According to the Family Planning Knowledge, Attitude and Practice in Hong Kong Survey 2012 among Hong Kong couples,1 the male condom was the most popular contraceptive. The proportion of couples who used a male condom doubled from 32.2% in 1987 to 69.6% in 2012. Combined oral contraceptive (COC) pill was the second most common form of contraception, though the proportion of women using a COC pill declined from 20.3% in 1987 to 10.8% in 2012. The failure rate of the male condom when used correctly is 6 times higher than that for the COC pill.2 Although the low-dose COC pill has a low incidence of complications, high efficacy, and many non-contraceptive benefits, relatively few women use it in Hong Kong. The report of the United Nations world contraceptive patterns 2013 estimated that the prevalence of pill use in Hong Kong women aged 15 to 49 years was 6.7%, which is much lower than other countries with similar development, wealth, and culture such as Australia (30.0%), Canada (21.0%), Singapore (10.0%), the UK (28.0%), and the US (16.3%).3 Unlike these countries, the COC pill is not a prescription drug in Hong Kong. Women can buy a low-dose COC pill that contains either 30-µg or 20-µg ethinylestradiol and one of the progestogens: levonorgestrel, gestodene, desogestrel, or drospirenone at any of the large-chain personal health and beauty retailers or pharmacy stores. All pills have similar efficacy. Their failure rate is 0.3% within the first year of perfect use.2 Low-dose pills are safer, better tolerated, and have equal or higher efficacy than high-dose pills that contain 50-µg ethinylestradiol.

With 70% of couples in Hong Kong using the male condom,1 the demand for abortion due to failed contraception cannot be ignored. It was shown that 77.4% of women who underwent an abortion were using contraception during the index pregnancy and 51.2% of them were using a male condom.1 The number of legal abortions in Hong Kong has reduced from 25 363 in 1995 to 10 359 in 2014 (personal communication, Department of Health), though the number of abortions carried out across the border is unknown. According to the results from the serial 5-yearly territory-wide family planning survey,1 the proportion of married women who went to China for their last abortion increased from 24.3% in 1992 to 47.2% in 2012. Given the limited resources assigned to abortion in public hospitals, women have to resort to the more expensive legal abortion service in private hospitals or the Family Planning Association of Hong Kong (FPAHK). The FPAHK performs 3000 medical and surgical first-trimester abortions each year and has reached its full service capacity. There is a need to further reduce unplanned pregnancies and abortion in Hong Kong. One plausible solution is to encourage more women to use more effective contraception such as the combined hormonal contraceptive pill, progestogen-only contraceptives, intrauterine contraceptive device, or sterilisation. The failure rate of these effective contraceptives when used correctly is <1% in the first year of use.2

Studies have shown that identifying women’s perspective can help doctors understand their motive to choose one contraceptive over another.4 One study identified personal choices, local factors, women’s perceived safety, effectiveness, and convenience of the method as determinants of contraceptive choice.5 Among the effective contraceptives available in Hong Kong, the COC pill is the most accepted. We performed this survey to determine the motivators and barriers to COC pill use.

The Family Planning Association of Hong Kong invited ESDlife to host the survey that was open to its female members aged between 18 and 45 years. The questionnaire was designed by the investigators. ESDlife is an online lifestyle media in Hong Kong. It is a joint venture between the Hong Kong SAR Government and a commercial firm that began in 2000 with the aim of providing e-government and e-commerce services. With the establishment of the Government’s own website in 2008, all government services have migrated to the official website and ESDlife remains a solely commercial portal. As of 2 January 2015, it had 297 152 members of whom 64.4% were female. Among the female members, 89.0% were within our target age range: 32.3% were 30-34 years old, 23.3% were 35-39 years old, 19.3% were 25-29 years old, 10.3% were 40-45 years old, and 3.8% were 18-24 years old.

ESDlife sent out 100 000 invitations randomly to its female members aged between 18 and 45 years on 21 April 2015 and invited them to participate in this online survey between 21 April 2015 and 20 May 2015. There were 16 questions that explored the basic demographic characteristics of respondents (6), their contraceptive choice (3), and their motivators and barriers to COC use (7). Invited members entered the survey via a link and those who had not used any contraception in the previous 12 months were screened out by the first question. Only eligible subjects could proceed with the survey. They could stop at any question and the questionnaire would be voided. To encourage participation, a $50 supermarket coupon was given to every 10th respondent via ESDlife. This study was reviewed and approved by the Health Services Subcommittee and Ethics Panel of the FPAHK.

