Contraceptive Use and Unintended Pregnancy
Jennifer J. Frost and Jacqueline E. Darroch
Table Of Contents
Jennifer J. Frost, PhD
Jacqueline E. Darroch, PhD
THE RISK OF UNINTENDED PREGNANCY|
AVAILABILITY OF CONTRACEPTIVE METHODS IN THE UNITED STATES
CONTRACEPTIVE SERVICE PROVIDERS
ATTITUDES ABOUT CONTRACEPTIVE METHODS
PATTERNS OF CONTRACEPTIVE USE
NONUSERS OF CONTRACEPTION
FAMILY PLANNING INFORMATION AND EDUCATION
|THE RISK OF UNINTENDED PREGNANCY|
At any one time, most women of reproductive age in the United States would like to avoid becoming pregnant. Half of 17-year-old adolescent girls in the United States have had intercourse; the others begin soon after, so that only 4% of all women aged 25 to 29 years have never had intercourse (Table 1). Yet, the most frequently desired number of children is two, leaving most of a woman's years between “sexual debut” and menopause ones in which neither they nor their partners wish to become pregnant.
*AGI tabulations of the 1995 National Survey of Family Growth (Cycle V).
† Have not had intercourse in the past 3 months.
Eleven percent (6.6 million) of all women in the United States aged 15 to 44 years are not at risk of unintended pregnancy because they have never had sexual intercourse, and another 6% (3.7 million) are not currently in a sexual relationship and have sex infrequently. An additional 5% (2.9 million) are sterile for reasons other than contraception. This includes both those who have passed menopause and those who cannot conceive as a result of physical or surgical sterility of themselves or their partner. Finally, 9% (5.2 million) of women are not at risk for unintended pregnancy because they either are currently pregnant, recently had a baby, or are trying to become pregnant.1
The proportion of women who are at risk of unintended pregnancy varies across age groups (see Table 1). Among adolescent girls aged 15 to 19 years, only 37% are at risk, primarily because a large proportion (57%) are not having intercourse. The proportion not currently having sexual intercourse drops to 19% of 20- to 24-year-olds and to 8% of women aged 30 years and older. Among women 20 years and older, 70% to 77% are at risk of unintended pregnancy, depending on age group. The proportions of women who are pregnant or trying to become pregnant are greatest from age 20 to 34 years, whereas the percentage of women who are noncontraceptively sterile rises with age to 13% of women aged 40 to 44 years.
The proportion of women at risk is highest for those who are currently married (81% are at risk), but sex and marriage are not so closely linked as they were 20 to 30 years ago. Between the typical age of first intercourse for women and the typical age of marriage, there is a 7-year gap for young women and a 10-year gap for young men in the United States. This time period is widening as youth become sexually active at increasingly younger ages and marry at older ages.2 Half (49%) of all never-married, noncohabiting women aged 15 to 44 years are at risk of unintended pregnancy. Just as it cannot be assumed that a woman who is having intercourse is married, neither can it be assumed that once married, always married. One in five women aged 15 to 44 years who have ever been married is separated, divorced, or widowed. Most of these women are in a sexual relationship, however, and three quarters (72%) are at risk of unintended pregnancy. Among the 41.8 million women aged 15 to 44 years who are at risk of unintended pregnancy, 43% (17.9 million) are not currently married.1
|AVAILABILITY OF CONTRACEPTIVE METHODS IN THE UNITED STATES|
A variety of contraceptive methods are available to women and men in the United States, but they are not all easily accessible. The most effective methods must be obtained by prescription or insertion by a clinician. These include oral contraceptives (OCs), long-acting hormonal methods (the injectable and the implant), intrauterine devices (IUDs), diaphragms, and cervical caps. In addition, surgical contraceptive sterilization is available to both men and women. Condoms (male and female) and spermicides, such as foams, jellies, and suppositories, are available without prescription. Instruction in the various methods of ovulation prediction and periodic abstinence is available from nonmedical sources as well as physicians and nurse clinicians. Use of certain OCs as emergency contraception has been approved by the U.S. Food and Drug Administration (FDA), and these are currently available by prescription.
|CONTRACEPTIVE SERVICE PROVIDERS|
In the United States, women can receive contraceptive services from private practice general and family practitioners and obstetrician-gynecologists, as well as from publicly supported clinics run by hospitals, health departments, Community Health Centers, and Planned Parenthood affiliates or independent clinic providers. In addition, some teenage and young adult women receive contraceptive services from school-based clinics and college or university health centers.
