https://orcid.org/0000-0001-6094-5143
Figures
Abstract
Background
Women living in high-quality healthcare systems are more likely to use oral contraceptives at some point in their lives. Research findings have sparked controversial discussions about contraception in the scientific community and the media, potentially leading to higher rates of method discontinuation. Understanding the underlying motives for method discontinuation is crucial for reproductive health equity and future programming interventions. To address this question, this study aims to explore women’s experiences of oral contraceptive use and discontinuation on YouTube.
Methods
A concurrent explanatory mixed-methods design was used to conduct content analysis of German YouTube videos. The information from 175 videos of 158 individuals was extracted through quantitative descriptive content analysis. Twenty-one individuals were included in the qualitative content analysis.
Findings
The body was a recurring theme in the pill biographies. Women described, for example, bodily sensations as reasons for taking and stopping the pill. They also described positive and negative side effects while taking the pill and after stopping. The most common side effects of taking the pill mentioned by YouTubers were mood swings (76/158), weight gain (45/158), headaches (33/158), and depressed mood (45/158). The symptoms after discontinuation reported most were facial skin impurities (108/158), decreased mood swings (47/158), hair loss (42/158), and weight loss (36/158). Overall, women overwhelmingly rated their discontinuation experience as positive (87/91).
Conclusions
The study identified key symptoms of oral contraceptive initiation and discontinuation by portraying the experiences of female YouTubers, adding valuable insights to the understanding of method initiation and discontinuation. Further research is needed to explore women’s personal experiences with method discontinuation beyond the YouTube platform.
Citation: Niemann J, Wicherski L, Glaum L, Schenk L, Stadler G, Richter M (2024) YouTube and the implementation and discontinuation of the oral contraceptive pill: A mixed-method content analysis. PLoS ONE 19(5): e0302316. https://doi.org/10.1371/journal.pone.0302316
Editor: Deidre Pretorius, Wits University: University of the Witwatersrand Johannesburg, SOUTH AFRICA
Received: January 13, 2024; Accepted: April 1, 2024; Published: May 24, 2024
Copyright: © 2024 Niemann et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Full data are available from the corresponding author or the Institute for Medical Sociology at the Martin-Luther-University Halle-Wittenberg (medizinische-soziologie@medizin.uni-halle.de) upon reasonable request.
Funding: This publication was supported by the Open Access Publication Fund of the Martin Luther University Halle-Wittenberg. The funders did not influence the data analysis and the results.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: IUD, Intrauterine device; OCP, Oral contraceptive pill; SNSs, Social networking sites; VTE, Venous thromboembolism
Introduction
The oral contraceptive pill (OCP) is a crucial contraceptive in high-quality healthcare systems in Northern and Western Europe [1–3]. Since its introduction 60 years ago, women have continued to report on the side effects of the pill [4]. Recent research has supported these claims, particularly regarding associations with side effects such as depression or venous thromboembolism (VTE) risk (e.g. [5–10]). However, most of these studies have reported associations, not causality. This has led to increasing criticism, especially by mainstream media [2,11–13].
The pill and mainstream media–a problematic relationship?
History of the relationship between the pill and mainstream media.
The dynamic between mainstream media and the OCP has had a long history: women’s right to sexual self-determination and the OCP’s side effects have been discussed in the media for more than half a century [14,15]. An important example is the “pill scare” phenomenon of 1995 [16–18], focusing on high-income countries. In this case, the dissemination and interpretation of scientific research regarding the risk of VTE associated with the OCP led to an increased number of discontinuations [16]. This was followed by individual contraceptive use and increased unintended pregnancies and abortions (e.g. in New Zealand [17], Britain [15], and Norway [18]). Media-critical discourse continued to emphasize the increased risk of VTE in the 2000s and early 2010s [15], while ignoring studies that found no increased risk [15]. This stance was also taken up in the OCP report [11] in Germany in 2015, which lacked scientific rigor [19]. The authors concluded there was a higher risk of thrombosis with the more modern 3rd and 4th generation OCPs. This was further disseminated by the media [20–22].
In 2016 and 2017, the media focused on the findings of increased risk of depression [23,24], based on two Danish studies [9,25]. These studies were, however, criticized in the scientific community due to methodological weaknesses [24]. Bitzer (2017), for example, criticized the lack of sensitivity analysis and questioned the biological plausibility [24]. Women shared their personal experiences with the OCP during this wave of OCP-skepticism under the #MyPillStory on social networking sites (SNSs) [26,27]. The VTE risk associated with the OCP was compared to that associated with the Vaxzervria vaccine (formerly COVID-19 Vaccine AstraZeneca) during the SARS-CoV-19 crisis. This is a difficult comparison because the VTE associated with OCPs is deep vein thrombosis and pulmonary embolism, whereas the VTE risk associated with the AstraZeneca vaccine is cerebral venous sinus thrombosis [13].
In summary, the media discussion of OCPs has underrepresented studies that do not show correlations with adverse side effects and have often failed to distinguish between absolute and relative risks [15,23]. The scientific analysis and evaluation of online contraceptive information has, therefore, become particularly important.
Researching SNSs and hormonal contraception.
The relationship between media journalism and healthcare decision-making has increased significantly with the advent of the Internet [14,28]. Greater access to online resources and SNSs has expanded the range of information available to women and increased their autonomy to choose contraception [13,14]. Hence, they have emerged as powerful tools for health communication.
This increase has also necessitated an exploration of the content, narratives, and quality of online information regarding (hormonal) contraception. Vieth et al. (2021) found that the internet was the most common source of contraceptive information among German women [29]. Studies, for instance, researched the experiences of birth control on YouTube [30–33], TikTok [34,35], and Reddit [36]. An analysis of German SNSs’ contraception content on YouTube, Instagram, and TikTok found clear shortcomings in the quality and completeness of information on these sites [37]. Additionally, a study by Alves and colleagues [38] found that most of the websites mentioning the VTE risk associated with OCPs do not refer to information from accredited health agency sources. In terms of health communication science, so-called health laypeople (users of a contraceptive method) can disseminate information on the Internet [39]. Döring et al. (2023) showed that most German contraceptive content on YouTube, Instagram, and TikTok was uploaded by health laypeople, sharing personal contraception stories [37].
Informed choice regarding contraceptive methods is an important component of the Sexual and Reproductive Justice Framework [26,40]. Knowledge and information can contribute to achieving justice through increased reproductive agency and contraceptive choice [26]. However, the biased media attention and misinformation might lead to higher discontinuation rates among OCP users.