Data analyses were accomplished using the Statistical Package for the Social Sciences (Windows version 22.0; SPSS Inc, Chicago [IL], US). Descriptive statistics were presented. Bivariate Chi squared test was performed to analyse the demographic characteristics that predicted COC pill use.

During the survey period, only completed questionnaires were captured by the system so the number of incomplete questionnaires was unknown. A total of 1566 women completed the survey within the 1-month period, 271 were screened out by Question 1 because they had not used regular contraception in the past 12 months and 1295 questionnaires were analysed. The response rate was 1.57%. The median age of the respondents was 32 years (interquartile range, 29-36 years). Half of them (50.7%) had a university education, 20.5% had a post-secondary education (diploma or associate degree), and 28.3% had a secondary education. The majority (65.5%) were married, 29.0% were unmarried, 3.3% were cohabiting, 2.1% had separated or divorced, and 0.2% were widowed. Over half of the respondents were nulliparous (56.7%) and had no plan for pregnancy (52.3%). They usually purchased contraceptives from a chain of personal health and beauty retailers (52.8%), convenience store and supermarket (43.9%), or pharmacy (23.6%). They usually sought contraceptive information from an online health website (46.5%), online forum (40.1%), gynaecologists (27.8%), or family planning clinic (21.6%). A summary of the socio-demographic characteristics is shown in Table 1.

Among the 1295 respondents, 453 (35.0%) had used more than one type of contraceptive in the previous 12 months. The contraceptive choices of the whole group were: male condom (76.1%), coitus interruptus (20.9%), safe period (16.2%), and COC pill (12.6%) [Table 1]. The contraceptive choices of the 986 male condom users were further analysed to estimate their risk of unplanned pregnancy. Among them, 598 (60.6%) used a male condom alone, 295 (29.9%) also used other less effective contraceptives such as a female condom, safe period, and coitus interruptus but whether they used them all together during coitus or switched between these contraceptives was unknown. Therefore, these condom users were indisputably at risk for unplanned pregnancy because they did not use other effective contraceptives with the male condom.

In this study sample, 842 (65.0%) women had never tried a COC pill. The main reasons were fear of side-effects (72.1%), satisfied with their current contraceptive (32.1%), and pill-taking was inconvenient for them (18.5%) [Table 2]. Among 453 women who had tried a COC pill, the median age they started use was 24 years (interquartile range, 20-28 years). Use of COC pill was associated with older age (mean ± standard deviation: users and non-users was 33.4 ± 5.8 and 32.4 ± 5.5 years, respectively; t test, P=0.003), not planning to get pregnant (P=0.002), and university education (P=0.004). There was no association with relationship status (P=0.968) or parity (p=0.427). These women preferred the COC pill because of convenience (47.7%), effectiveness (44.8%), menstrual regulation (33.6%), recommendation by their doctor (24.7%), reduced burden to partner (17.0%), for relief of dysmenorrhoea (14.1%), and improvement of acne (12.6%) [Table 3]. They chose a COC pill based on the dosage of hormones, type of hormones, and price. Among the 453 ever-users, 177 (39.1%) had been taking a COC pill in the previous 12 months. Use had stopped in 276 because they feared side-effects (39.1%); they experienced side-effects such as nausea, vomiting, breast tenderness, oedema, or weight gain (27.9%); they consistently forgot to take pills (19.9%); their doctor told them to stop (14.1%); or they were having less frequent coitus (12.3%) (Table 4).

The pattern of contraceptive use in this study sample was similar to that in the 2012 territory-wide survey.1 Male condom was the most popular contraceptive, used by 76.1% of couples in our study. The proportion of women using a COC pill in our study was also similar to that in the 2012 survey. Our survey has provided some information about the characteristics of women who chose to take the COC pill, such as older age, university education, and no plan for future pregnancy. A similar age profile and education attainment were identified in a national survey conducted in the US,6 in which parity and relationship status were also characteristics associated with COC pill use.