Private-practice physicians are the most numerous providers in the United States that are available to women seeking contraceptive information and services. More than 40 thousand family practice doctors and nearly 30 thousand obstetriciangynecologists provide office-based outpatient services.3 Approximately three in four women obtaining contraceptive or other reproductive health services in the past year report going to a private practitioner or Health Maintenance Organization for their care.4
An estimated 13.5 million visits annually to office-based private physicians include some type of contraceptive services. The 12.6 million contraceptive visits made by female patients represent 7% of all private physician visits by adolescent girls and women aged 15 to 44 years. Most (69%) of these visits are to an obstetrician/gynecologist, 21% are to a general or family practitioner, and 10% are to other types of physicians.
A contraceptive method is prescribed in two thirds of women's visits; in 80% of cases, this is an OC. Mostly, contraceptive care occurs in the course of visits for other related services. Only 19% of visits are described by the woman as having the sole function of instruction on general family planning or obtaining a specific contraceptive. A quarter are for gynecologic care, such as a Papanicolaou test or a gynecologic examination (13%) or for prenatal or postpartum care (12%). The remaining 56% have as their main-stated reason for the visit a general medical examination (15%) or other medical care (41%).
The most common expected source of payment for women's visits involving contraceptive care is private insurance (37%). Managed care and the patients themselves each account for 22% of visits compared with 12% to be paid by Medicaid or other government programs and 6% from other sources. Women younger than 20 years of age account for 14% of contraceptive visits to private physicians; 68% of visits are made by women aged 20 to 34 years and 18% by women aged 35 years and older.5
Annually, some six and a half million U.S. women receive contraceptive services, supplies, and information from more than 7000 publicly supported family planning clinics, located in 85% of all U.S. counties. The largest proportion (40%) of clinics are run by public health departments, and these serve 35% of all clinic clients. Planned Parenthood clinics account for 29% of all clients, whereas hospital family planning clinics serve 13%, and community and migrant health centers serve 10%. Clinics run by independent agencies such as community action groups, neighborhood health centers, and women's health centers account for 14% of all contraceptive clients.6
Family planning clinics, using a combination of federal, state, and local funds, provide care to those who cannot afford services from private physicians or who cannot use private physicians for other reasons. In most clinics, fees are based on the client's ability to pay, confidential services to teens are assured, and a range of contraceptive methods is offered. As a result, family planning clinic clients are primarily low-income (57% are below 100% of the federal poverty level and 33% are between 100% and 249% of the federal poverty level) and young (20% are younger than age 20 years, 50% are aged 20 to 29 years). Although a majority of clinic clients are non-Hispanic white, nearly 40% are minority women (19% are black, 14% are Hispanic, and 7% are Asian or other races).7 Lower income women go to clinics primarily because they cannot afford physicians' fees, because the clinic is more conveniently located, or because the clinic accepts Medicaid payment. Adolescents often go to clinics because of the free or low-cost services and because they are afraid a private physician will tell their parents about their contraceptive use. In addition, some women, especially teenagers who have never been to a physician on their own, go to clinics because they do not know a physician who would serve them. Clinic clients usually shift to private physicians when their incomes rise and as they become older.
Sixty percent of all publicly supported clinics receive federal Title X support and must therefore follow federal standard-of-care guidelines. These guidelines provide both medical protocols as well as mandates regarding confidentiality and key areas of outreach that clinics should seek to address. As a result, many publicly supported clinics provide outreach and information or education in local schools or in other community locations. These clinics often seek to reach out to women (and men) in need of contraceptive care who have special needs or risk factors for unintended pregnancy (e.g., because of homelessness, drug or alcohol abuse, or domestic violence).
