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Contraception Editorial January 2008

Reducing Unintended Pregnancy in the United States

By: James Trussell and L.L. Wynn

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Almost half (49%) of all pregnancies in the United States are unintended: There were 3.1 million in 2001 alone, the last year for which data are available.1 There has been no change in the recent past; these statistics were the same in 1994.2 One of every two women aged 15–44 in the United States has experienced at least one unintended pregnancy.2 What is responsible for the unacceptably high incidence of unintended pregnancy and what can be done to reduce this incidence?

Information on levels and trends in contraceptive use in the United States is based on the National Surveys of Family Growth (NSFG), periodic surveys conducted by the National Center for Health Statistics in which women ages 15–44 are interviewed about topics related to childbearing, family planning and maternal and child health. Among the 61.6 million women of reproductive age in 2002, about 62% (38.1 million) were using some method of contraception, according to the 2002 NSFG. Among the 38% (23.5 million) who were not currently using a method, only about one fifth were at risk of pregnancy. The remaining four fifths were not at risk because they had been sterilized for noncontraceptive reasons, were sterile, were trying to become pregnant, were pregnant, were interviewed within 2 months after the completion of a pregnancy or were not having intercourse during the 3 months prior to the survey.3

As can be seen in Table 1,4 almost 90% of the women at risk for an unintended pregnancy were using a contraceptive method. Today, the most popular contraceptive methods are oral contraceptive pills (11.6 million users), female sterilization (10.3 million users), male condoms (6.8 million users) and male sterilization (3.5 million users).3 Yet, even with the majority of women at risk for unintended pregnancy using some form of contraception, 10.7% of all women at risk were not using any contraceptive method. The mix of methods shown in Table 1 resulted in the staggering 3.1 million unintended pregnancies in 2001; less than half (48%) of these unintended pregnancies result from contraceptive failure, with 52% of unintended pregnancies contributed by the 10.7% of women who use no method at all.1

Table 1. Percentage and number of at-risk women and percentage of at-risk women currently using various methods from the 2002 NSFG

Percentage of at-risk women using a contraceptive method

Contraceptive method

Age range (years)

15–44

15–19

20–24

25–29

30–34

35–39

40–44

Pill

27.2

43.5

46.1

33.7

28.6

16.8

10.0

Female sterilization

24.1

0.0

3.2

13.5

24.9

37.2

45.8

Condom

16.0

22.1

20.2

18.4

15.5

14.1

10.5

No method

10.7

18.0

12.1

10.5

9.2

9.8

8.8

Male sterilization

8.2

0.0

0.7

3.7

8.4

12.8

16.8

Depo-Provera

4.8

11.4

8.8

5.8

3.8

1.8

1.5

Withdrawal

3.6

2.1

4.5

6.9

3.4

3.1

1.3

IUD

1.9

0.2

1.6

3.3

2.8

1.3

1.0

Fertility-awareness-based methods

1.3

0.0

1.1

0.9

1.5

1.8

2.0

Calendar rhythm

1.0

0.0

1.1

0.4

1.2

1.4

1.5

Implant, Lunelle or patch

1.2

1.0

1.3

2.2

1.2

0.7

0.3

Other methodsa

0.6

1.0

0.1

0.4

0.1

0.4

1.2

Diaphragm

0.3

0.0

0.1

0.4

0.2

0.0

0.5

Spermicides

0.3

0.5

0.1

0.1

0.4

0.3

0.3

 

Number of women in the cohort as well as percentage and number of at-risk women

Number of women (in millions)

61.6

9.8

9.8

9.2

10.3

10.9

11.5

Percentage of at-risk women

69.4

38.4

69.2

76.0

76.2

78.6

75.9

Number of at-risk women (in millions)

42.7

3.8

6.8

7.0

7.8

8.5

8.7

At-risk women are those who either are current contraceptive users or are nonusers who have had sex in the past 3 months and are not trying to become pregnant, are not pregnant or were not interviewed within 2 months after the completion of a pregnancy and are not sterile. Percentages may not add to 100 due to rounding.

Source: Ref. 4

a. Other methods include cervical cap, sponge and female condom.

