From: "Saved by Windows Internet Explorer 7" Subject: Contraceptive Use Among U.S. Women Having Abortions in 2000-2001 Date: Thu, 5 Jun 2008 10:21:14 -0400 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_01CD_01C8C6F5.E20C4040" X-MimeOLE: Produced By Microsoft MimeOLE V6.0.6001.18000 This is a multi-part message in MIME format. ------=_NextPart_000_01CD_01C8C6F5.E20C4040 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.guttmacher.org/pubs/journals/3429402.html =EF=BB=BF
CONTEXT: Knowing the extent to which contraceptive nonuse, incorrect = or=20 inconsistent use, and method failure account for unintended pregnancies = ending=20 in abortion, as well as reasons for nonuse and imperfect use, can help=20 policymakers and family planning providers support effective = contraceptive use.=20
METHODS: Contraceptive use patterns among a nationally representative = sample=20 of 10,683 women receiving abortion services in 2000-2001 were examined, = as well=20 as reasons for nonuse, problems with the most frequently used methods = and the=20 impact emergency contraceptive pills have had on abortion rates.
RESULTS: Forty-six percent of women had not used a contraceptive = method in=20 the month they conceived, mainly because of perceived low risk of = pregnancy and=20 concerns about contraception (cited by 33% and 32% of nonusers, = respectively).=20 The male condom was the most commonly reported method among all women = (28%),=20 followed by the pill (14%). Inconsistent method use was the main cause = of=20 pregnancy for 49% of condom users and 76% of pill users; 42% of condom = users=20 cited condom breakage or slippage as a reason for pregnancy. Substantial = proportions of pill and condom users indicated perfect method use = (13-14%). As=20 many as 51,000 abortions were averted by use of emergency contraceptive = pills in=20 2000.
CONCLUSIONS: Women and men need accurate information about fertility = cycles=20 and about the risk of pregnancy when a contraceptive is not used or is = used=20 imperfectly. Increased use of emergency contraceptive pills could = further reduce=20 levels of unintended pregnancy and abortion.
Perspectives on Sexual and Reproductive Health, 2002, 34(6):294-303=20
Some 45 of every 1,000 women aged 15-44 in the United States had an=20 unintended pregnancy in 1994 (the latest year for which data are=20 available).1 The high level of unintended pregnancy can be = attributed to=20 three factors: the failure of couples at risk of unintended pregnancy to = practice contraception, incorrect or inconsistent use of contraceptive = methods,=20 and method failure among those practicing contraception correctly and=20 consistently.
Approximately one-half of unintended pregnancies end in = abortion.2 A substantial minority of women having = abortions=E2=80=9442% in=20 1994-19953 and 49% in 19874=E2=80=94became pregnant because they and their = partners were not=20 using a contraceptive method. It is unknown, however, what proportion of = pregnancies among method users were due to inconsistent or incorrect=20 contraceptive use and what proportion were accounted for by method = failure.
In this article, we describe the extent to which contraceptive = nonuse,=20 problems with contraceptive use and failure of contraceptive methods = account for=20 unintended pregnancies ending in abortion in the United States. We also = examine=20 variations in these three factors among subgroups of women. Data for the = analyses come from a national survey of women having abortions, = conducted by The=20 Alan Guttmacher Institute (AGI) in 2000-2001. This survey, which = replicates=20 similar surveys of women having abortions in 1987 and 1994-1995,*=20 expands on previous work by examining reasons for nonuse of = contraceptives and,=20 among women using a contraceptive method, reasons for pregnancy. It also = includes information on use of emergency contraceptive pills, from which = we=20 estimate the impact of emergency contraception on abortion levels since=20 1994.
We used a self-administered questionnaire to gather information about = social=20 and demographic characteristics and contraceptive practices from a=20 representative sample of women obtaining abortions. We provide below an = overview=20 of the data collection method; procedures of sampling and weighting are=20 described in detail elsewhere.5
We selected a stratified probability sample of abortion facilities = from a=20 list of all hospitals, clinics and physicians' offices in which 30 or = more=20 abortions were performed in .=E2=80=A0 Eight hospitals and 92 nonhospital = facilities=20 successfully administered the survey to all women who had an abortion = during a=20 specified period, ranging from two to 12 weeks, between July 2000 and = June 2001;=20 71% of surveys were administered in 2000, and most were completed while = women=20 waited for their procedure. Usable questionnaires were returned by = 10,683 of the=20 13,071 women who had abortions at participating facilities during the = study=20 period, which produced a response rate of 82%.
We computed multistage weights to compensate for differential = nonresponse in=20 specific facilities and among subgroups of women, as well as for = deviations from=20 the original sampling plan. Nonresponse for most items was 2-4% but = ranged from=20 1% (for measures on previous pregnancy experience) to 33% (for items = about=20 reasons for nonuse of a contraceptive method).=E2=80=A1 We imputed missing information for = key demographic=20 and contraceptive use items on the basis of responses given by women = with=20 similar characteristics by using a "hot-deck" procedure.=C2=A7
The four-page questionnaire, prepared in both English and Spanish, = was=20 modeled on those used in AGI's prior surveys of U.S. women obtaining = abortions.=20 It included a description of the purpose of the survey, as well as an=20 explanation that participation was voluntary, confidential and = anonymous, and=20 would not affect the services that the woman would receive. The = questionnaire=20 and survey procedures were approved by the AGI Institutional Review = Board.