The provision of contraceptive services, like all areas of healthcare, has been affected by changes in the structure of healthcare financing and the rise of managed care. In the past, most privately insured women had employer-based indemnity health insurance plans that rarely covered either routine gynecologic checkups or reversible contraceptive services and supplies. However, such plans often covered sterilization services. Today, most privately insured women are enrolled in managed care plans. These plans are more likely to cover preventative care, including routine gynecologic checkups and some reversible contraceptive services and supplies. However, not all managed care plans cover all or even most methods, and often the process of obtaining contraceptive services within managed care plans places additional burdens on women seeking contraceptive care. These burdens include prior authorization requirements that may cause some women to delay care or forgo sensitive care that a woman may not want to disclose to her primary care physician.8
|ATTITUDES ABOUT CONTRACEPTIVE METHODS|
Women and men in the United States often have inaccurate fears about the risks of contraceptive methods, especially OCs, and they often judge the available methods unfavorably. The percentage of women reporting a favorable opinion about specific methods is highest for OCs, the male condom, vasectomy, and tubal ligation. Except for OCs, which 78% view favorably, no more than two thirds feel favorably about any other method. In fact, only 26% have a favorable opinion of the diaphragm, and fewer feel positively about implants, injectables, spermicides, the IUD, the female condom, or the cervical cap. Opinion about methods recently introduced into the United States (implants, injectables, and the female condom) may change as more women become aware of them.9
Whereas many women worry about the side effects of available methods, often they are not aware of a method's health benefits, such as OCs reducing the risk of ovarian cancer. Although concerns about OCs center on fears of side effects and health risks, the method usually receives favorable ratings on effectiveness, lack of interference with intercourse, and convenience. In contrast, those who judge condom, diaphragm, and spermicides unfavorable generally do so because of concerns about effectiveness, interference with intercourse, and the inconvenience these methods entail. Growing awareness of the risks of sexually transmitted diseases, including human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), has resulted in increasingly favorable attitudes about latex condoms, which are the one method that has been shown to decrease the risk of HIV infection and AIDS. The chief concern about periodic abstinence and withdrawal methods is their effectiveness.
|PATTERNS OF CONTRACEPTIVE USE|
More than nine in 10 women ages 15 to 44 years in 1995 who were at risk of unintended pregnancy were using a contraceptive method (Table 2). Thirty-six percent relied on contraceptive sterilization of themselves or their partner, 52% used reversible medical methods, 5% used nonmedical methods such as withdrawal and periodic abstinence, and 8% were currently using no contraceptive, even though they were at risk of unintended pregnancy.
IUD, intrauterine device.
*Alan Guttmacher Institute tabulations of the 1995 National Survey of Family Growth (Cycle V).
† Female barrier methods include the diaphragm, cervical cap, sponge, and female condom.
Patterns of contraceptive use differ by age. Younger women at risk of unintended pregnancy are more likely than older women to use no method of contraception. Nearly one in five teen women at risk uses no method compared to 6% to 7% of women at risk ages 25 and older. The proportion using reversible medical methods declines steeply with age from more than four of five women ages 20 to 24 years to fewer than one quarter of those ages 40 to 44. OCs are the most commonly used method among women younger than 30 years of age, accounting for 35% to 48% of these women. Condoms are second in popularity among this age group, accounting for 23% to 30% of women in this group. Although fewer than 3% of women at risk use Depo Provera injectible contraceptives, this method has grown in popularity since its introduction in the United States, particularly among young women. Eight percent of teens at risk used this method. As women become older and complete their families, male and female contraceptive sterilization becomes increasingly common, rising steeply from 5% of women at risk ages 20 to 24 to one in five women in their late 20s and to two of three women ages 40 to 44. Among women in their 20s, female sterilization is approximately four times more common than vasectomy. The margin narrows among older women to between two and two and a half times more common.
The proportion of women at risk of unintended pregnancy who use no contraceptive method is highest among never-married women, 14% compared to 5% of those who are currently married or cohabiting and 8% of formerly married women. Sterilization is the most frequently used method among women who are currently married (46%) as well as formerly married women (50%). The pill is the most commonly used method among never-married women (38%) and cohabiting women (34%). Condoms are most likely to be used by never-married women (28%).
The growing awareness of the protection that latex condoms give against contracting sexually transmitted diseases, including AIDS, undoubtedly has contributed to the increase in condom use among never-married women using contraception from 12% in 1982, to 15% in 1988, to 30% in 1995. The increase also was steep among formerly married method users: from 2% in 1982, to 6% in 1988, to 15% in 1995. Among currently married women, the proportion rose only from 14% in 1982 and 1988 to 17% in 1995.1,10
Although poor women and minority women at risk of unintended pregnancy have, in the past, been more likely than higher income and non-Hispanic white women to be using no contraceptive method, these differences have lessened. Compared to the 1980s, in 1995 there were no significant race/ethnicity or poverty differences in the percentages of women at risk of unintended pregnancy who used no method of contraception (Fig. 1). However, there is some variation in the types of methods used according to these subgroups. Low-income women are less likely to rely on reversible methods and more likely to rely on sterilization than higher income women. Forty percent of women at risk of unintended pregnancy who are below 150% of the poverty level use sterilization compared to 32% of women at 300% of poverty and above. Poor women relying on sterilization are more likely than higher income women to have been sterilized themselves rather than have a partner who has a vasectomy. Female sterilization accounts for 92% of all contraceptive sterilization among poor women compared with 58% among those with higher incomes.