In Table 2,5 we show estimates of contraceptive failure rates in the United States. Pregnancy rates during typical use show how effective the different methods are during actual use (including inconsistent or incorrect use). Pregnancy rates during perfect use show how effective methods can be, where perfect use is defined as following the directions for use; for many methods, perfect use requires use at every act of intercourse. The difference between pregnancy rates during imperfect use and pregnancy rates during perfect use reveals how forgiving of imperfect use a method is. Scrutiny of Table 2 reveals four important findings:

  1. The most effective methods during typical use are generally those not requiring adherence.
  2. Methods requiring adherence generally show a big difference between perfect-use and typical-use failure rates.
  3. Even the least effective methods are much more effective than no method at all.
  4. The most effective methods do not protect against sexually transmitted infections.

Table 2. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage of women continuing use at the end of the first year, United States

Method

Percentage of women experiencing an unintended pregnancy within the first year of use

Percentage of women continuing use at 1 yeara

Typical useb

Perfect usec

No methodd

85

85

 

Spermicidese

29

18

42

Withdrawal

27

4

43

Fertility-awareness-based methods

25

 

51

Standard days methodf

 

5

 

TwoDay methodf

 

4

 

Ovulation methodf

 

3

 

Sponge

Parous women

32

20

46

Nulliparous women

16

9

57

Diaphragmg

16

6

57

Condomh

Female (Reality)

21

5

49

Male

15

2

53

Combined pill and progestin-only pill

8

0.3

68

Evra patch

8

0.3

68

NuvaRing

8

0.3

68

Depo-Provera

3

0.3

56

IUD

ParaGard (copper T)

0.8

0.6

78

Mirena (LNG-IUS)

0.2

0.2

80

Implanon

0.05

0.05

84

Female sterilization

0.5

0.5

100

Male sterilization

0.15

0.10

100

Emergency Contraceptive Pills: Treatment initiated within 72 h after unprotected intercourse reduces the risk of pregnancy by at least 75%.i

Lactational Amenorrhea Method: It is a highly effective, temporary method of contraception.j

Source: Ref. 5

a Among couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 year.

b Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal, fertility awareness-based methods, the diaphragm, the male condom, the pill and Depo-Provera are taken from the 1995 NSFG corrected for underreporting of abortion; see the reference above for the derivation of estimates for the other methods.

c Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. For the derivation of the estimate for each method, see the reference above.

d The percentages becoming pregnant in Columns 2 and 3 are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within 1 year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within 1 year among women now relying on reversible methods of contraception if they abandoned contraception altogether.

e Foams, creams, gels, vaginal suppositories and vaginal film.

f The Ovulation and TwoDay methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on Cycle Days 8–19.

g With spermicidal cream or jelly.

h Without spermicides.

i The treatment schedule is one dose within 120 h after unprotected intercourse and a second dose 12 h after the first dose. Both doses of Plan B can be taken at the same time. Plan B (one dose is one white pill) is the only dedicated product specifically marketed for emergency contraception. The FDA has, in addition, declared the following 22 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel or Ovral (one dose is two white pills); Levlen or Nordette (one dose is four light orange pills), Cryselle, Levora, Low-Ogestrel, Lo/Ovral or Quasence (one dose is four white pills); Tri-Levlen or Triphasil (one dose is four yellow pills); Jolessa, Portia, Seasonale or Trivora (one dose is four pink pills); Seasonique (one dose is four light blue-green pills); Empresse (one dose is four orange pills); Alesse, Lessina or Levlite (one dose is five pink pills); Aviane (one dose is five orange pills); and Lutera (one dose is five white pills).

j However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of breast-feeds is reduced, bottle feeds are introduced or the baby reaches 6 months of age.

Comparison of Tables 1 and 2 shows clearly that the most effective long-acting reversible contraceptives — those not requiring adherence [intrauterine devices (IUDs) and implants] — are not used very frequently. Implanon was not approved by the Food and Drug Administration (FDA) until mid-2006 and, thus, could not appear in Table 1, but Norplant, which is no longer marketed, was used by only 1.3% of women at risk of pregnancy in 1995.6 This comparison, therefore, suggests three strategies for reducing unintended pregnancy:

  1. Increasing contraceptive use among those not using a method.
  2. Tipping the balance between those using effective methods that do not require adherence and those that do, so that relatively more people are relying on methods that do not require adherence at every act of vaginal intercourse to be effective.7
  3. Simultaneous use of condoms and a more effective method among those at risk of sexually transmitted infection.

