Contraception use, perceived susceptibility to pregnancy, and pregnancy desire among women experiencing homelessness.

Purpose: Women experiencing homelessness are at higher risk of unintended pregnancy. While contraception may reduce unintended pregnancy rates, women experiencing homelessness have low rates of effective contraception use. In addition to access and affordability, how women perceive their susceptibility to pregnancy on contraception may also explain disparate rates of contraception use. This qualitative study aimed to explore how women experiencing homelessness perceive their susceptibility to pregnancy with and without contraception. Methods: From December 2019 - March 2020, semi-structured interviews (n=19) were conducted among pregnancy-capable (i.e., not sterilized), English-speaking women experiencing homelessness in Fort Worth, TX, 18-45 years of age, as part of a larger system-wide study investigating contraception preferences for women experiencing homelessness. Participants were recruited through flyers at local shelters, active recruitment through case managers, community partnerships, and snowball sampling. Interview questions included hypothetical perceived susceptibility to pregnancy while on and off contraception, pregnancy attitudes, and actual contraception use. Interviews were audio-recorded, transcribed, and analyzed using a seven-step framework method for coding and theme identification. This study was approved by the North Texas Regional Institutional Review Board. Results: Women had a mean age of 33.4 years (SD=7.6 years), with reported race almost evenly split between Black (47%) and White (53%). Primary nighttime residence included emergency shelter (n=7), unsheltered locations (n=6), transitional housing (n=5), and rapid-rehousing (n=1). All but two women reported inconsistent or no contraception use. Most women were confident in general contraceptive efficacy and perceived low pregnancy susceptibility when using hypothetical contraception. Some women found their risk of pregnancy was equal with and without contraception based on perceptions of specific contraception efficacy (e.g., condoms versus pills); fertility and fecundity concerns; and high abstinence self-efficacy. When asked whether they would like to get pregnant in the next year, 47% said no (n=9), 21% said yes (n=4), and 32% said they did not know (n=6). All four participants who wanted to become pregnant in the next year did not report current contraception use at the time of the study. Most women who were unsure or not wanting pregnancy in the next year were also not using consistent contraception. Women who desired pregnancy in the next year or were uncertain of whether they wanted to get pregnant in the next year reported similar perceived susceptibility to pregnancy regardless of contraception use, compared to women not desiring pregnancy in the next year who had a higher perceived susceptibility to pregnancy without contraception and lower perceived susceptibility with contraception. Conclusions: Findings elucidate why some women experiencing homelessness may perceive similar pregnancy susceptibility with both contraception use and non-use. Given the need to have higher susceptibility to pregnancy without contraception use for consistent contraception uptake, findings may better explain lack of actual contraception use, preferences for contraception, and pregnancy desire. Understanding the interplay between perceived susceptibility to pregnancy, housing status, and pregnancy perceptions such as timing-based pregnancy intention can better promote contraception and pregnancy prevention for women experiencing homelessness who do not desire pregnancy.