Women were asked what contraceptive method, if any, they had last = used before=20 finding out they were pregnant, for how long they had been using that = method and=20 when they had stopped using it.**=20 We considered women to have been contraceptive users if they had been = using a=20 method during the calendar month they became pregnant and had not = intentionally=20 stopped doing so before becoming pregnant. Included in this category = were women=20 who had started using a method before becoming pregnant and had stopped = after=20 the month of conception. If the month of conception was unknown, a woman = was=20 considered a user if she had been using a method up to one month before = the=20 abortion, and a nonuser if she had stopped using a method at least three = months=20 before the abortion.
According to the dates of method use and the estimated dates of = conception,=20 10% of women had started or stopped using a contraceptive method during = the=20 month of conception. These women were classified as users if, in = response to=20 another question, they reported the use of a method during the month = they became=20 pregnant.=E2=80=A0=E2=80=A0 For women whom we still = could not classify as a=20 contraceptive user or nonuser because of missing data, we examined = responses to=20 other relevant questions when possible; otherwise, we imputed missing = items.
Women who had used oral contraceptives or barrier methods in the = month that=20 they had become pregnant were asked to indicate their perceived reason = for the=20 pregnancy from a list of potential reasons. The list included an = opportunity to=20 write in other reasons, as well as the option of indicating "I used it=20 perfectly, but the method failed."=E2=80=A1=E2=80=A1 Women who had not used = birth control in the month of=20 conception were provided with a list of potential reasons for nonuse and = an=20 opportunity to write in other reasons.
We present data that were weighted to be nationally representative of = women=20 having abortions during the 12-month study period. We used t-tests to = determine=20 whether subgroups differed significantly from one another in their = contraceptive=20 method use, perceived reasons for nonuse and perceived reasons for = pregnancy=20 while using the pill or condom. Logistic regression was used to examine=20 independent relationships between women's characteristics and = contraceptive use.=20 Tests of significance were performed using STATA version 7, which took = into=20 account the clustering and weighting of the sample. We used SPSS version = 11.01=20 for data management and all other analyses.
All social and demographic groups are represented among women having=20 abortions; the characteristics of this population have been discussed=20 elsewhere.6 More than half of respondents (56%) were in their = 20s; women=20 in their 30s accounted for 22% of abortions and adolescents for 19%. = Seventeen=20 percent of women were married, 67% had never been married and the = remainder had=20 previously been married; 31% of single women were cohabiting. The = majority of=20 women (61%) had one or more children. Women with family incomes less = than 200%=20 of the federal poverty level accounted for 57% of abortions; 27% were = poor (had=20 incomes below 100% of poverty). Forty-one percent of women were = non-Hispanic=20 white, 32% non-Hispanic black and 20% Hispanic; the remainder were = members of=20 other racial and ethnic groups.=C2=A7=C2=A7
More than half of women obtaining abortions in 2000 (54%) had been = using a=20 contraceptive method during the month they became pregnant (Table 1). This figure is slightly lower than the = proportion of women=20 having abortions in 1994 who had been contraceptive users (58%),7 but slightly higher than the proportion reported = in 1987=20 (51%).8 In 2000, approximately 15% of women had been using = the most=20 effective methods=E2=80=941% used long-acting methods (sterilization, = the IUD, implants=20 or injectables) and 14% the pill. Twenty-eight percent of all women = having=20 abortions had used the male condom, down from 32% in 1994 (the only = method to=20 decline by more than three percentage points).9 Withdrawal and periodic abstinence had been used = by roughly=20 one in 10 women having abortions.
Forty-six percent of women had not used a method in the month of = conception,=20 but 38% had used one previously. Of these prior users, 42% had used a=20 contraceptive method within three months of conception, and 65% had used = a=20 method within six months (not shown). Eight percent of women having = abortions=20 indicated that they had never used a contraceptive method, down from 11% = in=20 199410 and 9% in 1987.11
The pattern of contraceptive use among women having abortions was = very=20 different from that among all women at risk of having an unintended = pregnancy in=20 1995, the latest year for which national data are available (Table=20 1). The distribution of women having abortions by contraceptive = method used=20 is a function not only of the contraceptive use pattern of all women, = but also=20 of the rate of accidental pregnancy among method users (the use-failure = rate)=20 and of the proportion of women with accidental pregnancies who have=20 abortions.