Table 2 also suggests that widespread use of emergency contraceptive pills (ECPs) could help to reduce unintended pregnancy after no method was used, a condom broke or slipped off the penis or several oral contraceptive pills were missed. What is the potential for increasing ECP usage? In the past two decades, researchers have evaluated numerous interventions intended to accomplish this goal, including promotional campaigns, provision of ECPs in advance of need, distribution by pharmacists or over the counter and prescription by telephone.8,9,10,11,12,13,14,15,16,17,18,19,20,21,22 Most of these interventions have increased ECP use — some substantially — but whether any of these increases were sizeable enough to produce a large public health effect is doubtful. Almost all the studies that collected data on ECP use found that only a minority of women exposed to the intervention ever used ECPs, and few of those who became pregnant had tried to prevent the pregnancy using ECPs. No study to date has yet directly shown that any intervention has actually reduced pregnancy rates.23,24,25 It seems unlikely that EC will ever have a dramatic public health impact.

Clearly, the strategies suggested above, including widespread use of ECPs, would have the intended effect of reducing unintended pregnancy if they were successfully implemented. However, family planning providers have long encouraged and promoted use of contraception, use of the most effective methods and use of ECPs with no apparent success.

What makes a difference in unintended pregnancy rates?

Debates that frame the problem of unintended pregnancy in terms of what family planning providers can do leave out an important part of the picture. Although advances in technology in the form of long-acting reversible methods not requiring adherence may be helpful, as might the development of hormonal contraceptive methods for men, technology alone is not sufficient. Many policies discourage consistent, effective contraceptive use and deserve to be reconsidered.

For example, consider cost. Medicaid covers contraceptive supplies and services for poor women, and the federal government covers contraceptive supplies and services for its employees and their dependents. Yet, there is considerable variability in contraceptive coverage by private insurers. In 2002, almost every reversible contraceptive supply and service was covered by at least 89% of private insurance plans, and 86% of plans covered the five most popular prescription contraceptives.26 Breaking down those figures further, we see that legislative policy makes a difference in the extent to which contraceptives are covered by private insurance. Twenty-six states require private-sector insurers that cover prescription drugs to provide coverage for prescription contraceptives and related services;27 these mandates do not apply to the half of employees who have insurance through employers that self-insure.26 In those states, plans were much more likely to cover the five leading prescription contraceptives (87–92% vs. 47–61%).26

Although there has been considerable improvement in coverage of contraceptive supplies and services in the United States, some women are still not covered, and for many who are, the co-pays and deductibles constitute a considerable economic burden. When Kaiser Permanente Northern California eliminated the co-pay for the most effective forms of contraception (intrauterine contraceptives, injectables), couple-years of protection increased 28% while the caseload of females aged 15–44 fell by 1%. Couple-years of protection for intrauterine contraceptives and injectables rose 137% and 32%, respectively, while couple-years of protection for the pill, patch and ring rose only 16%.28

Coverage rules that impede consistent use also deserve attention. A delay in obtaining a needed contraceptive refill may result in significant reduction of contraceptive efficacy and is a very common reason for contraceptive failure. Yet, many insurance plans require women to fill prescriptions for contraception on a monthly basis. Because pregnancy is so expensive, marginal savings gained by limiting refill access are almost certain to be overwhelmed by added costs of pregnancy caused by reduced contraceptive effectiveness.

Lending weight to our suspicion that rates of unintended pregnancy are linked to both cost and access to medical care, recent analysis has shown that both unplanned pregnancies and abortions in the United States are closely linked to women's socioeconomic status. Poor women are four times as likely to have an unintended pregnancy as higher-income women and three times as likely to have an abortion.1

Reducing unintended pregnancy is a formidable challenge. There is no magic bullet, and there will always be a group of women and men who have unprotected sex or whose contraceptive methods fail.

Yet, a quick look at the rate of unintended pregnancy in other countries suggests that the problem is not simply one of ‘human nature’ or a matter of the limitations of existing contraceptive technologies. While 49% of pregnancies in the United States are unintended, the corresponding percentage in France is only 33%,29 and in Edinburgh, Scotland, it is only 28%.30,31 Compared with the United States, these countries have much lower proportions of women at risk for unintended pregnancy who use no contraception at all; while this figure is 11% in the United States, it is only 3% in France and 3% in the United Kingdom.29,32 Moreover, IUD use is much more common; while only 2% of women at risk use IUDs in the United States, 6% use IUDs in the United Kingdom and 20% use IUDs in France.29,32

