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Background Postpartum contraception prevents unintended pregnancies and short interpregnancy intervals. The Pregnancy Risk Assessment Monitoring System (PRAMS) collects population-based data on postpartum contraception nonuse and reasons for not using postpartum contraception. In addition to quantitative questions, PRAMS collects open-text responses that are typically left unused by secondary quantitative analyses. However, abundant preexisting open-text data can serve as a resource for improving quantitative measurement accuracy and qualitatively uncovering unexpected responses. We used PRAMS survey questions to explore unprompted reasons for not using postpartum contraception and offer insight into the validity of categorical responses. Methods and findings We used 31,208 categorical 2012 PRAMS survey responses from postpartum women in the US to calculate original prevalences of postpartum contraception use and nonuse and reasons for contraception nonuse. A content analysis of open-text responses systematically recoded data to mitigate survey bias and ensure consistency, resulting in adjusted prevalence calculations and identification of other nonuse themes. Recoded contraception nonuse slightly differed from original reports (21.5% versus 19.4%). Both calculations showed that many respondents reporting nonuse may be at a low risk for pregnancy due to factors like tubal ligation or abstinence. Most frequent nonuse reasons were not wanting to use birth control (27.1%) and side effect concerns (25.0%). Other open-text responses showed common themes of infertility, and breastfeeding as contraception. Comparing quantitative and qualitative responses revealed contradicting information, suggesting respondent misinterpretation and confusion surrounding the term “pregnancy prevention.” Though this analysis may be limited by manual coding error and researcher biases, we avoided coding exhaustion via 1-hour coding periods and validated reliability through intercoder kappa scores. Conclusions In this study, we observed that respondents reporting contraception nonuse often described other methods of pregnancy prevention and contraception barriers that were not included in categorical response options. Open-text responses shed light on a more comprehensive list of pregnancy prevention methods and nonuse options. Our findings contribute to survey questions that can lead to more accurate depiction of postpartum contraceptive behavior. Additionally, future use of these qualitative methods may be used to improve other health behavior survey development and resulting data., In a mixed-methods inquiry, Nicole Richards and colleagues investigate how open-text responses can provide insight into categorical reasons for postpartum contraception use and non-use among women in the US., Author summary Why was this study done? Survey respondents can occasionally provide open-ended answers that may be overlooked during quantitative data analysis. This study was conducted to study how qualitative inquiry of open-text responses to a survey question related to postpartum contraception use can be used to provide insight into data accuracy within quantitative surveys. What did the researchers do and find? Using a mixed-method approach, we calculated descriptive statistics from Pregnancy Risk Assessment Monitoring System (PRAMS) survey responses from 31,208 postpartum women in the US who provided categorized reasons for not using contraception and qualitatively analyzed respondents’ adjacent open-ended written answers to uncover more detailed information about respondents’ postpartum contraception behavior and interpretations of the survey question. Through systematic recategorization, we found that qualitative responses added to and altered quantitative contraception behavior reports and that reasons for contraception nonuse are incompletely captured by existing response categories. What do these findings mean? These findings suggest that researchers may be able to gain a better understanding of postpartum pregnancy prevention by using mixed-method analyses on categorical and open-ended responses. While qualitative inquiry may yield subjective interpretation, rigorous pragmatic data management can strengthen survey questions through open-text responses not captured in existing quantitative data. Family planning professionals may be able to obtain significant and detailed information about contraceptive behavior from open-ended responses, and this information may be useful to adjust clinical approaches to postpartum contraception conversations.

Investigators have linked rare copy number variation (CNVs) to neuropsychiatric diseases, such as schizophrenia. One hypothesis is that CNV events cause disease by affecting genes with specific brain functions. Under these circumstances, we expect that CNV events in cases should impact brain-function genes more frequently than those events in controls. Previous publications have applied “pathway” analyses to genes within neuropsychiatric case CNVs to show enrichment for brain-functions. While such analyses have been suggestive, they often have not rigorously compared the rates of CNVs impacting genes with brain function in cases to controls, and therefore do not address important confounders such as the large size of brain genes and overall differences in rates and sizes of CNVs. To demonstrate the potential impact of confounders, we genotyped rare CNV events in 2,415 unaffected controls with Affymetrix 6.0; we then applied standard pathway analyses using four sets of brain-function genes and observed an apparently highly significant enrichment for each set. The enrichment is simply driven by the large size of brain-function genes. Instead, we propose a case-control statistical test, cnv-enrichment-test, to compare the rate of CNVs impacting specific gene sets in cases versus controls. With simulations, we demonstrate that cnv-enrichment-test is robust to case-control differences in CNV size, CNV rate, and systematic differences in gene size. Finally, we apply cnv-enrichment-test to rare CNV events published by the International Schizophrenia Consortium (ISC). This approach reveals nominal evidence of case-association in neuronal-activity and the learning gene sets, but not the other two examined gene sets. The neuronal-activity genes have been associated in a separate set of schizophrenia cases and controls; however, testing in independent samples is necessary to definitively confirm this association. Our method is implemented in the PLINK software package., Author Summary Specific rare deletion and duplication events in the genome have now been shown to be associated with neuropsychiatric diseases such as 16p11.2 to autism and 22q11.21 to schizophrenia. However, controversy remains as to whether rare events impacting certain pathways as a group increase the risk of disease, and if so, what those pathways are. Other studies have used standard gene-set enrichment approaches to demonstrate that events discovered in cases contain more genes in neuro-developmental pathways than would be expected by chance. However, these analyses do not explicitly compare the relative enrichment in cases to any enrichment that may also be present in controls. Therefore, they can be confounded by the large size of brain genes or by larger size or frequency of CNVs in cases. Here we propose a case-control statistical test to assess whether a key pathway is differentially impacted by CNVs in cases compared to controls. Our approach is robust to skewed gene sizes and case-control differences in CNV rate and size.