Women using no contraceptive method made up a larger proportion of = women=20 having abortions than of all women at risk of unintended pregnancy (46% = vs. 7%),=20 mainly because the likelihood of pregnancy is extremely high among = fertile,=20 sexually active women when they do not use a contraceptive method. In = contrast,=20 a substantially lower proportion of women having abortions than of all = women at=20 risk of unintended pregnancy had used sterilization and other = long-acting=20 methods (1% vs. 41%), which reflects the very high rates of = use-effectiveness of=20 these methods. Pill users were underrepresented among women having = abortions,=20 whereas women using condoms and withdrawal were overrepresented. These = patterns=20 reflect the fact that women using oral contraceptives are more = successful in=20 avoiding accidental pregnancy than are those who rely on barrier or=20 nonprescription methods.12
The proportion of women having abortions who had not been using a=20 contraceptive when they became pregnant varied across social and = demographic=20 subgroups from 37% to 54% (Table 2). Bivariate analyses reveal that adolescents and = women aged=20 20-24 were significantly more likely than women aged 30 or older to be = nonusers=20 (47-50% vs. 44%). Decreases in income and education are associated with=20 increased contraceptive nonuse: Women with family incomes below 300% of = the=20 federal poverty level were more likely than women with higher incomes = not to be=20 using a method of birth control in the month they became pregnant = (45-52% vs.=20 40%), and women with less than a college degree were significantly more = likely=20 than college graduates to be nonusers (41-54% vs. 37%). Blacks, = Hispanics and=20 women of other races and ethnicities were more likely than whites to be = nonusers=20 (50-52% vs. 39%). Union status was barely associated with nonuse of=20 contraception. Women who were the most likely to be nonusers were also = the most=20 likely never to have used a contraceptive method. For example, = adolescents were=20 more likely than women aged 30 or older to have never practiced = contraception=20 (12-19% vs. 7%).
We used logistic regression to determine if the associations between=20 contraceptive nonuse and women's characteristics were independent of the = impact=20 of other characteristics (Table=20 2). In these analyses, adolescents were as likely as women aged 30 = or older=20 to have been using no method when they became pregnant; differences in = nonuse by=20 poverty status also disappeared. However, the likelihood of nonuse was = higher=20 among nonwhites and Hispanics than among whites (odds ratios, 1.5-1.7), = and=20 higher among women with no more than a high school education than among = college=20 graduates (1.7-1.9). In addition, women who were divorced, separated or = widowed=20 had a higher likelihood than married women of not having used a = contraceptive=20 method when they became pregnant (1.2).
The most common category of reasons for contraceptive nonuse was the=20 perception that a woman was at low risk of becoming pregnant (cited by = 33% of=20 nonusers, including 6% who thought that they or their partner was = sterile=E2=80=94Table 3, page 298). Concerns about contraceptive methods = were cited=20 by 32% of nonusers and included mainly problems with methods in the past = (20%)=20 and fear of side effects from methods (13%). A substantial proportion of = women=20 said they had had unexpected sex (27%), with 1% indicating that unwanted = sex was=20 a reason for nonuse. Slightly more than one in five women had been = ambivalent=20 about contraception. Twelve percent of nonusers had encountered problems = accessing contraception, such as financial barriers, and 10% indicated = their=20 partner's preferences as a reason for nonuse. The least common reasons = that=20 nonusers reported reflected ambivalence about becoming pregnant (5%) and = fear=20 that their parents would learn they were sexually active (2%). One-third = of=20 nonusers indicated multiple categories of reasons for not having used a = method.=20 The most common overlap was between perceived low risk of pregnancy and = not=20 expecting to have sex (9% of all nonusers=E2=80=94not shown).
Reasons for not having used a contraceptive method in the month of = conception=20 varied across subgroups of women (Table 4, page 299). Adolescents were more likely than = women aged 30=20 or older to attribute nonuse to ambivalence about contraception or to = fear that=20 their parents would find out they were having sex. Adolescents younger = than 18=20 were the most likely to indicate that unexpected sex was a reason for = nonuse but=20 the least likely to indicate that partner preferences were a reason. = Adolescents=20 aged 18-19 were more likely than women aged 30 or older to cite concerns = about=20 methods as a reason for nonuse. Women in their 20s were less likely than = older=20 women to indicate that perceived low risk was a reason for = pregnancy.
Union status is an indicator of, among other things, frequency and=20 predictability of sexual intercourse, which are likely to affect = contraceptive=20 use. For example, less-frequent sexual activity may help explain why=20 never-married and previously married women were more likely than married = women=20 to perceive themselves to be at low risk (35-36% vs. 29%). Previously = married=20 and never-married women also were more likely than married women to = indicate=20 that unexpected or unwanted sex was a reason they were not using a = contraceptive=20 method (33-40% vs. 17%). Never-married women, who are typically younger = than=20 women of other marital statuses, were more likely than married women to = cite=20 ambivalence about contraception and fear of parents' finding out they = were=20 having sex as reasons for nonuse, but they were less likely to report = that=20 ambivalence about pregnancy was a factor in their not having used a=20 contraceptive method.
The survey results support the concern that economic disadvantage = makes it=20 harder to obtain contraceptives. Women with incomes lower than 300% of = poverty=20 were more likely than the highest-income women to indicate this reason = for not=20 having used birth control (11-14% vs. 7%). Women with incomes less than = 300% of=20 poverty were less likely than the highest-income women to indicate that=20 ambivalence about pregnancy was a reason they had not been using a = contraceptive=20 method (4-5% vs. 6%).
