Jennifer J. Frost

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.

Factors associated with contraceptive choice and inconsistent method use, United States, 2004.

CONTEXT Pregnancies among contraceptive users account for nearly half of all unintended pregnancies and are almost entirely due to inconsistent or incorrect contraceptive use. Understanding what factors contribute to inconsistent contraceptive behavior can help efforts to reduce unintended pregnancy. METHODS In 2004, a nationally representative sample of women aged 18-44 using reversible contraceptive methods were surveyed to examine factors associated with contraceptive choice and with inconsistent use of the pill and condoms. Bivariate and multivariate analyses were used to examine the data. RESULTS Contraceptive choice was associated with a range of socioeconomic and partnership characteristics, and with pregnancy-, method- and provider-related experiences and attitudes; inconsistent pill or condom use was associated mainly with partnership, experiential and attitudinal factors. For example, not having a college education was negatively associated with pill use (odds ratio, 0.6) and positively associated with use of long-acting methods (1.8-1.9). Women for whom avoiding pregnancy was only a little or not important had reduced odds of using the pill (0.4) and elevated odds of using other methods, such as withdrawal or periodic abstinence (4.4), and of using condoms inconsistently (2.6). Use of a method chosen mostly out of dislike of other methods was positively associated with condom use (4.0) and negatively associated with use of the pill or long-acting methods (0.4 for each). Women who were not completely satisfied with their method were more likely than others to use their method inconsistently (1.6 for pill users and 1.9 for condom users). CONCLUSIONS Greater efforts are needed to provide women and their partners with a range of method options, to facilitate selection of methods that best suit their needs and circumstances, and to identify and assist users who are dissatisfied or are having difficulties using contraceptives effectively.

Understanding the impact of effective teenage pregnancy prevention programs.

A review of five rigorously evaluated adolescent pregnancy prevention programs shows that all five incorporate an emphasis on abstinence or delay of sexual initiation, training in decision-making and negotiation skills, and education on sexuality and contraception. Four of the five directly or indirectly provide access to contraceptive services. Comparisons between treatment and control groups show that all four programs that measured changes in rates of sexual initiation among adolescents had a significant effect on that outcome, reducing the proportion of adolescents who initiated sexual activity by as much as 15 percentage points; the programs were most successful when they targeted younger adolescents. Three of these four programs also significantly increased rates of contraceptive use among participants relative to controls; the most successful programs, which increased contraceptive use by as much as 22 percentage points, provided access to contraceptive services and targeted adolescents who were younger and those who were not yet sexually experienced. Two programs significantly decreased the proportion of adolescents who became pregnant; these programs were the two that were most active in providing access to contraceptive services.

The family planning attitudes and experiences of low-income women.

A 1995 telephone survey of 1,852 low-income women aged 18-34 who were sexually active and at risk of unintended pregnancy found that 83% were currently practicing contraception. They were more likely to do so if they held positive attitudes toward contraceptive use, if they talked frequently about intimate matters with their partners and girlfriends and if they were very satisfied with the services they received at their last gynecologic visit. Seventy percent of current users said they were very satisfied with their method. Women whose last visit was to a clinic, who were very satisfied with the care they received and who used the pill or a long-acting method were more likely than others to report being very satisfied with their contraceptive. Women very satisfied with their gynecologic care were more likely to use oral contraceptives and to take them consistently, but were less likely to report that their partner used condoms or, if they did, used them consistently. Most women had made a medical visit for gynecologic or contraceptive care in the past year (86%), and 80% were very satisfied overall with their care at their last visit. Women were more likely to be very satisfied if the staff was courteous, helpful and respectful and made an effort to find out their needs, if their clinicians gender matched their own preference and if the facility was clean and services were organized.

U.S. Women’s One‐Year Contraceptive Use Patterns, 2004

CONTEXT Unintended pregnancies occur far too often in the United States, and half occur when couples fail to practice contraception. Improved measures of the continuity of womens contraceptive use, nonuse and switching patterns can help identify ways to reduce unintended pregnancy. METHODS A nationally representative sample of 1,978 adult women at risk of unintended pregnancy was surveyed by telephone in 2004. Respondents provided detailed information about contraceptive use and periods of stopping or switching methods during the past year. A typology of patterns of contraceptive use was created, classifying women into mutually exclusive categories according to their exposure to pregnancy risk. RESULTS Twenty-three percent of women at risk of unintended pregnancy were exposed to a high risk of pregnancy because of gaps in contraceptive method use in the year prior to the survey--8% were consistent nonusers, and 15% experienced 1-11 months of nonuse while at risk. More than half of women used a method during each of the previous 12 months-38% used the same method or methods all year, and 24% switched methods. Fifteen percent of women had gaps in contraceptive use when they were not at risk. Women reported a variety of reasons for their gaps in contraceptive use, including method-related difficulties and side effects, infrequent sex and being ambivalent about avoiding pregnancy. CONCLUSIONS Strategies for reducing gaps in contraceptive use include improved counseling to help women both choose the right method and continue method use, especially when they have periods of infrequent sexual activity or are experiencing method-related side effects or problems.

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 womens 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.

The Impact of Publicly Funded Family Planning Clinic Services on Unintended Pregnancies and Government Cost Savings

Publicly funded family planning clinics serve millions of low-income women each year, providing a range of critical preventive services and enabling women to avoid unintended pregnancies. It is important to quantify the impact and cost-effectiveness of such services, in addition to these health benefits. Using a methodology similar to prior cost-benefit analyses, we estimated the numbers of unintended pregnancies prevented by all U.S. publicly funded family planning clinics in 2004, nationally (1.4 million pregnancies) and for each state. We also compared the actual costs of providing these services (

Public or private providers? U.S. women's use of reproductive health services.

1.4 billion) with the anticipated public-sector costs for maternity and infant care among the Medicaid-eligible women whose births were averted (

Specialized Family Planning Clinics in the United States: Why Women Choose Them and Their Role in Meeting Women's Health Care Needs

5.7 billion) to calculate net public-sector savings (

The Medicaid eligibility expansions for pregnant women: evaluating the strength of state implementation efforts.

4.3 billion). Thus, public expenditures for family planning care not only help women to achieve their childbearing goals, but they also save public dollars: Our calculations indicate that for every