Kathryn Kost

Contraceptive failure in the United States: a critical review of the literature.

The overall goal of this paper is to provide for the first time a comprehensive critical review of the literature on contraceptive failure in developed countries, primarily the United States. The first two sections of our paper lay the groundwork for a critical assessment of the extensive body of studies on this subject, by systematically exploring the concepts and measurement of contraceptive efficacy and the methodological pitfalls that snare many investigators and compromise their results. The next two sections focus on results in the literature. First we provide a method-by-method critique of the available studies and then we summarize our conclusions in a single table that provides efficacy information necessary for women and couples to make an informed choice of a method of contraception. We close with a set of substantive observations and also a set of methodological recommendations intended to improve the quality and comparability of findings from future research.

Predicting maternal behaviors during pregnancy: does intention status matter?

CONTEXT Womens behavior during pregnancy, which can affect the health of their infant, may be influenced by their attitude toward the pregnancy. METHODS Multivariate analyses of data from the 1988 National Maternal and Infant Health Survey and the 1988 National Survey of Family Growth were conducted to investigate whether women with unplanned births differ from other women in their pregnancy behavior, independent of their social and demographic characteristics. RESULTS Women with intended conceptions are more likely than similar women with unintended pregnancies to recognize early signs of pregnancy and to seek out early prenatal care, and somewhat more likely to quit smoking, but they are not more likely than women with comparable social and demographic characteristics to adhere to a recommended schedule of prenatal visits once they begin care, to reduce alcohol intake, or to follow their clinicians advice about taking vitamins and gaining weight. Social and demographic differences in these behaviors are largely unaffected by planning status, indicating that these differences are independently related to pregnancy behaviors. CONCLUSIONS Both the intendedness of a pregnancy and the mothers social and demographic characteristics are important predictors of pregnancy-related behavior.

The Public Costs of Births Resulting from Unintended Pregnancies: National and State‐Level Estimates

CONTEXT Births resulting from unintended pregnancies are associated with substantial maternity and infant care costs to the federal and state governments; these costs have never been estimated at the national and state levels. METHODS The proportions of births paid for by public insurance programs in 2006 were estimated, by pregnancy intention status, using data from the Pregnancy Risk Assessment Monitoring System and similar state surveys, or were predicted by multivariate linear regression. Public costs were calculated using state-level estimates of the number of births, by intention status, and of the cost of a publicly funded birth. RESULTS In 2006, 64% of births resulting from unintended pregnancies were publicly funded, compared with 48% of all births and 35% of births resulting from intended pregnancies. The proportion of births resulting from unintended pregnancies that were publicly funded varied by state, from 42% to 81%. Of the 2.0 million publicly funded births, 51% resulted from unintended pregnancies, accounting for

The Effects of Pregnancy Planning Status On Birth Outcomes and Infant Care

11.1 billion in costs-half of the total public expenditures on births. In seven states, the costs for births from unintended pregnancies exceeded a half billion dollars. CONCLUSIONS Public insurance programs are central in assisting American families in affording pregnancy and childbirth; however, they pay for a disproportionately high number of births resulting from unintended pregnancy. The resulting budgetary impact warrants increased public efforts to reduce unintended pregnancy.

Discontinuation and resumption of contraceptive use : results from the 2002 National Survey of Family Growth

CONTEXT The planning status of a pregnancy may affect a womans 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 mothers background characteristics, however, a mistimed pregnancy has no significant effect on any of these outcomes. An unwanted pregnancy increases the likelihood that the infants health will be compromised (odds ratio, 1.3), but the association is no longer significant when the mothers 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.

Abortion patients in 1994-1995: characteristics and contraceptive use.

BACKGROUND Discontinuation of contraceptive use that is not immediately followed by resumption of use of another method while a woman is at risk is a common cause of unintended pregnancy. STUDY DESIGN We provide new estimates of discontinuation for the pill, injectable, male condom, withdrawal and fertility-awareness-based methods, and identify socioeconomic characteristics associated with discontinuation for the pill, male condom and withdrawal. We provide new estimates of resumption of use by prior method used and identify socioeconomic characteristics associated with resumption of use. Estimates are obtained using the 2002 National Survey of Family Growth, supplemented by the 2001 Abortion Patient Survey to correct for underreporting of abortion. RESULTS The fraction of method use segments discontinued for method-related reasons within 1 year was highest for the male condom (57%), withdrawal (54%) and fertility-awareness-based methods (53%), and lowest for the pill (33%), with the injectable in-between (44%). However, contraception was abandoned altogether in only 25% of cases. The probability of resuming use of a contraceptive was 72% in the initial month of exposure to the risk of an unintended pregnancy; this rose to 76% by the third month. CONCLUSION The risk of discontinuation of use of reversible methods of contraception for method-related reasons, including a change of method, is very high, but fortunately the risk of abandoning use of contraception altogether is far lower, and most spells of exposure to risk of an unintended pregnancy following discontinuation are protected from the start by a switch to another method.

Unintended pregnancy rates at the state level.

