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Family planning is considered an essential human right by the United Nations Population Fund. Hormonal contraception is an effective way of family planning[1-3] but its use differs greatly between women from different countries and cultures.[1, 4, 5] The increasing numbers of immigrants in Europe actualises the need for studying the use of contraception in these groups.
Immigrants, defined as persons born abroad to two foreign-born parents, constituted 12% of the population in Norway by January 2013. Immigrants in Norway are a heterogeneous group originating from 220 different countries. Although immigrant women may have different needs and traditions for use of hormonal contraceptives as compared with the native population, patterns may change over time with adaptation to their new country of residence. Studies on screening for cervix cancer suggest that differences in use of health care services between immigrants and natives become less pronounced with increasing length of stay in a new country.
Induced abortions can be understood as unmet needs of contraception. Studies from the Nordic countries and the USA show that unintended pregnancy and induced abortion occur more commonly among minority women.[4, 8-10] The use of contraceptives, and the level of knowledge about contraceptive methods, appears to be lower among immigrant than native women undergoing induced abortion.[10-12] A newly published study based on a health survey studying self-reported use of contraceptives found a lower use of contraceptives among immigrants than native women in France. To our knowledge there are no prior studies that compare contraceptive use between different groups of immigrants and natives at the population level. Such knowledge is essential for gynaecologists, general practitioners (GPs), and other health professionals in order to provide adequate guidance regarding family planning.
The aim of this study was to analyse the use of hormonal contraceptives in various groups of immigrants and native women in Norway. In addition, we aimed to identify predictors for hormonal contraceptive use in these groups.
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The study population comprised 893 073 women aged 16–45 years, 130 080 (14.6%) of whom were immigrants. Of the immigrant women, 38% were born in Asia, 25% in Eastern Europe, 12% in Africa, 11% in Nordic countries, 10% in Western countries, and 5% in South and Central America. Characteristics of the study population are shown in Table S1. Women's mean age varied between the groups from 31 to 33 years, mean age on immigration from 22 to 27 years, and mean length of stay in Norway from 6 to 9 years. Compared with Norwegian women, fewer immigrants were working and/or in education, had a Norwegian spouse, and had a Norwegian GP, and more immigrant women were married and had given birth. The proportion of immigrant women having a female GP varied from 37 to 47%, compared with 40% of the native women.
Table 1 shows user rates of hormonal contraceptives according to women's area of origin and age. Oral hormonal contraceptives were dispensed to four times as many women than were non-oral formulations. Relatively more native women (38%) were dispensed hormonal contraceptives than were all groups of immigrants; user rates among immigrants varied between 15 and 24%. Use of oral hormonal contraceptives decreased with increasing women's age. Differences in using oral and non-oral hormonal contraceptives between the native women and the immigrant groups were most prominent among women aged 16–25 years. Non-oral contraceptives comprised a larger share of overall use of contraceptives for women from Africa and Asia than for native women and all other immigrant groups. Hormonal IUDs were most commonly used by older women.
Table 1. Use of hormonal contraceptives in Norway in 2008. Distribution by women's area of origin and age group
|Age group (years)||Hormonal contraceptives||Norway||Nordic countries||Western countriesa||Eastern Europe||Asiab||Africa||South and Central America|
|All women, n|| ||762 993||14 137||12 550||32 298||50 120||15 088||5887|
|IUD and implants, %||2.8||2.3||1.5||1.2||1.7||1.6||1.8|
|16–25, n|| ||238 404||3144||2128||8329||11 264||4061||1104|
|IUD and implants, %||1.1||0.9||0.4||0.7||0.9||1||1.4|
|26–35, n|| ||236 019||5573||5054||14 543||21 591||6517||2769|
|IUD and implants, %||3.4||2.1||1.6||1.2||2.1||1.9||1.9|
|36–45, n|| ||288 570||5420||5368||9426||17 265||4510||2014|
|IUD and implants, %||3.8||3.3||1.7||1.5||1.8||1.6||1.9|
Figure 1 shows the association between length of stay in Norway and use of hormonal contraceptives for the two aggregated immigrant groups as compared with the Norwegian women (reference, OR = 1), by three age groups. The likelihood of using hormonal contraceptives increased during the first 5 years after immigration. The differences in use of contraceptives between immigrants and Norwegians were smallest in the oldest age group.
Table 2 shows the association of use of any hormonal contraceptive with women's world region of origin. Women from Africa, Asia and Eastern Europe were less likely to receive any hormonal contraceptive than were native women and all other groups of immigrants. Because of interactions, the adjusted ORs for the aggregated groups are shown in Figure 2.
Table 2. Binary logistic regression. Crude OR and 95% confidence interval (CI) of use of hormonal contraceptives with women's world region of origin
|World region of origin||Crude OR (95% CI)|
|Nordic countries||0.53 (0.51–0.55)|
|Western countriesa||0.39 (0.37–0.40)|
|Eastern Europe||0.29 (0.28–0.29)|
|South and Central America||0.53 (0.50–0.57)|
Figure 2. Association of contraceptive use with age, for women (A) in work/education and (B) not in work/education. Odds ratio (OR) for three groups.
