Family planning clinic services in the United States: patterns and trends in the late 1990s.

CONTEXT: Publicly funded family planning clinics are a vital source of contraceptive and reproductive health care for millions of U.S. women. It is important periodically to assess the number and type of clinics and the number of contraceptive clients they serve. METHODS: Service data were requested for agencies and clinics providing publicly funded family planning services in the United States in 1997. The numbers of agencies, clinics and female contraceptive clients were tabulated according to various characteristics and were compared with similar data for 1994. Finally, county data were tabulated according to the presence of family planning clinics and private physicians likely to provide family planning care and according to the number of female contraceptive clients served compared with the number of women needing publicly funded care. RESULTS: In 1997, 3,117 agencies offered publicly funded contraceptive services at 7,206 clinic sites. Forty percent of clinics were run by health departments, 21% by community health centers, 13% by Planned Parenthood affiliates and 26% by hospitals or other agencies. Overall, 59% of clinics received Title X funding. Agencies operated an average of 2.3 clinics, and clinics served an average of 910 contraceptive clients per year. Altogether, clinics provided contraceptive services to 6.6 million women-approximately two of every five women estimated to need publicly funded contraceptive care. The total number of providers and the total number of women served remained stable between 1994 and 1997; at the local level, however, clinic turnover was high. Some 85% of all US counties had one or more publicly funded family planning clinics; 36% had one or more clinics, but no private obstetrician-gynecologist. CONCLUSIONS: Publicly funded family planning clinics are distributed widely throughout the United States and continue to provide contraceptive care to millions of US women. Clinics are sometimes the only source of specialized family planning care available to women in rural counties. However, the high rate of clinic tumover and the lack of significant growth in clinic numbers suggest that limited funding and rising costs have hindered the further expansion and outreach of the clinic network to new geographic areas and hard-to-reach populations.

Contraceptive failure in the first two years of use: differences across socioeconomic subgroups.

CONTEXT: While differences in levels of contraceptive use across socioeconomic subgroups of women have narrowed greatly over time, large disparities remain in rates of unintended pregnancy. One reason is variations in the effectiveness with which women and their partners use contraceptive methods. METHODS: Data on contraceptive use and accidental pregnancy from the 1988 and 1995 National Surveys of Family Growth were corrected for abortion underreporting and pooled for analysis. Use-failure rates were estimated for reversible methods during the first year, second year and first two years of use, for subgroups of women of various characteristics. RESULTS: The average failure rate for all reversible methods, adjusted for abortion underreporting, declines from 13% to 8% from the first year of method use to the second year. First-year failure rates are highest among women using spermicides, withdrawal and periodic abstinence (on average, 23-28% in the first year), and lowest for women relying on long-acting methods and oral contraceptives (4-8%). On average, they exceed 10% for all users except women aged 30-44, married women and women in the highest poverty-status category. The chance of accidental pregnancy does not differ significantly between method users younger than 18 and those aged 18-19. CONCLUSION: Both user and method characteristics determine whether contraceptive users will be able to avoid unintended pregnancy. Family planning providers should help clients to identify methods that they are most likely to use successfully, and counsel them on how to be consistent users and to avoid behaviors that contribute to method failure.

Adolescent pregnancy trends and demographics.

In the United States today, 9% of women aged 15 to 19 years become pregnant each year: 5% give birth, 3% have induced abortions, and 1% have miscarriages or stillbirths--rates much higher than those in other developed countries. Rates are highest among those who are older, from disadvantaged backgrounds, black or Hispanic, married, have much older male partners, and live in southern states. Teen pregnancies are overwhelmingly unintended, reflecting substantial gaps in contraceptive use, and difficulties using reversible methods effectively. Teen pregnancy, birth, and abortion levels have decreased in recent years, primarily because of more effective contraceptive use (responsible for about 75% of the decline), and because of fewer adolescents having sexual intercourse (about 25%). Much work remains to improve the conditions in which young people grow up, provide them with information and education regarding sexuality and relationships, and improve access to sexual and reproductive health services.

Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use.

CONTEXT: Adolescent pregnancy, birth, abortion and sexually transmitted disease (STD) rates are much higher in the United States than in most other developed countries. METHODS: Government statistics or nationally representative survey data were supplemented with data collected by private organizations or for regional or local populations to conduct studies of adolescent births, abortions, sexual activity and contraceptive use in Canada, the United States, Sweden, France and Great Britain. RESULTS: Adolescent childbearing is more common in the United States (22% of women reported having had a child before age 20) than in Great Britain (15%), Canada (11%), France (6%) and Sweden (4%); differences are even greater for births to younger teenagers. A lower proportion of teenage pregnancies are resolved through abortion in the United States than in the other countries; however, because of their high pregnancy rate, U.S. teenagers have the highest abortion rate. The age of sexual debut varies little across countries, yet American teenagers are the most likely to have multiple partners. A greater proportion of U.S. women reported no contraceptive use at either first or recent intercourse (25% and 20%, respectively) than reported nonuse in France (11% and 12%, respectively), Great Britain (21% and 4%, respectively) and Sweden (22% and 7%, respectively). CONCLUSIONS: Data on contraceptive use are more important than data on sexual activity in explaining variation in levels of adolescent pregnancy and childbearing among the five developed countries; however, the higher level of multiple sexual partnership among American teenagers may help explain their higher STD rates.

Socioeconomic disadvantage and adolescent women's sexual and reproductive behavior: the case of five developed countries.

