Introduction
Many publications confirm that a large number of pregnancies worldwide are unplanned.
According to the European Parliamentary Forum on Population and Development, 43% of
pregnancies in Europe are unintended [1]. Worldwide, there are 121 million unintended
pregnancies annually [2]. Although the numbers of unintended pregnancies have declined
in recent years [3], unwanted pregnancies still lead to 43.8 million abortions per
year worldwide [4]. Unreported cases may be much higher. According to Sedgh et al.,
50% of all unplanned pregnancies in 2012 led to induced abortions, 13% ended in miscarriage,
and only 37% resulted in live births [3].
Unintended pregnancies not only have physical implications, they are also subsequently
associated with poorer mental health conditions among the offspring [5]. According
to a British study, there are three main reasons for unplanned pregnancies: incorrect
application of contraceptives, a lack of knowledge about emergency contraception,
and poor information provided by medical personnel [6].
With regard to sociodemographic status in relation to unintended pregnancies, some
studies have reported that younger women aged between 18 and 29 years are more prone
to unwanted pregnancies [7]. A second peak in unwanted pregnancies was observed in
women over the age of 40. Surprisingly, more than 50% of pregnancies in women aged
over 40 appear to be unintended [8]. There was also a higher risk of unintended pregnancies
among ethnic minorities, unmarried women, and women with a low income [9].
The aim of the present study was to evaluate women’s level of knowledge about contraception
and sexual health in the three German-speaking countries—Austria, Germany, and Switzerland—and
to identify whether there are any negative or positive correlations between responses
to the survey questions and the frequency of unintended pregnancies, as well as the
individual participants’ sociodemographic status in the three different countries.
Materials and methods
Approval for the study was obtained from the ethics committee for Kepler University
Hospital in Linz (Ethics Committee for the State of Upper Austria) on August 23, 2012
(ref. no. L-4-12).
Hospitals in three different countries took part in this international multicenter
survey: Kepler University Hospital Linz (Austria), Erlangen University Hospital (Germany),
and Uri Cantonal Hospital (Altdorf, Switzerland). Only gynecological and obstetric
outpatients aged between 15 and 50 years were included in the study. Patients who
had language barriers preventing them from completing a questionnaire were excluded.
A validated questionnaire was used to evaluate the participant’s knowledge about contraception
and sexual health and to obtain information about her sociodemographic status. The
questionnaires were completed during the waiting time before appointments with the
physician. The goal was to obtain at least 200 completed questionnaires per center.
A two-tiered questionnaire was used. The first part identified the participant’s sociodemographic
characteristics. Information about the following parameters was requested: nationality;
current pregnancy status; age (years); immigration background; educational level;
income above €10,000 (CHF 18,000; including part-time employment or unemployment);
pregnancy history: number of all pregnancies and of unintended pregnancies, number
of previous induced abortions, number of previous miscarriages/stillbirths, number
of children, number of cesarean sections and vaginal deliveries; and marital status
(married, legally separated, widowhood, single, in partnership).
The second part of the questionnaire was a shortened version of a standardized questionnaire
developed by David et al. [10], with specific questions regarding participants’ knowledge
of female anatomy and physiological processes, and about their sources of information.
The questionnaire consisted of 10 questions about contraception, sexual health, anatomy,
physiology, and pregnancy prevention. One point was scored for each correctly answered
question, so that a maximum of 10 points could be obtained (see “Appendix”).
Statistical analysis
Two-sided 95% confidence intervals (95% CI) were calculated for responses to the items
listed in the questionnaire and the score values calculated. Forward stepwise multiple
regression analysis was carried out, with the score value as a dependent variable.
Spearman’s rank correlation coefficients or nonparametric, point biserial correlation
coefficients were calculated for the score and sociodemographic characteristics as
independent variables. Nonparametric variance analysis (Kruskal–Wallis analysis) was
used to compare metric and ordinal variables obtained in the three centers. Categorical
qualitative variables were compared using the chi-square test.
Multiple testing was not adjusted for type I errors. The resulting P values are therefore
only descriptive. The open-source R statistical software package, version 3.0.1 (Institute
for Statistics and Mathematics, University of Vienna, Austria), was used for statistical
analysis.
