My findings echo work overseas, showing how choices are shaped by:

1. effectiveness,

2. contraceptive burden, and

3. the degree of control afforded by various methods (see figure alongside).

These aspects influence how willing participants are to put up with the contraceptive burden and to give over control in order to use a LARC method. I discuss each of these aspects below and how they work together to shape participant’s decision-making.

Other international studies in similar countries⁶ and New Zealand³ have shown that those who are more motivated to avoid pregnancy may be more interested in how effective a method is; these women may be more open to or inclined to choose a LARC. A study in the USA, for example, proposed “a pregnancy desire spectrum” and concluded that: “Those strongly motivated to avoid pregnancy were most receptive to LARC methods, while those with less clear or mixed desires worried that these methods would prevent 'accidental' pregnancies that might not be unwelcome”.⁷ These conclusions correspond with my own preliminary findings. Based on participant’s accounts, their motivation to prevent pregnancy is related to a range of factors: personal (desire), situational (support), and social (consequences), as summarised in the diagram below.

Age, life stage, and relationship stage, like in other studies, play a role in where a participant lies on the “pregnancy desire spectrum”.^1,7 Some participants who were clear about wanting to avoid pregnancy in the foreseeable future where more open to long-term methods that were seen as more effective. Those participants who were not in a position to have (more) children saw the costs of unintended pregnancy as higher. They were more focused on the efficacy of the method. Some even spoke about seeking sterilisation for themselves (tubal ligation) or their partners (vasectomy). LARCs were considered the next best thing, when a permanent option was not made available to them. Worry or fear of becoming pregnant, known as 'reproductive anxiety', has therefore been found to motivate women to use LARC “because of the devices’ perceived effectiveness above and beyond other methods”.¹

In line with this, younger participants were more motivated to prevent pregnancy, and often expressed reproductive anxiety, because they wanted to achieve other life goals (e.g., education, career, travel), did not have enough resources, were not in a (settled) relationship, or felt otherwise unready. This echoes international trends which show that “college-attending young women, who typically are ages 18 to 24 years, tend to be highly motivated to prevent pregnancy, in part because they often give priority to finishing their education, establishing careers, and getting married before having children”.⁸

The opposite was true for many participants who were undecided about or open to having (more) children in the near future; they were less worried about the effectiveness of their contraceptive and interested in methods that could be more easily discontinued or reversed. In such cases, participants, like those in USA studies, considered LARC methods “too permanent”⁷ or “believed [long-acting] methods would prevent pregnancy longer than they desired, or were unsure how long they desired to prevent pregnancy”.⁹ This was usually because being older and in an established relationship was widely regarded as the ideal conditions for becoming a parent.

Pregnancy desires are clearly related to personal preferences, resources, and support. However, these desires are also shaped by cultural or societal ideals and norms about what counts as the ‘ideal' life course, including the best timing and spacing of children. In Western culture, early/single motherhood still attracts stigma. Several participants did speak their own or others’ experiences of stigma associated with being pregnant when young. For example: “I just had the stigma of being a teenage mother (.) who didn't finish high school. Every pregnancy was a disappointment, more than anything” (Lisa, 26, Pākeha, no contraception). Some expressed how this had motivated them to avoid being a ‘teen mum’, causing extreme pregnancy anxiety and making contraceptive use essential. This is evident, for example, when Sandra recounted her choice to take the “extra step” and change from the oral contraceptive pill to Jadelle, the contraceptive implant:

I know it was kind of like a shameful thing because I didn't have a home. I wasn't working and I had just finished high school and then I got into this relationship. It was like at all costs to try and not have children. So even though I had already been practicing safe sex, going the extra step was kind of diminishing or whatever other word, but I was like "Don't be another pregnant young person" (Sandra 24, Māori, implant user).

Although some mentioned that stigma associated with earlier motherhood is not common in Māori culture, wāhine Māori most often spoke about fear of or experience of stigma in mainstream society. Those who had teen/early pregnancies shared experiences of differential treatment, discrimination, and judgement in healthcare spaces. Some young Māori women referred to the dominant discourse of teenage pregnancy as inevitable for wāhine Māori and their attempts to avoid or resist this kind of racism. For example, Poppy (25, Māori, pregnant) said, “In terms of discriminating towards me as Māori, yeah like I said, hyper aware that that was an expectation of me. So, I refused to let that happen”. The motivation to avoid early pregnancy was related not only to the pursuit of other kinds of desires (e.g. education, employment), but also for their whānau, and to avoid discriminatory treatment. Similarly, other participants (both Māori and Pākehā ) who had had a previous unexpected/unwanted pregnancy were more determined to prevent another unintended pregnancy. For these participants, effectiveness of contraceptive became more important, confirming other findings in New Zealand³ and Australia.¹⁰

Individual needs and preferences come into play as the profiles of specific methods may be more or less appealing based on the mechanism used, the potential side-effects, and the location in the body.¹¹ Some might be unable, for example, to use a hormonal method, have a lifestyle or cultural view that does not allow some side-effects (e.g., heavy bleeding, non-menstruation), or simply be unwilling to tolerate certain outcomes. Some participants also expressed apprehension or distaste toward IUDs or implants due to how “invasive” they seemed. Like participants in international studies they described these methods as unnatural⁸ or alien¹². Some saw IUDs as less desirable because they are located internally, while others disliked the fact that the implants may be visible to others.