CONTEXT: Differences among developed countries in teenagers' patterns of sexual and reproductive behavior may partly reflect differences in the extent of disadvantage. However, to date, this potential contribution has received little attention. METHODS: Researchers in Canada, France, Great Britain, Sweden and the United States used the most current survey and other data to study adolescent sexual and reproductive behavior. Comparisons were made within and across countries to assess the relationships between these behaviors and factors that may indicate disadvantage. RESULTS: Adolescent childbearing is more likely among women with low levels of income and education than among their better-off peers. Levels of childbearing are also strongly related to race, ethnicity and immigrant status, but these differences vary across countries. Early sexual activity has little association with income, but young women who have little education are more likely to initiate intercourse during adolescence than those who are better educated. Contraceptive use at first intercourse differs substantially according to socioeconomic status in some countries but not in others. Within countries, current contraceptive use does not differ greatly according to economic status, but at each economic level, use is higher in Great Britain than in the United States. Regardless of their socioeconomic status, U.S. women are the most likely to give birth as adolescents. In addition, larger proportions of adolescents are disadvantaged in the United States than in other developed countries. CONCLUSIONS: Comparatively widespread disadvantage in the United States helps explain why U.S. teenagers have higher birthrates andpregnancy rates than those in other developed countries. Improving U.S. teenagers' sexual and reproductive behavior requires strategies to reduce the numbers of young people growing up in disadvantaged conditions and to help those who are disadvantaged overcome the obstacles they face.

Changing emphases in sexuality education in U.S. public secondary schools, 1988-1999.

CONTEXT: Since the late 1980s, both the political context surrounding sexuality education and actual teaching approaches have changed considerably. However, little current national information has been available on the content of sexuality education to allow in-depth understanding of the breadth of these changes and their impact on current teaching. METHODS: In 1999, a nationally representative survey collected data from 3,754 teachers in grades 7-12 in the five specialties most often responsible for sexuality education. Results from those teachers and from the subset of 1,767 who actually taught sexuality education are compared with the findings from a comparable national survey conducted in 1988. RESULTS: In 1999, 93% of all respondents reported that sexuality education was taught in their school at some point in grades 7-12; sexuality education covered a broad number of topics, including sexually transmitted diseases (STDs), abstinence, birth control, abortion and sexual orientation. Some topics--how HIV is transmitted, STDs, abstinence, how to resist peer pressure to have intercourse and the correct way to use a condom--were taught at lowergrades in 1999 than in 1988. In 1999, 23% of secondary school sexuality education teachers taught abstinence as the only way of preventing pregnancy and STDs, compared with 2% who did so in 1988. Teachers surveyed in 1999 were more likely than those in 1988 to cite abstinence as the most important message they wished to convey (41% vs. 25%). In addition, steep declines occurred between 1988 and 1999, overall and across grade levels, in the percentage of teachers who supported teaching about birth control, abortion and sexual orientation, as well as in the percentage actually covering those topics. However, 39% of 1999 respondents who presented abstinence as the only option also told students that both birth control and the condom can be effective. CONCLUSIONS: Sexuality education in secondary public schools is increasingly focused on abstinence and is less likely to present students with comprehensive teaching that includes necessary information on topics such as birth control, abortion and sexual orientation. Because of this, and in spite of some abstinence instruction that also covers birth control and condoms as effective methods of prevention, many students are not receiving accurate information on topics their teachers feel they need.

Sexuality education in fifth and sixth grades in U.S. public schools, 1999.

CONTEXT: While policymakers, educators and parents recognize the need for family life and sexuality education during children's formative years and before adolescence, there is little nationally representative information on the timing and content of such instruction in elementary schools. METHODS: In 1999, data were gathered from 1, 789 fifth- and sixth-grade teachers as part of a nationally representative survey of 5,543 public school teachers in grades 5-12. Based on the responses of 617 fifth- and sixth-grade teachers who said they teach sexuality education, analyses were carried out on the topics and skills sexuality education teachers taught, the grades in which they taught them, their teaching approaches, the pressures they experienced, whether they received support from parents, the community and school administrators, and their needs. RESULTS: Seventy-two percent of fifth- and sixth-grade teachers report that sexuality education is taught in their schools at one or both grades. Fifty-six percent of teachers say that the subject is taught in grade five and 64% in grade six. More than 75% of teachers who teach sexuality education in these grades cover puberty, HIV and AIDS transmission and issues such as how alcohol and drugs affect behavior and how to stick with a decision. However, when schools that do not provide sexuality education are taken into account, even most of these topics are taught in only a little more than half of fifth- and sixth-grade classrooms. All other topics are much less likely to be covered. Teaching of all topics is less prevalent at these grades than teachers think it should be. Gaps between what teachers say they are teaching and teachers' recommendations for what should be taught and by what grade are especially large for such topics as sexual abuse, sexual orientation, abortion, birth control and condom use for STD prevention. A substantial proportion of teachers recommend that these topics be taught at grade six or earlier. More than half (57%) of fifth- and sixth-grade sexuality education teachers cover the topic of abstinence from intercourse--17% as the only option for protection against pregnancy and STDs and 40% as the best alternative or one option for such protection. Forty-six percent of teachers report that one of their top three problems in teaching sexuality education is pressure, whether from the community, parents or school administrators. More than 40% of teachers report a need for some type of assistance with materials, factual information or teaching strategies. CONCLUSIONS: A large proportion of schools are doing little to prepare students in grades five and six for puberty, much less for dealing with pressures and decisions regarding sexual activity Sexuality education teachers often feel unsupported by the community, parents or school administrators.