Attitudes toward contraception and knowledge of particular = contraceptive=20 methods may vary among women (and men) from different racial and ethnic = groups;=20 these differences may, in turn, influence reasons for nonuse. Thirty-two = percent=20 of women who were classified as belonging to "other" racial and ethnic = groups=20 indicated that ambivalence about contraception was a reason for = nonuse=E2=80=94a=20 significantly higher proportion than that of white women (22%). Black = women were=20 less likely than white women to indicate that partner preferences were a = reason=20 for nonuse (8% vs. 11%), and Hispanic women were more likely than white = women to=20 identify fear of parents' finding out they were having sex as a reason = for=20 nonuse (5% vs. 2%).
Prior experience with contraceptive methods appears to influence = reasons for=20 subsequent gaps in contraceptive use. Women who had last used the = injectable or=20 pill=E2=80=94both hormonal methods that require a = prescription=E2=80=94were more likely than=20 prior condom users to indicate that concerns about methods and problems=20 accessing methods were reasons for nonuse. Unlike prescription methods, = however,=20 condoms are situational, meaning that they are used during the act of = sex and=20 require at least one partner to have the method on hand. Prior condom = users were=20 more likely than prior pill users to indicate that perceived low risk = for=20 pregnancy and unexpected sexual intercourse were reasons for nonuse. = Condoms=20 also require the cooperation of a male partner, and prior condom users = were more=20 likely than pill and injectable users to indicate that partner = preferences had=20 been a reason for nonuse, although prior users of withdrawal were more = likely=20 than condom users to indicate that this had been a problem. Women who = had never=20 used a contraceptive method, who tend to be younger than ever-users, = were less=20 likely than condom users to cite perceived low risk of pregnancy, but = more=20 likely to cite concerns about methods, ambivalence about contraception, = problems=20 accessing methods and fear of parents' finding out they were sexually = active as=20 reasons for nonuse.
Across all subgroups, women who became pregnant while using a = contraceptive=20 method were more likely to have been relying on male condoms than on any = other=20 method (Table 5, page 300). Adolescents younger than 18 were more = likely=20 than older women to have been using condoms when they became pregnant = (35% of=20 all women in this age-group having abortions), while women in their 20s = were the=20 most likely of any age-group to have been using the pill (15%). Women = aged 30 or=20 older were the most likely group to have been using methods other than = the pill=20 or condom (18%). Only 1% of this age-group were relying on long-acting = methods;=20 most had been using less-reliable methods=E2=80=94withdrawal, periodic = abstinence or=20 other barrier methods (8%, 5% and 4%, respectively=E2=80=94not shown). = Married women and=20 those with college degrees tend to be older than others, and these women = were=20 more likely than unmarried and less-educated women to have been using = methods=20 other than the pill or condom. Never-married women were more likely than = others=20 to have relied on the condom, whereas cohabiting women reported the = highest=20 levels of pill use in the month they became pregnant.
Poverty status appears to have little effect on the type of = contraceptive=20 method used among method users: The proportions of poor women reporting = use of=20 the pill, condom and other contraceptive methods were lower than the = proportions=20 among the highest-income women. Likewise, women with family incomes = within=20 100-299% of poverty reported use of the pill and methods other than the = condom=20 less commonly than did the highest-income women.
White women having abortions were, in general, more likely than = others to=20 have practiced contraception in the month they became pregnant: They = were more=20 likely than all other women to have used the pill (17% vs. 9-12%), more = likely=20 than black and Hispanic women to have used condoms (30% vs. 23-27%) and = more=20 likely than black women to have used other methods (15% vs. 10%).
Substantial minorities of women who had become pregnant despite = having used=20 the pill or condom indicated that they had used the method = perfectly=E2=80=9413% and=20 14%, respectively (Table 6, page 300).*=E2=80=A0=20 However, women most commonly cited inconsistent use as the reason for = becoming=20 pregnant=E2=80=9476% of pill users and 49% of condom users gave this = reason.
Nearly half of pill users had not taken their pill every day or had = not taken=20 it at the same time each day because they had forgotten to do so. Among = the=20 other reasons for inconsistent use were absence from home and hence lack = of=20 pills (16%), depletion of supplies (10%), illness (8%) and lack of = inclination=20 to take the pill (2%). Fourteen percent of inconsistent pill users = indicated=20 multiple reasons for irregular use (not shown).
The most common reasons women gave for not having used condoms = consistently=20 were that they perceived themselves to be at low risk (20%), they lacked = a=20 condom (14%) and they did not expect to have sex (13%). Other reasons = were=20 women's and partners' lack of inclination to use a condom (6% and 4%,=20 respectively). Eleven percent of inconsistent condom users indicated two = or more=20 reasons for not having used condoms regularly (not shown). Some 42% of = users=20 reported that they had become pregnant because of condom breakage or=20 slippage.
We used logistic regression to examine characteristics associated = with=20 inconsistent pill and condom use, as well as condom breakage and = slippage (Table 7, page 301). For each category of problem, the = comparison=20 group was women who reported they had used the method perfectly. Black = and=20 Hispanic women were more likely than white women to have used the pill=20 inconsistently (odds ratio, 2.1 for each). Women with less than a high = school=20 degree were more likely than those with a college degree to have been=20 inconsistent pill users (2.1). The longer a woman had been using the = pill, the=20 less likely she was to indicate that inconsistent use was the reason she = had=20 become pregnant.