OCP discontinuation.
Contraceptive discontinuation can be defined as “starting contraceptive use and then stopping for any reason while still at risk of an unintended pregnancy” [41]. A German study on the knowledge and perceptions about OCPs among young women showed that 64.5% (n = 1480) of those who used OCPs at some point discontinued the method [29]. Simmons et al. examined the cessation of contraceptive methods as part of a person’s Contraceptive Journey [42]. They defined key factors contributing to this decision: physiological factors, values, experiences, circumstances, and relationships (e.g. family, (sex) partners, friends, healthcare professionals). The discontinuation of OCPs deprives the body of an external source of artificial progesterone and estrogen, resulting in a change in the hormone levels in the body [43,44]. Current medical research on OCP discontinuation is limited to fertility restoration [45,46], fecundability [44], cycle characteristics [45,47], and reasons for discontinuation [29,42,48].
Contributing to the narrative of OCP discontinuation, Kissling explored posts of individual experiences on blogs and websites through a postfeminist lens [49]. Furthermore, Döring conducted a content analysis of German posts about the OCP on TikTok and YouTube [23]. She was interested in who the authors of the posts were, what the messages were about the OCP, and what the audience’s reactions were. She found that most of the posts on YouTube came from health laypeople. She characterizes them as “pill-weary women” who give autobiographical accounts of taking and stopping the OCP. Viewers’ reactions to these posts are mostly very positive, with many views and likes, very few dislikes, and lots of friendly comments. Adding to this, a recent study on birth control content on YouTube found that most women in 50 videos talked about their discontinuation experience with the OCP: the main outcomes after discontinuation were worsened acne (22%), improved mood (18%), cycle irregularities (14%), and increased energy (14%) [33].
However, the health consequences of discontinuing OCPs generally and on social media have not been adequately studied in the German context. There is also, as noted by Inoue et al., a lack of research on women’s own experiences after stopping OCPs [48].
Content analysis objectives and research questions
YouTube has established itself since 2005 as a way for individuals to share information and present themselves online. It is a video-sharing platform that is constantly changing [50]. Based on Döring’s and Pfender and Devlin’s analyses, YouTube videos uploaded by health laypeople, provide an opportunity to scientifically examine these personal experiences and determine the health consequences of initiating and discontinuing OCPs [33,39].
The overall objective of this content analysis was to investigate the personal physiological and psychological changes and lived experiences of German-speaking YouTubers after initiation and discontinuation of OCP treatment. We, therefore, aim to examine
- the reasons for starting and discontinuing the use of the OCP,
- to document any side effects experienced during and after use, and
- how the women describe their history with the OCP.
Methods
Design
The study follows the Open Science movement, i.e. the pre-registration, and all data are stored on the Open Science Foundation server (https://osf.io/fekdh/). It was designed as an (almost) simultaneous exploratory mixed-methods content analysis [51]. The quantitative component was primarily used to present overall video characteristics and estimates of video content data. The qualitative component explored YouTubers’ perceptions and beliefs as an in-depth analysis to complement the quantitative research. The qualitative and quantitative research strands were initially analyzed separately and then brought together for the interpretation and presentation of the results.
Sample
YouTube was initially searched from July 20 to 23, 2021. An updated search was performed on May 5, 2023. The internet browser and cookies history were cleared before the search to avoid biases from our laptop. The sample was examined by using common searches for videos of German-speaking women who explained their personal experiences with the discontinuation of the OCP. YouTube was searched using the autofill feature in the search bar (which uses an algorithm influenced by users’ popular searches to automatically fill search queries with root words) [52]. The following translated search terms were used: “stop taking the pill,” “stop taking the pill experience,” “discontinuation of the pill,” and “discontinuation of the pill experience” (the exact German terms are provided in [S1 Table]). This search was performed following previous YouTube analyses (e.g. [50,52,53]). The videos were sorted by the relevance filter (= year). All videos were included for each search term. They were then checked for duplicates.
Only videos that met our inclusion criteria, as shown in Table 1, were included.
If a YouTuber repeatedly uploaded more than one video, two to three videos were included: The first uploaded video (most likely to contain relevant information about the reasons for discontinuation or duration of OCP use) and the second and/or last uploaded video (probably the most recent version regarding immediate health consequences). If a YouTube video was uploaded with two women talking about their experiences, both individuals were included in the study. Different personal identifiers (see ethics) were assigned.
Fig 1 shows the flowchart of the search. A total of 1344 videos were initially collected by JN. After removing all duplicates, 591 videos were reviewed by JN and LW. After removing an additional 416 videos, a final number of 175 videos from 158 YouTubers were included in the sample for quantitative content analysis. All individuals could be identified as female.
Hereinafter, 18 videos were included as an initial sample for the qualitative content analysis. These were selected by JN and LW after reviewing all 175 videos, based on stratification factors, to represent the variety of experiences of the study sample:
- reasons for initiation and discontinuation,
- length of initiation,
- age at initiation and discontinuation, and
- experienced side effects during intake and after discontinuation.
After JN and LW coded the initial sample, three additional videos were included to reach the point of data saturation [54]. This resulted in a total qualitative sample of 21 videos.
Procedure and analysis of the content analysis
The uploaded videos (audio and text presentation) and the person(s) who reported on their personal experiences with stopping the OCP on the online platform YouTube were the units of analysis for the media content.
Procedure and analysis of the quantitative content analysis.
A predefined, theoretically driven codebook (S1 File) was developed. The quantitative content analysis consisted of coding content data related to the video (e.g. V001) and the person(s) reporting their experience (e.g. P001):
- Typical YouTube video characteristics, including posting date, video length, number of views, likes, and comments.
- General content data regarding the OCP persistence and discontinuation, such as the time of video recording after discontinuing the OCP (weeks), length of OCP persistence (years), age at initiation and OCP discontinuation, second discontinuation, reasons for initiation and discontinuation (0 = not mentioned, 1 = mentioned), and current contraceptive method (0 = not mentioned, 1 = mentioned).
- Content data regarding the OCP implementation, including the mention (0 = not mentioned, 1 = mentioned) of improvements (e.g. facial skin) and side effects (e.g. migraine).
- Content data regarding the OCP discontinuation, including the mention (0 = not mentioned, 1 = mentioned) of the physiological and psychological changes (e.g. mood swings).