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Figure 2 shows the association of use of some hormonal contraceptive with age for two aggregated groups of immigrants; Figure 2A is restricted to women in work/education, Figure 2B to those not being working and/or in education. Results presented in both figures are adjusted for having a female GP and having a Norwegian GP. The impact of adjustment varied between immigrant groups, but the confidence interval only overlapped with native women among the oldest women in the aggregated group with highest use of contraceptives who were working/in education.
Table 3 shows the adjusted association of using any hormonal contraceptive with women's characteristics, for native women and for two aggregated immigrant groups with relatively high and low use of hormonal contraceptives, respectively. In all three groups, being in work and/or education was a predictor of using oral contraceptives, with greatest impact on those immigrants with relatively high use of hormonal contraceptives. For immigrants, having lived in Norway for 5 years or more and a relatively young age of immigration, predicted use of hormonal contraceptives. In all groups, having a female GP increased the likelihood of using any contraceptive. Being married and giving birth were both associated with lower use of contraceptives in native women, but increased use in those immigrant groups with relatively low use. Adjusted data for immigrants according to each world area of origin are presented in Table S2.
Table 3. Association of use of hormonal contraceptives with women's characteristics, for Norwegian women and two immigrant groups. Odds ratio (OR) and 95% confidence interval
| ||Norway||Immigrants with high contraceptive usea||Immigrants with low contraceptive useb|
|Crude OR (95% CI)||Adjusted ORc (95% CI)||Crude OR (95% CI)||Adjusted ORc (95% CI)||Crude OR (95% CI)||Adjusted ORc (95% CI)|
| In work/education ||1.66 (1.64–1.69)||1.42 (1.40–1.45)||2.17 (2.01–2.34)||1.87 (1.72–2.04)||1.50 (1.45–1.57)||1.24 (1.19–1.29)|
| Length of stay in Norway ≥5 years ||–||–||1.29 (1.22–1.36)||1.21 (1.11–1.31)||1.57 (1.51–1.63)||1.29 (1.23–1.36)|
| Age at immigration (ref = 31–45 years) |
|0–15 years||–||–||4.55 (4.12–5.02)||1.22 (1.05–1.42)||3.73 (3.50–3.98)||1.38 (1.25–1.53)|
|16–30 years||–||–||2.07 (1.91–2.24)||1.07 (0.97–1.19)||1.95 (1.84–2.07)||1.23 (1.15–1.33)|
| Female general practitioner ||1.08 (1.07–1.09)||1.12 (1.11–1.13)||1.12 (1.06–1.19)||1.15 (1.08–1.23)||1.20 (1.15–1.24)||1.16 (1.12–1.21)|
| Norwegian general practitioner ||1.02 (1.01–1.03)||1.02 (1.01–1.04)||0.95 (0.89–1.01)||0.97 (0.91–1.04)||1.09 (1.05–1.13)||1.08 (1.04–1.12)|
| Delivery between January 2008 and June 2009 ||0.84 (0.83–0.86)||0.82 (0.80–0.83)||1.08 (1.00–1.16)||0.93 (0.85–1.01)||1.18 (1.13–1.24)||1.12 (1.06–1.18)|
| Married ||0.30 (0.30–0.31)||0.66 (0.65–0.66)||0.67 (0.64–0.71)||0.91 (0.85–0.97)||0.82 (0.79–0.85)||1.13 (1.08–1.18)|
| Age, years ||0.90 (0.90–0.90)||0.91 (0.91–0.91)||0.95 (0.94–0.95)||0.93 (0.92–0.93)||0.96 (0.96–0.96)||0.95 (0.95–0.96)|
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This nationwide registry-based study confirms that fewer immigrant women use hormonal contraception compared with native women, and these observations are consistent after adjustment for socio-economic and provider-related factors. However, our study was unable to ascertain whether these differences were related to factors such as desires for fertility or preferences for non-hormonal contraception in recently arrived and established immigrants. Furthermore, the extent to which immigrant contraceptive needs are met is unclear. Further work including qualitative research is necessary to examine the cultural, economic, healthcare system or provider-related reasons why immigrants use fewer hormonal contraceptives compared with native women. In addition, the association between choice of contraceptive method and culture or country of origin should be investigated. Finally, method switching and discontinuation should be targeted in longitudinal studies.
Disclosure of interests
The authors declare that they have no conflict of interests.
Contribution to authorship
GO performed the statistical analysis and prepared the manuscript. SR participated in the design and preparation of the manuscript. ED conceived and planned the study and supervised the analyses and writing of the manuscript. All authors read and approved the final manuscript.
Details of ethics approval
This study is part of the project ‘immigrants' health in Norway’, which has been approved by the Regional Committee for Medical and Health Research Ethics (ref. 2009/1747) in 2009 and the Norwegian Data Inspectorate (ref. 10/00069-6 IUR) in 2010. The Norwegian Directorate of Health (ref. 10/6022) has granted an exemption from the duty of confidentiality.
No external funding was necessary for this publication.