No matter how dedicated they are, family planning providers cannot fix such structural problems. Instead, policy interventions are needed on a broader scale. Two examples illustrate this approach. In early 2007, Senator Harry Reid (D-NV) and Representative Louise Slaughter (D-NY) reintroduced the Prevention First Act, an omnibus piece of legislation that would help prevent unintended pregnancies by expanding women's access to contraception and young people's access to sex education. In addition, Senator Hilary Rodham Clinton (D-NY) and Representative Nita Lowey (D-NY) recently introduced the Unintended Pregnancy Reduction Act to ensure that low-income women across the country have equal access to contraceptive services and equal access to pregnancy-related care if they do become pregnant. Essentially, it would guarantee that the same women who have access to Medicaid-funded pregnancy care would also have access to contraceptive services and supplies.33 Two analyses suggest that not only would this change serve women by ensuring that they have greater access to medical care and control over their reproductive lives, it would also result in reduced birth rates and significant public-sector cost savings.33,34,35

James Trussell
Princeton University
Princeton NJ
University of Hull
Hull, United Kingdom

L.L. Wynn
Macquarie University
Australia

References

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  3. Mosher WD, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982–2002. Advance data from vital and health statistics, no 350. Hyattsville, MD: National Center for Health Statistics; 2004.
  4. Trussell J. Choosing a contraceptive: efficacy, safety, and personal considerations. In:  Hatcher RA,  Trussell J,  Nelson AL,  Cates W,  Stewart FH,  Kowal D editor. Contraceptive technology: nineteenth revised edition. New York, NY: Ardent Media; 2007;p. 19–47.
  5. Trussell J. Contraceptive efficacy. In:  Hatcher RA,  Trussell J,  Nelson AL, Cates W,  Stewart FH,  Kowal D editor. Contraceptive technology: nineteenth revised edition. New York, NY: Ardent Media; 2007;p. 747–826.
  6. Trussell J. The essentials of contraception: efficacy, safety, and personal considerations. In:  Hatcher RA,  Trussell J,  Stewart F,  Nelson A,  Cates W, Guest F,  Kowal D editor. Contraceptive technology: eighteenth revised edition. New York, NY: Ardent Media; 2004;p. 221–252.
  7. National Collaborating Centre for Women's Health . Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception. London: RCOG Press; 2005.
  8. Marston C, Meltzer H, Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over-the-counter in Great Britain: repeated cross-sectional surveys. BMJ. 2005;331:271–273.
  9. Raymond EG, Spruyt A, Bley K, Colm J, Gross S, Robbins LA. The North Carolina DIAL EC project: increasing access to emergency contraceptive pills by telephone. Contraception. 2004;69:367–372.
  10. Moreau C, Bajos N, Trussell J. The impact of pharmacy access to emergency contraceptive pills in France. Contraception. 2006;73:602–608.
  11. Glasier A, Fairhurst K, Wyke S, et al.. Advanced provision of emergency contraception does not reduce abortion rates. Contraception. 2004;69:361–366.
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  13. Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol. 2000;96:1–7.
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  16. Lo SS, Fan SYS, Ho PC, Glasier AF. Effect of advanced provision of emergency contraception on women's contraceptive behavior: a randomized controlled trial. Hum Reprod. 2004;19:2404–2410.
  17. Raine TR, Harper CC, Rocca CH, et al.. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA. 2005;293:54–62.
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  20. Trussell J, Raymond E, Stewart FH. Advance supply of emergency contraception: a randomized trial in adolescent mothers [Letter to the editor]. Pediatr Adolesc Gynecol. 2006;19:251.
  21. Walsh TL, Frezieres RG. Patterns of emergency contraception use by age and ethnicity from a randomized trial comparing advance provision and information only. Contraception. 2006;74:110–117.
  22. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol. 2006;108:1098–1106.
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  25. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev. 2007;(2).
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  28. Postlethwaite D, Trussell J, Zoolakis A, Shaber R, Petitti D. A comparison of contraceptive procurement pre- and post-benefits change. Contraception 2007;76:360–5.
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  30. Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet. 2006;368:1782–1787.
  31. Trussell J, Raymond EG. Preventing unintended pregnancy: let us count the ways. Lancet 2006;368:1747–8; Erratum, Lancet 2006;368:2124.
  32. Dawe F, Rainford L. Contraception and sexual health, 2003. London: Office for National Statistics; 2004.
  33. Gold RB. Rekindling efforts to prevent unplanned pregnancy: a matter of ‘equity and common sense’. Guttmacher Policy Rev. 2006;9:2–7.
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  35. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Wom Health Iss. 2007;17:66–74.

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Used with permission from Elsevier, Inc.