The translated codebook is available as (S1 File). JN and LG independently assessed the intercoder reliability of the codebooks based on 17 randomly selected videos from the sample. The Krippen-Dorff’s Alpha reliability coefficient was calculated for all content variables in the codebook. The following average reliability value was obtained for the codebook: 0.813, indicating good measurement accuracy [55].
Data was collected by downloading the videos and the text presentation. These were transferred directly into MAXQDA 2020, where the material was coded by JN. The data were then transferred to an Excel spreadsheet. Quantification was performed by JN using descriptive data analysis (frequencies and percentages) in STATA 14.2.
Procedure and analysis of the qualitative content analysis.
This analysis consisted of coding the content data related to the person sharing their experiences (e.g. P001) in the uploaded video. After selection, the videos of YouTubers were transcribed verbatim. Their content was then analyzed by JN and LW according to Mayring’s qualitative content analysis [56]. A category system was developed beforehand, according to which, the content-related aspects of the material were examined. The category system is available as (S2 Table).
The categories were developed based on the current state of research and by considering the codebook of the quantitative research strand. Further subcategories were created based on the research questions and inductively from the material. Coding rules were subsequently defined, and anchor examples were added. The videos were transcribed and coded by LW and JN in MAXQDA 2020.
Reflexibility. The two main researchers involved in the qualitative research (JN and LW) have taken and stopped the OCP themselves. Although we were not required to participate in interviews, our lived experiences were part of the knowledge production in this study. Both researchers talked about the process of coding and creating categories throughout the data analysis.
Ethics
The ethical approval for this study has been granted by the Ethical Review Committee of the Medical Faculty at Martin Luther University Halle-Wittenberg. The German Society for Online Research [57] states that the use of publicly available data for scientific research is ethically appropriate even without informed consent. Before a person uploads a video on YouTube, they have to consent that their data can be reused through third parties [58]. Therefore, a certain level of awareness can be assumed [59]. We are aware that this requires a certain level of maturity. Therefore, we decided to only include adult YouTubers who are aware of their publicity (e.g. through follower numbers) and the publicly available works.
All videos and individuals were pseudonymized at the beginning of the data collection to minimize the risk of identification. This makes it impossible or very difficult to identify them in the research process: All videos were assigned a video identification number (e.g. V001). All people have a personal identification number (e.g. P001). The personal data (e.g. title, YouTube channel name) were separated from the factual data (e.g. time of posting, views) and stored on different media (USB key).
The collection and analysis method complied with the terms and conditions for the source of the data.
Results
The 175 Videos analyzed in this study were posted between 2014 and 2023. The mean video length was 14.8 minutes. The detailed general characteristics are available in the (S3 Table).
General characteristics of the OCP persistence
The mean duration of OCP use was 8.2 years. Women started using OCPs at a mean age of 14.8 years. The mean age of discontinuation was 23.1 years. See Table 2 for details.
The OCP implementation and discontinuation
The following results show that embodiment and effects on the body play a central role in OCP use and discontinuation. This recurs in the detailed descriptions of the psychological and physical aspects of each phase of the OCP autobiographies uploaded.
Characteristics of the OCP implementation.
Table 3 details all the information on the OCP implementation. A total of 57 of 158 YouTubers changed their type of OCP during the implementation period. Aspects of this are that switching may have occurred because of side effects of the OCP (P018, P149), side effects that occurred after switching (P010, P100), or side effects persisted and worsened after switching (P149).
The reasons for taking the OCP were varied and included facial skin impurities (35/158), contraception (30/158), and/or painful menstruation (27/158). Many felt that the OCP was the only option available to them and were unaware of alternative contraceptive methods. The women expressed the normality of the OCP as a solution for treating facial skin impurities (P002) and the gynecologist’s recommendation for easing menstrual cramps (P010). According to the average age at initiation, it was stated that pregnancy was not an option due to the young age and that the OCP was considered a safe method of contraception (P006, P018, P149).
Positive side effects during implementation.
Overall, 45 of the 158 women experienced improvements while using OCPs. The improvements were consistent with the main reasons for initiation: facial skin impurities (25/158), painful bleeding (19/158), and decreased bleeding (12/158). The OCP appears to be particularly convenient as it combines the treatment of medical problems, such as painful bleeding, with the need for contraception (P007, P010).
Negative side effects during implementation.
Physiological side effects were reported by 101 of the YouTubers in the study. The most common side effects were weight gain (45/158), headaches (33/158), and water retention (30/158). Headaches seemed to be very distressing and interfered with women’s lives (e.g. P001, P007, P100). A total of 103 women reported psychological side effects. The most common psychological side effects were mood swings (76/158), depressed mood (45/158), and deterioration of libido (31/158). Mood swings were characterized as being moody, irritable, unrelaxed, aggressive, or angry (e.g. P010, P032, P054). Women also reported feeling that something was missing or feeling emotionally numb while on the OCP (e.g. P032, P085, P148).
Characteristics of the OCP treatment discontinuation
As described in Table 4, the main reasons given by YouTubers for discontinuing the use of OCPs were the side effects experienced (74/158), increased awareness of the topic (21/158), and the desire to stop taking hormones (34/158). Qualitatively, side effects that led to discontinuation could include a tipping point where a user could no longer tolerate the side effects. In particular, the severe impact of headaches while taking the OCP was reported as a side effect leading to discontinuation (P001, P007, P018). A total of 27 of all YouTubers in the study reported discontinuing the OCP for the second time. The reasons for resuming the OCP were changes (e.g. facial blemishes) after the first discontinuation. However, as one YouTuber explained in P018, the side effects of the OCP were even worse, which then led to the final discontinuation of the method. Ultimately, former users of the OCP had a variety of reasons for stopping, but all prioritized their overall health and well-being.
Improvements after discontinuation.
Out of 158 YouTubers, 54 mentioned physiological improvements and 82 mentioned psychological improvements from discontinuation. The most common improvements mentioned were weight loss (37/158), the disappearance of headaches (23/158), decreased fatigue (13/158), decreased mood swings (47/158), increased libido (40/158), and decreased depressive mood (19/158). Women reported that discontinuation improved their psychological mood: They felt more relaxed and had a more positive attitude (P001, P002, P036, P048, P054). They also reported a return or increase in their libido (P002, P100, P140, P149). Many expressed that they did not expect how intense this return would be (P010). They reported feeling more in tune with their bodies and experiencing a greater sense of euphoria after weaning off the OCP.
Negative changes after discontinuation.
