Perspectives on hormonal contraception among young adults in the European Region

Contraceptive use varies widely across the European continent (Dereuddre, Van de Putte & Bracke, 2016). Patterns of contraceptive use reflect policy variations which are more favourable to modern contraception access in Northern and Western Europe than Eastern Europe (EPF, 2024). These differences described in the 2024 Contraception Policy Atlas developed by EPF are particularly striking for young people as only 30 % of countries in the region “cover contraceptives in the national health systems for young people.” Young people face several barriers to accessing contraception, including financial limitations, social taboos and confidentiality issues (International Planned Parenthood Federation, 2012; Parliamentary Assembly, 2020). Additionally, while young people tend to need the most information, they often access information that is only partial or non-evidence-based and fails to provide them with a comprehensive understanding of their contraceptive options, and where and how to access services (International Planned Parenthood Federation, 2012). 

In recent years exaggerated risks and a general unease about interference with natural bodily functions have lessened women’s interest in hormonal contraception. Repeated pill scares in Europe following rare cardiovascular adverse events and social media discussions about hormonal effects on mental health, libido and fertility have fuelled public mistrust and hesitancy towards hormonal contraception (Foran, 2019). Some have labelled this phenomenon as “hormonophobia,” or “hormonal scepticism” due to a systematic “overestimation of health risks” associated with hormonal contraception (Le Guen et al., 2021). 

It is important to understand current patterns of hormonal utilization among young people living in the European region in order to reduce inequities in contraceptive choices and utilization. This secondary analysis aims to describe hormonal contraceptive utilization and associated factors among young adults and the extent to which hormonal hesitancy informs their contraceptive decisions.

This study draws on the EPF study “Contraceptive Use and Awareness Among Young People in the European Region”, an online cross-sectional survey conducted in July and August 2022 in the European Region (Michielsen, Farje De la Torre & Selznick, 2022). It is a secondary analysis of the collected data, done in the framework of a master thesis written by the first author for a Master of Science in Public Health at the Johns Hopkins Bloomberg School of Public Health (Selznick, 2023).

The study sample included respondents between the ages of 18 and 30 who were living in one of the countries of the European region. Respondents were recruited via convenience sampling, which involved the EPF compiling a list of contacts from each European country to disseminate the survey to the relevant groups and contacts, including organizations, researchers, community leaders, doctors, and activists who either worked with young people, focused on family planning, or had a large audience or network of 18 to 30-year-olds in Europe. A total of 2,603 respondents completed the survey, which was available in 13 languages. The questionnaire solicited information about the respondents' country of residence, their socio-demographic background (sex, age, education, occupation, economic status and religion) and their knowledge, attitudes and use of contraception. 

We restricted analysis to countries that had at least 30 respondents who were female at birth and selected a subsample of those who were in need of contraception at the time of the survey. Participants in need of contraception were identified as being female at birth, in current heterosexual or bisexual partnerships, non-pregnant and not trying to become pregnant at the time of the survey, and did not have fertility related reasons as their explanation for not using contraception. Our analytical sample included 1,315 respondents, ranging from 20 respondents in Armenia to 349 respondents in Italy, as seen in Figure 1.

We considered three outcome measures: knowledge of hormonal methods, current contraceptive use, and hormonal contraception hesitancy. Knowledge of hormonal methods was defined as a numeri-cal variable (0 to 6) based on the number of hormonal methods the respondent knew, in terms of “what it looks like” and/or “how it is used.” Current contraceptive use was defined as a three-category variable: non-use, hormonal method use (pills, implants, patch, vaginal ring, injectables and intrauterine devices), and other method use (diaphragms, male condoms, female condoms, withdrawal, male sterilization, female sterilization and fertility awareness). This categorization assumes that most intrauterine devices are hormonal (intrauterine systems, IUS) rather than copper IUDs, as IUS are more common among younger women. Hormone hesitancy was a binary variable combining non-users of contraception who reported they “don’t want to use hormones'' or are “scared of side effects” and contraceptive users who chose their method because they wanted one that was hormone-free.

