avanzo et al, 1992) indirectly ..... Although the doctrine of the Roman Catholic Church might have had an ...
Human Reproduction vol.11 no.3 pp.533-539, 1996
Contraceptive use and attitudes in Italy 1993
BJ.Oddens International Health Foundation, Avenue de Broqueville 116/9, B-1200 Brussels, Belgium
Surveys conducted between 1979 and 1991 indicated that contraceptive practice in Italy underwent rapid changes over that period. In order to assess current contraceptive use and attitudes, a survey was conducted among a random sample of 2000 Italian women aged 15-45 years. Replies were received from 1542 women (77.1%). Of the selfdefined non-sterile, sexually active women who wished to avoid pregnancy, 3 0 3 % were using oral contraceptives, 8.1% an intrauterine device, and 1.1% sterilization, while 29.6% were using traditional methods, principally coitus interruptus. In reply to questions about the relative advantages and disadvantages of various contraceptive methods, women expressed worries with respect to the safety of oral contraceptives, intrauterine devices and sterilization. Relatively high percentages of women answered 'do not know' with respect to the various aspects of intrauterine devices, periodic abstinence and sterilization that were investigated. In view of the findings of previous studies, the current data obtained suggested that traditional methods are being gradually displaced by modern methods in Italy. Nevertheless, the use of traditional contraception is widespread, the same probably being true of inconsistent use of condoms. Furthermore, lack of information on the contraceptive options available seems to be a central issue in Italy. Key words: attitudes/contraceptive revolution/contraceptive use/Italy
Introduction Both the 1979 World Fertility Survey (1982) and the 1984 International Health Foundation survey (Riphagen et al, 1984) showed that the use rates of medical contraceptive methods (oral contraceptives, intrauterine devices and sterilization) were considerably lower in Italy than in other West European countries studied at around the same time (Riphagen and Lehert, 1989). In 1984, 6% of sexually active, fertile women aged 15-44 years who were not pregnant and did not want to become pregnant used oral contraceptives (OCs) and 15% an intrauterine device (IUD); less than 1 % relied on female or male sterilization. The use rate of barrier methods (predominantly condoms, but also to a minor extent diaphragms and/or spermicides) was 23% and the remaining women relied on © European Society for Human Reproduction and Embryology
coitus interruptus or periodic abstinence (27%), or did not use any contraceptive method at all (30%). In comparison, the overall use rate of OCs, IUDs and sterilization in North West European countries (21% in Italy) ranged at the time between 50% (West Germany) and 69% (Great Britain) (Riphagen and Ketting, 1990). Attitude measurements carried out in the 1984 study showed that Italian women were concerned about the health safety of OCs, IUDs and sterilization. Such concerns were not, however, unique to Italy; they were also reported in other West European countries, such as France, the United Kingdom, Spain, West Germany, Austria, Sweden and Denmark (Riphagen and Ketting, 1990). Regional surveys conducted in Italy between 1986 and 1991 indicated that Italian contraceptive practice might have undergone major changes during the previous decade (Spinelli et al, 1993). OC use rates appeared to have increased rapidly to about 16-21%. Whereas OCs and IUDs had a very bad popular image in Italy in the early 1980s (Benagiano, 1990), the 1989 regional survey carried out in Southern Italy revealed that many women were by then prepared to recommend the use of OCs or an IUD to a friend (Spinelli et al, 1993). The rapid decline in Italian abortion rates since 1982 (D'Avanzo et al, 1992) indirectly supported the indications that the use of traditional contraceptive methods, which are generally less effective in preventing pregnancy than medical methods (Harlap et al, 1991), had decreased over the previous decade. In order to investigate contraceptive practice in Italy further at national level, as well as Italian women's beliefs about the advantages and disadvantages of various contraceptive methods, we conducted a survey in 1993, the results of which are presented in this paper. This was one of a series of similar surveys, the others being conducted in Great Britain (Oddens et al, 1994a), Germany (Oddens et al, 1994b) and Sweden (report in course of preparation).