Inconsistent condom use and condom breakage or slippage were = predicted by=20 some of the same characteristics. For example, adolescents younger than = 18 were=20 less likely than women aged 30 or older to report inconsistent condom = use (odds=20 ratio, 0.3) and condom breakage or slippage (0.5). Black women were more = likely=20 than white women to report both forms of imperfect use (2.1 for each). = Odds were=20 similarly raised for women who intended to have a child or more = children. A=20 further predictor of inconsistent condom use was having an income below = 100% of=20 poverty, whereas further predictors of breakage or slippage were being = unmarried=20 and having less than a high school education.
In 2000, 1.3% of women having abortions reported having taken = emergency=20 contraceptive pills to prevent the pregnancy. Thirty-five percent of = women who=20 had taken emergency contraceptive pills had not used any birth control = method in=20 the month they became pregnant. Sixty-five percent of those who had used = emergency contraceptive pills had done so as a backup to = contraception=E2=80=9411% had=20 been taking the pill;*=E2=80=A1 40% had been using condoms (17% = reported=20 inconsistent use and 23% breakage or slippage); and 14% had been using = other=20 methods.
Although most women who had used emergency contraceptives had done so = for=20 backup, they accounted for only a small proportion of women who reported = problems related to condom or pill use: Just 3% of women who had = experienced=20 condom breakage or slippage and 2% of inconsistent condom users had = relied on=20 emergency contraception as a backup method. Among women who had taken = the pill=20 inconsistently, fewer than 1% had also taken emergency contraceptive = pills=20 (although 28% had used another backup method, such as condoms or=20 withdrawal).
Trussell and colleagues have estimated that for each pregnancy that = occurs=20 after use of emergency contraceptive pills, three pregnancies are=20 prevented.13 In 2000, 1.3 million abortions were performed in = the=20 United States.14 If 17,000 (1.3%)*=C2=A7 pregnancies that ended in abortion = occurred after=20 the use of emergency contraceptive pills, approximately 51,000 = pregnancies that=20 would have ended in abortion were prevented. By comparison, only 0.1%, = or 1,400,=20 of the 1.4 million abortions in 1994 occurred after use of oral = emergency=20 contraceptives, and about 4,000 abortions were prevented by their use. = The=20 increase in the use of emergency contraceptive pills may account for a=20 significant part of the recent reduction in abortions nationally: The = number of=20 abortions in 2000 was 110,000 fewer than in 1994, and an estimated = 47,000 more=20 abortions were prevented by emergency contraception in 2000 than in = 1994; thus,=20 emergency contraception could account for 43% of the decrease in = abortions.
The commonly accepted estimate that we used=E2=80=94that emergency = contraceptive pill=20 use prevents 75% of pregnancies that would have occurred without its = use=E2=80=94is=20 based on studies evaluating the Yuzpe regimen of combined oral=20 contraceptives.15 However, levonorgestrel alone has been shown to = be more=20 effective than the Yuzpe regimen.16 If the levonorgestrel-only product approved for = use in the=20 United States in 1999 was widely used during 2000 and 2001, the number = of=20 abortions averted may have been even higher than our estimate.
On the other hand, studies have found that the effectiveness of the = Yuzpe=20 regimen ranges from 56% to 89%.17In addition, some users of emergency = contraceptives who=20 became pregnant and had abortions may have used the method = incorrectly=E2=80=94for=20 example, after they were already pregnant. Although some studies = estimating=20 effectiveness of emergency contraception include women who used the = method=20 inappropriately, most use screening criteria to include only women for = whom=20 emergency contraception was most likely to be effective (e.g., women who = had had=20 only one act of unprotected intercourse and who were not pregnant before = taking=20 emergency contraceptive pills). If the proportion of women having = abortions in=20 2000 who became pregnant after correctly using emergency = contraceptives=20 was actually lower than 1.3%, the number of abortions prevented may be = lower=20 than our estimate.
On the basis of our survey findings, we estimate that of the 1.3 = million=20 women who underwent induced abortions in 2000, 608,000 had not been = using a=20 contraceptive method around the time they became pregnant, 610,000 had = been=20 using a method but not consistently or correctly, and 95,000 had thought = they=20 were using the method perfectly but became pregnant because of method = failure.=E2=80=A0* Although these estimates are = based solely on=20 women's retrospective reports and perceptions of why they became = pregnant, they=20 raise issues that are common among all contraceptive users and thus need = to be=20 addressed.
Method failure rates during perfect use are quite low for oral = contraceptives=20 and male condoms (0.1-0.5% and 3%, respectively, in the first year of=20 use).18 Previous research has found that some women = overreport=20 compliance with contraceptive regimens,19 and women having abortions may have overreported = perfect=20 method use. Nonetheless, the potential number of unintended pregnancies = due to=20 method failure is quite large. In 1995, 10 million women were using the = pill,=20 and eight million the condom.20 If all 10 million women using the pill did so = perfectly=20 over the full year, 0.1-0.5%, or 10,000-50,000 users, would have become=20 pregnant. Similarly, if all eight million condom users used the method = perfectly=20 for the year, 3%, or 240,000, would have become pregnant. These = estimates=20 confirm the validity of the number of abortions that women attributed to = method=20 failure during perfect use (95,000). This finding underscores the = importance of=20 providing women and their partners with information and services they = need to=20 select methods with which they are most likely to be successful, as well = as the=20 continuing need for development of additional method choices.