Sexually transmitted diseases among adolescents in developed countries.

CONTEXT: Sexually transmitted diseases (STDs) are responsible for a variety of health problems, and can have especially serious consequences for adolescents and young adults. An international comparison of levels and trends in STDs would be useful to identify countries that are relatively successful in controlling the incidence of STDs, as a first step toward improving policies and programs in countries with high or growing STD incidence. METHODS: Incidence data for the past decade on three common bacterial STDs--syphilis, gonorrhea and chlamydia--were obtained for as many as 16 developed countries from official statistics, published national sources or scientific articles, and unpublished government data. Rates of incidence per 100,000 were calculated for adolescents, for young adults and for the total population. (These estimates should be considered conservative, because STDs commonly are underreported.) RESULTS: The incidence of these three STDs has generally decreased over the last decade, both in the general population and among adolescents. However, the Russian Federation is an important exception: Syphilis has risen dramatically in the 1990s. Except in the Russian Federation and Romania, the syphilis rate in the mid-1990s was quite low, with rates of less than seven reported cases per 100,000 teenagers in most developed countries. Gonorrhea incidence is many times higher than that of syphilis in several countries, and this disease disproportionately affects adolescents and young adults. Gonorrhea rates among adolescents can be as high as 600 per 100,000 (in the Russian Federation and the United States), although in many countries the reported rate among teenagers is below 10 per 100,000. In all countries with good reporting, chlamydia incidence is extremely high among adolescents (between 563 and 1,081 cases per 100,000). The reported incidence of all three STDs is generally higher among female teenagers than among males of the same age; this is especially true for chlamydia. CONCLUSION: Prevention programs, active screening strategies and better access to STD diagnosis and treatment services, especially for adolescents and young adults, are necessary to reduce the incidence and the burden of STDs among young people.

Adolescent pregnancy and childbearing: levels and trends in developed countries.

CONTEXT: Adolescent pregnancy occurs in all societies, but the level of teenage pregnancy and childbearing varies from country to country. A cross-country analysis of birth and abortion measures is valuable for understanding trends, for identifying countries that are exceptional and for seeing where further in-depth studies are needed to understand observed patterns. METHODS: Birth, abortion and population data were obtained from various sources, such as national vital statistics reports, official statistics, published national and international sources, and government statistical offices. Trend data on adolescent birthrates were compiled for 46 countries over the period 1970-1995. Abortion rates for a recent year were available for 33 of the 46 countries, and data on trends in abortion rates could be gathered for 25 of the 46 countries. RESULTS: The level of adolescent pregnancy varies by a factor of almost 10 across the developed countries, from a very low rate in the Netherlands (12 pregnancies per 1,000 adolescents per year) to an extremely high rate in the Russian Federation (more than 100 per 1,000). Japan and most western European countries have very low or low pregnancy rates (under 40 per 1,000); moderate rates (40-69 per 1,000) occur in Australia, Canada, New Zealand and a number of European countries. A group of five countries--Belarus, Bulgaria, Romania, the Russian Federation and the United States--have pregnancy rates of 70 or more per 1,000. The adolescent birthrate has declined in the majority of industrialized countries over the past 25 years, and in some cases has been more than halved. Similarly, pregnancy rates in 12 of the 18 countries with accurate abortion reporting showed declines. Decreases in the adolescent abortion rate, however, were less prevalent. CONCLUSIONS: The trend toward lower adolescent birthrates and pregnancy rates over the past 25 years is widespread and is occurring across the industrialized world, suggesting that the reasons for this general trend are broader than factors limited to any one country: increased importance of education, increased motivation of young people to achieve higher levels of education and training, and greater centrality of goals other than motherhood and family formation for young women.

PIP: This article examines levels of adolescent childbearing, abortion and pregnancy in developed countries in the mid-1990s, as well as trends over recent decades. Birth, abortion and population data from national vital statistics reports, official statistics, published national and international sources, and government statistical offices were analyzed. Analysis results show that level of adolescent pregnancy varies by a factor of almost 10 across developed countries, from a very low rate in the Netherlands to an extremely high rate in the Russian Federation. A pattern of decline in the adolescent birth rate in industrialized countries over the past 25 years was well documented. Part of the overall decline in childbearing across industrialized countries is the general trend of declining teenage fertility. In addition, a decline in abortion rates has been reported, although little information is available on trends in adolescent abortion specifically. The general trend reflects the increased importance of achieving higher levels of education and training, and greater centrality of goals other than motherhood and family formation for young women. However, a number of factors are likely to have had a greater impact on teenagers.

Determinants of trends in condom use in the United States, 1988-1995.