In general, 123 of all women in the study experienced negative physiological and 32 experienced psychological changes after discontinuation. An increase in facial skin impurities was the negative physiological change most reported after discontinuation (108/158). This was followed by hair loss (42/158), painful menstruation (36/158), and menstrual cycle irregularities (31/158). Negative psychological changes included mood swings (16/158) or the onset of premenstrual syndrome (10/158). The YouTubers claimed that their facial skin impurities were never as bad as they were after stopping the OCP. They mostly described their facial blemishes as “normal” and not as severe as in people with “real” acne. Conversely, they also described the onset of facial skin deterioration as a major challenge and burden. Due to the strong identification with their facial skin and external appearance, this had become a problem. Thus, good make-up and the thought that others also have facial skin imperfections should help to conceal and accept one’s facial skin, which is seen as a flaw (P002, P018, P100). A minority of women stated that discontinuing the product caused a worsening of their psychological state (P085).
Evaluation of contraceptive discontinuation.
Overall, 87 of 91 YouTubers rated their experience of discontinuation as positive. The women reflected on the strong influence of the OCP on their bodies and health (P002, P010). They described how happy they were to have freed their bodies from artificial hormones (P079), and that they were more in tune with their bodies and more aware of themselves (P010, P044, P100, P149). Words that appeared frequently in the conclusions were “liberated” and “freer.” Women felt freer after weaning off the OCP, for example, even though they said it was difficult to put this into words (P032, P036, P054).
Critical views on the OCP treatment
Looking back on their time on the OCP, women also expressed critical views. It was emphasized that the first sexual experiences in life were made under the influence of the pill (P010, P044). As one YouTuber explained:
“One of the things I think is very fatal about very young girls being prescribed the pill is that many start taking it before they even have a sex life. That’s exactly what happened to me. That is, every sexual experience I had was under the influence of the pill, so I didn’t even know what sex and my sexuality would be like without the pill. So, for years I thought a lot of things were normal.” (P010)
The pill was also seen as a moneymaker for the medical/pharmaceutical market (P032) and as a beauty product (P119, P149). The method of prescribing hormones to young girls at the beginning of puberty was questioned. They YouTubers also criticized the fact that the OCP was/is prescribed as a solution to non-contraceptive problems, such as facial blemishes or cycle irregularities. As this woman explained:
“And then I really wonder if it’s necessary to try to influence that with drugs and hormones. Or,
maybe you could approach it differently or go in the direction of facial skin care and see a dermatologist to see if that might help […]. Instead of just taking these hormones, especially at a young age, to get a better picture, I find it a little bit critical, to be honest, because I always think to myself, I don’t know, it’s coming from something else in your body. And you’re just not treating the cause, you’re just treating the problem at that moment.” (P119)
The general cost of contraception as a female burden was also mentioned. P130 described that:
“Of course, it costs money, and you shouldn’t forget that either. It’s also really absurd that we women have to pay for it and the men don’t. Not because of men and women, but I think the health insurance should pay for it. I can’t even think about paying that much a month. And I never go to the doctor. Never. I never have anything. I don’t even know what for.”
What is interesting here is that they see the financial burden as something that should be negotiated and shared between men and women. She goes one step further and demands that health insurance should cover contraception. Women described different aspects of stopping the OCP in several videos.
Recommendations regarding the OCP
The first recommendation was that women should not stop taking the OCP without information and indiscriminately (P018, P050). Women should make up their minds, seek medical advice (P002, P007), and not stop taking the OCP overnight, especially if it is being used for contraception. It was also mentioned that both starting and stopping the OCP is a very individual matter (P018, P032).
The second recommendation emphasized that discontinuation is an individual decision. The YouTubers explained that the choice of contraception is a private matter (P006). You should not be talked into it (P018, P054) and make your own informed decision:
“It doesn’t have to be for everyone and I would say to you don’t let anybody talk you into something if you feel comfortable with it and it doesn’t have to be the pill, it actually applies to all situations in life. If you feel comfortable with something and you think it works for you, then stick with it. Don’t let anybody talk you into something that you don’t feel is right for you.” (P085)
Finally, some YouTubers also recommended stopping the OCP (P140, P010). They were extremely positive about their experience of stopping, describing how it is better to do without:
“That’s why I can advise every woman and every girl to think about whether you take the pill, whether you start taking it or whether you continue taking it. Do some research. Pay attention to your body, pay attention to possible side effects, and think twice. So if you are thinking about going off the pill, I wish you perseverance and I promise you it will have a positive impact on your life and you will not regret it.” (P010)
Discussion
This analysis demonstrates that bodily experiences and the body itself are significant components in OCP autobiographies, from initiation to the period after discontinuation. The primary reasons for initiation are to address facial skin impurities, use as a contraceptive method, and to alleviate painful menstrual cramps. Common side effects experienced during the use of OCPs include mood swings, weight gain, headaches, depressed mood, decreased libido, water retention, and migraines. Women have described these effects as burdensome, despite the OCPs serving both medical and contraceptive purposes. Women predominantly discontinue OCPs due to side effects, a desire to cease hormone intake, and increased awareness of related issues. After discontinuation, individuals commonly reported deterioration in facial skin impurities and hair. But noted weight loss, reduced mood swings, increased libido, and a generally positive experience of feeling more connected to their bodies and freer. To the best of the authors’ knowledge, this is one of the few studies on the personal views and experiences of women who have discontinued the OCP. The combination of quantitative description and qualitative analysis in interpreting the results was not only helpful in measuring experiences with the OCP, they showed how these experiences are perceived and lived. The results of this study are consistent with scientific research on the positive and negative side effects [60–62] of OCPs, the reasons for discontinuation [29,48,63], and embodiment [64,65].
Puberty is the time when most girls in quality healthcare systems visit a gynecologist for the first time. This may be for specific health problems, such as menstrual cramps, acne, and cycle irregularities, or contraceptive advice [66,67]. In our sample, most women initiated the OCP during puberty, an age when physical and hormonal development from girl to woman is not yet complete. The OCP, therefore, acts as a drug in an organism that is not yet fully developed [68]. In this context, health professionals must provide information and advice on the costs and benefits of contraception.
The side effects reported by the YouTubers during OCP treatment are generally consistent with the associated side effects reported in other studies [43,61,69] and listed on the OCP’s package inserts [70]. However, the high number of side effects experienced by YouTubers was striking. This may be because YouTubers may be more likely to report discontinuing the pill if they have experienced side effects while either taking or discontinuing the OCP. Thus, there may be a publication bias in the YouTube videos and the results should be interpreted with caution.