Results
A total of 605 completed questionnaires were obtained: 203 from Austria, 202 from
Germany, and 200 from Switzerland. The women’s mean age was 32.96 ± 9.12 years; 54%
were married, 21.5% were living in a partnership, and 19.3% were single; 44.8% had
completed upper secondary school education; and 63.5% stated that their net income
was over € 10,000 / CHF 18,000 (Table 1).
Table 1
Selected sociodemographic characteristics relative to each country
Center
Age (year)
Married (%)
In partnership (%)
Single (%)
Upper secondary school education (%)
Annual net income > € 10,000/CHF 18,000 (%)
Austria
31.92 (± 9.08)
48.8
24.1
19.2
51.7
55.7
Germany
33.18 (± 8.17)
53.3
26.7
17.3
52.9
72.7
Switzerland
33.79 (± 10)
60.0
13.5
21.5
44.8
63.5
Electronic or paper media were the main source of the information that the patients
had in all three test centers. In Germany and Switzerland, family and friends were
the second most important source of information, whereas in Austria schools were the
second most important source of knowledge. Physicians played a minor role here in
all three countries (Table 2).
Table 2
Most relevant sources of information about female health, physiology, and contraception
among the participants
Austria
Germany
Switzerland
1
Media (80.3%)
Media (82.7%)
Media (81.8%)
2
Education (72.4%)
Family and friends (71.8%)
Family and friends (75.0%)
3
Family and friends (71.4%)
Education (68.8%)
Education (73.5%)
4
Others (4.9%)
Physicians (5.0%)
Others (10.0%)
5
Physicians (3.4%)
Others (4.5%)
Physicians (2.0%)
More than 90% of the women were interested or very interested in understanding the
physiological processes of the female reproductive system, with only marginal differences
between the countries. Only 0.8% of the women interviewed expressed no interest in
the topic at all (Fig. 1).
Fig. 1
Level of interest in female physiology among the participants
When asked to assess their level of knowledge about female anatomy and physiology,
only 12.7% of the participants stated that they had a very good level. The great majority
of them regarded their level of knowledge as good (62.0%), while only 19.3% thought
that it was satisfactory, 5.6% said it was adequate, and only 0.3% regarded their
knowledge level as insufficient.
The participants had a mean score of 7.57 ± 1.83 points in the knowledge test. Austrian
women had slightly lower scores (7.43 ± 1.85), and German women had slightly higher
scores (7.68 ± 1.93). The mean score for the participants in central Switzerland was
between these two levels (7.59 ± 1.71).
Closer examination of the test data showed that the participants had varying levels
of knowledge about certain topics. While more than 90% of the women were able to answer
the questions about sexually transmitted diseases (STDs) correctly (questions 1 and
2), the question about the fertile phase during the female menstrual cycle (question
3) was answered correctly by fewer women (70.6%). The questionnaire revealed gaps
in the participants’ knowledge regarding the physiological processes of menstruation
and ovulation (questions 5–7). Fewer than 50% were familiar with the hormonal changes
causing menstrual bleeding. There was a good level of knowledge about contraceptives
and the anatomy of the female genital organs (questions 4 and 8). Ninety percent were
able to answer these two questions correctly. Two-thirds of the participants were
less well informed about check-ups for gynecological cancer surveillance (questions
9 and 10) (Fig. 2a–f).
Fig. 2
Correctly answered questions per category, in percent (questions are listed in the
Appendix). a Questions 1 & 2: sexually transmitted diseases. b Questions 3 and 4:
conception and contraception. c Questions 5 and 6: physiology of the female reproductive
system. d Question 8: anatomy of the female reproductive system. e Questions 9 and
10: check-ups for gynecological cancer surveillance
In the group of 605 women interviewed, a significant correlation was observed between
unintended pregnancies and the participants’ level of knowledge about contraception.
In women with previous unintended pregnancies, there was also a significantly lower
level of knowledge in comparison with women who had not had any unintended pregnancies
(P = 0.024).
With regard to sociodemographic status, the following factors were found to influence
the level of knowledge: nationality (P < 0.001), age (P < 0.001), income (P < 0.001),
educational level (P < 0.001), marital status (P < 0.001), previous planned pregnancies
(P = 0.004), previous unplanned pregnancies (P = 0.024), previous induced abortions
(P = 0.027), and previous miscarriages or stillbirths (P = 0.004). All of these parameters
showed significant or very significant P values (Table 3).