CONTEXT: Although overall condom use has increased substantially over the past decade, information is needed on whether dual method use has also become more common. In addition, there is little information on which characteristics of women influence condom use and dual method use, and on whether these characteristics have changed over time. METHODS: Data from the 1988 and 1995 National Surveys of Family Growth are examined to evaluate trends in condom use--either use alone or use with another highly effective method (dual method use). Logistic and multinomial regression analyses are presented to analyze the influence of women's characteristics on condom use. RESULTS: Current condom use rose significantly between 1988 and 1995, from 13% to 19% of all women who had had sex in the past three months. Dual method use increased from 1% in 1988 to 3% in 1995, still a very low level. In both years, current condom use was higher among women younger than 20 (32-34% in 1995) than among those aged 30 or older (less than 20% in 1995). Likewise, current condom use was most common among never-married women who were not cohabiting in both 1988 (20%) and in 1995 (34%). Multivariate analyses showed that women in the early stage of a relationship (six months or less in duration) were much more likely than those in a long-standing relationship (five years or more in length) to use the condom (odds ratio, 1.5). In both 1988 and 1995, younger women and better educated women were more likely to be currently using the condom than were older or less-educated women. For example, in 1995, women younger than 18 were 1.8 times as likely as 40-44-year-olds to be using condoms, and college graduates were 1.5 times as likely as high school graduates to do so. Further, women who were not in a union and either had never been married or were formerly married were more likely to be current condom users in 1995 than were married women (odds ratios, 1.5-1.9). Poor women were less likely than higher income women to be condom users in 1995 (odds ratios, 0.7-0.8), but poverty had made little difference in 1988. Groups likely to be dual method users were those also likely to be at greater risk of sexually transmitted disease: women in a union of less than six months duration (2.8), women younger than 20 (4.6-6.8), unmarried women (2.8-7.5) and women with two or more partners in the past three months (1.7). CONCLUSIONS: While the increase in condom use, especially among unmarried and adolescent women, is encouraging, condom use overall is substantially less than that needed to protect women and men against sexually transmitted diseases (including HIV). Moreover, steps need to be taken to understand why levels of dual method use are low and how they may be increased.

PIP: This study examines data from the 1988 and 1995 National Surveys of Family Growth to assess trends in condom use, either used alone or used with another highly effective method (dual method). Results showed that condom use increased significantly from 13% in 1988 to 19% in 1995 among women who had had sex in the past 3 months. Dual method use increased from 1% in 1988 to 3% in 1995. In both years, current condom use was higher among women younger than 20 than among those aged 30 or older, and among never-married women who were not cohabiting. Multivariate analysis showed that women in the early stage of a relationship were more likely to use a condom than those in a long-standing affair. Women with higher education chose condom as a contraceptive method. Poor women were less likely to be condom users in 1995, but poverty had made a little difference in 1998. Dual method users were those also likely to be at greater risk of sexually transmitted disease: women in a union of less than 6 months (2.8), women younger than 20 (4.6-6.8), unmarried women (2.8-7.5), and women with two or more partners in the past 3 months (1.7).

Age differences between sexual partners in the United States.

CONTEXT: Researchers have examined the age of partners of young women at first intercourse and of young women who have given birth, but little is known about the age of partners of young women in current sexual relationships or young women who have had an abortion. METHODS: Data from the 1995 National Survey of Family Growth (NSFG) were used to examine age differences between women and their current partner and women's use of contraceptives at last intercourse, by marital status and by the age difference between women and their partner. Data from the NSFG and the 1994-1995 Alan Guttmacher Institute Abortion Patient Survey, with supplemental information from other sources, were used to estimate 1994 pregnancy rates for women by their age and marital status, according to the age difference between the women and their partner. RESULTS: Among all sexually active women aged 15-44, 10% had a partner who was three or more years younger, 52% a partner who was within two years of their age, 20% a partner who was 3-5 years older, and 18% a partner who was six or more years older. In contrast, 64% of sexually active women aged 15-17 had a partner within two years of their age, 29% a partner who was 3-5 years older, and 7% a partner who was six or more years older. Among women younger than 18, the pregnancy rate among those with a partner who was six or more years older was 3.7 times as high as the rate among those whose partner was no more than two years older. Among women younger than 18 who became pregnant, those with a partner who was six or more years older were less likely to have an unintended pregnancy (70%) or to terminate an unintended pregnancy (21%) than were those whose partner was no more than two years older (82% and 49%, respectively). Among women younger than 18 who were at risk of unintended pregnancy, 66% of those who had a partner who was six or more years older had practiced contraception at last sex, compared with 78% of those with a partner within two years of their own age. Young women who were Catholic and those who had first had sex with their partner within a relatively committed relationship were less likely to be involved with a man who was six or more years older than were young women who were Protestants and those who first had sex with their partner when they were dating, friends or had just met. Young women who had ever been forced to have sex were twice as likely as those who had not to have a partner who was 3-5 years older. CONCLUSION: Although the proportion of 15-17-year-old women who have a much older partner is small, these adolescents are of concern because of their low rate of contraceptive use and their relatively high rates of pregnancy and birth. Research is needed to determine why some young women have relationships with an older man, and how their partner's characteristics affect their reproductive behavior.

PIP: Data from the 1995 National Survey of Family Growth (NSFG), a nationally representative survey of 10,847 women aged 15-44 years, and the 1994-95 Alan Guttmacher Institute Abortion Patient Survey, together with supplemental data from other sources, were used to estimate 1994 pregnancy rates for women by their age and marital status, according to the age difference between the women and their partner. Among all sexually active women, 10% had a partner who was 3 or more years younger, 52% a partner within 2 years of their age, 20% a partner 3-5 years older, and 18% a partner 6 or more years older. 64% of sexually active women aged 15-17 years had a partner within 2 years of their age, 29% a partner 3-5 years older, and 7% a partner 6 or more years older. Among women under 18 years old, the pregnancy rate among those with a partner 6 or more years older was 3.7 times higher than the rate among those whose partner was no more than 2 years older. Among women under age 18 who became pregnant, those with a partner 6 or more years older were less likely to have an unintended pregnancy or to terminate an unintended pregnancy than were those whose partner was no more than 2 years older. Among women under age 18 at risk of unintended pregnancy, 66% of those with a partner 6 or more years older used contraction at most recent sex, compared with 78% of those with a partner within 2 years of their own age. Young Catholic women and those who had first had sex with their partner within a relatively committed relationship were less likely to be involved with a man who was 6 or more years older than were young women who were Protestants and those who first had sex with their partner when they were dating, friends, or had just met.