Inconsistent method use was the most common reason women using the = pill or=20 condoms became pregnant. Condom users also had to deal with problems of = slippage=20 and breakage, which, although fairly rare, increase the chance of = pregnancy. For=20 example, couples in clinical trials comparing the efficacy of latex and=20 polyurethane condoms reported slippage or breakage of 1-4% of the = condoms they=20 had used during a six-month period.21 Among women having abortions, 42% of those using = condoms=20 became pregnant because of breakage or slippage. Condom breakage or = slippage and=20 inconsistent condom use could be reduced by improving knowledge about = correct=20 condom use and users' ability to modify their condom use behaviors. = Pregnancies=20 resulting from inconsistent pill use could be reduced by couples' = increased=20 reliance on condoms as a backup method and by increased adherence to = daily oral=20 contraceptive regimens. In particular, women who have not completed high = school,=20 those who intend to have a child or more children and black women could = benefit=20 from efforts to improve contraceptive use, because women in these groups = had an=20 increased likelihood of imperfect pill or condom use.
While most women having abortions who had been contraceptive users = were aware=20 that they had not used their method correctly, only a minority had used = any=20 backup method. Although we could not estimate the impact of other backup = methods, the estimated large impact of emergency contraception on = reducing=20 abortion attests to the importance of making sure that all women and = their=20 partners have knowledge of and access to this option.
Researchers, policymakers and health care providers often regard = women who=20 use contraceptives and those who do not as different populations, each = having=20 different needs. To the contrary, it is clear from these women having = abortions=20 that most nonusers were prior contraceptive users who had not yet = started=20 another method. Furthermore, there was a substantial amount of overlap = in=20 women's reasons for inconsistent use and for nonuse.
Nearly one-fifth of all women having abortions=E2=80=94one in three = nonusers and one=20 in five condom users=E2=80=94were not using a contraceptive method or = were using it=20 inconsistently because of a perceived low risk of pregnancy. Some of = these women=20 may have assumed they were having intercourse in a "safe time" in their=20 menstrual cycle; others may have thought their risk of pregnancy was low = because=20 they were postpartum or breastfeeding. Furthermore, some may have simply = perceived the risk of becoming pregnant to be low, and some may have = thought=20 they or their partner was sterile. The frequency of perceived low risk = for=20 pregnancy among women who had abortions shows that women and their = partners need=20 accurate information about the probability of conception when = contraception is=20 not used, the variability of fertility cycles and the importance of = consistent=20 contraceptive use.
Twenty-seven percent of contraceptive nonusers and 13% of condom = users=E2=80=94or 16%=20 of all women having abortions=E2=80=94became pregnant because they were = not expecting to=20 have sex. Ambivalence about contraception had been experienced by 22% of = nonusers, and small proportions of pill and condom users indicated that = they did=20 not care or they "didn't feel like" using their method. Very few women = indicated=20 that ambivalence about childbearing intentions had directly influenced = their=20 contraceptive use, but among women who had used condoms in the month = they became=20 pregnant, those who intended to have a child or more children were more = likely=20 than those who did not to report inconsistent condom use or condom = breakage or=20 slippage.
Substantial levels of unexpected sex, ambivalence about contraception = and the=20 association of fertility intentions with imperfect condom use all = reflect the=20 high degree of ambivalence toward sexuality that characterizes the = United=20 States.22 Women and men need more opportunities and forums = for=20 discussing issues such as whether and when sexual intercourse should = occur in a=20 relationship, methods of pregnancy prevention and decision-making about=20 appropriate timing of childbearing. The increased emphasis in public = school=20 sexuality education programs and in other public education efforts on = abstinence=20 as the only option for unmarried people suggests that fewer, rather than = more,=20 young women and men will be exposed to accurate information about = sexuality=20 issues in the coming years. In 1999, for example, 40% of sexuality = education=20 teachers in secondary public schools either taught that contraceptive = methods=20 and condoms are ineffective or did not cover them at all.23 Many adults continue to lack venues for learning = about and=20 discussing relationships, sexuality and contraception.
Some women having abortions had not been using contraceptives because = they=20 had problems accessing methods and services. Difficulties getting = prescriptions=20 refilled also resulted in inconsistent pill use. Making it easier for = women and=20 their partners to obtain contraceptive methods could alleviate these = problems=20 and, possibly, motivate some women who use less-effective methods to = adopt more=20 effective ones. Whereas some higher-income women reported access = problems, poor=20 and low-income women were much more likely to do so. The proportion of = women of=20 reproductive age covered by Medicaid has decreased, from 13% in 1994 to = 9% in=20 2000, while the proportion without health insurance has fluctuated = between 18%=20 and 20% during the same period.24 At the same time, funding for free and low-cost=20 contraceptive services and supplies for low-income women through Title X = has not=20 increased when adjusted for inflation.25 Clearly, more efforts need to be made to provide = health=20 insurance coverage for poor and low-income women (and men), as well as = increased=20 funding for family planning services. Family planning and other = reproductive=20 health services need to provide women and their partners with = information about=20 and access to a wide range of methods so they can choose, and receive, = the ones=20 best suited to their current lifestyles, including newly available and = highly=20 effective methods.