We examined age, education, occupation, socioeconomic status, religion and region of residence as correlates of hormonal contraceptive knowledge, use, and hesitancy. Region was defined according to the EPF atlas categories of contraceptive policy access at the time of the survey (EPF, 2022) from most favourable, green coloured countries, to most unfavourable, red coloured countries, as illustrated in Figure 2 below. 

The analysis began with a description of the sample characteristics. Next, we examined the mean number of known hormonal contraceptives by socio-demographic characteristics and tested for differences using bivariate linear regression. Contraceptive use status was also examined by sociodemographic characteristics and differences tested for using Pearson’s chi-squared test. We further investigated factors associated with hormonal method use among all women in need of contraception and among contraceptive users using multivariate logistic regressions. The classification of IUDs as hormonal methods may lead to misclassification, especially in Eastern Europe where a greater proportion of women use copper IUDs that are less costly than IUS. For this reason, a sensitivity analysis was conducted by reclassifying all IUDs into non hormonal methods to examine how IUD classification changed our conclusions. The results remained the same. Finally, we explored sociodemographic factors associated with hormonal contraceptive hesitancy, testing for differences using Pearson’s chi-squared test and subsequently conducting a multivariate logistic regression model. Ethical approval for secondary data analysis (ONZ-2022-0489) was obtained from the Ethical Committee of Ghent University Hospital. Participants had to approve an informed consent form before starting the survey.

The characteristics of the study sample are presented in Table 1. A large proportion of respondents (58 %) resided in three countries, Italy, Romania and Belgium. This represented a range of contraceptive access conditions, which are shown in yellow, orange and dark green. While 26.8 % of respondents lived in favourable contraceptive access countries (green), 38.9 % resided in moderately favourable contraceptive access countries (yellow), 22.3 % lived in less favourable contraceptive access countries (orange), and 12 % lived in the least favourable access countries (red). Half (54.1 %) of the respondents were between 18 and 24, the majority had a higher level of education (83.5 % attended or had graduated from a college or university), 44.8 % were still students, and 44.3 % were in employment. Almost half (47.9 %) reported that they found it relatively easy or very easy to cover their basic needs (food, housing) while 17.0 % found that their financial situation was difficult or very difficult.

Firstly, we assessed the respondents’ knowledge of hormonal contraceptive methods. Altogether respondents knew about half of the six types of hormonal contraceptive. Knowledge about hormonal contraceptives varied by sociodemographic characteristics (Table 2). More specifically, the average number of hormonal methods respondents knew about was highest among respondents living in favourable contraceptive policy countries compared with countries with a less favourable policy climate, among students and people who are in employment as compared with unemployed respondents, and among respondents from advantaged socioeconomic backgrounds compared with those with a less advantaged economic background.

Secondly, we mapped the use of hormonal contraceptive methods. Altogether, 43.3 % of respondents in need of contraception were using other methods, 39.9 % were using hormonal methods, and 16.9 % were not using any form of contraception at the time of the survey. 

The use of hormonal contraception was highest in countries with the most favourable (62.3 %) and with moderately favourable (43.6 %) policies. Within the countries with the most favourable policy situations, the majority of respondents used hormonal contraception (62.3 %). Barrier and traditional methods were most commonly used in countries with less favourable (56 %) or the least favourable policies (55.7 %) 

Respondents who were self-employed, looking for a job or in a difficult financial situation were less likely to use hormonal contraception.

A quarter of respondents in need of contraception (25.3 %) were classified as having hormonal contraceptive hesitancy, based on their decision not to use contraception because they “didn’t want to use hormones” (n = 100), were “scared of side effects” (n = 60), or because they chose other methods to avoid hormones (n = 213). Altogether, side effects represented 18 % of the reasons for contraceptive hesitancy. 