Pregnancy rates among U.S. women and their partners in 1994.

CONTEXT: When rates of pregnancy, birth and abortion are calculated only for the women involved, men's role in reproduction is ignored, resulting in limited understanding of their influence on these outcomes. METHODS: Data from the 1995 National Survey of Family Growth and from the 1994-1995 Alan Guttmacher Institute Abortion Patient Survey were combined with national natality statistics to estimate pregnancy rates in 1994 for women and their male partners, by age and marital status at the time of conception. RESULTS: Nine percent of both men and women aged 15-44 were involved in conceiving a pregnancy in 1994 (excluding those resulting in miscarriages). Pregnancy levels were highest among women aged 20-24 and among male partners aged 25-29. Men younger than 20 were involved in about half as many pregnancies as were women this age (9% compared with 18%). In contrast, men aged 35 and older were involved in roughly twice as many pregnancies as were similarly aged women (19% compared with 9%). Three out of every four pregnancies in 1994 resulted in a birth. However, 47% of pregnancies involving men younger than 18 ended in abortion, compared with about 34% of those involving men aged 40 and older. In comparison, 31% of pregnancies among women younger than 18 resulted in abortion, while 39% of those among women aged 40 and older were terminated. CONCLUSION: The overall rate at which men were involved in causing a pregnancy is similar to the pregnancy rate among women. Men are typically older than women when they are involved in a pregnancy, however. This implies that men may bring more experience and resources to the pregnancy experience.

PIP: This study examines pregnancy rates and pregnancy outcomes among US women and their male partners in 1994. Sources of data include the 1995 National Survey of Family Growth, the 1994-95 Alan Guttmacher Institute Abortion Patient Survey, and statistics records of the National Center for Health Statistics. Findings revealed that 9% of both men and women aged 15-44 were involved in conceiving a pregnancy in 1994. Pregnancy levels were highest among women aged 20-24 and among 25-29 year old male partners. In addition, men younger than age 20 and women were engaged in 9% and 18% of pregnancies, respectively. A significantly contrasting result was noted among men and women aged 35 and older; 19% of men and 9% of women were involved in pregnancies at these ages. Furthermore, the study indicated that 3 out of every 4 pregnancies in 1994 resulted in a birth. However, 47% of pregnancies involving men below 18 years resulted in abortion, compared with about 34% of those involving men aged 40 and older. In comparison, 31% of pregnancies among women below 18 years old ended up in abortion, while 39% of those among women aged 40 and older were terminated. Although there are similarities in the levels and distributions of pregnancies among both sexes, the findings indicate that among couples involved in pregnancy, it is common for men to be older than women.

Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth.

CONTEXT: Unintended pregnancy remains a major public health concern in the United States. Information on pregnancy rates among contraceptive users is needed to guide medical professionals' recommendations and individuals' choices of contraceptive methods. METHODS: Data were taken from the 1995 National Survey of Family Growth (NSFG) and the 1994-1995 Abortion Patient Survey (APS). Hazards models were used to estimate method-specific contraceptive failure rates during the first six months and during the first year of contraceptive use for all U.S. women. In addition, rates were corrected to take into account the underreporting of induced abortion in the NSFG. Corrected 12-month failure rates were also estimated for subgroups of women by age, union status, poverty level, race or ethnicity, and religion. RESULTS: When contraceptive methods are ranked by effectiveness over the first 12 months of use (corrected for abortion underreporting), the implant and injectables have the lowest failure rates (2-3%), followed by the pill (8%), the diaphragm and the cervical cap (12%), the male condom (14%), periodic abstinence (21%), withdrawal (24%) and spermicides (26%). In general, failure rates are highest among cohabiting and other unmarried women, among those with an annual family income below 200% of the federal poverty level, among black and Hispanic women, among adolescents and among women in their 20s. For example, adolescent women who are not married but are cohabiting experience a failure rate of about 31% in the first year of contraceptive use, while the 12-month failure rate among married women aged 30 and older is only 7%. Black women have a contraceptive failure rate of about 19%, and this rate does not vary by family income; in contrast, overall 12-month rates are lower among Hispanic women (15%) and white women (10%), but vary by income, with poorer women having substantially greater failure rates than more affluent women. CONCLUSIONS: Levels of contraceptive failure vary widely by method, as well as by personal and background characteristics. Income's strong influence on contraceptive failure suggests that access barriers and the general disadvantage associated with poverty seriously impede effective contraceptive practice in the United States.

PIP: This study estimated method-specific contraceptive failure rates in the US. Estimates were adjusted for underreporting of induced abortion in the main survey. The correction made a sizeable impact, as 25% of the 2,157,473 conceptions due to contraceptive failure were aborted. Data were obtained from the 1995 National Survey of Family Growth and the 1994-95 Abortion Patient Survey. Analysis was based on hazard models for failure in the first 6 and 12 months. Data include 7276 contraceptive use segments. The mean duration was 9.6 months. The pill and condom had the largest shares of use segments. The lowest failure rates were for implants and injectables (2-3%). Failure rates were as follows: oral pills (8%), diaphragm and cervical cap (12%), male condom (14%), periodic abstinence (21%), withdrawal (24%), and spermicides (26%). Failure rates were highest among cohabiting and other unmarried women; women with an annual family income below 200% of the federal poverty level; among Black and Hispanic women; and among adolescents and women in their 20s. The failure rate among low income women declined during 1988-95. Women above the 200% of poverty level had stable rates. Poverty continued to have a negative impact on effective contraceptive use. Four models were used to examine the effects of socioeconomic factors on contraceptive failure.