Fear of side-effects was the major reason cited by both subgroups of women who stopped or had never tried a COC pill. Studies carried out in both developed and developing countries have also shown that the experience of side-effects as well as the fear of side-effects are major reasons for discontinuation.7 8 9 10 It appeared that fear of side-effects was a unique barrier across different countries and cultures. Minor side-effects such as breast tenderness, fluid retention, nausea, and vomiting were transient and usually subsided after one to two cycles. Major health hazards such as myocardial infarction, stroke, thromboembolism, breast cancer, and cervical cancer are rare. Two meta-analyses showed a 2-fold increase in myocardial infarction and stroke in low-dose COC pill users compared with non-users.11 12 The risk of venous thromboembolism was increased by 3- to 5-fold depending on the type of progestogen used.13 Since the baseline incidence of these vascular events in women of reproductive age is very low (myocardial infarction: 0.2 per 100 000 at age 30-34 years to 2.0 at age 40-44 years14; stroke: 1 per 100 000 at age 30-34 years to 1.6 at age 40-44 years14; thromboembolism: 2 per 10 000 women at reproductive age15), the absolute risk of such vascular complications is very small. Breast cancer risk with a low-dose COC pill is also small. A large meta-analysis of case-control studies from 25 countries showed a modest increase in breast cancer risk with the COC pill (relative risk=1.24; 95% confidence interval [CI], 1.15-1.33).16 The risk of cervical cancer depends on the duration of use. Women who used a COC pill for less than 5 years have no increased risk of cervical cancer. The odds ratio for cervical cancer after using COC for 5 to 9 years was 2.82 (95% CI, 1.46-5.42) and 4.03 (95% CI, 2.09-8.02) for 10 years or longer.17 Cervical cancer is largely preventable by regular cervical smears, safe sex, as well as avoidance of smoking. The overall morbidity and mortality associated with the low-dose COC pill are low and most healthy women can use it without major concerns.

The lack of access to consultation services has exacerbated concern about side-effects, both for women who experience them and for those who fear them.9 At our clinics, women are counselled about the common side-effects and complications of the COC pill. This prevents them from panicking when minor side-effects occur. They are also told to stop taking the COC pill immediately and consult a doctor if they develop signs and symptoms of a major complication. Such counselling helps women establish realistic expectations and they are able to use COC safely. An information sheet detailing side-effects and complications, warning signs and symptoms for major complications, commonly used drugs that interact with COC pill, and missed pill management is given to all users. When first prescribed, we usually provide two packs and then review acceptability after 2 months. Women are advised that different COC pills vary slightly in their side-effect profile and they can change to another formulation if they have problems. We also offer walk-in clinics for any woman who wishes to get contraceptive advice from nurses. The above COC pill delivery mode conforms to the World Health Organization recommendations.18

Apart from side-effects and complications, women should be informed of the non-contraceptive benefits of the COC pill, such as menstrual regulation and relief of dysmenorrhoea; reduced risk for endometrial, ovarian, and colorectal cancers; lower incidence of gynaecological diseases such as endometriosis, pelvic inflammatory disease, ectopic pregnancy; and improved acne and bone health. All such information should be shared with women to help them establish an impartial perspective on the risks and benefits of the COC pill.

The main limitation of this survey is the very low response rate, albeit not unexpected with online survey. There was also selection bias as members of an exclusive group were invited to participate. Those who participated in the survey prompted self-selection bias as they might be systematically different from those who chose not to respond. When we planned the study, we had explored other alternatives such as face-to-face interview, phone interview, or online survey for the general public. Nonetheless, the first would be too expensive and in the last two alternatives, we would be unable to verify respondent’s age or gender. We settled with this arrangement as it was the most convenient means to reach our target group since ESDlife only allowed female members aged 18 to 45 years to participate. The demographic statistics provided by ESDlife revealed that the education attainment and income reported by its female members were better than the population average. The contraceptive choice in this group matched that of the population study and the sample size was not small. Although the results obtained cannot be generalised to the local population, we believe they provide useful insight into the reasons why women do or do not use the COC pill. The other limitation is the number of questions we could ask was limited by the budget. If we had a larger budget to include more questions, we would have explored the type of COC pill used, total duration of use, and the switch pattern in women who used more than one contraceptive in the previous 12 months. Lastly, there was a discrepancy in the number of women who were using a COC pill in the past 12 months. For “Question 15. Are you still on COC in the past 12 months?”, 177 responded positively. In response to Question 7, however, only 163 chose COC pill as one of the contraceptives they had used in the past 12 months. Some women might have omitted COC when they selected their contraceptives from the list provided in Question 7.

The COC pill remains underutilised in Hong Kong compared with many western countries. The male condom is the most popular contraceptive and the proportion of women using a COC pill is one sixth of that of women who use a male condom. A considerable proportion of respondents expressed concerns about actual or anticipated side-effects. Doctors should focus on this area during contraceptive counselling and help dispel the underlying myths and misconceptions surrounding COC pill use. Studies have shown that minor side-effects are transient, major complications are rare in healthy women, and there are many non-contraceptive benefits of the COC pill. These facts should be emphasised during COC counselling to help women balance the risks and benefits of the COC pill and make an informed choice about contraception.

Sponsorship was provided by Pfizer Corporation Hong Kong Limited to cover all costs incurred with ESDlife and incentives for participants. The company was not involved in the study design, execution, data interpretation, or manuscript preparation.

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