Contraceptive use at first intercourse rose from 50% of women who began having sex before 1980 to 76% of those who first had intercourse from 1990 to 1995. This change resulted from greater condom use, which increased from 18% of those who had intercourse for the first time before 1980, to 54% of those beginning intercourse more recently.11
|NONUSERS OF CONTRACEPTION|
There are 3.1 million women who are at risk of unintended pregnancy who use no contraceptive method, 8% of all those at risk. Nonusers account for 14% of never-married, noncohabiting women and 8% of those who are formerly married but only 5% of married or cohabiting women who are at risk of unintended pregnancy. The proportion of women at risk who are using no contraceptive method is similar among those below 150% of the federal poverty level and women from 150% to 299% of poverty (8%) and among women at or above 300% of poverty (7%).12
Among low-income women at risk of unintended pregnancy, method use is more common among those who have been to college, cohabiting and never-married women, those in a relationship for a year or more, women with one to two children, and those wanting to have children in the future. It is less likely among those who would be glad if they became pregnant and among English-speaking Hispanic women. Women at risk are more likely to use a contraceptive if they are satisfied with the care they receive from their gynecologic provider, if they talk frequently with their partner or girlfriends about contraception, if they feel strongly that they do not need their partner's approval for contraceptive use, if they believe contraception is important in preventing pregnancy, and if they think that their friends see contraceptive use as important.13
Nearly half of all pregnancies (49%) in the United States are unintended.14 Hence, they occur to women who want to have a baby later but not now (generally called mistimed) or to women who did not want to have any (more) children at all (called unwanted) (Table 3). The proportion of pregnancies that are unintended is highest among adolescents (78%) and varies considerably by age. The percentage of pregnancies that are unintended is lowest among women aged 30 to 34 years (33%) and rises again among older women to 51% among women 40 years of age and older. Unintended pregnancies are also relatively more likely to occur among never-married women (78%), black women (72%), and low-income women (61% for women below 100% of the federal poverty level).
NA = not available.
*Forrest JD: Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynecol 170:1485, 1994
† Henshaw SK: Unintended pregnancy in the United States. Fam Plann Perspect 30:24, 1998
The percentage of pregnancies that are unintended has declined in recent years from 57% in 1987 to 49% in 1994 (see Table 2). These declines have occurred across all age categories but have been more significant among older women. These declines have also been more significant among low-income women. In 1987, 75% of all pregnancies to women with family incomes below 100% of the poverty level were unintended. This dropped to 61% in 1994. In comparison, the percentage of unintended pregnancies to women with incomes at 200% or more of the federal poverty level fell from 45% in 1987 to 41% in 1994.
Among all unintended pregnancies, more than half (54%) end in an abortion whereas 46% result in an unintended birth. This relationship differs for adolescents, who, in recent years, have been more likely to resolve unintended pregnancies with a birth. More than half of all unintended pregnancies to adolescents results in an unintended birth (55%), whereas 45% are resolved with an abortion. These percentages represent a significant change in the resolution of unintended pregnancies among adolescents. Throughout the 1980s, adolescents who were pregnant unintentionally were more likely to obtain an abortion (55% to 53%) than to carry the pregnancy to term.
Nearly half (48%) of all women ages 15 to 44 have had at least one unintended pregnancy at some time in their lives; 28% have had one or more unplanned births, 30% have had one or more abortions, and 11% have had both. Given current rates of pregnancy and abortion, by the time she is 45 years old, the typical woman in the United States will have experienced 1.42 unintended pregnancies and 43% of women will have had an abortion.
Women who are using no contraceptive method account for approximately 8% of all women at risk of unintended pregnancy. Because they are more likely to become pregnant than those who are using a method, these women account for nearly half of all unplanned pregnancies, an estimated 47% (Fig. 2).
