Lawrence B. Finer

Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.

CONTEXT Many pregnancies are unintended, particularly in certain population groups. Determining whether unintended pregnancy rates and disparities in rates between subgroups are changing may help policymakers target reproductive health services to those women most in need. METHODS To calculate rates of unintended pregnancy and related outcomes, data on pregnancy intendedness from the 2002 National Survey of Family Growth were combined with birth, abortion and population data from federal, state and nongovernmental sources. RESULTS In 2001, 49% of pregnancies in the United States were unintended. The unintended pregnancy rate was 51 per 1,000 women aged 15-44, meaning that 5% of this group had an unintended pregnancy. This level was unchanged from 1994. The rate of unintended pregnancy in 2001 was substantially above average among women aged 18-24, unmarried (particularly cohabiting) women, low-income women, women who had not completed high school and minority women. Between 1994 and 2001, the rate of unintended pregnancy declined among adolescents, college graduates and the wealthiest women, but increased among poor and less educated women. The abortion rate and the proportion of unintended pregnancies ending in abortion among all women declined, while the unintended birth rate increased. Forty-eight percent of unintended conceptions in 2001 occurred during a month when contraceptives were used, compared with 51% in 1994. CONCLUSIONS More research is needed to determine the factors underlying the disparities in unintended pregnancy rates by income and other characteristics. The findings may reflect a need for increased and more effective contraceptive use, particularly among high-risk groups.

Unintended pregnancy in the United States: Incidence and disparities, 2006

BACKGROUND The incidence of unintended pregnancy is among the most essential health status indicators in the field of reproductive health. One ongoing goal of the US Department of Health and Human Services is to reduce unintended pregnancy, but the national rate has not been estimated since 2001. STUDY DESIGN We combined data on womens pregnancy intentions from the 2006-2008 and 2002 National Survey of Family Growth with a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US Census Bureau. RESULTS Nearly half (49%) of pregnancies were unintended in 2006, up slightly from 2001 (48%). The unintended pregnancy rate increased to 52 per 1000 women aged 15-44 years in 2006 from 50 in 2001. Disparities in unintended pregnancy rates among subgroups persisted and in some cases increased, and women who were 18-24 years old, poor or cohabiting had rates two to three times the national rate. The unintended pregnancy rate declined notably for teens 15-17 years old. The proportion of unintended pregnancies ending in abortion decreased from 47% in 2001 to 43% in 2006, and the unintended birth rate increased from 23 to 25 per 1000 women 15-44 years old. CONCLUSIONS Since 2001, the United States has not made progress in reducing unintended pregnancy. Rates increased for nearly all groups and remain high overall. Efforts to help women and couples plan their pregnancies, such as increasing access to effective contraceptives, should focus on groups at greatest risk for unintended pregnancy, particularly poor and cohabiting women.

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.

Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use

OBJECTIVES We explored the relative contributions of declining sexual activity and improved contraceptive use to the recent decline in adolescent pregnancy rates in the United States. METHODS We used data from 1995 and 2002 for women 15 to 19 years of age to develop 2 indexes: the contraceptive risk index, summarizing the overall effectiveness of contraceptive use among sexually active adolescents (including nonuse), and the overall pregnancy risk index, calculated according to the contraceptive risk index score and the percentage of individuals reporting sexual activity. RESULTS The contraceptive risk index declined 34% overall and 46% among adolescents aged 15 to 17 years. Improvements in contraceptive use included increases in the use of condoms, birth control pills, withdrawal, and multiple methods and a decline in nonuse. The overall pregnancy risk index declined 38%, with 86% of the decline attributable to improved contraceptive use. Among adolescents aged 15 to 17 years, 77% of the decline in pregnancy risk was attributable to improved contraceptive use. CONCLUSIONS The decline in US adolescent pregnancy rates appears to be following the patterns observed in other developed countries, where improved contraceptive use has been the primary determinant of declining rates.

Changes in use of long-acting contraceptive methods in the United States, 2007–2009

OBJECTIVE To examine trends in the use of long-acting reversible contraceptive (LARC) methods-the intrauterine device (IUD) and implant--and the extent to which these methods have replaced permanent sterilization and less effective short-acting methods. DESIGN We tabulated data from female survey respondents overall and by demographic subgroups. We performed t-tests of the differences in the proportions of female contraceptors using LARC in 2007 and 2009. We also looked at use of LARC, sterilization, other methods, and no method among women at risk of unintended pregnancy. SETTING In-home survey. PATIENT(S) All female respondents to the surveys. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Current use of LARC methods in 2009, and change in use from 2007. RESULT(S) The proportion of contraceptors using LARC increased significantly from 2.4% in 2002 to 3.7% in 2007 and 8.5% in 2009. The increase occurred among women in almost every age, race, education, and income group. Among women at risk of unintended pregnancy, increases in LARC use more than offset decreases in sterilization. CONCLUSION(S) LARC methods (primarily IUDs) are contributing to an increase in contraceptive effectiveness in the United States.

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.

Trends in Premarital Sex in the United States, 1954–2003

Objectives. Policy and programmatic efforts promoting sexual abstinence until marriage have increased, but it is unclear whether establishing such behavior as normative is a realistic public health goal. This study examined the proportion of individuals in various cohorts who had had premarital sex (defined as either having had vaginal intercourse before first marrying or ever having had intercourse and never having married) by various ages. Methods. Data from four cycles of the National Survey of Family Growth, 1982–2002, and event history analysis techniques, including Kaplan-Meier life-table procedures and Cox proportional-hazards regression models, were used to examine the incidence of premarital sex by gender and historical cohort. Results. Data from the 2002 survey indicate that by age 20, 77% of respondents had had sex, 75% had had premarital sex, and 12% had married; by age 44, 95% of respondents (94% of women, 96% of men, and 97% of those who had ever had sex) had had premarital sex. Even among those who abstained until at least age 20, 81% had had premarital sex by age 44. Among cohorts of women turning 15 between 1964 and 1993, at least 91% had had premarital sex by age 30. Among those turning 15 between 1954 and 1963, 82% had had premarital sex by age 30, and 88% had done so by age 44. Conclusions. Almost all Americans have sex before marrying. These findings argue for education and interventions that provide the skills and information people need to protect themselves from unintended pregnancy and sexually transmitted diseases once they become sexually active, regardless of marital status.

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

Sexual Initiation, Contraceptive Use, and Pregnancy Among Young Adolescents

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.

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

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.