The strata of this analysis are characterized by their young age at quitting. This may reflect the medium of YouTube as a YouTube consumer, which is specific to the sample of this study. However, it could also reflect the fact that women stop using the OCP at a relatively young age, particularly compared to the average age of women at first birth in the European Union (29.4 years) and Germany (31.2 years) in 2019 [71].
The main reasons for discontinuing OCP use reported were side effects and the desire to stop taking hormones. This is consistent with the quantitative literature, where side effects [29,48,63] or concerns about long-term effects [29] are predominantly cited as the main reasons for discontinuation. Additionally, Pfender and Devlin’s analysis (2023) reported that 22 out of 50 YouTubers discontinued hormonal contraception in favor of “being more natural” [33]. A systematic review of medical and epidemiologic studies in 2015 [48], which examined OCP discontinuation, found that pregnancy was among the top two reasons for discontinuation. This discrepancy could be explained by the young age at discontinuation of the sample included in this study. However, it may be some of the other reasons for discontinuation mentioned above that prompted the women to create a YouTube video.
Scientific studies show that women especially are under social pressure when it comes to their external appearance [72–74]. Even mild forms of acne, for instance, are associated with a reduced quality of life [75]. The study showed that facial skin impurities were the most common symptom after discontinuation of OCP therapy. Even the mild symptoms reported by women were associated with reduced self-esteem and discomfort. Accordingly, medically harmless facial skin complaints after discontinuation represent a major psychological burden for female YouTubers. The literature also describes that women, on average, experience longer cycles and more variability in cycle length after discontinuation [46,47,76]. This is consistent with the experience of female YouTubers. The OCP has also been questioned and studied for its possible negative association with mental [10,25,61,77] and sexual health [10,62,69]. Research on these topics should still be interpreted with caution, as there is limited consistency in the direction of the evidence [10]. Although it did not seem to be a central theme among the YouTubers, women in our sample reported mood swings and a decrease in libido as side effects of OCPs and their improvement after discontinuation. Interestingly, the prescription of OCPs before young girls have a regular sex life was also criticized. Despite the negative impact of health symptoms after discontinuation, such as facial skin impurities, the women overwhelmingly experienced discontinuation as positive.
When OCPs are discontinued for reasons other than pregnancy, the use of other effective contraceptive methods is very important for reproductive health, otherwise, women are at high risk of becoming pregnant. The data show that most YouTubers switch to condoms or a copper implant (IUD, ball, or chain). However, NFP, a modern fertility awareness-based method, is also used quite frequently. Both copper implants [78] and modern fertility awareness-based methods are effective ways to prevent pregnancy [79,80]. In addition, research shows that women have an increasing desire for more autonomy in their contraceptive choices [81–84]. Informed women’s choices are associated with better contraceptive adherence and fewer contraceptive failures [85]. However, there may be differences in the counseling and recommendations of healthcare providers regarding contraceptive methods. Research by Irala et al. (2011), for example, suggests that OCPs and the IUD were predominantly chosen as contraceptive methods because of the doctor’s suggestion/recommendation rather than because of the women’s wishes [86]. The opposite was true for the male condom or modern fertility awareness-based methods. A German study (2022) found that participants said they would like to be better informed about the OCP [29], and that women who received information from their gynecologist were more likely to feel well-informed (OR 1.59, CI: 1.10–2.30) than those who received information from the Internet [29]. Healthcare providers should be made more aware of alternative contraceptive methods other than OCPs to increase the autonomy in contraceptive choice and ensure contraceptive effectiveness.
Looking at all the results, the body and bodily perception seem to play a central role in all phases of the OCP autobiography. The embodiment is reflected in the reasons for initiating and weaning off OCPs, the side effects experienced, and the changes that occur after stopping the OCP [79]. This role of bodies and contraception is consistent with other research: the OCP and other contraceptive methods, for example, have led to women having greater control over their reproductive bodies [80,81], and the importance of the (gendered) body in women’s contraceptive decision-making [36,80,82].
Future research directions
The framing of health information can influence health-related beliefs, attitudes, and behaviors [87]. The increase in information and interpretation of scientific evidence in the media can improve informed contraceptive choices. Conversely, they can also negatively affect public health through misinterpretation of scientific evidence [28]. We emphasize the need to further investigate the relationship between SNSs and individual contraceptive method choice discontinuation. There is a need for longitudinal and qualitative research to examine and explore the underlying processes and how these choices change over the life course [42]. In the context of our study design, it would be interesting to investigate if and how the private experiences of influencers on YouTube and other SNSs platforms (e.g. Instagram & TikTok) are used as health information regarding method discontinuation choices. In particular, women who seek contraceptive information online appear to have lower levels of trust in information provided by their gynecologists [29]. It would also be interesting to explore the underlying motivations and phenomena behind the public uploading of such private information, especially within the dynamics of self-presentation and online marketing.
Strengths and limitations
The methodological strength of this study was its mixed methods design. It allowed for a greater contextual understanding of the descriptive data presented through the qualitative analysis. In addition, the findings represent the personal views and experiences of the women. These are naturally expressed and not biased by the research design itself. However, because these findings are based on YouTube, they may have limited generalizability and transferability to the general population. The sample may be biased because the women who post content on YouTube may be different from the average woman who discontinues hormonal contraception. This recruitment method did not allow us to collect important background information (e.g. socioeconomic status, gender, ethnicity). Furthermore, for a large proportion of our study participants, we had to assume from looks and past upload history that they were adults. The study is also limited in terms of validating the qualitative aspect of this study as the data is retrospective, thus, preventing iteration and triangulation as additional validation methods. In addition, women who experience severe side effects during use and health symptoms after discontinuation may be more likely to post their experiences on YouTube than women with no side effects or symptoms. Thus, we do not know which of the data is factual and which might be influenced by self-presentation on SNSs. The reach of the videos may also have led women to be less open about this sensitive topic than, for example, in face-to-face interviews. This study is also limited to the content of what women report in their videos. It cannot, for example, consider changes in life circumstances (e.g. change of life/sexual partner, facial skin care routine).
Conclusions
This content analysis of YouTube videos portrayed the personal implementation and discontinuation experiences of OCPs among female YouTubers. In doing so, the study provided valuable insights into the lived experiences, perceptions, and opinions of women who discontinued OCPs in the context of quality healthcare systems. Future qualitative and quantitative research is needed to provide information on the motivations, subsequent health symptoms, and healthcare needs associated with discontinuing OCPs.
