A prospective measure of unintended pregnancy in the United States.

OBJECTIVE: To describe a new measure, the unintended pregnancy risk index (UPRI), which is based primarily on attitudinal and behavioral measures of women's prospective pregnancy desire, and compare it to the unintended pregnancy rate, typically calculated retrospectively. STUDY DESIGN: We used three rounds of the National Survey of Family Growth to calculate trends in the UPRI and compare it to the retrospective rate. The UPRI estimates the annual risk of becoming unintentionally pregnant on a scale from 0 to 100. It is based on women's prospective pregnancy desire as well as fecundity, sexual activity and contraceptive use patterns. RESULTS: Among all women aged 15-34, the UPRI ranged from 7.4 in 2002 to 5.7 in 2013. The retrospective unintended pregnancy rate had similar levels and declines for the same overall period, although the UPRI declined earlier than the retrospective rate. CONCLUSIONS: Changes in the use of any contraceptive method, the methods used and the effectiveness of the methods used all contributed to the decline in the UPRI. IMPLICATIONS: The sufficiency of retrospective measures of pregnancy intention has been challenged, and data availability has constrained needed surveillance of the unintended pregnancy rate. The UPRI offers a new measure that can be calculated with existing national surveillance data or for any population for which data on prospective pregnancy desire, pregnancy risk and contraceptive use are available.

Contraceptive Failure in the United States: Estimates from the 2006-2010 National Survey of Family Growth.

CONTEXT: Contraceptive failure rates measure a woman's probability of becoming pregnant while using a contraceptive. Information about these rates enables couples to make informed contraceptive choices. Failure rates were last estimated for 2002, and social and economic changes that have occurred since then necessitate a reestimation. METHODS: To estimate failure rates for the most commonly used reversible methods in the United States, data from the 2006-2010 National Survey of Family Growth were used; some 15,728 contraceptive use intervals, contributed by 6,683 women, were analyzed. Data from the Guttmacher Institute's 2008 Abortion Patient Survey were used to adjust for abortion underreporting. Kaplan-Meier methods were used to estimate the associated single-decrement probability of failure by duration of use. Failure rates were compared with those from 1995 and 2002. RESULTS: Long-acting reversible contraceptives (the IUD and the implant) had the lowest failure rates of all methods (1%), while condoms and withdrawal carried the highest probabilities of failure (13% and 20%, respectively). However, the failure rate for the condom had declined significantly since 1995 (from 18%), as had the failure rate for all hormonal methods combined (from 8% to 6%). The failure rate for all reversible methods combined declined from 12% in 2002 to 10% in 2006-2010. CONCLUSIONS: These broad-based declines in failure rates reverse a long-term pattern of minimal change. Future research should explore what lies behind these trends, as well as possibilities for further improvements.

Declines in Unintended Pregnancy in the United States, 2008-2011.

BACKGROUND: The rate of unintended pregnancy in the United States increased slightly between 2001 and 2008 and is higher than that in many other industrialized countries. National trends have not been reported since 2008. METHODS: We calculated rates of pregnancy for the years 2008 and 2011 according to women's and girls' pregnancy intentions and the outcomes of those pregnancies. We obtained data on pregnancy intentions from the National Survey of Family Growth and a national survey of patients who had abortions, data on births from the National Center for Health Statistics, and data on induced abortions from a national census of abortion providers; the number of miscarriages was estimated using data from the National Survey of Family Growth. RESULTS: Less than half (45%) of pregnancies were unintended in 2011, as compared with 51% in 2008. The rate of unintended pregnancy among women and girls 15 to 44 years of age declined by 18%, from 54 per 1000 in 2008 to 45 per 1000 in 2011. Rates of unintended pregnancy among those who were below the federal poverty level or cohabiting were two to three times the national average. Across population subgroups, disparities in the rates of unintended pregnancy persisted but narrowed between 2008 and 2011; the incidence of unintended pregnancy declined by more than 25% among girls who were 15 to 17 years of age, women who were cohabiting, those whose incomes were between 100% and 199% of the federal poverty level, those who did not have a high school education, and Hispanics. The percentage of unintended pregnancies that ended in abortion remained stable during the period studied (40% in 2008 and 42% in 2011). Among women and girls 15 to 44 years of age, the rate of unintended pregnancies that ended in birth declined from 27 per 1000 in 2008 to 22 per 1000 in 2011. CONCLUSIONS: After a previous period of minimal change, the rate of unintended pregnancy in the United States declined substantially between 2008 and 2011, but unintended pregnancies remained most common among women and girls who were poor and those who were cohabiting. (Funded by the Susan Thompson Buffett Foundation and the National Institutes of Health.).

Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries.