Table 3
Correlation between sociodemographic factors and level of knowledge (multiple regression
analysis)
Coefficient
T score
P value
Nationality
1.839
7.897
< 0.001**
Educational level
0.811
6.064
< 0.001**
Marital status
0.608
4.059
< 0.001**
Age (years)
0.028
3.253
0.001**
Annual net income more than EUR 10.000/ CHF 18.000
0.288
2.000
0.046*
Abortions/ stillbirths (n)
0.350
2.745
0.006**
Previous pregnancies (yes/no)
– 0.368
– 2.197
0.028*
*Significant, **very significant
Multiple regression analysis showed that a married 20-year old woman with an annual
net income above € 10,000 who had completed upper secondary school education and did
not have any previous pregnancies reached a cumulative score of 8.318. By contrast,
a 20-year old woman with an immigrant background and an annual net income of less
than € 10,000, with no access to upper secondary school education, who had been unintentionally
pregnant more than once and also had at least one abortion, reached a low cumulative
score of 4.754.
Discussion
These findings are comparable with the results of recent studies reporting gaps in
women’s knowledge about contraceptive options. Although a few studies have evaluated
the level of knowledge in this area among Austrian adolescents [11, 12], adult Austrian
women have only been interviewed in one study so far. The results of the study showed
that almost 50% of women did not know how oral contraceptives actually work. Most
of them were convinced that oral contraceptives have serious and harmful side effects
[13]. A study conducted by David et al. among German and Turkish women regarding contraception
and physiological processes showed knowledge gaps similar to those in the present
study [10]. Only 44.8% of the German women interviewed and 22.7% of the Turkish women
were able to positively identify the fertile phase during a woman’s menstrual cycle.
When asked about which hormonal changes induce menstrual bleeding, the results were
even poorer: 39.5% of the German women and 12.8% of the Turkish women knew the correct
answer, roughly the same level as in the present study [10].
A correlation was observed between sociodemographic status and the level of knowledge
about contraception. The women in the German study center achieved the best scores
(7.68), while women in the other participating centers had lower ones. These differences
may in part be explained by certain sociodemographic differences. German women were
more likely to have German citizenship and a higher level of school education. They
also had higher incomes and fewer previous pregnancies. By contrast, women in the
Austrian study center more often had an immigrant background, a lower level of school
education, were earning less and had been pregnant more often. All of these factors,
as well as others, have an influence on the level of knowledge.
Only one study, conducted in Switzerland, has reported results comparable with the
above findings. Women in the study were able to name more contraceptive methods if
they were well educated and had a good socioeconomic status [14].
In all of the countries included in this study, the media were women’s main source
of information about contraceptive options (Table 2). This underlines the importance
of the Internet, magazines, and other types of media in providing adequate sexual
education. It contrasts with the findings of an earlier study among Austrian adolescents,
in which the main source of information was found to be medical professionals and
the women’s partners [13]. The study is only poorly comparable with the present survey,
however, as it was published more than 30 years ago. It can be assumed that digital
media are much more important nowadays, as they are easily and anonymously accessible.
In another study, Loeber et al. argue that women with multiple unintended pregnancies
should be provided with access to professional counseling about better contraceptive
usage [15].
The present study may be subject to a certain degree of bias, as the questionnaire
was handed out in a waiting room with other patients present. It is not known whether
the participants had any help from an accompanying or neighboring person. Nevertheless,
it is the first multicenter and three-country study investigating the level of women’s
information about the use of contraceptives and their knowledge of female physiology
and sexually transmitted diseases, correlated with sociodemographic status and data
on unintended pregnancies.
Conclusion
These results show that most of the women who took part were well informed about sexually
transmitted diseases, but that there were gaps in their knowledge concerning the anatomy
and physiology of the female reproductive system. This is an important finding, as
a statistically significant correlation was found between the level of knowledge and
unintended pregnancies. Statistically significant correlations with some sociodemographic
factors were also noted. The present study underlines the importance of providing
women with adequate counseling in order to avoid unintended pregnancies and induced
abortions.