Substantial proportions of adolescents who were not using=20 contraceptives=E2=80=94particularly of those younger than = 18=E2=80=94indicated that fear of=20 their parents' finding out they were sexually active was a barrier to=20 contraceptive use. Making sure that adolescents continue to have access = to=20 confidential reproductive health care services and increasing their = awareness of=20 these services are likely to result in greater contraceptive use and = fewer=20 unintended pregnancies.
Some women having abortions indicated that their partners' = expectations and=20 desires had prevented them from using a method or from using a method=20 consistently. Efforts to increase knowledge about fertility and = contraception=20 and to improve access to reproductive health services need to include = men as=20 well as women. Women who rely on condoms, withdrawal and periodic = abstinence=20 require the cooperation of their partners to avoid becoming pregnant, = and=20 partners can influence women's use of "female" methods.
Women who want to avoid or delay childbearing must expend time, = effort and,=20 often, money to prevent unintended pregnancy. While the overwhelming = majority of=20 women at risk of pregnancy successfully use contraceptives, efforts to = support=20 and improve use levels and use-effectiveness need attention.
1. Henshaw SK, Unintended pregnancy in the United = States,=20 Family Planning Perspectives, 1998, 30(1):24-29 & 46.
2. Ibid.
3. Henshaw SK and Kost K, Abortion patients in = 1994-1995:=20 characteristics and contraceptive use, Family Planning = Perspectives,=20 1996, 28(4):140-147 & 158.
4. Henshaw SK and Silverman J, The characteristics and = prior=20 contraceptive use of U.S. abortion patients, Family Planning=20 Perspectives, 1988, 20(4):158-168.
5. Jones R, Darroch JE and Henshaw SK, Patterns in the=20 socioeconomic characteristics of women obtaining abortions in 2000-2001, = Perspectives on Sexual and Reproductive Health, 2002, = 34(5):226-235.
6. Ibid.
7. Henshaw SK and Kost K, 1996, op. cit. (see reference = 3).
8. Henshaw SK and Silverman J, 1988, op. cit. (see = reference=20 4).
9. Henshaw SK and Kost K, 1996, op. cit. (see reference = 3).
10. Ibid.
11. Henshaw SK and Silverman J, 1988, op. cit. (see = reference=20 4).
12. Ranjit N et al., Contraceptive failure in the = first two=20 years of use: differences across socioeconomic subgroups, Family = Planning=20 Perspectives, 2001, 33(1):19-27.
13. Trussell J, Rodriguez G and Ellertson C, Updated = estimates=20 of the effectiveness of the Yuzpe regimen of emergency contraception,=20 Contraception, 1999, 59(3):147-151.
14. Jones R, Darroch JE and Henshaw SK, 2002, op. cit. = (see=20 reference 5).
15. Trussell J, Rodriguez G and Ellertson C, 1999, op. = cit. (see=20 reference 13).
16. Task Force on Postovulatory Methods of Fertility = Regulation,=20 Randomized controlled trial of levonorgestrel versus the Yuzpe regimen = of=20 combined oral contraceptives for emergency contraception, Lancet, = 1998,=20 352(9126):428-433.
17. Trussell J, Rodriguez G and Ellertson C, 1999, op. = cit. (see=20 reference 13).
18. Hatcher RA et al., eds., Contraceptive = Technology,=20 17th rev. ed., New York: Ardent Media, 1998.
19. Potter L et al., Measuring compliance among oral=20 contraceptive users, Family Planning Perspectives, 1996,=20 28(4):154-158.
20. Piccinino LJ and Mosher WD, Trends in = contraceptive use in=20 the United States: 1982-1995, Family Planning Perspectives, 1998, = 30(1):4-10 & 46.
21. Frezieres RG et al., Evaluation of the efficacy of = a=20 polyurethane condom: results from a randomized, controlled clinical = trial,=20 Family Planning Perspectives, 1999, 31(2):81-87.
22. Frost JJ et al., Teenage Sexual and = Reproductive Behavior=20 in Developed Countries: Country Report for the United States, = Occasional=20 Report, New York: The Alan Guttmacher Institute (AGI), 2001, No. 8.
23. Darroch JE, Landry DJ and Singh S, Changing = emphases in=20 sexuality education in U.S. public secondary schools, Family Planning = Perspectives, 2000, 32(5):204-211 & 265.
24. AGI, special tabulations of data from U.S. Census = Bureau=20 Current Population Surveys, 1995-2000.
25. AGI, Fulfilling the Promise: Public Policy and = U.S.=20 Family Planning Clinics, New York: AGI, 2000.
The authors thank Suzette Audam, Karen D'Angelo, Lori Frohwirth, = Kathleen=20 Manzella and Ednesha Saulsbury for survey fielding and research = assistance, and=20 Susheela Singh for reviewing several drafts of this article. They also = thank=20 staff of participating facilities for distributing and returning = surveys. The=20 analysis on which this article is based is part of a larger effort to = document=20 contraceptive effectiveness and unintended pregnancy, which is supported = in part=20 by National Institutes of Health grant HD 40378. The conclusions and = opinions=20 expressed in this manuscript are solely the authors'.