The level of unintended pregnancy in the United States is high compared with most other industrialized countries.15 The difference is especially striking among adolescents, although unintended pregnancy and abortion rates also are high among adult women in the United States. Although there is no evidence that the young women in the United States are more (or less) sexually active than the young women in many other industrialized countries, the United States has adolescent pregnancy rates that are six to seven times higher than the rates for the Netherlands, three to four times higher than the rates for Sweden and France, and nearly twice as high as the rates for Canada and England and Wales (Fig. 3). The factors responsible for these differences are not entirely clear; however, it is likely that they are due, in part, to differences in the levels of disadvantage among countries, to variation in the family planning education and services provided to youth, and to greater or lesser openness regarding sexuality among countries.
The high levels of unintended pregnancy and abortion in the United States result from two basic factors. The primary factor is that many women at risk of unintended pregnancy do not use any contraceptive method, usually because of gaps between methods or between stable relationships. The secondary factor is the relatively high rates of ineffective use among those who are using contraceptive methods. Although technologic improvements in contraceptive methods can reduce both these factors, the greatest impact comes from stronger motivation by women and men to avoid unintended pregnancy and from increased awareness of the comparative benefits and risks of methods and of nonuse and knowledge on how to use contraceptives effectively.
|FAMILY PLANNING INFORMATION AND EDUCATION|
Rising public concern over the occurrence of unintended pregnancy and, particularly, of unintended, nonmarital adolescent pregnancy and childbearing in the United States has drawn attention to the manner in which young people are educated about sexuality, contraception, and how to avoid pregnancy and other negative consequences of sexual activity. Parents and other adults have long played a key role in controlling the sexual behavior of adolescents and in providing basic information about sex and pregnancy avoidance. During the past 25 years, there has been a proliferation of organized efforts to augment the information, education, and support traditionally provided by families. Beginning with programs and services for young, pregnant women, these efforts have expanded to include legislative mandates regarding the teaching of sexuality or family life education in schools, development and distribution of a variety of sexuality education curricula, as well as integrated community interventions and media involvement. Organized efforts to implement sexuality education and related activities have also been influenced by growing public concern and awareness of HIV/AIDS and the need to provide young people with the information and means to avoid infection.
Increasingly, policies and programs to encourage abstinence among unmarried teenagers have become popular. Some of these programs attempt to accomplish this objective by giving young people encouragement, offering moral support, and teaching interpersonal skills to resist pressures to become sexually active. Others seek to convince teenagers that sex before marriage is immoral and emphasis is placed on the negative consequences of sexual intercourse while occasionally withholding or distorting information about the availability and effectiveness of contraception.16 In fact, although most public schools provide some sort of sexuality education to middle or junior and senior high school students, the education provided is often too little, too late.
On a broader scale, community and service organizations have implemented interventions aimed at increasing the life options of disadvantaged young people through, for example, role models and mentoring, community service projects, job training, and activities aimed at reducing risky behaviors. Such interventions are expected indirectly to reduce levels of unintended teenage pregnancy and childbearing and sexually transmitted infections in the belief that teenagers who are more positive about their futures are less likely to participate in risk-taking behaviors, including risky sexual practices.
Other policies or programs implemented with the hope of reducing unprotected teenage sexual behavior include: (1) comprehensive school-based sexuality education curricula that include discussion of abstinence, but also include information about contraceptive methods and services; (2) programs that address the social pressures faced by teens to have sex and that provide modeling and practice of communication, negotiation, and refusal skills; (3) condom availability programs in schools; and (4) multicomponent programs that include community-wide activities, such as media involvement, social marketing, and links between school-based activities and contraceptive service providers.16
Evaluations of a variety of programs and approaches aimed at affecting teenage sexual and reproductive behavior have shown that some programs have had a positive effect on the behavior of youth. In addition, results of multiple studies indicate that the provision of contraceptive information and access does not encourage youth to become sexually active at younger ages. Reviews of the evaluation research suggest that greater success may be achieved through integrated approaches that address both the antecedents of sexual risk-taking (e.g., poverty, violence, social disorganization), as well as provide young people with the information, skills, and resources to make responsible decisions about sexual behavior and the avoidance of unintended outcomes.17
11. Abma J, Chandra A, Mosher W et al: Fertility, Family Planning, and Women's Health: New Data from the 1995 National Survey of Family Growth, Vol 23, no. 19. Washington DC, National Center for Health Statistics, Vital Health Statistics, 1997