Results of a 1994-1995 national survey of 9,985 abortion patients reveal that women who live with a partner outside marriage or have no religious identification are 3.5-4.0 times as likely as women in the general population to have an abortion. Nonwhites, women aged 18-24, Hispanics, separated and never-married women, and those who have an annual income of less than +15,000 or who are enrolled in Medicaid are 1.6-2.2 times as likely to do so; residents of metropolitan counties have a slightly elevated likelihood of abortion. When age is controlled, women who have had a live birth are more likely to have an abortion than are those who have never had children. Catholics are as likely as women in the general population to have an abortion, while Protestants are only 69% as likely and Evangelical or born-again Christians are only 39% as likely. Since 1987, the proportion of abortions obtained by Hispanic women and the abortion rate among Hispanics relative to that for other ethnic groups have increased. The proportion of abortion patients who had been using a contraceptive during the month they became pregnant rose from 51% in 1987 to 58%. Nonuse is most common among women with low education and income, blacks, Hispanics, unemployed women and those who want more children. The proportion of abortion patients whose pregnancy is attributable to condom failure has increased from 15% to 32%, while the proportions reporting the failure of other barrier methods and spermicides have decreased.

Intention status of U.S. births in 1988: differences by mothers socioeconomic and demographic characteristics.

CONTEXT Unintended pregnancy is a key reproductive health indicator, but rates have never been calculated for all 50 states. METHODS State-level estimates of unintended pregnancy rates in 2006 were calculated using data from several sources. The proportion of births resulting from unintended pregnancies was obtained from the Pregnancy Risk Assessment Monitoring System and similar state surveys, and the intention status of pregnancies ending in abortion from a national survey of abortion patients. These proportions were applied to birth and abortion counts for each state, and fetal losses were estimated. Rates of unintended pregnancy were obtained by dividing relevant figures by the number of women aged 15-44 in each state. Six states and the District of Columbia had no appropriate survey data; their rates were predicted using multivariate linear regression. RESULTS In 2006, the median state unintended pregnancy rate was 51 per 1,000 women aged 15-44. Most rates fell within a range of 40-65 unintended pregnancies per 1,000 women. The highest rate was in Mississippi (69); the lowest rate was in New Hampshire (36). Rates were generally highest in the South and Southwest, and in states with large urban populations. In 29 states and the District of Columbia, more than half of pregnancies were unintended; in nine, a consistent upward trend in unintended pregnancy rates between 2002 and 2006 was apparent; no state had a consistent decline. CONCLUSIONS These rates provide benchmarks for measuring the impact on unintended pregnancy of state policies and practices, such as those governing sex education and the funding of contraceptive services.

Characteristics of women in the United States who use long-acting reversible contraceptive methods.

The National Maternal and Infant Health Survey provides new data on the prevalence of unintended childbearing in the United States: Thirty-six percent of births in 1988 were mistimed and 7% were unwanted, while 57% were intended. Although the level of unintended childbearing is high in almost all socioeconomic subgroups of women, the proportion of births that were mistimed or unwanted was 50% or more among age-groups 15-17 (78%), 18-19 (68%) and 20-24 (50%), and among never-married women (73%), formerly married women (62%), black women (66%), women living below the federal poverty level (64%) or at 100-149% of the poverty level (52%), women with less than 12 years of education (58%) and women who already had two children (53%) or three or more children (60%). Multivariate analyses indicate that births to unmarried women--whether formerly married or never-married--are less likely than those to married women to be wanted and more likely to be mistimed. Poverty status has no independent effect on the odds that a birth is unwanted or on the odds that a birth to an unmarried woman is mistimed. Among currently married women, those who are poorer are more likely than women above 150% of the poverty level to have a mistimed birth. Black women are more likely than either Hispanic or white women to report a birth as unwanted and are more likely than white women to say a wanted birth was mistimed.

Pregnancy Intentions, Maternal Behaviors, and Infant Health: Investigating Relationships With New Measures and Propensity Score Analysis

OBJECTIVE: To examine characteristics of U.S. women that are associated with use of long-acting reversible contraception and changes in these characteristics between 2002 and 2006–2008. METHODS: We analyzed data from two nationally representative samples of women aged 15–44 in the National Survey of Family Growth, including 7,643 women in 2002 and 7,356 women in 2006–2008. We conducted simple and multinomial logistic regression analyses to identify demographic and reproductive health characteristics associated with use of long-acting reversible contraception. RESULTS: Long-acting reversible contraception (intrauterine devices and subdermal implants) use among U.S. women using contraception increased from 2.4% in 2002 to 5.6% in 2006–2008. The largest increases in long-acting reversible contraception use during this time occurred among the youngest and oldest age groups, non-Hispanic white and non-Hispanic African American women, foreign-born women, and those in the highest income group. High prevalence of long-acting reversible contraception use in 2006–2008 was seen among women who had given birth once or twice (10%), foreign-born women (8.8%), and Hispanic women (8.4%). After adjusting for key demographic and reproductive health characteristics, in comparison with users of other contraceptive methods and with those not using contraception who were at risk for unintended pregnancy, foreign-born women and women who experienced coitarche before age 18 were approximately twice as likely to be using long-acting reversible contraception as women without those characteristics. CONCLUSION: A more diverse population of women used long-acting reversible contraception in 2006–2008 compared with 2002. However, there is likely more potential for increased uptake, especially among populations historically not considered to be candidates for these methods. LEVEL OF EVIDENCE: III