Women's interest in vaginal microbicides.

CONTEXT: Each year, an estimated 15 million new cases of sexually transmitted diseases (STDs), including HIV, occur in the United States. Women are not only at a disadvantage because of their biological and social susceptibility, but also because of the methods that are available for prevention. METHODS: A nationally representative sample of 1,000 women aged 18-44 in the continental United States who had had sex with a man in the last 12 months were interviewed by telephone. Analyses identified levels and predictors of women's worry about STDs and interest in vaginal microbicides, as well as their preferences regarding method characteristics. Numbers of potential U.S. microbicide users were estimated. RESULTS: An estimated 21.3 million U.S. women have some potential current interest in using a microbicidal product. Depending upon product specifications and cost, as many as 6.0 million women who are worried about getting an STD would be very interested in current use of a microbicide. These women are most likely to be unmarried and not cohabiting, of low income and less education, and black or Hispanic. They also are more likely to have visited a doctor for STD symptoms or to have reduced their sexual activity because of STDs, to have a partner who had had other partners in the past year, to have no steady partner or to have ever used condoms for STD prevention. CONCLUSIONS: A significant minority of women in the United States are worried about STDs and think they would use vaginal microbicides. The development, testing and marketing of such products should be expedited.

PIP: Research is underway to develop safe, effective microbicides that women can use vaginally to prevent sexually transmitted disease (STD) transmission. To estimate potential interest in microbicide use, interviews were conducted in 1998 with a nationally representative sample of 1000 sexually active US women 18-44 years of age. 20% of these women had either had an STD in the past or thought they might be infected. 93% of respondents indicated they would be interested in using a vaginal microbicide if they found themselves in a situation where they were at risk of STD transmission and 40% expressed current interest in such a product. Women who were not in a union were almost 3 times as likely as cohabiting women and 12 times as likely as married women to be both worried about contracting an STD and very interested in using a vaginal microbicide. Women who were 25-34 years of age, had a family income under US$20,000, did not have a college education, and were Black or Hispanic also were significantly more likely to express worry about their STD risk and interest in the product. The strongest independent predictor of whether a woman was worried about STDs and very interested in using a microbicide was whether she and her partner were already using condoms for STD prevention (odds ratio, 8.8). Two-thirds of respondents preferred a product that could be applied several hours before intercourse and was available without a prescription. 84% said they would use microbicide along with condoms rather than as a substitute for them. The findings of this survey suggest an estimated 12.6 million US women 15-44 years of age would be interested in current use of a microbicide. More than 7 million of these women would remain interested even if the product protected only against HIV, was just 70-80% effective, and cost $2 per application. Given this level of interest, the development, testing, and marketing of such products should be expedited.

Trends in sexual activity among adolescent American women: 1982-1995.

CONTEXT: The formulation of policies and development of programs regarding adolescent sexual and reproductive health requires up-to-date information on levels of and trends in teenage sexual activity. METHODS: Analysis of three NSFG surveys, carried out in 1982, 1988 and 1995, allows examination of the sexual behavior of teenage women over a 13-year time period, using comparable data for the entire time period. RESULTS: The proportion of adolescent women who ever had sexual intercourse increased somewhat during the 1980s, but this upward trend stabilized between the late 1980s and the mid-1990s. Throughout the period, there has been little change in the proportion currently sexually active: In each of the surveys, about 40% of all 15-19-year-olds had had sexual intercourse in the last three months. The average number of months in the past year in which sexually experienced teenagers had had intercourse declined during the 1980s, with no change in the continuity of sexual intercourse taking place between 1988 and 1995, when the mean remained at 8.6 months. Differences in teenage sexual behavior across poverty and racial and ethnic subgroups were large in the early 1980s, but narrowed over the 13-year period. CONCLUSIONS: Only continued monitoring will tell whether the patterns observed during 1988-1995 signify a temporary leveling off in the trend toward increasing adolescent sexual activity, stability in behavior or the beginnings of a decline. Nevertheless, the sustained level of initiation of sexual activity during adolescence is by now a recognized pattern of behavior, and is an important characteristic of the transition to adulthood in the United States.

PIP: A study on the trends in sexual activity among adolescent American women over a 13-year period is presented. Data from the National Survey of Family Growth (NSFG) carried out in 1982, 1988 and 1995 were used to examine the sexual behavior of teenage women. Analysis of these three NSFG surveys demonstrated an increase in the proportion of adolescent women who ever had sexual intercourse during the early to mid-1980s. This upward trend stabilized between the late 1980s and the mid-1990s. All the surveys revealed that about 40% of all teenagers age 15-19 years had sexual intercourse in the last 3 months. Large differences in teenage sexual behavior across poverty and racial and ethnic subgroups were observed in the early 1980s, but narrowed over the 13-year period. These findings suggest that trends in levels of sexual activity among American adolescents must be viewed from a long-term perspective. Only continued monitoring will show whether the patterns observed from 1988 to 1995 indicate stability in behavior, a temporary leveling off in the trend toward increasing adolescent sexual activity or the precursor of a decline. Nevertheless, the constant level of initiation of sexual activity during adolescence is by now a recognized pattern of behavior. It is considered an essential characteristic of the transition to adulthood in the US.