Hormonal hesitancy varied from 6.7 % among hormonal method users to 31.6 % among traditional method users, reaching 53.1 % among non-users. Hesitancy was higher among the oldest age group, women with the highest level of education, and women who were self-employed. These patterns were mostly driven by differences in hesitancy levels among contraceptive users, while no sociodemographic differences in hesitancy were observed among non-users. More specifically, we found higher levels of hesitancy among contraceptive users living in the countries with the most favourable contraceptive policies, among older women, and among highly educated women. Hesitancy was also higher among non-religious women.

In multivariate analysis, it was only the policy environment that remained significant, with greater hesitancy in countries with a more favourable policy environment.

This study showed that there are wide variations in the use of contraception in general, and hormonal contraception in particular, across Europe. Regional disparities correlate with policies supporting or restricting access to contraception with greater levels of awareness and use in the most favourable contraceptive policy settings. Within-country disparities were also identified, since young people of the lowest socioeconomic status feel less knowledgeable about contraceptives and are less likely to use hormonal contraceptives than more affluent populations.

One in four respondents in need of contraception and over half of non-users express concerns about hormonal contraception. While hesitancy correlates with lower levels of use at the individual level, we also found greater levels of hesitancy in countries with the most favourable contraceptive policies and which have the highest levels of knowledge and usage of hormonal contraceptive methods. Hesitancy is also higher among women of a higher socioeconomic status. While misinformation and concerns about side effects are often cited as primary reasons for contraceptive hesitancy, we found that hormonal sceptics feel better informed about hormonal contraception than others and only 18 % directly cite side effects as their main reason for not using hormonal methods. Research highlights the role social networks and influencers play in enabling the spread of misinformation contributing to hormonal hesitancy, which can explain why hesitancy predominantly exists among groups who have greater access to and an increased awareness of contraception (Svahn et al., 2021). Respondents with greater access to information through social media and other media forums are more likely to discuss their contraceptive decision with their peers, including having discussions about the side effects and alternative options (Merz et al., 2021; Kofinas et al., 2014). 

Given the critical role of contraception in reducing unintended pregnancies among young people and promoting sexual health, these results call for more investment in proper information on contraception across Europe so that women can make informed choices. This is particularly relevant seeing that social media is increasingly promoting natural family planning methods, highlighting negative anecdotes about hormonal contraception, and often providing misleading and misguided information (Schneider-Kamp & Takhar, 2023). Societal shifts in medical authority, including increased individual responsibility, heightened distrust of providers, and opposition to the medicalization of women’s health, reinforce these messages. These shifts need to be acknowledged and accommodated in research and policy (Schneider-Kamp & Takhar, 2023). Given that young adults are often the targeted demographic group of these messages, efforts should be made to address these concerns while disseminating factual, accurate information about contraception. This should be accompanied by easy access to affordable modern contraception for young adults throughout Europe that helps them make informed contraceptive decisions.

This study has several limitations. The most important limitation is the use of convenience sampling to select participants. This is likely to introduce selection bias and limit the generalizability of the findings. Although the numbers of respondents are well distributed across regions, the sample population has a higher level of education, a higher socioeconomic status, and a higher employment rate than the general population of young people living in Europe (International Labour Organization, 2022; Eurostat, 2022). As such, it is likely that knowledge and use of hormonal methods are overestimated and social disparities under-estimated. On the other hand, as contraceptive hesitancy seems to be greater among more affluent populations, we may have overestimated this phenomenon. Secondly, the EPF study was not specifically designed to explore hormonal hesitancy, leading to an imperfect composite measure and limited information about the reasons for hesitancy, which may differ by region and socioeconomic status. Future research should expand on these exploratory findings using mixed-method approaches to better characterize the contours and reasons for hormonal hesitancy, who is susceptible to it and how it influences contraceptive decisions. This information is needed to inform decision making aids as well as counselling approaches to respond to a person’s concerns, preferences and needs with respect to contraception.