Alongside this, participants were not always sure what the outcome of using a specific method would be due to lack of knowledge, not being fully informed, or uncertainty about the effects until actually trying the method. Instead, like participants in an Australian study, participants described a process or “cycle of trial and error” as they tried to find “a method with side effects they could tolerate and an effectiveness they could live with”.²

Overall, most participants conveyed a sense of a lack of alternatives and spoke about having to make do with the “best of a bad bunch” suggesting that finding a suitable method most often entailed finding a method with manageable side-effects, rather than one with none at all.² Alongside this, options could be further limited by what is made available in the public healthcare system and how accessible services are (especially in terms of cost), as another local study also reports.³

It is also important to note, as other researchers have, that in addition to personal preferences, the willingness to tolerate side-effects and continue with a specific method or not is also related to the social meanings of side-effects.¹³ Side-effects that negatively alter a women’s appearance (i.e., weight gain, acne) or mood have social consequences for women because they may not be able to meet expectations of how they should look or behave. Women may be less prepared to tolerate weight gain in a society that values thinness, similarly, being perceived as “angry, emotional, or out of control”¹³ due to hormonal contraceptives may also not be acceptable. These issues were certainly mentioned by participants as important factors in choosing between different methods, alongside individual and systemic aspects.

LARCs “require women to relinquish some control over their bodies”.² Participants differed in terms of how they felt about this. In line with international research,[coombe 2016]² many participants reported that they did not like the loss of bodily control associated with some LARC methods, either because they preferred to have direct control over administering the method¹² or because of unwanted side-effects. These participants may, like those in a recent US study, feel that the effectiveness of a LARC lessens, rather than increases, their agency.⁷

On the other hand, also echoing the same US study, some expressed a sense of security because of the long-term effectiveness of LARCs.⁷ The implication of this, as suggested by an Australian investigation, is that effectiveness was important enough to make some women willing to deal with (potential) side-effects of LARC and to relinquish control to health professionals.² Therefore, the higher the motivation to prevent pregnancy, the more open a women may be to handing over some control in order to use a highly effective long-acting method. LARCs can offer peace of mind in terms of effectiveness, and also potentially reduce other mental or emotional contraceptive burdens, but the trade-off is less user control and reliance on a healthcare provider to reverse (with the exception of Depo Provera). This was less unattractive to woman who, as mentioned above, are ambivalent about having children or less firm in their desire to prevent pregnancy in the long-term. These women wanted to be able to “hop on” or off a contraceptive according to changes in their circumstances or desires.

Overall, participants generally painted a picture in which their choices were restricted or constrained. Several women presented contraception as a “necessary evil”, that is, as necessary if one wished to avoid pregnancy. Any negative aspects of contraception (especially side effects) were considered preferable to an unwanted pregnancy. This reminds us that the more important avoiding pregnancy is, the more willing women may be to tolerate the undesirable aspects of contraception. Regardless of the method chosen, using contraception was seen as a must. Contraceptive non-use makes it very difficult for women to give an account of themselves that is not open to judgement, because to a large extent using contraceptives is seen as the default, “normal”, and "responsible" option.¹⁴ Opting out of contraception (for example to use non-medical options) is difficult to do without being seen as irresponsible and this was mentioned only by a small minority of participants. Those participants who had requested tubal ligation (sterilisation) reported that they had met with resistance from health providers, making LARCs their next best, but not preferred, option.

In addition, almost all the participants indicated that they as women were the one primarily or exclusively responsible for preventing pregnancy. Given that most contraceptives are female-body based, if participants were seeking to limit side-effects, they had to opt for non-hormonal or relatively less-effective methods than LARCs (e.g., condoms, withdrawal, “natural” family planning). Most reported that male partners were concerned, supportive, or involved in discussions about contraception, but only a very few mentioned how male partners shared some of the (non-physical) contraceptive burden. These men would try to reduce the financial or mental/emotional burden (e.g., tracking appointments, reminders to use/take a contraceptive, providing support during procedures). Some participants had asked their partner to have a vasectomy and so take up the main responsibility for preventing pregnancy. This option is the only male-user method that is comparable to long-term contraception, but it is also permanent and so only an option when no (further) children are desired.