Supporting information
S3 Table. Video descriptives, detail (N = 175).
https://doi.org/10.1371/journal.pone.0302316.s003
(DOCX)
S1 File. Translated codebook for the quantitative content analysis.
https://doi.org/10.1371/journal.pone.0302316.s004
(PDF)
Acknowledgments
We recognize that people other than cisgender women have menstrual periods and use birth control to prevent pregnancy. In this article, we understand the word “women” to be an inclusive term. However, when referencing research, we use the term used to describe the participants throughout the publication.
We want to thank the thoughtful comments of the reviewers of this study for their encouraging thoughts and comments on this publication.
References
- 1.
United Nations Department of Economic and Social Affairs. Contraceptive Use by Method 2019.Data Booklet. 2019 [cited 24 Jan 2021]. Available: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf.
- 2. Khialani D, Jones ME, Szépligeti SK, Ording AG, Ehrenstein V, Petersen I, et al. Combined hormonal contraceptive use in Europe before and after the European Commission mandated changes in product information. Contracept X. 2020;2: 100018. pmid:32550533
- 3. Johnson S, Pion C, Jennings V. Current methods and attitudes of women towards contraception in Europe and America. Reprod Health. 2013;10: 7. pmid:23384291
- 4. Dhont M. History of oral contraception. Eur J Contracept Reprod Health Care. 2010;15 Suppl 2: S12–8. pmid:21091163
- 5. Burrows LJ, Basha M, Goldstein AT. The effects of hormonal contraceptives on female sexuality: a review. J Sex Med. 2012;9: 2213–2223. pmid:22788250
- 6. Hertel J, König J, Homuth G, Van der Auwera S, Wittfeld K, Pietzner M, et al. Evidence for Stress-like Alterations in the HPA-Axis in Women Taking Oral Contraceptives. Sci Rep. 2017;7: 14111. pmid:29074884
- 7. Sitruk-Ware R. Hormonal contraception and thrombosis. Fertil Steril. 2016;106: 1289–1294. pmid:27678035
- 8.
European Medicines Agency. Combined hormonal contraceptives. 2019 [cited 16 Dec 2019]. Available: https://www.ema.europa.eu/en/find-medicine/human-medicines/referrals/combined-hormonal-contraceptives.
- 9. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry. 2016;73: 1154–1162. pmid:27680324
- 10. Buggio L, Barbara G, Facchin F, Ghezzi L, Dridi D, Vercellini P. The influence of hormonal contraception on depression and female sexuality: a narrative review of the literature. Gynecol Endocrinol. 2022;38: 193–201. pmid:34913798
- 11.
Boeschen D, Günther J, Chytrek D, Schoch G-G, Glaeske G, Technikerkrankenkasse. Pillenreport. Ein Statusbericht zu oralen Kontrazeptiva. 2015. Available: https://www.tk.de/resource/blob/2043476/f68a7108f6cdeae1a58e438d312e3ac6/studienband-pillenreport-2015-data.pdf.
- 12. Alves P, Petersen I, Stevenson F. Searching for Information on the Risks of Combined Hormonal Contraceptives on the Internet: A Qualitative Study Across Six European Countries. J Med Internet Res. 2019;21: e10810. pmid:30882358
- 13. Mitra A. Blood clots, COVID-19 vaccines and the contraceptive pill: are we heading for a repeat of the 1995 pill scare? BMJ Sex Reprod Heal. 2021;47: 303–304. pmid:34158352
- 14. Lackie E, Fairchild A. The birth control pill, thromboembolic disease, science and the media: a historical review of the relationship. Contraception. 2016;94: 295–302. pmid:27343747
- 15. Contraception Foran T. and the media: lessons past, present and future. Eur J Contracept Reprod Heal Care. 2019;24: 80–82.
- 16. Spitzer WO. The 1995 pill scare revisited: anatomy of a non-epidemic. Hum Reprod. 1997;12: 2347–2357. pmid:9436662
- 17. Goodyear-Smith F, Arroll B. Termination of pregnancy following panic-stopping of oral contraceptives. Contraception. 2002;66: 163–167. pmid:12384204
- 18. Skjeldestad FE. Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives. Contraception. 1997;55: 11–14. pmid:9013055
- 19. Neulen J. Pillenreport 2015 der Techniker Krankenkasse. Stellungnahme des Zürcher Gesprächskreises. Frauenarzt. 2016;57.
- 20.
ntv. Neue Anti-Baby-Pillen Pillenreport warnt vor Thromboserisiko. In: 2015 [Internet]. 2015. Available: https://www.n-tv.de/wissen/Pillenreport-warnt-vor-Thromboserisiko-article16108041.html.
- 21.
t-online. Thrombose durch Antibabypille Studie: Neue Generation der Pille birgt Risiken. In: 2015 [Internet]. 2015. Available: https://www.t-online.de/gesundheit/sexualitaet/verhuetung/id_75726592/pillenreport-2015-neue-antibabypille-birgt-risiken.html.
- 22.
Focus online. TK PillenreportNeue Antibabypillen haben erhöhtes Thromboserisiko. In: 2015. 2015.
- 23. Döring N. Mehr Frust als Lust? Die Antibabypille in Sozialen Medien. Medien + erziehung zeitschrift für Medien. 2021;65: 27–34.
- 24. Bitzer J. Hormonal contraception and depression: another Pill scandal? Eur J Contracept Reprod Heal Care. 2017;22: 1–2. pmid:28155568
- 25. Skovlund CW, Morch LS, Kessing LV, Lange T, Lidegaard O. Association of Hormonal Contraception With Suicide Attempts and Suicides. Am J Psychiatry. 2018;175: 336–342. pmid:29145752
- 26. Kissling EA. No Justice, No Pill/Know (Reproductive) Justice, Know the Pill. Women’s Reprod Heal. 2016;3: 109–112.
- 27.
Maas C. #MyPillStory. Frust mit Nebenwirkungen der Pille. Tübingen; 2016.
- 28. Leask J, Hooker C, King C. Media coverage of health issues and how to work more effectively with journalists: a qualitative study. BMC Public Health. 2010;10: 535. pmid:20822552
- 29. Vieth SJ, Hartmann-Boyce J, Maass N, Jani A. Survey of young women’s state of knowledge and perceptions about oral contraceptives in Germany. AJOG Glob Reports. 2022;2: 100119. pmid:36338537
- 30. Broussard K, Becker A. Self-removal of long-acting reversible contraception: A content analysis of YouTube videos. Contraception. 2021;104: 654–658. pmid:34400154
- 31. Paul J, Boraas CM, Duvet M, Chang JC. YouTube and the single-rod contraceptive implant: a content analysis. J Fam Plan Reprod Heal Care. 2017;43: 195–200.