*For ease of presentation, we will refer to the survey = dates as=20 1994 and 2000.
&134;Facilities providing at least 30 abortions = accounted for=20 more than 99% of all reported procedures in 1996, the year of AGI's most = recent=20 survey of all U.S. abortion providers when our survey was fielded.
=E2=80=A1This high level of nonresponse for nonusers was = because=20 contraceptive use was imputed for some women (10% of nonusers) and = because of a=20 problem with survey wording. The question introducing the series of = items asking=20 about reasons for nonuse read "Why have you never used a method or = during the=20 month you became pregnant, why were you not using any contraceptive or = other=20 method to prevent pregnancy?" Women who read this rapidly may have = assumed that=20 the following items pertained only to women who had never used a method. = By=20 examining cross-tabulations of nonresponse by prior contraceptive use, = we found=20 support for this explanation: Only 18% of women who had never used a = method=20 failed to answer this series of items, compared with 36% of prior = users.
=C2=A7For each item requiring imputation, we used = cross-tabulations to=20 identify the variables most strongly associated with it. Respondents = were sorted=20 according to these variables in the order of the strength of the item's=20 association with the variable to be imputed, so that similar cases were = adjacent=20 to one another in the file. A missing value was then replaced by the = value of=20 the preceding case in the file with available data. Subcategories of = specific=20 reasons for contraceptive nonuse and specific reasons for inconsistent = pill and=20 condom use were not imputed on a case-by-case basis; instead, we assumed = that=20 women who did not provide responses to these items resembled women who = did=20 provide responses.
**Twelve percent of all women having abortions indicated = that they=20 had last used more than one contraceptive method. Information from an = item=20 asking about the method used in the month of pregnancy allowed us to = determine=20 the last method used for about half of these women (5% overall). We = assumed that=20 the rest had been using the most effective method they reported.
=E2=80=A0=E2=80=A0Some of these women reported both that = they had used a=20 contraceptive method in the month they became pregnant and that they had = stopped=20 method use before becoming pregnant. In past AGI surveys, such women = were=20 classified as nonusers. However, on the basis of changes in the survey,=20 including changed order of questions, reworded questions and new items = about=20 pill and barrier method users' perceptions of why they became pregnant, = we=20 classified them as users in this analysis. Most of these women answered = the new=20 questions, and their responses indicated that they had been = contraceptive users=20 when they became pregnant, although they may have used their method=20 inconsistently. Information provided by respondents on problems with = specific=20 methods provides assurance that our classification was correct and = comparable=20 between surveys. We estimate that if this procedure incorrectly = categorized=20 women as contraceptive users, this would have affected fewer than 1% of = all=20 respondents.
=E2=80=A1=E2=80=A1One percent of pill users and of condom = users indicated both=20 perfect use and some other potential reason for pregnancy (e.g., = inconsistent=20 use). Estimates of perfect use are restricted to those who gave only = this=20 response.
=C2=A7=C2=A7All racial designations refer to non-Hispanic = women of those=20 races.
*=E2=80=A0The questionnaire directed all barrier method = users to answer the=20 series of items about reasons for pregnancy. Because male condoms were = the most=20 commonly used method among women having abortions and because problems=20 associated with condom use are, in many ways, distinctly different from = those of=20 other barrier methods, we limited the analysis of potential reasons for=20 pregnancy to women who had been using male condoms in the month they = became=20 pregnant.
*=E2=80=A1The item asking about last method used did not = include emergency=20 contraceptive pills as a response category. Rather, all women were asked = in a=20 subsequent item whether they had used emergency contraceptive pills to = prevent=20 the current pregnancy. Some women who indicated both use of emergency=20 contraception and pill use may have used only emergency contraceptive = pills.
*=C2=A7The 95% confidence interval around the 1.3% = estimate is=20 1.0-1.6%, and 13,000-21,000 abortions may have occurred after the use of = emergency contraception.
=E2=80=A0*Pill and barrier method users who indicated = that "other reasons"=20 were responsible for their pregnancy were considered imperfect = contraceptive=20 users, as were barrier method users who experienced slippage or = breakage. The=20 questionnaire did not ask about reasons for pregnancy among the 1% of = women who=20 were using long-acting methods or the 10% using nonhormonal, nonbarrier = methods.=20 We assumed that similar proportions of women had used the pill and = long-acting=20 methods perfectly (12.7%) and that users of nonhormonal, nonbarrier = methods had=20 levels of perfect use equal to those of all barrier method users (14.4%, = which=20 is slightly higher than the level among male condom users).=20
Rachel K. Jones is senior research associate, Jacqueline E. Darroch = is senior=20 vice president and vice president for science, and Stanley K. Henshaw is = senior=20 fellow, all with The Alan Guttmacher Institute, New York.