Subjects and methods Study population The sample for the survey was obtained by random-walk sampling, whereby fieldworkers from a survey agency which collaborated in carrying out the study (DIRECTA, Milano) followed designated routes throughout the country (including Sicily, but excluding Sardinia), starting from predetermined locations selected on the basis of regional quotas and the degree of urbanization. The routes were also worked out in such a way that they gave equal coverage of urbanization differences within the areas surrounding the start locations. For each region quotas for age were set. Given the topic under study, all the fieldworkers involved were female and they were specially trained in advance. They identified women aged 15—45 533
BJ.Oddens
Thble I. Percentage distribution of respondents in the sample and in the national population*, by background characteristics Respondents
National
n
%
n (X1000)
%
Age 15-19 20-24 25-29 30-34 35-39 40-45
258 280 265 247 228 264
16.7 18.2 17.2 16.0 14.8 1 17.1 /
2148 2433 2223 2075 3844
16.9 19.1 17.5 16.3 30.2
Civil status Ever married Never married
815 725
52.9 47.1
7558 5165
59.4 40.6
Education Elementary/none Licenza media Diploma superiore University or equivalent
110 578 717 135
7.2 37.5 46.6 8.8
2009 6393 3714 606
15.8 50.3 29.2 4.8
Gainful employment No job Part time Full time
989 136 411
64.4 8.91 26.8 /
7234 5486
56.9 43.1
Parity 0 children 1-2 children 3 or more
826 616 93
53.8 40.1 6.1
*For national statistics, see Istituto Nationale de Statistico (1994).
years by visiting their homes and inviting them to participate in the study. Recruitment took place both during the day and in the evening, in order to allow gainfully employed women a reasonable chance of being included in the sample. A questionnaire was handed over for selfcompletion and was picked up again by appointment approximately 1 week later. The field work was conducted from 20 October to 10 November 1993. Some selection bias was inherent in the study design. First, owing to the recruitment procedure used, women who were often at home were more likely to be approached for inclusion in the survey. Secondly, women who considered contraception important might have been more willing to participate. Finally, women of higher educational level were probably more likely to complete the relatively extensive contraception questionnaire (Oddens et al, 1994a). In this latter respect we decided to accept the potential selection bias caused by the self-administration procedure, since this approach has been shown to yield more reliable data than interview procedures when the study topic is relatively sensitive in nature (De Leeuw et al, 1989). Self-administration procedures nevertheless have the disadvantage that respondents may skip questions they do not wish to answer, although it must be remembered that in such cases interview procedures more frequently evoke socially desirable or less accurate replies. The overall response rate achieved does not differ substantially between the two techniques (De Leeuw et al, 1989). Characteristics of respondents and analysis of non-response Of the 2000 women invited to take part in the study, 1542 (77.1%) actually participated. Since the survey agency did not record reasons for non-response, selected characteristics of the sample were compared against the most recent national statistics in order to evaluate the extent to which selection bias had possibly played a role (Table I). It emerged that the distribution of age and civil status in the study sample accorded well with the national female population. However,
534
more women of high educational level were represented in the sample than had been expected on the basis of national statistics, while women in gainful employment were somewhat underrepresented. It therefore seemed warranted to conclude that the study design had resulted in a sample which was skewed towards women with a higher level of education and women who were not in gainful employment. Questionnaire The survey instrument was a questionnaire of the self-administration type and was identical to that used in the British and German studies (Oddens et al, 1994a,b). Some parts of this questionnaire were derived from that used in the International Health Foundation surveys in the 1980s (questions on demographic characteristics, current contraceptive use, information sources and motives for using the current contraceptive method; Riphagen and Lehert, 1989), while other parts were newly developed, following a series of open interviews and pilot tests (questions about advice respondents had received favouring use of a particular method and attitudes towards various methods) (Oddens et al, 1995). These latter questions and possible answers have been described elsewhere (Oddens et al, 1994b). All the questions reported on here were of the closed type. A translation of the questionnaire into Italian was provided by Aardvark Translation Services Ltd, Ascot, UK. Final linguistic checks against the English original, and subsequent amendments, were made by Dr A. Spinelli (Istituto Superiore di Sanita', Rome). Analysis The data on all the women surveyed were analysed. However, in the analysis of current contraceptive use only women who were 'exposed' to the risk of conception were taken into account. According to the definition of Riphagen and Lehert (1989), these 'exposed' women were those respondents who presented themselves as not having had fertility problems, and who were sexually active, not pregnant and not trying to get pregnant at the time of the survey. The question on contraceptive use concerned the 'main method currently used'. However, various combinations of contraceptive methods were incidentally reported. Where a woman was using more than one method, she was classified as a user of the most effective one in preventing pregnancy. The following rank order was used for classifying methods by effectiveness: female sterilization > male sterilization > OC > IUD > barrier methods > periodic abstinence > coitus interruptus > no method. Users of combinations of periodic abstinence and barrier methods on 'unsafe' days were grouped together with users of periodic abstinence into a single 'periodic abstinence' category. This classification was closely in line with the conventions adopted in previous surveys on contraception (Mosher, 1990; Skjeldestad, 1994).