- 32. Kim JH, Kim HK. Content and quality of YouTube regarding women’s health: a scoping review. Korean J Women Heal Nurs. 2023;29: 179–189. pmid:37813661
- 33. Pfender EJ, Devlin MM. What Do Social Media Influencers Say About Birth Control? A Content Analysis of YouTube Vlogs About Birth Control. Health Commun. 2023;38: 3336–3345.
- 34. Wu J, Trahair E, Happ M, Swartz J. TikTok, #IUD, and User Experience With Intrauterine Devices Reported on Social Media. Obstet Gynecol. 2023;141: 215–217. pmid:36473194
- 35. Pfender EJ, Tsiandoulas K, Morain SR, Fowler LR. Hormonal Contraceptive Side Effects and Nonhormonal Alternatives on TikTok: A Content Analysis. Health Promot Pract. 2024. pmid:38166482
- 36. Latack KR, Patel J, Moog D, Spencer D, Nguyen BT. Withdrawal method inquiries and user experiences: An analysis of content posted on 4 gendered forums on Reddit. Contraception. 2021;104: 170–175. pmid:33852898
- 37. Döring N, Lehmann S, Schumann-Doermer C. Verhütung auf YouTube, Instagram und TikTok. Bundesgesundheitsblatt—Gesundheitsforsch—Gesundheitsschutz. 2023.
- 38. Gomes Alves P, Petersen I, Stevenson F. Searching for Information on the Risks of Combined Hormonal Contraceptives on the Internet: A Qualitative Study Across Six European Countries. J Med Internet Res. 2019;21: e10810. pmid:30882358
- 39.
Döring N. Die Bedeutung von Videoplattformen für die Gesundheitskommunikation. Handbuch der Gesundheitskommunikation. Wiesbaden: Springer Fachmedien Wiesbaden; 2019. pp. 171–183. https://doi.org/10.1007/978-3-658-10727-7_14
- 40. Ross LJ. Reproductive Justice as Intersectional Feminist Activism. Souls. 2017;19: 286–314.
- 41. Castle S, Askew I, Population Council. CONTRACEPTIVE DISCONTINUATION: REASONS, CHALLENGES, AND SOLUTIONS. 2015. Available: https://popdesenvolvimento.org/images/imprensa/FP2020_ContraceptiveDiscontinuation_SinglePageRevise_12.16.15.pdf.
- 42. Simmons RG, Baayd J, Waters M, Diener Z, Turok DK, Sanders JN. Assessing contraceptive use as a continuum: outcomes of a qualitative assessment of the contraceptive journey. Reprod Health. 2023;20: 33. pmid:36793112
- 43. Gnoth C, Frank-Herrmann P, Schmoll A, Godehardt E, Freundl G. Cycle characteristics after discontinuation of oral contraceptives. Gynecol Endocrinol. 2002;16: 307–317. pmid:12396560
- 44. Yland JJ, Bresnick KA, Hatch EE, Wesselink AK, Mikkelsen EM, Rothman KJ, et al. Pregravid contraceptive use and fecundability: prospective cohort study. BMJ. 2020; m3966. pmid:33177047
- 45. Davis AR, Kroll R, Soltes B, Zhang N, Grubb GS, Constantine GD. Occurrence of menses or pregnancy after cessation of a continuous oral contraceptive. Fertil Steril. 2008;89: 1059–1063. pmid:17658522
- 46. Girum T, Wasie A. Return of fertility after discontinuation of contraception: a systematic review and meta-analysis. Contracept Reprod Med. 2018;3: 9. pmid:30062044
- 47. Nassaralla CL, Stanford JB, Daly KD, Schneider M, Schliep KC, Fehring RJ. Characteristics of the Menstrual Cycle After Discontinuation of Oral Contraceptives. J Women’s Heal. 2011;20: 169–177. pmid:21219248
- 48. Inoue K, Barratt A, Richters J. Does research into contraceptive method discontinuation address women’s own reasons? A critical review. J Fam Plan Reprod Heal Care. 2015;41: 292–299. pmid:25605480
- 49.
Kissling EA. What Does Not Kill You Makes You Stronger: Young Women’s Online Conversations about Quitting the Pill. Reframing Reproduction. London: Palgrave Macmillan UK; 2014. pp. 236–250. https://doi.org/10.1057/9781137267139_15
- 50. Basch CH, Menafro A, Mongiovi J, Hillyer GC, Basch CE. A Content Analysis of YouTubeTM Videos Related to Prostate Cancer. Am J Mens Health. 2017;11: 154–157.
- 51. Schoonenboom J, Johnson RB. How to Construct a Mixed Methods Research Design. Kolner Z Soz Sozpsychol. 2017/07/05. 2017;69: 107–131.
- 52. Devendorf A, Bender A, Rottenberg J. Depression presentations, stigma, and mental health literacy: A critical review and YouTube content analysis. Clin Psychol Rev. 2020;78: 101843. pmid:32304914
- 53. Donzelli G, Palomba G, Federigi I, Aquino F, Cioni L, Verani M, et al. Misinformation on vaccination: A quantitative analysis of YouTube videos. Hum Vaccin Immunother. 2018;14: 1654–1659. pmid:29553872
- 54. Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25: 1229–1245. pmid:20204937
- 55.
Krippendorff K. Content Analysis: An Introduction to Its Methodology. 2455 Teller Road, Thousand Oaks California 91320: SAGE Publications, Inc.; 2019. https://doi.org/10.4135/9781071878781
- 56.
Mayring P. Qualitative Inhaltsanalyse. Grundlagen und Techniken. Weinheim: Beltz Verlagsgrupp; 2015.
- 57.
ADM Arbeitskreis Deutscher Markt- und Sozialforschungsinstitute e.V., Arbeitsgemeinschaft Sozialwissen- schaftlicher Institute e.V. (ASI), BVM Berufsverband Deutscher Markt- und Sozialforscher e.V., Deutsche Gesellschaft für Online Forschung e.V. (DGOF). Richtlinie für Untersuchungen in den und mittels der Sozialen Medien (Soziale Medien Richtlinie). 2021 [cited 3 Feb 2023]. Available: https://www.dgof.de/wp-content/uploads/2021/03/RL-Soziale-Medien-neu-2021-3.3.2021.pdf.