Sexual partnership patterns as a behavioral risk factor for sexually transmitted diseases.

CONTEXT: Women's and men's number of sexual partners and protective practices such as condom use can have a direct effect on their risk of contracting sexually transmitted diseases (STDs), including HIV. METHODS: The 1988 and 1995 cycles of the National Survey of Family Growth and five rounds of the General Social Survey conducted from 1988 to 1996 are used to examine women's and men's numbers of recent sexual partners. Levels of direct risk for STDs (two or more partners in the past year) and the social and demographic correlates of multiple partnership are analyzed among women and men. In addition, women's indirect risk for STDs (their partners' involvement with other partners in the past year) is used to estimate their overall risk of STDs through multiple partnerships. RESULTS: At least three-quarters of sexually active U.S. women and men in the late 1980s and mid-1990s had had only one sexual partner in the preceding 12 months. Moreover, there is no indication that the proportion with more than one partner in the past year changed substantially over that period. Nevertheless, combining women's and men's partnership reports suggests that about 17 million women aged 15-44--34% of those sexually active in the past year--were at risk for STDs because of direct exposure to multiple partners (5.4 million), indirect exposure (6.3 million) or both direct and indirect exposure (5.5 million). In all, 21% of women were at direct risk and 23% were at indirect risk. In comparison, among men aged 18-44, 24% were at direct risk for STDs and an unknown proportion were at indirect risk. Multivariate analyses indicated that unmarried individuals, women younger than 40 and men aged 20-29, blacks and women in the South were all at elevated risk for STDs because of multiple partnership. Overall, in 1995, 19% of sexually active women aged 15-44 had used condoms to protect against STDs over the preceding year, and 19% of those sexually active in the three months before the survey were current condom users. Condom use specifically for STD prevention was more common among women reporting both direct and indirect risk for STDs (58%) and among those at direct risk (46%) than among other women; women whose partners put them at indirect risk only were less likely to be current or recent condom users than women who were not at risk or were only at direct risk. CONCLUSIONS: There is a continuing need to educate people regarding their risk for STDs, to increase the use of existing barrier methods and to develop new methods that protect against STD infection. In addition, if we are to develop a better understanding of the extent of STD risk through multiple partnership, the collection of information on number of partners and relationships between partners must be expanded and improved.

PIP: This study examines the effects of sexual partnership patterns and protective practices on the risk of contracting sexually transmitted diseases (STDs), including HIV in the US. Data from the 1988 and 1995 cycles of the National Survey of Family Growth and five rounds of the General Social Survey conducted from 1988 to 1996 were used to examine women's and men's number of recent sexual partners. Included in the analysis are the levels of direct risks for STDs and the social and demographic correlates of multiple partnership among women and men. The results of the analysis revealed that having multiple sexual partners or having a partner who has multiple partners over a relatively short period of time are key behavioral factors that contribute to an individual's risk for STDs. Combining women's and men's partnership reports suggested that about 17 million women aged 15-44 were at risk for STDs because of direct exposure to multiple partners (5.4 million), indirect exposure (6.3 million), or both direct and indirect exposure (5.5 million). Meanwhile, among men aged 18-44, about 24% were at direct risk for STDs and an unknown proportion were at indirect risk. Condom use for STD prevention was more common among women reporting both direct and indirect risk for STDs (58%) and among those at direct risk. The findings in this study indicated that there is a need for continued and increased emphasis on public education concerning the risk factors in STDs, as well as the methods to prevent and control STD infection.

The effects of pregnancy planning status on birth outcomes and infant care.

CONTEXT: The planning status of a pregnancy may affect a woman's prenatal behaviors and the health of her newborn. However, whether this effect is independent or is attributable to socioeconomic and demographic factors has not been explored using nationally representative data. METHODS: Data were obtained on 9,122 births reported in the 1988 National Maternal and Infant Health Survey and 2,548 births reported in the 1988 National Survey of Family Growth. Multiple logistic regression analyses were employed to examine the effects of planning status on the odds of a negative birth outcome (premature delivery, low-birth-weight infant or infant who is small for gestational age), early well-baby care and breastfeeding. RESULTS: The proportion of infants born with a health disadvantage is significantly lower if the pregnancy was intended than if it was mistimed or not wanted; the proportions who receive well-baby care by age three months and who are ever breastfed are highest if the pregnancy was intended. In analyses controlling for the mother's background characteristics, however, a mistimed pregnancy has no significant effect on any of these outcomes. An unwanted pregnancy increases the likelihood that the infant's health will be compromised (odds ratio, 1.3), but the association is no longer significant when the mother's prenatal behaviors are also taken into account. Unwanted pregnancy has no independent effect on the likelihood of well-baby care, but it reduces the odds of breastfeeding (0.6). CONCLUSIONS: Knowing the planning status of a pregnancy can help identify women who may need support to engage in prenatal behaviors that are associated with healthy outcomes and appropriate infant care.