Results Of the 1542 women surveyed, 68.4% were defined as being 'exposed'. The pattern of current contraceptive use by these exposed women is presented in Table II. The barrier methods used comprised condoms (96.3%), diaphragms (0.9%) and spermicides (0.9%). The remaining 1.9% used combinations of condoms, diaphragms and spermicides. Of all barrier method users, 37.5% also reported practising coitus interruptus, while 4.3% used no method at all, indicating that barrier methods were used incidentally rather than consistently in a number of cases. Analysis of current contraceptive use by exposed women according to region revealed statistically significant differences, with higher use rates of OCs and IUDs in Northern Italy, and
Contraception in Italy
Table II. Percentage of exposed* women currently using a contraceptive method, by year 1979*
1984b
1991C
1986C
1993d
1993 National (n = 1050)
Oral contraceptives Intrauterine device Barrier methods' Periodic abstinence Coitus interruptus Sterilization No method Age of the sample
10.5 2.5 11.0 7.2 48.2 0.05). The reasons given by respondents for deciding on the method they used at the time of the survey are indicated in Table V. In general, reliability, non-disturbance of sex life and ease of use were reported as motives for choosing the contraceptive method in current use. The most important sources of information on the method currently used were gynaecologists (51.9%), friends (34.6%), partners (34.4%), magazines (17.6%), newspapers (16.1%) and books (14.1%); it should be noted that more than one answer could be given. Family planning clinics, general practitioners and schools were mentioned less frequently in this connection, viz. by 11.5, 5.0 and 4.6% of the contraception users respectively. In order to explore further which social influences had played a role in the contraception decisions of the respondents, they were asked whether they had ever been influenced by their partner or physician to use a particular method (see Table VI). Analysis was restricted to the exposed women, since the question did not apply to all the non-exposed women, in particular those 536
Rollobl*
Oaf* for h u l t h
Ho disturbance of sax l i t * Em«y to as*
Figure 1. Knowledge of main characteristics of various contraceptive methods compared against available 1984 data (Riphagen and Lehert, 1989) - regrouped mean ratings of respondents who did not indicate 'do not know'. O = oral contraceptives, I = intrauterine device, S = sterilization, C = condoms, P = periodic abstinence. * No 1984 data available.
who were infertile or had never engaged in sex. Substantial percentages of the women reported having been persuaded by their partners to use OCs, condoms or coitus interruptus and by their physicians to use OCs, condoms or IUDs. Few women had been advised by either their partner or their physician to use periodic abstinence or sterilization. The mean ratings for certain key characteristics of OCs, condoms, IUDs, periodic abstinence and sterilization are presented in Figure 1. Respondents rated each method
Contraception in Italy
Table VI. Percentages of exposed* women who reported being influenced by their partner or physician to use a particular contraceptive method Oral contraceptives
Condoms
Intrauterine device
Coitus interruptus
Periodic abstinence
Sterilization
Partner often sometimes
21.9 24.6
24.0 26.8
4.6 8.5
25-5 20.3
4.2 9.8
0.7 1.4
Physician often sometimes
37.6 25.4
11.9 16.4
12.1 19.1
1.8 4.8
1.7 6.2
1.1 1.5
•Exposed = sexually active, not pregnant or wishing to get pregnant, and not infertile.