- 58.
YouTube DE. Nutzungsbedingungen. 2019 [cited 3 Feb 2021]. Available: https://www.youtube.com/t/terms.
- 59. Patterson AN. YouTube Generated Video Clips as Qualitative Research Data: One Researcher’s Reflections on the Process. Qual Inq. 2018;24: 759–767.
- 60. Fuchs A, Matonóg A, Sieradzka P, Pilarska J, Hauzer A, Czech I, et al. Anti-androgenic therapy in young patients and its impact on intensity of hirsutism, acne, menstrual pain intensity and sexuality—a preliminary study. Ginekol Pol. 2019;90: 520–526. pmid:31588549
- 61. Lewandowski SK, Duttge G, Meyer T. Quality of life and mental health in adolescent users of oral contraceptives. Results from the nationwide, representative German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Qual Life Res. 2020;29: 2209–2218. pmid:32144614
- 62. de Castro Coelho F, Barros C. The Potential of Hormonal Contraception to Influence Female Sexuality. Int J Reprod Med. 2019;2019: 9701384. pmid:30941356
- 63. Fruzzetti F, Perini D, Fornaciari L, Russo M, Bucci F, Gadducci A. Discontinuation of modern hormonal contraceptives: an Italian survey. Eur J Contracept Reprod Heal Care. 2016;21: 449–454. pmid:27715345
- 64. Hardon A, Harries J. Towards an Anthropology of contraception: on the pill, control and embodiment. AM Riv Della Soc Ital Di Antropol Medica. 2001;6: 211–226. Available: https://www.amantropologiamedica.unipg.it/index.php/am/article/view/119/112.
- 65. Littlejohn KE. “It’s those Pills that are Ruining Me.” Gend Soc. 2013;27: 843–863.
- 66. Grover SR. Gynaecology problems in puberty. Best Pract Res Clin Endocrinol Metab. 2019;33: 101286. pmid:31278062
- 67. Tracy EE. Contraception: Menarche to Menopause. Obstet Gynecol Clin North Am. 2017;44: 143–158. pmid:28499527
- 68. Gruber DM. Hormonelle Kontrazeption bei Jugendlichen < 18 Jahren. J für Gynäkologische Endokrinol. 2021;31: 25–28.
- 69. Both S, Lew-Starowicz M, Luria M, Sartorius G, Maseroli E, Tripodi F, et al. Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med. 2019;16: 1681–1695. pmid:31521571
- 70.
Jenapharm GmbH & Co. KG. Gebrauchsinformation: Information für Anwender. Maxim0,03 mg/2 mg, überzogene Tablette Ethinylestradiol/ Dienogest. Jena. In: 2018 [Internet]. [cited 4 Dec 2021]. Available: https://www.meine-gesundheit.de/medikamente/beipackzettel_Maxim-ueberzogene-Tabletten.pdf/b4f11697-e012-4a5d-b860-76a6529a8f07.
- 71.
eurostat. Fertility indicators. 2021. Available: https://ec.europa.eu/eurostat/databrowser/bookmark/bf4fd992-7565-4f68-a499-a11b487fbb18?lang=en
- 72. Helfert S, Warschburger P. The face of appearance-related social pressure: gender, age and body mass variations in peer and parental pressure during adolescence. Child Adolesc Psychiatry Ment Health. 2013;7: 16. pmid:23680225
- 73. Fardouly J, Pinkus RT, Vartanian LR. The impact of appearance comparisons made through social media, traditional media, and in person in women’s everyday lives. Body Image. 2017;20: 31–39. pmid:27907812
- 74. Gattario KH, Frisén A. From negative to positive body image: Men’s and women’s journeys from early adolescence to emerging adulthood. Body Image. 2019;28: 53–65. pmid:30583277
- 75. Samuels D V., Rosenthal R, Lin R, Chaudhari S, Natsuaki MN. Acne vulgaris and risk of depression and anxiety: A meta-analytic review. J Am Acad Dermatol. 2020;83: 532–541. pmid:32088269
- 76. Barnhart KT, Schreiber CA. Return to fertility following discontinuation of oral contraceptives. Fertil Steril. 2009;91: 659–663. pmid:19268187
- 77. Kristjánsdóttir J, Sundelin C, Naessen T. Health-related quality of life in young women starting hormonal contraception: a pilot study. Eur J Contracept Reprod Heal Care. 2018;23: 171–178. pmid:29671353
- 78. Mansour D, Inki P, Gemzell-Danielsson K. Efficacy of contraceptive methods: A review of the literature. Eur J Contracept Reprod Heal Care. 2010;15: 4–16.
- 79. Frank-Herrmann P, Heil J, Gnoth C, Toledo E, Baur S, Pyper C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study. Hum Reprod. 2007;22: 1310–1319. pmid:17314078
- 80. Freundl G, Frank-Herrmann P, Brown S, Blackwell L. A new method to detect significant basal body temperature changes during a woman’s menstrual cycle. Eur J Contracept Reprod Heal Care. 2014;19: 392–400. pmid:25159914
- 81. Minnis AM, Mavedzenge SN, Luecke E, Dehlendorf C. Provider Counseling to Young Women Seeking Family Planning Services. Perspect Sex Reprod Health. 2014;46: 223–231. pmid:24786186
- 82. Goldhammer DL, Fraser C, Wigginton B, Harris ML, Bateson D, Loxton D, et al. What do young Australian women want (when talking to doctors about contraception)? BMC Fam Pract. 2017;18: 35. pmid:28298197
- 83. Dixon SC, Herbert DL, Loxton D, Lucke JC. ‘As many options as there are, there are just not enough for me’: Contraceptive use and barriers to access among Australian women. Eur J Contracept Reprod Heal Care. 2014;19: 340–351.
- 84. Dehlendorf C, Krajewski C, Borrero S. Contraceptive Counseling. Clin Obstet Gynecol. 2014;57: 659–673.
- 85. Branden P. Contraceptive choice and patient compliance The health care provider’s challenge. J Nurse Midwifery. 1998;43: 471–482.
- 86. de Irala J, Osorio A, Carlos S, Lopez-del Burgo C. Choice of birth control methods among European women and the role of partners and providers. Contraception. 2011;84: 558–564. pmid:22078183
- 87. Gallagher KM, Updegraff JA. Health Message Framing Effects on Attitudes, Intentions, and Behavior: A Meta-analytic Review. Ann Behav Med. 2012;43: 101–116. pmid:21993844