Muslim women in the United States are an understudied population; thus, significant knowledge gaps persist pertaining to their most basic health indicators and behaviors [1, 2]. This is, in part, because religious identification is not routinely collected in social science studies, making it impossible to examine outcomes across religion. In the studies that collect this information, often in large nationally representative datasets, religious identification is restricted and difficult (if not impossible) to access. Therefore, researchers and clinicians know little about American Muslim women’s contraceptive utilization; whereas in comparison, studies on contraception in immigrant, racial, and ethnic minority groups are abundant [3,4,5,6,7]. These studies have found 62–75% of American women aged 15–44 used some form of contraception with oral contraceptive pills being the most popular, followed by female sterilization, and male condoms [8,9,10,11]. In contrast, the United Nations reported utilization of any contraception was 38.5% in Pakistan, 59.7% in Egypt, 38.6% in Saudi Arabia, 67.8% in Morocco, 62.4% in Lebanon, 63.8% in Tunisia, and 62.3% in Indonesia, all Muslim majority countries , illustrating significant variability in contraceptive use across nations. The range of these rates suggests contraceptive utilization is associated with a spectrum of factors and cannot simply be extrapolated from one group to another.Since Muslim women residing in the United States have intersectionality in their cultural profile -- as religious, racial, and ethnic minorities, possibly identifying as an immigrant, while also being American -- their health outcomes and health behaviors are likely nuanced not aligning completely with American women, in general, Muslim women living abroad, or racial and ethnic minority women in the United States. Considering these knowledge gaps and the multifaceted cultural profile of American Muslim women, we conducted an exploratory study to 1) identify demographic and sociocultural (including religious) associates of contraceptive utilization, and 2) to detect if these women’s contraceptive use patterns align more with those of American women, in general or with heavily foreign-born minority populations. To inform the design of this study, we explored prior contraception research on minority and non-minority populations to identify potentially pertinent factors to include in the analyses, as well as applicable theories.
Not only does contraceptive utilization vary across nations, it fluctuates widely across racial and ethnic groups in the United States [13,14,15,16]. American white (single race) women reported using highly effective forms of contraceptives, specifically oral contraceptive pills and condoms, more often than African American and Hispanic women [10, 11, 13, 14]. Racial and ethnic minorities were also less likely to use contraception all together and tended to use lower-efficacy methods more frequently than white, America women [10, 11, 13, 14]. Consequently, racial and ethnic minorities in the United States were twice as likely to experience an unintended pregnancy compared to white women . Contraceptive methods that were in the direct control of the woman were found to be more popular among ethnic minorities and were used when the woman desired to maintain her personal control over reproduction or to obfuscate contraception utilization from her partner [14, 16]. A study in California found that African American and Hispanic women were more likely to use injectable contraceptives and emergency contraceptive pills compared to oral contraceptive pills, potentially to minimize risk that her partner would become aware of her contraception use . Building upon findings related to contraceptive utilization, Gomez and Marin identified three primary factors influencing the method of contraception selected: the role of contraception in preventing pregnancy and/or disease, the influence of cultural sexual gender norms, and complexities of contraception with a steady partner . These three factors recognize the influence of gender-based power differentials and highlight the impact that a power imbalance has on contraceptive choices, which is particularly relevant to socially conservative, patriarchal sub-populations such as American Muslims .
Other theorists have examined factors which influence contraceptive use, and their theoretical frameworks suggest there are three behavioral factors that significantly influence the use of and type of contraceptive method selected: 1) Autonomous decision making authority of the woman, 2) Ability to negotiate with her health care provider (and health insurance coverage) about contraceptive preferences, and 3) Influence of cultural subjective norms directly and indirectly related to contraception [18,19,20,21,22,23]. With respect to condom use, the theory of planned behavior suggests that an individual’s decision to use or not to use condoms reflects a combination of beliefs about the benefits of use and the barriers to use . Although informative to understanding motivations to contraception use, these theories fail to incorporate the influence of stigma. Stigma is the process by which a group is labeled as socially deviant and devalued due to attributes or behaviors deemed as discrediting, such as American Muslim women who use contraception even though their religious or cultural orientation prohibits pre-marital sex and suggests the purpose of intercourse is for procreation; these women could become stigmatized by others who do not use contraception or may internalize stigma even without being confronted about the behavior [24,25,26,27,28,29].
Nativity may also play a role in the decision to use contraceptives. The healthy migrant effect asserts that foreign-born individuals are healthier and more resilient than their American born peers; this is due to a selection bias in that only the healthiest individuals from a given population immigrate to the United States [30,31,32]. This protective effect is magnified in higher-income and highly educated immigrants, indicating socioeconomic status, is a powerful associate of health behaviors in foreign-born populations [30,31,32]. Although the healthy migrant effect has been historically applied to physical health outcomes, recent studies have found this effect to be pertinent to mental health outcomes, as well [30,31,32]. Since many American Muslim women were born abroad, their nativity may be associated with utilization or non-utilization of contraceptives. In addition, immigrants often hail from cultures that avoid health care associated with sexual engagement (stigmatized), perceived premature sexual debut, and gendered norms and expectations [33,34,35]; thus, nativity may be associated with contraceptive utilization in American Muslim women. Considering the countervailing forces affecting American Muslim women’s potential health behaviors and significant gaps in knowledge related to this population, we believe examining contraceptive utilization patterns in American Muslim women is a worthy endeavor and will provide valuable insights into the family planning choices of this infrequently studied population.