Table VII. Percentage of women stating 'do not know' to question on various method attributes, by method
Reliable Safe for health No disturbance of sex life Easy to use
Oral contraceptives
Condoms
Intrauterine device
Periodic abstinence
Sterilization
3.7 8.2 10.1 2.9
4.0 6.8 12.9 7.0
20.3 23.8 47.1 27.2
16.7 20.0 28.8 23.0
22.1 39.9 47.0 48.1
between the extremes of 'very reliable' and 'very unreliable', 'very safe for health' and 'very unsafe for health', etc. After exclusion of the respondents who had answered 'do not know' (Table VII), the responses were regrouped into three categories. Comparison with similar ratings from 1984 showed that condoms were currently rated as being more reliable and OCs and IUDs as being somewhat safer for health. OCs and periodic abstinence were seen as causing less disturbance to sex life. Relatively high percentages of women answered 'do not know' with respect to the various aspects of IUDs, periodic abstinence and sterilization that were investigated (Table VH). Respondents' expectations as to the disadvantages they would personally suffer when using a contraceptive method, as well as the advantages from which they would benefit, are presented in Table V m for a number of contraceptive methods. OCs were associated with relief from menstrual disturbances, a number of side effects (e.g. weight gain), cardiovascular disease and cancer. Respondents believed that IUDs might cause infection and that they did not belong in the body. They recognized that condoms could prevent HIV transmission, but also felt that condoms might tear easily and were a messy method. Periodic abstinence was seen as a natural but complicated method and sterilization was felt to have possible effects on feelings of femininity. From the answers to questions concerning the practical daily problems encountered when using these methods, it emerged that 23.8% of the sample felt they might have difficulty in remembering to take OCs on a daily basis, while 26.7% thought they might forget to take them during their holidays. It was felt by 65.5% that they would be embarrassed if they had to buy condoms in a shop. A substantial proportion (46.4%) were not confident that a condom would be used every time they had intercourse and 54.2% thought they would not be able to refuse intercourse if their partner was unwilling
Table VTH. Percentage of women replying 'yes' or 'possibly' to questions on various method attributes, by method Oral contraceptives Regular periods Less painful periods Less heavy periods Relief of skin disorders Cancer prevention Easy to obtain Cardiovascular disease risk Cancer risk Weight gain Depression Headache Painful tense breasts Nausea
81.0 69.3 56.6 51.8 27.1 84.1 35.6 29.7 74.8 36.8 32.7 42.8 36.7
Intrauterine devices Abdominal cramps Heavier periods Infection Infertility Something strange that does not belong in the body
47.2 41.0 60.9 23.2 80.9
Condoms Cancer prevention AIDS/STD prevention Natural method Easy to obtain Messy method Tear easily
10.6 89.2 28.4 91.0 59.7 63.1
Periodic abstinence Natural method Partner involved Leam to know body better Complicated method
69.6 32.7 39.6 66.8
Sterilization Major, risky operation Feel less feminine
44.2 64.9
537
BJ.Oddens
to use a condom. Fear was ; expressed by 83.8% regarding sterilization and by 64.0% about using an IUD. In the case of periodic abstinence, 80.3% of the respondents did not feel capable of calculating the 'safe* period and 19.3% thought they would be unable to avoid intercourse on 'unsafe' days. Discussion The current survey yielded a satisfactory response rate for this type of research (De Leeuw et aL, 1989). Despite the fact that the survey used a probability sample, this seemed to be skewed towards women of higher educational level and women who were not in gainful employment. The results must therefore be interpreted with caution. Given the significant association between educational level and contraceptive use, for example, the general use rates of modem contraceptive methods in Italy may be somewhat lower than reported here. The current results seemed to confirm earlier reports of changes in the pattern of contraceptive use in Italy. The use of OCs appeared to have increased^ while reliance on coitus interruptus or no method at all seemed to have declined. Nevertheless, the use rates of coitus interruptus and condoms are relatively high, and those of OCs and sterilization are low as compared, for example, with the current situation in Germany and Great Britain. The present survey also suggested that where barrier methods were used, their use might sometimes be inconsistent The Italian fertility rate is among the lowest in the world (PeYez and Iivi-Bacci, 1992), while its abortion rate is at only an intermediate level in Western Europe (18.1 per 1000 women aged 15—44 years, including illegal abortions; Spinelli et aL, 1993). However, the Italian pattern of contraceptive use, with relatively high use rates of coitus interruptus, no method and condoms, would suggest higher failure rates than the patterns in Germany and Great Britain: the annual failure rate for coitus interruptus is 15%, for reliance on 'luck' 85% and for condoms 10%, whereas that for OCs is 4%, for IUDs 3% and for sterilization 0.3% (Harlap et aL, 1991). Further scrutiny shows that the Italian abortion pattern differs from that in North West Europe (D'Avanzo et aL, 1992). In most North West European countries the majority of abortions involve adolescents (Henshaw and Morrow, 1990), for whom the use of contraception during their first sexual experiences is problematical (Oddens, 1994). In contrast, the majority of abortions in Italy involved married women, aged 25-34 years, who already had children (Henshaw and Morrow, 1990; Spinelli et aL, 1993). These observations have led us to speculate that abortion in Italy is more frequently related to failure of contraception (and subsequent termination of pregnancy), whereas in North West Europe it is more frequently related to lack of contraceptive experience and 'trial and error' problems in a specific stratum of the population. In this sense, the current findings indirectly indicate that the contraceptive use pattern within the Italian population as a whole might indeed have consequences in terms of the specific pattern of unintended pregnancies and abortions in that country. Various reasons can be advanced for the differences in contraceptive use that were observed between Italy, Germany 538