PIP: The planning status of a pregnancy has been shown to influence maternal behaviors during pregnancy (e.g., smoking and weight gain) as well as pregnancy outcomes such as prematurity and low birth weight. It is possible, however, that the apparent effects of planning status actually reflect demographic and socioeconomic differences between women who plan their pregnancies and those who did not intend to conceive. This issue was explored through use of data on 9122 births reported in the 1988 US National Maternal and Infant Health Survey and 2548 births reported in the 1988 National Survey of Family Growth. In the first survey, 16% of intended births, compared with 20% of mistimed and 26% of unwanted births, had at least one negative outcome. Similarly, the proportions of infants who received well-baby care by 3 months and were breast-fed were highest when the pregnancy was intended. However, when the mother's physical and socioeconomic characteristics and the infant's health status at birth were controlled, a mistimed pregnancy had no significant effect on any of these outcomes. An unwanted birth was significantly more likely than an intended one to be associated with negative infant health outcomes when a woman's prior pregnancy experiences, physical characteristics, and socioeconomic status were controlled (odds ratio, 1.3), but the association lost significance when the mother's prenatal behaviors were considered. Unwanted pregnancy had no independent effect on the likelihood of well-baby care, but significantly reduced the likelihood of breast feeding (odds ratio, 0.6). These associations should be reassessed with more sophisticated measures and study design. However, intention status at conception does appear to represent a useful gross indicator for identifying women in need of special services and support during pregnancy.

Mainstreaming contraceptive services in managed care--five states' experiences.

CONTEXT: The ongoing, rapid national transition from a health care financing and delivery system dominated by traditional indemnity insurance to one dominated by managed care has enormous implications for the accessibility of contraceptive services. METHODS: In each of five areas with relatively mature managed care environments (all of Colorado, Massachusetts and Michigan, as well as selected counties in California and Florida), all managed care organizations serving commercial or Medicaid enrollees were asked about their coverage of contraceptive services and the procedures for obtaining that care. In addition, all publicly funded family planning agencies in these areas were queried about their involvement with managed care plans, and representative samples of reproductive-age women at risk of unintended pregnancy and enrolled in managed care plans were asked about their plan's coverage and their experiences in obtaining contraceptive services. RESULTS: Fifteen percent of health maintenance organizations and point-of-service plans did not cover all five of the most commonly used medical contraceptive methods, and another 6% covered none of the methods. Only half the plans informed enrollees--and even fewer informed enrollees insured indirectly as dependents--of whether they covered contraceptive services. One in four women in commercial plans were unsure whether their plan covered oral contraceptives, and two in three did not know if their plan covered the other medical methods. Only one in four commercial plans have brought community-based family planning providers into their networks, and more than half of all publicly funded family planning agencies reported having no contracts with managed care organizations. Finally, nearly one in three women in managed care plans reported difficulties in obtaining contraceptive services, with 13% of enrollees in commercial plans waiting at least four weeks for an appointment for contraceptive care. CONCLUSIONS: To adequately address the contraceptive needs of their employees, employers must ensure that the health insurance plans they purchase provide adequate coverage of contraceptive methods. For their part, managed care organizations and state Medicaid programs should examine their policies and procedures to ensure that services are easily accessible to women needing contraceptive care.

Measuring the extent of abortion underreporting in the 1995 National Survey of Family Growth.

CONTEXT: Induced abortions are often severely underreported in national surveys, hampering the estimation and analysis of unintended pregnancies. To improve the level of abortion reporting, the 1995 National Survey of Family Growth (NSFG) incorporated new interview and self-report procedures, as well as a monetary incentive to respondents. METHODS: The weighted numbers of abortions reported in the main interview of the 1995 NSFG (Cycle 5), in the self-report and in the two procedures combined are compared with abortion estimates from The Alan Guttmacher Institute. The Cycle 5 estimates are also compared with estimates from previous cycles of the NSFG. RESULTS: The self-report produces better reporting than the main interview, but combining data from the two procedures yields the highest count of abortions. For the period 1991-1994, the level of reporting is 45% in the main interview, 52% in the self-report and 59% when the two methods are combined. The level of abortion reporting in the combined data ranges from 40% for women with an income less than the federal poverty level to more than 75% among women who were older than 35, those who were married at the time of their abortion and those with an income above 200% of the poverty level. The completeness of abortion reporting in the main interview of Cycle 5, though indicating a remarkable improvement over reporting in Cycle 4, is comparable to the levels in Cycles 2 and 3. CONCLUSIONS: The usefulness of the NSFG remains extremely limited for analyses involving unintended pregnancy and abortion.

PIP: This study assessed the extent of full reporting of induced abortion in the 1995 National Survey of Family Growth (NSFG). NSFG has new interview and self-report procedures for correcting undercounts. NSFG Cycles 2-4 were found to record under 50% of abortions that actually occurred in the US. This study compared the level of abortions reported under each of two NSFG survey procedures (the main interview and the self-report). These 2 sources were used to derive the best abortion estimates available from Cycle 5. Estimates from Cycle 5 were compared to earlier cycles for general reporting and for reporting on subgroups of women. Self-reported abortion data appeared to be somewhat less consistent than main interviews and lacked valid dates. The computer entries could increase the potential for input errors. Analysis includes the comparison between: 1) the number of abortions that were reported in the main interview with those that actually occurred in the US; 2) self-reported abortions with external estimates; and 3) both sources of abortions with external estimates. In general, women reported abortions more completely in self-reports during 1976-90. A more complete count occurred with the combined sources. Even with the new procedures in Cycle 5, abortions were undercounted. The combined sources yielded 64% of the actual abortion events. Abortion reporting in the main interview and combined sources varied widely across subgroups. However, for some subgroups, self-reports improved reporting by 33%. Higher level of education was associated with a low accuracy of reporting.