BACKGROUND: The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect. STUDY DESIGN: We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage. RESULTS: In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women. CONCLUSIONS: Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA. IMPLICATIONS: Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012.

OBJECTIVE: To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15-44 years using contraception between 2008-2010 and 2011-2013 with specific attention to associations between race, income, and age and their LARC use. METHODS: We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15-44 years, consisting of 6,428 females in 2008-2010 and 5,601 females in 2011-2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview. RESULTS: The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1-11.1%), those with fewer than two sexual partners in the previous year (9.2-12.4%), and those who were nulliparous (2.1-5.9%) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women. CONCLUSION: During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users. LEVEL OF EVIDENCE: III.

Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends.

PURPOSE: To examine pregnancy rates and outcomes (births and abortions) among 15- to 19-year olds and 10- to 14-year olds in all countries for which recent information could be obtained and to examine trends since the mid-1990s. METHODS: Information was obtained from countries' vital statistics reports and the United Nations Statistics Division for most countries in this study. Alternate sources of information were used if needed and available. We present estimates primarily for 2011 and compare them to estimates published for the mid-1990s. RESULTS: Among the 21 countries with complete statistics, the pregnancy rate among 15- to 19-year olds was the highest in the United States (57 pregnancies per 1,000 females) and the lowest rate was in Switzerland (8). Rates were higher in some former Soviet countries with incomplete statistics; they were the highest in Mexico and Sub-Saharan African countries with available information. Among countries with reliable evidence, the highest rate among 10- to 14-year olds was in Hungary. The proportion of teen pregnancies that ended in abortion ranged from 17% in Slovakia to 69% in Sweden. The proportion of pregnancies that ended in live births tended to be higher in countries with high teen pregnancy rates (p = .02). The pregnancy rate has declined since the mid-1990s in the majority of the 16 countries where trends could be assessed. CONCLUSIONS: Despite recent declines, teen pregnancy rates remain high in many countries. Research on the planning status of these pregnancies and on factors that determine how teens resolve their pregnancies could further inform programs and policies.

Unintended pregnancy and the changing demography of American women, 1987-2008.

BACKGROUND: In 1987, the U.S. unintended pregnancy rate was 59 per 1,000 women aged 15-44; the rate fell to 54 in 2008. Over this period, American women experienced dramatic demographic shifts, including an aging population that was better educated and more racially and ethnically diverse. OBJECTIVE: This study aims to explain trends in unintended pregnancy and understand what factors contributed most strongly to changes in rates over time, focusing on population composition and group-specific changes. METHODS: We used the 1988 and 2006-10 waves of the National Survey of Family Growth and employed a decomposition approach, looking jointly at age, relationship status, and educational attainment. RESULTS: When we decomposed by the demographic factors together, we found that changes in population composition contributed to an increase in the overall rate, but this was more than offset by group-specific rate declines, which had an impact nearly twice as great in the downward direction. Increases in the share of the population that was cohabiting and the share that was Hispanic were offset by declines in rates among married women. CONCLUSIONS: Our findings suggest that a combination of compositional shifts and changes in group-specific rates drove unintended pregnancy, sometimes acting as counterbalancing forces and at other times operating in tandem.

Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update.

BACKGROUND: The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013. STUDY DESIGN: Data for this study come from a subset of the 1842 women aged 18-39 years who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice. RESULTS: Between fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the intrauterine device. CONCLUSIONS: The implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time. IMPLICATIONS: This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.

Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program.

UNLABELLED: Policy Points: The US publicly supported family planning effort serves millions of women and men each year, and this analysis provides new estimates of its positive impact on a wide range of health outcomes and its net savings to the government. The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent. CONTEXT: Each year the United States' publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified. METHODS: Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child. FINDINGS: In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion-$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion. CONCLUSIONS: Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.

Trends in ages at key reproductive transitions in the United States, 1951-2010.

BACKGROUND: Key sexual and reproductive health milestones typically mark changing life stages with different fertility intentions and family planning needs. Knowing the typical ages at such events contributes to our understanding of changes in family formation and transition to adulthood and helps inform needs for reproductive health services. METHODS: We used data from the 1982-2010 National Surveys of Family Growth and the 1995 National Survey of Adolescent Males and event history methods to examine trends over time for women and men in the median ages at several reproductive and demographic events. FINDINGS: Women's reports indicate that age at menarche has changed little since 1951. Women's and men's median ages at first sex declined through the 1978 birth cohort, but increased slightly since then, to 17.8 years for women and 18.1 for men. The interval from first sex to first contraceptive use has narrowed, although Hispanic women have a longer interval. Age at first union (defined as the earlier of first marriage or first cohabiting relationship) has remained relatively stable, but the time between median age at first sex and median age at first birth has increased to 9.2 years for women and 11.4 for men. For some women and men born in the late 1970s, median age at first birth was earlier than median age at first marriage for the first time in at least the past several decades. CONCLUSION: The large majority of the reproductive years are spent sexually active. Thus, women have a lengthy period during which they require effective methods. In particular, the period between first sex and first childbearing has lengthened, but long-acting method use, although increasing, has not kept up with this shift. Moving the contraceptive method mix toward underutilized but highly effective contraceptive methods has the potential to reduce the unintended pregnancy rate.

Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requirement.

BACKGROUND: As part of the Affordable Care Act, a federal requirement for private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients, took effect for millions of Americans in January 2013. STUDY DESIGN: Data for this study come from a subset of the 3207 women aged 18-39 years who responded to two waves of a national longitudinal survey. This analysis focused on the 889 women who were using hormonal contraceptive methods in both the fall 2012 and spring 2013 waves and the 343 women who used the intrauterine device at either wave. Women were asked about the amount they paid out of pocket in an average month for their method of choice. RESULTS: Between Wave 1 and Wave 2, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 40%; by contrast, there was no significant change among publicly insured or uninsured women (whose coverage was not affected by the new federal requirement). Similar changes were seen among privately insured women using the vaginal ring. CONCLUSIONS: The initial implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women. Additional progress is likely as the requirement phases in to apply to more private plans, but with evidence that not all methods are being treated equally, policymakers should consider stepped-up oversight and enforcement of the provision. IMPLICATIONS: This study measures the out-of-pocket costs for women with private, public and no insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs and areas that need further progress.

Shifts in intended and unintended pregnancies in the United States, 2001-2008.

OBJECTIVES: We monitored trends in pregnancy by intendedness and outcomes of unintended pregnancies nationally and for key subgroups between 2001 and 2008. METHODS: Data on pregnancy intentions from the National Survey of Family Growth (NSFG) and a nationally representative survey of abortion patients were combined with counts of births (from the National Center for Health Statistics), counts of abortions (from a census of abortion providers), estimates of miscarriages (from the NSFG), and population denominators from the US Census Bureau to obtain pregnancy rates by intendedness. RESULTS: In 2008, 51% of pregnancies in the United States were unintended, and the unintended pregnancy rate was 54 per 1000 women ages 15 to 44 years. Between 2001 and 2008, intended pregnancies decreased and unintended pregnancies increased, a shift previously unobserved. Large disparities in unintended pregnancy by relationship status, income, and education increased; the percentage of unintended pregnancies ending in abortion decreased; and the rate of unintended pregnancies ending in birth increased, reaching 27 per 1000 women. CONCLUSIONS: Reducing unintended pregnancy likely requires addressing fundamental socioeconomic inequities, as well as increasing contraceptive use and the uptake of highly effective methods.

Unintended pregnancy and unsafe abortion in the Philippines: context and consequences.

Despite advances in reproductive health law, many Filipino women experience unintended pregnancies, and because abortion is highly stigmatized in the country, many who seek abortion undergo unsafe procedures. This report provides a summary of reproductive health indicators in the Philippines­in particular, levels of contraceptive use, unplanned pregnancy and unsafe abortion­and describes the sociopolitical context in which services are provided, the consequences of unintended pregnancy and unsafe abortion,and recommendations for improving access to reproductive health services.

Sexual initiation, contraceptive use, and pregnancy among young adolescents.

OBJECTIVE: To present new data on sexual initiation, contraceptive use, and pregnancy among US adolescents aged 10 to 19, and to compare the youngest adolescents' behaviors with those of older adolescents. METHODS: Using nationally representative data from several rounds of the National Survey of Family Growth, we performed event history (ie, survival) analyses to examine timing of sexual initiation and contraceptive use. We calculated adolescent pregnancy rates by single year of age using data from the National Center for Health Statistics, the Guttmacher Institute, and the US Census Bureau. RESULTS: Sexual activity is and has long been rare among those 12 and younger; most is nonconsensual. By contrast, most older teens (aged 17-19) are sexually active. Approximately 30% of those aged 15 to 16 have had sex. Pregnancy rates among the youngest teens are exceedingly low, for example, ∼1 per 10 000 girls aged 12. Contraceptive uptake among girls as young as 15 is similar to that of their older counterparts, whereas girls who start having sex at 14 or younger are less likely to have used a method at first sex and take longer to begin using contraception. CONCLUSIONS: Sexual activity and pregnancy are rare among the youngest adolescents, whose behavior represents a different public health concern than the broader issue of pregnancies to older teens. Health professionals can improve outcomes for teenagers by recognizing the higher likelihood of nonconsensual sex among younger teens and by teaching and making contraceptive methods available to teen patients before they become sexually active.