and Great Britain. We have discussed potential explanations for the differences between Germany and Great Britain elsewhere (Oddens and Lehert, manuscript in preparation). Basically, these differences could be attributed to aspects of health care policy and the organization of the relevant services in these countries. For example, 'natural family planning', as a more sophisticated variant of periodic abstinence, has been promoted in Germany with government support, resulting in a relatively higher use rate of this method. On the other hand, German women had less easy access to sterilization than British women due to the organization of family planning services. If we examine the family planning situation in Italy, the central issue seems to be a lack of good, open information about contraception and sexuality (Benagiano, 1990; Spinelli et aL, 1993). Sex education in schools is virtually non-existenL At the political level, several proposals aimed at having sex education included in school curricula have been discussed, but these have always met with so much resistance that they have never been approved. In addition, the mass media have emphasized the presumed disadvantages of modern contraceptives rather than their advantages. There have been no real government family planning programmes, and physicians are not always adequately trained with respect to contraception issues. This reported lack of information was confirmed by our findings indicating that considerable percentages of respondents were ignorant, for example, of the reliability of IUDs, periodic abstinence and sterilization. Lack of information is probably not the only explanation for the Italian situation. For example, the legal position in regard to sterilization is unclear (Spinelli et aL, 1993). Since it is not authorized under any specific law, sterilization might theoretically be regarded legally as a mutilation of the body. This might explain why, as the present survey indicated, physicians seem to be reluctant to propose sterilization to eligible women and their partners. Another factor that calls for further consideration is the role of the partner (Benagiano, 1990). Partners in Italy might be more involved in contraceptive choices than partners were found to be in the other countries. For example, in Germany and Great Britain 24 and 29% of exposed respondents respectively reported that their partners had persuaded them to rely on condoms (unpublished results from Oddens et aL, 1994a,b), as compared with 51% in Italy ('often' and 'sometimes' replies considered together). Partner involvement in contraceptive choices is in principle something to be encouraged. On the other hand, partners in Italy apparently favoured the use of coitus interruptus in a number of cases, according to the women surveyed Further research might address the contraceptive preferences of Italian men in order to elucidate whether this is indeed the case, as well as their possible motives for preferring this rather ineffective family planning method. Although the doctrine of the Roman Catholic Church might have had an impact on contraceptive use in Italy in the past, direct influences were not detected in the present study. Virtually all the respondents were Roman Catholic, but contraceptive use (including the use of OCs and IUDs) did not differ significantly between women who attended church services frequently and those who rarely or never attended. This was
Contraception in Italy
consistent with the impression reported by Benagiano (1990), to the effect that the majority of women, including practising Roman Catholics, do not adhere to the papal doctrine forbidding the use of contraceptive methods other than natural family planning. The contraceptive use patterns varied significantly among the regions surveyed, but the reasons for this are not well understood. Spinelli et al. (1993) observed that the levels of knowledge regarding contraception and fertility were lower in Southern Italy as compared with Northern Italy. Variations in knowledge might indeed underlie the regional differences in contraceptive use, although further research is necessary to investigate this hypothesis. Contraceptive choices are very much determined by what people perceive as the advantages and disadvantages of the methods available. It has already been mentioned that many women were ignorant of the various aspects of the use of IUDs, periodic abstinence and sterilization. In 1984 it was found that, among those who had formed opinions, concerns about safety issues were those most frequently expressed (Riphagen and Lehert, 1989). The same applied in the case of the present survey. As was also true for the countries surveyed in 1984, such beliefs and concerns are not unique to Italy: views to the effect that OCs are related to cardiovascular disease and cancer, that IUD use is associated with increased infection risk and that sterilization causes a woman to feel less feminine were voiced virtually to the same extent in Britain and Germany (Oddens et al., 1994a,b), and are probably commonly held throughout the developed world (Oddens, 1994). Nevertheless, it should be noted that many Italian women also recognized the advantages of these methods. OCs, for example, were generally seen as an effective method of family planning which was easy to obtain and could relieve menstrual problems. In this connection, the increase in OC use observed indicated that more Italian women currently felt that the advantages of OCs outweighed their possible disadvantages than was the case at the time of the earlier surveys. In conclusion, it may be said that the data reported here substantiate earlier findings which indicated that Italian couples were increasingly adopting modern contraceptive methods. Nevertheless, the knowledge possessed by Italian women was often poor, especially where IUDs and sterilization were concerned. More women in Italy than in North West European countries, such as Germany and Great Britain, were found to be using family planning methods of the generally less effective kind. The need for better information and improved sex education and contraceptive services would seem highly relevant in this connection.
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Acknowledgement I am indebted to Dr A. Spinelli for her extensive help with the preparatory work for this study.
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